Abstract
Purpose:
To compare the dietary quality among adolescents who skip lunch and those who do not and explore associations between school-level variables, demographic variables and lunch skipping.
Design:
Cross-sectional
Setting:
Public schools in New Orleans, Louisiana (n = 21)
Participants:
718 adolescents
Methods:
Adolescents participated in a 24-hour dietary recall using the Automated Self-Administered 24-Hour (ASA24) Dietary Assessment Tool early in 2013. Data were converted into Healthy Eating Index (HEI-2010) scores. Mean scores were compared between students who skipped lunch and those who did not. A multilevel analysis was conducted to assess relationships between school environment, demographics, and lunch skipping.
Results:
Of the 718 respondents, 88.3% were Black and 15.3% skipped lunch. Students who ate lunch had a mean HEI score of 46.6 compared to a mean score of 41.7 for students who skipped lunch (p < .001). Students who skipped lunch also had significantly lower intake of total vegetables (p = .02), whole fruits (p < .001), total dairy (p = .003), total protein (p < .001).
Conclusions:
Skipping lunch was associated with lower quality diet, though diet quality was low among all students. Considering over 15% of the sample did not eat lunch in a closed-campus school setting, further research should consider how to encourage students to participate in the National School Lunch Program, which has the ability to increase diet quality in adolescents.
Purpose
A healthy diet is a key factor in preventing chronic disease. 1 Adolescence is an important developmental period where healthy dietary behaviors track into adulthood. 2 Yet, diet quality is poor among adolescents in the U.S, particularly among adolescents of color. 3 Studies indicate that consumption of unhealthy foods may be too high and consumption of healthy foods may be too low among non-Hispanic Black adolescents. 4
Many adolescents in the U.S. consume a large proportion of their daily food at school. 5 Despite access to the National School Lunch Program (NSLP) and the School Breakfast Program (SBP) programs, meal skipping is common among adolescents and is associated with less healthy dietary patterns. 6 Because of the limited research relative to lunch skipping among non-Hispanic Black adolescents, this study examined the dietary quality among adolescents who skip lunch and those who do not and explore associations between school-level variables, demographic variables and lunch skipping.
Methods
Design
The data were collected within a school-based study that used a cross-sectional design to examine the school food environment in middle/high schools in New Orleans, Louisiana. 7 Twenty-one schools (average student population: 50% female, 91% Black, and 88% economically disadvantaged) agreed to participate with a total enrollment of 4,947 students. Schools were approached for participation; school officials then selected classrooms to participate. Students who participated in a previously administered survey (n = 1,978; 52% female; 83.1% Black), were recruited in class to participate in the 24-hour dietary recall (24HRD). This resulted in 718 participants. Participants received were entered into a drawing for an iPod for returning parental consent forms and then were given a pen for participation the 24HRD. All materials and protocols were approved by the Tulane University Institutional Review Board. Written informed consent was obtained from all subjects.
Data Collection
Research Assistants (RAs; master of public health students) completed an extensive training and assisted participants in conducting a single 24HDR using the Automated Self-Administered 24-Hour Dietary Assessment Tool-Kids (ASA24-Kids-2012) from January to April 2013. RAs were trained conduct the 24HRD in an interviewer-assisted method. Demographic (race/ethnicity, age, gender, grade) information was collected through a log and linked to the 24HDR. School food environment data (e.g. presence of vending machines or snack stores, number and types of food/beverages offerings in the cafeteria, advertisements) were collected through a tool developed for this study during the 24HDR data collection; though not necessarily on the exact days recall data were collected. Two scans of the cafeteria environment and were conducted by 2 trained observers on 2 different days.
Data Analysis
All analyses were conducted using SAS Institute version 9.4 (SAS Institute, Cary, NC, USA). The main outcome variable for the study was a dichotomous variable indicating if an individual skipped lunch for the day of the 24HDR (yes/no).
Associations between the outcome, environmental, and demographic variables were calculated using chi-square tests, accounting for school clustering (random effect) through a generalized linear mixed model modeling the dichotomous outcome of lunch skipping. Generalized estimating equation regression methods were used to test multilevel models including both school-level and individual-level effects.
A Healthy Eating Index (HEI)-2010 score was calculated for each individual from 24HRD data. 8 The HEI is a scoring system that ranges from 0 to 100 assessing 12 different categories. 9 Person-level scores were averaged and mean HEI scores for each category were compared between 2 groups (those who skipped lunch and those who ate lunch) using a t-test, also accounting for clustering at the school level.
Results
Among the sample, 88.3% were Black, 30.0% of the students were high school students and 64.3% were female. In total, 15.3% of respondents’ skipped lunch on the day the recall was completed (Table 1). No statistically significant associations between lunch skipping and race, grade, or gender or between school-level environmental variables were found (data not shown).
Descriptive Characteristics of Adolescents in Grades 7-12 in New Orleans, LA, Public Schools Participating in the 24-Hour Dietary Recall.
The total mean HEI score for students was 45.73. Adolescents who ate lunch had a mean HEI score of 46.6 compared to 41.7 for adolescents who did not each lunch (p < 0.001) and significantly higher HEI scores for whole fruits (p < 0.001), total vegetables (p = 0.020), total dairy (p = 0.003), and total protein (p < .001) (Table 2).
Mean Healthy Eating Index-2010 Scores Between Lunch Eaters and Lunch Skippers in Grades 7-12 in New Orleans, LA, Public Schools.
*SOFAAS, Solid fats, alcohol, and added sugars.
Discussion
HEI scores across the entire sample were quite low (46.6), consistent with previous research, 10 but much lower than scores associated with good health. 11 While the HEI scores of those who ate lunch in this study are about average for adolescents, this is well below scores associated with good health and HEI scores of those who skipped lunch were even lower. Data suggest that further work needs to be done to increase the quality of adolescents’ diets overall.
Diet quality may be particularly low among Black adolescents, who made up the majority of this sample, because of cost, convenience, and targeted marketing of unhealthy foods outside the school system. 12 Previous research found that non-Hispanic Black individuals are more likely to consume empty calorie food as snacks compare to those of other racial and ethnic groups, 13 thus lowering HEI scores. Given the results from previous studies, it is possible that participants in the present study were using empty calorie snacks to supplement hunger instead of eating lunch during the traditional lunch period.
Over 15% of the adolescents in this study skipped lunch, indicating their non-participation in the NSLP. While the NSLP provides a healthy lunch for adolescents and improves overall diet quality, 14 additional promotion for participation in the program may help reach adolescents who skip lunch. Research suggests that if students and parents believe in the nutritional value of the meal, students are more likely to participate. 15,16 Nationally, trends in participation drop from elementary school to high school. 17 Findings from the School Nutrition & Meal Cost Study indicate that one of the major reasons for nonparticipation is that they don’t like the taste. 17 These factors may have contributed to lunch skipping and should be explored further to understand how knowledge, attitudes, beliefs or other environmental determinants that may inform increased NSLP participation.
Strengths and Limitations
The results of this study should be interpreted in light of its limitations. The 24HDR data were self-reported, thus subject to the biases inherent with self-reported data, additionally one only day of dietary intake was collected and may not be representative of usual intake. There are also limitations due to the number of students who participated in the dietary recall compared to those eligible for participation. Yet, data provide some insight into the overall dietary quality of adolescents and the contribution or lunch skipping in a primary Black sample, though may not be generalizable to other populations or sub-groups.
So WHAT? Implications for health Promotion Practioners and Researchers
What is Already known on this Topic?
Diet quality is poor among adolescents in the U.S. Yet despite having access to meals at school through the National School Lunch Program, a proportion of adolescents skip lunch each day.
What does this Article add?
Because diet quality is lower among adolescence of color, this study provides a contribution to the understanding of diet quality among non-Hispanic Black adolescents. The results indicated that adolescents who skip lunch have poorer dietary quality than those who eat lunch. Yet, diet quality among adolescents in the sample still remains low.
What are the Implications for Health Promotion Practice or Research?
Health promotion practitioners can use the results of this study to encourage healthy dietary patterns among adolescents, including encouraging participation in the NSLP which has demonstrated higher nutritional quality that lunch coming from other sources. Health promotion researchers can use the results of this study by further exploring motivations for adolescent participation in the NSLP.
Footnotes
Authors’ Note
Carolyn C. Johnson conceived, designed and supervised the study; Leann Myers provided all of the statistical and design support and Spencer Clason analyzed the data under the supervision of Lori Andersen Spruance. Lori Andersen Spruance and Keelia O’Malley implemented the study by performing the field work; Lori Andersen Spruance, Spencer Clason, and Jordyn Hansen Burton wrote the first draft of the paper. All authors participated substantially in the review of the paper. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Tulane University Institutional Review Board. Written informed consent was obtained from all subjects.
Acknowledgments
The authors would like to acknowledge their school partners that enabled this work.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number U48-DP001948, from the CDC Prevention Research Center Special Interest Project SIP 12-063. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
