In the United States, more than 95% of children are enrolled in school, where they consume up to half of their total daily energy intake (1). The federally regulated National School Lunch Program (NSLP) is a major source of food at school. However, student participation in the NSLP declines by 27% from elementary to high school because competitive foods from venues such as à la carte programs, snack bars, vending machines, and school stores become more available (2). Furthermore, competitive foods, which are often high in fat, sodium, and added sugars, are not subject to the same nutrition guidelines that apply to foods served in the NSLP (3). Higher availability of competitive foods in schools is associated with higher consumption of these foods and lower consumption of healthful items (2,4,5). In addition, school policies, such as open campus, which allow students to leave school during lunch, may result in students purchasing food from nearby convenience stores and fast-food establishments (4). These policies may further increase intake of high-fat foods because french fries and hamburgers are the most frequently sold items in fast-food restaurants (6). Other food practices, such as allowing students to eat or drink in school hallways and classrooms, have been associated with higher student weight (7).

This study focuses on alternative high schools and their students, a group of youth at risk of academic failure (8). Nationwide, more than half a million students are enrolled in 6,600 public alternative school programs (9). Alternative high schools are more likely than traditional high schools to have high enrollment of minority and low-income students (10). Alternative high school students are also more likely than traditional high school students to engage in health-compromising behaviors (11). Studies have shown a high prevalence of overweight and obesity, unhealthful dietary practices, and low physical activity levels among students attending alternative high schools (12-14).

Few studies have examined the alternative school food environment (15,16). Results from a focus group study of alternative high school students found that students were dissatisfied with the food at school, including the school lunch. Many students report skipping lunch and snacking on vending machine food or purchasing food off-campus (16). Since 2006, public school districts are required to have a written local wellness policy that sets nutrition guidelines for foods and beverages available at school (17). Although it seems that alternative and traditional high schools in the same district would have the same wellness policies, alternative schools may be governed at the school level and their policies may vary from those of traditional schools or may be interpreted differently (8). Therefore, the application of wellness policies, including those that affect the school food environment, may lack uniformity among schools in the same district.

Our aim was to assess correlations between food opportunities during the school day and dietary behaviors, specifically consumption of sugar-sweetened beverages, high-fat foods, and fruits and vegetables, and use of fast-food restaurants among alternative high school students.

Among this sample of students, 52% were male, 63% were younger than 18 years (mean, 17.2 y; range, 14.0-19.9 y), 61% were minorities (mean, 62%; range, 31%-96%), and 60% received free/low-cost lunches (mean, 61%; range, 40%-96%). On average, students consumed regular soda more than 10 times a week and visited a fast-food restaurant about 3 times a week (Table 1). In our key informant interview, we found that 4 of the 6 schools did not have wellness advisory councils, and, of the 3 schools that had either vending machines or school stores, none had policies for the food sold in these places (Table 2). More than 60% of the foods and beverages sold in vending machines and school stores were categorized as foods and beverages to limit.

Student reporting of food opportunities during the school day showed that the most frequent food opportunities were getting lunch at a fast-food restaurant (76%), drinking (75%) and eating (70%) in the classroom, and drinking in the school hallways (70%) (Table 3). The results of the multivariate models between each dietary behavior and the food opportunities scale (Table 4) indicate that students who reported using the food opportunities more frequently during the school week had higher consumption of regular soda, sports drinks, other sugar-sweetened beverages, high-fat foods, and fast-food restaurant use. There were no significant associations between the scale and fruit and vegetable consumption.

In our study, alternative high school students reported having multiple food opportunities during the school day, and more frequent food opportunities were associated with higher consumption of sugar-sweetened beverages, high-fat foods, and fast-food restaurant use but were not associated with fruit and vegetable consumption. The results of this study add to an increasing body of research that supports a link between the school food environment and students' dietary practices (4,5,24) and provide support for school policies that limit access to high-calorie, low-nutrition foods (25).

Although all 6 study schools participated in the US Department of Agriculture federally regulated NSLP, half of the schools had an open-campus policy and a third allowed students to leave campus during other periods. Compared with a sample of students predominantly from large suburban traditional high schools, the students in this study more frequently ate lunch at fast-food restaurants (76% vs 18%), purchased lunch at convenience stores (59% vs 8%), and bought food from vending machines (56% vs 43%) at least 1 or 2 times per week (4). Results from national studies have indicated that school food practices limiting access to competitive food sources were associated with up to a 90-calorie reduction in energy intake from sugar-sweetened beverages during the school day among middle or high school students (25). Considering the excess of unhealthful items sold in competitive sources in our schools, limiting the availability of these foods could potentially lower energy intake.

The school food environment is a matter of national concern because of the obesity epidemic among youth (26). As a result, national efforts have focused on creating a more healthful food environment through better school health and nutrition assessments and policies (2,17,24). Furthermore, the Institute of Medicine report of 2007 includes recommendations on the nutrient quality of competitive foods sold at schools (27). Findings from the School Health Policies and Programs Study (SHPPS) 2006 suggest that progress has been made toward a healthier school food environment (24), including higher participation in the NSLP and lower à la carte sales (28). However, the SHPPS focused only on traditional public schools. Results from national studies have shown that Hispanic and African American high school students consume energy-dense foods more frequently than their white counterparts do (25). Considering the high rates of obesity among minority youth and those living below the federal poverty level (26), collecting national data on alternative school health programs and policies, including the food environment, would provide important information to help design health programs to meet the unique needs of this population.

This study had strengths and limitations. The strengths include a diverse sample of adolescents with respect to sex, race/ethnicity, and SES, and the use of measures that have been previously tested in other adolescent populations. This study is the first to examine associations between school food opportunities and dietary behaviors among alternative high school students. Even though the student participation rate was lower than expected, the demographic distribution of our sample closely resembles the demographic characteristics of alternative high school students in our study schools and national studies (29). Limitations also include the cross-sectional nature of the study that considers only the associations between the school food opportunities and student dietary behaviors. Previous research has shown that, compared with 24-hour dietary recalls, the 6-item questionnaire used to measure fruit and vegetable consumption may underestimate the prevalence of fruit and vegetable intake among urban adolescents; however, it performed equally to the Harvard Food Frequency Questionnaire (21). The dietary measures include foods eaten during the entire day; therefore, some eating behaviors may be the result of factors outside of the school environment.

Our findings indicate that the students in our alternative schools have multiple food opportunities during the school day, which is concerning, considering the high enrollment of youth who are at risk for obesity and related health outcomes. To achieve effective outcomes in preventing chronic disease, intervention programs need to target youth who have the highest health-risk behaviors and to tailor these programs to meet their needs. Having data available on alternative high schools and their students will enable researchers to design more effective school health and nutrition interventions. Schools should increase the availability of more healthful foods and beverages, implement closed-campus policies, and improve the quality of school meals to encourage more students to participate in the NSLP. The success of these interventions can be improved by implementing principles from social marketing (30). After having a clear understanding of the target audience, efforts can focus on offering healthful foods that taste good, are priced appropriately, are located conveniently, and are promoted through venues used by these students.

This research was supported by a grant from the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, R21DK072948. It was also supported in part by the Adolescent Health Protection Program grant no. T01-DP000112 from the Centers for Disease Control and Prevention. We gratefully thank the school staff and students who participated in the Team COOL pilot study.