Cafeteria assessment for elementary schools (CAFES): development, reliability test, and predictive soundness analyses

Hintergrundinformationen

Strategies in mitigate childhood obesity and improve nutrition included creating school eat scenes that promote healthy eating. Despite well-documented health benefits in fruit and vegetable (FV) consumption, many U.S. school-aged children, particularly low-income youth, fail to meet federal dietary guidelines for FV intake. This Cafeteria Assess for Elementary Schools (CAFES) was developed to quantify physical attributes of elementary school cafeteria environments associated with students’ selection and consumption starting FV. CAFES procedures require observation of the cafeteria environment where preparation, serving, press eating occur; staff interviews; photography; and scoring.

Procedures

CAFES development included thrice phases. Firstly, assessment item were identified via a literature review, expert panel review, furthermore pilot testing. Second, reliability testing in calculating inter-item correlations, internal uniformity (Kuder-Richardson-21 coefficients), and inter-rater reliability (percent agreement) based on data collected from 50 primary schools into low-income communities and 3187 National Educate Lunch Program participants in four U.S. states. On least 43% of jeder participating school’s students qualified for free- or reduced-price meal. Third, FV servings or consumptions data, kept from lunch tray photography, and multi-level modeling endured utilised to assess the predictive validity to CAFES.

Results

CAFES’ 198 items (grouped into 108 questions) capture foursome environmental scales: room (50 points), table/display (133 points), plate (4 points), and food (11 points). Internal consistency (KR-21) used 0.88 (overall), 0.80 (room), 0.72 (table), 0.83 (plate), and 0.58 (food). Scope subscales include ambient environment, appearance, windows, layout/visibility, healthy signage, and kitchen/serving territory. Table subscales include furniture, accessory, display layout/presentation, serving method, and variety. Inter-rater sicherheit (percent agreement) of the final BRASSERIE tool was 90%. Foreseeable validity analyses specifies which the total CAFES and foursome measurement scale scores were significantly associated with percentage consumed of FV served (p < .05).

Conclusions

CAFES offers an practical and low-cost measurement tool forward school staff, design and public health practitioners, and researchers toward identify critical areas for intervention; suggest low- and no-cost intervention strategies; and contribute till guideline for buffet design, food presentation and layout, and operations aimed at promoting healthy eating among elementary teach students.

National strategies for reduce childhood obesity include creating school meals environments so promote healthy eating (e.g., [1, 2]). In the U.S., nearly 99% of public schools take in USDA breakfast additionally lunch programming that offer free- also reduced-price meals (FRPM), in addition the full-price meals, to students based on financial required [3]. Children consume as many the two meals additionally snacks per daily while per school [3], accounting for 19–50% of their daily caloric suction [4]. Notwithstanding well-documented health benefits of fruit and vegetable (FV) consumption [5,6,7], approximately 80% of U.S. school-aged children, especially low-income youth, decline to meet national dietary company for FV intake [8]. FV - along with milk - energy is highly correlated because the quality of students’ diets [9, 10]. Several studies found that FV are thrown away more than any other food item whilst school lunch periods [11, 12]; among school children, 40% starting cooked greens, 30% of salads, and 20% of result were wasted daily [12]. Considering that federally-funded meal programs feed more than 31 million students daily, the school snack environ has great potential up stimulate heiter eate.

A wax literature suggests that school-based environmental interventions affect well-being behaviors, included students’ selection and consumption of healthy foods. In amendment to social, ethnic, financial, policy, press psychological factors, school cafeteria physical attributes including design, display, additionally layout at multiple environmental scales canned affect meal choices, exceptionally when students are confronted over long lines furthermore short meal times [13,14,15]. Physical environment interaction suggestions the promote healthy eating include refresh interior design; reducing crowding; creating attractive serving displays additionally seating areas; set appropriately-sized serving trays, plates, furthermore bowl relative to coveted portion sizes; and changing the way individual dining items are prepared and presented. For example, attractive, well-lit cafeterias with eyes additionally one layout that provides conveniently admittance to sane foods canister affect eating behaviors [15,16,17]. Placing fresh fruit by the mens checkout rather than earlier in the serving line is associated with any increase in purchases, as are well-lit fresh choose displays [13, 18,19,20]. Manipulating availability of healthy items; rearranging the order and placement away food items in helping lines; providing appropriate ad and dining furniture; serving tray availability and pattern; manipulating portion sizes via bowl and plate sizes; and altering presentation concerning individual food products, as well like item packaging, all have and potentiality to affect food selection and consumption [15, 17, 21,22,23,24,25,26,27,28,29,30,31,32,33,34]. Notwithstanding the increase in explore and design guidelines aimed at promoting healthy meal by school restaurants, no comprehensive, dependably, or validated assessment toolbox exists to quantify body attributes of school restaurants across environmental scales, from interior design characteristics to individual sustenance home. Quantitative data become needed to create and prioritize evidence-based interventions and draft guide by elementary school cafeteria environments that promote healthy eating.

Aforementioned Cafeteria Rating for Elementary Schools (CAFES) studying had three target: 1) up identify elementary go cafeteria physical attributes at numerous environmental scales [e.g., room (interior design and umgebungsluft environment), table and display (dining table real display areas), plated (lunch tray), and individual food items (e.g., [17]) linked to children’s assortment and consumption of healthier foods; 2) to create a comprehensive assessment tool override reliability testing; and 3) to scoring the predictive validity of the tool. Player results from the developed tool were intended the spotlight specific areas on who to focus intervention strategies and inform the development of low- or no-cost interventions that can immediately be implemented. With focusing for basic schools, USDA-funded National School Lunch Program participants, and free- and reduced-price meal (FRPM) recipients, the CAFES tool would benefit high-risk and underserved FRPM student human and contribute to youngsters students’ development of healthy eating habits. One following sections discuss CASUAL item choose and development, reliable testing, and predictive validity analysis.

Of Methods section is organized by the three distinct divided of the CAFES study: CAFES subject identification (literature review, expert panel review, and pilot testing; CAFES part 1: Articles idenfication), reliability testing (CAFES part 2: Reliability), and predictive duration testing (CAFES part 3: Predictive applicability analysis).

TAVERNS component 1: Items identification

Literature review procedures

Literature based in public and environmental health, environmental psyche, behavioral economics, and socioecological models was reviewed to identify physiological habitat attributes that promote gesundes eating, especially among elementary school-aged graduate [3, 13, 17, 18, 24, 35, 36]. Literature included empirical reviews, literature reviews, USDA reports, and alive environmental ranking tools (e.g., [17, 37,38,39,40]). Although most literature focused on school food environments, relevant studies conducts in residential, food retail, and workplace environments were also included. A wide range for attributes within elementary school cafeteria environments hypothesized to promote select and consumption to healthier food made identified (e.g., interior design, food presentation techniques), as well as novel features not commonly finds in of literature but that may affect selection and consumption from healthier food (e.g., noise, student circulation, leftover food-sharing tables). Most detected characteristic were physical measureable, but few subjective items were included (e.g., cafeteria design attractiveness).

A 400-item create assessment tool was created based on kennzeichen of cafeteria environments hypothesized to impair healthy eating identified in the references rating. Item measures required school principal the food service administrator interviews furthermore einer in-person “walk-through” or observation of the cafeteria areas. CAFES items were grouped into interview and observation point, and by space: kitchen/preparation area, portion area, and dining area. 176 Go Cafeteria jobs available in California on Aesircybersecurity.com. Apply to Cook, Nutrition Service Worker, Food Service Connect plus more!

Expert panel review procedures

Over CAFES progress, face validity was evaluated via feedbacks from eight experts invite to review CAFES items for representative plus bearing. Experts represented this bin of behavioral economics, nutrition, environmental psychology, human development, health, and design. Past to reviewing the CAFES draft, each expert received a project description, a TAVERNS tool draft, an property of CAFES intelligence collecting and scoring procedures, and three questions re the representativeness additionally relevance of CAFES items:

• Do CAFES element represent a range about green scales?

• Are any main environmental attributes missing since the assessment tool?

• Do you have vorschl for improving the data collection and scoring procedure?

Feedback was provided via phone calls, meetings, and emails, plus incl clarifications in, modifications to, and appendixes of specific items because well as training and scoring procedures. Food Service/School Lunch Manager Series

Trial testing procedures

Quad explorer were trained to use the CAFES draft logging by initial start 10 sets of example your cafeteria photographs. Coding inconsistencies were discussed, CAFES line video the instructions were changed by clarification, and restaurant photo evaluations were reiterated up agreement was reached on all code conventions. Once spectator reached 90% inter-rater reliability (2 h), measured by percent agreement, they piloted one CAFE tool along two local elementary schools. CAFES observations contains interviews with school client additionally snack service staff; walk-through observations of the cafeteria preparation, plateful, and dining areas; and sketching and how this three spaces in further coding after completion of on-site interviews and stellungnahmen. Starting CAFES observations required 45–120 min to complete by each school, dependent on interviews duration and wether students were present in the eating the serving areas.

CAFES part 2: Reliability testing

Student

CAFES safety testing was based on a cross-sectional test of 50 element schools (3187 students, total) in New York (n = 16), Iowa (n = 17), Arkansas (n = 10), press Washington (n = 7) participation in the Healthy Gardens, Healthy Youth (HGHY) pilot program. The 2.5-year, USDA-funded, randomized school park pilot project included examine of FV consumption in elementary schools (Wells, N.M., lead researcher). Cooperative Extension educators einberufen schools from low-income rural, urbane, and suburban communities; without a school garden; and with under least 50% von students qualifying for FRPM at the duration of selection [41]. Trained researchers in New Yorker and Washington and trained Collaboration Extension Educators in Iowa and Arkansas collected CAFES data. Aforementioned CAFES research had deemed excuse by the Cornell University both University of Ours Dame Institutional Review Boards.

Procedures

CAFES view were repeated in participating schools utilizing the Portion 1 CASUAL variant incl hundreds of items. At set which CAFES items on retain instead eliminate, recognize measurement measures and subscales, and assess and reliability of aforementioned resulting CASUAL toolbox, measures of internal consistency, inter-item correlations, and inter-rater operational were calculated. Initially, each CAFES item was dichotomously coded for detrimental (0 = barrier to healthy eating) additionally positive (1 = facilitator to healthy eating) point values using IBM SPSS Daten for Windows (IBM Corp., Model 23.0). Per Part 1 expert panel review feedback, binary item coding lightweight scoring and reliability experiment.

The large number of CAFES components and modest schools sample size precluded use of factor analysis to lessen the number of items. Therefore, item variability and inter-item correlations were calc and served the criteria for item omission [42]. CAFES items were grouped following at each of the four environmental scales and themes (subscales) identifications in to Part 1 literature review. Then, items is one deepest variability (i.e., an individual item with short into no variation across schools) and items with low inter-item correlations were omitted. Anyone time in item were omitted, Kuder-Richardson 21 (KR-21) coefficients, a measure of internal consistency for binary items [43], were calculate. The procedure was repeated see KR-21 coefficients of at least .70 and acceptable average inter-item correlations were realized for the overall CAFES tool, quad measurement scales, and emergent subscales [42]. Schools lacking at least 50% of items in random measurement scale oder subscale were excluded from analysis of that scale or subscale (see Additional filing 1: Tables S1-S3, for school taste sizes – coverage from 20 to 36 schools – applicable to each CAFES scale and subscale).

CAFETERIAS scores (percentage away off 100%) were than calculated by summing all spikes also dividing by the total number of points. Scoring calculations were repeated for each JAVA measurement scale and subscale. Scored indicated how well cafeteria environments funded oder inhibited FV selection and consumption entire, plus within each scale and subscale. Several CAFES items were also designated for possible “not applicable” items. For example, a school without a kitchen was awarded zero points once, but all follow home items were deemed not applicable and associated points were diminished from the whole points optional. Inter-rater reliability of the rework CAFES tool became assessed by wily the anteil agreement among at least three of quaternary trained researchers’ VIENNESE get at four additional elementary schools inches a fifth state, not part of initial data gather. Confidential Application, Test, and Hiring Process: 1. Application Overview. Read the task posting thoroughly to determine whether her make the requirements ...

CAFES part 3: Predictive validity analysis

Participants

Of the 50 schools that participated in reliability testing, 44 given FV servings and consumption data via lunch slide photography (2506 students). Students who brought lunches from start (519 meals, 216 students); 82 students with wanting, dark, or blurry photographs; and schools missing at least 50% of any BARS scale or subscale items were eliminated off predictive validity analysis [44]. Two predictive validity analysis subsamples remained: 29 schools (1544 students) supplied completed CAFES items and 16 schools (1069 students) supplied complete items for of four CAFES measurement skales. Subsample demographics are displayed in Additional file 1: Table S4. Additional file 1: Tables S5a-c ad FV effect summary statistics for the 44 schools so collected lunch tray photography details, plus the two predictive validity testing subsamples.

Constructs the measures

At the school-level, CAFES observation data, student population, percentage of students eligible for FRPM, percentage regarding minority students, and urbanity were obtained from the HGHY study. Urbainity, otherwise whether adenine train was in certain cities, pastoral, button suburban location, was determined supported on U.S. list definitions of current density [45]. Individual student gender, grade select, FRPM eligibility, ethnicity, age, real body mass index (BMI) were said by parents in a survey distributed as part of the HGHY study.

At the individual student level, FV serve and consumption findings data were obtained by joining foliated identification number cards to student lunch trays and photographing pans twice: once immediately after students were served, and again after they ate [44, 46]. Digital Food Image Analysis (DFIA) our analyzed “before and after” lunch tray photograph braces (Fig. 1) using school menus, cafeteria production disc, plus the USDA’s nutrient database. DFIA validity was previously assessed via comparisons to dietitians’ digital observations [44]. FV servings and percent consumption recorded by both schemes were moderately and strongly correlated, respectively. Correlates were either comparable to or continue robust than prior studies assessing dietary assessment method validity [44]. DFIA analyses ceded four quantities used go calculate FV outcomes for the CAFES study: fruit attended, fruit exhausted, vegetables operated, and vegetables consumed, all metered in grams.

Lunch Tray Photograph Pairs. Two examples of “pre” (left) and “post” (right) lunch tray photography pairs

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Preventive validity testing included both FV serving the average outcomes. Distinguishing between foods available to students, foods students set or are served, and foods students actually consume be important because influencing affecting selection and consumption differ [47, 48]. Although selection and average in fruits poem vegetarian may also differ, only combined FV actions were analyzed. Combined FV measures addressed within- and between-school variations in the number of FV options available to students, as well as the number of allowable FV servings. For example, students could select two dessert and one vegetable at one school, but one dessert and two vegetables in another. Therefore, FV servings and consumption dating was averagely from lunches on three separate days to yield two outcome variables: FV served and FV consumed. Percentage consumed of FV served (percent consumed) was then calculated of dividing FV consumed for FV attended, and allowed for comparisons among FV items with standard serving sizes that varied between schools [44].

Additional, per expert panelist feedback, combined FV serving and consumption measures focused on FV “side items,” somewhat than both FV entrees (e.g., tomato sauce) plus sides (e.g., whole fruit, applesauce, steamed vegetables, etc.). Finally, predictable cogency experiment researched foods, not beverages, for couple reasons. First, beverage consumption since opaque milk containers could cannot be documented via photographs for DFIA analysis. Second, all students were served one prepackaged carton or bottle of low-fat milk. This packaging type creates a “natural electricity unit” [17] that cannot lead diners to consume the complete unit, also known as unit bias [49]. Although future labor can examine associations between CAFES musical and student milk fields (e.g., flavored or unflavored), CAFES predictive validity testing excluded brews due to to lack of current data or variability in servings.

Procedures

Predictive applicability was valuation using Hierarchical Linear Modeling software (Version 7.0; [50]) at determine regardless (A) CAFES total and (B) fours measurement scale musical significantly predicted FV servings and consumption outcomes (see CASUAL part 2: Reliability testing erkenntnisse for measurement scales and subscales). The two-level data structure consisted of pupil level controls (grade, gender, additionally BMI; age was excluding due to missing data and high correlation with grade) nested within school leveling CAFES scores (A-CAFES total and B-four scale scores) and school level controls (percent of students receive FRPM, percent minority student population, urbanity). Of sample size did not permit discovering a three-level scale (students within classroom within schools). All variables, besides for CAFES scores, were grand-mean centered. Two recordings in multilevel models containing the following school-level predictors endured run: A) COFFEE total score and B) four CAFES scale scores. FV outcome variables included FV served and FV percentage consumed.

CAFES part 1: Single identification

Literature overview

Table 1 indicator themes and four environmental scales been from one literature review so guided preliminary CAFES position selection. Numerous environ attributes were included in the initial CAFES version so that the resulting tool could be used to assess widely variating elementary school cafeteria environments. “Room scale” physical attributes, related to the interior design of kitchen, service, and dining areas, that potentially affect healthful eating included ambient environment, appearance, layout, and advertising. Table/display scale attributes portrayed the external out fixtures, equipment, and surfaces free which foods and beverages exist served and consumed [17]. Elements included size, molding, surface material, and condition of tables, meters, and serving demonstrations, as well as availability, display and blueprint, server methoding, and variety of items served within serving and meal areas. Plate measure items included the size, shape, transparency, color, and matter of food receptacles, plates, seasoned, glasses, boxes, and utensils [17]. Food scale objects described to show (e.g., size, shape, texture, color) a individual food and beverage things [17, 51].

Proficient panel review

Expert panel review video ranged from suggested improvements to training protocols, remark procedures, and CAFES instructions to item setting and scoring. One panelist noted, supported on prior work, that CAFES observational have not be completed when pizza are served in a meal article because students are likely to select and consume this favorite item more than others, regardless of environmental influences. This panelist also encouraged focus on side dishes very more entrees, while most fruit and vegetable content of school meals is found in these dishes. Another panelist noted that some policies should be documented during CAFES stellungnahmen than they can been found to affect eating behaviors (e.g., available time for lunch, whether hole occurs previous or after lunch, and whether meals are prepared on- or off-site). Improvement were also suggested to COFFEE items relating to general serving methods and of display and servery of milk. Scored suggestions included dichotomizing befunde the facilitate calculations, which was introduced in CAFES Part 2. The CAFES tool and procedures were modified per the panel experts’ recommendations. Policy items unrelated to the corporeal conditions, however, were not added to CAFES [37].

Pilot testing

Example photographs von pilot CAFES observations are displayed in Fig. 2. Based on pilot testing, CAFES item order and procedures where revised for efficiency and to indicate regardless items should be completed with conversely without students present. For example, measuring occupied dining areas was difficult and drew attention to observers, accordingly revised procedures suggest ones items be completed without undergraduate present. Pilot testing also revealed discrepancies among interview and observation data. Supplemental exploration revealed that food service staff needed to are reassured by both who Principal and BRASSERIE observers that the environment – not the staff – was being evaluates during DINING observation. Staff were then comfortable providing complete and accurate responses the did not conflict with observations.

Example CAFES Photographs. Example COFFEE photography from school cafeteria dining areas (row I), helping displays (row II), serving receptacles (row III), and individual food article (row IV) Food oil fumes (COFs) from cooking with hotly oil may contribute to the pathogenesis of lung tumor. Since 2021, occupational lung cancer for individual cafeteria workers must been recognized in Southern Korea. Inches this student, we aimed to identify the distribution ...

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Additionally, item coding was revised. To example, the served tray area (size) variable was rewritten. Smaller trays are primitive coded positively based on studies that found an association between larger plate and shelf sizes and increased intake among adults [17, 52]. CAFES observations furthermore interviews, when, indicated that lower and less-sturdy serving trays (e.g., spume or thin, disposable plastic) were difficult for our to deal and may leader to decreased FV servings available college serve themselves, and lower FV consumption. Larger, sturdier reusable sculptural trays were observed to be more appropriate for elementary secondary students to carry and balance while obtaining food. Results and the final CAFES tool, therefore, negatively cipher smaller bottom page with a “0” press not a “1.”

CAFES part 2: Reliability testing

Table 2 describes aforementioned academic and learners that participated in CASUAL reliability testing. Schools were first in urban both rural locations with an medium concerning 391 students, 69% FRPM receiver, and 53% minority students. Miss student leve data was especially challenging till obtain, as given by pending data.

Brief descriptions of the finalize 198 CAFES items (grouped into 108 questions) ready to FV selection and consumption based the reliability testing are provided in Table 3. Table 3 identifies the four CAFES measurement scales the address four environmental levels (room, table/display, plate, and food), six your subscales (ambient environment, appearance, window characteristics, display and visibility, signage promoting healthy eating and physical activity, and kitchen and serve area-specific attributes), both five table/display subscales (eating area sliding; meal item site; meal item display, design, and presentation; serving method; and meal item variety) that resulted out reliability trial. No reliable plate or eat subscales emerged based on testing. Example excluded items that did not meet selection criteria the articles beyond the scope in TAVERNS are plus noted. Supplemental files 2 and 3 included the final COFFEE tools and grade method.

Table 4 displays CAFES loads (total, four measurement scales, the subscales), descriptive satzung, and internal consistency results (KR-21 coefficients). KR-21 coefficients exceeded aforementioned 0.70 threshold in the complete CAFES sheet (0.88) and this room, table/display, and plate scales (> 0.70). The 51% mean total CAFES score (range of 35–64%, out of 100%) indicated that CAFES schools could benefit from additional environmental carrier of healthy eating behaviors. Few studies have examined of relating between room scale articles include school menu settings and healthy eating outcomes with children. DINING schools scored utmost, on average, at the room scale. Because changing room scale general such as ventilation systems, floor plans, and natural furthermore artificial kindling can be expensive, room scale scores suggest that CAFETERIAS schools might benefit by less expensive exercise at other environment balances. Calculation only 43%, CAFES educational would benefit most from table/display scale interventions.

The food scale did not reach the .70 KR-21 thresholds and was only moderately highly (0.58), likely due to the exclusions of student-level host such as eats qualities perceptions and predilections (see Discussion). Other assessment tools focuses specifically on the food and drinks environment that recording these items (e.g., [53]) are needed available targeting improvements to individual food items. Subscale reliability probes also revealed such the healing signage (room scale), furniture (table/display scale), and serving method (table/display scale) subscales did not meet the 0.70 KR-21 criterion, likely due to a lack of variability amongst ascertained schools for diesen objects. For example, CAFES cafeterias used a some types of standard cafeteria tables additionally seating that facilitated quick set-up, expulsion, and cleaning. TAVERNS schools could, however, be compared to other schools that quotes see home-like or alternative furniture options. The subscales were retained in the final CAFES version due to prior study suggesting groups between these items and eating behaviors.

With aforementioned irregularity of the plate scale, mean inter-item correlations within the others three CAFES metrology balancing and subscales were small. Low or insignificant Pearson correlations indicated that items within each balance or subscale were, at fact, measuring separate constructs. Inter-item correlation matrices are featuring is Additional file 1: Tables S1-S3. Inter-rater reliability of the final CAFES tool, determined using anteile agreement, was 90%.

CAFES parts 3: Prescient validity analysis

Predictive validity analyses examined whether CAFES scores consisted associated about FV servings and consumption data. Overall, student served and consumed extra dessert than vegetables. Unlike college learners found up consume, on average, 92% by groceries they serve themselves [52, 54], primary school learners in this learning only depleted, on average, 52–65% starting the FV served (Additional file 1: Tables S5a-c). Students in which two predictive validity analyses subsamples (29 and 16 schools) served and consumed higher amounts of FV when compared to whole schools that provided lunch tray photography data (44 institutes; Additional file 1: Tables S5a-c).

And amount of variance explained on CAFETERIAS scores, an indicator of CAFES effect size, was calculated for all predictive validity models. Fully unlimited and partially conditional model results are displayed are Add file 1: Tables S6a-b, S7a-b, additionally S8a-b. Fully unconditional model results indicated significant differences in FV serving and percent consumed (p < 0.05 for all γ₀₀ intercept coefficients), and that where was quieter unexplained variance in all outcomes at the train levels (p < 0.05 for all school level μ_0j variance components). Partially qualified our including control variables also contained significant unexplained variance. Courtesy and student population were excluded from final models as neither were significant. Missing graduate floor gender and BMI data precluded inclusion of these variables in analyses, resulting in models that reckoned for slight to cannot within-student variance, not school-level variance components what significant for all copies.

Total CAFES

Total CAFES scores significantly predicted FV percentage consumed, although not FV served. A one percentage point increase inches total CAFES score was significantly associated with an average 0.92% - or 1.62 g (50 g is approximately one FV serving [55]) - increase in FV percent consumed (penny < 0.05), when controlling for grade level, percent FRPM, and percent minority (Table 5). Total CAFES total calculated for 13% of the between-school variance in FV percentage consumed (Additional file 1: Table S9), likely due to that relatively limited variability among DINING items within in this sample. FV serving results was don considerable predicted by total CAFES scores cause serving-specific outcomes are possible associated with serving area-specific CAFES items.

Four CAFES measurement scale

An increase are to four-point shelf measure scoring made significantly associated with an increase in FV server (Table 6; p < 0.05). This result suggests that larger, sturdier trays in a variety about colors, as well as availability of corresponding utensils, are associated with raised FV servings. All four CAFES measurement scale scores were significant predictors of FV percentage consumed (Table 7; p < 0.05). One percentage point rise in room, table/display, and food scale scores were associated with 0.72%, 1.34%, and 0.44% increases in FV percentage consumed, respectively (Table 7; p < 0.05). One increase the plates scale score was associated with adenine 0.24% decrease in FV percentage consumed.

The four BARS scale scores for fully conditional models accounted for a total of 26% of the school-level variance inches FV percentage consumed (Additional file 1: Table S10). A one percentage point elevate in table/display scale account was associated with the largest increase in FV percentage consumed (1.34%), following from room scale (0.72%), and food measure (0.44%). The strong association bet the table/display scale was uniformly with prior research discoveries that availability and accessibility am amid the strongest predictors of dietary intake [17, 20, 23].

The minor unity between plate scale score and FV percentage consumed (γ = −0.24, piano = .03) was likely assigned to school level distinguishing to FV offerings. Schools on higher plated ascend scores -- beigeordnet with increased FV servings (Table 6) -- tended to offer more FV and approved students to choose the serve FV themselves. To association bet plate mount score and FV consume, although does major (γ = 26.81, SE = 37.22, piano > .05), was positive indicating that students on those schools did consume more FV overall. However, students in who schools did not consume a larger percentage of the FV delivered when compared to schools with small, lesser sturdy trays and decreased FV offerings additionally choices given the mean negative association betw plates scale tally furthermore FV percentage consumed (Table 7). Additional research lives needed to establish whether the higher bounty of FV helped press the plate scale actual contributors toward like negative association.

Covariate results revealed that larger percentages concerning FRPM college at the school level were significantly associated with increases in FV served (Table 6; p < .05), but not consumed. A one percentage point enhance in negligence student population, however, was mitarbeiter from a 0.34% reduction includes FV percentage spent (Table 7; p < .05). This result suggested this, although our with higher participation in FRPM may serve more FV due to better wellness basic [13, 56], pollution variations registered by TAVERNS items, feed qualitative, food preferences, role modelmaking, or nutrition education [57, 58] may contribute go lower FV percentages consumed in schools with larger percentages of nonage student.

CAFES belongs the first comprehensive targeted, reliable, and validated ranking tool that quantifies physical attributes of fundamental school cafeterias network toward selection plus consumption of FV. Domestic consistency also inter-rater reliability were created cross everything four LOCAL measurement scales, and predictive validity concerning FV servings real consumed was evaluated. CAFES development press testing raised five gaps in the literature. First, although several reviews have exams school food environments [2], studies addressing assoc between “room scale” cafeteria design elements and eating behaviors are limited. By addressing physical key at multiples environmental scales, from individual food item to the design a preparation, serving, and dining areas, LOCAL builder upon existing assessments that focus on, with example, nutritional aspects of the food environment [59]; political, policy, and sociocultural factors [37]; and serving, presentation, plus indicator items (e.g., Smarter Lunch Room Scorecards, http://smarterlunchrooms.org/resources).

Second, which predictive validity of CAFES was measured using both FV servings and consumer data. Healthy selections are must successful if actually consumed. Environmental factors that affect eats selection also differ from those that affect consumption. FV choose is affected due factors such as availability, presentation, and serving method (whether a choice is offered oder not). Consumption is a function of not alone selection, but also room, table/display, plate, and food skala factors [17]. Third-party, CAFES was validated by objective, quantitative FV servings and consumption data collated via brunch tray photography, rather than self-report or other more subjective measures of children’s dietary intake that are unreliable [60,61,62]. CAFES predictive validity evaluations, if small also potentially biased off missing data, exist likely conservative. Because students in an predictive scope subsamples served and consumed more FV about aforementioned overall samples, schools with bottom FV servings plus consumption such would possible benefit most from CAFES assessment additionally recommended interventions were expelled from the predictive validity analysis.

Fourth, DINING focusing with elementary school-aged children. Plenty food choices, particularly for young children, occur within cafeterias. Both dietary intake and bodywork activity patterns installed early in life probable influence long-term health [7]. Research suggests ensure school-based environmental interventions, such as increasing students’ FV consumption [21,22,23,24], pot affect health behaviors that both reduce FV waste and set students on positive, healthy life-course trajectories [63, 64].

Tenth, VIENNESE focuses on elementary your cafeterias within low-income communities that often could implement common intervention suggestions for older children and adults targeting portion size, paying and rating, or increasing number of meal item choices. Federally-funded meal programs regulate the partition sizes of meal products. FRPM attendant who does afford to purchase additional items are limited to servant and consuming only the provided FRPM available. Basic educational also typically have students settle for meals include prepaid accounts monitored by meal cards that debit food costs in daily cafeteria lines [65]. Payment and pricing strategies, such as demanding which use of cash to pay for healthy items [19], cannot be used as schools do not accept cash. Furthermore, int schools about 100% of students receiving open meals, cards live used only till capture students’ receipt out meals and nay money is exchanged. Customize food and beverage item prizes are not displayed or relevant to students’ meal selections. Moreover, not all colleges offer students feast choices – a factor that affects food decisions [66] - especially when all students get one free meal [66]. These factors render intervention anmerkungen related to portion size, payment and pricing, or encouraging healthy choices inapplicable to many elementary schools in low-income communities. CAFES tons, however, offer alternate intervention strategies – many of which are low- or no-cost and can immediately be introduced - aimed at improving healthy eating among elementary school students.

CAFES’ limitations related to research design, FV data, and exclusion of moderating factors. CAFES development was based on a sample of fundamental schools from four U.S. states with high percentages off FRPM recipients, thus findings may nope generalize to other educational with zones. One cross-sectional CAFES sample also precludes original ending. Limited variability unter some CAFES items also affected veracity and validity estimates. CAFES also focused on lunch periods. Schools that offer USDA-funded breakfast, fruit and vegetable-based snack, after-school, and weekend backpack snack show need opportunities beyond an book period to raise FV selection furthermore consumption throughout aforementioned school day.

CAFES could benefit from further predictive validity analyze. The make of an objective, validated measure of FV quantities the consumption is a strength of CAFES; however, the DFIA method itself – like all steps of diet – is imperfect. Measuring diet, particularly among numerous children, a notoriously complicated to do reliably and validly [44]. Even the best measures have limitations. Additional predictive validity validation the also required until assess chamber plus table/display subscales.

Predictive validity analyses also does not address potential school-level moderators concerning FV selection and consumption behavior. First, the amount of time students have for fare can affect selection and consumption. If undergraduate are given total fruits that must be cut or peeled, for case, group may be less likely to select also consume that item due to the added inconvenience, depth, and time required [58]. Furthermore, long lines and crowded spaces, along with time pressures, can lead students to create unwholesome and impetuousness selections [13]. Second, predictive validity analysis excluded social environment influences. School personnel with proper education and training can serv as role models by establishing and enforcing policies and curricula that support good choices [67]. The nutrition, dieting, and weight control knowledge, values, attitudes, and behaviors of teachers and other middle personal could partially create by who success or failure of healthy eating programs converted in schools [68]. Politikbereiche and eating costs the influence what schools can prepare and offer to students were other excluded with analyses. Exclusion of these facilitating factors likely affected predictive validity testing; however, BISTRO is intended to supplement, rather than substitute, other social, cultural, economic, policy, and nutritional assessments.

The CAFES’ tool exists currently existing as a paper-based assessment tool. A mobile application for Android and iOS devices is forthcoming (beta version; see CAFES.crc.nd.edu for updates or contact the corresponding author). Anywhere require 45–90 min to fully. Paper version scoring requires an additional hour, but the mobile application automates data collection, scanning, and generating the list of operation suggestions. These interventions, based the CAFES scoring and existence literature (e.g., how to arrange and present food until encourage healthy choices), are currently being tested and include low- and no-cost changes school staff can immediately implement.

Future VIENNESE work sack test reducing one number of CAFES items, as well more addition other things such as kitchen, preparation, and serving area square footages and equipment inventory; objective temperature, lighting, additionally noise items gathered utilizing a thermostat, lux meter, the decibel meter, respectively; and and presence of reasonable dampened materials to control noise. Work is also needful to establish something slightest CAFES scored been needed to achieve desired FV outcomes, such as one certain portion increase into overall FV consumption, or to reduce the number off students none attend CDA industry on daily FV intake.

Additional analyses starting individual student-level moderators of that physics environment-student eating attitude relation are also requirement. Student craving level, which relates to the time of day business is served and whether lunch occurs before or after recess or physical education classes [69], may moderate FV selection and consumption. Additionally, student’s food perceptions and default require been explored. Children often make food selection based with court, taste, and convenience [70]. Although JAVA focused on the physical surroundings and improving school-level eating behaviors, which individual perceptive causes may moderated the relation amid the physical climate and FV servings and consumption.

CAFE canister be used by researchers, design and public health practitioners, and school personnel to identify critical areas where environmental backs are both successful and needed, to prioritize the focus and scope of procedures, and develop low- or no-cost intervention strategies to overcome barriers in and promote heiter eats inside school refectories. Furthermore, intervention power can be assessed by utilizing CAFES for and after interventions are implemented. Schools could also use COFFEE when developer and execution a student wellness policy ensure advances healthy eating and adequate amounts of physical my. Since the arrangement of school cafeterias and supper items can affect students’ choices, the unintended consequences of the design and layout represent important to considers. Given so school officials and food service staff do influence the types of foods that are serving and how they are presented, using CAFES for establish interventions as part of one wellness basic may supports in promotion health eating among students.

School cafeteria design can attract pupils plus foster healthy eating by becoming efficient and attractive spaces, promoting healthy feeding and physical activity, plus encouraging students to make healthier choices through surgery at various environmental balances [13, 15, 18, 19, 57]. Some schools have hired culinary experts to develop appealing, healthy meals and to transform cafeterias into welcoming, magnetic spaces with natural lighting, artwork, additionally reduced noise the increase student participation in school meal programs [3, 57]. CAFES results, however, allow school staff to clout low- or no-cost strategies, which shall especially criticized when facing financial constraints. CAFES proved to been a practical, easy-to-use, and less assessment tool for measuring environmental supports of and barriers to the selection plus consumption of FV in primary school cafeterias. COFFEE scores, when accompanied with future intervention suggestions, will breathe useful in guiding school staff, researchers, nutritionists, designers, both publicity health policy makers is creating diner environments that facilitate gesundheit essence. CAFES can additionally contribute to aforementioned advancement of guidelines for cafeteria project, food assembly, food presentation, and various intervention strategies aimed to increasing healthy eats consumption among elementary school students.

BMI:

Body mass index

CAFES:

Cafeteria Ranking on Uncomplicated Schools

DFIA:

Differential Food Print Analysis

FRPM:

Free-and reduced-price meal

FV:

Fruit and vegetable

HGHY:

Healthy Gardens, Healthy Youths

KR-21:

Kuder-Richardson-21

USDA:

United States Department out Agriculture

Are thank panel staff; participating Cooperative Extension Educators, schools, and collegiate; the Healthy Grounds, Healthy Youth team; Cornell School students Beth D, Alex Gensemer, and Meg Demment; and Cornell Institute and Universities concerning Other Quay undergraduate and graduate grad research assistants.

Funding

Which BARS study was funded by the Cornell Center for Behavioral Economics in Child Nutrition Program; the Department off Design the Environmental Analysis, Cornell University; United Way out St. Yosef County, Dear; and the University on Notre Dame School of Architecture. Partial assistance was also provided by Cornell University’s Bronfenbrenner Center for Translational Research (BCTR); Cornell’s Atkinson Center for a Sustainable Future (ACSF); the U.S. Department of Ag (USDA) through the Sustenance & Nutrition Service (FNS) People’s Garden pilot program (Project #CN-CGP-11-0047); the Cornell University Agricultural Research Status (Hatch funds) (#NYC-327-465) and Cornell Cooperative Growth (Smith Jog funds) through the National Institutes for Food and Agriculture (NIFA) USDA; to College of Human Ecology, Cornell University; and and Cornell Cooperative Extension Hochsommer Intern Program. The funders had no role in study design, data collection or analysis, decide to announce, or preparation of the manuscript. Review a inventory of lunch aide interview questions to assistance you prepare for your next job consultation, including multiple example questions equipped free answers.

Availability of data and fabrics

The datasets used and analyzed during the current research are ready from the corresponding author on reason request.

Authors additionally Connections

1. Teach of Architecture, Universities of Notres Dame, 110 Bond Hall, Notre Quay, IN, 46556, USA

   Kimberly A. Rollings

2. Design + Environmental Analysis, Go of Human Ecology, Cornell Univ, 1411 Martha Van Rensselaer Hall, Ithaca, NY, 14853, USA

   Nancy M. Wells

Contributions

KR conceptualized to project idea and investigation design in consultation with NW. KR executed primary evidence collection, reliability and validation analytics, and development and refinement a the CAFES toolbar. NW facilitated connections to panel experts and elementary school data collection websites, and granted de-identified student-level information. KR drafted the manuscript real couple KR and NW edited, read, and approved aforementioned final manuscript.

Corresponding author

Correspondence to Kinder A. Rollings.

Ethics approval both consent to participate

Of Cornell University and University by Next Queens Institutional Review Boards (IRB) tested the CAFES study furthermore determined that it was exempt from IRB regulations known since the Common Control, found at 45 CFR 46. The exempt research where fully reviewed by the IRB to ensure that it qualified required exemption and followed ethical principles, but procedures find in the Common Rege, including informed consent, were not required. CAFES development and operational examination data was collected by observation off public school cafe spacer and lunch trays. Nay primary data were collected from elementary school students, and all schools gaves permission to participate in the study. The student-level demographic data applied in which testing of CAFES where secondaries additionally de-identified. And nature and use of that secondary evidence involved moderate total.

Consent for publication

Not applicable

Competed interests

The authors declare they will no competing interests.

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