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• Research article
• Open access
• Published: 03 October 2018

Cafeteria assessment for elementary schools (CAFES): development, reliability testing, and predictive validity analysis

• Kimberly A. Rollings   ORCID: orcid.org/0000-0002-3091-3340 1 &
• Nancy M. Wells 2  

BMC Public Health volume  18 , Article number:  1154 ( 2018 ) Cite this article

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Strategies to reduce childhood obesity and improve nutrition include creating school food environments that promote healthy eating. Despite well-documented health benefits of fruit and vegetable (FV) consumption, many U.S. school-aged children, especially low-income youth, fail to meet national dietary guidelines for FV intake. The Cafeteria Assessment for Elementary Schools (CAFES) was developed to quantify physical attributes of elementary school cafeteria environments associated with students’ selection and consumption of FV. CAFES procedures require observation of the cafeteria environment where preparation, serving, and eating occur; staff interviews; photography; and scoring.

CAFES development included three phases. First, assessment items were identified via a literature review, expert panel review, and pilot testing. Second, reliability testing included calculating inter-item correlations, internal consistency (Kuder-Richardson-21 coefficients), and inter-rater reliability (percent agreement) based on data collected from 50 elementary schools in low-income communities and 3187 National School Lunch Program participants in four U.S. states. At least 43% of each participating school’s students qualified for free- or reduced-price meals. Third, FV servings and consumption data, obtained from lunch tray photography, and multi-level modeling were used to assess the predictive validity of CAFES.

CAFES’ 198 items (grouped into 108 questions) capture four environmental scales: room (50 points), table/display (133 points), plate (4 points), and food (11 points). Internal consistency (KR-21) was 0.88 (overall), 0.80 (room), 0.72 (table), 0.83 (plate), and 0.58 (food). Room subscales include ambient environment, appearance, windows, layout/visibility, healthy signage, and kitchen/serving area. Table subscales include furniture, availability, display layout/presentation, serving method, and variety. Inter-rater reliability (percent agreement) of the final CAFES tool was 90%. Predictive validity analyses indicated that the total CAFES and four measurement scale scores were significantly associated with percentage consumed of FV served ( p  < .05).

Conclusions

CAFES offers a practical and low-cost measurement tool for school staff, design and public health practitioners, and researchers to identify critical areas for intervention; suggest low- and no-cost intervention strategies; and contribute to guidelines for cafeteria design, food presentation and layout, and operations aimed at promoting healthy eating among elementary school students.

Peer Review reports

National strategies to reduce childhood obesity include creating school food environments that promote healthy eating (e.g., [ 1 , 2 ]). In the U.S., nearly 99% of public schools participate in USDA breakfast and lunch programs that offer free- and reduced-price meals (FRPM), in addition to full-price meals, to students based on financial need [ 3 ]. Children consume as many as two meals and snacks per day while at school [ 3 ], accounting for 19–50% of their daily caloric intake [ 4 ]. Despite well-documented health benefits of fruit and vegetable (FV) consumption [ 5 , 6 , 7 ], approximately 80% of U.S. school-aged children, especially low-income youth, fail to meet national dietary guidelines for FV intake [ 8 ]. FV - along with milk - consumption is highly correlated with the quality of students’ diets [ 9 , 10 ]. Several studies found that FV are thrown away more than any other food item during school lunch periods [ 11 , 12 ]; among school children, 40% of cooked vegetables, 30% of salads, and 20% of fruits were wasted daily [ 12 ]. Considering that federally-funded meal programs feed more than 31 million students daily, the school cafeteria environment has great potential to encourage healthy eating.

A growing literature suggests that school-based environmental interventions affect health behaviors, including students’ selection and consumption of healthy foods. In addition to social, cultural, economic, policy, and psychological factors, school cafeteria physical attributes including design, display, and layout at multiple environmental scales can affect meal choices, especially when students are faced with long lines and short meal times [ 13 , 14 , 15 ]. Physical environment intervention suggestions to promote healthy eating include updating interior design; reducing crowding; creating attractive serving displays and seating areas; selecting appropriately-sized serving trays, plates, and bowls relative to desired portion sizes; and changing the way individual food items are prepared and presented. For example, attractive, well-lit cafeterias with windows and a layout that provides convenient access to healthy foods can affect eating behaviors [ 15 , 16 , 17 ]. Placing fresh fruit by the cafeteria checkout rather than earlier in the serving line is associated with an increase in purchases, as are well-lit fresh fruit displays [ 13 , 18 , 19 , 20 ]. Manipulating availability of healthy items; rearranging the order and placement of food items in serving lines; providing appropriate display and dining furniture; serving tray availability and design; manipulating portion sizes via bowl and plate sizes; and altering presentation of individual food items, as well as item packaging, all have the potential to affect food selection and consumption [ 15 , 17 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ]. Despite the increase in research and design guidelines aimed at promoting healthy eating in school cafeterias, no comprehensive, reliable, or validated assessment tool exists to quantify physical attributes of school cafeterias across environmental scales, from interior design characteristics to individual food items. Quantitative data are needed to develop and prioritize evidence-based interventions and design guidelines for elementary school cafeteria environments that promote healthy eating.

The Cafeteria Assessment for Elementary Schools (CAFES) study had three aims: 1) to identify elementary school cafeteria physical attributes at multiple environmental scales [e.g., room (interior design and ambient environment), table and display (dining table and display areas), plate (lunch tray), and individual food items (e.g., [ 17 ]) linked to children’s selection and consumption of healthier foods; 2) to create a comprehensive assessment tool via reliability testing; and 3) to evaluate the predictive validity of the tool. Scores resulting from the developed tool were intended to highlight specific areas on which to focus intervention strategies and inform the development of low- or no-cost interventions that can immediately be implemented. By focusing on elementary schools, USDA-funded National School Lunch Program participants, and free- and reduced-price meal (FRPM) recipients, the CAFES tool would benefit high-risk and underserved FRPM student populations and contribute to younger students’ development of healthy eating habits. The following sections discuss CAFES item selection and development, reliability testing, and predictive validity analysis.

The Methods section is organized by the three distinct parts of the CAFES study: CAFES item identification (literature review, expert panel review, and pilot testing; CAFES part 1: Item idenfication ), reliability testing (CAFES part 2: Reliability) , and predictive validity testing ( CAFES part 3: Predictive validity analysis ).

CAFES part 1: Item identification

Literature review procedures.

Literature based in public and environmental health, environmental psychology, behavioral economics, and socioecological models was reviewed to identify physical environment attributes that promote healthy eating, especially among elementary school-aged students [ 3 , 13 , 17 , 18 , 24 , 35 , 36 ]. Literature included empirical studies, literature reviews, USDA reports, and existing environmental assessment tools (e.g., [ 17 , 37 , 38 , 39 , 40 ]). Although most literature focused on school cafeteria settings, relevant studies conducted in residential, food retail, and workplace environments were also included. A wide range of attributes within elementary school cafeteria environments hypothesized to promote selection and consumption of healthier food was identified (e.g., interior design, food presentation techniques), as well as novel features not commonly found in the literature but that may affect selection and consumption of healthier food (e.g., noise, student circulation, leftover food-sharing tables). Most identified features were objectively measureable, but some subjective items were included (e.g., cafeteria design attractiveness).

A 400-item draft assessment tool was created based on attributes of cafeteria environments hypothesized to affect healthy eating identified in the literature review. Item measures required school principal and food service manager interviews and an in-person “walk-through” or observation of the cafeteria areas. CAFES items were grouped into interview and observation items, and by space: kitchen/preparation area, serving area, and dining area.

Expert panel review procedures

During CAFES development, face validity was evaluated via feedback from five experts invited to review CAFES items for representativeness and relevance. Experts represented the fields of behavioral economics, nutrition, environmental psychology, human development, health, and design. Prior to reviewing the CAFES draft, each expert received a project description, a CAFES tool draft, a description of CAFES data collection and scoring procedures, and three questions concerning the representativeness and relevance of CAFES items:

Do CAFES items represent a range of environmental scales?

Are any key environmental attributes missing from the assessment tool?

Do you have suggestions for improving the data collection and scoring procedures?

Feedback was provided via phone calls, meetings, and emails, and included clarifications to, modifications to, and additions of specific items as well as training and scoring procedures.

Pilot testing procedures

Four researchers were trained to use the CAFES draft protocol by first coding 10 sets of example school cafeteria photographs. Coding discrepancies were discussed, CAFES item text and instructions were modified for clarification, and cafeteria photo evaluations were repeated until agreement was reached on all coding conventions. Once observers reached 90% inter-rater reliability (2 h), measured by percent agreement, they piloted the CAFES tool at two local elementary schools. CAFES observations included interviews with school principals and food service staff; walk-through observations of the cafeteria preparation, serving, and dining areas; and sketching and photographing those three spaces for further coding after completion of on-site interviews and observations. Initial CAFES observations required 45–120 min to complete at each school, depending on interview duration and whether students were present in the eating and serving areas.

CAFES part 2: Reliability testing

Participants.

CAFES reliability testing was based on a cross-sectional sample of 50 elementary schools (3187 students, total) in New York ( n  = 16), Iowa ( n  = 17), Arkansas ( n  = 10), and Washington ( n  = 7) participating in the Healthy Gardens, Healthy Youth (HGHY) pilot program. The 2.5-year, USDA-funded, randomized school garden pilot project included examination of FV consumption in elementary schools (Wells, N.M., lead researcher). Cooperative Extension educators recruited schools from low-income rural, urban, and suburban communities; without a school garden; and with at least 50% of students qualifying for FRPM at the time of selection [ 41 ]. Trained researchers in New York and Washington and trained Cooperative Extension Educators in Iowa and Arkansas collected CAFES data. The CAFES study was deemed exempt by the Cornell University and University of Notre Dame Institutional Review Boards.

CAFES observations were repeated at participating schools using the Part 1 CAFES version containing hundreds of items. To determine which CAFES items to retain or eliminate, identify measurement scales and subscales, and assess the reliability of the resulting CAFES tool, measures of internal consistency, inter-item correlations, and inter-rater reliability were calculated. First, each CAFES item was dichotomously coded into negative (0 = barrier to healthy eating) and positive (1 = facilitator of healthy eating) point values using IBM SPSS Statistics for Windows (IBM Corp., Version 23.0). Per Part 1 expert panel review feedback, binary item coding facilitated scoring and reliability testing.

The large number of CAFES items and modest school sample size precluded use of factor analysis to reduce the number of items. Therefore, item variability and inter-item correlations were calculated and served as criteria for item omission [ 42 ]. CAFES items were grouped according to each of the four environmental scales and themes (subscales) identified in the Part 1 literature review. Then, items with the lowest variability (i.e., an individual item with little to no variation across schools) and items with low inter-item correlations were omitted. Each time an item was omitted, Kuder-Richardson 21 (KR-21) coefficients, a measure of internal consistency for binary items [ 43 ], were calculated. The procedure was repeated until KR-21 coefficients of at least .70 and acceptable average inter-item correlations were achieved for the overall CAFES tool, four measurement scales, and emergent subscales [ 42 ]. Schools lacking at least 50% of items within any measurement scale or subscale were excluded from analysis of that scale or subscale (see Additional file 1 : Tables S1-S3, for school sample sizes – ranging from 20 to 36 schools – applicable to each CAFES scale and subscale).

CAFES scores (percentage out of 100%) were then calculated by summing all points and dividing by the total number of points. Scoring calculations were repeated for each CAFES measurement scale and subscale. Scores indicated how well cafeteria environments promoted or inhibited FV selection and consumption overall, and within each scale and subscale. Several CAFES items were also designated as possible “not applicable” items. For example, a school without a kitchen was awarded zero points once, but all subsequent kitchen items were deemed not applicable and associated points were deducted from the total points possible. Inter-rater reliability of the revised CAFES tool was assessed by calculating the percent agreement among at least three of four trained researchers’ CAFES responses at four additional elementary schools in a fifth state, not part of initial data collection.

CAFES part 3: Predictive validity analysis

Of the 50 schools that participated in reliability testing, 44 provided FV servings and consumption data via lunch tray photography (2506 students). Students who brought lunches from home (519 meals, 216 students); 82 students with missing, dark, or blurry photographs; and schools missing at least 50% of any CAFES scale or subscale items were eliminated from predictive validity analysis [ 44 ]. Two predictive validity analysis subsamples remained: 29 schools (1544 students) supplied complete CAFES items and 16 schools (1069 students) supplied complete items for the four CAFES measurement scales. Subsample demographics are displayed in Additional file 1 : Table S4. Additional file 1 : Tables S5a-c display FV outcome summary statistics for the 44 schools that collected lunch tray photography data, and the two predictive validity testing subsamples.

Constructs and measures

At the school-level, CAFES observation data, student population, percentage of students eligible for FRPM, percentage of minority students, and urbanity were obtained from the HGHY study. Urbanity, or whether a school was in an urban, rural, or suburban location, was determined based on U.S. census definitions of population density [ 45 ]. Individual student gender, grade level, FRPM eligibility, ethnicity, age, and body mass index (BMI) were reported by parents in a survey distributed as part of the HGHY study.

At the individual student level, FV servings and consumption outcome data were obtained by attaching laminated identification number cards to student lunch trays and photographing trays twice: once immediately after students were served, and again after they ate [ 44 , 46 ]. Digital Food Image Analysis (DFIA) software analyzed “before and after” lunch tray photograph pairs (Fig. 1 ) using school menus, cafeteria production records, and the USDA’s nutrient database. DFIA validity was previously assessed via comparisons to dietitians’ digital observations [ 44 ]. FV servings and percent consumption recorded by both methods were moderately and strongly correlated, respectively. Correlations were either comparable to or more robust than prior studies assessing dietary assessment method validity [ 44 ]. DFIA analyses yielded four quantities used to calculate FV outcomes for the CAFES study: fruit served, fruit consumed, vegetables served, and vegetables consumed, all measured in grams.

Lunch Tray Photograph Pairs. Two examples of “pre” (left) and “post” (right) lunch tray photography pairs

Predictive validity testing included both FV serving and consumption outcomes. Distinguishing between foods available to students, foods students choose or are served, and foods students actually consume is important because factors affecting selection and consumption differ [ 47 , 48 ]. Although selection and consumption of fruits verses vegetables may also differ, only combined FV measures were analyzed. Combined FV measures addressed within- and between-school variations in the number of FV options available to students, as well as the number of allowable FV servings. For example, students could select two fruits and one vegetable at one school, but one fruit and two vegetables at another. Therefore, FV servings and consumption data were averaged from lunches on three separate days to yield two outcome variables: FV served and FV consumed. Percentage consumed of FV served (percent consumed) was then calculated by dividing FV consumed by FV served, and allowed for comparisons among FV items with standard serving sizes that varied between schools [ 44 ].

Furthermore, per expert panelist feedback, combined FV serving and consumption measures focused on FV “side items,” rather than both FV entrees (e.g., tomato sauce) and sides (e.g., whole fruit, applesauce, steamed vegetables, etc.). Finally, predictive validity testing examined foods, not beverages, for two reasons. First, beverage consumption from opaque milk containers could not be documented via photographs for DFIA analysis. Second, all students were served one prepackaged carton or bottle of low-fat milk. This packaging type creates a “natural consumption unit” [ 17 ] that can lead diners to consume the entire unit, also known as unit bias [ 49 ]. Although future work could examine associations between CAFES scores and student milk selections (e.g., flavored or unflavored), CAFES predictive validity testing excluded beverages due to the lack of consumption data and variability in servings.

Predictive validity was assessed using Hierarchical Linear Modeling software (Version 7.0; [ 50 ]) to determine whether (A) CAFES total and (B) four measurement scale scores significantly predicted FV servings and consumption outcomes (see CAFES part 2: Reliability testing results for measurement scales and subscales). The two-level data structure consisted of student level controls (grade, gender, and BMI; age was excluded due to missing data and high correlation with grade) nested within school level CAFES scores (A-CAFES total and B-four scale scores) and school level controls (percent of students receiving FRPM, percent minority student population, urbanity). The sample size did not permit exploring a three-level model (students within classes within schools). All variables, except for CAFES scores, were grand-mean centered. Two sets of multilevel models containing the following school-level predictors were run: A) CAFES total score and B) four CAFES scale scores. FV outcome variables included FV served and FV percentage consumed.

Literature review

Table 1 displays themes and four environmental scales drawn from the literature review that guided preliminary CAFES item selection. Numerous environmental attributes were included in the initial CAFES version so that the resulting tool could be used to assess widely varying elementary school cafeteria environments. “Room scale” physical attributes, related to the interior design of kitchen, serving, and dining areas, that potentially affect healthy eating included ambient environment, appearance, layout, and advertising. Table/display scale attributes described the appearance of furnishings, equipment, and surfaces from which foods and beverages are served and consumed [ 17 ]. Items included size, shape, surface material, and condition of tables, counters, and serving displays, as well as availability, display and layout, serving method, and variety of items served within serving and dining areas. Plate scale items included the size, shape, transparency, color, and material of lunch trays, plates, bowls, glasses, containers, and utensils [ 17 ]. Food scale items described the appearance (e.g., size, shape, texture, color) of individual food and beverage items [ 17 , 51 ].

Expert panel review

Expert panel review feedback ranged from suggested improvements to training protocols, observation procedures, and CAFES instructions to item adjustments and scoring. One panelist noted, based on prior work, that CAFES observations should not be completed when pizza is served as a meal item because students are likely to select and consume that favorite item more than others, regardless of environmental influences. This panelist also encouraged focus on side dishes rather than entrees, as most fruit and vegetable content of school meals is found in those dishes. Another panelist noted that some policies should be documented during CAFES observations as they have been found to affect eating behaviors (e.g., available time for lunch, whether recess occurs before or after lunch, and whether meals are prepared on- or off-site). Improvements were also suggested to CAFES items relating to general serving methods and the display and serving of milk. Scoring suggestions included dichotomizing results to facilitate calculations, which was implemented in CAFES Part 2. The CAFES tool and procedures were modified per the panel experts’ recommendations. Policy items unrelated to the physical environment, however, were not added to CAFES [ 37 ].

Pilot testing

Example photographs from pilot CAFES observations are displayed in Fig. 2 . Based on pilot testing, CAFES item order and procedures were revised for efficiency and to indicate whether items should be completed with or without students present. For example, measuring occupied dining areas was difficult and drew attention to observers, so revised procedures suggest those items be completed without students present. Pilot testing also revealed discrepancies between interview and observation data. Additional exploration revealed that food service staff needed to be reassured by both the Principal and CAFES observers that the environment – not the staff – was being evaluated during CAFES observations. Staff were then comfortable providing complete and accurate responses that did not conflict with observations.

Example CAFES Photographs. Example CAFES photographs from school cafeteria dining areas (row I), serving displays (row II), serving trays (row III), and individual food items (row IV)

Additionally, item coding was revised. For example, the serving tray area (size) variable was recoded. Smaller trays were originally coded positively based on studies that found an association between larger plate and bowl sizes and increased intake among adults [ 17 , 52 ]. CAFES observations and interviews, however, indicated that smaller and less-sturdy serving trays (e.g., foam or thin, disposable plastic) were difficult for students to handle and may lead to decreased FV servings when students serve themselves , and lower FV consumption. Larger, sturdier reusable plastic trays were observed to be more appropriate for elementary school students to carry and balance while obtaining food. Results and the final CAFES tool, therefore, negatively code smaller tray sizes with a “0” and not a “1.”

Table 2 describes the schools and students that participated in CAFES reliability testing. Schools were primarily in urban and rural locations with an average of 391 students, 69% FRPM recipients, and 53% minority students. Missing student level data was especially challenging to obtain, as indicated by missing data.

Brief descriptions of the final 198 CAFES items (grouped into 108 questions) relevant to FV selection and consumption based on reliability testing are provided in Table 3 . Table 3 identifies the four CAFES measurement scales that address four environmental levels (room, table/display, plate, and food), six room subscales (ambient environment, appearance, window characteristics, layout and visibility, signage promoting healthy eating and physical activity, and kitchen and serving area-specific attributes), and five table/display subscales (eating area furniture; meal item availability; meal item display, layout, and presentation; serving method; and meal item variety) that resulted from reliability testing. No reliable plate or food subscales emerged based on testing. Example excluded items that did not meet selection criteria and items beyond the scope of CAFES are also noted. Additional files 2 and 3 contain the final CAFES tool and scoring procedures.

Table 4 displays CAFES scores (total, four measurement scales, and subscales), descriptive statistics, and internal consistency results (KR-21 coefficients). KR-21 coefficients exceeded the 0.70 threshold for the total CAFES score (0.88) and the room, table/display, and plate scales ( > 0.70). The 51% mean total CAFES score (range of 35–64%, out of 100%) indicated that CAFES schools could benefit from additional environmental supports of healthy eating behaviors. Few studies have examined the relationship between room scale items in school cafeteria settings and healthy eating outcomes among children. CAFES schools scored highest, on average, at the room scale. Because changing room scale attributes such as ventilation systems, floor plans, and natural and artificial lighting can be expensive, room scale scores suggest that CAFES schools might benefit from less expensive interventions at other environmental scales. Averaging only 43%, CAFES schools would benefit most from table/display scale interventions.

The food scale did not reach the .70 KR-21 threshold and was only moderately reliable (0.58), likely due to the exclusion of student-level moderators such as food quality perceptions and preferences (see Discussion ). Other assessment tools focusing specifically on the food and beverage environment that capture these items (e.g., [ 53 ]) are needed when targeting improvements to individual food items. Subscale reliability analyses also revealed that the healthy signage (room scale), furniture (table/display scale), and serving method (table/display scale) subscales did not meet the 0.70 KR-21 criterion, likely due to a lack of variability between observed schools for these items. For example, CAFES cafeterias used a few types of standard cafeteria tables and seating that facilitated quick set-up, removal, and cleaning. CAFES schools could, however, be compared to other schools that offer more home-like or alternative furniture options. The subscales were retained in the final CAFES version due to prior research suggesting associations between these items and eating behaviors.

With the exception of the plate scale, mean inter-item correlations within the other three CAFES measurement scales and subscales were low. Low or insignificant Pearson correlations indicated that items within each scale and subscale were, in fact, measuring separate constructs. Inter-item correlation matrices are presented in Additional file 1 : Tables S1-S3. Inter-rater reliability of the final CAFES tool, determined using percent agreement, was 90%.

Predictive validity analyses examined whether CAFES scores were associated with FV servings and consumption data. Overall, students served and consumed more fruit than vegetables. Unlike college students found to consume, on average, 92% of foods they serve themselves [ 52 , 54 ], elementary school students in this study only consumed, on average, 52–65% of the FV served (Additional file 1 : Tables S5a-c). Students in the two predictive validity analyses subsamples (29 and 16 schools) served and consumed higher amounts of FV when compared to all schools that provided lunch tray photography data (44 schools; Additional file 1 : Tables S5a-c).

The amount of variance explained by CAFES scores, an indicator of CAFES effect size, was calculated for all predictive validity models. Fully unconditional and partially conditional model results are displayed in Additional file 1 : Tables S6a-b, S7a-b, and S8a-b. Fully unconditional model results indicated significant differences in FV serving and percent consumed ( p  < 0.05 for all γ 00 intercept coefficients), and that there was still unexplained variance in all outcomes at the school level ( p  < 0.05 for all school level μ 0j variance components). Partially conditional models including control variables also contained significant unexplained variance. Urbanity and student population were excluded from final models as neither were significant. Missing student level gender and BMI data precluded inclusion of these variables in analyses, resulting in models that accounted for little to no within-student variance, but school-level variance components were significant for all models.

Total CAFES

Total CAFES scores significantly predicted FV percentage consumed, but not FV served. A one percentage point increase in total CAFES score was significantly associated with an average 0.92% - or 1.62 g (50 g is approximately one FV serving [ 55 ]) - increase in FV percentage consumed ( p  < 0.05), when controlling for grade level, percent FRPM, and percent minority (Table 5 ). Total CAFES score accounted for 13% of the between-school variance in FV percentage consumed (Additional file 1 : Table S9), likely due to the relatively limited variability among CAFES items within in this sample. FV serving outcomes were not significantly predicted by total CAFES scores because serving-specific outcomes are likely associated with serving area-specific CAFES items.

Four CAFES measurement scales

An increase in the four-point plate scale score was significantly associated with an increase in FV served (Table 6 ; p  < 0.05). This result suggests that larger, sturdier trays in a variety of colors, as well as availability of appropriate utensils, are associated with increased FV servings. All four CAFES measurement scale scores were significant predictors of FV percentage consumed (Table 7 ; p  < 0.05). One percentage point increases in room, table/display, and food scale scores were associated with 0.72%, 1.34%, and 0.44% increases in FV percentage consumed, respectively (Table 7 ; p  < 0.05). An increase in plate scale score was associated with a 0.24% decrease in FV percentage consumed.

The four CAFES scale scores in fully conditional models accounted for a total of 26% of the school-level variance in FV percentage consumed (Additional file 1 : Table S10). A one percentage point increase in table/display scale score was associated with the largest increase in FV percentage consumed (1.34%), followed by room scale (0.72%), and food scale (0.44%). The strong association between the table/display scale was consistent with prior research findings that availability and accessibility are among the strongest predictors of dietary intake [ 17 , 20 , 23 ].

The negative association between plate scale score and FV percentage consumed (γ = −0.24, p  = .03) was likely attributed to school level differences in FV offerings. Schools with higher plate scale scores -- associated with increased FV servings (Table 6 ) -- tended to offer more FV and allowed students to choose and serve FV themselves. The association between plate scale score and FV consumed, although not significant (γ = 26.81, SE  = 37.22, p  > .05), was positive indicating that students in those schools did consume more FV overall. However, students in those schools did not consume a larger percentage of the FV served when compared to schools with smaller, less sturdy trays and decreased FV offerings and choices given the significant negative association between plate scale score and FV percentage consumed (Table 7 ). Additional research is needed to establish whether the higher amounts of FV served or the plate scale variables contributed to this negative association.

Covariate results revealed that higher percentages of FRPM students at the school level were significantly associated with increases in FV served (Table 6 ; p  < .05), but not consumed. A one percentage point increase in minority student population, however, was associated with a 0.34% reduction in FV percentage consumed (Table 7 ; p  < .05). This result suggested that, although schools with higher participation in FRPM may serve more FV due to stronger wellness policies [ 13 , 56 ], environmental variations captured by CAFES items, food quality, food preferences, role modeling, or nutrition education [ 57 , 58 ] may contribute to lower FV percentages consumed in schools with larger percentages of minority students.

CAFES is the first comprehensive objective, reliable, and validated assessment tool that quantifies physical attributes of elementary school cafeterias linked to selection and consumption of FV. Internal consistency and inter-rater reliability were established across all four CAFES measurement scales, and predictive validity of FV servings and consumption was evaluated. CAFES development and testing addressed five gaps in the literature. First, although several studies have examined school food environments [ 2 ], studies addressing associations between “room scale” cafeteria design elements and eating behaviors are limited. By addressing physical attributes at multiple environmental scales, from individual food item to the design of preparation, serving, and dining areas, CAFES builds upon existing assessments that focus on, for example, nutritional aspects of the food environment [ 59 ]; economics, policy, and sociocultural factors [ 37 ]; and serving, presentation, and display items (e.g., Smarter Lunch Room Scorecards, http://smarterlunchrooms.org/resources ).

Second, the predictive validity of CAFES was assessed using both FV servings and consumption data. Healthy selections are only successful if actually consumed. Environmental factors that affect food selection also differ from those that affect consumption. FV selection is affected by factors such as availability, presentation, and serving method (whether a choice is offered or not). Consumption is a function of not only choice, but also room, table/display, plate, and food scale factors [ 17 ]. Third, CAFES was validated by objective, quantitative FV servings and consumption data gathered via lunch tray photography, rather than self-report or other more subjective measures of children’s dietary intake that are unreliable [ 60 , 61 , 62 ]. CAFES predictive validity estimates, although small and potentially biased from missing data, are likely conservative. Because students in the predictive validity subsamples served and consumed more FV than the overall sample, schools with lower FV servings and consumption that would likely benefit most from CAFES assessment and recommended interventions were excluded from the predictive validity analysis.

Fourth, CAFES focuses on elementary school-aged children. Many food decisions, particularly for young children, occur within cafeterias. Both dietary intake and physical activity patterns established early in life likely influence long-term health [ 7 ]. Research suggests that school-based environmental interventions, such as increasing students’ FV consumption [ 21 , 22 , 23 , 24 ], can affect health behaviors that both reduce FV waste and set students on positive, healthy life-course trajectories [ 63 , 64 ].

Fifth, CAFES focuses on elementary school cafeterias within low-income communities that often cannot implement common intervention suggestions for older children and adults targeting portion size, payment and pricing, or increasing number of meal item choices. Federally-funded meal programs regulate the portion sizes of meal items. FRPM participants who cannot afford to purchase additional items are limited to serving and consuming only the provided FRPM options. Elementary schools also typically have students pay for meals with prepaid accounts monitored by meal cards that debit meal costs in daily cafeteria lines [ 65 ]. Payment and pricing strategies, such as requiring the use of cash to pay for unhealthy items [ 19 ], cannot be used when schools do not accept cash. Furthermore, in schools with 100% of students receiving free meals, cards are used only to record students’ receipt of meals and no money is exchanged. Individual food and beverage item prices are not displayed or relevant to students’ meal selections. Moreover, not all schools offer students meal choices – a factor that affects food decisions [ 66 ] - especially when all students receive a free meal [ 66 ]. These factors render intervention suggestions related to portion size, payment and pricing, and encouraging healthy choices inapplicable to many elementary schools in low-income communities. CAFES scores, however, suggest alternative intervention strategies – many of which are low- or no-cost and can immediately be implemented - aimed at improving healthy eating among elementary school students.

Limitations

CAFES’ limitations related to research design, FV data, and exclusion of moderating factors. CAFES development was based on a sample of elementary schools from four U.S. states with high percentages of FRPM recipients, thus findings may not generalize to other schools or regions. The cross-sectional CAFES sample also precludes causal conclusions. Limited variability among some CAFES items also affected reliability and validity estimates. CAFES also focused on lunch periods. Schools that offer USDA-funded breakfast, fruit and vegetable snack, after-school, and weekend backpack snack programs have opportunities beyond the lunch period to increase FV selection and consumption throughout the school day.

CAFES could benefit from further predictive validity analysis. The use of an objective, validated measure of FV servings and consumption is a strength of CAFES; however, the DFIA method itself – like all measures of diet – is imperfect. Measuring diet, particularly among numerous children, is notoriously difficult to do reliably and validly [ 44 ]. Even the best measures have limitations. Additional predictive validity testing is also needed to assess room and table/display subscales.

Predictive validity analyses also did not address potential school-level moderators of FV selection and consumption behavior. First, the amount of time students have for meals can affect selection and consumption. If students are given whole fruit that must be cut or peeled, for example, they may be less likely to select and consume that item due to the added inconvenience, difficulty, and time required [ 58 ]. Furthermore, long lines and crowded spaces, along with time pressures, can lead students to making unhealthy and impulsive selections [ 13 ]. Second, predictive validity analysis excluded social environment influences. School personnel with proper education and training can serve as role models by establishing and enforcing policies and curricula that support healthy choices [ 67 ]. The nutrition, dieting, and weight control knowledge, values, attitudes, and behaviors of teachers and other school personnel could partially account for the success or failure of healthy eating programs implemented in schools [ 68 ]. Policies and food costs that influence what schools can prepare and offer to students were also excluded from analyses. Exclusion of these moderating factors likely affected predictive validity testing; however, CAFES is intended to supplement, rather than replace, other social, cultural, economic, policy, and nutritional assessments.

Future work

The CAFES’ tool is currently available as a paper-based assessment tool. A mobile application for Android and iOS devices is forthcoming (beta version; see CAFES.crc.nd.edu for updates or contact the corresponding author). Each require 45–90 min to complete. Paper version scoring requires an additional hour, but the mobile application automates data collection, scoring, and generating the list of intervention suggestions. These interventions, based on CAFES scoring and existing literature (e.g., how to arrange and present food to encourage healthy choices), are currently being tested and include low- and no-cost changes school staff can immediately implement.

Future CAFES work can test reducing the number of CAFES items, as well as adding other items such as kitchen, preparation, and serving area square footages and equipment inventory; objective temperature, lighting, and noise items gathered using a thermostat, lux meter, and decibel meter, respectively; and the presence of sound dampening materials to control noise. Work is also needed to establish what minimum CAFES scores are needed to achieve desired FV outcomes, such as a certain percentage increase in overall FV consumption, or to reduce the number of students not meeting USDA recommendations for daily FV intake.

Additional analyses of individual student-level moderators of the physical environment-student eating behavior relation are also needed. Student hunger level, which relates to the time of day lunch is served and whether lunch occurs before or after recess or physical education classes [ 69 ], may moderate FV selection and consumption. Additionally, student’s food perceptions and preferences should be explored. Children often make food choices based on appeal, taste, and convenience [ 70 ]. Although CAFES focused on the physical environment and improving school-level eating behaviors, these individual perceptual factors may moderate the relation between the physical environment and FV servings and consumption.

Implications

CAFES can be used by researchers, design and public health practitioners, and school personnel to identify critical areas where environmental supports are both successful and needed, to prioritize the focus and scope of interventions, and develop low- or no-cost intervention strategies to overcome barriers to and promote healthy eating within school cafeterias. Furthermore, intervention effectiveness can be assessed by using CAFES before and after interventions are implemented. Schools can also use CAFES when developing and implementing a student wellness policy that promotes healthy eating and adequate amounts of physical activity. Since the arrangement of school cafeterias and meal items can affect students’ choices, the unintended consequences of the design and layout are important to consider. Given that school officials and food service staff do influence the types of foods that are served and how they are presented, using CAFES to establish interventions as part of the wellness policy may assist in promotion health eating among students.

School cafeteria design can attract students and encourage healthy eating by becoming efficient and attractive spaces, promoting healthy eating and physical activity, and encouraging students to make healthier choices through interventions at various environmental scales [ 13 , 15 , 18 , 19 , 57 ]. Some schools have hired culinary experts to develop appealing, healthy meals and to transform cafeterias into welcoming, attractive spaces with natural lighting, artwork, and reduced noise to increase student participation in school meal programs [ 3 , 57 ]. CAFES results, however, allow school staff to leverage low- or no-cost strategies, which is especially critical when facing financial constraints. CAFES proved to be a practical, easy-to-use, and inexpensive assessment tool for measuring environmental supports of and barriers to the selection and consumption of FV in elementary school cafeterias. CAFES scores, when accompanied with future intervention suggestions, will be useful in guiding school staff, researchers, nutritionists, designers, and public health policy makers in creating cafeteria environments that facilitate healthy eating. CAFES can also contribute to the development of guidelines for cafeteria design, food layout, food presentation, and other intervention strategies aimed at increasing healthy food consumption among elementary school students.

Abbreviations

Body mass index

Cafeteria Assessment for Elementary Schools

Digital Food Image Analysis

Free-and reduced-price meal

Fruit and vegetable

Healthy Gardens, Healthy Youth

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United States Department of Agriculture

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Acknowledgements

We thank panel experts; participating Cooperative Extension Educators, schools, and students; the Healthy Gardens, Healthy Youth team; Cornell University students Beth Myers, Alex Gensemer, and Meg Demment; and Cornell University and University of Notre Dame undergraduate and graduate student research assistants.

The CAFES study was funded by the Cornell Center for Behavioral Economics in Child Nutrition Program; the Department of Design and Environmental Analysis, Cornell University; United Way of St. Joseph County, Indiana; and the University of Notre Dame School of Architecture. Partial support was also provided by Cornell University’s Bronfenbrenner Center for Translational Research (BCTR); Cornell’s Atkinson Center for a Sustainable Future (ACSF); the U.S. Department of Agriculture (USDA) through the Food & Nutrition Service (FNS) People’s Garden pilot program (Project #CN-CGP-11-0047); the Cornell University Agricultural Experiment Station (Hatch funds) (#NYC-327-465) and Cornell Cooperative Extension (Smith Lever funds) through the National Institutes for Food and Agriculture (NIFA) USDA; the College of Human Ecology, Cornell University; and the Cornell Cooperative Extension Summer Intern Program. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

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Contributions

KR conceptualized the project idea and research design in consultation with NW. KR executed primary data collection, reliability and validation analyses, and development and refinement of the CAFES tool. NW facilitated connections to panel experts and elementary school data collection sites, and provided de-identified student-level data. KR drafted the manuscript and both KR and NW edited, read, and approved the final manuscript.

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Correspondence to Kimberly A. Rollings .

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The Cornell University and University of Notre Dame Institutional Review Boards (IRB) reviewed the CAFES study and determined that it was exempt from IRB regulations known as the Common Rule, found at 45 CFR 46. The exempt research was fully reviewed by the IRB to ensure that it qualified for exemption and followed ethical principles, but procedures found in the Common Rule, including informed consent, were not required. CAFES development and reliability testing data were collected via observation of public school cafeteria spaces and lunch trays. No primary data were collected from elementary school students, and all schools gave permission to participate in the study. The student-level demographic data used in the testing of CAFES were secondary and de-identified. The nature and use of that secondary data involved minimal risk.

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Additional files

Additional file 1:.

Additional CAFES data tables. This file contains additional data tables related to CAFES development, reliability testing, and predictive validity analyses. Table S1. Pearson Inter-Item Correlations Among CAFES Total and Four Scale Scores. Table S2. Pearson Inter-Item Correlations Among CAFES Room Scale and Subscale Scores. Table S3. Pearson Inter-Item Correlations Among CAFES Table/Display Scale and Subscale Scores. Table S4. CAFES Predictive Validity Subsamples: School and Student Level Socio-Demographics. Table S5a. CAFES Students’ Fruit and Vegetable (FV) Servings and Percentage Consumed. Table S5b. Predictive Validity Subsample-CAFES Total: Student FV servings and Percentage Consumed. Table S5c. Predictive Validity Subsample-Four CAFES Scales: Student FV Servings and Percentage Consumed. Table S6a. Predictive Validity-CAFES Total Score: Fully Unconditional Model. Table S6b. Predictive validity-CAFES Total Score: Partially Conditional Model. Tables S7a-b. Predictive Validity-Four CAFES Scale Scores: Fully Unconditional Models. Tables S8a-b. Predictive Validity-Four CAFES Scale Scores: Partially Conditional Models. Table S9. Variance Accounted for by CAFES Total Score Models. Table S10. Variance Accounted for by Models with Four CAFES Scale Scores. (DOCX 101 kb)

Additional file 2:

CAFES paper form. This file contains the paper version of the CAFES tool. (PDF 1586 kb)

Additional file 3:

CAFES scoring spreadsheet. This spreadsheet file contains three worksheets. The first is the manual scoring entry spreadsheet for CAFES items. The second worksheet displays the resulting CAFES scores. The third worksheet provides a description of the CAFES scales and subscales. (XLSX 1508 kb)

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Rollings, K.A., Wells, N.M. Cafeteria assessment for elementary schools (CAFES): development, reliability testing, and predictive validity analysis. BMC Public Health 18 , 1154 (2018). https://doi.org/10.1186/s12889-018-6032-2

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Students aren't eating healthy school lunches, despite availability; how cafeterias fail to improve student health.

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Getting fresh fruits and vegetables onto lunch trays in public schools was only half the battle, because it turns out most kids still aren’t eating them. Researchers from Johns Hopkins Bloomberg School of Public Health, studied students’ eating habits and found nearly six out of 10 won’t even touch a healthy food option on their plate.

"We have been thinking that if young children choose healthy food, they will eat it," said the study’s co-author Dr. Susan M. Gross, a research associate at the Johns Hopkins Bloomberg School of Public Health, in a press release . "But our research shows that is not necessarily so." Gross will present her team's findings at the American Public Health Association’s annual meeting on Monday.

Researchers watched 274 kids in kindergarten, and first and second grade, in 10 different New York City public school cafeterias, and noted their food selection and eating habits. They waited to see how many 6- to 8-year-olds would choose a fruit, vegetable, whole grain, low-fat milk, and lean protein to place on their tray. Researchers took photos of each tray, which revealed all of them took a milk and whole grain, 75 percent of the kids chose a protein, 59 percent chose a vegetable, and 58 percent chose a fruit. But did they eat it?

Not really. Only 75 percent of the kids took at least a bite of their protein and 24 percent ate one bite of their vegetables. You’d think it’s the food’s palatability that’s to blame here, but the taste is not the problem as much as the environment. Researchers say the cafeteria plays a large role in whether a child eats his food or not, which comes right back down to mindless eating tricks. The noise level, supervision; how many kids were in the cafeteria that day; the length of their lunch period; and the way the food is packaged, all determined how much a child ate off from their plate.

The students were much more likely to finish all of their food if a teacher ate with them in the cafeteria, as well as when their food was cut up into smaller bites. When it was quieter the kids ate more vegetables and whole grains, and when the lunch period was longer, they ate more of their total food in general.

"As much as we are focused on menus in the school lunch program, we need to look more at our cafeteria environments, especially with our youngest children," Gross said. "We can give kids the healthiest food possible, but if they don't have time to eat it or they are distracted by how noisy the cafeteria is, they're not going to eat it. They're on their own and we need to do as much as possible to help them through that lunch period."

The selection of food is significantly better than it used to be in school cafeterias, so parents can’t hate the school for trying. It’s become a trial-and-error run for administrators and legislative initiatives to get kids eating healthier, which could ultimately decrease rates of childhood obesity.

Just a few years ago, schools would loopholes through the United States Department of Agriculture's regulations. For example, a small container of fries counted as a vegetable. Yes, they’re made out of a potato but they’re a starch that’s been fried . The fruit requirement could also be fulfilled by providing a small cup of fruit juice, which meant kids were missing out on important fiber intake. At the time, more than 90 percent of the food brought into a school cafeteria was frozen, including pizza, which counted as two servings of whole grain. The rates have dropped, but a child’s appetite for school lunches are still not where they should be, according to these new findings.

Congress is currently preparing to overhaul the Child Nutrition Act for 2015. The Act funds the National School Lunch Program and National School Breakfast Program, programs that weren’t originally welcomed by many people because mass production of healthier foods can become costly — it also requires different standards for storage, depending on the type of food. Fresh fruit, for example, goes bad quicker than chunks of fruit suspended in high fructose gelatin. It's also easier to accomodate a basket a bunch of plastic containers in storage than a basket of apples or bananas.

Source: Gross SM, Zucker A, Biehl E, et al. Does selection of foods in the school cafeteria by 6-8 year olds translate into consumption? Results of a cafeteria observation study. The American Public Health Association’s Annual Meeting. 2014.

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The cafeteria diet: A standardized protocol and its effects on behavior

Affiliations.

• 1 Department of Psychology, UiT The Arctic University of Norway, Tromsø, Norway. Electronic address: [email protected].
• 2 Department of Psychology, UiT The Arctic University of Norway, Tromsø, Norway; Regional Health Authority of North Norway, Norway. Electronic address: [email protected].
• PMID: 33309818
• DOI: 10.1016/j.neubiorev.2020.11.003

Obesity is a major health risk, with junk food consumption playing a central role in weight gain, because of its high palatability and high-energy nutrients. The Cafeteria (CAF) diet model for animal experiments consists of the same tasty but unhealthy food products that people eat (e.g. hot dogs and muffins), and considers variety, novelty and secondary food features, such as smell and texture. This model, therefore, mimics human eating patterns better than other models. In this paper, we systematically review studies that have used a CAF diet in behavioral experiments and propose a standardized CAF diet protocol. The proposed diet is ad libitum and voluntary; combines different textures, nutrients and tastes, including salty and sweet products; and it is rotated and varied. Our summary of the behavioral effects of CAF diet show that it alters meal patterns, reduces the hedonic value of other rewards, and tends to reduce stress and spatial memory. So far, no clear effects of CAF diet were found on locomotor activity, impulsivity, coping and social behavior.

Keywords: Animal model; Cafeteria diet; Food preference; Junk food; Memory; Obesity; Reward system; Stress; Systematic review; Western diet.

Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.

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Students’ Satisfaction with the University Cafeteria: Structural Relationships of Food Quality, Staff, Price Fairness, and Ambiance

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• Mui Ling Dyana Chang 4 ,
• Norazah Mohd Suki 5 &
• Norbayah Mohd Suki 6  

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This study aims to investigate the relationship between the food quality, price fairness, staff, and ambiance of the university cafeteria with students’ satisfaction. To test the conceptual model and test the proposed hypotheses, a quantitative survey was performed via a structured self-administered questionnaire among 78 undergraduates from Universiti Teknologi MARA (UiTM), Sabah campus, Malaysia, utilizing convenience sampling method. Data was analyzed using structural equation modeling (SEM) technique via AMOS 21.0 computer program with maximum likelihood estimation. The empirical results provided strong support that students’ satisfaction with the university cafeteria is very much influenced by food quality, followed by staff and ambiance, respectively. Implications of the study from managerial and theoretical perspectives together with directions for future research are also discussed. The findings of this study may help the university cafeteria to improve service quality and raise students’ satisfaction.

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Chang, M.L.D., Suki, N.M., Suki, N.M. (2015). Students’ Satisfaction with the University Cafeteria: Structural Relationships of Food Quality, Staff, Price Fairness, and Ambiance. In: Omar, R., Bahrom, H., de Mello, G. (eds) Islamic perspectives relating to business, arts, culture and communication. Springer, Singapore. https://doi.org/10.1007/978-981-287-429-0_35

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Cafe Politics: How Food Service Operators Influence University Students’ Satisfaction and Dining Frequency

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The study delves into the intricate relationship between cafe operations and politics and how it influences the overall dining experience of university students. This research aims to explore the influence of cafe operations on the satisfaction and behaviour of university students and its effect on their dining frequency. The data were gathered through a survey of 201 students, employing a convenient sampling technique. The results suggest that the quality of food, ambience, value for money, food and beverage options, and service quality significantly impact students' overall satisfaction with the campus meal service operation and their dining frequency. These findings emphasize the importance of food service operators focusing on food quality, ambience, value for money, food and beverage options, and service quality to attain student satisfaction. These factors could positively impact the university's reputation, student retention, and marketability to potential students. This study is significant for university food service operators as it provides valuable insights into the various elements of the food service experience that influence student satisfaction and dining frequency. This research contributes to the existing literature by filling the gap in knowledge regarding the impact of cafe operations on student behaviour and satisfaction. Moreover, this study provides a robust framework for future research. Ultimately, this research aims to enhance university students' dining experience, thereby improving their overall academic performance and well-being.

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Cafeteria culture: an anthropological approach to lunchtime in a central florida elementary school.

Emily Herrington , University of Central Florida

Public school cafeterias are used by nearly 51 million children (ages 4-17) in the United States every day. With over 40% of the approximately 73 million children (ages 0-17) participating in the National School Lunch Program (NSLP), public school lunches carry resounding nutritional, social, and educational significance for their consumers. This fact, coupled with frequent media attention to school lunch food, notwithstanding, a notable lack of social scientific engagement with both students' perspectives and NSLP operators persists. Divided into two studies, this research utilizes ethnographic methods to explore students' lunchtime experiences within a Central Florida public elementary school cafeteria. Both works are grounded in information collected from 22 semi-structured and unstructured interviews with students, parents, cafeteria workers, school faculty, and a county official while also participating in a one-month lunchtime observation period in Spring 2017. The first study utilizes ethnographic methods to investigate students' food selection, social practices, and mealtime behaviors within the cafeteria. In this work, I argue that student's preferences are most often informed by taste and familiarity, though both age and personal belief systems strongly outline students' experiences. In the second study, I focus on the top-down priorities of nutrition, food production, and student feedback that guide how institutions construct lunch menus for elementary students. Specifically, I investigate what role public institutions play in forming elementary school students' understandings of food and expectations for mealtimes. Synthesizing findings from both studies, I assess how social, economic, and industry pressures are tangible within local cafeteria and governmental contexts. This research contributes to academic scholarship and public policy regarding childhood nutrition in institutionalized settings and advocates for the inclusion of elementary-aged children as important social actors in their call for increased and dietarily-inclusive food options.

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Almost two-thirds of baby foods sold in U.S. grocery stores are unhealthy, a new study has found.

The research was conducted by The George Institute for Global Health and published in the scientific journal Nutrients.

The study found that 60% of infant and toddler foods in U.S. supermarkets do not meet nutritional requirements nor promotional requirements defined by the World Health Organization.

To conduct the study, researchers evaluated over 650 baby and toddler food products sold at 10 popular U.S. grocery stores.

The findings uncovered that 70% of the products failed to meet protein requirements, and 44% surpassed total sugar requirements.

The research showed 1 in 4 products did not meet calorie requirements, and 1 in 5 had higher-than-recommended sodium levels.

Dr. Elizabeth Dunford, research fellow at The George Institute, said she was concerned about the rising popularity of these processed baby foods due to convenience.

“Early childhood is a crucial period of rapid growth and when taste preferences and dietary habits form, potentially paving the way for the development of chronic diseases such as obesity, diabetes and some cancers later in life,” Dunford said in a press release.

“Time-poor parents are increasingly choosing convenience foods, unaware that many of these products lack key nutrients needed for their child’s development, and tricked into believing they are healthier than they really are.”

RELATED STORY | Lawmakers introduce bill to limit heavy metals in baby food

The fastest growing infant and baby food products are food pouches. The sector has seen a 900% increase in the proportion of sales from pouches in the last 13 years, the research said. But these pouches are among the most unhealthy products evaluated in the study.

Less than 7% of the studied food pouches met total sugar recommendations, the research showed.

The study also pointed out failures in marketing.

More than 99% of products studied had at least one prohibited claim on their packaging. On average, products featured about four prohibited claims on their packaging, saying the foods were “non genetically modified” had “no artificial colors/flavors,” or were “organic," for example.

Dr. Daisy Coyle, a research fellow and dietitian at The George Institute, said the claims are likely to deceive busy parents.

“We saw this not only in the use of misleading claims but also in the use of misleading names, where the product name did not reflect the main ingredients found on the ingredient list,” Coyle said.

“For example, snack and finger foods often referred to fruit or vegetables in the product name, despite primarily being made of flour or other starches,” she continued.

This comes as obesity in children has more than doubled in the U.S. since the 1970s, according to the Centers for Disease Control and Prevention.

RELATED STORY | Chemical used in rocket fuel, missiles found in various foods, including baby products, report finds

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• v.3(4); Winter 2009

Comparison of student's satisfaction on school food service environment by the eating place and gender

Jisook jung.

1 Department of Food and Nutrition, Kyungwon University, Bokjeong-dong, Sujeong-gu, Seongnam, Gyeonggi 461-701, Korea.

Youngmee Lee

2 Nutritional Education Program, National Institute of Health and Nutrition, Shinjuku-ku Tokyo,162-8636, Japan.

The purpose of this study was to compare student's satisfaction with school food service environment to improve the quality of middle school meal service. A survey was conducted of 680 students (boys 246, girls 433) from 6 middle schools providing school meals from October to November 2007. The questionnaires were directly distributed to the subjects for comparison of satisfaction of school meals depending on the eating place. As for the quantity of food, classroom group (3.40) expressed significantly higher satisfaction than cafeteria group (3.16, P < 0.01), but as for the satisfaction on hygiene, classroom group (2.76) showed significantly lower satisfaction than cafeteria group (3.03, P < 0.01). About the satisfaction of school meal environment, classroom group showed more satisfaction on distribution time, eating place, eating atmosphere ( P < 0.001). The classroom group showed higher satisfaction than cafeteria group in cases of quantity, diversity of types of soup, dessert, and the cost of school meal. To improve eating place and hygiene of school meal, sufficient cafeteria space and pleasant environment is needed to be established.

Introduction

Adolescents need a balanced nutrition intake because their physical development and activity are dramatically increasing ( Kim, 2002 ). They prefer more tasty and trendy food, so they eat a lot of fast food and instant snacks, which is affected by food commercials and convenience ( The Food and Drug Association, 2007 ). As a result of that, there are a lot of health problems caused from much intake of sugar, salt, fat, etc ( Chung & Han, 2000 ). Therefore, in early 1997, the school meal program started to operate in all the primary schools, and expanded to high schools in 1999 and middle schools in 2002 ( The Ministry of Education, 1999 ) to improve their body strength and dietary life by providing a healthy well-balanced lunch ( Lee, 2003 ). Thanks to the school meal policy, the school meal service increased nationwide but there are many problems related to facility costs, securing financial resources and utilizing human resources in middle and high schools rather than in primary schools because of insufficient financial support ( Kim & Lee, 2003 ; Lee et al., 2002 ).

The Ministry of Education and Human Resources Department comes up with "comprehensive school meal improvement measures (2007~2011)" as a means of substantiating the school meal operation and making school meal facilities better. It is aimed at modernizing the school meal facilities, increasing the rate of installing air cooling system and reducing the number of schools which don't have their own cafeterias. Particularly, it plans to reduce the rate of schools without their own cafeterias from 23.7% in 2006 to 20% in 2011. The rate of providing school meal service in urban areas is lower than rural area with only 51.5% ( The Ministry of Education, 2007 ). Currently, schools without their own cafeterias are providing school meals in the classrooms, which have problems with a high risk of safety accidents in the process of moving the meals, improper meal temperature, unclean status of meal provision and providing uneven meal quantity to students ( Kim & Lee, 2004 ). However, even if there is a cafeteria in a school, the space is small, waiting time for meals is prolonged making students unsatisfied ( Lee, 2005 ). There are single-sex schools in Korea, and boys and girls might have different needs and satisfaction for the school meals. The satisfaction of school meals is related to improving the effects of school meals ( Kim & Lee, 2003 ), so we need to improve the school meal services to enhance the students' nutrition status and health ( Kim, 2005 ).

Satisfaction of school meals varies depending on the quality of meals, diversity of food, food hygiene and environment ( Kim et al., 2003 ), but the eating place of school meals is different from cafeterias to classrooms and gender of meal eater is different. Service is the most important factor to improve the satisfaction on school meals. We need to examine the satisfaction on school meals by eating place and gender to improve the satisfaction of school meal. However, there was little research done on the comparison of satisfaction between eating places (cafeterias and classrooms) and gender (boy and girl) in school meals. We surveyed the satisfaction on school meals among middle school students in different eating places and gender; therefore, this study can provide basic data to improve the quality of school food service.

Subjects and Methods

The survey was conducted with 680 first to third grade students (boys 246, girls 433) in the 6 middle schools (Seongnam city in Gyeongki province) from October to November 2007 They were surveyed after listening to the purpose and outline of the survey. The questionnaires were directly distributed to the students and retrieved immediately after completion, and students filled them by reading directions on their own.

The questionnaire consisted of the subject's gender, eating place, school type and satisfaction of meal service. It was about school meals such as the place of getting school meals, a desired place to get school meals, satisfaction on a school meal environment (satisfaction over the eating place, atmosphere, the extent of disturbing of food and taking classes, etc), and satisfaction on the food in the meals (food temperature, the quantity of boiled rice and soup, diversity of types of soup, menu, the price of meals, food hygiene, etc). The questionnaires used 5 point Likert type scale (5: very much agree~1: totally disagreed) for satisfaction on the environment of eating place and satisfaction on food of school meals.

Statistical Analysis

Statistical tests were performed using SPSS (ver.12.0) for Windows to analyze the data. Frequency and percentage was assessed for each item, and satisfaction on the environment of eating place of school meals and satisfaction on food of school meal service were compared using t-test by calculating standard deviation and average for each group of measured values by 5 point Likert style scales.

Eating place of school meal and type of school

The eating place of school meal and type of school are presented in < Table 1 >. Among 680 participants, 434 participants were in middle schools (119 students in boys' school, 315 in girls' school) and 246 were in coed schools. Eating place was 412 in classrooms and 267 in cafeterias.

Comparison of satisfaction depending on the eating places

1) satisfaction with the meal service environment by eating place.

The results of satisfaction of meal service environment depending on the eating places (cafeteria, classroom) are as shown in < Table 2 >. Satisfaction on the eating places (cafeteria 3.67 and classroom 3.02), atmosphere (cafeteria 3.41 and classroom 3.00) and satisfaction on the time of distributing meals (cafeteria 3.36 and classroom 2.58) presented that the students who eat school meals in their classrooms have significantly higher satisfaction than those in cafeterias ( P < 0.001). As for the cleanliness of eating environment, there was no significant difference between the two groups. As the easiness of plate arrangement, cafeteria group (2.40) showed significantly higher than classroom group (2.24) ( P < 0.05,). As for the opportunity to express dissatisfaction over school food, classroom group (2.34) had better satisfaction than cafeteria group (2.16) with significantly different ( P < 0.05).

Satisfaction on the food service environment by eating place

1) 5 Likert scale (5:very satisfied-1:very dissatisfied)

2) Mean ± S.D

* P < 0.05, ** P < 0.01, *** P < 0.001, NS : not significant

2) Satisfaction of food in school meal by the eating place

The results of satisfaction of food in school meal depending on the eating place are shown in < Table 3 >. As for the food temperature, there is no significant difference between cafeteria (3.51) and classroom (3.48). As for the quantity of food, classroom group (3.40) showed significantly higher satisfaction than cafeteria group (3.16, P < 0.01), but classroom group (2.76) showed significantly lower satisfaction than cafeteria group (3.03, P < 0.01) in hygiene. As for satisfaction on others such as balance of nutritional composition of meal, salinity, diversity of food, taste of food and harmony of food color, classroom group showed higher than cafeteria group but the difference was not significantly different. As for satisfaction on diversity of soup, the cost of meal, frequency of getting dessert, classroom group showed higher satisfaction but the difference was not significantly different.

Satisfaction on the meal by eating place

Comparison of satisfaction on the meal service environment depending on gender

The results of satisfaction of meal service environment depending on gender difference are shown in < Table 4 >. As for sanitation and atmosphere of eating place, the boy group showed less satisfaction than the girl group but there was no significant difference. As for distribution time (boy 2.80, girl 3.19; P < 0.001), easiness of plate arrangement (boy 2.87, girl 2.98; P < 0.05), comfortable for after lunch class (boy 2.51, girl 2.33; P < 0.05) and opportunity to express dissatisfaction on school meal (boy 2.15, girl 2.35; P < 0.05), girl group showed significantly higher satisfaction than boy group.

Satisfaction on the food service environment by gendera

Comparison of satisfaction on the food of school meal

Comparison of satisfaction over the between genders is presented in < Table 5 >. The results of satisfaction of food in school meal depending on gender differences are shown in < Table 3 >. As for the food temperature, boy group (3.69) showed significantly higher satisfaction than girl group (3.37, P < 0.001). As for the quantity of school meal, the girl group (3.37) showed significantly higher satisfaction than the boy group (3.19) ( P < 0.05). However, the boy group expressed significantly higher satisfaction than the girl group on other factors such as nutrition (boy 3.36, girl 3.16; P < 0.01), salinity (boy 3.22, girl 3.03; P < 0.01), diversity of side dishes (boy 3.21, girl 3.03; P < 0.05), tasty (boy 3.17, girl 2.92; P < 0.01), satisfaction over menu (male students 3.07, female students 2.90; P < 0.05) and sanitary (boy 3.06, girl 2.76; P < 0.001). Therefore, in general, the boy group is more satisfied with overall school meal status than the girl group.

Satisfaction on the meal by gender

* P < 0.05, †* P < 0.01, *** P < 0.001, NS : not significant

This study was carried out to improve students' satisfaction for school meal service. We surveyed the satisfaction on school meals among middle school students in different eating places and gender. To eat meals in classrooms, it needs to be conducted by transferring meals in large distribution server with student meal servers by dumbwaiter to the classroom. Then, students in charge or helpers distribute the meals to each student ( Chyun et al., 1999 ). On the other hand, eating school meals in the cafeteria, students take food as they want and meal helpers distribute food in the designated area, which makes the school food distributed with warmth and cleaniness, managed with hygiene. Also, students can have their meals in a pleasant and hygienic place. However, school cafeterias take a lot of space, and small space provokes dissatisfaction on prolonged distribution time ( Lee, 2005 ). Since there are benefits and defects in both distribution methods, we need to examine student's preference in eating place and satisfaction of school meal service, so we can improve meal distribution methods and efficiency depending on the characteristics of each school.

A comparison of satisfaction on school meal environment presented those students who eat school meals in their classroom showed more satisfaction on meal distribution time, eating place, eating atmosphere ( P < 0.001). As for satisfaction on food of school meals, classroom group showed higher satisfaction than cafeteria group (in quantity, diversity of types of soup, the cost of school meal, dessert). As for hygiene, cafeteria group has higher satisfaction than that of classroom, but waiting time for meal distribution, classroom group has higher satisfaction than that of classroom because students prefer to have meals at their seats due to convenience ( An, 2008 ), and eating meal in classroom has faster service than cafeteria distribution ( Lee & Lyu, 2005 ). In this study, the reason that cafeteria group showed more dissatisfaction on meal plate arrangement and disruption to studying after having meal than class room distribution group ( P < 0.05) is considered that cafeteria distribution takes more meal distribution time than that of classroom and requires plate management without help. In case of hygiene, the cafeteria group showed higher satisfaction than the classroom distribution group because kitchen employees distribute meals in the cafeteria, so the management of school meals is convenient and hygienic. The classroom group showed significantly greater satisfaction than cafeteria group ( P < 0.05) because meal distribution in the cafeteria is usually self-controlled by students. Particularly, in the research about the students' preferred eating place ( Lee & Jang, 2005 ), students preferred to eat meals in cafeteria due to inconvenience of transferring meal plates and unsanitary environment of classroom, but at the same time they preferred classroom distribution due to the long waiting time for meal distribution and inconvenience of going to the cafeteria. Therefore, it needs to try various methods to reduce waiting time such as differentiating meal time in each grade and installing many distributing counters.

Comparison over school meal satisfaction between gender showed that boys were satisfied with overall food of school meal, but they thought the meal time was not proper ( P < 0.001) and the school meal disrupted the 5 th period class study after lunch ( P < 0.05). On the other hand, girls were dissatisfied over meal temperature ( P < 0.001) and hygiene ( P < 0.05). Therefore, the differentiating school meal service depending on gender is recommended. In boy's school, it should be considered to reduce waiting time such as installing many distributing counters. In girl's school, it should be considered to manage hygienic factors and maintain warmth or coolness of food such as equipping with containers for maintaining temperature of food and reducing interval time between cooking and distribution. Though conversion of eating place from classroom to cafeteria is very much in need, there is some difficulty toward it. Therefore, schools that do not have a cafeteria for eating meals should secure safe distributing cart to maintain proper food temperature, and conduct student education for proper self-distribution.

As the results of this research, there were differences of satisfaction on school meal service by eating places and gender. The satisfaction on school meals is related to improving the effects of school meal ( Kim & Lee, 2003 ), so we should serve the school meal in different methods by different in eating place and single sex-schools. To get more information about meal satisfaction in school service, a further research need for the preference menu by eating place and gender.

This research was supported by the Kyungwon University Research Fund in 2009.

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Recent applications of near-infrared spectroscopy in food quality analysis.

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