Despite the importance of fruits and vegetables (FVs) as essential components of a healthy diet, most children do not consume the recommended number of servings of these foods. School meals account for a significant portion of children's overall dietary intake. Changing the school environment is a cost-efficient and effective method for improving dietary intake and can significantly impact the pernicious problem of pediatric obesity. The 2010 Healthy Hunger-Free Kids Act (HHFKA) mandated enhanced focus on FVs in the National School Lunch Program (NSLP), and specifically requires children to take a fruit and/or vegetable at meals (the ?serve? model). However, there are significant concerns over increased FV plate waste under this mandate. Simultaneously, there is great national support for school salad bars as a means to increase FV intake within the NSLP. Salad bars might be a particularly effective approach within the ?serve? model, as they foster choice, which is linked to increased FV consumption in children. However, little empirical research has investigated the impact of salad bars on FV intake in schools. Further, although FV consumption can facilitate healthy weight management if these foods replace items high in calories, there is a great need to better understand how increasing FV intake, and salad bars, relates to children's diet quality and energy intake at lunch within the NSLP. This is particularly important to investigate in low income and racial/ethnic minority children, who face disproportionate obesity risks and are most likely to be impacted by school obesity policies, such as the HHFKA, given their reliance on school meals. This time-sensitive application will use validated methods, informed by our extensive formative work, to conduct a comprehensive evaluation of salad bars in a northern Virginia school district. This district is installing salad bars into 141 elementary schools over 5-years, facilitating the conduct of a waitlist control, cluster randomized controlled trial. Specifically, 12 pairs of matched schools will be randomly selected: half receiving a salad bar (Intervention) and half serving pre-portioned FVs only, standard under the NSLP (Control). Thus groups will have different FV presentation methods; however all schools will be operating under a policy requiring students to take at least one FV serving. Schools will be matched on Title I status (a proxy for socioeconomic status) and percent of racial/ethnic minority students based on higher obesity risk. Dietary intake will be objectively assessed at lunch in each pair of schools, prior to (baseline), and 4-6 weeks after salad bars are installed (post), resulting in ~14,160 lunch observations throughout the study duration. We will also obtain cafeteria sales and NSLP participation data to examine how salad bars impact these critical revenue sources. Finally, we will assess implementation factors and cafeteria personnel's perspectives, to identify barriers and facilitators to salad bars and inform sustainability efforts. No prior RCTs have prospectively examined the effects of salad bars on FV and energy intake. As such, this study has great potential to inform school nutrition policies and programs designed to enhance dietary intake and reduce obesity.

Public Health Relevance

Despite their potential to improve dietary intake in children within the National School Lunch Program (NSLP), the practice of installing salad bars in schools has advanced well ahead of the evidence. This research conducts a large-scale investigation, comparing 12 schools with salad bars with 12 schools serving pre-portioned fruits and vegetables only on: 1) fruit, vegetable, and energy intake; 2) plate waste; and 3) NSLP participation. This study has significant potential to inform school nutrition policies and programming designed to enhance dietary intake and reduce obesity in millions of children who participate in the NSLP.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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Special Emphasis Panel (ZDK1)
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Esposito, Layla E
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Virginia Commonwealth University
Schools of Medicine
United States
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