Svisco E, Byker Shanks C, Ahmed S, Bark K.

Variation of Adolescent Snack Food Choices and

Abstract

Food processing is used for transforming whole food ingredients into food commodities or edible
products. The level of food processing occurs along a continuum from unprocessed to minimally
processed, processed, and ultra-processed. Unprocessed foods use little to no processing and have zero
additives. Minimally processed foods use finite processing techniques, including drying, freezing, etc., to
make whole food ingredients more edible. Processed foods combine culinary ingredients with whole
foods using processing and preservation techniques. Ultra-processed foods are manufactured using
limited whole food ingredients and a large number of additives. Ultra-processed snack foods are
increasing in food environments globally with detrimental implications for human health. This research
characterizes the choices, consumption, and taste preferences of adolescents who were offered apple
snack food items that varied along a processing level continuum (unprocessed, minimally processed,
processed, and ultra-processed). A cross-sectional study was implemented in four elementary school
classrooms utilizing a buffet of apple snack food items from the aforementioned four food processing
categories. A survey was administered to measure students’ taste acceptance of the snacks. The study
found that the students selected significantly (p < 0.0001) greater quantities of ultra-processed snack
foods (M = 2.20 servings, SD = 1.23) compared to minimally processed (M = 0.56 servings, SD = 0.43) and
unprocessed (M = 0.70 servings, SD = 0.37) snack foods. The students enjoyed the taste of ultra-
processed snack foods (M = 2.72, SD = 0.66) significantly more (p < 0.0001) than minimally processed (M
= 1.92, SD = 1.0) and unprocessed (M = 2.32, SD = 0.9) snack foods. A linear relationship was found
between the selection and consumption quantities for each snack food item (R2 = 0.88). In conclusion, it
was found that as processing levels increase in apple snack foods, they become more appealing and
more heavily consumed by elementary school students. If applied broadly to snack foods, this conclusion
presents one possible explanation regarding the high level of diet-related diseases and nutrient
deficiencies across adolescents in America. Food and nutrition education, food product development,
and marketing efforts are called upon to improve adolescent food choices and make less-processed
snack food options more appealing and accessible to diverse consumers.

1. Introduction

Processed foods have increasingly dominated the United States’ food supply, food environments, and
diets over the past five decades [1] with detrimental implications for nutrition and human health
[2,3,4,5]. The trend of increased processed food consumption characterizes the nutrition transition as a
shift towards nutrient-poor diets filled with ultra-processed food items [2]. The overconsumption of
ultra-processed foods that are often formulated using saturated or trans fats, excess sugar, excess salt,
and artificial ingredients has had negative implications for diet-related health outcomes, including
increased incidence of obesity, Type 2 Diabetes, cardiovascular disease, and cancer [2,3,4,5]. One in five
children ages 6 to 19 and living in the United States are classified as obese with a body mass index at or
above the ninety-fifth percentile [6]. A recent article demonstrates that a 10% increase in consumption
of ultra-processed foods among study participants was associated with a significant increase (greater
than 10%) in overall cancer and breast cancer [5]. Along with the United States, the nutrition transition
and associated nutrition and health outcomes are occurring in communities globally [7].

Ultra-processed foods comprise 58% of the consumed calories and 90% of the added sugar intake in the
American diet [1]. It was found that meals prepared with ultra-processed and processed food ingredients
had one third more added sugar, one fourth more saturated fat and sodium, less than half the fiber
content, and two thirds more calories when compared to meals prepared from the processed and
minimally processed groups [4]. For adolescents, regardless of country of residence, obesity was
positively correlated with the taste of fat and sugar-enriched food products [8]. Eliminating ultra-
processed products from a diet can improve consumer health with studies reporting decreases in
attention deficit hyperactivity disorder (ADHD) symptoms [9], a reduction in insulin resistance in children
with Type 2 Diabetes [10], and decreased mineral deficiencies in children with autism [11].

Food processing (Table 1) can be characterized at different levels along a continuum from unprocessed,
minimally processed, and processed culinary ingredients up to processed foods and ultra-processed
foods. The different levels of food processing vary according to the degree of manipulation including the
utilization of new technologies and the input of artificial ingredients that take foods further from their
natural state [1]. At the extreme end, ultra-processed food items often have little physical resemblance
to the fresh and wholesome food items that they were originally derived from [12]. The addition of extra
processing steps and artificial ingredients transforms food products such as meats, fruits, and vegetables
into new foods that can be both visually and nutritionally different compared to their original whole food
state [4]. Unprocessed foods include fresh fruits, vegetables, and meats that have undergone limited
processing including cleaning, portioning, chilling, grating, etc. [13]. Minimally processed foods have
undergone a small amount of processing such as drying, freezing, or fermentation [13]. Processed
culinary ingredients include sugar, oil, fat, salt, and other ingredients that are originally taken from plants
and then milled, pressed, or pulverized to be used in cooking or baking [13]. Processed products are
whole food ingredients that have been combined with processed culinary ingredients using processing
methods along with preservation techniques such as salting, pickling, smoking, curing, etc. [13]. Lastly,
ultra-processed foods are created using ingredients that are not used in culinary work [1], including
artificial flavors, colors, sweeteners, emulsifiers, and preservatives. Ultra-processed products can be
fortified with micronutrients and are formulated to be “ready-to-eat” versions of whole food items.
Monteiro CA, Levy RB, Claro RM, de Castro IR, Cannon G. Increasing consumption of ultra-
processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr.
2011 Jan;14(1):5-13. doi: 10.1017/S1368980010003241. PMID: 21211100.

Abstract

Objective: To assess time trends in the contribution of processed foods to food purchases made by
Brazilian households and to explore the potential impact on the overall quality of the diet.

Design: Application of a new classification of foodstuffs based on extent and purpose of food processing
to data collected by comparable probabilistic household budget surveys. The classification assigns
foodstuffs to the following groups: unprocessed/minimally processed foods (Group 1); processed
culinary ingredients (Group 2); or ultra-processed ready-to-eat or ready-to-heat food products (Group 3).

Setting: Eleven metropolitan areas of Brazil.

Subjects: Households; n 13,611 in 1987-8, n 16,014 in 1995-5 and n 13,848 in 2002-3.

Results: Over the last three decades, the household consumption of Group 1 and Group 2 foods has
been steadily replaced by consumption of Group 3 ultra-processed food products, both overall and in
lower- and upper-income groups. In the 2002-3 survey, Group 3 items represented more than one-
quarter of total energy (more than one-third for higher-income households). The overall nutrient profile
of Group 3 items, compared with that of Group 1 and Group 2 items, revealed more added sugar, more
saturated fat, more sodium, less fibre and much higher energy density.

Conclusions: The high energy density and the unfavourable nutrition profiling of Group 3 food products,
and also their potential harmful effects on eating and drinking behaviours, indicate that governments
and health authorities should use all possible methods, including legislation and statutory regulation, to
halt and reverse the replacement of minimally processed foods and processed culinary ingredients by
ultra-processed food products.
Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-
processed foods and likely impact on human health. Evidence from Canada. Public Health Nutr.
2013 Dec;16(12):2240-8. doi: 10.1017/S1368980012005009. Epub 2012 Nov 21. PMID: 23171687;
PMCID: PMC10271334.

Abstract

Objective: To investigate consumption of ultra-processed products in Canada and to assess their

Design: Application of a classification of foodstuffs based on the nature, extent and purpose of food
processing to data from a national household food budget survey. Foods are classified as
unprocessed/minimally processed foods (Group 1), processed culinary ingredients (Group 2) or ultra-
processed products (Group 3).

Setting: All provinces and territories of Canada, 2001.

Subjects: Households (n 5643).

Results: Food purchases provided a mean per capita energy availability of 8908 (se 81) kJ/d (2129 (se 19)
kcal/d). Over 61·7 % of dietary energy came from ultra-processed products (Group 3), 25·6 % from Group
1 and 12·7 % from Group 2. The overall diet exceeded WHO upper limits for fat, saturated fat, free sugars
and Na density, with less fibre than recommended. It also exceeded the average energy density target of
the World Cancer Research Fund/American Institute for Cancer Research. Group 3 products taken
together are more fatty, sugary, salty and energy-dense than a combination of Group 1 and Group 2
items. Only the 20 % lowest consumers of ultra-processed products (who consumed 33·2 % of energy
from these products) were anywhere near reaching all nutrient goals for the prevention of obesity and
chronic non-communicable diseases.

Conclusions: The 2001 Canadian diet was dominated by ultra-processed products. As a group, these
products are unhealthy. The present analysis indicates that any substantial improvement of the diet
would involve much lower consumption of ultra-processed products and much higher consumption of
meals and dishes prepared from minimally processed foods and processed culinary ingredients.
De Vlieger, N. M., Collins, C., & Bucher, T. (2017). What is a nutritious snack? Level of processing and
macronutrient content influences young adults' perceptions. Appetite, 114, 55-63.

Abstract:

Snacking has become more prevalent in developed countries. While poor food choices pose health risks,
nutritious choices contribute important nutrients to overall dietary intakes. Young adults consumer
snacks frequently and nutritious choices should be promoted among this group. However, how young
adults define the term ‘nutritious’ currently and how they evaluate the nutritiousness of various snack
foods required further investigation. The current study used a mixed methods design with 115 young
adults invited to sort 32 commonly available snack foods into a line ranging from 'not nutritious' to 'very
nutritious'. The sorting data was analysed by hierarchical cluster analysis and multi-dimensional scaling
(MDS) analysis. Participants were also asked to define the word ‘nutritious’, with definitions then
categorized and number of counts per category analysed. Predictors of perceived snack nutritiousness
were sugar (β = −0.45, P < 0.005), fat (β = −0.43, P < 0.05), nut (β = 0.45, P < 0.05) and fruit/vegetable
(β = 0.33, P < 0.05) content. Level of food processing was significantly related to perceived nutritiousness
(β = 0.79, P=<0.05). The terms given within the definitions most frequently were: ‘vitamins’ (40%), ‘good
for body/body needs’ (40%), ‘minerals’ (39%), ‘low in sugars’ (36%), ‘protein’ (32%), ‘healthy’ (28%) and
‘long lasting source of energy’ (27%). Results of the current study provide first insight into how young
adults interpret the term ‘nutritious’. This could help in the design of more effective nutrition education
materials and food product labels to guide healthy choices in this age group.
Hartmann C, Siegrist M, van der Horst K. Snack frequency: associations with healthy and unhealthy food
choices. Public Health Nutr. 2013;16(8):1487–96.

Abstract

Objective

We examined associations between snack frequency, sociodemographic characteristics, BMI, dietary and
eating behaviour. In order to identify whether various subgroups of high-frequency snack consumers
exist, we investigated underlying food patterns and lifestyle factors.

Design

The data were based on the Swiss Food Panel Questionnaire of 2010, which included an FFQ, questions
relating to sociodemographics and lifestyle factors. Data were examined using ANOVA, regression
analysis and hierarchical cluster analysis. Gender differences were also investigated in the analysis of the
data.

Setting

A sample of 6189 adults participating in the Swiss Food Panel filled in a questionnaire (response rate 30
%).

Subjects

The sample consisted of both men and women, with a mean age of 54·4 (SD 13·5) years.

Results

There was no association between snack frequency and BMI. Consumption frequency of sweets and
savouries as well as fruit intake increased with increasing snack frequency. Additionally, three different
subgroups of high-frequency snack consumers could be revealed: healthy, moderate and unhealthy
dietary-pattern groups. The latter included respondents who were less health-conscious and was
characterized by high alcohol consumption frequency, daily breakfast skipping and watching television
during the main meal.

Conclusions

High snack frequency occurred in the context of healthy as well as unhealthy dietary behaviour and
lifestyle patterns. Women made healthier dietary food choices and were more likely to consume fruits as
snacks, while men chose unhealthy foods, such as sweets and savouries, more often.

Eating frequency is affected by cultural/social norms, lifestyle factors, the environment and an
individual's personal attitudes towards his/her health(Reference La Bounty Paul, Jacob and Elfego1,
Reference Chiva2). Changes in lifestyle and the environment over the last few decades have probably
been the most important causes of the overweight epidemic in Western society(Reference Hill and
Melanson3). The increasing proportion of snacking in the Western diet has been a particular cause for
concern, since the foods and drinks typically consumed as snacks tend to be energy-dense(Reference
Piernas and Popkin4). In the scientific literature, no consensus exists about whether a higher frequency
of eating, and particularly snacking, promotes or prevents weight gain(Reference Hampl, Heaton and
Taylor5, Reference Johnson and Anderson6).

In spite of an unclear association with body weight, snacking per se does not have a negative effect on
diet quality. Snacking can increase the opportunity for healthy, low-energy food choices, resulting in a
wider variety of foods in the diet and a balanced intake of nutrients contributing significantly to daily
micro- and macronutrient intakes(Reference Holmback, Ericson and Gullberg7–Reference Mills, Perry
and Reicks9).

An important issue related to snack frequency is whether energy intake from snacks between meals will
be compensated for by a lower energy intake from the main meals, because a higher number of eating
occasions seems not to be associated with an improvement in appetite control and provides more
opportunities to consume excess energy(Reference Leidy and Campbell10). Nevertheless, meal skipping,
especially breakfast skipping, is associated with overeating later in the day, due to intense hunger
followed by ingestion of high-fat, sugar-dense snacks(Reference Schlundt, Hill and Sbrocco11).

Overweight and obesity status was found to be associated with higher intakes of fat, refined grains, red
meat, added sugars and sugar-sweetened beverages(Reference Mills, Perry and Reicks9). These foods are
common in an obesogenic environment(Reference Swinburn, Egger and Raza12), which may increase the
likelihood for choosing unhealthy snacks, make restrained eating more difficult and result in an increased
energy intake over the course of the day. A comparison between snacking patterns in obese adults and a
reference population showed that with increasing snack occasions, energy intake from candies,
chocolate, cakes, cookies and desserts increased more steeply in the obese population compared with
the control population(Reference Berteus-Forslund, Torgerson and Sjostrom13).

However, high snack frequency is not in itself a reason for energy increase and weight gain. The
inconsistent associations between snack frequency and body weight reported in the literature could
indicate that an individual's overall nutrition pattern plays a more important role than snack frequency
itself. Certain energy-dense foods with trends for increased consumption (e.g. beef, pork and pizza) were
shown to be important components of meals, rather than snacks(Reference Nielsen, Siega-Riz and
Popkin14). Dietary behaviour should also be considered when assessing snacking(Reference Johnson and
Anderson6), because a food that is consumed as a snack and a food that is consumed as a meal could
both have a considerable influence on the quality of the diet, energy intake and weight gain.

The meal environment may be another influencing factor on dietary and eating behaviour. For example,
family meals were associated with higher fruit and vegetable consumption(Reference Boutelle,
Birnbaum and Lytle15), whereas families with a higher frequency of television (TV) watching during
meals reported higher proportions of energy intake from snack foods, sodas and meat(Reference Coon,
Goldberg and Rogers16). In general, watching TV during dinner is considered to be a less healthy eating
behaviour, and it is likely to correspond with diets high in fat and low in fruit and vegetables(Reference
Boutelle, Birnbaum and Lytle15, Reference Coon, Goldberg and Rogers16). Lifestyle and socio-economic
factors are likely related to different food choices as well. In the study by Holmback et al., a low daily
eating frequency (referring to all eating occasions, including snacks) occurred in the context of an
unhealthy lifestyle, which was defined by higher intakes of alcohol and high-fat foods and low levels of
leisure-time physical activity(Reference Holmback, Ericson and Gullberg7). Gender differences in
behaviours relating to food choices have also been observed. For example, on the whole men eat less
fresh fruit and vegetables and consume more meat than do women(Reference Beer-Borst, Hercberg and
Morabia17, Reference Dynesen, Haraldsdottir and Holm18).

The current literature does not contain any universally accepted definition of snacking, but two main
approaches have been used to define the term ‘snack’(Reference Johnson and Anderson6). The first
approach focuses on the food consumed; foods are identified as snacks by their nutrient content or
because they are commonly associated with snacking(Reference Johnson and Anderson6, Reference
Whybrow, Mayer and Kirk19). The second approach focuses on the time of food consumption(Reference
Johnson and Anderson6). Everything consumed between the main meals is defined as a snack. In our
study, we asked for the usual frequency of food consumption between the three main meals (breakfast,
lunch, dinner) and calculated ‘snack frequency’ per week.

The aim of the present study was to examine the associations between snack frequency,
sociodemographic characteristics, BMI, dietary and eating behaviours. In order to identify whether
different subgroups of high-frequency snack consumers exist, we investigated underlying food patterns
and lifestyle factors. It was hypothesised that ‘high snack consumers’ could be separated into two
groups: a group with mainly unhealthy food choices and snack consumption preferences for sweets and
savouries, and a group with more healthy food choices and snack consumption preferences for items
such as fruits.
Correa-Burrows P, Burrows R, Orellana Y, Ivanovic D. The relationship between unhealthy snacking at
school and academic outcomes: a population study in Chilean schoolchildren. Public Health Nutr.
2015;18(11):2022–30.

Abstract

Objective

We examined the association between unhealthy snacking at school and academic outcomes in students
from the Santiago Metropolitan Region (Chile).

Design

Cross-sectional population-based study.

Setting

We measured the nutritional quality of snacks at school using an FFQ, and accounting for the amounts of
saturated fat, fibre, sugar and salt in the foods, and academic outcomes using national standardized test
scores in Language and Mathematics. Multivariate regression analyses modelled the relationship
between unhealthy snacking at school (exposure), potential confounders and performance in
Mathematics and Language (outcomes).

Subjects

Random sample of 1073 students (13·1 (SD 2·3) years old) attending public, partially subsidized and
private schools.

Results

Fifty-six per cent of students ate items at snack time that were high in fat, sugar, salt and energy, and
thus were considered to have unhealthy snaking. Thirty-six per cent and 8 % were considered to have
poor-to-fair and healthy snacking, respectively. Unhealthy snacking significantly lowered the odds of
good academic performance in both domains. Students having unhealthy snacks were 56 % less likely to
pass in Language (fully adjusted OR=0·44; 95 % CI 0·23, 0·85) and 66 % less likely to pass in Mathematics
(fully adjusted OR=0·34; 95 % CI 0·19, 0·64) compared with students having healthy snack items.

Conclusions

Schoolchildren eating unhealthy foods at snack time had worse academic performance in Language and
Mathematics, as measured by a standardized test. Although association does not imply causation, these
findings support the notion that academic and health-related behaviours are linked. More research is
needed on the effect of school health programmes on educational outcomes.

Most research studies performed in developing and middle-income countries have examined the
association between macro- and micronutrient deficiencies and several measures of cognitive
functioning in children( Reference Walker, Wachs and Gardner1 – Reference Gupta, Goel and Shah3 ).
The economic boom of the past two decades, however, has paved the way for an increase in non-
communicable diseases associated with overweight and obesity since infancy. The consumption of salty,
sugary and high-fat processed foods, major elements of the so-called Western diet, which contribute to
excessive nutrient intake and weight gain, is becoming extremely prevalent among school-age children
from these countries( Reference Bonilla-Chacin, Marcano-Vázquez and Sierra4 ). This is a subject of huge
concern for public health officials, academics and all those struggling against the obesity
epidemic( Reference Fraser5 ).

The Western diet does not merely lead to obesity and cardiovascular and metabolic disorders. Studies in
both animal and human models have found evidence for an association between cognitive functioning
and excess consumption of the macronutrients that are the primary components of the Western diet.
They indicate that excessive intakes of saturated fats and simple carbohydrates are related to
impairment in several learning and memory processes dependent on the hippocampus( Reference
Morris, Evans and Bienias6 – Reference Smith and Foster10 ). Exposure to these macronutrients
interferes with hippocampal functioning directly, by cutting down the production of neurotrophins,
increasing the level of neuroinflammatory markers and altering the blood–brain barrier, and indirectly by
impairing glucose regulation( Reference Gale, Martyn and Marriott11 – Reference Kanoski and
Davidson13 ).

With the exclusion of research about the effect of breast-feeding on cognitive evolution and/or
functioning later in life, few works have addressed the cognitive impact of dietary rules in children rather
than focusing on individual nutrients, the predominant approach to studying this subject. In the UK, the
Avon Longitudinal Study of Parents and Children (ALSPAC) has offered evidence suggesting that
unhealthy dietary practices during early childhood have a lasting association with intelligence in mid-
childhood and adolescence( Reference Northstone, Joinson and Emmett14 – Reference Smithers, Golley
and Mittinty16 ). Similarly, in children from New Zealand, Theodore et al. found a positive relationship
between cognitive abilities and dietary patterns at 3·5 and 7 years of age( Reference Theodore,
Thompson and Waldie17 ), whereas Nyaradi et al. reported that Australian children with better diet
quality during the early years of life showed higher verbal and non-verbal abilities later in mid-
childhood( Reference Nyaradi, Li and Hickling18 ).

The nutritional quality of food and meal patterns is related to specific outcomes that are important for
the educational attainment of children and teens. Studies of nutrition and academic performance and/or
behaviour have typically focused on the effect of malnutrition and micronutrient deficiency( Reference
Taras19 , Reference Dewey and Begum20 ). Very few have addressed the effect of overnutrition and they
have been mostly carried out in developed countries( Reference Sigfúsdóttir, Krisjánsson and
Allegrante21 – Reference Florence, Asbridge and Veugelers25 ). Due to the lack of evidence from
countries undergoing transitional processes, the aim of the present study was to examine the association
between diet as a composite measure and academic outcomes in children from Chile, a middle-income
country that underwent a profound shift from under- to overnutrition in less than two
decades( Reference Albala, Vio and Kain26 – Reference Vio, Albala and Kain28 ). Specifically, we
examined the relationship between unhealthy snacking at school and the ability to perform in Language
and Mathematics. We hypothesized that an increase in consumption of unhealthy food items during
snack time would be associated with poor academic outcomes in both domains.
Neumark-Sztainer, D., French, S.A., Hannan, P.J. et al. School lunch and snacking patterns among high
school students: Associations with school food environment and policies. Int J Behav Nutr Phys Act 2, 14
(2005).

Abstract

Objectives

This study examined associations between high school students' lunch patterns and vending machine
purchases and the school food environment and policies.

Methods

A randomly selected sample of 1088 high school students from 20 schools completed surveys about
their lunch practices and vending machine purchases. School food policies were assessed by principal
and food director surveys. The number of vending machines and their hours of operation were assessed
by trained research staff.

Results

Students at schools with open campus policies during lunchtime were significantly more likely to eat
lunch at a fast food restaurant than students at schools with closed campus policies (0.7 days/week vs.
0.2 days/week, p < .001). Student snack food purchases at school were significantly associated with the
number of snack machines at schools (p < .001) and policies about the types of food that can be sold. In
schools with policies, students reported making snack food purchases an average of 0.5 ± 1.1 days/week
as compared to an average of 0.9 ± 1.3 days/week in schools without policies (p < .001). In schools in
which soft drink machines were turned off during lunch time, students purchased soft drinks from
vending machines 1.4 ± 1.6 days/week as compared to 1.9 ± 1.8 days/week in schools in which soft drink
machines were turned on during lunch (p = .040).

Conclusion

School food policies that decrease access to foods high in fats and sugars are associated with less
frequent purchase of these items in school among high school students. Schools should examine their
food-related policies and decrease access to foods that are low in nutrients and high in fats and sugars.

Background

Research studies have clearly shown that adolescents' dietary intakes are not consistent with national
recommendations. Areas of concern include high intakes of saturated fat, total fat, and soft drinks, and
low intakes of fruits, vegetables, fiber, and calcium-rich foods [1–3]. These dietary patterns are of
concern because of their potential for increasing risk for developing obesity, heart disease, osteoporosis,
dental caries, and various types of cancer [4].

Adolescent eating patterns are influenced by factors proximal to the adolescent such as individual food
preferences [5], family meal patterns [6], and parental role modeling [7]. However, it is increasingly
becoming clearer that adolescent eating patterns are also influenced by more distal factors such as
media messages and social norms [8, 9]. Since adolescents spend a large amount of time in school, an
important question – is to what extent does the school food environment influence adolescent eating
patterns [10]. In Bronfenbrenner's ecological model, which shows concentric spheres of influences on
the individual ranging from proximal factors (i.e., individual characteristics) to distal factors (i.e. social
norms and public policies), the school lies in the middle [11].

Although there are federal regulations regarding the types of foods that can be served in the United
States Department of Agriculture (USDA) reimbursable school meals [12, 13], few regulations are in
place for alternative foods, such as those served a la carte in the cafeteria or in snack bars, and in
vending machines [14]. A study of 55 high schools revealed that school environments do not always
foster healthful eating practices consistent with national dietary guidelines [15]. In a statewide survey of
food policies in 336 Minnesota high schools, two-thirds of the principals indicated that only healthy food
choices should be provided to students at school, yet only one-third reported that their school had an
overall policy about nutrition and food. Even fewer reported the presence of specific policies about the
types of foods and beverages sold in vending machines, school stores, or at school functions [16]. School
vending machines were prevalent and 77% of the principals reported that their school or district had a
contract with a soft drink company. Vending machine hours were limited in some way in 81% of the
schools, but only about a third of the schools limited the vending machine hours to before and after
school only or after all lunch periods were completed. While it is important to respect adolescents
increasing autonomy and decision-making skills, research clearly shows that food availability is one of
the strongest correlates of food choices in adolescents [17, 18]. Schools provide a setting in which it is
possible to increase the availability and attractiveness of a range of healthy food options from which
students can make choices, and restrict the availability of foods that are low in nutrients and high in fats
and sugars.

The few studies that have examined associations between school food environment and student eating
patterns suggest that the school food environment has a significant impact on food choices. Cullen and
colleagues [19] found that fourth grade students attending elementary schools without a la carte food
items consumed more fruits, juices, and vegetables than fifth graders who attended a middle school with
a la carte food line (or snack bar). Kubik et al found that among seventh-grade students in 16 schools,
having a school a la carte program was associated with lower intakes of fruits and vegetables and higher
intakes of calories from total and saturated fats [20]. They also found that the number of snack vending
machines was associated with lower fruit intakes, suggesting that students may be choosing alternative
snack foods from the vending machines rather than fruit. However, policies were not examined regarding
the types of foods sold in vending machines and their hours of operation and the impact of such policies
on vending machine purchases.

This study expands on the limited, but growing, body of literature that explores the role of schools in
influencing the dietary practices of youth. Specifically, our study objectives are: 1) to describe school
lunch practices and vending machine purchases in a large sample of high school students; and 2) to
examine associations between eating patterns of high school students and school food environment and
policies.