RESEARCH

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UproDuschool-aged children in the United States (33% of 6- to11-year-olds and 34% of 12- to 19-year-olds) was over-

R.search, Inc, Washington, DC. A. Wilson is a senior pro-gramming analyst, Mathematica Policy Research, Inc,Cambridge, MA. P. M. Gleason is a senior fellow, Math-emS

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Di0dweight or obese, accounting for 25 million American chil-dren (5,6). Children from low-income or minority familiesare more likely to be overweight and to receive free orreduced-price school meals than children from higher-income non-Hispanic white families (7-9).

Obesity is a multifactorial, complex issue, and a childsweight status is affected by energy intake and expendi-ture over the course of a day and over time (1,4,6). Schoolsplay an important role in shaping the dietary and phys-ical activity behaviors of children (1-3). School food poli-cies affect childrens access to foods available in vendingmachines or served la carte as alternatives to eating aschool meal. These competitive foods are often low-nu-trient and energy-dense, and thus provide excess energy

atica Policy Research, Inc, Geneva, NY.TATEMENT OF CONFLICT OF INTEREST: Seege S89.ddress correspondence to: Ronette R. Briefel, DrPH,, Mathematica Policy Research, Inc, 600 Marylande, Ste 550, Washington, DC 20024-2512. E-mail:iefel@mathematica-mpr.comddress reprint requests to: Jackie Allen, Mathematicalicy Research, Inc, PO Box 2393, Princeton, NJ 08543-93. E-mail: jallen@mathematica-mpr.comublished by Elsevier Inc. on behalf of the Americanetetic Association.002-8223/09/10902-1003$0.00/0oi: 10.1016/j.jada.2008.10.064

Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION S79rrent Research

onsumption of Low-Nutoods and Beverages at Sther Locations among Sarticipants and Nonpart

NETTE R. BRIEFEL, DrPH, RD; ANDER WILSON; PHILIP M. GLEASO

STRACTkground Access to foods and beverages on school cam-

ses, at home, and other locations affects childrens dietality, energy intake, and risk of obesity.jectives To describe patterns of consumption of emptyorieslow-nutrient, energy-dense foods, includinggar-sweetened beveragesby eating location amongtional School Lunch Program (NSLP) participants andnparticipants.ign Cross-sectional study using 24-hour dietary recall

ta from the 2004-2005 third School Nutrition Dietarysessment Study.jects/setting A nationally representative sample of14 children in grades one through 12, including 1,386LP participants.tistical analyses performed Comparisons, using t tests, ofproportionof childrenconsuming low-nutrient, energy-

nse foods and beverages, mean daily energy and energym low-nutrient, energy-dense foods, and energy den-y by NSLP participation status.ults On a typical school day, children consumed 527pty calories during a 24-hour period. Eating at homevided the highest mean amount of energy from low-

trient, energy-dense foods (276 kcal vs 174 kcal atool and 78 kcal at other locations). NSLP participantssumed less energy from sugar-sweetened beverages at

R. Briefel is a senior fellow, Mathematica Policy Re-nt, Energy-Denseool, Home, andool LunchipantsD

ool than nonparticipants (11 kcal vs 39 kcal in elemen-y schools and 45 kcal vs 61 kcal in secondary schools,0.01), but more energy from low-nutrient, energy-

nse solid foods such as french fries and higher-fatked goods in secondary schools (157 kcal vs 127 kcal,0.01). Participants were not more likely to consume

gar-sweetened beverages or low-nutrient, energy-nse foods at home or other locations. School lunch par-ipants consumption at school was less energy-densen nonparticipants consumption at school (P0.01).ergy density was highest for consumption at locationsay from home and school.clusions Improving home eating behaviors, where thegest proportion of total daily and energy from low-trient, energy-dense foods are consumed (especiallym sugar-sweetened beverages, chips, and baked goods)warranted. At schools, consumption of energy from-nutrient, energy-dense foods may be reduced by lim-g access to competitive foods and beverages, enforcing

ong school wellness policies, and minimizing the fre-ency of offering french fries and similar potato prod-ts and higher-fat baked goods in school meals or late.m Diet Assoc. 2009;109:S79-S90.

nderstanding the role of eating behaviors and schoolmeal program participation in childrens food con-sumption patterns is critical to addressing and im-

ving the weight status of Americas children (1-4).ring the period between 2003 and 2006, one in three

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S80ative to their nutrient value (10-13). Examples of low-trient and energy-dense items are sugar-sweetenedverages, salty/high-fat chips, high-fat baked goods, andsserts. Some low-nutrient and energy-dense items,ch as breakfast pastries, brownies, cookies, and frenches, may also be available to children as part of a schoolal. Research has shown that limiting access to low-trient and energy-dense foods at school reduces thesumption of these items in schools (2,3,12). Further,ess to such junk foods or empty calories has beenated to increased energy intake at school and higher bodyss index (BMI) among middle school children (14).eyond the campus, childrens access to healthful or

s healthful foods and beverages in the home and near-ool or community affects their overall diet. There isong evidence linking particular dietary behaviors to

risk of childhood overweight. Consumption of fastds and low-nutrient and energy-dense foods and bev-ges, particularly sugar-sweetened beverages, is prev-nt among US children and adolescents and can lead toreased energy intake, increased BMI, or obesity, de-

nding upon energy expenditure (15-25). Equally impor-t is that these low-nutrient and energy-dense items dis-ce more healthful alternatives such as fresh fruits andetables and low-fat milk and can reduce childrens diet

ality and intake of essential nutrients (13,15,17,19,24).everal other factors are associated with childhoodrweight and obesity, including social influences, fam-resources, knowledge and attitudes about diet, the

quency of eating and snacking, and genetics (1,17,26-). Increases in childrens BMI and overweight in the80s and 1990s have been accompanied by increases in

frequency of eating away from home and by shifts intypes of foods and beverages and portion sizes con-

med (1,17,32-35).tudies of breakfast and adiposity have found varyingults across age and sex subgroups (27). Skippingakfast may be a risk factor for increased adiposityong older children or adolescents and appears to bere important for girls than for boys (27). There isited information on eating frequency and adiposityong children. Cross-sectional studies have found nonificant relationship, but a longitudinal study of girlsed 9 to 19 years found that meal frequency was signif-ntly and inversely related to BMI (28,30). Snackingquency does not appear to be related to childhoodiposity, but the evidence is clouded by the lack of asistent definition of snack across research studies).n 2007 more than 30 million children participated inNational School Lunch Program (NSLP) (9). The ev-

nce linking participation in school meals to obesity hasen weak or mixed. A 2004 review by Fox and colleagues) found no definitive evidence linking NSLP participa-n and overweight. Studies published since that 2004iew found either no relationship or suggestive evi-

nce among only the youngest elementary school stu-nts (37-39). Research using national data collected in

2004-2005 third School Nutrition Dietary Assessmentdy (SNDA-III) found that usual participation in the

hool Breakfast Program (SBP), but not the NSLP, wasociated with a lower BMI (39). Gleason and Dodd (39)

ggest that eating breakfast (ie, not skipping breakfast)February 2009 Suppl 1 Volume 109 Number 2d energy distributions across the day are possible ex-nations.

childs food environment can be viewed as consistingschool, home, and other locations away-from-home/oolaway locations. One of the nutritional benefitsschool meal programs is that certain low-nutrient,

ergy-dense foods and beverages (eg, soft drinks anddy) cannot be part of the meals. Participants presum-

ly consume less of these kinds of foods and beverages atool than do nonparticipants. However, school mealsy contain some types of low-nutrient, energy-denseds (eg, french fries, pastries, and high-fat bakedds), and frequent consumption of these items by par-

ipants may diminish the nutritional benefits of schoolal participation. Alternatively, if school meal partici-nts consume fewer low-nutrient, energy-dense foodsd beverages at school, it may be that they make up forse at school differences by consuming more low-nu-

ent, energy-dense items off campus, either at home orother locations. Understanding the dietary patterns ofool meal participants and nonparticipants will informpolicy debate about how best to maximize the benefits

school meal programs and identify areas to target toprove childrens eating behaviors.his article uses nationally representative, cross-sec-

nal data from the 2004-2005 SNDA-III to describe theting patterns of public school lunch program partici-nts and nonparticipants. We focus on three componentshildrens diets: meal and snack patterns; consumption of-nutrient, energy-dense foods and beverages (eg, sugar-

eetened beverages); and location (ie, school, home, away).e fundamental motivation for this descriptive analysis istest the research hypothesis that children who partic-te in a school lunch program are likely to consumeportionately fewer sugar-sweetened beverages and-nutrient, energy-dense items at school, and compen-e for their school behavior by eating proportionatelyre of these items at home and away locations. Becausey observed relationship between school lunch partici-tion and dietary patterns could be driven by differencesthe characteristics of participants and nonpartici-

nts, such as socioeconomic status, no causal inferencesbe drawn. However, exploring the relationship be-

een school lunch participation and dietary patternsay from school is a first step in understanding thetary patterns of school lunch participants and nonpar-ipants leading to more in-depth analysis in the future.

also compare childrens energy intake and energynsity across food environments (ie, school, home, oray) to gain a better understanding of consumptiontterns in different food environments and their poten-l association with risk of obesity.

THODSple Design

e SNDA-III data set is based on a nationally represen-ive, cross-sectional sample of students at US publicools participating in the NSLP. Data were collected

ring spring 2005. The sample design included a strat-d sample of school districts, schools within districts,d children (or students) within schools. The final sam-

includes 2,314 children in grades one through 12,

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Olftributed among 287 schools. Twenty-fourhour di-ry recalls, child surveys, and parent surveys werelected for each selected child.bout one third of school children sampled were in

mentary school (most in grade five or six); two thirdsre in middle school or high school. Because overallal and snack patterns did not differ significantly be-een middle and high school, these groups were com-ed as secondary schools to simplify data presentation.erall, 62% of children participated in the NSLP on aical school day and 18% in the SBP (40). Most studentso participate in the SBP on a given day also participatethe NSLP, though the reverse is not necessarily true.out 54% of children were non-Hispanic white, 22%spanic, 17% non-Hispanic African American, and 7%er race/ethnicity (40).

ta Collectiondata collection instruments and procedures were re-

wed and approved by the US Department of Agricul-e (USDA), Food and Nutrition Service, the 2004 Edu-ion Information Advisory Committee of the Council ofief State School Officers, and the Office of Manage-nt and Budget. In addition, the study worked with anytitutional review process a school district required.ne 24-hour recall was collected for each child and a

ond days intake on a subsample (with the help ofrents for elementary school children) using the USDAtomated Multiple Pass Method software (version 2.3,03, USDA, Agricultural Research Service, Beltsville,

). Dietary recalls were processed with the SurveyNeting system (version 3.14, 2004, USDA, Agricultural

search Service) and the Food Nutrient Database foretary Studies (version 1.0, 2004) (41). The responsee among children selected for data collection was 63%). Children and their parents responded to separate

rveys to obtain information on household and otherdent characteristics. The response rate for the parenterview, given that the child had completed the in-ool interview, was 89% (40). Additional details on datalection are described elsewhere (40). The dietary find-s in this paper are group means based on a single daysake per sampled child.

alytic Methodskey aspect of the analysis presented here comparesildren who participate in the NSLP to those who do not.rticipation was defined using target day participation;t is, whether the child consumed a school lunch on the

y in which the 24-hour dietary recall was completed.ildren in food-based menu-planning schools werented as participating in NSLP if either the child con-

med at least three of the required five food groups (ie,e grain, one mean/meat alternate, two fruits and/oretables, and one milk) and all three were on the schoolnu for the target day, or if the child reported consum-at least one of the required five groups and reportedsuming a school lunch on the target day. Children in

trient standard menu-planning schools were countedparticipating in NSLP if either the child consumed atst one entre and one side, both of which were on theFebruary 2009 Sool menu for the target day, or the child reportedsuming one entre or one side that was on the schoolnu for the target day and also reported consuming aool lunch for that day (42).e classified foods and beverages as low-nutrient, ener-

dense items if they were energy-dense and low in nutri-ts or were of minimal nutritional value, as defined byDA school meal regulations (43). All beverages reportedthe study were grouped into seven mutually exclusiveegories, including sugar-sweetened beverages, flavoredlk, unflavored milk (whole/2%, skim/1%), 100% fruitce, diet/low-energy drinks, and bottled water (44). Fors analysis, we considered only sugar-sweetened bever-es (including soda, fruit-flavored sweetened beverages,ergy and sports drinks, and sweetened iced teas) aseting our criteria of a low-nutrient, energy-dense bever-

e.e classified low-nutrient, energy-dense solid foods

o five mutually exclusive categories: higher-fat bakedds, including muffins and desserts such as cakes,kies, and brownies; candy (all types) and sweetened

m; dairy-based desserts (eg, ice cream); french friesd similar potato products; and chips and salty snacks, potato chips, corn chips, and buttered popcorn).ods in all five groups were included as low-nutrient,ergy-dense items for this analysis.o determine eating patterns, we used child- (or re-ndent-) defined eating occasions. Breakfasts, lunches,

d suppers/dinners were reported as such. Snacks in-ded foods reported as snacks, drinks, and extendedsumption (ie, typically a drink consumed over a long

riod of time). Some children reported more than oneakfast, lunch, or supper/dinner (eg, a breakfast at

me and a breakfast at school). Children were allowedltiple meals of the same meal name, but each childs counted once in the population estimates. If a childorted eating a school lunch they were considered aool lunch participant even if they reported a secondch at another location.he 24-hour dietary recall interviews captured thee and name of each eating occasion, the foods and

verages reported at each eating occasion, and therce from which each item was obtained. We used this

ormation to deduce where each eating occasion wassumed and to assign the location of eating occasions asool, home, or away in the following manner:

or each food or beverage reported in the 24-hour re-all, a child was asked if the item was consumed atchool. All foods reported as consumed at school, and allther items consumed at the same eating occasion as aood a child reported as consumed at school, were con-idered to be consumed at school.oods that were not eaten at school and were obtained

rom home, a friend/classmate (excluding entire classes)r neighbor, or a relative were considered to have beenonsumed in the home environment. In addition, anyood consumed at the same eating occasion time as aood obtained from one of these sources was also con-idered to have been eaten in the home environment.ther foods were considered to have been consumed at

ocations away from home and school. These includedoods obtained from restaurants, non-school vendingupplement to the Journal of the AMERICAN DIETETIC ASSOCIATION S81

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cross all sample children, 31,108 food items were re-rted (unweighted count); 28% of reported items weretained and consumed at school; 8% were brought fromme and consumed at school; 2% were obtained from anay location and consumed at school; and 1% were

tained from school and consumed elsewhere. Aboutlf (51%) of reported items were obtained and consumedhome and 10% obtained and consumed at away loca-ns.nergy density is the amount of energy in foods con-

med by individuals per gram of weight of those foods,45). Energy density was calculated by summing theal number of kilocalories consumed by individuals at aation and dividing by the total number of grams con-med at that location. Most children consumed only oneverage at a meal or snack; it was important to includebeverages in the energy density calculation becauseluding low- and nonenergy-containing beverages inenergy density calculation would provide an artifi-

lly high estimate of the energy density of a meal orack. Therefore, energy density was calculated based onal consumption of all foods and beverages. For eachild, energy density was calculated for each location.ans were taken across this child-location-level vari-

le. Mean daily energy density was calculated for thel sample, whereas mean energy density by locations calculated only for the sample that consumed at leaste item at that location.

tistical Methodsconducted descriptive analyses of the meal and snack

tterns of children; mean energy density; energy for-nutrient, energy-dense foods and sugar-sweetened

verages; and total energy by location. All statisticalcedures were completed using Statistical Analysis

ftware (SAS) (version 9.1, 2004, SAS Institute, Cary,), and SUDAAN (release 9, 2005, Research Triangletitute, Research Triangle Park, NC), incorporating ap-priate sampling weights for school children and de-n effects caused by the SNDA-III complex sample de-n. We conducted t tests to determine whether therere statistically significant differences in eating pat-ns, energy intake, and energy density between schoolch program participants and nonparticipants. Differ-

ces were considered statistically significant at P0.05;alues were not adjusted for multiple comparisons be-se the analysis was exploratory rather than confirma-y (46). None of the analyses controlled for family orild characteristic other than school meal participation.

ULTSal and Snack Patternsble 1 shows the proportion of children reporting eatingakfast, lunch, supper/dinner, and snacks by locationsumed (note that breakfast and lunch include allals, not only reimbursable school meals). The majoritychildren reported eating breakfast, supper/dinner, andFebruary 2009 Suppl 1 Volume 109 Number 2least one snack at home. Nearly all children (91%)sumed lunch at school, whereas 23% consumed break-t, and 40% reported at least one snack at school. NSLPrticipants consumed breakfast and lunch at schoolre frequently than nonparticipants (P0.01). Break-t was the meal most commonly skipped by children in

th elementary and secondary school. On an averageool day, the most common eating occasion away fromool or home was a snack (17%), followed by supper/ner (13%).

terns of Consumption of Sugar-Sweetened Beverages and-Nutrient, Energy-Dense Solid Foods

ble 2 shows the proportion of children consuming sugar-eetened beverages; low-nutrient, energy-dense solidds; and any low-nutrient, energy-dense solid food orgar-sweetened beverage, by location consumed. Over-, 68% of children consumed sugar-sweetened beveragessome location during the day, about half (50%) con-

med sugar-sweetened beverages at home, and onerth (25%) at school. Most children (88%) consumede amount of a low-nutrient, energy-dense solid food,

d nearly all (95%) consumed empty calories from a-nutrient, energy-dense item over the course of a 24-

ur period (on a Monday through Friday).n elementary schools, NSLP nonparticipants werere than four times as likely as participants to consume

gar-sweetened beverages at school (38% vs 9%,0.01); however, there were no significant differences be-

een the proportion of participants and nonparticipantso reported consumption of low-nutrient, energy-denseid foods, or low-nutrient, energy-dense solid foods andar-sweetened beverages combined, at school, home, oray (Table 2). The consumption patterns of secondaryool NSLP participants and nonparticipants at homere similar, although nonparticipants were more likelyconsume sugar-sweetened beverages at school (38% vs%, P0.01) and away (21% vs 15%, P0.01). Secondaryool NSLP participants were more likely to consume

y low-nutrient, energy-dense solid food at school (67%55%, P0.01), contributing to being more likely tosume any low-nutrient, energy-dense item at school% vs 67%, P0.05). Secondary school lunch partici-

nts were less likely to consume any low-nutrient, en-y-dense item at other locations away from school and

me (23% vs 30%, P0.05).

an Daily Energy Intake, Energy Density, and Energy from-Nutrient, Energy-Dense Items

e previous section describes the proportion of childrensuming various types of low-nutrient, energy-dense

ms, but it is also important to consider the amounts ofse items consumed, because both contribute to the

pulation estimates of average energy consumed from-nutrient, energy-dense items. Table 3 shows mean

ergy and mean energy density for total diet (ie, all foodsd beverages) and for dietary components (eg, sugar-eetened beverages; low-nutrient, energy-dense solidds; and any low-nutrient, energy-dense item) amongLP participants and nonparticipants by the location inich the foods were consumed. Table 3 also shows the

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aDinbNcIdS*S**portion of energy consumed at school, home, or otherations over the course of a typical school day. On av-ge across all children, 35% of daily energy was con-

med at school. Among NSLP participants, the propor-n was 40% in elementary school and 38% in secondaryool (Table 3). Among children who participate in bothSBP and the NSLP, up to 51% of daily energy was

sumed at school; the majority of daily energy (47%)s also obtained at school (data not shown).mong elementary school children, there were no sig-cant differences in the amount of energy consumed atool, away, or over the entire day; however, at home,mentary school participants consumed an average of9 kcal fewer than nonparticipants (1,105 kcal vs 1,224l, respectively, P0.05). Among secondary school chil-n, NSLP participants consumed more energy at school8 kcal vs 533 kcal, P0.01) and over the entire day250 kcal vs 2,076 kcal, P0.01), but consumed lessergy away (208 kcal vs 309 kcal, P0.01). Mean energysumed at home was not different between secondaryool participant groups.verall, children consumed an average of 527 kcal fromlow-nutrient, energy-dense items over the course of a

able 1. Meal and snack patterns among participants and nonpart004-2005a

ting occasion

Elementary School

NSLPparticipantsb

(n531)

NSLPnonpart(n201

4tal daily consumption (% eating)

reakfast 901.6 922.6nch 1000* 952.0upper/dinner 961.0 952.2nacksc 951.4 932.6onsumption at school (% eating)reakfast 343.6** 82.4nch 1000** 902.8upper/dinner 31.0d 21.0d

nacksc 403.2** 566onsumption at home (% eating)reakfast 573.4** 843.6nch 0.70.6* 62.0d

upper/dinner 821.8 833.2nacksc 842.0 793.2onsumption away from school/home (% eating)

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nch 0.10.1* 41.4upper/dinner 111.4 122.8nacksc 151.8 163.2

ata are from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recalthe 24-hour dietary recall interview. Tabulations are weighted to be nationally representSLP participation is participation on the target recall day.ncludes eating occasions reported by the child (or respondent) as a snack or a drink.tatistic is potentially unreliable due to a coefficient of variation 30%.ignificantly different from nonparticipants at 0.05 level.Significantly different from nonparticipants at 0.01 level.February 2009 Sy (Table 3). In elementary schools, NSLP participantssumed less than one third the mean amount of energym sugar-sweetened beverages as nonparticipants (11l vs 39 kcal, P0.01). In the other locations, there aresignificant differences in sugar-sweetened beveragesumption for elementary school participants vs non-

rticipants. In secondary schools, NSLP participantssumed significantly less energy from sugar-sweetened

verages at school (45 kcal vs 61 kcal, P0.01) andnificantly fewer away (34 kcal vs 52 kcal, P0.05).wever, NSLP participants in secondary schools con-med more energy from low-nutrient, energy-dense solidds at school (157 kcal vs 127 kcal, P0.01), but lessergy from such foods away (44 kcal vs 70 kcal, P0.05).igures 1 and 2 show the mean energy intake fromcific categories of low-nutrient, energy-dense items atool. On average, NSLP participants consumed signif-ntly more energy from french fries and similar potatoducts in elementary school and significantly less from

gar-sweetened beverages, candy, and chips/saltyacks compared with nonparticipants (Figure 1). Ele-ntary school participants had a higher intake of chips/ty snacks at home compared with nonparticipants

ts in the National School Lunch Program (NSLP), school year

Secondary School

All (n2,314)ts

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%standard error 3

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242** 131.6 231.81000** 682.8 910.8

10.4d 20.6d 20.4362.4 372.6 402.0

542.6** 622.0 612.020.8** 91.4 40.6

791.8 752.0 801.0851.4 821.4 831.0

10.4d** 30.6 20.40.80.4d** 111.4 30.4131.4 162.0 130.8202.0 201.8 171.0

iew, school year 2004-2005. Meals and snacks are defined by child or respondentf children in public NSLP schools. Sample sizes are unweighted.daconfrokcanoconpaconbesigHosufooen

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S844.2 kcal vs 194.3 kcal, P0.05, data not shown),rtially offsetting an observed difference at school3.1 kcal vs 517.8 kcal, P0.01). No other differ-

ces were observed for elementary school childrens con-mption of any other low-nutrient, energy-dense solidd categories at home or at away locations.n average, NSLP participants consumed significantly

re energy from french fries/similar potato products,ked goods, and dairy-based desserts in secondaryool and significantly less from sugar-sweetened bev-ges and salty snacks compared with nonparticipantsgure 2). Among secondary school children, there weredifferences in mean energy intake from low-nutrient,

ergy-dense solid foods at home between NSLP partici-nts and nonparticipants; however, energy consumedm french fries/similar potato products at away loca-ns were significantly lower for NSLP participants com-red to nonparticipants (153.6 kcal vs 376.1 kcal,0.01, data not shown), partially offsetting an observedference at school (456.1 kcal vs 143.4 kcal, P0.01).verall, NSLP participants in secondary schools con-

med less energy from low-nutrient, energy-dense itemsaway locations (78 kcal vs 122 kcal, P0.05), but

owed no significant differences at school, at home, orthe total day (Table 3). Mean energy density for con-

mption at school was lower among NSLP participants

able 2. Consumption of sugar-sweetened beverages (SSBs) and low-cipants in the National School Lunch Program (NSLP) (% eating)ab

ting occasion

Elementary School

NSLPparticipantsc

(n531)

NSLPnonparticip(n201)

4ll locationsED beverages (ie, SSBs) 602.8 654.9ED solid foods 902.2 872.9tal LNED items 951.4 952.0t schoolED beverages (ie, SSBs) 91.5** 384.6ED solid foods 634.1 664.8tal LNED items 654.2 763.8t homeED beverages (ie, SSBs) 482.7 454.0ED solid foods 612.7 623.6tal LNED items 762.0 773.2way from school and homed

ED beverages (ie, SSBs) 121.5 9.32.1e

ED solid foods 141.7 18.13.2tal LNED items 191.9 20.63.2

ata are from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recallchildren in public NSLP schools. Sample sizes are unweighted.NED items include SSBs (eg, carbonated soft drinks, fruit-flavored juice drinks, lemwer-/reduced-fat), cookies, ice cream, cake-type desserts, muffins (eg, regular, not lowies/similar potato products.SLP participation is participation on the target recall day.onsumed at other locations away from school and home.tatistic is potentially unreliable due to a small sample size or a coefficient of variation ignificantly different from nonparticipants at 0.05 level.Significantly different from nonparticipants at 0.01 level.February 2009 Suppl 1 Volume 109 Number 2n nonparticipants (1.32 vs 1.67 in elementary schoold 1.30 vs 1.56 in secondary school, both P0.01). Meanergy density over the entire day was lower for NSLPrticipants in elementary school than nonparticipants21 vs 1.33, P0.01), but higher for NSLP participantssecondary school (1.14 vs 1.08, P0.05).

ferences between Children Who Consume Sugar-Sweetenederages at School and Those Who Do Notaddition to describing consumption patterns compar-school lunch participants and nonparticipants (in Ta-

s 1 through 3) we investigated whether at school be-vior with respect to sugar-sweetened beverages wasociated with the consumption of energy outside ofool, either at home or away locations. Table 4 showsproportion of children consuming sugar-sweetened

verages, mean energy intake from sugar-sweetenedverages, and mean total 24-hour energy intake from allds and beverages, stratified by whether or not anyount of sugar-sweetened beverage was consumed atool. Elementary school children had no differences inproportion consuming sugar-sweetened beverages at

me or away from home/school based on their schoolsumption of sugar-sweetened beverages. Secondary

ent, energy-dense (LNED) foods among participants and nonpar-

Secondary School

All (n2,314)

NSLPparticipantsc

(n855)

NSLPnonparticipants(n727)

standard error 3

722.0* 781.5 681.4901.3 851.8 881.1960.7 951.0 950.7

292.6** 382.4 251.5672.3** 552.4 621.9741.8* 672.5 691.9

552.0 521.7 501.3601.8 572.1 601.4791.6 771.3 771.0

151.4** 212.0 150.9151.6* 221.9 171.0231.9* 302.2 231.1

w, school year 2004-2005. Tabulations are weighted to be nationally representative

s, sweetened teas, and energy or sports drinks), chips (eg, regular, not), pastries, donuts, crispy rice bars, candy, energy bars, fruit snacks, and frenchthaanenpa(1.in

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aDinbLlofrcNdMeMfC*S**ool children who consumed a sugar-sweetened bever-e at school were more likely to consume a sugar-sweet-ed beverage at home (59% vs 51%, P0.05), but lessely to consume a sugar-sweetened beverage away (15%20%, P0.05).onsumers of sugar-sweetened beverages at school ob-

ned a mean of 112 kcal from sugar-sweetened beverageselementary school and 157 kcal in secondary school.ergy from sugar-sweetened beverages account for the

able 3. Mean daily energy, energy density, and mean energy from sugods consumed by participants and nonparticipants in the National Sc

ting location

Intake by Loc

Elementary Scho

NSLPparticipantsc

(n531)

NSLPnonpa(n20

4ll locationsED beverages (ie, SSBs) (kcal) 1077.4 118ED solid foods (kcal) 33418.2 378

ll LNEDs (kcal) 44118.1 495tal energy (kcal) 2,04837.1 2,075ergy densityd 1.210.013** 1.33t schoolED beverages (ie, SSBs) (kcal) 112.0** 39ED solid foods (kcal) 12110.6 166

ll LNEDs (kcal) 13211.4** 206tal energy (kcal) 79024.2 710

ercentage of daily energy consumed atschool (% kcal) 401.1 35ergy densitye 1.320.034** 1.67t homeED beverages (ie, SSBs) (kcal) 777.2 61ED solid foods (kcal) 17712.1 171

ll LNEDs (kcal) 25411.9 232tal energy (kcal) 1,10532.0* 1,224

ercentage of daily energy consumed athome (% kcal) 531.1 58ergy densitye 1.230.027 1.28way from home or schoolf

ED beverages (ie, SSBs) (kcal) 202.9 17ED solid foods (kcal) 366.8 40

ll LNEDs (kcal) 569.2 57rcentage of daily energy consumedaway from home and school (% kcal) 70.7 7tal energy (kcal) 15317.3 142ergy densitye 1.890.115 2.15

ata are from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recallthe 24-hour dietary recall interview. Tabulations are weighted to be nationally representNED items include SSBs (eg, carbonated soft drinks, fruit-flavored juice drinks, lemwer-/reduced-fat), cookies, ice cream, cake-type desserts, muffins (eg, regular, not lowies/similar potato products.SLP participation is participation on the target recall day.ean daily energy density calculated for 24-hour period among all persons.ean daily energy density calculated only among those who consumed any food or beveronsumed at other locations away from school and home.ignificantly different from nonparticipants at 0.05 level.Significantly different from nonparticipants at 0.01 level.February 2009 Stire energy differential between sugar-sweetened bever-es consumers and nonconsumers in elementary school,d more than half the differential in secondary school.an total daily energy intake for at-school consumers ofar-sweetened beverages was 114 kcal greater in elemen-y school and 260 kcal greater in secondary school thanrespective means for nonconsumers of sugar-sweet-

ed beverages at school (both P0.01). There were nonificant differences in the energy from sugar-sweet-

eetened beverages (SSBs) and low-nutrient, energy-dense (LNED)Lunch Program (NSLP)ab

and NSLP Participation Status

All (n2,314)

Secondary School

antsNSLPparticipantsc

(n855)

NSLPnonparticipants(n727)

eanstandard error 3

1969.8 2249.9 1595.239917.5 38016.6 36810.059622.1 60422.4 52712.0

2,25044.0** 2,07643.5 2,10924.52 1.140.014* 1.080.021 1.180.012

454.4** 614.8 362.51578.5** 1278.7 1386.120310.1 18911.3 1747.480817.4** 53324.2 72012.7

380.7** 261.0 350.61 1.300.031** 1.560.071 1.420.030

1166.5 1106.6 933.719813.4 18312.9 1837.031515.9 29316.6 2767.5

1,23435.8 1,23333.8 1,18520.0

531.0** 601.1 560.68 1.160.027 1.120.020 1.190.015

343.7* 526.3 312.1446.4* 708.1 473.6789.0* 12213.3 785.1

90.7** 141.1 90.420819.8** 30925.2 20310.5

7 1.770.122 1.570.092 1.790.063

ew, school year 2004-2005. Meals and snacks are defined by child (or respondent)f children in public NSLP schools. Sample sizes are unweighted.s, sweetened teas, and energy or sports drinks), chips (eg, regular, not), pastries, donuts, crispy rice bars, candy, energy bars, fruit snacks, and french

the location (ie, sample sizes vary for location estimates).enaganMesugtartheensig

11.227.331.267.40.04

5.220.521.645.5

1.80.09

7.216.919.852.0

1.80.04

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Interviative oonadeer-fat

age atupplement to the Journal of the AMERICAN DIETETIC ASSOCIATION S85

enbeers

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S86ed beverages consumed at home or away locationstween the at-school consumers and the nonconsum-

of sugar-sweetened beverages at school.here were no significant differences in total energy at

me, away, or over the entire day between the two groupsthe elementary school level. Among secondary schoolldren who consumed sugar-sweetened beverages atool, energy intake over the entire day averaged 229l higher than those who consumed no sugar-sweet-

ed beverages at school (P0.01). There were no differ-ces between consumers and nonconsumers in meanergy from all items consumed at home and away be-een the two groups.onsumers of any sugar-sweetened beverages at school

re significantly less likely to be participants in theLP or both the school lunch and breakfast programsth P0.01). For example, participation in the NSLPs 38% among consumers of sugar-sweetened beveragesschool compared to 80% among nonconsumers in ele-ntary school, and 44% to 54% in secondary school,pectively (data not shown, P0.01).

ure 1. Consumption of low-nutrient, energy-dense items at school,NSLPa participation status (elementary schools). aNSLPNationalool Lunch Program. bSSBssugar-sweetened beverages. cIncludesilar potato products. *Significantly different from participants at0.01.

ure 2. Consumption of low-nutrient, energy-dense items at school,NSLPa participation status (secondary schools). aNSLPNationalool Lunch Program. bSSBssugar-sweetened beverages. cIncludesilar potato products. *Significantly different from participants at0.05. **Significantly different from participants at P0.01.February 2009 Suppl 1 Volume 109 Number 2CUSSIONe meals a school offers, as well as its overall foodvironment, are important factors in childrens dailyergy intake and diet quality, but consumption patternshome and other locations are also key to diet and tok of overweight and obesity (1,2,4,24,25,35). We ana-ed nationally representative data from SNDA-III froming 2005 to improve our understanding of school-aged

ildrens consumption patterns across a typical 24-hourriod that included attending public school. A key fea-e of this analysis involves examining consumption of-nutrient, energy-dense foods and beverages over therse of the day and across eating locations. Althoughanalysis examines the relationship between school

al participation and dietary patterns, it is descriptived should not be interpreted as capturing the effects ofrticipation on dietary patterns. Rather, exploring pat-ns of intake among school lunch participants and non-rticipants may identify areas for further research todress the question of whether school lunch causesse observed differences in childrens patterns of con-

mption. Determining eating behaviors associated withsuming empty calories could lead to improved nutri-

n education and health promotion messages for chil-n and their parents, as well as identify areas for schoolllness policies to target.

tary Patterns among All School-Aged Childrenan average day that US children attended public

ools offering the NSLP, they received more than onerd (35%) of their daily energy from foods consumed atool and more than half (56%) from foods consumed at

me. Less than 10% of their daily energy came fromds consumed at other locations. Whereas proportion-ly less energy was consumed away from school and

me, these meals and snacks consumed away fromool and home were the most energy-dense.early all children consume lunch and dinner/supper

a typical school day, but a nontrivial percentage (16%)l to consume any breakfast, including nearly one inr secondary school students. This is important givent previous studies have found that skipping breakfastssociated with increased weight gain from adolescence

adulthood and that eating breakfast is associated wither BMI (23,27,30,39). Participation in the schoolakfast program is one avenue by which children whould typically skip breakfast could access breakfast atool.NDA-III data show that snacking in childhood and

olescence is prevalent across all ages and school mealrticipation groups and most prevalent at home. Over-, 94% of children reported consuming at least oneack during the day, and eight of 10 children consumedsnack at home, after school and/or before bedtime.acking at school was somewhat less common, but stilldespread as four of 10 children consumed a snack atool, a behavior associated with the number of snackchines and school policies (11,12,14). The extent of

acking among children is of concern given that priorearch has shown that the number of eating occasionsa significant positive predictor of consumption of low-trient, energy-dense items, and that snacking at home

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aD Intervieof .bS as, andcC*S**positively associated with consumption of sugar-sweet-ed beverages and salty snacks (12,23,24,29). With suchdespread snacking, results from SNDA-III and otherdies suggest the need to improve childrens and ado-cents snack choices both at home and at school touce consumption of energy-dense foods and beveragest provide significant energy from low-nutrient, energy-

nse foods over the course of the day.ow-nutrient, energy-dense foods often contain both fat

d sugar, whose tastes are immediately appealing evenyoung children (47,48). As with snacking, consumptionlow-nutrient, energy-dense foods and beverages is com-n among children. On a typical school day, 1 kcal out ofry 4 kcal they consume comes from a low-nutrient,

ergy-dense food or beverage, with about two-thirds ofs amount from low-nutrient, energy-dense foods and

remaining one-third from sugar-sweetened bever-es. Part of the reason for the high level of consumptionlow-nutrient, energy-dense foods and beverages may bem the easy access to these items by most children.reased access to low-nutrient, energy-dense items isociated with consumption of high-fat and high-sugards and beverages among children and adolescents,23,35). Competitive food sources such as school stores

d snack bars, vending machines, and la carte offer-s provide increased access to low-nutrient, energy-

nse items at school, and school meals are also a sourcehigher-fat baked goods and french fries (11,12,44,49).another analysis using SNDA-III data, we found thatool food practices, including childrens access to schoolres and snack bars and pouring rights contracts were

able 4. Mean daily energy and mean energy from sugar-sweetened

take

Elementary School

Consumers of SSBsat school (n115)

Nonconsumers (no Sat school) (n617)

4%SBs (% consuming)aily total 1000.0** 542.6t school 1000.0** 00.0t home 494.3 472.6wayc 143.3 111.4

4 meanergy from SSBs (kcal)aily total 20212.2** 926.9t school 1124.2** 00.0t home 648.3 746.6wayc 257.1 182.6

nergy (kcal)aily total 2,07952.3 2,05037.8t school 86340.2** 74921.5t home 1,04054.0 1,15731.7wayc 17635.0 14516.9

ata are from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recallchildren in public National School Lunch Program schools. Sample sizes are unweightedSBs include carbonated soft drinks, fruit-flavored juice drinks, lemonades, sweetened teonsumed at other locations away from school and home.ignificantly different from children who did not consume SSBs at school at 0.05 level.Significantly different from children who did not consume SSBs at school at 0.01 level.February 2009 Snificantly related to consumption of sugar-sweetenedverages in secondary schools (44).

owever, consumption of low-nutrient, energy-densems is not limited to those consumed at school. Amongondary students, both NSLP participants and nonpar-ipants consumed about 300 kcal from low-nutrient,ergy-dense foods on average at home; among elemen-y school children, the figure ranged from 230 to 250l from low-nutrient, energy-dense foods consumed at

me. In addition, whereas the total amount of energym low-nutrient, energy-dense items consumed awaym home and school was not great, the foods consumedthese other locations were likely to include a largeportion of low-nutrient, energy-dense items, as 38% of

ergy consumed at these locations was from low-nutri-t, energy-dense items. This led to the energy density ofds consumed away from school and home being highern the energy density of foods consumed at school or

me.

tary Patterns of School Lunch Participants andnparticipantsLP participants get a greater percentage of their en-y from foods consumed at school than do nonpartici-

nts, though the difference is modest. Among children inmentary school, participants get 40% of their energym foods consumed at school compared with 35% amongnparticipants. Among secondary school students, the

parable figures are 38% and 26%. Similarly, there areferences in the proportion of NSLP participants and

ages (SSBs) based on consumption of SSBs at schoolab

Secondary School

All (n2,314)Consumers of SSBsat school (n512)

Nonconsumers (no SSBsat school) (n1,070)

ard error 3

1000.0** 622.0 681.41000.0 00.0 251.5592.7* 512.0 501.3151.6* 201.5 150.9

tandard error 3

32011.7** 1537.7 1595.21576.0** 00.0 362.51257.7 1076.5 933.7385.6 463.8 312.1

2,31553.4** 2,08631.8 2,10924.584423.7** 58418.5 72012.7

1,22339.3 1,23927.5 1,18520.024824.4 26318.0 20310.5

w, school year 2004-2005. Tabulations are weighted to be nationally representative

energy or sports drinks.sigbe

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DieNoNSergpaelefronocomdifupplement to the Journal of the AMERICAN DIETETIC ASSOCIATION S87

noschpaatbrethiwieaha

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S88nparticipants who consume breakfast and lunch atool. For example, a third of elementary school NSLP

rticipants and only 8% of nonparticipants eat breakfastschool, whereas nonparticipants are more likely to eatakfast at home. At the secondary school level, only twords of nonparticipants eat lunch at school comparedth all NSLP participants. Among nonparticipants whot lunch away from school, about half eat at home andlf eat at some other location.here were clear differences in the consumption of-nutrient, energy-dense items at school. Even thoughLP participants consumed a larger amount of total

ergy at school than nonparticipants, they consumednificantly less energy from sugar-sweetened bever-es. This was especially true at the elementary schoolel, where participants consumed an average of 11 kcald nonparticipants consumed 39 kcal from sugar-sweet-ed beverages. There was no evidence that participantsde up for consuming fewer sugar-sweetened beveragesschool by consuming more sugar-sweetened beveragestside of school. This is encouraging because researchs shown that consumption of sugar-sweetened bever-es is associated with higher energy intake and higher

I and overweight among children and adolescents,18-21).he results with respect to low-nutrient, energy-dense

ds was less clear. At the elementary school level, theference between energy from low-nutrient, energy-nse foods among participants and nonparticipants wast statistically significant. At the secondary school level,ergy from low-nutrient, energy-dense foods were sig-cantly higher among participants than nonpartici-

nts; however, this followed directly from the fact thatrticipants overall energy intake from foods consumedschool was higher than that of nonparticipants. Thecific low-nutrient, energy-dense foods that partici-

nts were more likely to consume at school includedher-fat baked goods and french fries.ne of the key research questions we addressed was

ether school meal participation is associated withher or lower consumption of low-nutrient, energy-

nse items away from school. The underlying issue heres whether participants, because they were consumingool meals that presumably did not include certaines of low-nutrient, energy-dense items (such as softnks or potato chips), were more likely to seek out thesems once they left school for the day. We found nonificant differences between NSLP participants andnparticipants consumption patterns of low-nutrient,ergy-dense foods and beverages at home, with oneall exception: elementary school participants con-med more energy from salty snacks at home than non-rticipants. At locations away from home and school,re were no significant differences in consumption of-nutrient, energy-dense items at the elementaryool level, and participants consumed significantly less

ergy from low-nutrient, energy-dense items at the sec-dary school level.

e also examined the relationship between childrenssumption of sugar-sweetened beverages at school andir low-nutrient, energy-dense item consumption overremainder of the day. Children who did not consume

gar-sweetened beverages at school consumed less low-February 2009 Suppl 1 Volume 109 Number 2trient, energy-dense energy from sugar-sweetened bev-ges all day. In addition, consumption of a schoolakfast or school lunch was associated with consumings energy from sugar-sweetened beverages at school.is suggests that reduced access to sugar-sweetenedverages in the school environment was not associatedth increased consumption away from campus. In fact,other analysis of SNDA-III data found that for elemen-y school children, most sugar-sweetened beveragessumed at school were brought from home (44).

ta Limitationsis analysis is based on cross-sectional, self-reporteday dietary recall data that may be subject to over- orderreporting of intake. The data reflect consumptionschool days (Mondays through Fridays) and not Sat-

days and Sundays, when consumption in general or atay locations may be higher. Finally, comparisons of the

ting patterns of school lunch participants and nonpar-ipants are descriptive and do not control for differencesthe background characteristics of the two groups.erefore, they should not be interpreted as indicatingcausal effects of the school meal programs.

NCLUSIONSDA-III findings, as well as prior research on childrens

d adolescents eating behaviors, suggest that both fam-eating practices, at home and away from home, andschool food environment are important factors to ad-

ss in the prevention of childhood overweight and obe-y. SNDA-III data provide a recent view of US publicool childrens consumption of low-nutrient, energy-

nse foods and beverages and their associated energy. Ah proportionabout one fourthof average daily en-y was categorized as from low-nutrient, energy-denseds or beverages.n important and challenging opportunity to improve

ldrens diets and reduce low-nutrient, energy-dense foodsumption is increased emphasis on behaviors at home,ere the largest proportion of total energy and energym low-nutrient, energy-dense foods are consumedes-ially from sugar-sweetened beverages, chips/salty

acks, and baked goods. Food and nutrition profession-should encourage parents to serve more healthful

verages, such as low-fat milks, 100% fruit juices (inderation), and water in place of sugar-sweetened bev-ges for meals and snacks at home and in bag lunchesschool. To reduce consumption of low-nutrient, ener-

-dense foods at home, parents should serve reduced- orer-fat baked goods and dairy-based desserts; offerre healthful alternatives such as fresh fruit; and min-ize the frequency of fast foods high in fat, salt, andgar. Parents also play a key role in their modeling ofalthful eating behaviors at home and in their selectionfoods at away locations. Parents can let adolescentsow that eating healthful breakfasts and lunches isportant and that skipping meals can be detrimental tointaining a healthful weight. Avenues for more health-eating away from home and school include improvingd and beverages choices, selecting smaller portiones, and eating less frequently at places that offerstly energy-dense selections.

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Ref1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.he school food environment provides an importantd feasible opportunity to improve childrens diet andalth behavior. SNDA-III data show that areas to im-ve include eliminating sugar-sweetened beverages

ailable in schools, limiting or eliminating access toer competitive food sources, minimizing the frequency

offering french fries and higher-fat baked goods, insti-ing strong school wellness policies, providing nutrition

ucation to parents and children, and encouraging thenging of more healthful bag lunches from home (espe-lly for nonparticipants in elementary school). It is en-raging that school lunch participants do not seem toke up for lower consumption of low-nutrient, energy-

nse foods and beverages when they go home, for thest part. These study findings are relevant to schooltrition and wellness policies and efforts to improve thealthfulness of school meals, and highlight the need fortinued emphasis on nutrition education and healthmotion for families and parents of children of all ages

d at all income levels.

ATEMENT OF CONFLICT OF INTEREST: The au-rs have no conflict of interest to report with the spon-of this supplement article or products discussed in

s article.his research was supported by a grant from the US

partment of Agriculture, Economic Research Service,tract no. 59-5000-6-0076. The opinions expressed arese of the authors and do not necessarily represent thews or recommendations of Mathematica Policy Re-rch, Inc, the Economic Research Service, or the USpartment of Agriculture.he authors thank Allison Hedley Dodd, PhD, for input

the study analysis plan and Mary Kay Crepinsek, MS,, and Liz Condon, MS, RD, for assistance with catego-ation of the food and beverage variables used for thisalysis. The authors also thank Michael Ponza, PhD,d Katherine Ralston, PhD, for their review of an earlierft of the manuscript.

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Trends in the association of poverty with overweight among USadolescents, 1971-2004. JAMA. 2006;295:2385-2393.Gordon-Larsen P, Adair LS, Popkin BM. The relationship of ethnicity,socioeconomic factors, and overweight in US adolescents. Obes Res.2003;11:121-129.National School Lunch Program: Participation and lunches served.US Dept of Agriculture, Food and Nutrition Service Web site.February 2009 Shttp://www.fns.usda.gov/pd/slsummar.htm. Accessed September10, 2008.OToole T, Anderson S, Miller C, Guthrie J. Nutrition services andfoods and beverages available at school: Results from the SchoolHealth Policies and Programs Study 2006. J Sch Health. 2007;77:500-521.Wiecha JL, Finkelstein D, Troped PJ, Fragala M, Peterson KE. Schoolvending machine use and fast-food restaurant use are associated withsugar-sweetened beverage intake in youth. J Am Diet Assoc. 2006;106:1624-1630.Cullen KW, Zakeri I. 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S90 February 2009 Suppl 1 Volume 109 Number 2

Consumption of Low-Nutrient, Energy-Dense Foods and Beverages at School, Home, and Other Locations among School Lunch Participants and NonparticipantsMETHODSSample DesignData CollectionAnalytic MethodsStatistical Methods

RESULTSMeal and Snack PatternsPatterns of Consumption of Sugar-Sweetened Beverages and Low-Nutrient, Energy-Dense Solid FoodsMean Daily Energy Intake, Energy Density, and Energy from Low-Nutrient, Energy-Dense ItemsDifferences between Children Who Consume Sugar-Sweetened Beverages at School and Those Who Do Not

DISCUSSIONDietary Patterns among All School-Aged ChildrenDietary Patterns of School Lunch Participants and NonparticipantsData Limitations

CONCLUSIONSAcknowledgmentsReferences