Abstract
The Smart Snacks in School standards (hereafter, Smart Snacks) were issued in 2013 with the aim of improving students' dietary intake behaviors. Goals of Smart Snacks included reducing total energy intake, consumption of solid fats and added sugars, and sodium intake. Smart Snacks standards were required to be implemented by the start of the 2014 to 2015 school year at all US schools participating in federal child nutrition programs. To examine the association of state laws that specifically direct schools to implement Smart Snacks with student dietary consumption outcomes. This cross-sectional study used nationally representative data collected in the 2014 to 2015 school year as part of the School Nutrition and Meal Cost Study. Students in grades 1 through 12 (ages approximately 6-18 years) were randomly selected from 310 public schools in 30 US states and the District of Columbia. Analytic weights were applied and all percentages reported are weighted. Analyses were conducted from March 1, 2018, to December 12, 2019. State laws requiring schools to implement Smart Snacks. A 24-hour recall was used to assess student dietary intake as daily kilocalories consumed as (a) total energy, (b) solid fats and added sugars combined, (c) solid fats, or (d) added sugars. Milligrams of daily sodium consumption were also computed. Among 1959 students (mean [SD] age, 11.9 [3.5] years; 1014 [50.9%] boys), 420 students (22.5%) attended school in a state with Smart Snacks laws, and 528 students (26.1%) consumed snacks obtained at school. In covariate-adjusted models, total energy intake did not vary based on state law. Adjusted mean daily kilocalories from solid fats and added sugars was significantly lower among students in states with laws (508.7 [95% CI, 463.0 to 554.4] kcal) than among students in states without laws (562.5 [95% CI, 534.3 to 590.8] kcal; difference, -53.9 [95% CI, -104.5 to -3.2] kcal; P = .04). Consumption of sodium did not differ by state law. Kilocalories from solid fats contributed more to the difference than kilocalories from added sugars (-37.7 [95% CI -62.8 to -12.6] kcal vs -16.2 [95% CI, -51.3 to 19.0] kcal). These findings suggest that students in states with laws requiring schools to implement Smart Snacks had better dietary intake than students in states without laws, consuming a mean of 53.9 fewer kilocalories from solid fats and added sugars per day, after adjusting for covariates. State-level policy mechanisms may support schools' implementation of federal standards in ways that are associated with healthier diets among children and adolescents.
Highlights
Dietary intake is the primary modifiable behavioral risk factor associated with morbidity and mortality among people in the United States, with unhealthful dietary habits associated with cardiovascular disease, stroke, diabetes, and obesity.[1,2] The Dietary Guidelines for Americans provide science-based advice to reduce these risks through optimal diets
Adjusted mean daily kilocalories from solid fats and added sugars was significantly lower among students in states with laws (508.7 [95% CI, 463.0 to 554.4] kcal) than among students in states without laws (562.5 [95% CI, 534.3 to 590.8] kcal; difference, −53.9 [95% CI, −104.5 to −3.2] kcal; P = .04)
These findings suggest that students in states with laws requiring schools to implement Smart Snacks had better dietary intake than students in states without laws, consuming a mean of 53.9 fewer kilocalories from solid fats and added sugars per day, after adjusting for covariates
Summary
Dietary intake is the primary modifiable behavioral risk factor associated with morbidity and mortality among people in the United States, with unhealthful dietary habits associated with cardiovascular disease, stroke, diabetes, and obesity.[1,2] The Dietary Guidelines for Americans provide science-based advice to reduce these risks through optimal diets. Large-scale studies conducted in the early 2000s reported that sugar-sweetened beverages, other sugary foods, and snacks high in fat and sodium were common in schools across the United States[9,10,11] and significantly affected students’ consumption of empty calories. As directed by the Healthy, Hunger-Free Kids Act of 2010,12 the US Department of Agriculture (USDA) issued revised standards for school meals in 2012 and new standards for all foods and beverages sold in other locations at schools in 2013.13 These standards aligned with the Dietary Guidelines for Americans[3] and science-based recommendations.[14] The latter, named the Smart Snacks in School standards (hereafter, Smart Snacks), aimed to increase the availability and consumption of healthful options such as fruit, vegetables, whole grain foods, and low-fat dairy and to reduce availability and consumption of high-calorie items with high amounts of fat, added sugar, and sodium. Smart Snacks was required to be implemented in schools by July 1, 2014.13
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