A Comparison of Fruits,Vegetables,Sugar-Sweetened Beverages,and Desserts in the Packed Lunches of Elementary School Children

Abstract

Background:

An estimated 40% of children bring a packed lunch to school. These lunches are not required to meet nutrition standards. The aim of this study was to compare differences in the nutritional quality of elementary packed lunches by the presence or absence of sugar-sweetened beverages (SSB), desserts, and fruits and vegetables (FVs).

Methods:

Observational data for prekindergarten and kindergarten packed lunches were collected from three schools in rural Virginia for 5 consecutive school days and analyzed for macro- and micronutrients and by the presence or absence of food and beverage items.

Results:

Of the 561 packed lunch observations collected, 41.7% contained no FV, 41.2% contained an SSB, and 61.1% contained a dessert. The nutrient profile of packed lunches with at least one fruit or vegetable had significantly higher levels of carbohydrate, fiber, sugar, vitamin A, and vitamin C. Packed lunches containing an SSB had significantly higher levels of sugar and vitamin C and significantly lower levels of protein, fiber, vitamin A, calcium, and iron. Packed lunches containing a dessert had significantly higher levels of energy, carbohydrate, fat, saturated fat, sodium, sugar, vitamin C, and iron and significantly lower levels of vitamin A.

Conclusions:

Additional research is needed to fully understand parent and child motivations for packing lunches and the decision processes that influence the inclusion of food items. The development of packed lunch interventions, encouragement of National School Lunch Program participation, or enactment of school policies to increase the nutritional value of packed lunches is warranted.

Introduction

Childhood obesity is associated with increased cardiovascular disease risk, type 2 diabetes, respiratory problems, psychological trauma, associated quality-of-life issues, and increased risk for adult obesity.^1–6 In the United States, one third of children ages 2–19 are overweight and 17.3% of children are obese.^6,7 Increases in childhood obesity rates may be partially attributed to decreases in the nutritional quality of diets. Fewer than 15% of children between the ages of 4 and 8 years consume the recommended amounts of fruits and vegetables (FVs),⁸ whereas intakes of solid fats and added sugars have increased to nearly 40% of total calories.^9–11

The National School Lunch Program (NSLP) is a promising avenue to influence the dietary quality of children.^12,13 However, whereas approximately 60% of children participate in the NSLP, 40% of children do not participate.¹⁴ These children are presumably packing lunches, especially in elementary schools, which most likely do not offer “competitive” foods and do not have open campuses.¹⁴ Unlike the NSLP, which is mandated to meet nutrition standards aligned with the 2010 Healthy and Hunger-Free Kids Act,^15,16 packed lunches are not required to meet any nutrition standards.

A small number of studies have been published on the nutritional quality of packed lunches in a school setting.^{12,14,17–24} These studies used a wide variety of dietary data collection methods covering different time frames (e.g., 24-hour recalls and 1- to 3-day food observations) and were conducted with a variety of ages ranging from kindergarten to 12th grade. To our knowledge, no studies reported data over a full school week (5 consecutive days), with prekindergarten classes attending school, or compared differences among packed lunches between students.

The present study was part of a larger research program that compared the nutritional quality of packed lunches to meals served by the NSLP. The purpose of these analyses was to compare differences in the nutritional quality of packed lunches by the presence or absence of sugar-sweeteened beverages (SSBs), dessert items, and FVs.

Methods

Participants

Administrators from eight elementary schools in a rural area in Virginia were contacted by e-mail and telephone. Of the eight, three (37.5%) agreed to participate. Permission was granted through the County Public School Research Office. The three schools had free and reduced-price school lunch participation rates of 33.3%, with white (78.3%), black (6.4%), and Asian/Pacific Islander (6.2%) individuals, 46.6%, with white (94.9%), black (1.6%), and Hispanic/Latino (0.8%) individuals, and 52.7%, with white (78.9%), black (12.2%), and Hispanic/Latino (3.7%).²⁵ Prekindergarten and kindergarten students were selected because young ages represent a malleable time to promote food acceptance.^26–28 No identifying information for any student was collected. The institutional review board for (blinded for review) approved all aspects of the study. Parental and student consent was not required.

Observational Protocol

Observational data were collected in each elementary school for 5 consecutive school days. Observational checklists reflecting commonly brought items in packed lunches were used to record the presence of all food and drink items brought from home, with open sections for additional foods not reflected on the checklist. Each researcher was assigned a specific grouping of students to observe for a lunch period, approximately 10 students per researcher.

Nutrition students were recruited and trained as observers in direct observation to assess lunch contents, specifically visual item identification and portion-size estimation. Observations of five premeasured sample packed lunches were conducted with researchers, for a total of 24 items. Food and beverage items selected represented commonly found items in elementary packed lunches. Accuracy was determined by dividing the number of items accurately recorded by the number total number of items (item identification=93.8%; portion estimation=92.1%).

Interobserver reliability (IOR) was assessed with average pair-wise percent agreement tests run in JMP^® (Version 11; SAS Institute Inc., Cary, NC). Observers demonstrated 90.7% agreement for item identification and 86.8% agreement for portion estimation, with adequate IOR defined in the literature as at least 85% agreement.²⁹ Each researcher was assigned approximately 10 students to observe for a lunch period.

Statistical Analysis

Nutrient content of packed lunch items was analyzed using Nutritionist Pro™ Diet Analysis software (version 5.1; Axxya Systems, Stafford, TX) based on serving sizes recorded at the time of observation. USDA reference items were selected when available. If items were not found in the Nutritionist Pro database, nutrition fact labels for product brand and type were used for analysis. Students who brought a packed lunch and purchased milk at school were classified as a packed lunch observation. Students who participated in the NSLP, but also brought food from home (n=5; 0.9%), were excluded. Students who brought more than one beverage category (i.e., SSB and water beverage) were excluded (n=18; 3.2%) from the beverage comparison analysis only (Table 2) to compare students with an SSB to all other beverage categories.

Descriptive statistics were used to describe the nutritional quality of packed lunches with and without SSBs, dessert items, and FVs. Shapiro-Wilk's test was used to determine whether data were parametric. Comparisons of mean quantities of macro- and micronutrients (calories, protein, fat, saturated fat, carbohydrates, sugar, fiber, vitamin A, vitamin C, calcium, and iron) were carried out in JMP (Version 11; SAS Institute Inc.) using Mann-Whitney-Wilcoxon's test.

Results

Nutritional Profile of Packed Lunches by Fruits and Vegetables

A total of 561 packed lunches were observed. Roughly 42% (41.7) contained no fruit or vegetable (n=234) and the remaining 58.3% contained at least one fruit or vegetable (n=327). The nutrient profile of packed lunches with at least one fruit or vegetable had significantly higher levels of carbohydrate, fiber, sugar, vitamin A, and vitamin C, compared to packed lunches without a fruit or vegetable (Table 1). Only 12.5% of packed lunches contained a fruit and vegetable (Table 3).

Table 1.

Comparisons of Nutrients between Pre-Kindergarten and Kindergarten Students Who Packed Lunch with or without a Fruit or Vegetable Present in Three Schools

	No fruit or vegetable present (n=234) Mean	At least one fruit or vegetable present (n=327) Mean	Mann-Whitney-Wilcoxon's significance test p value^*
Energy (kcal)	597 (median=589) IQR=243	618 (median=589) IQR=325	0.36
Carbohydrate (g)	83 (median=80) IQR=41	93 (median=89) IQR=38	<0.01
Protein (g)	18 (median=17) IQR=8.2	19 (median=17) IQR=8.5	0.71
Fat (g)	22 (median=21) IQR=14	20 (median=19) IQR=14	0.04
Saturated fat (g)	7.0 (median=6.5) IQR=5.5	6.7 (median=6.0) IQR=6.0	0.36
Sodium (mg)	924 (median=858) IQR=499	856 (median=790) IQR=478	0.02
Fiber (g)	3.3 (median=3.0) IQR=2.5	5.8 (median=5.5) IQR=4.0	<0.01
Sugar (g)	40 (median=38) IQR=28	48 (median=47) IQR=26	<0.01
Vitamin A (IU)	955 (median=500) IQR=526	1680 (median=579) IQR=773	<0.01
Vitamin C (mg)	34 (median=12) IQR=60	49 (median=42) IQR=62	<0.01
Calcium (mg)	297 (median=283) IQR=257	311 (median=301) IQR=297	0.36
Iron (mg)	3.1 (median=3.0) IQR=2.0	3.6 (median=3.0) IQR=2.0	0.08

Significance <0.01, Mann-Whitney-Wilcoxon's test, comparison of mean quantities.

IQR, interquartile range.

Nutritional Profile of Packed Lunches by Sugar-Sweetened Beverages

Of the 543 packed lunches with one beverage category, 58.7% did not contain an SSB (n=319), whereas 41.2% did (n=224). The presence of an SSB resulted in significantly higher levels of sugar and vitamin C and significantly lower levels of protein, fiber, vitamin A, calcium, and iron, compared to those without an SSB (Table 2). For lunches not containing an SSB, the most common beverages were milk (20.7%), water (16.4%), no beverage (11.0%), and juice with no sugar added (10.7%; Table 3). There was not an association between the presence of an SSB and the presence of a fruit or vegetable (Table 3), because approximately half of the lunches with an SSB also had a fruit and/or vegetable.

Table 2.

Comparisons of Nutrients between Pre-Kindergarten and Kindergarten Students Who Packed Lunch with or without a Sugar-Sweetened Beverage or Dessert Present in Three Schools

	No SSB present (n=319) Mean	SSB present (n=224) Mean	Mann-Whitney-Wilcoxon's test for SSB p value^*	No dessert present (n=218) Mean	Dessert present (n=343) Mean	Mann-Whitney-Wilcoxon's test for dessert p value^*
Energy (kcal)	594 (median=578) IQR=224	617 (median=605) IQR=247	0.21	527 (median=525) IQR=208)	661 (median=642) IQR=246	<0.01
Carbohydrate (g)	85 (median=82) IQR=38	91 (median=89) IQR=39	0.02	75 (median=73) IQR=32	97 (median=95) IQR=37	<0.01
Protein (g)	19 (median=17) IQR=10	17 (median=16) IQR=8	<0.01	18 (median=17) IQR=8.5	18 (median=17) IQR=9	0.91
Fat (g)	20 (median=19) IQR=14	22 (median=21) IQR=13	0.09	18 (median=18.0) IQR=13.5	23 (median=21.5) IQR=14.5	<0.01
Saturated fat (g)	6.5 (median=6.0) IQR=5.5	7.2 (median=6.5) IQR=5.5	0.03	5.5 (median=5.5) IQR=5.5	7.7 (median=7.0) IQR=5.0	<0.01
Sodium (mg)	876 (median=810) IQR=464	872 (median=802) IQR=488	0.87	816 (median=761) IQR=484	928 (median=857) IQR=496	<0.01
Fiber (g)	5.1 (median=4.5) IQR=3.5	4.2 (median=4.0) IQR=4.0	<0.01	5.0 (median=4.5) IQR=3.5	4.6 (median=4.5) IQR=3.8	0.15
Sugar (g)	41 (median=40) IQR=26	48 (median=48) IQR=24	<0.01	35 (median=36) IQR=25.5	51 (median=49) IQR=22	<0.01
Vitamin A (IU)	1457 (median=553) IQR=700	1195 (median=492) IQR=619	<0.01	1907 (median=583) IQR=817	1041 (median=500) IQR=647	<0.01
Vitamin C (mg)	38 (median=16.5) IQR=60	49 (median=47) IQR=62	<0.01	33 (median=15) IQR=62.5	49 (median=49) IQR=55	<0.01
Calcium (mg)	317 (median=312) IQR=291	272 (median=235) IQR=238	<0.01	309 (median=300) IQR=275	303 (median=286) IQR=296	0.62
Iron (mg)	3.7 (median=3.0) IQR=2.0	2.9 (median=3.0) IQR=2.0	<0.01	3.0 (median=3.0) IQR=2.5	3.6 (median=3.5) IQR=1.5	<0.01

Significance <0.01, Mann-Whitney-Wilcoxon's test, comparison of mean quantities.

SSB, sugar-sweetened beverage; IQR, interquartile range.

Table 3.

Observation of Food Items Brought by Elementary Children in Packed Lunches among Three Schools

	%
Fruits and vegetables
At least one fruit or vegetable item (not juice)	58.3
At least one fruit and vegetable item (not juice)	12.5
No fruit or vegetable items	41.7
Sugar-sweetened beverages and other drink types
Sugar-sweetened beverage	41.2
Juice with no sugar added	10.7
No beverage	11.0
Water	16.4
Milk (flavored and unflavored)	20.7
Dessert items
At least one dessert item (i.e., grain-based desserts, chocolate bars, dairy-based desserts, gummies, candy)	61.1
More than one dessert item	17.0
No dessert item	38.9
Item combinations
Sugar-sweetened beverage with no fruit and vegetable items	50.4
Sugar-sweetened beverage with fruit and vegetable items	49.6
Dessert present with no fruit and vegetable items	50.1
Dessert present with fruit and vegetable items	49.9

Nutritional Profile of Packed Lunches by Dessert Items

Of all packed lunches (n=561), a majority did contain a dessert item (n=343; 61.1%), and 17% contained more than one dessert item (Table 3). Packed lunches with a dessert item had significantly higher levels of energy, carbohydrate, fat, saturated fat, sodium, sugar, vitamin C, and iron and significantly lower levels of vitamin A, compared to packed lunches without a dessert item (Table 2). Grain-based desserts (44.1%), followed by fruit snacks or gummies (28.3%), were the most frequently brought items. The presence of a dessert item was not associated with the presence of a fruit or vegetable (Table 3), because approximately half of lunches with a dessert also had a fruit and/or vegetable.

Discussion

To our knowledge, this is the first study to compare the nutritional profile of packed lunches for prekindergarten and kindergarten children by the presence or absence of specific food and beverage items. The results suggest that lunches containing SSBs and dessert items, and do not contain FVs, have lower nutritional quality. For example, the presence of SSBs in packed lunches resulted in lower calcium and higher sugar levels than lunches that did not contain an SSB. This is especially concerning owing to the potential for displacement of milk, which only accounted for one fifth of beverages in our sample. Other studies have shown that SSBs negatively contribute to the diets of children and that SSB consumption is a marker of an overall poor-quality diet.^9,10,30,31

Nearly two thirds of the packed lunches contained at least one dessert item, and approximately one fifth of those lunches contained two dessert items, which contributed to increased levels of energy, fat, saturated fat, and sugar, compared to lunches that did not contain dessert. Our findings were consistent with previous studies that found that solid fats and added sugars are significant contributors to energy in children's diets.^31,32 Therefore, lunches containing desserts may lead to increased caloric intake and, ultimately, higher body mass and childhood obesity.^33,34

According to MyPlate,³⁵ half of a child's lunch should be comprised of FVs; however, our findings among prekindergarten and kindergarten students were that almost half did not bringing any FV items in their packed lunch, resulting in lower levels of fiber, vitamin A, and vitamin C, when compared to children with a fruit or vegetable present. The presence of both fruit and vegetable items was even more rare, occurring in just one tenth of prekindergarten and kindergarten packed lunches. The importance of exposure to FVs is critical for acceptance, especially in young children, given that childhood eating habits track into adulthood.^26–28,36

Several factors may limit the generalizability of this study. The sample is restricted to prekindergarten and kindergarten elementary students in a rural area in Virginia and may not be applicable to urban, ethnically diverse, older students, or other areas of the United States. This study only examined foods and beverages offered to children over the school lunch period. Students may compensate for nutritional deficiencies with food served at other locations, or the packed lunches may not be indicative of overall diet. Possibly, the greatest limitation of this study was in not measuring actual consumption of food items. Researchers were not permitted to use weighing techniques to approximate consumption, and thus we are not able to estimate the impact that packed lunches have on actual intake. To protect the privacy of elementary students, the research team did not collect any identifying information to track students over the 5-day study period, which would have allowed for student-level analyses. Students who packed 1 day likely packed multiple days, but may not have packed all 5 days. Thus, the influence of individual children on overall results is varied.

Conclusions and Implications

Packing lunches that do not contain FVs, and do contain SSBs or desserts, is a missed opportunity for parents to reinforce healthy habits and instill healthy food preferences that will carry into adulthood. Very few studies have interventions aimed at increasing the nutritional quality of packed lunches or attempted to discern the factors that motivates parents to pack,^37–41 and interventions that have done so have produced moderate results.^37,38 Additional research is needed to fully understand parent and child motivations for packing lunches and the decision processes that influence the inclusion of certain food items before effective interventions to increase the nutritional value of packed lunches can be developed.

In addition to research, encouraging participation in the NSLP, through marketing strategies and educational campaigns, growth of farm-to-school opportunities, or collaboration with parents and students on NSLP menu options all represent other avenues to positively impact the nutritional profile of elementary children's lunches. Finally, changes in school policies may be another option that may help improve the nutritional quality of packed lunches for elementary children. On a national scale, the Healthy, Hunger-Free Kids Act requires schools to strengthen their wellness policies and maintain a healthy school environment.¹⁵ Enacting county or state policies or recommendations aligned with MyPlate and the nutrition standards of the NSLP could improve the nutritional quality of packed lunches by encouraging FVs with every meal and snack, substituting milk or water for SSBs, and using fruit as a dessert.

Footnotes

Acknowledgments

The authors thank the school administrators in the elementary schools in which the study was conducted, for allowing the researchers to conduct observations, and the graduate and undergraduate nutrition students for their substantial contributions to the research, including assistance in data collection and entry.

Author Disclosure Statement

No competing financial interests exist.

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