Date of Award
Doctor of Philosophy
Jean D. Skinner
Betty Ruth Carruth, Dileep S Sachan, Sandra Twardosz
Objectives The primary purpose of this intervention study was to increase the calcium intake of children in selected South Carolina middle schools. A secondary purpose was to describe the relationship between South Carolina middle school children’s perceived satisfaction with their school foodservice pre- and post-intervention. Sub-objectives were to determine if satisfaction was related to students’ perception of having a choice in school lunch participation and to identify the foodservice-related factors that predicted satisfaction. Strengths and weaknesses of the methodology used in the study were evaluated. A third purpose was to understand the school eating environment in middle schools by determining foods and beverages available to children during the lunch period. Design A pretest/posttest randomized intervention/control group design was implemented. Schools were selected based on enrollment and current participation in the school breakfast program from a larger pool of 163 middle schools in South Carolina. The assessment of the availability of foods and beverages in each school was an observational study conducted only once. Subjects/setting Ten intervention and 10 control schools participated. Students from selected classes in grades 6-8 completed pre- (n=1034) and post- (n=1049) 24-hour food recalls and school foodservice satisfaction surveys (SFSS), pre- (n=980) and post- (n=836). Intervention Teachers, foodservice managers, and district directors in the intervention schools were provided in-service training about the study goals, information about the importance of calcium intake in middle school children, and possible strategies to increase children’s calcium intake. Teachers also received supplemental materials that focused on increasing calcium intake for children in grades 6-8. Control schools did not receive training or supplemental materials about calcium. Main outcome measures Based on pre-and post-intervention 24-hour food recalls changes, calcium intakes were determined for intervention vs. control groups. Calcium intakes were determined for breakfast vs. no breakfast consumption groups. Changes in satisfaction with school foodservices were assessed by the SFSS pre- and post- the intervention. SFSS scores of students who perceived they had a choice in eating school meals were compared to those who perceived they did not have a choice. Factors relating to students overall satisfaction with school foodservice were determined. Strengths and weaknesses of the research were identified. Foods and beverages available for sale during lunch periods in vending machines, school canteens, and school cafeterias were identified. Statistical analyses performed Statistical analyses included group means of calcium intakes (mg/day), univariate analysis of variance (UNIANOVA), chi-square tests, Tukey HSD, and Pearson correlations. Scoring of the SFSS was based on a 7 point hedonic scale with 1 = lowers and 7 = highest. General linear models (GLM) were used to test differences pre/post intervention changes in SFSS scores for intervention vs. control students. Posttest SFSS scores of the choice vs. no choice groups were tested with GLM. A stepwise regression of analysis of students’ responses to the SFSS questions was performed to identify variables that contributed significantly to overall satisfaction with school foodservice. The mean scores of foods and beverages other than school lunches available to students during lunch periods were counted. Results The intervention was not successful in improving children’s dietary intake of calcium nor in increasing children’s satisfaction with their school’s foodservice program. Pretest/posttest changes in calcium intake and foodservice satisfaction were not significant and did not differ between intervention and control schools. The posttest calcium intake means were 719 mg and 666 mg in intervention and control groups respectively. These intakes are considerably below the recommended Adequate Intake (AI) of 1300 mg/day. Males consumed significantly more calcium than females (p<0.001), and this difference persisted after controlling for males’ greater energy intakes (p<0.01). However, males’ mean calcium intake was only 64.1% and females/ intake 47.5% of the AI. Students who ate breakfast had significantly higher mean intakes of calcium than students who had no breakfast [789 mg. vs. 487 mg calcium, (p<0.05)], but still > 500 mg. less than the AI. Students who perceived they had a choice had significantly higher scores on overall foodservice satisfaction (p<0.05) and on the 5 satisfaction factors than did the no choice group. Seven of the SFSS questions measured over 53% of the variance in overall foodservice satisfaction (p<0.001), among the students who felt they had a choice. Strengths of the study included the randomized pretest/posttest intervention/control group design, successful recruitment of schools, and data collection and analyses. Weaknesses in the study included student recruitment issues related to return of parental permission forms, lack of a formal process evaluation of the classroom intervention or the cafeteria component, no pilot testing of intervention materials with South Carolina students, and a compressed timeline due to initiating study during the last 4 months of the school year resulting in a short duration for the intervention. The mean number of food and beverage items available in addition to school lunches was 21.7 with a range of 0-62 item in the 20 schools. Applications/conclusions While the intervention was not successful in changing patterns of calcium intake, intakes below recommendations confirmed the need for an effective calcium intervention. Because 28% of these middle school students skipped breakfast and breakfast consumption was positively related to calcium intake, strategies for increasing breakfast consumption at school should be explored. Addressing the low calcium intakes of middle school children through a supportive school environment and policy changes should be a priority. Extensive choices of foods and beverages of low nutritional value were available to South Carolina middle school children during lunch periods. School districts should consider adopting policies and standards for all food and beverages available in schools during lunch periods. Students’ satisfaction with school foodservice was related to food quality, including availability of choices and foods liked by students as well as appearance of the food. Smiling and greeting students by foodservice staff was also an important factor in students’ satisfaction with school foodservice. Staff my play an important role in providing food choices that appeal to middle school students and ensure the school meal programs provide adolescents the nutrients they need. Conducting research in middle schools is feasible. However, adequate planning is essential, and careful monitoring of interventions at the individual student, classroom, cafeteria, and school level is important.
Pilant, Vivian Bowie, "Factors Influencing Calcium Intake and Foodservice Satisfaction in South Carolina Middle School Children. " PhD diss., University of Tennessee, 2004.