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European Journal of Clinical Nutrition (2012) 66, 1335–1341 & 2012 Macmillan Publishers Limited All rights reserved 0954-3007/12 www.nature.com/ejcn

ORIGINAL ARTICLE

Associations between usual school lunch attendance and eating habits and sedentary behaviour in French children and adolescents C Dubuisson1, S Lioret1, A Dufour1, JL Volatier1, L Lafay1 and D Turck2 BACKGROUND/OBJECTIVE: Our objective was to investigate whether school lunch attendance was associated with overall eating habits and sedentary behaviour in a French sample of children and adolescents. SUBJECTS/METHODS: Data for the study were taken from the second French cross-sectional dietary survey (INCA2-2006-07). In total, 1413 school children aged 3–17 years old were classified according to their school type and their usual school lunch attendance. Eating habits included meal regularity, dietary diversity, purchase in vending machine, snacking habits and frequency of eating in fast-foods. Two composite indices of eating habits were derived from multiple correspondence analyses. Sedentary behaviour was assessed by the average daily screen times for TV and computer. The association between school lunch attendance and each variable was tested. Multivariate association between school lunch attendance and the composite indices of eating habits and sedentary behaviours was studied. RESULTS: In all, 69.0% (CI95%: 64.2–73.9) of secondary school children and 63.0% (CI95%: 58.5–67.5) of pre- and elementary school children usually attended school lunch at least once a week. Pre- and elementary school children attending school lunches showed a higher dietary diversity score (P ¼ 0.02) and ate morning snacks more frequently (P ¼ 0.02). In secondary school children, attending school canteen was related to a lower rate of skipping breakfast (P ¼ 0.04) and main meals (P ¼ 0.01). In all school children, school lunch attendance was simultaneously associated with healthier overall eating habits and less sedentary behaviour. CONCLUSION: In France, children attending school canteens seem to have healthier eating habits and display less sedentary behaviour, independently of their socio-economic and demographic background. European Journal of Clinical Nutrition (2012) 66, 1335–1341; doi:10.1038/ejcn.2012.137; published online 10 October 2012 Keywords: school lunch attendance; dietary diversity; eating habits; sedentary behaviour

INTRODUCTION Over recent decades, obesity and chronic non-communicable diseases such as diabetes, cancers and cardiovascular diseases have become major public health issues. Dietary habits and physical activity have been proven to be key determinants.1 To prevent these diet-related diseases from becoming more prevalent, it has been recommended that nutritional policies be set up. In France, such a policy has been implemented since 2001 with the launching of the PNNS (National Nutrition and Health Programme).2–4 Since its beginning, the PNNS has included actions dealing with nutritional education of children and nutritional quality of school meals. It is agreed that childhood and adolescence are critical periods in the settlement of food habits and food preferences, which remain in adulthood.5,6 Moreover, children could be a vehicle for improving the dietary behaviour of their families.7,8 Leading children towards healthier dietary habits could therefore be an effective way of improving population health on a long-term basis. To target children and adolescents, school is considered as a privileged setting since they spend most of their out-of-home time at school. In France, a school day lasts 6–8 h, equally divided between morning and afternoon, and nearly all schools supply warm meals at lunchtime

(which include a starter, a main dish and side dish, a dairy product and/or a dessert). Schools should create a healthy food environment by providing children with nutritionally balanced school meals and nutritional education.9 In France, several statutory measures have been taken to improve the school food environment: discouragement of morning snacks in preschools and elementary schools in 2004,10 ban of the vending machines in school premises in 2005,11 compulsory nutritional guidelines on school meal composition in 2011.12,13 However, individual food choices and eating habits result from complex and multiple influences including individual, social, physical and macroeconomic factors.14 To our knowledge, most of the published studies on school canteens limited their investigations to the food and nutrient intakes of children. However, some data suggested that school lunch attendance could be associated with specific lifestyle behaviours.15 Given this background, our objective was to investigate whether school lunch attendance was associated with overall eating habits and sedentary behaviour in a national sample of children and adolescents. In this way, we aimed to provide a better description of children attending school canteens, who are targeted by the new regulation on school

1 Risk Assessment Department, French Agency for Food, Environmental and Occupational Health and Safety (ANSES), Maisons-Alfort, France and 2Department of Paediatrics, Jeanne de Flandre Children’s Hospital and Lille University Faculty of Medicine, Lille, France. Correspondence: C Dubuisson, French Agency for Food, Environmental and Occupational Health and Safety (ANSES), Risk Assessment Department, Dietary Survey Unit, 27–31 Avenue du Geńe´ral Leclerc, 94701 MAISONS ALFORT CEDEX, France. E-mail: [email protected] Contributors: CD analysed the data and wrote the paper. LL, SL, J-LV and DT helped to write the paper. CD, AD, LL, SL, and J-LV contributed to the design and data collection of the INCA2 survey. All the authors reviewed the manuscript. Received 28 May 2012; revised 4 September 2012; accepted 4 September 2012; published online 10 October 2012

School lunches and eating and sedentary behaviour C Dubuisson et al

1336 meal composition, so as to define a point of reference for future evaluations of its efficiency in promoting healthier eating habits. MATERIALS AND METHODS All the analyses conducted in this study used data from the second French national cross-sectional dietary survey, INCA2.

Study design and subjects The INCA2 survey was performed between December 2005 and May 2007, by the French Food Safety Agency. Two nationally representative samples of the French population (1455 children aged 3–17 years old and 2624 adults aged 18–79 years old) were obtained by using a multistage cluster sampling design described elsewhere.16–18 Regarding children, the initial participation rate was 69%. Twenty-six non-schooled children were excluded as well as sixteen children whose school canteen attendance was unknown, leading to a final sample of 1413.

Measurements The INCA2 dietary survey was originally designed to assess individual dietary intake. It included a 7-day food record, plus one self-administered and one face-to-face questionnaire. A trained and certified investigator delivered the 7-day record and the self-administered questionnaire to the home and explained to the parents or caregivers and the child how to complete them. After the survey week, the investigator came back and checked the accuracy of the information reported in the documents and amended it with the help of the participant if necessary. Then, he administrated the face-to-face questionnaire partly to the child and partly to his/her adult caregiver (mainly the mother (80%)). Each day of the food record was divided into three main meals (breakfast, lunch and dinner) and three between-meal eating occasions. The participants were asked to report as precisely as possible all food and beverage intakes. One line of the record corresponded to one item consumed (food or drink), and thus to one eating occasion for this specific item. Foods and beverages recorded were then allocated a food code from the nomenclature including 1280 items, classified into 34 groups. Data on eating habits, including usual school canteen attendance, snacking, eating in fast-food restaurants and purchase in vending machine, were gathered by the self-administered questionnaire. The face-to-face questionnaire collected information on the school type attended by the child, socioeconomic issues (household’s income, head of household’s and child caregiver’s occupations, employment status and educational level), indices of household living standards and child’s sedentary behaviour over the 7 last days. Other information, such as region, type of settlement in which the household was located and the household composition, was collected during the face-to-face interview. The survey was approved by the Data Protection Authority (Commission Nationale Informatique et Liberte´s).

Data analysis Children were classified according to their school type, that is, preschool, elementary, lower and upper secondary schools. Because of similar catering organisation, we grouped preschools and elementary schools together, and also lower and upper secondary schools together. Usual school canteen attendance was defined as previously19 from the self-reported questionnaire as a dichotomised variable: occasional or regular user (at least one lunch/week) and non-user (never or less than one lunch/week). Eating habits included meal regularity; dietary diversity; purchase in food and beverage vending machines; snacking habits; and frequency of eating in fast-food restaurants. Meal regularity was assessed from the 7-day food record through two dichotomised variables: the first identified the children who ate breakfast every day of the food-record period and the second identified the children who ate all three main meals (breakfast, lunch and dinner) every day. The dietary diversity score (DDS)20 was estimated by the number of food groups eaten out of five possibilities (fruit, vegetables, starchy foods, dairy products and meat-fish-egg), over 3 days randomly selected from within the 7-day food record (2 weekdays and 1 week-end day). Children who had eaten all five food groups were identified in a dichotomised variable (yes/no). At the time of INCA2 survey, vending machines were no longer accessible in school premises. However, the latter could be found in train or subway stations, sport centres and other public places like cinemas, and would mainly provide sweets and fatty snacks. Vending machine purchasers were identified through a European Journal of Clinical Nutrition (2012) 1335 – 1341

dichotomised variable (yes/no). Snacking was defined as eating apart from the daily three main meals (breakfast, lunch and dinner). The afternoon snack, which is recommended in France as a fourth eating occasion in children and adolescents,21 was counted as a snack. Two variables were used to assess snacking habits: the first corresponded to the daily snack frequency (more than once a day/once a day/less than once a day/never) while the second focused on the morning snacks (every day or often/sometimes/never). Finally, the frequency of eating in fast-food restaurants was estimated using a 4-class variable: at least once a week/at least once a month/less than once a month/never. Composite indices of eating habits were derived from multiple correspondence analysis performed on the matrix of the variables previously described (meal regularity, breakfast regularity, eating in fast-food restaurant, purchase in vending machine, daily snacking habit, morning snacking habit, DDS equal to 5). The first two dimensions derived from the multiple correspondence analysis were retained and the coordinates of each subject on these dimensions were divided into tertiles to be used as summary variables in multivariate adjusted analyses. Sedentary behavior: The average daily screen times (in min/day) for computer and TV during the previous 7 days were used as a proxy of sedentary behaviour.

Statistical analysis All analyses were computed on STATA (StataCorp (2005) Stata Statistical Software: Release 11, College Station, TX, USA: StataCorp LP). Individual data were weighted for unequal sampling probabilities and for differential non-responses by region, urban area size, age, gender, head of the household’s occupation, size of the household and season, to ensure national representativeness of the sample. Analyses were performed taking into account the complex design of the survey (STATA’s svy: procedures) and the individual weighting factor. Univariate associations were tested with Pearson’s w2 tests to compare frequencies and linear regression to compare means. Then, by using logistic regressions, these univariate associations were adjusted for age (in years), gender and socio-economic and demographic characteristics previously identified as linked to school lunch participation.19 Critical P-values were set at P ¼ 0.05. Finally, multivariate logistic regression analyses were performed to investigate the association between usual school canteen attendance as the dependant variable and the composite indices of eating habits and TV and computer screen times as independent variables. All four variables were introduced simultaneously and then removed step by step from the model (according to the P-value) to avoid collinearity. These associations were also tested after adjustment for age, gender and socio-economic variables. Critical P-values for selecting the final remaining variables in the model were set at P ¼ 0.10.

RESULTS Sample characteristics Characteristics of the subjects are presented in Table 1, according to the school type. The rate of regular school lunch attendance was higher among secondary school children compared with preand elementary school children, at 64.3 and 49.8%, respectively (Po0.001). Conversely, occasional school lunch attendance was three times more frequent among pre- and elementary school children, with 13.4% against 4.8% in secondary school children. In the following analyses, regular and occasional school canteen users were considered together in comparison with non-users. Description of the summary indices The characteristics of the first two dimensions of eating habits derived from the multiple correspondence analysis are described in Table 2. They explained respectively 52.1 and 14.3% of the total variance. The first dimension was mainly characterised by skipping breakfast or skipping main meals, whereas the second dimension was inversely related to frequently eating daily and morning snacks. The coordinate on the first dimension, labeled ‘meal skipping pattern’, was negatively associated with breakfast regularity (Po0.001), main meal regularity (Po0.001), having one snack/day (Po0.001) and a DDS equal to 5 (Po0.001), and & 2012 Macmillan Publishers Limited


1337 Table 1.

Characteristics of 3–17 year-old children sampled in the INCA2 survey, according to their school type Pre- and elementary school children

Secondary school children

All 3–17 years

P-value

Nraw/Nweighted Gender, male, % (CI95%) Age, years, mean (CI95%)

608/795 53.2 (48.8–57.6) 7.3 (7.1–7.5)

805/620 48.0 (43.2–53.9) 14.3 (14.1–14.5)

1413/1415 50.9 (47.6–54.3) 10.4 (10.1–10.6)

0.11

School type, % (CI95%) Preschool (3–5 years old) Elementary school (6–10 years old) Lower secondary school (11–14 years old) Upper secondary school (15–17 years old)

32.3 (28.4–36.6) 67.7 (63.4–71.7) — —

— — 65.4 (60.7–69.7) 34.7 (30.3–39.3)

18.2 38.0 28.6 15.2

School canteen attendance, % (CI95%) Regular user (X three times a week) Occasional user (X once a week, othree times a week) Non-user (o once a week)

49.8 (45.2–54.4) 13.2 (10.4–16.7) 37.0 (32.6–41.6)

64.3 (59.4–68.9) 4.8 (3.4–6.7) 31.0 (26.3–36.0)

56.1 (52.8–59.4) 9.5 (7.7–11.7) 34.4 (31.2–37.6)

(15.9–20.7) (34.7–41.5) (25.9–31.5) (13.0–17.7) o0.001

Abbreviation: CI, confidence interval.

positively associated with frequent morning snacking (Po0.001), eating in fast-food restaurants (Po0.001) and purchase in vending machines (Po0.001). It can be interpreted as a proxy of unhealthy eating habits. The coordinate on the second dimension, labelled ‘non-snacking pattern’, was negatively associated with every variable used to perform the multiple correspondence analysis: breakfast regularity (Po0.001), main meal regularity (Po0.001), frequent total daily snacking (Po0.001), frequent morning snacking (Po0.001), frequent use of fast-food (Po0.001), use of vending machines (Po0.001) and a DDS of 5 (P ¼ 0.002). Associations between usual school lunch attendance and eating habit Independently of socio-economic background, usual school lunch attendance was associated with higher DDS and morning snack frequency in pre- and elementary school children (Table 3). In secondary school children, school lunch attendance was related to a higher regularity of breakfast and main meals. Associations between usual school lunch attendance and sedentary behaviour In all school children, usual school lunch attendance was associated with a lower level of sedentary behaviour, after adjustment on socio-economic variables (Table 4). The average total screen time was 30 min/day lower in school canteen users in pre- and elementary school children, and 40 min/day lower in secondary school children. In pre- and elementary school children, the total screen time difference corresponded to TV screen time only, whereas in secondary school children it was equally distributed between TV and computer screen time. Of the latter, only the difference in computer screen time was significant. Multivariate associations between usual school lunch attendance and overall eating habits and sedentary behaviour In pre- and elementary school children, usual school lunch attendance was simultaneously and negatively associated with the meal skipping pattern, the non-snacking pattern and average TV screen time (Table 5). In secondary school children, it was simultaneously and negatively related to the meal skipping pattern and average computer screen time. DISCUSSION The present study sought to establish whether school lunch attendance was associated with specific lifestyle patterns. Using a & 2012 Macmillan Publishers Limited

national sample of school children, we found different eating and sedentary behaviour in children attending school canteens compared with children who do not attend school canteens, independently of their socio-economic background. Strengths and limits of the INCA2 survey All results were based on a national sample of children and adolescents aged 3–17 years. This wide age range enabled us to cover all French school types: preschools (3–5 years old), elementary schools (6–10 years old), lower secondary schools (11–14 years old) and upper secondary schools (15–17 years old). However, our investigations were limited due to the variation of the self-administered questionnaire with age classes. It was therefore impossible to draw conclusions concerning physical activity, since the measurement tools were not consistent within a school type. Moreover, the very low prevalence of some eating habits among the paediatric population, such as eating in fastfood restaurants, means that statistic power was insufficient to establish associations. This low prevalence may partly be related to the participant’s understanding that take-away was not addressed by the corresponding question. Concerning the results on dietary diversity and meal regularity, we used data from the food record without considering whether the children who reported usually attending school canteens actually did participate in school lunches during the survey week. Our working hypothesis was that eating habits were usual and would not change according to school or holiday periods.22 School lunch attendance and eating habits School lunch attendance was associated with a higher DDS in preand elementary school children. This result was in line with previous national French data from 1999.23 It is of interest since dietary diversity has been related to a greater adequacy of nutrient intake.24,25 The way association of school lunch attendance with dietary diversity differs according to school type may be partly explained by their diverse catering systems. First, school meal variety may differ between the two school types: respectively 78.8 and 56.9% of pre- or elementary school children and secondary school children considered school meal variety satisfactory in a French national survey on school canteen perception.26 Second, single menus are generally proposed in preschool and elementary schools whereas food choice is often offered in secondary schools. By eating the only food proposed, younger children are therefore led to taste more foods and to improve their dietary diversity, whereas, by having choice European Journal of Clinical Nutrition (2012) 1335 – 1341


1338 Table 2.

Characteristics of the first dimensions related to eating habits derived from the correspondence analysis (n ¼ 1329) First dimension (52.1%)

Second dimension (14.3%)

‘Meal skipping pattern’

‘Non snacking pattern’

Coordinates

Contribution

Coordinates

Contribution

Breakfast regularity No Yes

2.572 0.970

0.259 0.098

0.794 0.300

0.025 0.009

Main meal regularity No Yes

1.968 1.302

0.220 0.146

0.591 0.391

0.020 0.013

Purchase in vending machine No Yes

0.418 1.156

0.018 0.051

0.197 0.544

0.004 0.011

Total daily snacking 4Once/day Once/day oOnce/day Never

0.603 0.587 0.638 0.109

0.019 0.024 0.006 0.000

2.182 0.846 1.645 3.564

0.243 0.050 0.039 0.102

Morning snacking Always or often Sometimes Never

0.462 0.083 0.273

0.010 0.000 0.006

2.300 0.070 1.481

0.255 0.000 0.166

Eating in fast-food restaurants XOnce/week XOnce/month and oonce a week oOnce/month Never

1.894 0.741 0.243 0.899

0.037 0.018 0.004 0.024

0.107 1.111 0.407 0.309

0.000 0.041 0.012 0.003

Dietary diversity score DDSo5 DDS ¼ 5

1.072 0.394

0.044 0.016

0.390 0.143

0.006 0.002

Abbreviation: DDS, dietary diversity score. Reading example: To characterise the first dimension, we accounted for the variables’ categories contributing the most to the dimension and then for the value and sign of their coordinates. Here, breakfast regularity ‘No’ and main meal regularity ‘No’ contributed respectively 25.9 and 22.0% to the dimension, while breakfast regularity ‘Yes’ and main meal regularity ‘Yes’ contributed 9.8 and 14.6%. The coordinates of these categories were strongly positive for breakfast and main meal irregularity and negative for breakfast and main meal regularity. Therefore, the first dimension was characterised as a ‘Meal skipping pattern’.

between several food options, secondary school children may be inclined to eat the foods they prefer or those they are used to eating.23,27–29 Yet, regularly exposing children to unfamiliar or ‘unpopular’ foods could lead them to increase their liking and their consumption of different foods.30,31 This could apply particularly to fruit, vegetables and protein foods, which seem to be more concerned by food neophobia.32 Further results (data not shown) in secondary school children showed that the DDS was positively associated with odds of liking fruit, fruit juice, vegetables, fish, milk, cheese and yoghurt. Taking into account that food preferences can be translated into overall dietary intake of children and adolescents,33 food variety of school lunches should be considered as an efficient approach for changing food preferences and promoting healthy diets in children and adolescents. However, it would be better achieved by a more constrained food offer in secondary school canteens.34 In secondary school children, attending school canteen was related to a more regular meal pattern. Previous studies have shown that regular breakfast was correlated with healthier dietary and lifestyle behaviours,35–37 better nutritional intake35 and lower odds of being overweight in children and adolescents.35,38–40 Nevertheless, skipping breakfast has been shown to become more European Journal of Clinical Nutrition (2012) 1335 – 1341

widespread in developed countries, including France, with higher prevalence among adolescents and young people.35,36,41 In our study, adolescents attending school canteens ate breakfast more regularly. Beyond a more regular meal pattern, school lunch attendance was also associated with healthier overall eating habits, as represented by the meal skipping pattern in all school children. However, because INCA2 is a cross-sectional survey, we cannot conclude whether attending school lunch is part of this healthy eating habit pattern or whether it can lead to establishing healthier eating habits in young children that remain into adolescence. Nevertheless, pre- and elementary school children eating school lunch declared eating morning snacks more frequently. In France, morning snacking was associated with higher sugar and lipids intake and higher total daily energy intake.42 It was also considered instrumental in getting children used to an overall snacking habit. These conclusions led to discouraging the distribution of morning snacks in pre- and elementary schools in 2004. The time period between the government decision and the fieldwork of the survey may explain that this practice was still observed in the INCA2 survey. It may have been too short to detect changes in morning snacking habits of children. It would & 2012 Macmillan Publishers Limited


1339 Table 3.

Associations between school canteen (SC) attendance and eating habits, after adjustment on age, gender and socio-economic variables (ORa, (CI95%)) in schoolchildren from the INCA2 sample Preschool and elementary school children SC non-user

ORaa

SC user

SC non-user

ORaa

4.67 (4.59–4.75)

600 1.68 (1.10–2.57) 0.02

4.69 (4.64–4.75) 0.21

4.60 (4.47–4.73)

795 1.06 (0.76–1.48) 0.74

90.1 (85.7–93.3) 0.07

84.2 (78.0–89.0)

600 1.60 (0.84–3.04) 0.15

65.5 (60.6–70.2) o0.001

45.9 (36.3–55.7)

795 1.50 (1.02–2.21) 0.04

78.7 (73.7–83.0) 0.05

70.4 (62.4–77.2)

600 1.58 (0.93–2.70) 0.09

53.0 (48.2–57.7) o 0.001

31.5 (23.9–40.2)

795 1.66 (1.12–2.47) 0.01

21.9 (16.2–28.9)

595 0.70 (0.40–1.20) 0.19

34.2 (29.6–39.0) 0.79

35.5 (26.8–45.4)

784 1.10 (0.71–1.71) 0.65

41.2 47.2 5.5 6.1

(34.4–48.4) (40.2–54.2) (3.2–9.4) (3.3–11.1)

589 2.46 (0.86–6.99) 2.50 (0.85–7.36) 1.39 (0.35–5.59) 1.00 0.11b

34.7 45.5 14.5 5.3

44.5 33.7 13.7 8.2

(33.8–55.6) (25.7–42.6) (8.3–21.8) (5.1–12.9)

771 1.04 (0.42–2.60) 1.38 (0.58–3.27) 1.33 (0.48–3.69) 1.00 0.67b

43.9 (36.7–51.4) 11.6 (7.7–17.1) 44.5 (37.4–51.9)

585 1.76 (1.11–2.80) 1.86 (0.95–3.64) 1.00 0.02b

23.9 (19.3–29.3) 14.6 (11.3–18.8) 61.4 (56.1–66.5) 0.05

37.1 (26.7–48.9) 10.4 (5.6–18.4) 52.5 (42.1–62.7)

754 0.70 (0.44–1.11) 1.70 (0.91–3.15) 1.00 0.22b

598 1.00 1.48 (0.47–4.62)

9.0 (6.6–12.2) 21.7 (17.6–26.3)

13.0 (8.6–19.1) 28.6 (20.6–38.4)

1.34 (0.43–4.13) 0.97 (0.29–3.24) 0.31b

48.6 (43.2–54.0) 20.7 (16.9–25.3) 0.19

39.0 (28.9–50.1) 19.4 (12.8–28.4)

SC user Dietary diversity score, mean (CI95%) n 4.82 (4.77–4.86) P-value 0.003 Breakfast regularity, % (CI95%) n P-value Main meal regularity, % (CI95%) n P-value

Purchase in vending machine, % (CI95%) n 13.4 (10.1–17.5) P-value 0.01 Total daily snacking, % (CI95%) n 4Once/day Once/day oOnce/day Never P-value Morning snacking, % (CI95%) n Always or often Sometimes Never P-value Eating in fast-food restaurants, % n XOnce/week XOnce/month and oonce a week oOnce/month Never P-value


37.8 55.8 3.7 2.8

(32.3–43.5) (50.0–61.4) (2.2 – 6.2) (1.4–5.4) 0.10

43.9 (37.8–50.2) 14.3 (10.7–18.8) 41.8 (36.1–47.8) 0.65

(29.4–40.3) (40.4–50.8) (11.2–18.4) (3.3–8.5) 0.12

(CI95%) 2.3 (1.2–4.3) 21.5 (17.3–28.5)

2.9 (1.4–5.9) 17.4 (12.7–23.4)

56.8 (50.6–62.8) 19.4 (15.3–24.4) 0.42

55.1 (47.1–62.8) 24.7 (18.2–32.5)

781 1.00 1.18 (0.60–2.31) 1.41 (0.74–2.67) 1.09 (0.74–2.67) 0.71b

Abbreviations: CI, confidence interval; ORa, odds ratio adjusted. aOR adjusted on age, sex and socio-economic variables. bP-value for trend.

be interesting to monitor this issue using data from the next INCA3 survey (2013–14). School lunch attendance and sedentary behaviour School lunch attendance was associated with a lower sedentary level whatever the children’s age. This result was already established for French 3- to 14-year-old children using data from the INCA1 survey (1998–99).15 In the present study, the total screen time was calculated as the sum of computer and TV screen times. However, we cannot exclude that some children watched TV while using a computer and that their sedentary level was overestimated. Bearing this limitation in mind, we found that the total sedentary level was 30–40 min/day lower in children eating school lunches. Even though the total screen time was higher in secondary school children compared with pre- and elementary school children, the duration difference according to school & 2012 Macmillan Publishers Limited

canteen use was similar for both school types. This could be explained by a supplementary screen time during lunchtime: children going home for lunch have the opportunity to watch TV, or to use a computer, contrary to children staying at school for lunch. This suggested that school lunch attendance can have an indirect role on lifestyle habits, through the definition of constraint on school day organisation. Television viewing was associated with higher consumption of commonly advertised foods (soft drinks, sweets and snacks) and lower consumption of fruit and vegetables43–45 while sedentary behaviour has been linked to overweight.46,47 By reducing screen time, school lunch attendance may therefore contribute to limiting the development of unhealthy food habits and weight gain in children and adolescents.47 In conclusion, attending school canteen is associated with healthier eating habits and a lower screen sedentary level in France. These findings concerned children aged 3–17 years old. European Journal of Clinical Nutrition (2012) 1335 – 1341


1340 Table 4. Associations between school canteen (SC) attendance and sedentary behaviour, after adjustment on age, gender and socio-economic variables (ORa, (CI95%)) in schoolchildren from the INCA2 sample Preschool and elementary school children SC user Computer screen (min/day) (s.e.) n 27 (2) P-value 0.85 TV screen (min/day) (s.e.) n 98 (4) P-value 0.009


SC non-user

ORaa

SC user

SC non-user

ORaa

28 (3)

605 0.998 (0.993–1.004) 0.57

77 (4) 0.04

95 (7)

798 0.997 (0.995–0.999) 0.03

127 (10)

605 0.997 (0.995–0.999) 0.02

123 (5) 0.03

144 (8)

798 0.999 (0.997–1.001) 0.33

605 0.997 (0.996–0.999) 0.02

201 (6) 0.002

239 (11)

798 0.999 (0.998–0.999) 0.03

Sedentarity (total screen) (min/day) (s.e.) n 125 (5) 155 (11) P-value 0.01

Abbreviation: ORa, odds ratio adjusted. aOR adjusted on age, sex and socio-economic variables.

Table 5.

Multivariate-adjusted odds ratios (ORa, (CI95%)) for school canteen attendance in schoolchildren from the INCA2 sample Preschool and elementary school children ORaa


ORab (n ¼ 550)

ORaa

ORab (n ¼ 677)

Meal skipping pattern, % (CI95%) n 550 T1 1.00 T2 0.70 (0.41–1.18) T3 0.62 (0.35–1.09) P-value 0.09c

1.00 0.61 (0.35–1.08) 0.57 (0.31–1.04) 0.06c

678 1.00 0.78 (0.43–1.43) 0.49 (0.29–0.83) 0.007c

1.00 0.79 (0.44–1.43) 0.52 (0.31–0.88) 0.01c

Snacking pattern, % (CI95%) n T1 T2 0.93 T3 0.62 P-value

1.00 0.77 (0.42–1.40) 0.48 (0.26–0.89) 0.03c

683 1.00 1.41 (0.79–2.49) 0.93 (0.51–1.71) 0.92c

550 1.00 (0.53–1.66) (0.35–1.10) 0.10c

Computer screen (min/day) (s.e.) n 605 0.998 (0.993–1.004) P-value 0.57 TV screen (min/day) (s.e.) n P-value

605 0.997 (0.995–0.999) 0.02

798 0.997 (0.995–0.999) 0.03

0.997 (0.995–0.999) 0.02

0.997 (0.995–1.000) 0.07

798 0.999 (0.997–1.001) 0.33

Abbreviation: CI, confidence interval. aOR adjusted on age, sex and socio-economic variables. bMulti-adjusted OR on the variables selected by the backward step-by-step logistic regression procedure, after adjustment on age, sex and socio-economic variables. cP-value for trend.

However, we cannot conclude whether school lunch attendance leads per se to healthier habits or whether it is just part of an overall eating and sedentary pattern. Nevertheless, our results indicated that the new compulsory measures on school meal composition will mainly affect children with already healthier behaviour. From a public health point of view, this could be considered as not very efficient, unless a way is found to improve school lunch attendance of children with suboptimal lifestyle habits.

CONFLICT OF INTEREST The authors declare no conflict of interest.

European Journal of Clinical Nutrition (2012) 1335 – 1341

ACKNOWLEDGEMENTS INCA2 was supported by a grant from the French Food Safety Agency (AFSSA), now ANSES.

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