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Keywords:

  • dietary assessment;
  • farm to school;
  • fruits and vegetables;
  • school-aged children;
  • school intervention

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Evidence of success in FTS programmes
  5. Conclusion
  6. Acknowledgements
  7. Conflict of interest
  8. References

The majority of children in the United States (US) do not consume the recommended amounts of fruits and vegetables for their age and gender. Farm to School (FTS) has been promoted as a strategy to increase consumption of these foods among US schoolchildren in primary and secondary schools (ages 5–19). FTS programmes connect schools to farmers and locally grown foods through a variety of activities that provide nutrition education and exposure to fruits and vegetables. This paper reviews the literature assessing the impact of these programmes on fruit and vegetable consumption among children in the US and makes recommendations for future research to improve knowledge of the efficacy of such approaches.

While FTS programmes are becoming increasingly popular in the US, there is a paucity of peer-reviewed research assessing its overall impact on children's actual consumption of fruits and vegetables. Instead, the majority of literature on FTS has focused on school lunch participation rates and self-reported intake or selection of fruits and vegetables in programme evaluations that are usually self-conducted by individual FTS programmes. These studies tended to use surveys that have not been validated against actual fruit and vegetable consumption and so are not necessarily representative of actual consumption. To a lesser extent, validated self-report dietary assessment methods have been used but these methods are subject to children's misreporting. Based on the types of methods used in most of the current literature on FTS, it is difficult to draw conclusions about its true impact on children's fruit and vegetable consumption. However, continued implementation of FTS is encouraged based on the positive outcomes observed in other school interventions with similarities to FTS. Future studies assessing the impact of FTS on children's dietary behaviour should adopt validated dietary assessment methods to measure fruit and vegetable consumption, especially those that require observation of children's actual intake in order to eliminate errors from children's self-report.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Evidence of success in FTS programmes
  5. Conclusion
  6. Acknowledgements
  7. Conflict of interest
  8. References

As of 2010, 32% of children and adolescents were overweight or obese in the United States (US) (Ogden et al. 2012). While rates of childhood obesity in the US appear to be levelling off since the steady increases observed in the National Health and Nutrition Examination Surveys (NHANES) conducted in the 1980s and 1990s (Ogden et al. 2012), overweight and obesity remains a health risk for close to one third of American children and adolescents. Childhood overweight and obesity have been associated with risk factors for cardiovascular disease and type 2 diabetes (Hannon et al. 2005; Freedman et al. 2007). Furthermore, obesity in childhood increases the likelihood of adult obesity (Serdula et al. 1993; Whitaker et al. 1997; Biro & Wien 2010) and related health conditions such as coronary heart disease, type 2 diabetes mellitus and certain cancers (NIH 1998). Moreover, it has been suggested that the current generation of children may be the first in over 100 years to live shorter and less healthy lives than their parents because of obesity-related illnesses (Olshansky et al. 2005).

In response to the growing rates of childhood obesity, many programmes have targeted healthier dietary behaviour within the school environment. An increasingly popular programme in the US is Farm to School (FTS), which provides nutrition education and exposure to locally grown foods while also supporting local farmers. Having grown exponentially since its grassroots beginnings in the mid-1990s, FTS programmes have been launched in over 2500 school districts in the US. Their focus is on building connections between locally produced food and schoolchildren (NFSN 2012). FTS has been described by the National Farm to School Network (NFSN) as ‘a program that connects schools (K-12) and local farms with the objectives of serving healthy meals in school cafeterias, improving student nutrition, providing agriculture, health and nutrition education opportunities, and supporting local and regional farmers’ (NFSN 2012). The first FTS initiatives in the 1990s were developed out of an interest to support local farms and to improve school menu offerings (Vallianatos et al. 2004). National support for FTS programming in the US has increased in recent years, as evidenced by the US Department of Agriculture's (USDA) financial support for the programme in the Healthy, Hunger-Free Kids Act of 2010, which provides US $40 million for FTS programming over eight years (USDA 2010). The popularity of FTS in the US is also illustrated by its increased implementation in recent years; 33.1% of public and 25.4% of private schools reported involvement in FTS and/or garden education activities in a survey conducted in the 2009–2010 school year (Turner & Chaloupka 2012).

FTS functions as a multicomponent school-based intervention by addressing nutrition in the classroom, cafeteria and other settings outside of the school environment. Some of the most commonly adopted activities by FTS programmes include taste tests, school gardens, field trips to local farms, food preparation, and procurement and promotion of locally grown foods in school meals and salad bars. As a result of the grassroots nature of FTS programmes, as well as the variation in regional crops and length of growing seasons, individual school or school district activities may vary, although the purchasing of locally produced foods by schools is a central theme (Kloppenburg et al. 2008).

It is thought that FTS may increase consumption of fruits and vegetables because of its emphasis on these foods in educational activities and school meals. Although, greater consumption of fruits and vegetables has been associated with reduced risk of chronic diseases including cardiovascular disease (He et al. 2007), stroke (He et al. 2006) and some cancers (WCRF/AICR 2007), less than 25% of US children aged 9–18 consume the recommended levels for their age and gender for fruits, while only about 5% meet the recommendations for vegetables (Krebs-Smith et al. 2010). US recommendations for children's fruit and vegetable consumption are shown in Table 1 (USDA & DHHS 2010). Efforts to increase fruit and vegetable consumption early in life are of particular interest as dietary behaviours established in childhood may influence food choices made as an adult (Mikkilä et al. 2004) and ultimately health status.

Table 1. Dietary Guidelines for Americans (2010) recommendations for children'sa fruit and vegetable intakes
 Fruits (cups)Vegetables (cups)
  1. a

    Recommendations vary for age, gender and activity level. The recommendations presented are based on a sedentary activity level.

Source: USDA & DHHS (2010).
Children, years
2–311
4–81–1.51.5
Girls, years
9–131.52
14–181.52.5
Boys, years  
9–131.52.5
14–1823

Given the benefits associated with increasing children's fruit and vegetable consumption, the widespread adoption of FTS programmes could translate into improved diets for a large number of children. FTS appears promising for several reasons. Many FTS activities offer an opportunity to work with fruits and vegetables, while multiple exposures to a food are known to increase preferences for that food (Birch & Fisher 1998; Wardle et al. 2003; Chadwick & Crawford 2013). Additionally, FTS programmes may offer a greater variety of fruits and vegetables than traditional lunch programmes (Joshi & Azuma 2009) and increasing fruit and vegetable variety may raise consumption levels (Adams et al. 2005). Finally, the school environment is recognised as a major influence on children's dietary patterns. Over 31 million children participated in the US National School Lunch Program in 2010 (USDA 2011) and up to half of US children's energy intake is consumed at school (Briefel et al. 2009). Thus, any changes made to school meals through programmes such as FTS stand to impact a large number of US children.

There is, however, a paucity of peer-reviewed research on the impact of FTS programmes on children's actual dietary intake. Instead, the majority of the literature on FTS is composed of programme evaluations, which are typically self-conducted by schools. FTS evaluations report on the impact of a FTS programme with respect to students, teachers, food service personnel, farmers, parents and/or the community. Among the FTS evaluations available in the literature, many have discussed the programme's impact on students’ dietary behaviours. This article discusses the results of available peer-reviewed research on FTS, as well as the grey literature, in order to summarise findings of the programme's impact in the US to date. A literature review was conducted in May 2012. A search was performed for all published research on ‘farm to school’ in several databases (PubMed, Science Direct, Web of Science, Expanded Academic ASAP, Academic Search Premier, CAB Direct, ERIC and ABI/Inform Global ProQuest). Research article titles and abstracts were reviewed to identify those that addressed children's dietary behaviour. Unpublished reports of FTS evaluations were found by reviewing resources posted on the NFSN website (NFSN 2012), as well as searching for unpublished reports cited in published articles and reports. This article begins by discussing the results of the literature review and follows up with recommendations for future research.

Evidence of success in FTS programmes

  1. Top of page
  2. Summary
  3. Introduction
  4. Evidence of success in FTS programmes
  5. Conclusion
  6. Acknowledgements
  7. Conflict of interest
  8. References

School lunch participation rates

As FTS programmes frequently offer salad bars to highlight locally purchased fruits and vegetables, many evaluations of the programme are based on changes in school meal participation rates after the installation of a salad bar, or improvement to an existing salad bar programme in schools. To date, programme evaluations have reported increased participation and uptake of school lunches after the introduction of a salad bar (Flock et al. 2003; AE/PPSNS/FCKE 2006; Joshi et al. 2006; Christensen 2003, cited in Joshi et al. 2008; Feenstra & Ohmart 2004, cited in Joshi et al. 2008; Feenstra & Ohmart 2005, cited in Joshi et al. 2008; Center for HPDP 2011). Other programme evaluations focused on participation rates specific to the salad bar. One report found that, on average, three times as many children selected the salad bar option during lunch in comparison with the previous year. The authors concluded that this was a direct result of improvements to the salad bar during the second year, when locally produced fruits and vegetables were offered in place of pre-cut fruits and vegetables purchased through a large-scale produce vendor (Mascarenhas & Gottlieb 2000). Furthermore, two other reports found that 21–67% of FTS participants selected the salad bar instead of the hot meal during lunch (Joshi et al. 2006; Center for HPDP 2011). Research also demonstrated that school lunch participants consume more fruits and vegetables than non-participants (Condon et al. 2009), so increased school lunch participation may result in greater consumption of these foods. It is also possible that the increased selection of salad bar meals might result in increased fruit and vegetable consumption but more research is needed before conclusions may be made. Regardless, increases in school meal participation rates are not sufficient to conclude that FTS necessarily results in increased fruit and vegetable consumption.

Food selection

FTS programmes have measured participants’ selection of fruits and vegetables by observing individual lunch trays or using food production records as a proxy for fruit and vegetable consumption. These reports concluded that students who choose a salad bar meal over a hot lunch select from 58% to almost 100% more servings of fruits and vegetables (Joshi et al. 2006; Feenstra & Ohmart 2005, cited in Joshi & Beery 2007). Others compared the amount of fruits and vegetables children selected during lunch, finding that students selected 25–82% more servings of fruits and vegetables after the implementation of an FTS programme than were selected prior to implementation (Flock et al. 2003; AE/PPSNS/FCKE 2006). Although it is tempting to conclude that children are eating more fruits and vegetables if they are selecting more of these foods during lunch, estimates of food selection do not account for plate waste. It has been estimated that about 13% of all school meals selected are wasted (Buzby & Guthrie 2002) and about 30% to 50% of all fruits and vegetables selected in schools are not consumed (Marlette et al. 2005). Researchers have attempted to develop a proxy for fruit and vegetable consumption based on the amount selected but the proxy may only be appropriate for younger schoolchildren participating in school meal programmes that offer a limited number of menu items (Gray et al. 2007). A recent study observing food selection and consumption of either school lunches or lunches brought from home similarly concluded that food selection was a poor indicator of food consumption (Gatenby 2011). Plate waste may also vary between hot lunch meals and salad bar meals; one FTS evaluation found that less food was wasted by children selecting foods from the salad bar (26% wasted) in comparison with children selecting foods from the hot lunch line (51% wasted) (Bowers & Adams 2002, cited in Vallianatos et al. 2004). The reported increase in fruit and vegetable selection among FTS participants suggests increased consumption, but given the variability in plate waste, it would be unwise to estimate fruit and vegetable consumption solely based on the amount selected at the lunch counter.

Surveys

Other FTS evaluations asked children questions about dietary intake using methods that were not validated against actual consumption. One FTS evaluation compared students who reported consuming three or more servings of fruits and vegetables per day before (42%) and after (53.6%) the first year of an FTS programme (Joshi & Azuma 2006). Another survey found that when children were asked if they consumed fruits and vegetables ‘more often’, ‘less often’ or at the ‘same’ frequency after participating in an FTS programme in comparison with the previous year, 40% of students reported consuming vegetables ‘more often’ and 60% reported consuming fruits ‘more often’ (Schmidt et al. 2006). In a survey where students in an FTS programme were asked to estimate the amount of fruits and vegetables they consume to the nearest cup, 67% of participants reported consuming amounts that met or exceeded recommendations based on the 2005 Dietary Guidelines for Americans (Powers et al. 2011). Although encouraging, such high reports of fruit and vegetable consumption were likely the result of using a crude survey question that only allowed estimation to the nearest whole cup, in addition to the limits of self-reporting; by comparison, a US study that used 24-h dietary recalls showed that less than one in four children aged 9–13 met the recommendations for fruit or vegetable consumption (Krebs-Smith et al. 2010).

Dietary assessments

Validated dietary assessments have been used less frequently to assess fruit and vegetable consumption among schoolchildren (some of the limitations of dietary assessment methods are discussed in the following section). One study used 24-h dietary recalls to assess dietary intake in an FTS programme, whereby children self-reported a significant increase in frequency of fruit and vegetable consumption from 2.97 times per day before the introduction of the salad bar, to 4.09 times per day post-introduction, with almost all of the change in consumption (84%) because of increases in the frequency of fruit and vegetable consumption during lunch (Slusser et al. 2007). A recent report summarising findings from four US FTS programmes used a variation of the 24-h dietary recall method, the School Lunch Recall, which was validated against meal observations (Paxton et al. 2011). The report described changes related to fruit and vegetable consumption in two of the four schools. In one school, it was found that fruit consumption increased by half a serving (vegetable consumption was not reported). In the second school, changes in fruit and vegetable consumption related to the FTS implementation were not reported but it was observed that children choosing a salad bar lunch selected 1.66 and two times more servings of fruits and vegetables, respectively, in comparison with children choosing a hot lunch meal (Center for HPDP 2011). This report was limited to a short summary of key findings and it was unclear whether additional, perhaps less compelling, results on the programme's impacts related to fruit and vegetable consumption were not included.

Programmes similar to FTS

Results from FTS evaluations and research demonstrate the programme's impact on school lunch participation, as well as fruit and vegetable selection, but for the most part, these estimates may be far removed from actual consumption. Although children's self-reports of fruit and vegetable intake may provide some insight into dietary behaviours, with the exception of two studies (Slusser et al. 2007; Center for HPDP 2011), most of the reports used methodologies that have not been validated against actual intake. Consequently, little concrete evidence is available to indicate the actual impact of FTS on children's dietary intake.

However, studies of programmes similar to FTS provide more insight into their potential impact. First, FTS programmes procure local fruits and vegetables, which are often featured during school lunchtime in salad bars. Studies comparing fruit and vegetable consumption before and after the introduction of a salad bar found increased frequency of fruit and vegetable consumption per day using 24-h recalls (Slusser et al. 2007), as well as increased fruit and vegetable consumption using direct observation during school lunch (Kerfoot & Fournet 1996). However, a third study that used weighed plate waste found no significant difference in fruit and vegetable consumption among children in schools offering salad bars in comparison with those in schools offering pre-portioned fruit and vegetable items (Adams et al. 2005). The latter study speculated that fruit and vegetable consumption might be more closely related to the number of fruit and vegetable offerings than the way in which they are served. Nevertheless, this still supports the notion that salad bars increase fruit and vegetable consumption, as school salad bars generally provide a greater variety of fruits and vegetables than traditional school lunch programmes (Schmidt & McKinney 2004).

FTS programmes also emphasise nutrition education through activities that teach children about the origins of their food, such as school garden programmes. School garden programmes provide nutrition education to children outside of the traditional classroom through hands-on activities including planting, harvesting, and preparing fruits and vegetables. Studies on garden education programmes reported varying levels of impact on children's fruit and vegetable consumption. Significant increases in fruit and/or vegetable consumption have been reported following the implementation of school garden programmes using self-administered 24-h recall workbooks (McAleese & Rankin 2007), 24-h recalls averaged with self-reported servings of fruits and vegetables (increase seen among boys only) (Lautenschlager & Smith 2007), surveys (Hermann et al. 2006), a garden vegetable frequency questionnaire validated against a 24-h recall (Ratcliffe et al. 2011) and direct observation during school lunchtime (Parmer et al. 2009). In contrast, no change in consumption was observed in studies that used 24-h recalls (Morgan et al. 2010) or self-administered 24-h journals (Lineberger & Zajicek 2000). The variability of these results suggests that the type of dietary assessment methodology used may influence the findings.

FTS programmes may be especially effective at influencing dietary behaviour because of the variety of settings and activities involved in this multi-component programme, as researchers have suggested that multi-component school interventions exhibit a synergistic effect on fruit and vegetable consumption (Perry et al. 2004). Reviews of the literature on multi-component school interventions such as FTS, have found significant increases in fruit and vegetable consumption in the majority of studies, with increases between 0.2 and 0.99 additional servings per day (Stables et al. 2005; Knai et al. 2006). A school-based intervention with many similarities to FTS programmes (e.g. use of local produce in school meals, garden education, cooking classes, nutrition education) found significantly greater (+0.92 half-cup servings/day) fruit and vegetable consumption among fourth- and fifth-grade students (aged 9–11 years), with the most exposure to the intervention than consumption among those with the least exposure (−0.64 half-cup servings/day) over a 2-year period using 3-day food diaries (Wang et al. 2010).

The success of such interventions that are similar in nature to FTS warrants further research. As interest in FTS programmes continues and in light of some of the limitations that have been highlighted, recommendations are considered for future evaluation purposes.

Recommendations for future assessments of fruit and vegetable consumption

Given the limitations of the methodologies used in past evaluations of FTS programmes in the US, future research should focus on the use of validated dietary assessment methods that demonstrate good agreement with measures of actual fruit and vegetable consumption. Weighed plate waste, where the exact weights of all foods served are measured before and after a meal, is recognised as a ‘gold standard’ for measuring food consumption. However, this method is rarely adopted in school-based research because it is labour and time intensive (Kirks & Wolff 1985). Therefore, other methods based on mealtime observations or children's self-report are typically used more often. The following is a brief discussion of the advantages and limitations of the most commonly used methods of dietary assessment.

Self-reported intake

School-based interventions frequently rely on children's self-reports of fruit and vegetable consumption (Stables et al. 2005; Knai et al. 2006; Delgado-Noguera et al. 2011; Thomson & Ravia 2011). Common instruments include Food Frequency Questionnaires (FFQs), food intake records and 24-h dietary recalls. Self-report methods are generally easy to administer and are more practical than mealtime observations for collecting data over the course of an entire day or several days.

However, a variety of limitations have been discussed that affect the accuracy of children's self-reported intake (Livingstone et al. 2004; Thompson & Subar 2008). FFQs collect information on the frequency with which a specified list of foods have been consumed within the past week, month, year, or other specified length of time, and therefore, may be a useful way of tracking habitual dietary intake. Although easy to administer, FFQs can overestimate children's vegetable and total fruit and vegetable consumption (Burrows et al. 2009; Di Noia & Contento 2009; Slater et al. 2010). In contrast, the 24-h recall is facilitated by a trained interviewer who asks the child to list all foods and beverages consumed during the last 24-h, collecting details on food preparations, portion sizes and brand names. Interviewers ask additional questions or provide prompts to identify forgotten foods and gather specific details about food preparation methods. Lytle et al. (1998) compared children's lunch intake as reported in a 24-h recall to observed intake and found that the 24-h recall accurately estimated fruit consumption but overestimated vegetable and total fruit and vegetable consumption.

For example, children may misreport their intake if they forget to report foods (omissions) or if they report consuming foods that were not eaten (intrusions) (Livingstone et al. 2004). Also, many children have a difficult time estimating portion sizes, even with the assistance of visual prompts (Matheson et al. 2002; Lillegaard et al. 2005). Food records, which ask children to record all foods consumed at the time of each meal or snack, may reduce error caused by forgotten or misidentified foods, yet the method still resulted in significant under-reporting of energy intake in more than half of the studies in a recent review (Burrows et al. 2010). This is likely the result of the high level of responsibility food records place on children and adolescents, who, in response to the burdensome task, may change their diets – reducing overall intake, consuming only foods that are easier to report or simply under-reporting food intake (Rebro et al. 1998).

However, new variations of dietary assessments that can overcome some of these issues continue to be explored. For example, the School Lunch Recall (SLR) questionnaire, a variation of the 24-h recall, was piloted among third- to fifth graders (aged 8–11 years) as a method for children to self-report consumption of school lunch items shortly after lunch (Paxton et al. 2011); a method which has been used to measure fruit and vegetable consumption among third- to fifth-grade students in FTS programmes (Center for HPDP 2011). In comparison with direct observation, the SLR estimated school lunch consumption within ±0.63 servings. Unfortunately, the accuracy of self-reported fruit and vegetable intake was not reported, although omissions and intrusions (i.e. foods reported but not observed eaten) occurred equally across all observed food categories (Paxton et al. 2011). The use of technology-based dietary assessment has also been encouraged (Thompson et al. 2010). Mobile telephone food records are being developed that estimate food portions from images of a meal, removing error caused by children's inaccurate portion size estimations (Daugherty et al. 2012; Martin et al. 2012). Other variations of self-report have been more challenging to adapt to young children, such as an automated, web-based 24-h dietary recall, which had a high incidence of misreporting among children compared with the traditional 24-h recall method (i.e. in-person interviews) (Baranowski et al. 2012).

Mealtime observations

Although self-report methods are improving, mealtime observations are advantageous in terms of accuracy and applicability to the school setting. The ‘gold standard’, weighed plate waste, has been used to test the validity of two other observation methods: direct observation and digital imaging. Each method determines consumption based on visual estimation of food selections and plate waste, although direct observation estimations are made while present in the cafeteria and digital imaging estimations are made by viewing ‘before’ and ‘after’ meal images at a later occasion. Direct observation and digital imaging have both been validated against weighed plate waste in a laboratory setting (Williamson et al. 2003) and further validation tests have been conducted in institutional and field settings for direct observation (Comstock et al. 1981; Graves & Shannon 1983; Kirks & Wolff 1985; Thompson et al. 1987; Dubois 1990; Gittelsohn et al. 1994; Shankar et al. 2001; Connors & Rozell 2004). Fruit and vegetable consumption tends to be overestimated with both digital imaging (+4.8 g) (Williamson et al. 2003) and direct observation (between +3 and +9 g) (Shankar et al. 2001; Williamson et al. 2003), but on a practical level this degree of error is quite small. In addition, newer methods are increasingly feasible; researchers using digital imaging have suggested that data collection could be carried out by a coordinated group of school staff or volunteers (Swanson 2008), thus reducing the labour costs of data collection by trained researchers.

One of the limitations with mealtime observations is that they only measure food intake during one meal within the day. However, an accurate estimation of fruit and vegetable consumption during school lunch is especially valuable in assessing the impact of FTS programmes. Children choosing school lunch consume, on average, more than half of their daily intake of fruits and vegetables during lunch, while school lunch is an especially large contributor to total fruit and vegetable intake among those who consume the least of these foods (Robinson-O'Brien et al. 2010). Not surprisingly, FTS and other multi-component school-based interventions mostly influence schoolchildren's dietary habits during school lunchtime; school-based interventions assessed by self-report over a 24-h period have found that the greatest change in fruit and vegetable consumption occurs during lunchtime (Perry et al. 1998; Slusser et al. 2007; Wang et al. 2010). These findings suggest that dietary assessment methods measuring only children's lunchtime fruit and vegetable consumption may be able to detect the majority of the impact of a school-based intervention such as FTS.

Conclusion

  1. Top of page
  2. Summary
  3. Introduction
  4. Evidence of success in FTS programmes
  5. Conclusion
  6. Acknowledgements
  7. Conflict of interest
  8. References

FTS programmes are promoted as a tool to increase children's fruit and vegetable consumption but little research is available that measures children's actual consumption. Several reports have highlighted increased school meal participation rates and increased fruit and vegetable selection in FTS programmes but these do not necessarily indicate increased consumption. Other assessments of FTS are based on survey questionnaires or children's self-reported dietary assessments, both of which are prone to misreporting. Although these findings are encouraging as they indicate possible increased intake of fruits and vegetables by schoolchildren, they are not sufficient enough to draw broad conclusions regarding the effectiveness of FTS programmes in the US. Therefore, based on the positive impact of programmes assessing school gardens, salad bars and similar multi-component school interventions, more research is recommended.

Limitations of the current available literature on FTS may be largely attributed to the dearth of resources a school can employ to evaluate its own school-based programme. A recent FTS summary encouraged schools to allot 5–10% of FTS budgets towards evaluation in order to collect information on student behaviours prior to commencing the programme and to work in conjunction with research institutions when possible (Joshi & Azuma 2009). This financial commitment would make it easier for these programmes to be evaluated using more rigorous and robust research methods.

Replacing the use of surveys and fruit and vegetable selection data with validated dietary assessment methods will strengthen future studies on the nutritional impact of FTS programmes. In particular, specific methods, such as mealtime observations, are recommended, as they are not susceptible to children's misreporting and have become increasingly feasible to conduct in school cafeteria environments, as well as provide the most accurate data. The continued implementation and evaluation of FTS programmes is encouraged given their potential to improve children's dietary habits and promote healthier, longer lives.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Evidence of success in FTS programmes
  5. Conclusion
  6. Acknowledgements
  7. Conflict of interest
  8. References

This research was made possible by a grant from the University of Vermont Agricultural Experiment Station and the University of Vermont Bickford Scholar fund.

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  3. Introduction
  4. Evidence of success in FTS programmes
  5. Conclusion
  6. Acknowledgements
  7. Conflict of interest
  8. References
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