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Lessons of Fresh Start can guide schools seeking to boost student fruit consumption

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Authors

Patricia B. Crawford , UC Berkeley
Gail Woodward-Lopez, UC Berkeley
Wendi Gosliner, UC Berkeley
Karen Webb, UC Berkeley

Publication Information

California Agriculture 67(1):21-29. https://doi.org/10.3733/ca.v067n01p21

Published online January 01, 2013

PDF  |  Citation  |  Permissions

Author Affiliations show

Abstract

Less than 11% of young school-aged children eat the recommended amounts of fruits and vegetables, despite abundant evidence that these foods protect against many types of cancer, heart disease and diabetes, and when combined with other dietary changes can help protect against obesity. In 2005, California became the first state to address the availability of fresh and local produce in the federal School Breakfast Program through state funding. The California Fresh Start Program doubled the number of different fresh fruits offered to students. With the greater variety, the number of fresh fruit servings taken by students in the Fresh Start pilot program more than doubled. Evaluation of the program revealed many lessons, which are especially important now, as schools across the country prepare to increase the number of fruits and vegetables offered in the School Breakfast Program by or before July 2014 as mandated by the Healthy, Hunger-Free Kids Act.

Full text

While the health benefits of fruits and vegetables are widely acknowledged, consumption of these foods among children and youth is at a low level. Fewer than 11% of school-aged children eat fruits and vegetables at the recommended levels (Guenther et al. 2006); as many as one-third of high school students eat vegetables less than once a day, and 28% eat fruit less than once a day (CDC 2011). Further, data collected by the Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey shows that the fruits and vegetables adolescents consume tend to be the less nutritious forms: Fruit juices and fried potatoes are major contributors (Kimmons et al. 2009). Children's low consumption of fruits and vegetables has been documented in numerous studies. It is clearly addressed in the 2010 USDA Dietary Guidelines (USDA DHHS 2010), which note that intakes of fried potatoes and fruit beverages have seen recent growth, while intakes of fresh fruits and vegetables have not.

Children consume up to half of their daily calories at school, which gives schools a potentially critical role in increasing children's consumption of fresh fruits and vegetables. Above, children eat breakfast at Centennial Elementary School, Fresno Unified School District.

Children consume up to half of their daily calories at school, which gives schools a potentially critical role in increasing children's consumption of fresh fruits and vegetables. Above, children eat breakfast at Centennial Elementary School, Fresno Unified School District.

Importance of school programs

The United States is confronting an epidemic of poor nutrition among children. Schools can play an important role in addressing this epidemic, both by serving food directly to students and by using the power of role modeling to demonstrate healthy diets to students and their families.

Despite educational efforts, at the population level fruit and vegetable intakes have changed very little, prompting some to suggest that alternative individual-, community- and population-level interventions are necessary (Thomson and Ravia 2011). One promising approach is to provide more servings of fruits and vegetables in schools and youth-serving programs (Delgado-Noguera et al. 2011; Knai et al. 2006). Findings suggest that if children are provided with healthful, appealing foods, they will eat them.

A European review of the literature found that availability and accessibility of fruits and vegetables and taste preferences were the determinants most consistently and positively related to consumption (Blanchette and Brug 2005). Furthermore, a combination of increased access to fruits and vegetables at school with nutrition education in the curriculum has a considerably greater impact than nutrition education alone, although both are important (Coyle et al. 2009; He et al. 2009; Knai et al. 2006). The USDA Fresh Fruit and Vegetable Program, which provides an extra serving of a fruit or vegetable as a between-meal snack to children at schools in low-income communities that apply for the program, is being evaluated and shows promise for increasing children's consumption (FNS 2010).

The greatest room for improvement in children's fruit and vegetable consumption is at school, where children consume up to half of their calories (Briefel et al. 2009). The National Academy of Sciences Institute of Medicine has urged school action to increase fruit and vegetable intake (Glickman et al. 2012), and federal policies resulting from the Healthy, Hunger-Free Kids Act of 2010 mandate this increase.

The California Fresh Start Program was a pilot school breakfast program that informed state and federal policymakers about the opportunities, challenges and benefits of programs to increase produce consumption in schools. Lessons from the program are especially important now for two reasons: School districts will be increasing offerings of fruits and vegetables in the School Breakfast Program in July 2014 to meet the new school nutrition guidelines in the Healthy, Hunger-Free Kids Act; and childhood obesity has escalated, with the consequent risk of serious chronic conditions including type 2 diabetes and heart disease. Here, we highlight the results of the California Fresh Start Program, which was conducted during the 2006–2007 school year, and recommend promising strategies for increasing produce consumption by children in the school setting. The barriers we identify to program implementation can provide guidance to policymakers and administrators in school districts nationwide. A comprehensive report on the California Fresh Start Program can be found at the Center for Weight and Health, UC Berkeley, website: http://cwh.berkeley.edu/sites/default/files/primary_pdfs/Evaluation_of_the_California_Fresh_Start_Program_Report.pdf .

To meet the nutrition guidelines in the Healthy, Hunger-Free Kids Act, schools need to increase servings of fruits and vegetables. Above, fresh oranges and kiwifruit are attractively combined to appeal to high school students.

To meet the nutrition guidelines in the Healthy, Hunger-Free Kids Act, schools need to increase servings of fruits and vegetables. Above, fresh oranges and kiwifruit are attractively combined to appeal to high school students.

California legislation

Responding to the critical state of children's nutritional health, California enacted Senate Bill 281, commonly known as the California Fresh Start Program (CFSP), which was signed into law in 2005. It was the first statewide legislation to specifically address fresh and local produce in schools.

The innovative pilot program offered a 10-cent per meal reimbursement to schools to increase the servings of fruits and vegetables they offered in the School Breakfast Program. Priority was given to serving fresh fruits and vegetables and, where possible, California-grown produce.

The program goals were to promote the consumption of fresh fruits and vegetables, increase school breakfast participation and ultimately improve children's lifelong eating habits and decrease the incidence of obesity. Supplementing fruits and vegetables in the breakfast program, which serves more than a million California students each day, was an important first step in reaching school-age children, nearly all of whom are at nutritional risk due to low produce consumption.

Program participation

Of California public school students who eat breakfast at school, 78% were reached by the California Fresh Start Program during the 2006–2007 school year. Fewer than half of California's school districts participated in the program, but participating school districts had larger student enrollments than nonparticipating districts (median enrollment was 4,069 and 1,047, respectively). A higher proportion of participating versus nonparticipating districts were in urban areas. The ethnic profile of students (mostly white and Hispanic) and the average school breakfast participation rates (about 20%) were similar in participating and nonparticipating school districts.

Program evaluation

An independent evaluation of the California Fresh Start Program was conducted to answer the following questions:

  • How did schools spend the additional 10 cents per breakfast?

  • To what extent did school purchases of fresh fruits and vegetables increase?

  • What impact did the program have on children's dietary intake of fruits and vegetables and on their participation in the School Breakfast Program?

  • What effects did the program have on school food service operations, including needs for equipment and facilities, labor, nutrition education materials and staff training on safe handling, serving and marketing of fruits and vegetables?

School districts were stratified according to their number of elementary, middle and high schools, and the schools were randomly selected for participation in the evaluation. Of 93 schools that were contacted, 20 were ineligible because they were not participating in the program and four declined to participate in the evaluation. Of the remaining 69 schools, 61 were able to supply sufficiently complete data for the evaluation. The Committee for the Protection of Human Subjects at UC Berkeley approved the study. Parents received letters about the study, and students consented verbally to participate.

Data were collected before and during the program. Breakfast menu production records and invoices were sought from the schools' child nutrition directors on 20 randomly selected days during the months of September, October and November in the year before the program was implemented and during the program (2006 and 2007). Data from the menu production records included the nature and number of fruit servings prepared and taken by students at breakfast. Nonfood expenses directly relating to operating the program were also reported.

Of the 61 nutrition directors, 55 recorded their views of the program's impact on nutrition services operations, perceived student satisfaction, challenges and barriers to operating the program, nutrition education and promotional techniques, and staff training and needs. A stratified random sample of 18 schools was selected for site visits, which were successfully conducted at 16 schools: six elementary, six middle and four high schools. This sample was similar to other schools participating in the program in terms of school level, enrollment, geographic location, free- and reduced-price enrollment and student ethnicity. Interviews with nutrition directors were conducted at each of the 16 schools.

Student surveys were completed by 1,205 students in grades 4 to 12 in a convenience sample of one or two classes at each of the 16 visited schools (total of 28 classes) as well as at the school cafeterias during breakfast service. Questions were asked about where breakfast is eaten, how often fruits and vegetables are consumed at breakfast, favorite fruits to eat at breakfast, importance of eating fruits and vegetables at breakfast, change in fruit and vegetable consumption compared to the previous year and basic socio-demographic information. The cafeteria questionnaire asked additional questions regarding opinions about the school breakfast and perceptions of change since the previous year. The classroom questionnaire included questions regarding barriers to eating the school breakfast.

Student surveys revealed a preference for fruit to be served in salad bar style. Above, a Sacramento school offers fruit alongside vegetables in its salad bar.

Student surveys revealed a preference for fruit to be served in salad bar style. Above, a Sacramento school offers fruit alongside vegetables in its salad bar.

In addition, trained research staff facilitated classroom discussions with students in 28 classes in grades 4 to 12 (a convenience sample of one or two classes at each of the 16 schools). Students were questioned about their views on breakfast in general, the School Breakfast Program, the California Fresh Start Program and factors influencing their school breakfast participation and food choices.

Nutrition directors recorded School Breakfast Program participation on a standardized form. The researchers obtained monthly participation data during the course of the evaluation, including number of operating days and school average daily attendance. In addition, observations of the breakfast environment were made at each of the visited schools.

Costs of specific fruits and vegetables were calculated from invoices provided by the nutrition directors. The costs of fruits and vegetables prepared and served were based on the total value of the prepared items reported on the menu production records. Nonfood expenses identified on invoices were classified as transportation, facilities, large and small equipment, material, promotional, training, additional staff time, and other. The percentage of total nonfood expenses for each category was calculated.

Differences in both fresh fruit and total fruit taken by students and in the variety of fruits offered at each school were calculated from menu production records and analyzed by t-test. Descriptive findings were reported for schools demonstrating more successful program implementation, specifically, schools with increases of 0.10 or more units of total and fresh fruit taken and increases greater than 0.90 for number of different fresh fruits offered.

Although the California Fresh Start Program was designed to increase fruit and vegetable consumption, its effect was almost completely seen on fruit consumption, since vegetables were rarely included in the breakfast menu; vegetables represented less than 1% of produce offered to students. Thus the results presented here are based on fruit offerings.

Increased fruit consumption

The California Fresh Start Program resulted in substantial increases in the variety of all, and especially fresh, fruits offered to students. More than twice as many different fresh fruits were offered per day during the program compared with the same period a year before: an average of 1.38 fruits compared to 0.66 (table 1). When considering all forms of fruit (fresh, juice, canned, frozen and dried), there was a 46% increase in the average number of fruits offered per day: 2.55 fruits compared with 1.75 prior to the program (table 1). The California Fresh Start Program brought the offerings into compliance with dietary recommendations for two produce servings at breakfast.

Number of different fruits, by form, offered per day at breakfast before and during the California Fresh Start Program (n = 61 schools)

TABLE 1. Number of different fruits, by form, offered per day at breakfast before and during the California Fresh Start Program (n = 61 schools)

During the program, fresh fruit made up the majority of the fruit offered at breakfast. Juice, which previously had been the primary source of fruit, decreased substantially as a proportion of total fruit. All types of fresh fruit were offered with greater frequency; however, apples remained the most commonly offered individual fruit, followed by oranges and bananas. Stone fruits, though offered less frequently, showed the greatest percentage increase during the program (table 2).

Frequency (% of observation days) with which different fresh fruits were offered at school breakfast before and during the California Fresh Start Program (n = 61 schools)

TABLE 2. Frequency (% of observation days) with which different fresh fruits were offered at school breakfast before and during the California Fresh Start Program (n = 61 schools)

Our findings suggest that when offered a greater variety of fruits and less juice, students will increase their intake of fruit, especially fresh varieties (fig. 1). Students eating the school breakfast took more than twice as many fresh fruit servings during the California Fresh Start Program than before the program, 0.32 servings compared to 0.14, while taking substantially less juice and nearly the same amounts of canned, frozen and dried fruit offerings (fig. 1).

Average number of servings of fruits taken by students per day at breakfast before and during the California Fresh Start Program (n = 44 schools).

Fig. 1. Average number of servings of fruits taken by students per day at breakfast before and during the California Fresh Start Program (n = 44 schools).

Although there were no direct measures of student consumption in this evaluation, the amounts taken, as recorded by food service personnel, provide a reasonable indirect basis for assessing student consumption. Observations by research staff and food service personnel confirmed that most students who choose to take a fruit at breakfast do eat it. Therefore, student consumption of fresh fruit at breakfast appears to have doubled as a result of the California Fresh Start Program.

During the program, students took more of almost all types of fruit; however, the percentage increases were greatest for less common fruits such as cantaloupe, tangerines/tangelos and blueberries, which were not often offered before the program. Increases of about 20% to 30% were observed for common fruits such as apples, bananas and oranges; increases were 100% or more for tangerines, berries and cantaloupe, reflecting their appeal among students, and the low frequency with which they were offered before the program. Although the greatest increase in offerings occurred for the most common fruits — apples, oranges and bananas — the relative increase in servings of fruits was highest for the less common fruits. The demand for more common fruits may be approaching saturation, but unmet demand exists for a wider variety of fruits. Thus, future increases in the fruit servings students take at breakfast will likely require offerings of fruits other than apples, oranges and bananas.

During the California Fresh Start Program, students eating school breakfast took more than twice as many fresh fruit servings as before the program. Juice, the largest source of fruit, decreased substantially as a proportion of total fruit offered. Above, Fresno students at Cooper Academy enjoy breakfast.

During the California Fresh Start Program, students eating school breakfast took more than twice as many fresh fruit servings as before the program. Juice, the largest source of fruit, decreased substantially as a proportion of total fruit offered. Above, Fresno students at Cooper Academy enjoy breakfast.

Schools with greatest success

While the overall impact of the program on the amount of fruit — particularly the amount of fresh fruit — taken by students is impressive, this impact is even more dramatic when looking specifically at the schools that experienced the greatest success in implementing the program. At these schools, the California Fresh Start Program led to a 46% increase in the total amount of fruits taken by students, and a 383% increase in the fresh fruits and vegetables taken (table 3). It had the most impact in schools where students took the lowest number of fruit servings before the program — schools with the greatest need for an increase in produce intake. Schools that offered increased quantities of fruit, more variety of fruits and more unusual fruits and less juice were most successful in increasing student selection of fresh fruit. Limiting juice and providing fruits other than apples, oranges and bananas appear to be particularly important for increasing student consumption of fresh fruit. The fruits most often served at breakfast are rarely the ones that students most prefer (e.g., watermelon and strawberries).

Number of total and fresh fruits taken per student, and variety offered, before and during the California Fresh Start Program, for more- and less-successful schools∗

TABLE 3. Number of total and fresh fruits taken per student, and variety offered, before and during the California Fresh Start Program, for more- and less-successful schools∗

Students' attitudes

Students' attitudes toward eating fruit, already positive, showed modest changes during the program. Most students (77%) reported it was important to have fruit at breakfast, saying that fruits and vegetables are “good for you because it's healthy, makes you strong; there is natural sugar, and it contains vitamins like A and C.” However, only 13% said they always eat fruits and vegetables at breakfast, and only 19% said they often do. This may be due in part to the fruits most often served at breakfast not being the fruits students prefer.

Students prefer more exotic fruits than they are currently served. Fruits mentioned were mangos, kiwi, strawberries, peaches, pineapple, watermelon and grapes, with melons and berries being most popular (fig. 2). Students also want more variety in the ways fruit is presented, including chopped fruit, fruit salads, salad-type fruit bars, fruit with condiments and ethnic favorites. Variety, convenience, quality and freshness are key concerns. High school students, in particular, expressed a desire for more tropical fruits such as mangos.

Student survey responses regarding which one fruit was their favorite (n = 1,205 students surveyed).

Fig. 2. Student survey responses regarding which one fruit was their favorite (n = 1,205 students surveyed).

Factors associated with success

Successful implementation of the California Fresh Start Program was not significantly related to school characteristics or student socio-demographics. The type of school (elementary, middle or high), ethnicity/race of the students, rural-urban geographic location, percentage of free- and reduced-price meal participation and size of student enrollment did not have any statistically significant association with the program's success in terms of the number of fresh and total fruit servings students took or the variety of fruits offered.

Whether students were offered and/or took more fruit was affected by a variety of school institutional and economic factors, including the physical layout of the school's food service department and the availability of funding for program support. Because the California Fresh Start Program did not mandate or provide funding for facility improvements, it is not surprising that only about 9% of the schools made improvements to their kitchen, dining area, serving areas or points of service. Data from the evaluation indicated that adequate dining space for students was related to students taking more fruit and an appealing dining ambience was related to students taking more fresh fruit.

A test kitchen for healthier school meals prepared a variety of vegetables, fruits and homemade vinaigrette to tempt students to try more fresh produce. Variety, convenience, quality and freshness are key concerns among students.

A test kitchen for healthier school meals prepared a variety of vegetables, fruits and homemade vinaigrette to tempt students to try more fresh produce. Variety, convenience, quality and freshness are key concerns among students.

Almost one-third (31%) of schools did not have sufficient facilities to seat all students comfortably. The temperature was uncomfortably cold in many of the serving and dining areas, which may have played a role on cold days in students' preference for hot breakfast items rather than cold fruit. The student survey revealed that a majority of students want more options regarding when and where they can eat breakfast, particularly the options of eating in the classroom and indoors or outdoors. Only about one-third of schools offered students the choice of eating indoors or outdoors. Our findings suggest an investment in facilities has the potential to attract higher participation in the breakfast program and to increase students' intake of fresh fruit.

Schools that offered more variety of fruits were more likely to have made improvements in customer service, nutrition education, student attitudes and the quality and appeal of the fruit offered. Quality concerns were prominent in discussions with students about the changes in foods offered. Students noticed both positive and negative changes in food and beverage temperatures, freshness, taste, portion size and preparation.

In addition to presentation, the position of fruit in the serving sequence might affect student selections. At one site, the fruit was not visible; it had to be requested. Fresh fruit was the first item offered in the serving sequence at only three of the 13 sites where these data were recorded.

Nutrition directors at schools where students chose more fresh and total fruit were more likely to describe inadequate storage space and facilities. (Perhaps having to expand offerings heightened their awareness of inadequate facilities.)

Nutrition education, promotion

Many schools increased nutrition education and promotion efforts among students as part of the California Fresh Start Program but lacked the staff time and resources to mount a sufficiently intensive effort. Of the nutrition directors surveyed, 96% reported that lack of opportunity (time allotted in students' school day or an appropriate school location) was a barrier to fully providing the nutrition education component of the program, 87% reported a lack of staff time as a reason, and 81% reported that lack of funding was a barrier (Return to top

Author notes

Funding for this research was provided by California Healthy Kids Resource Center and the Nutrition Services Division of the California Department of Education. The authors would like to thank the administrators, food service personnel and students of the participating schools for their involvement as well as Sheila Stern and Lauren Goldstein for their editorial assistance.

References

Blanchette L, Brug J. Determinants of fruit and vegetable consumption among 6- to 12-year-old children and effective interventions to increase consumption. J Hum Nutr Diet. 2005. 18(6):431-43. https://doi.org/10.1111/j.1365-277X.2005.00648.x PubMed PMID: 16351702

Briefel RR, Wilson A, Gleason PM. Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants. J Am Diet Assoc. 2009. 109:S79-S90. https://doi.org/10.1016/j.jada.2008.10.064 PubMed PMID: 19166676

[CDC] Centers for Disease Control and Prevention. Fruit and vegetable consumption among high school students—United States, 2010. MMWR Morb Mortal Wkly Rep. 2011. 60(46):1583-6. PubMed PMID: 22108538

Coyle K, Potter S, Schneider D, et al. Distributing Free Fresh Fruit and Vegetables at School: Results of a Pilot Outcome Evaluation. Public Health Rep. 2009. 124:660-9. PubMed PMID: 19753944

Delgado-Noguera M, Tort S, Martinez-Zapata MJ, et al. Primary school interventions to promote fruit and vegetable consumption: A systematic review and meta-analysis. Prev Med. 2011. 53(1–2):3-9. https://doi.org/10.1016/j.ypmed.2011.04.016 PubMed PMID: 21601591

Evans CE, Christian MS, Cleghorn CL, et al. Systematic review and meta-analysis of school-based interventions to improve daily fruit and vegetable intake in children aged 5 to 12. Am J Clin Nutr. 2012. 96:889-901. https://doi.org/10.3945/ajcn.111.030270 PubMed PMID: 22952187

[FNS] Food and Nutrition Service, USDA. Fresh Fruit and Vegetable Program: A Handbook for Schools 2010. www.fns.usda.gov/cnd/ffvp/handbook.pdf (accessed June 19, 2012)

FNS. Nutrition Standards in the National School Lunch and School Breakfast Programs. Final rule. Fed Regist. 2012. 77(17):4088-167. PubMed PMID: 22359796

Glickman D, Parker L, Sim L, et al. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. 2012. Washington DC: National Academies Press.

Guenther P, Dodd K, Reedy J, et al. Most Americans eat much less than recommended amounts of fruits and vegetables. J Am Diet Assoc. 2006. 106(9):1371-9. https://doi.org/10.1016/j.jada.2006.06.002 PubMed PMID: 16963342

He M, Beynon C, Sangster Bouck M, et al. Impact evaluation of the Northern Fruit and Vegetable Pilot Programme—a cluster randomised controlled trial. Public Health Nutr. 2009. 12(11):2199-208. https://doi.org/10.1017/S1368980009005801 PubMed PMID: 19476675

Hoffman JA, Franko DL, Thompson DR, et al. Longitudinal behavioral effects of a school-based fruit and vegetable promotion program. J Pediat Psychol. 2010. 35(1):61-71. https://doi.org/10.1093/jpepsy/jsp041 PubMed PMID: 19439567

Kimmons J, Gillespie C, Seymour J, et al. Fruit and vegetable intake among adolescents and adults in the United States: Percentage meeting individualized recommendations. Medscape J Med. 2009. 11(1):26- PubMed PMID: 19295947

Knai C, Pomerleau J, Lock K, et al. Getting children to eat more fruit and vegetables: A systematic review. Prev Med. 2006. 42(2):85-95. https://doi.org/10.1016/j.ypmed.2005.11.012 PubMed PMID: 16375956

Ohri-Vachaspati Turner L, Chaloupka FJ. Fresh fruit and vegetable program participation in elementary schools in the United States and availability of fruits and vegetables in school lunch meals. J Acad Nutr Diet. 2012. 112(6):921-6. https://doi.org/10.1016/j.jand.2012.02.025 PubMed PMID: 22709817

Overby NC, Klepp KI, Bere E. Introduction of a school fruit program is associated with reduced frequency of consumption of unhealthy snacks. Am J Clin Nutr. 2012. 96(5):1100-110. https://doi.org/10.3945/ajcn.111.033399 PubMed PMID: 23034961

Thomson CA, Ravia J. A systematic review of behavioral interventions to promote intake of fruit and vegetables. J Am Diet Assoc. 2011. 111(10):1523-35. https://doi.org/10.1016/j.jada.2011.07.013 PubMed PMID: 21963019

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Lessons of Fresh Start can guide schools seeking to boost student fruit consumption

Patricia B. Crawford, Gail Woodward-Lopez, Wendi Gosliner, Karen Webb
Webmaster Email: wsuckow@ucanr.edu

Lessons of Fresh Start can guide schools seeking to boost student fruit consumption

Share using any of the popular social networks Share by sending an email Print article
Share using any of the popular social networks Share by sending an email Print article

Authors

Patricia B. Crawford , UC Berkeley
Gail Woodward-Lopez, UC Berkeley
Wendi Gosliner, UC Berkeley
Karen Webb, UC Berkeley

Publication Information

California Agriculture 67(1):21-29. https://doi.org/10.3733/ca.v067n01p21

Published online January 01, 2013

PDF  |  Citation  |  Permissions

Author Affiliations show

Abstract

Less than 11% of young school-aged children eat the recommended amounts of fruits and vegetables, despite abundant evidence that these foods protect against many types of cancer, heart disease and diabetes, and when combined with other dietary changes can help protect against obesity. In 2005, California became the first state to address the availability of fresh and local produce in the federal School Breakfast Program through state funding. The California Fresh Start Program doubled the number of different fresh fruits offered to students. With the greater variety, the number of fresh fruit servings taken by students in the Fresh Start pilot program more than doubled. Evaluation of the program revealed many lessons, which are especially important now, as schools across the country prepare to increase the number of fruits and vegetables offered in the School Breakfast Program by or before July 2014 as mandated by the Healthy, Hunger-Free Kids Act.

Full text

While the health benefits of fruits and vegetables are widely acknowledged, consumption of these foods among children and youth is at a low level. Fewer than 11% of school-aged children eat fruits and vegetables at the recommended levels (Guenther et al. 2006); as many as one-third of high school students eat vegetables less than once a day, and 28% eat fruit less than once a day (CDC 2011). Further, data collected by the Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey shows that the fruits and vegetables adolescents consume tend to be the less nutritious forms: Fruit juices and fried potatoes are major contributors (Kimmons et al. 2009). Children's low consumption of fruits and vegetables has been documented in numerous studies. It is clearly addressed in the 2010 USDA Dietary Guidelines (USDA DHHS 2010), which note that intakes of fried potatoes and fruit beverages have seen recent growth, while intakes of fresh fruits and vegetables have not.

Children consume up to half of their daily calories at school, which gives schools a potentially critical role in increasing children's consumption of fresh fruits and vegetables. Above, children eat breakfast at Centennial Elementary School, Fresno Unified School District.

Children consume up to half of their daily calories at school, which gives schools a potentially critical role in increasing children's consumption of fresh fruits and vegetables. Above, children eat breakfast at Centennial Elementary School, Fresno Unified School District.

Importance of school programs

The United States is confronting an epidemic of poor nutrition among children. Schools can play an important role in addressing this epidemic, both by serving food directly to students and by using the power of role modeling to demonstrate healthy diets to students and their families.

Despite educational efforts, at the population level fruit and vegetable intakes have changed very little, prompting some to suggest that alternative individual-, community- and population-level interventions are necessary (Thomson and Ravia 2011). One promising approach is to provide more servings of fruits and vegetables in schools and youth-serving programs (Delgado-Noguera et al. 2011; Knai et al. 2006). Findings suggest that if children are provided with healthful, appealing foods, they will eat them.

A European review of the literature found that availability and accessibility of fruits and vegetables and taste preferences were the determinants most consistently and positively related to consumption (Blanchette and Brug 2005). Furthermore, a combination of increased access to fruits and vegetables at school with nutrition education in the curriculum has a considerably greater impact than nutrition education alone, although both are important (Coyle et al. 2009; He et al. 2009; Knai et al. 2006). The USDA Fresh Fruit and Vegetable Program, which provides an extra serving of a fruit or vegetable as a between-meal snack to children at schools in low-income communities that apply for the program, is being evaluated and shows promise for increasing children's consumption (FNS 2010).

The greatest room for improvement in children's fruit and vegetable consumption is at school, where children consume up to half of their calories (Briefel et al. 2009). The National Academy of Sciences Institute of Medicine has urged school action to increase fruit and vegetable intake (Glickman et al. 2012), and federal policies resulting from the Healthy, Hunger-Free Kids Act of 2010 mandate this increase.

The California Fresh Start Program was a pilot school breakfast program that informed state and federal policymakers about the opportunities, challenges and benefits of programs to increase produce consumption in schools. Lessons from the program are especially important now for two reasons: School districts will be increasing offerings of fruits and vegetables in the School Breakfast Program in July 2014 to meet the new school nutrition guidelines in the Healthy, Hunger-Free Kids Act; and childhood obesity has escalated, with the consequent risk of serious chronic conditions including type 2 diabetes and heart disease. Here, we highlight the results of the California Fresh Start Program, which was conducted during the 2006–2007 school year, and recommend promising strategies for increasing produce consumption by children in the school setting. The barriers we identify to program implementation can provide guidance to policymakers and administrators in school districts nationwide. A comprehensive report on the California Fresh Start Program can be found at the Center for Weight and Health, UC Berkeley, website: http://cwh.berkeley.edu/sites/default/files/primary_pdfs/Evaluation_of_the_California_Fresh_Start_Program_Report.pdf .

To meet the nutrition guidelines in the Healthy, Hunger-Free Kids Act, schools need to increase servings of fruits and vegetables. Above, fresh oranges and kiwifruit are attractively combined to appeal to high school students.

To meet the nutrition guidelines in the Healthy, Hunger-Free Kids Act, schools need to increase servings of fruits and vegetables. Above, fresh oranges and kiwifruit are attractively combined to appeal to high school students.

California legislation

Responding to the critical state of children's nutritional health, California enacted Senate Bill 281, commonly known as the California Fresh Start Program (CFSP), which was signed into law in 2005. It was the first statewide legislation to specifically address fresh and local produce in schools.

The innovative pilot program offered a 10-cent per meal reimbursement to schools to increase the servings of fruits and vegetables they offered in the School Breakfast Program. Priority was given to serving fresh fruits and vegetables and, where possible, California-grown produce.

The program goals were to promote the consumption of fresh fruits and vegetables, increase school breakfast participation and ultimately improve children's lifelong eating habits and decrease the incidence of obesity. Supplementing fruits and vegetables in the breakfast program, which serves more than a million California students each day, was an important first step in reaching school-age children, nearly all of whom are at nutritional risk due to low produce consumption.

Program participation

Of California public school students who eat breakfast at school, 78% were reached by the California Fresh Start Program during the 2006–2007 school year. Fewer than half of California's school districts participated in the program, but participating school districts had larger student enrollments than nonparticipating districts (median enrollment was 4,069 and 1,047, respectively). A higher proportion of participating versus nonparticipating districts were in urban areas. The ethnic profile of students (mostly white and Hispanic) and the average school breakfast participation rates (about 20%) were similar in participating and nonparticipating school districts.

Program evaluation

An independent evaluation of the California Fresh Start Program was conducted to answer the following questions:

  • How did schools spend the additional 10 cents per breakfast?

  • To what extent did school purchases of fresh fruits and vegetables increase?

  • What impact did the program have on children's dietary intake of fruits and vegetables and on their participation in the School Breakfast Program?

  • What effects did the program have on school food service operations, including needs for equipment and facilities, labor, nutrition education materials and staff training on safe handling, serving and marketing of fruits and vegetables?

School districts were stratified according to their number of elementary, middle and high schools, and the schools were randomly selected for participation in the evaluation. Of 93 schools that were contacted, 20 were ineligible because they were not participating in the program and four declined to participate in the evaluation. Of the remaining 69 schools, 61 were able to supply sufficiently complete data for the evaluation. The Committee for the Protection of Human Subjects at UC Berkeley approved the study. Parents received letters about the study, and students consented verbally to participate.

Data were collected before and during the program. Breakfast menu production records and invoices were sought from the schools' child nutrition directors on 20 randomly selected days during the months of September, October and November in the year before the program was implemented and during the program (2006 and 2007). Data from the menu production records included the nature and number of fruit servings prepared and taken by students at breakfast. Nonfood expenses directly relating to operating the program were also reported.

Of the 61 nutrition directors, 55 recorded their views of the program's impact on nutrition services operations, perceived student satisfaction, challenges and barriers to operating the program, nutrition education and promotional techniques, and staff training and needs. A stratified random sample of 18 schools was selected for site visits, which were successfully conducted at 16 schools: six elementary, six middle and four high schools. This sample was similar to other schools participating in the program in terms of school level, enrollment, geographic location, free- and reduced-price enrollment and student ethnicity. Interviews with nutrition directors were conducted at each of the 16 schools.

Student surveys were completed by 1,205 students in grades 4 to 12 in a convenience sample of one or two classes at each of the 16 visited schools (total of 28 classes) as well as at the school cafeterias during breakfast service. Questions were asked about where breakfast is eaten, how often fruits and vegetables are consumed at breakfast, favorite fruits to eat at breakfast, importance of eating fruits and vegetables at breakfast, change in fruit and vegetable consumption compared to the previous year and basic socio-demographic information. The cafeteria questionnaire asked additional questions regarding opinions about the school breakfast and perceptions of change since the previous year. The classroom questionnaire included questions regarding barriers to eating the school breakfast.

Student surveys revealed a preference for fruit to be served in salad bar style. Above, a Sacramento school offers fruit alongside vegetables in its salad bar.

Student surveys revealed a preference for fruit to be served in salad bar style. Above, a Sacramento school offers fruit alongside vegetables in its salad bar.

In addition, trained research staff facilitated classroom discussions with students in 28 classes in grades 4 to 12 (a convenience sample of one or two classes at each of the 16 schools). Students were questioned about their views on breakfast in general, the School Breakfast Program, the California Fresh Start Program and factors influencing their school breakfast participation and food choices.

Nutrition directors recorded School Breakfast Program participation on a standardized form. The researchers obtained monthly participation data during the course of the evaluation, including number of operating days and school average daily attendance. In addition, observations of the breakfast environment were made at each of the visited schools.

Costs of specific fruits and vegetables were calculated from invoices provided by the nutrition directors. The costs of fruits and vegetables prepared and served were based on the total value of the prepared items reported on the menu production records. Nonfood expenses identified on invoices were classified as transportation, facilities, large and small equipment, material, promotional, training, additional staff time, and other. The percentage of total nonfood expenses for each category was calculated.

Differences in both fresh fruit and total fruit taken by students and in the variety of fruits offered at each school were calculated from menu production records and analyzed by t-test. Descriptive findings were reported for schools demonstrating more successful program implementation, specifically, schools with increases of 0.10 or more units of total and fresh fruit taken and increases greater than 0.90 for number of different fresh fruits offered.

Although the California Fresh Start Program was designed to increase fruit and vegetable consumption, its effect was almost completely seen on fruit consumption, since vegetables were rarely included in the breakfast menu; vegetables represented less than 1% of produce offered to students. Thus the results presented here are based on fruit offerings.

Increased fruit consumption

The California Fresh Start Program resulted in substantial increases in the variety of all, and especially fresh, fruits offered to students. More than twice as many different fresh fruits were offered per day during the program compared with the same period a year before: an average of 1.38 fruits compared to 0.66 (table 1). When considering all forms of fruit (fresh, juice, canned, frozen and dried), there was a 46% increase in the average number of fruits offered per day: 2.55 fruits compared with 1.75 prior to the program (table 1). The California Fresh Start Program brought the offerings into compliance with dietary recommendations for two produce servings at breakfast.

Number of different fruits, by form, offered per day at breakfast before and during the California Fresh Start Program (n = 61 schools)

TABLE 1. Number of different fruits, by form, offered per day at breakfast before and during the California Fresh Start Program (n = 61 schools)

During the program, fresh fruit made up the majority of the fruit offered at breakfast. Juice, which previously had been the primary source of fruit, decreased substantially as a proportion of total fruit. All types of fresh fruit were offered with greater frequency; however, apples remained the most commonly offered individual fruit, followed by oranges and bananas. Stone fruits, though offered less frequently, showed the greatest percentage increase during the program (table 2).

Frequency (% of observation days) with which different fresh fruits were offered at school breakfast before and during the California Fresh Start Program (n = 61 schools)

TABLE 2. Frequency (% of observation days) with which different fresh fruits were offered at school breakfast before and during the California Fresh Start Program (n = 61 schools)

Our findings suggest that when offered a greater variety of fruits and less juice, students will increase their intake of fruit, especially fresh varieties (fig. 1). Students eating the school breakfast took more than twice as many fresh fruit servings during the California Fresh Start Program than before the program, 0.32 servings compared to 0.14, while taking substantially less juice and nearly the same amounts of canned, frozen and dried fruit offerings (fig. 1).

Average number of servings of fruits taken by students per day at breakfast before and during the California Fresh Start Program (n = 44 schools).

Fig. 1. Average number of servings of fruits taken by students per day at breakfast before and during the California Fresh Start Program (n = 44 schools).

Although there were no direct measures of student consumption in this evaluation, the amounts taken, as recorded by food service personnel, provide a reasonable indirect basis for assessing student consumption. Observations by research staff and food service personnel confirmed that most students who choose to take a fruit at breakfast do eat it. Therefore, student consumption of fresh fruit at breakfast appears to have doubled as a result of the California Fresh Start Program.

During the program, students took more of almost all types of fruit; however, the percentage increases were greatest for less common fruits such as cantaloupe, tangerines/tangelos and blueberries, which were not often offered before the program. Increases of about 20% to 30% were observed for common fruits such as apples, bananas and oranges; increases were 100% or more for tangerines, berries and cantaloupe, reflecting their appeal among students, and the low frequency with which they were offered before the program. Although the greatest increase in offerings occurred for the most common fruits — apples, oranges and bananas — the relative increase in servings of fruits was highest for the less common fruits. The demand for more common fruits may be approaching saturation, but unmet demand exists for a wider variety of fruits. Thus, future increases in the fruit servings students take at breakfast will likely require offerings of fruits other than apples, oranges and bananas.

During the California Fresh Start Program, students eating school breakfast took more than twice as many fresh fruit servings as before the program. Juice, the largest source of fruit, decreased substantially as a proportion of total fruit offered. Above, Fresno students at Cooper Academy enjoy breakfast.

During the California Fresh Start Program, students eating school breakfast took more than twice as many fresh fruit servings as before the program. Juice, the largest source of fruit, decreased substantially as a proportion of total fruit offered. Above, Fresno students at Cooper Academy enjoy breakfast.

Schools with greatest success

While the overall impact of the program on the amount of fruit — particularly the amount of fresh fruit — taken by students is impressive, this impact is even more dramatic when looking specifically at the schools that experienced the greatest success in implementing the program. At these schools, the California Fresh Start Program led to a 46% increase in the total amount of fruits taken by students, and a 383% increase in the fresh fruits and vegetables taken (table 3). It had the most impact in schools where students took the lowest number of fruit servings before the program — schools with the greatest need for an increase in produce intake. Schools that offered increased quantities of fruit, more variety of fruits and more unusual fruits and less juice were most successful in increasing student selection of fresh fruit. Limiting juice and providing fruits other than apples, oranges and bananas appear to be particularly important for increasing student consumption of fresh fruit. The fruits most often served at breakfast are rarely the ones that students most prefer (e.g., watermelon and strawberries).

Number of total and fresh fruits taken per student, and variety offered, before and during the California Fresh Start Program, for more- and less-successful schools∗

TABLE 3. Number of total and fresh fruits taken per student, and variety offered, before and during the California Fresh Start Program, for more- and less-successful schools∗

Students' attitudes

Students' attitudes toward eating fruit, already positive, showed modest changes during the program. Most students (77%) reported it was important to have fruit at breakfast, saying that fruits and vegetables are “good for you because it's healthy, makes you strong; there is natural sugar, and it contains vitamins like A and C.” However, only 13% said they always eat fruits and vegetables at breakfast, and only 19% said they often do. This may be due in part to the fruits most often served at breakfast not being the fruits students prefer.

Students prefer more exotic fruits than they are currently served. Fruits mentioned were mangos, kiwi, strawberries, peaches, pineapple, watermelon and grapes, with melons and berries being most popular (fig. 2). Students also want more variety in the ways fruit is presented, including chopped fruit, fruit salads, salad-type fruit bars, fruit with condiments and ethnic favorites. Variety, convenience, quality and freshness are key concerns. High school students, in particular, expressed a desire for more tropical fruits such as mangos.

Student survey responses regarding which one fruit was their favorite (n = 1,205 students surveyed).

Fig. 2. Student survey responses regarding which one fruit was their favorite (n = 1,205 students surveyed).

Factors associated with success

Successful implementation of the California Fresh Start Program was not significantly related to school characteristics or student socio-demographics. The type of school (elementary, middle or high), ethnicity/race of the students, rural-urban geographic location, percentage of free- and reduced-price meal participation and size of student enrollment did not have any statistically significant association with the program's success in terms of the number of fresh and total fruit servings students took or the variety of fruits offered.

Whether students were offered and/or took more fruit was affected by a variety of school institutional and economic factors, including the physical layout of the school's food service department and the availability of funding for program support. Because the California Fresh Start Program did not mandate or provide funding for facility improvements, it is not surprising that only about 9% of the schools made improvements to their kitchen, dining area, serving areas or points of service. Data from the evaluation indicated that adequate dining space for students was related to students taking more fruit and an appealing dining ambience was related to students taking more fresh fruit.

A test kitchen for healthier school meals prepared a variety of vegetables, fruits and homemade vinaigrette to tempt students to try more fresh produce. Variety, convenience, quality and freshness are key concerns among students.

A test kitchen for healthier school meals prepared a variety of vegetables, fruits and homemade vinaigrette to tempt students to try more fresh produce. Variety, convenience, quality and freshness are key concerns among students.

Almost one-third (31%) of schools did not have sufficient facilities to seat all students comfortably. The temperature was uncomfortably cold in many of the serving and dining areas, which may have played a role on cold days in students' preference for hot breakfast items rather than cold fruit. The student survey revealed that a majority of students want more options regarding when and where they can eat breakfast, particularly the options of eating in the classroom and indoors or outdoors. Only about one-third of schools offered students the choice of eating indoors or outdoors. Our findings suggest an investment in facilities has the potential to attract higher participation in the breakfast program and to increase students' intake of fresh fruit.

Schools that offered more variety of fruits were more likely to have made improvements in customer service, nutrition education, student attitudes and the quality and appeal of the fruit offered. Quality concerns were prominent in discussions with students about the changes in foods offered. Students noticed both positive and negative changes in food and beverage temperatures, freshness, taste, portion size and preparation.

In addition to presentation, the position of fruit in the serving sequence might affect student selections. At one site, the fruit was not visible; it had to be requested. Fresh fruit was the first item offered in the serving sequence at only three of the 13 sites where these data were recorded.

Nutrition directors at schools where students chose more fresh and total fruit were more likely to describe inadequate storage space and facilities. (Perhaps having to expand offerings heightened their awareness of inadequate facilities.)

Nutrition education, promotion

Many schools increased nutrition education and promotion efforts among students as part of the California Fresh Start Program but lacked the staff time and resources to mount a sufficiently intensive effort. Of the nutrition directors surveyed, 96% reported that lack of opportunity (time allotted in students' school day or an appropriate school location) was a barrier to fully providing the nutrition education component of the program, 87% reported a lack of staff time as a reason, and 81% reported that lack of funding was a barrier (Return to top

Author notes

Funding for this research was provided by California Healthy Kids Resource Center and the Nutrition Services Division of the California Department of Education. The authors would like to thank the administrators, food service personnel and students of the participating schools for their involvement as well as Sheila Stern and Lauren Goldstein for their editorial assistance.

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