The Committee on evaluation of Children's Health of the National Research Council and Institute of Medicine have recently proposed a new conceptual model for children's health. In this model, the biological, behavioral and social and physical environmental influences on children's health operate within the broader context of policy and services. The food policies in schools are an important part of the broader context which affects children's health around obesity and physical activity .
In this survey of competitive food policies among the largest school districts in each state and the District of Columbia, we found that substantial changes to nutrition policies and foods offered at schools had occurred by 2004–2005. None of the districts, however, had adopted a policy that met all recommendations of the Institute of Medicine guidelines for the role of schools in preventing childhood obesity . Overall, the Los Angeles Unified School District, which passed the first new competitive food policy among the largest districts in the U.S., had the most comprehensive policy.
The majority of school district policies that had been adopted since 2002 sought to impact the type and quantity of competitive foods and beverages available by setting specific limits on content and portions. Portion sizes of foods were more often restricted than those of beverages.
Almost universally, the representatives of nutrition services interviewed described multiple changes in recent years to improve nutrition in the schools, such as offering more fresh fruits and vegetables and eliminating regular chips, fried foods, and sodas from the cafeteria à la carte menus. Assessing changes to the school lunch program was beyond the scope of this study, however many school districts noted implementation of part or all of the USDA Healthy School Meals Initiative  and the CDC Coordinated School Health Program Guidelines for School Health Programs to Promote Lifelong Healthy Eating . Based on these findings, we predict multiple positive changes in the next version of the School Health Policies and Programs Study (SHPPS), scheduled for 2006 .
School nutrition representatives cited the financial impact of limiting competitive foods as the major obstacle among school districts in adopting a competitive foods policy, specifically one that limits the sale of sodas. Anecdotal reports from some schools and districts show no detrimental financial impact in converting to healthy vending options . However, no published studies have examined this issue. Contrary to our expected findings, school districts with exclusive vending contracts were not less likely to have adopted a competitive foods policy. Both districts with exclusive vendor contracts (e.g. Coca-Cola or Pepsi), and those with individual school contracts, grappled with anticipated financial losses if soda sales were restricted. In fact, in school districts without a district-wide contract, nutrition services personnel frequently cited resistance from individual school principals in developing a policy restricting soda sales. Several school districts adopted new district-wide vending contracts in order to centralize purchasing and approval of foods and beverages sold. Many were placing the management of new contracts under the division of food or nutrition services in order to ensure better nutritional content of vended items.
Beyond the financial constraints, respondents identified several additional barriers to adopting and implementing a competitive food policy. One barrier was the lack of priority among school district administrators to address child nutrition. Respondents from nutrition services in some districts described their struggle to find support among administrators or school board members to champion the cause for improving nutrition, particularly given the burden of increasing requirements for achieving academic benchmarks. Another barrier in some districts were parents and students who resisted changes to the school's food and drink offerings, wanting to protect students' "free will" in choosing what they eat, even if it is unhealthy. These aforementioned barriers are likely to remain an issue for school districts as they move forward to adopt and implement Wellness Policies.
Successful implementation of new competitive foods policies in individual schools across the districts is relatively unknown. Nutrition services personnel often noted school non-compliance under current USDA requirements to keep vending machines off during mealtimes, depending on individual school administrators' oversight and commitment to compliance. In this study, less than one-third of the competitive food policies included clauses for monitoring and enforcement, and only two policies included consequences for non-compliance. Based on these findings, individual school compliance with the policies may depend heavily on the advocacy or support by each schools' administrators and staff, and may therefore vary widely from school to school. For those school districts that had opted to require time limitations for sale of competitive foods without content or portion size requirements, non-compliance could be a significant problem, and such policies would likely have little effect.
Current data about the potential impact of these new policy changes is limited. There is evidence that specific foods, especially soft drinks, may contribute to obesity [36, 37]. The degree to which eliminating these products from schools will directly impact rates of childhood obesity is uncertain, however. There is agreement among most national organizations about the elements of school nutrition policies that are likely to have an impact, and specific policy guidelines have been recommended by the National Alliance for Nutrition and Activity (NANA) , but no optimal school policy to reduce childhood obesity has been identified or tested. Nevertheless, the improved nutrition environment in which children are more likely to consume healthier foods should provide sufficient reason for enacting policies to improve school nutrition. A promising outcome of policy changes reported by district representatives in this study was to note that snack food and beverage vendors were changing product lines and developing new products in order to comply with new district and state policies.
Limitations of this study include possible incomplete or inaccurate information provided by nutrition and food services representatives. Every reasonable effort was made to verify information when nutrition personnel were uncertain about the district's policies or plans, particularly for vending, which is often managed by the purchasing department. Another study limitation is that changes seen in the larger urban school districts may not be generalizable to smaller school districts. Our sample included a few smaller districts in less populated states, which reported similar rates of new policies and faced similar challenges in incorporating policies. Finally, these data represent a summary of the largest districts for 2004–2005 school year and may not be current as policies and state legislation are changing continually.
In our study of nutrition policies for competitive foods in the largest school districts across the country in 2004–2005, we found more than one-third of districts had adopted new competitive food policies since 2002. Most policies required specific criteria for sales of healthier foods and beverages. For example, over 60% of policies prohibited sales of soda in all schools, which based on available data, may have the most potential for impacting childhood obesity [36, 37]. At the state level, eleven states had adopted new policies for competitive foods in schools, but only four of these had specific school nutrition guidelines.
None of the school district policies in 2004–2005 among states or their largest school districts met the Institute of Medicine's recommendations for schools' role in preventing obesity. Notable gaps in nutrition policies included not establishing portion sizes for both foods and beverages, not addressing fundraising or marketing food to students, and not measuring physical health indicators. In addition, most policies in 2004–2005 did not include guidelines for nutrition education or physical activity. Finally, few policies addressed monitoring or consequences for non-compliance.
The USDA is requiring all school districts participating in the National School Lunch Program to develop a Wellness Policy by 2006–2007, including nutrition guidelines for all foods available at school, and guidelines for physical activity and nutrition education . Based on the findings from this study, few large school districts across the country had heretofore adopted a comprehensive Wellness Policy. The requirement to develop a Wellness Policy represents a crucial and unprecedented opportunity for nutritionists, pediatricians, nurses, parents and others interested in child health, to influence school nutrition policies. As school districts adopt new Wellness Policies, studies are needed to assess outcomes, particularly impact on child well-being such as child nutrition and overweight, and financial impact for school districts and their nutrition services departments.