Project BreakFAST: Rationale, design, and recruitment and enrollment methods of a randomized controlled trial to evaluate an intervention to improve School Breakfast Program participation in rural high schools.

Abstract

A 20-year trend documents an increase in youth routinely skipping breakfast [1]. Breakfast skipping increases with age from 20% among children age 9–13 to 36% among adolescents age 13–18 [2]. Minority youth are sometimes but not always reported to have higher rates of skipping breakfast compared with their white peers [3], [4], [5] and girls are more likely to skip breakfast than boys, especially to lose weight [3], [6], [7]. Observational studies indicate breakfast eaters have healthier diets [8], [9], make better food choices, and are less likely to eat high fat snacks [10], [11]. Establishing healthy weight promoting behaviors during adolescence, such as eating breakfast is especially important as the average American gains 30 pounds between 18 and 35 years of age [12]. Cross-sectional [13] and observational [14] studies provide evidence of an increase in body mass index (BMI) among breakfast skippers. Eating breakfast and particularly the school provided breakfast is also associated with an improvement in cognition and academic outcomes among adolescents. This benefit may be more realized by undernourished and urban, minority youth, suggesting a promising strategy for closing the achievement gap [15], [16], [17]. Students in rural schools are more likely to attend small schools, live in poverty, be food insecure, be eligible for free or reduced priced school meals, and come to school unprepared to learn compared to students from urban or suburban areas [18]. A 2015 meta-analysis found that rural youth have 26% greater odds of obesity, compared to urban children [19]. Very little research has been done on how to improve the school food environment in small town and rural schools even though these environments are lagging behind urban and suburban schools [20]. The few studies on rural schools have focused on younger students [21], the school lunch program [22], or competitive food options [23]. The purpose of this clinical trial is to evaluate the effectiveness of a school-based intervention designed to increase participation in the National School Breakfast Program (SBP) among rural high school students by improving physical access to the program, changing social norms, and engaging in promotional activities.