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Objective: The World Health Organization recommends people reduce their free sugar consumption to <10% of daily energy intake. This study aimed to determine the viability of the 'Healthier Drinks at Healthcare Facilities' strategy to reduce the amount of free sugar available in beverages and influence consumer purchasing patterns., Methods: Beverage environment modifications at a children's hospital limited the availability of less healthy options. Using a convergent parallel mixed-methods design, sales data from retail food outlets (n=7) and vending machines (n=14) were collected from January 2017 to May 2018. Employees (n=105) and visitors (n=102) completed surveys, and retail food outlet managers (n=3) completed semi-structured interviews. Data were analysed via descriptive statistics, independent t-tests and content analysis., Results: The strategy decreased the availability of less healthy beverages and resulted in a significant increase in the proportion of 'green' (healthier) beverages sold (3%, p=0.002), and a decrease in the proportion of 'red' (less healthy) beverages sold (5%, p=0.011). Overall, sales did not change (p=0.243). The majority of participants supported the strategy., Conclusions: Overall, a shift in consumer purchasing patterns resulted. Further modification of the beverage environment is encouraged to increase impact. Implications for public health: This strategy was feasible and acceptable in a healthcare setting., (© 2020 The Authors.)

Purpose: To determine whether increasing the proportion of healthier options in vending machines decreases the amount of calories, fat, sugar, and sodium vended, while maintaining total sales revenue., Design: This study evaluated the impact of altering nutritious options to vending machines throughout the Banner Health organization by comparing vended items' sales and nutrition information over 6 months compared to the same 6 months of the previous year., Setting: Twenty-three locations including corporate and patient-care centers., Intervention: Changing vending machine composition toward more nutritious options., Measures: Comparisons of monthly aggregates of sales, units vended, calories, fat, sodium, and sugar vended by site., Analysis: A pre-post analysis using paired t tests comparing 6 months before implementation to the equivalent 6 months postimplementation., Results: Significant average monthly decreases were seen for calories (16.7%, P = .002), fat (27.4%, P ≤ .0001), sodium (25.9%, P ≤ .0001), and sugar (11.8%, P = .045) vended from 2014 to 2015. Changes in revenue and units vended did not change from 2014 to 2015 ( P = .58 and P = .45, respectively)., Conclusion: Increasing the proportion of healthier options in vending machines from 20% to 80% significantly lowered the amount of calories, sodium, fat, and sugar vended, while not reducing units vended or having a negative financial impact.

Context: Healthy vending machine policies are viewed as a promising strategy for combating the growing obesity epidemic in the United States. Few studies have evaluated the short- and intermediate-term outcomes of healthy vending policies, especially for interventions that require 100% healthy products to be stocked., Objective: To evaluate the potential impact of a 100% healthy vending machine nutrition policy., Design: The vendor's quarterly revenue, product sales records, and nutritional information data from 359 unique vending machines were used to conduct a baseline and follow-up policy analysis., Setting: County of Los Angeles facilities, 2013-2015., Participants: Vending machines in facilities located across Los Angeles County., Intervention: A healthy vending machine policy executed in 2013 that required 100% of all products sold in contracted machines meet specified nutrition standards., Outcome Measures: Policy adherence; average number of calories, sugar, and sodium in food products sold; revenue change., Results: Policy adherence increased for snacks and beverages sold by the vending machines by 89% and 98%, respectively. Average snack and beverage revenues decreased by 37% and 34%, respectively, during the sampled period., Conclusions: Although a 100% healthy vending policy represents a promising strategy for encouraging purchases of healthier foods, steps should be taken to counteract potential revenue changes when planning its implementation.

(1) Background: Our aim was to conduct objective, baseline food environment audits of two major western Sydney public hospitals and compare them to recently revised state nutritional guidelines. (2) Methods: A cross-sectional assessment was conducted (June-July2017) across 14 fixed food outlets and 70 vending machines in two hospitals using an audit tool designed to assess the guideline's key food environment parameters of availability, placement, and promotion of 'Everyday' (healthy) and 'Occasional' (less healthy) products. (3) Results: Availability: Overall, Everyday products made up 51% and 44% of all products available at the two hospitals. Only 1/14(7%) fixed outlets and 16/70(23%) vending machines met the guideline's availability benchmarks of ≥75% Everyday food and beverages. Proportion of Everyday products differed among different types of food outlets (café, cafeteria, convenience stores). Placement: On average, food outlets did not meet recommendations of limiting Occasional products in prominent positions, with checkout areas and countertops displaying over 60% Occasional items. Promotion: Over two-thirds of meal deals at both hospitals included Occasional products. (4) Conclusion: Baseline audit results show that substantial improvements in availability, placement, and promotion can be made at these public hospitals to meet the nutrition guidelines. Audits of other NSW hospitals using the developed tool are needed to investigate similarities and differences in food environment between sites. These findings highlight the need for ongoing tracking to inform whether the revised guidelines are leading to improved food environments in health facilities., Competing Interests: The authors declare no conflict of interest. The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

The American Heart Association conducted policy, systems, and environmental (PSE) focused interventions to increase healthy vending in 8 communities. PSE interventions were assessed using the Nutrition Environment Measures Survey Vending Assessment to see changes in the food environment. Baseline and follow-up assessments were conducted with 3 settings and a total of 19 machines. PSE changes resulted in increased availability of healthy options and decreased unhealthy options. Implementation of PSE interventions targeting the food environment can be an effective method of providing increased access to healthy foods and beverages with the goal of increasing consumption to decrease chronic diseases.

Background/objectives: Targeting obesogenic features of children's environment that are amenable to change represents a promising strategy for health promotion. The school food environment, defined as the services and policies regarding nutrition and the availability of food in the school and surrounding neighborhood, is particularly important given that students travel through the school neighborhood almost daily and that they consume a substantial proportion of their calories at school., Subjects/methods: As part of the Quebec Adipose and Lifestyle Investigation in Youth (QUALITY) cohort study, we assessed features of school indoor dietary environment and the surrounding school neighborhoods, when children were aged 8-10 years (2005-2008). School principals reported on food practices and policies within the schools. The density of convenience stores and fast-food outlets surrounding the school was computed using a Geographical Information System. Indicators of school neighborhood deprivation were derived from census data. Adiposity outcomes were measured in a clinical setting 2 years later, when participants were aged 10-12 years (2008-2011). We conducted cluster analyses to identify school food environment types. Associations between school types and adiposity were estimated in linear regression models., Results: Cluster analysis identified three school types with distinct food environments. Schools were characterized as: overall healthful (45%); a healthful food environment in the surrounding neighborhood, but an unhealthful indoor food environment (22%); or overall unhealthful (33%). Less healthful schools were located in more deprived neighborhoods and were associated with greater child adiposity., Conclusions: Despite regulatory efforts to improve school food environments, there is substantial inequity in dietary environments across schools. Ensuring healthful indoor and outdoor food environments across schools should be included in comprehensive efforts to reduce obesity-related health disparities.

In light of the childhood obesity epidemic, many cities are adopting healthy park vending policies, but the evidence on the effectiveness of these policies is scant. This study examines how implementation of a healthy vending policy in Carson, California, changes the types of beverages that are available in park vending machines. The study design is a pre-posttest with post-only comparison group. The main outcome is proportion of beverages in vending machines that is consistent with caloric and sugar content guidelines for children as defined by the Nutrition Environment Measures-Vending (NEMS-V) tool. This study finds that prior to implementation of the vending policy, 70% of the beverages did not meet NEMS-V guidelines, on average. After implementation of the vending policy, this number declined to 7%. This study suggests that healthy vending policies can have an impact on the types of beverages that are available in city parks.

Objective: To assess agreement among three nutrient profiling systems used to evaluate the healthfulness of vending machine products in recreation and sport settings in three Canadian provinces. We also assessed whether the nutritional profile of vending machine items in recreation and sport facilities that were adhering to nutrition guidelines (implementers) was superior to that of facilities that were not (non-implementers)., Design: Trained research assistants audited the contents of vending machines. Three provincial nutrient profiling systems were used to classify items into each province's most, moderately and least healthy categories. Agreement among systems was assessed using weighted κ statistics. ANOVA assessed whether the average nutritional profile of vending machine items differed according to province and guideline implementation status., Setting: Eighteen recreation and sport facilities in three Canadian provinces. One-half of facilities were implementing nutrition guidelines., Subjects: Snacks (n 531) and beverages (n 618) within thirty-six vending machines were audited., Results: Overall, the systems agreed that the majority of items belonged within their respective least healthy categories (66-69 %) and that few belonged within their most healthy categories (14-22 %). Agreement among profiling systems was moderate to good, with κ w values ranging from 0·49 to 0·69. Implementers offered fewer of the least healthy items (P<0·05) and these items had a better nutritional profile compared with items in non-implementing facilities., Conclusions: The policy outcomes of the three systems are likely to be similar, suggesting there may be scope to harmonize nutrient profiling systems at a national level to avoid unnecessary duplication and support food reformulation by industry.

Policies that change environments are important tools for preventing chronic diseases, including obesity. Boards of health often have authority to adopt such policies, but few do so. This study assesses 1) how one local board of health developed a policy approach for healthy food access through vending machine guidelines (rather than regulations) and 2) the impact of the approach. Using a case study design guided by "three streams" policy theory and RE-AIM, we analyzed data from a focus group, interviews, and policy documents. The guidelines effectively supported institutional policy development in several settings. Recognition of the problem of chronic disease and the policy solution of vending machine guidelines created an opening for the board to influence nutrition environments. Institutions identified a need for support in adopting vending machine policies. Communities could benefit from the study board's approach to using nonregulatory evidence-based guidelines as a policy tool.

Non-communicable diseases (NCDs) such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes are the leading cause of death worldwide. To decrease the global burden of NCDs and strengthen national efforts to combat NCDs, the World Health Organization (WHO) released the Global Action Plan for the Prevention and Control of NCDs 2013-2020. This plan provides established procedures and several policy options for member countries and other partners. Although many countries recognize that prevention of NCDs is an important health priority, their governments currently face a challenge: How do they adopt a multi-sectoral approach to promoting a healthy lifestyle among their populations? For this, all sectors of the food system (primary production, food processing, distribution, marketing, retail, catering, and food service) need to coordinate with each other for future governance. Since regulatory policy intervention areas for diet-related NCDs are widespread throughout the global food system, for future perspectives, comprehensive and coordinated approaches are needed for policy development and implementation across all levels of governments and food sectors in order to ensure sustainable policy action.

Two quantitative risk assessment (RA) models were developed to describe the risk of salmonellosis and listeriosis linked to consumption of raw milk sold in vending machines in Italy. Exposure assessment considered the official microbiological records monitoring raw milk samples from vending machines performed by the regional veterinary authorities from 2008 to 2011, microbial growth during storage, destruction experiments, consumption frequency of raw milk, serving size, and consumption preference. Two separate RA models were developed: one for the consumption of boiled milk and the other for the consumption of raw milk. The RA models predicted no human listeriosis cases per year either in the best or worst storage conditions and with or without boiling raw milk, whereas the annual estimated cases of salmonellosis depend on the dose-response relationships used in the model, the milk storage conditions, and consumer behavior in relation to boiling raw milk or not. For example, the estimated salmonellosis cases ranged from no expected cases, assuming that the entire population boiled milk before consumption, to a maximum of 980,128 cases, assuming that the entire population drank raw milk without boiling, in the worst milk storage conditions, and with the lowest dose-response model. The findings of this study clearly show how consumer behavior could affect the probability and number of salmonellosis cases and in general, the risk of illness. Hence, the proposed RA models emphasize yet again that boiling milk before drinking is a simple yet effective tool to protect consumers against the risk of illness inherent in the consumption of raw milk. The models may also offer risk managers a useful tool to identify or implement appropriate measures to control the risk of acquiring foodborne pathogens. Quantification of the risks associated with raw milk consumption is necessary from a public health perspective.

Background: The purpose of this study was to describe promotions for unhealthy and healthy foods and beverages within Minnesota secondary schools from 2008 to 2012, and to examine associations with school-level coordination of environmental improvements and students' dietary behaviors., Methods: The Minnesota School Health Profiles and Minnesota Student Survey data were used along with National Center for Education Statistics data to conduct analyses accounting for school-level demographics., Results: There was no significant improvement over time in the proportion of schools that banned advertising for unhealthy products in school buildings, on school grounds, on buses, or in publications. Whereas more than two thirds of schools had implemented strategies focused on the promotion of fruits/vegetables by 2012, only 37% labeled healthful foods with appealing names and just 17% used price incentives to encourage healthy choices. The number of stakeholders representing different roles on school health councils was positively correlated with implementation of healthy food and beverage promotion strategies. Little evidence was found to support an influence of in-school advertising bans or promotions on students' diets., Conclusions: Policy changes are needed to protect students from food and beverage advertising and additional opportunities exist to reduce disparities in the selection of healthy options at school., (© 2014, American School Health Association.)

Background: The objective of this case study was to evaluate the acceptability, sales impact, and implementation barriers for the Chicago Park District's 100% Healthier Snack Vending Initiative to strengthen and support future healthful vending efforts., Community Context: The Chicago Park District is the largest municipal park system in the United States, serving almost 200,000 children annually through after-school and summer programs. Chicago is one of the first US cities to improve park food environments through more healthful snack vending., Methods: A community-based participatory evaluation engaged community and academic partners, who shared in all aspects of the research. From spring 2011 to fall 2012, we collected data through observation, surveys, and interviews on staff and patron acceptance of snack vending items, purchasing behaviors, and machine operations at a sample of 10 Chicago parks. A new snack vending contract included nutrition standards for serving sizes, calories, sugar, fat, and sodium for all items. Fifteen months of snack vending sales data were collected from all 98 snack vending machines in park field houses., Outcomes: Staff (100%) and patrons (88%) reacted positively to the initiative. Average monthly per-machine sales increased during 15 months ($84 to $371). Vendor compliance issues included stocking noncompliant items and delayed restocking., Interpretation: The initiative resulted in improved park food environments. Diverse partner engagement, participatory evaluation, and early attention to compliance can be important supports for healthful vending initiatives. Consumer acceptance and increasing revenues can help to counter fears of revenue loss that can pose barriers to adoption.

Background: Sports, such as youth baseball (YB), are popular outlets for increasing activity, yet there has been no investigation of food environments surrounding them. The aim of this study was to observe the types of foods available and consumed by players and spectators at YB events., Methods: This was an observational assessment, by environmental scan, of foods consumed by players and family members at a YB field in northwest North Carolina., Results: Participants included boys from six YB teams (n=51) between 8 and 11 years of age and families. A total of 12 YB games were observed. Most team snacks (72%) consisted of high-calorie food items, including French fries, candy, and cookies; most beverages (53%) consumed by players were sugar sweetened. We observed 313 spectators and players, who consumed a total of 249 foods and 276 beverages. Most food and beverage items (89%) were purchased from the concession stand, of which 73% were considered less-healthy options., Conclusions: High-calorie snacks and sugar-sweetened beverages dominate the YB environment. Despite the benefits of participating in sports, families of children participating in sports leagues may be increasing their risk for poor nutritional habits as a result of increased exposure to unhealthy foods and disruption of meal times.

Background: Vending machines and shops located within health care facilities are a source of food and drinks for staff, visitors and outpatients and they have the potential to promote healthy food and drink choices. This paper describes perceptions of parents and managers of health-service located food outlets towards the availability and labelling of healthier food options and the food and drinks offered for sale in health care facilities in Australia. It also describes the impact of an intervention to improve availability and labelling of healthier foods and drinks for sale., Methods: Parents (n = 168) and food outlet managers (n = 17) were surveyed. Food and drinks for sale in health-service operated food outlets (n = 5) and vending machines (n = 90) in health care facilities in the Hunter New England region of NSW were audited pre (2007) and post (2010/11) the introduction of policy and associated support to increase the availability of healthier choices. A traffic light system was used to classify foods from least (red) to most healthy choices (green)., Results: Almost all (95%) parents and most (65%) food outlet managers thought food outlets on health service sites should have signs clearly showing healthy choices. Parents (90%) also thought all food outlets on health service sites should provide mostly healthy items compared to 47% of managers. The proportion of healthier beverage slots in vending machines increased from 29% to 51% at follow-up and the proportion of machines that labelled healthier drinks increased from 0 to 26%. No outlets labelled healthier items at baseline compared to 4 out of 5 after the intervention. No changes were observed in the availability or labelling of healthier food in vending machines or the availability of healthier food or drinks in food outlets., Conclusions: Baseline availability and labelling of healthier food and beverage choices for sale in health care facilities was poor in spite of the support of parents and outlet managers for such initiatives. The intervention encouraged improvements in the availability and labelling of healthier drinks but not foods in vending machines.

Background: Addressing the limitations of existing Local Wellness Policies (LWPs) and promoting their implementation remain priorities for health and education agencies. One gap has been the absence of a standard assessment to support LWP revision. During planning for an initiative to improve school nutrition and physical education policy, the Wellness School Assessment Tool (WellSAT) was evaluated., Methods: Five public health practitioners used WellSAT to assess 50 LWPs. A randomized, counterbalanced design ensured each LWP was coded twice by separate raters. Models evaluated the extent to which WellSAT ratings reflected differences in the LWPs and order, familiarity and rater effects. During field testing, 18 public health practitioners used WellSAT as part of a statewide public health initiative., Results: In pilot testing the majority of the variability in WellSAT scores (median = 88%; range = 76% to 100%) was attributable to differences between policies. Correlations between independent raters' strength and comprehensiveness scores were strong, r = .88 and r = .77, respectively. During field testing, WellSAT was well accepted by public health practitioners and members of the school community., Conclusions: WellSAT represents a reliable and feasible tool for health and education agencies to use in improving LWPs and aligning them with recognized standards., (Published 2013. This article is a U.S. Government work and is in the public domain in the USA.)

According to ecological models, the physical environment plays a major role in determining individual health behaviors. As such, researchers have started targeting the consumer nutrition environment of large-scale foodservice operations when implementing obesity-prevention programs. In 2010, the American Hospital Association released a call-to-action encouraging health care facilities to join in this movement and improve their facilities' consumer nutrition environments. The Hospital Nutrition Environment Scan (HNES) for Cafeterias, Vending Machines, and Gift Shops was developed in 2011, and the present study evaluated the inter-rater reliability of this instrument. Two trained raters visited 39 hospitals in southern California and completed the HNES. Percent agreement, kappa statistics, and intraclass correlation coefficients were calculated. Percent agreement between raters ranged from 74.4% to 100% and kappa statistics ranged from 0.458 to 1.0. The intraclass correlation coefficient for the overall nutrition composite scores was 0.961. Given these results, the HNES demonstrated acceptable reliability metrics and can now be disseminated to assess the current state of hospital consumer nutrition environments., (Copyright © 2013 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to assess the evolution of food supply (apart from school catering) between school years 2004/2005 and 2009/2010, in middle- and high-schools from the Aquitaine region (southwest France), in order to evaluate the impact of actions conducted within the framework and the program Nutrition, Prevention and Health of children and adolescents in Aquitaine (southwest France)., Methods: Two surveys were carried out among all middle- and high-schools of the Aquitaine region in 2004/2005 (n=536) and 2009/2010 (n=539) within the framework of a regional multidisciplinary public health program "Nutrition, prevention and health of children and teenagers in Aquitaine". For both 2004/2005 and 2009/2010, data were collected using the same questionnaire and dealt with school characteristics and modalities of food supply (apart from school catering)., Results: Response rate was 84.1% in 2004/2005 and 79.6% in 2009/2010. The proportion of schools offering food to pupils (apart from school catering) significantly decreased in 5 years (from 80.1% to 50.1%, P<0.001). Between 2004/2005 and 2009/2010, we observed a stabilization in the proportion of schools offering free food (from 19.7 to 17%, P=0.3), a significant decrease of those selling food (from 62.8 to 37.1, P<0.001), offering vending machines (from 43.5 to 7.2, P<0.001) and a significant increase of those offering water supply (from 8.2 to 44%, P<0.001). The composition of each modality of food supply (apart from school catering) has also been improved: less sweet and fat food, more bread and fruits., Conclusion: This study shows an overall improvement of food supply apart from school catering (food sale, free food and vending machines) in middle- and high-schools from the Aquitaine region (southwest France) between 2004/2005 and 2009/2010. This improvement is related to the proportion of schools offering food (quantitative improvement), as well as to the composition of food supply (qualitative improvement). These results show an improvement of food supply (apart from school catering), suggesting that actions implemented in the framework of the program "Nutrition, prevention and health of children and adolescents in Aquitaine" may have led to these improvements., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

A quantitative risk assessment was developed to describe the risk of campylobacteriosis and hemolytic uremic syndrome (HUS) linked to consumption of raw milk sold in vending machines in Northern Italy. Exposure assessment considered the microbiological status of dairy farms, expected milk contamination, storage conditions from bulk tank to home storage, microbial growth during storage, destruction experiments, consumption frequency of raw milk, age of consumers, serving size, and consumption preference. The differential risk between milk handled under regulation conditions (4°C throughout all phases) and the worst field handling conditions was considered. The probability of Campylobacter jejuni infection was modeled with a single-hit dose-response beta-Poisson model, whereas for HUS an exponential dose-response model was chosen and two probabilities were used to model the higher susceptibility of children younger than 5 years old. For every 10,000 to 20,000 consumers each year, the models predicted for the best and worst storage conditions, respectively, 2.12 and 1.14 campylobacteriosis cases and 0.02 and 0.09 HUS cases in the 0- to 5-year age group and 0.1 and 0.5 HUS cases in the >5-year age group. The expected pediatric HUS cases do not differ considerably from those reported in Italy by the Minister of Health. The model developed may be a useful tool for extending the assessment of the risk of campylobacteriosis and HUS due to raw milk consumption at the national level in Italy. Considering the epidemiological implications of this study, the risk of illness linked to raw milk consumption should not be ignored and could be reduced by the use of simple measures. Boiling milk before consumption and strict control of temperatures by farmers during raw milk distribution have significant effects on campylobacteriosis and HUS and are essential measures for risk management.

Background: The high prevalence of obesity puts children at risk for chronic diseases, increases health care costs, and threatens to reduce life expectancy. As part of the response to this epidemic, the New York City (NYC) Department of Education (DOE)--the nation's largest school district--has worked to improve the appeal and nutritional quality of school food. This article highlights some of the structural and policy changes that have improved the school food environment over the past decade, with the aim to share lessons learned and provide recommendations and resources for other districts interested in making similar modifications., Methods: This article details changes DOE has implemented over 10 years, including revised nutrition standards for school meals and competitive foods; new school food department staffing; food reformulations, substitutions, and additions; and transitions to healthier beverages., Results: NYC's revised nutrition standards and hiring of expert staff increased availability of fruits and vegetables, whole grains, and low-fat dairy and decreased sugary beverages, and foods high in saturated fats and added sugars--the major contributors to discretionary calorie intake. DOE also introduced healthier beverages: switching from high-calorie, high-fat whole milk to low-fat milk and increasing access to water., Conclusions: NYC has successfully improved the quality of its school food environment and shown that healthier food service is possible, even under budgetary constraints. Several broad factors facilitated these efforts: fostering community partnerships and inter-agency collaboration, implementing policies and initiatives that target multiple sectors for greater impact, and working to make incremental improvements each year., (© 2012, American School Health Association.)

Objectives: The school environment has been the focus of many health initiatives over the years as a means to address the childhood obesity crisis. The availability of low-nutrient, high-calorie foods and beverages to students via vending machines further exacerbates the issue of childhood obesity. However, a healthy overhaul of vending machines may also affect revenue on which schools have come to depend. This article describes the experience of one school district in changing the school environment, and the resulting impact on food and beverage vending machines., Study Design: Observational study in Ann Arbor public schools., Methods: The contents and locations of vending machines were identified in 2003 and surveyed repeatedly in 2007. Overall revenues were also documented during this time period., Results: Changes were observed in the contents of both food and beverage vending machines. Revenue in the form of commissions to the contracted companies and the school district decreased., Conclusions: Local and national wellness policy changes may have financial ramifications for school districts. In order to facilitate and sustain school environment change, all stakeholders, including teachers, administrators, students and healthcare providers, should collaborate and communicate on policy implementation, recognizing that change can have negative financial consequences as well as positive, healthier outcomes., (Copyright © 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

The safety of raw milk sold in Northern Italy was investigated in relation to hygiene quality parameters and presence of Salmonella spp., Listeria monocytogenes, thermotolerant Campylobacter, and Verocytotoxin producing Escherichia coli O157:H7. The performance of different analytical methods used-official culture method (ISO), modified Bacteriological Analytical Manual cultural method (mBAM), and polymerase chain reaction (PCR)-was evaluated. The presence of Mycobacterium avium subsp. paratuberculosis (Map) was investigated only by PCR. All samples met regulations for alkaline phosphatase and inhibitory substance, while 18% and 44.8% of samples collected from vending machines had, respectively, somatic cell count (SCC) >300,000/mL and total bacterial count (TBC) >50,000 CFU/mL. The correlation between hygienic quality parameters in samples collected from bulk tank and vending machines showed a significant increase of TBC in vending machines meaning that raw milk was mishandled during distribution and sale. All pathogens investigated were detected in raw milk sold at vending machines; a total of five samples (5%) had at least one pathogen, of which two were detected by PCR and three by mBAM. None of the samples was positive by cultural ISO methods. Even if the comparison of analytical methods showed that none performs significantly better than the others, testing a higher volume of milk (25 versus 210 mL) affects significantly the detection rate of pathogens. Three samples (3%) were positive for Map, suggesting that raw milk is a significant source of Map exposure for consumers. The observed TBC increase and the detection of several pathogenic bacteria pose questions on the safety of raw milk; the use of ISO seems inefficient in detecting a low contamination level of pathogens in milk and consequently not appropriate as official method for testing. In order to ensure consumer's safety, a new approach for the raw milk chain is required.

Purpose: To examine the association between school wellness council structure over 2 years and low-nutrient, energy-dense vending fare assessed as a food score (range: 0-7), following enactment of federal legislation., Methods: Multivariate linear regression was used to examine 2006/2007 and 2008/2009 data among a cohort of middle (n = 16) and high (n = 38) schools located in a Midwest metropolitan area., Results: Schools with district and school councils had a significantly lower mean food score (3.28) than schools with district-only (4.50) and no councils (4.99)., Conclusions: Wellness councils, particularly a structure that includes both a district and school council, may contribute to decreasing low-nutrient, energy-dense food/beverage availability in middle and high schools., (Copyright © 2011 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: A US federal mandate that school districts devise and implement local wellness policies (LWPs) has potential widespread impact on the nutritional content of foods and beverages available in schools and on the amount of physical activity that students engage in; however, evidence concerning the mandate's effectiveness is limited. This study describes the content of LWPs of 6 US school districts and steps taken toward their implementation and evaluation., Methods: During visits to 6 school districts, we interviewed 88 school and community representatives about the content of their district's LWPs and how the LWPs were being implemented and evaluated., Results: The 6 LWPs were consistent with the federal mandate, although they varied in content and degree of specificity, and none had been fully implemented. All 6 districts were pursuing strategies to ensure that foods and beverages available at school met nutrition standards but did not offer nutrition education to all K-12 students. All 6 districts offered students only limited opportunities for physical activity, and all 6 collected data to monitor process and outcomes of their LWPs., Conclusions: Partial implementation of LWPs in the districts we visited resulted in significant improvement in the nutritional quality of foods available at district schools, but only slight improvement in students' opportunities for school-based physical activity. We provide recommendations for school districts on implementation and evaluation. Future research is needed to determine the impact of these LWPs on students' health., (© Published 2011. This article is a US Government work and is in the public domain in the USA.)

The Child Nutrition and WIC Reauthorization Act of 2004 required school districts participating in the federal school meals program to establish by the start of the 2006-2007 school year policies that included nutrition guidelines for all foods sold on school campus during the school day and policy development involving key stakeholders. For many schools, policy development was done by wellness councils. This study examined the association between having a wellness council and availability of low-nutrient, energy-dense foods/beverages in school vending machines following enactment of the federal legislation. In 2006-2007, Minnesota middle (n=35) and high (n=54) school principals reported whether their school and district had a wellness council. Trained research staff observed foods/beverages in vending machines accessible to students. Low-nutrient, energy-dense foods/beverages (snacks >3 g fat or >200 calories/serving, and soda, fruit/sport drinks and reduced-fat/whole milk) were grouped into seven categories (eg, high-fat baked goods) and a food score was calculated. Higher scores indicated more low-nutrient, energy-dense vending fare. Multivariate linear regression, adjusted for school characteristics, was used to examine associations between scores and a three-category council variable (district-only; district and school; no council). Among schools, 53% had district-only councils, 38% district and school councils, and 9% had no council. Schools with both a district and school council had a significantly lower mean food score than schools without councils (P=0.03). The potential of wellness councils to impact availability of low-nutrient, energy-dense vending fare is promising. There may be an added benefit to having both a school and district council., (Copyright © 2011 American Dietetic Association. Published by Elsevier Inc. All rights reserved.)

Background: Policy that targets the school food environment has been advanced as one way to increase the availability of healthy food at schools and healthy food choice by students. Although both state- and district-level policy initiatives have focused on school nutrition standards, it remains to be seen whether these policies translate into healthy food practices at the school level, where student behavior will be impacted., Objective: To examine whether state- and district-level nutrition policies addressing junk food in school vending machines and school stores were associated with less junk food in school vending machines and school stores. Junk food was defined as foods and beverages with low nutrient density that provide calories primarily through fats and added sugars., Design: A cross-sectional study design was used to assess self-report data collected by computer-assisted telephone interviews or self-administered mail questionnaires from state-, district-, and school-level respondents participating in the School Health Policies and Programs Study 2006. The School Health Policies and Programs Study, administered every 6 years since 1994 by the Centers for Disease Control and Prevention, is considered the largest, most comprehensive assessment of school health policies and programs in the United States., Subjects/setting: A nationally representative sample (n=563) of public elementary, middle, and high schools was studied., Statistical Analysis: Logistic regression adjusted for school characteristics, sampling weights, and clustering was used to analyze data. Policies were assessed for strength (required, recommended, neither required nor recommended prohibiting junk food) and whether strength was similar for school vending machines and school stores., Results: School vending machines and school stores were more prevalent in high schools (93%) than middle (84%) and elementary (30%) schools. For state policies, elementary schools that required prohibiting junk food in school vending machines and school stores offered less junk food than elementary schools that neither required nor recommended prohibiting junk food (13% vs 37%; P=0.006). Middle schools that required prohibiting junk food in vending machines and school stores offered less junk food than middle schools that recommended prohibiting junk food (71% vs 87%; P=0.07). Similar associations were not evident for district-level polices or high schools., Conclusions: Policy may be an effective tool to decrease junk food in schools, particularly in elementary and middle schools., (Copyright 2010 American Dietetic Association. Published by Elsevier Inc. All rights reserved.)

States and school districts around the country are developing policies that set nutrition standards for competitive foods and beverages sold outside of the US Department of Agriculture's reimbursable school lunch program. However, few tools exist for monitoring the implementation of these new policies. The objective of this research was to develop a computerized assessment tool, the Food and Beverage Environment Analysis and Monitoring System (FoodBEAMS), to collect data on the competitive school food environment and to test the inter-rater reliability of the tool among research and nonresearch professionals. FoodBEAMS was used to collect data in spring 2007 on the competitive foods and beverages sold in 21 California high schools. Adherence of the foods and beverages to California's competitive food and beverage nutrition policies for schools (Senate Bills 12 and 965) was determined using the data collected by both research and nonresearch professionals. The inter-rater reliability between the data collectors was assessed using the intraclass correlation coefficient. Researcher vs researcher and researcher vs nonresearcher inter-rater reliability was high for both foods and beverages, with intraclass correlation coefficients ranging from .972 to .987. Results of this study provide evidence that FoodBEAMS is a promising tool for assessing and monitoring adherence to nutrition standards for competitive foods sold on school campuses and can be used reliably by both research and nonresearch professionals., (Copyright 2010 American Dietetic Association. Published by Elsevier Inc. All rights reserved.)

Aim: To develop healthier vending guidelines and assess their effect on the nutrient content and sales of snack products sold through hospital vending machines, and on staff satisfaction., Methods: Nutrition guidelines for healthier vending machine products were developed and implemented in 14 snack vending machines at two hospital sites in Auckland, New Zealand. The guidelines comprised threshold criteria for energy, saturated fat, sugar, and sodium content of vended foods. Sales data were collected prior to introduction of the guidelines (March-May 2007), and again post-introduction (March-May 2008). A food composition database was used to assess impact of the intervention on nutrient content of purchases. A staff survey was also conducted pre- and post-intervention to assess acceptability., Results: Pre-intervention, 16% of staff used vending machines once a week or more, with little change post-intervention (15%). The guidelines resulted in a substantial reduction in the amount of energy (-24%), total fat (-32%), saturated fat (-41%), and total sugars (-30%) per 100 g product sold. Sales volumes were not affected, and the proportion of staff satisfied with vending machine products increased., Conclusions: Implementation of nutrition guidelines in hospital vending machines led to substantial improvements in nutrient content of vending products sold. Wider implementation of these guidelines is recommended.

Purpose: This study identifies trends in the availability of various food choices in United States' middle and high schools from 2004 to 2007, and examines the potential associations between such food availability and students' self-reported eating habits and body mass index (BMI)-related outcomes., Methods: Data are based on nationally representative samples of 78,442 students in 684 secondary schools surveyed from 2004 to 2007 as part of the Youth, Education, and Society (YES) study and the Monitoring the Future (MTF) study. In the YES study, school administrators and food service managers completed self-administered questionnaires on their school's food environment. In the MTF study, students in the same schools completed self-administered questionnaires, providing data used to construct BMI and food consumption measures., Results: Overall, there was a decrease in the availability of regular-sugar/fat food items in both middle and high schools, and some indication of an increase in high school availability of reduced-fat food items through school lunch or a la carte. Some minimal evidence was found for relationships between the school food environment and student BMI-related outcomes and food consumption measures., Conclusions: United States secondary schools are making progress in the types of foods offered to students, with food items of lower nutritional value becoming less prevalent in recent years. Continued monitoring of food environment trends may help clarify whether and how such factors relate to youth health outcomes.

Purpose: To determine extent and factors associated with implementation of California's school nutrition standards 1 year after standards became active., Methods: Information on competitive foods and beverages available in schools was collected from a representative sample of 56 public high schools in California. Adherence to nutrition standards was calculated for each item and summarized for each school by venue. The association between schools' sociodemographic characteristics and adherence to standards was determined by multivariate analysis., Results: The majority of schools were adhering to the required beverage standards. None of the schools selling competitive foods were 100% adherent to the food standards. Adherence to both standards tended to be highest in food service venues. In univariate analyses, percent nonwhite enrollment, population density, percent free/reduced-price (FRP) meal eligibility, and school size were significantly correlated with the beverage adherence rate. Percent nonwhite enrollment and population density remained significant in the multivariate regression model. Percent nonwhite enrollment and percent FRP meal eligibility were significantly correlated with the food adherence rate in univariate analysis, but neither remained significant in the multiple regression model., Conclusions: California high schools are making progress toward implementation of the state nutrition standards. Beverage standards appear easier to achieve than nutrient-based food standards. Additional support is needed to provide schools with resources to implement and monitor these policies. Simpler standards and/or a reduction in the foods and beverages sold could better enable schools to achieve and monitor adherence.

Objective: The purpose of this study was to evaluate the food environment found in the sports, recreational and cultural facilities of Quebec City. The study also consulted with municipality representatives in order to understand the actions needed to facilitate the introduction of healthier food choices in these venues., Method: Observation visits were carried out in order to determine the nature of the food sold and served in the sports, recreational and cultural facilities. Semi-structured interviews were conducted with Quebec City representatives, community organizations, caterers and a representative of the Ministère de l'Agriculture, des Pêcheries et de l'Alimentation du Québec., Results: In general, there was little availability of healthy food choices in the vending machines and snack bars found in the sports and recreational facilities. The city does not have guidelines or a food policy for the food sold in its sports, recreational and cultural facilities, even though a majority of the questioned representatives said they were concerned about the quality of the food served in these facilities. Different solutions are proposed to correct this situation., Conclusion: Most foods offered in sports, recreational and cultural facilities are of low nutritional value. Citywide guidelines should be introduced to control the quality and the quantity of healthy foods and snacks sold in the municipal facilities. Although introducing these measures may be challenging, a majority of the municipal representatives agree with the proposed changes. They believe that a healthier food environment goes hand in hand with the practice of physical activity.

In order to understand the development of the microbial population within a hot-drinks vending machine a new machine was placed in a staff area of a university campus vending only hot chocolate. The machine was cleaned weekly using a detergent based protocol. Samples from the mixing bowl, dispense area, and drink were taken over a 19-wk period and enumerated using plate count agar. Bacillus cereus was identified using biochemical methods. Vended drinks were sampled at 0, 3, 6, and 9 min after vending; the hot chocolate powder was also sampled. Over the 1st 8 wk, a significant increase in the microbial load of the machine components was observed. By the end of the study, levels within the vended drink had also increased significantly. Inactivation of the automatic flush over a subsequent 5-wk period led to a statistically but not operationally significant increase in the microbial load of the dispense area and vended drink. The simple weekly clean had a significant impact on the microbial load of the machine components and the vended drink. This study demonstrated that a weekly, detergent-based cleaning protocol was sufficient to maintain the microbial population of the mixing bowl and dispense point in a quasi-steady state below 3.5 log CFU/cm2 ensuring that the microbial load of the vended drinks was maintained below 3.4 log CFU/mL. The microbial load of the drinks showed no significant changes over 9 min after vending, suggesting only spores are present in the final product.

Objective: This study assessed the impact of changes in school food policy on student lunch consumption in middle schools., Methods: Two years of lunch food records were collected from students at three middle schools in the Houston, Texas area. During the first year, no changes occurred in the school food environment. After that school year was completed, chips and dessert foods were removed from the snack bars of all schools by the Food Service Director. Students recorded the amount and source of food and beverage items consumed. Point-of-service purchase machines provided a day-by-day electronic data file with food and beverage purchases from the snack bars during the 2-year period. Independent t-tests and time series analyses were used to document the impact of the policy change on consumption and sales data between the two years., Results: In general, student consumption of sweetened beverages declined and milk, calcium, vitamin A, saturated fat and sodium increased after the policy change. Snack chips consumption from the snack bar declined in year 2; however, consumption of snack chips and candy from vending increased and the number of vending machines in study schools doubled during the study period. Ice cream sales increased significantly in year 2., Conclusions: Policy changes on foods sold in schools can result in changes in student consumption from the targeted environments. However, if all environments do not make similar changes, compensation may occur.

Objective: This study examined the types and extent of competitive foods available in public high schools in Pennsylvania., Design: We developed, pilot tested, and distributed surveys to school foodservice directors in a random sample of 271 high schools in Pennsylvania., Subjects: Two hundred twenty-eight surveys were returned, for a response rate of 84%. Statistical analyses were performed: Descriptive statistics were used to examine the extent of competitive food sales in Pennsylvania public high schools. The survey data were analyzed using SPSS software version 11.5.1 (2002, SPSS base 11.0 for Windows, SPSS Inc, Chicago, IL)., Results: A la carte sales provide almost dollar 700/day to school foodservice programs, almost 85% of which receive no financial support from their school districts. The top-selling a la carte items are "hamburgers, pizza, and sandwiches." Ninety-four percent of respondents indicated that vending machines are accessible to students. The item most commonly offered in vending machines is bottled water (71.5%). While food items are less often available through school stores and club fund-raisers, candy is the item most commonly offered through these sources., Conclusions: Competitive foods are widely available in high schools. Although many of the items available are low in nutritional value, we found several of the top-selling a la carte options to be nutritious and bottled water the item most often identified as available through vending machines.

The study reported in this paper sampled 40 water vending machines distributed throughout the city of Los Angeles, California, in the water servicing area of the Los Angeles Department of Water and Power. The authors examined water samples for temperature, turbidity, chlorine content, fungal growth, coliform bacteria, fecal coliform bacteria, Pseudomonas spp., Pseudomonas aeruginosa, and heterotrophic plate counts using plate count agar and R2A agar. Roughly 48 percent of the original 40 samples were sampled in a second or third round, and these subsequent samples were examined for coliform bacteria, fecal coliform bacteria, Pseudomonas spp., Pseudomonas aeruginosa, and both heterotrophic plate counts. Observations were made of vending-machine external conditions, identifying information, and permits. Statistically significant associations were found between operator accessibility and poor machine conditions, operator accessibility and permits, and operator accessibility and the servicing interval. Statistically significant associations also were found between operator accessibility and presence of fungi, Pseudomonas spp., and Pseudomonas aeruginosa, and between presence of fungi and the servicing interval. In addition, statistically significant associations indicate that the quality of machine maintenance is a factor in microbial levels. The microbial content of the water suggested a need for further research into potential health effects in susceptible populations.

This statement is intended to inform pediatricians and other health care professionals, parents, superintendents, and school board members about nutritional concerns regarding soft drink consumption in schools. Potential health problems associated with high intake of sweetened drinks are 1) overweight or obesity attributable to additional calories in the diet; 2) displacement of milk consumption, resulting in calcium deficiency with an attendant risk of osteoporosis and fractures; and 3) dental caries and potential enamel erosion. Contracts with school districts for exclusive soft drink rights encourage consumption directly and indirectly. School officials and parents need to become well informed about the health implications of vended drinks in school before making a decision about student access to them. A clearly defined, district-wide policy that restricts the sale of soft drinks will safeguard against health problems as a result of overconsumption.

Objectives: This study described the food environment in 20 Minnesota secondary schools., Methods: Data were collected on school food policies and the availability and nutritional content of foods in school à la carte (ALC) areas and vending machines (VMs)., Results: Approximately 36% and 35% of foods in ALC areas and in VMs, respectively, met the lower-fat criterion (< or = 5.5 fat grams/serving). The chips/crackers category constituted the largest share of ALC foods (11.5%). The median number of VMs per school was 12 (4 soft drink, 2 snack, 5 other). Few school food policies were reported., Conclusions: The availability of healthful foods and beverages in schools as well as school food policies that foster healthful food choices among students needs greater attention.

Neurophysiological and neuropsychological studies in monkeys sometimes require an automated food-pellet dispenser. Commercially available dispensers typically sequester the pellet until delivery and, once delivered, the pellet's availability cannot be controlled. The custom-designed dispenser described here overcomes those two limitations. The device is composed of two separate units: a feeder and an electronic controller. The feeder manipulates food pellets with actuators driven by air pressure and delivers them into a serving bowl. The controller's settings determine whether the monkey can retrieve a pellet from the bowl. If the experiment requires that the pellet be visible and within reach, but unavailable for retrieval, the controller enables a trap-door mechanism at the bottom of the bowl. Any motion near the serving bowl, such as that caused by the approach of a monkey's hand, will then trigger the opening of the trap door, which causes the pellet to fall into an enclosed pellet collector. This rapid pellet-removal mechanism can also be triggered by other computer-controlled contingencies. Two of these dispensers have been in operation in an applied laboratory setting for over 2 years.

A survey of the microbiological quality of water sampled from office dispensers in Merseyside found half of the samples to be either unsatisfactory (23/56) or unacceptable (5/56) in terms of guidelines from the Automatic Vending Association of Britain. Factors that appeared to be linked to unsatisfactory microbiological quality were time between filling and sampling and filling on site.