The Impact of 1 Year of Healthier School Food Policies on Students’ Diets During and Outside of the School Day

Published:September 10, 2018DOI:



      In 2012, Massachusetts implemented both the updated national school meal standards and comprehensive competitive food/beverage standards that closely align with current national requirements for school snacks.


      This study examines the impact of these combined standards on school meal and snack food selections, as well as food choices outside of school. In addition, this study examines the impact of these standards on nutrients consumed.


      The NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) Study was an observational cohort study conducted among students from spring 2012 to spring 2013.


      One hundred sixty students in 12 middle schools and high schools in Massachusetts completed two 24-hour recalls before (spring 2012) and after implementation (spring 2013) of the updated standards.

      Main outcome measures

      Changes in school meals, competitive food, and after-school snack selection, as well as nutrients consumed outside of school were examined.

      Statistical analyses performed

      Logistic regression and mixed-model analysis of variance were used to examine food selection and consumption.


      After implementation, 13.6% more students chose a school meal (70.1% vs 56.5%; P=0.02). There were no differences in competitive food purchases but a significant decrease in the number of after-school unhealthy snacks consumed (0.69 [standard error=0.08] vs 1.02 [standard error=0.10]; P=0.009). During the entire day, students consumed, on average, 22 fewer grams of sugar daily after implementation compared with before implementation (86 g vs 108 g; P=0.002).


      With the reduction in the number of unhealthy school snacks, significantly more students selected school meals. Students did not compensate for lack of unhealthy snacks in school by increased consumption of unhealthy snacks outside of school. This provides important new evidence that both national school meal and snack policies may improve daily diet quality and should remain strong.


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      1. Food Research Action Center (FRAC). Facts: National school lunch program. Accessed July 2, 2017.

        • Finkelstein D.M.
        • Hill E.L.
        • Whitaker R.C.
        School food environments and policies in US public schools.
        Pediatrics. 2008; 122: e251-e259
        • Guthrie J.F.
        • Newman C.
        • Ralston K.
        • Prell M.
        • Ollinger M.
        Nutrition Standards for Competitive Foods in Schools.
        Washington, DC: US Department of Agriculture, Economic Research Service, 2013
        • Fox M.K.
        • Gordon A.
        • Nogales R.
        • Wilson A.
        Availability and consumption of competitive foods in US public schools.
        J Am Diet Assoc. 2009; 109: S57-S66
      2. Healthy, Hunger-Free Kids Act of 2010. Public Law 111-296, 124 Stat, 3183.

        • Cohen J.F.
        • Richardson S.
        • Parker E.
        • Catalano P.J.
        • Rimm E.B.
        Impact of the new U.S. Department of Agriculture school meal standards on food selection, consumption, and waste.
        Am J Prev Med. 2014; 46: 388-394
        • Schwartz M.B.
        • Henderson K.E.
        • Read M.
        • Danna N.
        • Ickovics J.R.
        New school meal regulations increase fruit consumption and do not increase total plate waste.
        Child Obes. 2015; 11: 242-247
        • United States Department of Agriculture
        Nutrition standards in the National School Lunch and School Breakfast Programs.
        Federal Register. 2012; 77
      3. United States Department of Agriculture. Smart Snacks in School: USDA’s “All foods sold in schools” standards. Accessed June 14, 2017.

        • Hoffman J.A.
        • Rosenfeld L.
        • Schmidt N.
        • et al.
        Implementation of statewide competitive food and beverage standards: The Massachusetts NOURISH Study (Nutrition Opportunities to Understand Reforms Involving Student Health).
        J Acad Nutr Diet. 2015; 115: 1299-1307
        • Gorski M.T.
        • Cohen J.F.
        • Hoffman J.A.
        • et al.
        Impact of nutrition standards on competitive food quality in Massachusetts middle and high schools.
        Am J Public Health. 2016; 106: 1101-1108
        • Rosenfeld L.E.
        • Cohen J.F.
        • Gorski M.T.
        • et al.
        How do we actually put smarter snacks in schools? NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) conversations with food-service directors.
        Public Health Nutr. 2017; 20: 556-564
        • Cohen J.F.
        • Gorski M.T.
        • Hoffman J.A.
        • et al.
        Healthier standards for school meals and snacks: Impact on school food revenues and lunch participation rates.
        Am J Prev Med. 2016; 51: 485-492
        • McPherson R.S.
        • Hoelscher D.M.
        • Alexander M.
        • Scanlon K.S.
        • Serdula M.K.
        Dietary assessment methods among school-aged children: Validity and reliability.
        Prev Med. 2000; 31: S11-S33
      4. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey (NHANES), 2016. Accessed July 2, 2017.

      5. ASA24 [computer program]. Version 2011. Bethesda, MD: National Institutes of Health; Accessed March 1, 2012.

      6. SAS PROC GENMOD [computer program]. Version 9.4, Cary, NC: SAS Institute; 2013.

        • Briefel R.R.
        • Crepinsek M.K.
        • Cabili C.
        • Wilson A.
        • Gleason P.M.
        School food environments and practices affect dietary behaviors of US public school children.
        J Am Diet Assoc. 2009; 109: S91-S107
        • Woodward-Lopez G.
        • Gosliner W.
        • Samuels S.E.
        • Craypo L.
        • Kao J.
        • Crawford P.B.
        Lessons learned from evaluations of California's statewide school nutrition standards.
        Am J Public Health. 2010; 100: 2137-2145
        • Fung T.T.
        • Malik V.
        • Rexrode K.M.
        • Manson J.E.
        • Willett W.C.
        • Hu F.B.
        Sweetened beverage consumption and risk of coronary heart disease in women.
        Am J Clin Nutr. 2009; 89: 1037-1042
        • Malik V.S.
        • Schulze M.B.
        • Hu F.B.
        Intake of sugar-sweetened beverages and weight gain: A systematic review.
        Am J Clin Nutr. 2006; 84: 274-288
        • Hu F.B.
        • van Dam R.M.
        • Liu S.
        Diet and risk of type II diabetes: The role of types of fat and carbohydrate.
        Diabetologia. 2001; 44: 805-817
        • Fox M.K.
        • Dodd A.H.
        • Wilson A.
        • Gleason P.M.
        Association between school food environment and practices and body mass index of US public school children.
        J Am Diet Assoc. 2009; 109: S108-S117
        • Jahn J.L.
        • Cohen J.F.
        • Gorski-Findling M.T.
        • et al.
        Product reformulation and nutritional improvements after new competitive food standards in schools.
        Public Health Nutr. 2018; 21: 1011-1018


      J. F. W. Cohen is an assistant professor, Department of Health Sciences, Merrimack College, North Andover, MA, and an adjunct assistant professor, Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA.


      M. T. Gorski Findling is a post-doctoral fellow, Interfaculty Initiative in Health Policy, Harvard Graduate School of Arts and Sciences, Harvard University, Cambridge, MA.


      L. Rosenfeld is a scientist and lecturer, Institute for Child, Youth, and Family Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA.


      L. Smith is the managing director, FSG, Boston, MA.


      E. B. Rimm is a professor, Departments of Nutrition and Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA.


      J. A. Hoffman is an associate professor, Department of Applied Psychology, Bouvé College of Health Sciences, Northeastern University, Boston, MA.