Evaluation of the New York City Breakfast in the Classroom Program

Abstract

Objectives. We determined the impact of Breakfast in the Classroom (BIC) on the percentage of children going without morning food, number of locations where food was consumed, and estimated calories consumed per child.

Methods. We used a cross-sectional survey of morning food consumed among elementary school students offered BIC and not offered BIC in geographically matched high-poverty-neighborhood elementary schools.

Results. Students offered BIC (n = 1044) were less likely to report not eating in the morning (8.7%) than were students not offered BIC (n = 1245; 15.0%) and were more likely to report eating in 2 or more locations during the morning (51.1% vs 30%). Overall, students offered BIC reported consuming an estimated 95 more calories per morning than did students not offered BIC.

Conclusions. For every student for whom BIC resolved the problem of starting school with nothing to eat, more than 3 students ate in more than 1 location. Offering BIC reduced the percentage of students not eating in the morning but may contribute to excess calorie intake. More evaluation of BIC’s impact on overweight and obesity is needed before more widespread implementation.

Food insecurity and obesity are both serious concerns in urban, low-income communities,¹ particularly for children. Food insecurity occurs “whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain.”² According to the US Department of Agriculture, in 2010, 11.3% of US children lived in households with food insecurity (reporting mainly reductions in quality and variety of children’s meals), and 1.3% were affected by very low food security (termed “food security with hunger” before 2006).³

Obesity is a major public health problem among children nationally^4,5 and in New York City (NYC).⁶ Nearly 21% of public school students aged 5 to 14 years are obese.⁶ Obesity levels are higher among low-income children who qualify for free school meals (23.4%) than among those who do not (18.9%).⁷ Paradoxically, obesity often occurs among children with food insecurity. Therefore, any effort to address food insecurity should also address obesity.

On any given day, between 12% and 34% of children and adolescents report skipping breakfast.⁸ Eating breakfast may improve short-term memory and academic performance, particularly in undernourished children.⁸ The national school breakfast program was established in 1966 and permanently authorized in 1975 to provide for students in need of adequate nutrition in the morning.⁹ Through local departments of education, the school breakfast program provides meals to youths living below 130% of the federal poverty level.⁹ However, breakfast consumption among youths has declined since 1965.¹⁰ In NYC, more than 70% of public school students qualify for free or reduced-price meals. The NYC Department of Education serves more than 800 000 meals each day, using rigorous guidelines initiated in 2005,¹¹ and has introduced initiatives to increase participation in school meals, such as providing universal free breakfast in the cafeteria to all students, regardless of family income and, more recently, providing breakfast in the classroom (BIC) in some schools.

BIC is a program intended to serve those who do not or are unable to take advantage of before-school breakfast in the cafeteria. BIC was piloted in selected public school classrooms in NYC at the discretion of school principals starting in January 2008. In the 2009–2010 school year, a number of elementary schools in low-income NYC neighborhoods initiated BIC, consisting of 4-item breakfasts delivered to classrooms and offered to students by their teacher. Breakfast items included milk, cereal, fruit or 100% fruit juice, and 1 additional item, such as carrot bread or string cheese. By January 2010, approximately 19% of approximately 1500 NYC schools served BIC in some or all classrooms.

Given the coexisting problems of food insecurity and obesity, our goal was to determine the impact of BIC on the potential to both reduce breakfast skipping and increase calorie consumption. Specifically, we evaluated whether BIC was associated with any of the following changes in children’s morning food consumption: percentage who did not eat, eating locations, and estimated calories consumed.

METHODS

We conducted a cross-sectional survey of third-, fourth-, and fifth-grade students attending schools in the high-need NYC neighborhoods of East and Central Harlem, North and Central Brooklyn, and the South Bronx between January and March 2010. Nine schools conducting BIC in some or all of their classrooms and 7 matched schools without BIC were selected and agreed to participate in the evaluation. Matching occurred geographically (e.g., Manhattan BIC schools with Manhattan comparison schools) and, where possible, demographically (i.e., by grade and racial/ethnic composition of enrolled students). Each principal determined school participation; all students in each participating classroom were surveyed. Schools with BIC were limited, so we included all schools that agreed to participate in the study; we randomly selected matching schools and classrooms from willing, similar, geographically matched schools. In BIC schools, we included in the evaluation only classrooms offering BIC. Both BIC and comparison schools offered free breakfast every school day to all students; in comparison schools, free breakfast was offered only in the school cafeteria.

Questionnaire

Students completed a brief, paper-based questionnaire in the first 30 minutes of the school day to ascertain food consumption that morning. We developed the questionnaire after a review of the literature, consultation with other researchers, and review of instruments such as the NYC Youth Risk Behavior Survey¹² and those used for the Child and Adolescent Trial for Cardiovascular Health.^13–15

Students were asked their gender and whether they ate at any of 4 locations: home, bodega or restaurant, school cafeteria, or classroom. Students were not asked their race/ethnicity because of the sensitivity and complexity of the question. For each location, students were asked to use a pick-list to indicate all foods eaten. Food items included general categories typically used on food frequency questionnaires such as the Block Food Frequency Questionnaire,¹⁶ modified to reflect potential responses from children in this community. For example, for home, respondents were asked, “Did you eat or drink anything you got from home today?” Responses were captured with the question “If yes, what did you eat? Please circle all that apply” (see Figure A, available as a supplement to the online version of this article at http://www.ajph.org, for a list of foods). The instrument was tested and developed with input from students and piloted with students in Philadelphia, Pennsylvania, as part of a study conducted by Temple University.¹⁷

Questionnaire Administration

The survey was conducted with passive parental consent. Before survey distribution, consent forms were sent home with a study description, advising parents they could opt their child out of participation by signing an enclosed form and sending it to school with their child.

On the day of the survey, trained survey administrators entered the classroom during the first period of class, introduced themselves, provided a brief overview of the survey, explained that all responses were to be for where and what they ate that morning only, and distributed the survey. Each child whose parents had passively consented was given a survey. The survey administrator read through the survey questions and the response categories and provided time for students to complete their surveys. After all students completed the survey, the survey administrator collected all of the surveys and refusals into an envelope, thanked the participants, and distributed incentives (pencils with colorful erasers). Survey administration lasted about 15 minutes.

Calorie Determination

We estimated caloric values for foods listed on the questionnaire using nutritional information from the NYC Department of Education,¹⁸ the US Department of Agriculture’s National Nutrient Database for Standard Reference,¹⁹ and an online calorie database (Livestrong.com²⁰; see Table A, available as a supplement to the online version of this article at http://www.ajph.org). In addition, we visited bodegas near BIC and comparison schools, asked employees what items school-aged children frequently purchased, purchased these items, and recorded calories from their nutritional packaging information. The lowest and highest plausible values for each food were assigned using the lowest and highest calorie values found in nutrition databases or from packaging information among different foods representing each category. Calorie values within this range were assigned for typical items. For example, for the food questionnaire item “Donut, biscuit, pastry, cake, pie, muffin,” we used 180 calories (the calories in a reduced-fat blueberry muffin listed on the NYC Department of Education Web site) for the lowest plausible value, 600 calories (the calories in a 4-oz raspberry cream cheesecake available for sale in a store near 1 of the study schools) for the highest plausible value, and 220 calories (the calories in a cinnamon biscuit listed on the NYC Department of Education Web site) for calories in a typical item. For items with a potentially large calorie difference between foods served in school and those available elsewhere (because foods served at school have to meet NYC agency nutritional guidelines),¹¹ we limited the upper end of the plausible range when obtained at school (but not when obtained from home or a bodega) to the highest calorie food for that category listed on the NYC Department of Education Web site. For example, the highest plausible value for “Donut, biscuit, pastry, cake, pie, muffin” was limited to 220 calories when consumed in the cafeteria or classroom but allowed to range up to 600 calories when consumed at home or from a bodega. Similarly, because hot foods would not usually be served for BIC, the upper plausible calorie limit for cereal served in the classroom was limited to the highest calorie cold cereal listed on the NYC Department of Education Web site (Raisin Bran, 130 cal), whereas the upper limit for cereal served in the cafeteria or elsewhere was the highest-calorie cereal found in the nutrition databases (Farina, a hot cereal listed on the NYC Department of Education Web site, 412 cal).

Data Analysis

Because the primary purpose of this study was to address the policy question of whether breakfast should be offered to all children in classrooms, the primary analyses compared children in BIC classrooms with children in comparison classrooms, regardless of whether they actually ate BIC; that is, these analyses were intention-to-treat analyses. We compared the percentage who ate from each location or each food item by BIC status and tested differences by using the Pearson χ² test. To estimate the difference in calories among students in BIC and comparison schools, we calculated overall morning calorie intake for each student using the base-case estimated values for typical calorie content of individual food items and then compared the estimated mean caloric intake for BIC and comparison students. In sensitivity analyses, we used the lowest and highest plausible values for energy content of different food items from the calorie determination and assessed the impact of the varying energy content of each item on the difference in estimated average calorie intake among students in BIC versus comparison classrooms. We performed secondary comparative analyses for students within BIC classrooms, comparing those who ate BIC with those who did not for number of items, locations where they received food, and total calories consumed. We calculated summary descriptive statistics for survey responses using SAS version 9.2 (SAS Institute, Cary, NC). We conducted calorie estimate analyses using SPSS version 19 (IBM, Armonk, NY).

RESULTS

We surveyed a total of 2289 students (1044 in 57 BIC classrooms and 1245 in 67 comparison classrooms); 52 (2%) refused participation. Overall, 52% of participants were girls; we noted no significant gender differences between BIC and comparison classrooms (Table 1). We found significantly more third graders (37% vs 29%; P < .001) and significantly fewer fifth graders (29% vs 35%; P < .01) in BIC versus comparison classrooms. BIC students were less likely to attend school in Brooklyn; other differences by borough were not significant.

TABLE 1—

Demographics of Students From Breakfast in Classroom (BIC) and Comparison Classrooms: New York City, January–March 2010

Characteristic	BIC (n = 1044), No. (%)	Comparison (n= 1245), No. (%)a	P
Gender
Male	510 (49)	580 (47)	.28
Female	525 (50)	657 (53)	.24
Missing	9 (1)	8 (1)	.54
Grade
Third	385 (37)	363 (29)	<.001
Fourth	357 (34)	443 (36)	.49
Fifth	302 (29)	439 (35)	<.01
Borough
Bronx	213 (20)	237 (19)	.41
Brooklyn	230 (22)	337 (27)	<.01
Manhattan	601 (58)	671 (54)	.08

^aPercentages do not total 100 because of rounding.

Food Item Analysis

Overall, students in BIC classrooms were less likely than students in comparison classrooms to report eating nothing in the morning (8.7% vs 15.0%; P < .001; Table 2). Students in BIC classrooms were also more likely to eat from multiple locations (51.1% vs 30.0% ate at ≥ 2 locations; P < .001). Although students in comparison classrooms most frequently ate at home (69.7%), students in BIC classrooms most frequently ate in the classroom (66.6%) and were less likely to eat at home (59.9% vs 69.7%; P < .001) or in the school cafeteria (14.1% vs 26.9%; P < .001). Percentages of students eating at bodegas, however, were similar (20% for each). Overall, 228 students offered BIC (21.8%) ate only in the classroom in the morning; 349 (33.4%) did not eat in the classroom, and for 467 (44.7%), BIC was, at a minimum, a second source of morning food (data not shown).

TABLE 2—

Percentage of Students Who Ate at Each Location among Breakfast in Classroom (BIC) and Comparison Groups: New York City, January–March 2010

Variable	BIC (n = 1044), No. (%)	Comparison (n = 1245), No. (%)	Pa
Home	625 (59.9)	868 (69.7)	<.001
Bodega	205 (19.6)	253 (20.3)	.68
Cafeteria	147 (14.1)	335 (26.9)	<.001
Classroom	695 (66.6)	75 (6.0)	<.001
School (overall)	740 (70.9)	385 (30.9)	<.001
Didn’t eat	91 (8.7)	187 (15.0)	<.001
≥ 2 locations	533 (51.1)	373 (30.0)	<.001

^aFor difference in percentage eating in location, BIC vs comparison classrooms.

For students in both BIC classrooms and comparison classrooms, the average number of items eaten increased with the number of locations in which children ate (Table 3). Whereas children who reported eating at 1 location reported eating 2.4 items, those who ate at 2 or more locations reported eating more than twice as many items (5.3 items). Those who ate at all 4 possible locations ate 10.8 items. Within BIC schools, those who ate BIC averaged 4.5 food items per child, whereas those who ate something but not BIC averaged 3.1 food items.

TABLE 3—

Number of Eating Locations and Average Number of Items Eaten: New York City; January–March 2010

No. of Eating Locations	Items per Child, Mean	BIC (n = 1044), No. (%)	Comparison (n = 1245), No. (%)	Pa
0	0	91 (8.7)	187 (15.0)	<.001
1	2.4	420 (40.2)	685 (55.0)	<.001
2	4.3	380 (36.4)	287 (23.1)	<.001
3	7.3	120 (11.5)	72 (5.8)	<.001
4	10.8	33 (3.2)	14 (1.1)	<.01
≥ 2	5.3	533 (51.1)	373 (30.0)	<.001

Note. BIC = Breakfast in Classroom.

^aFor difference in percentage eating in number of eating locations, BIC vs comparison classrooms.

We found some differences in foods consumed by students in BIC classrooms compared with comparison classrooms (Table 4). Students offered BIC were much more likely than other students to consume cereal (60.1% vs 34.2%), milk (54.3% vs 32.0%), or juice (48.7% vs 21.2%; P < .001 for each), all staple foods of BIC. In BIC classrooms, nearly 5% more students reported eating bread, whereas 5% to 6% fewer students ate eggs or meat. Consumption of fruits or vegetables in the morning was similar among students in BIC and comparison classrooms (17.3% vs 15.1%). We also found no difference between the 2 groups in the percentage of students eating candy, doughnuts, or chips; similar percentages (17.1% vs 18.1%) reported eating at least 1 of these items, with similar patterns for home and bodega consumption. We also found no difference in the percentage of students consuming sugary drinks.

TABLE 4—

Consumption of Food Items by BIC and Comparison Groups: New York City; January–March 2010

Food Item	BIC (n = 1044), No. (%)	Comparison (n = 1245), No. (%)	Pa
Cereal	627 (60.1)	426 (34.2)	<.001
Breadb	288 (27.6)	282 (22.7)	<.01
Wafflec	122 (11.7)	237 (19.0)	<.001
Doughnutd	81 (7.8)	120 (9.6)	.11
Chips	71 (6.8)	81 (6.5)	.78
Milke	567 (54.3)	399 (32.0)	<.001
Eggs	163 (15.6)	252 (20.2)	<.01
Meat	164 (15.7)	276 (22.2)	<.001
Fruit	173 (16.6)	178 (14.3)	.13
Vegetable	23 (2.2)	34 (2.7)	.42
Juice	508 (48.7)	264 (21.2)	<.001
SSBf	148 (14.2)	199 (16.0)	.23
Candy	83 (8.0)	81 (6.5)	.18
Coffee/Tea	107 (10.2)	121 (9.7)	.67
Water	244 (23.4)	291 (23.4)	≥.99

Note. BIC = Breakfast in Classroom; SSB = sugar sweetened beverage.

^aPercentage BIC vs comparison schools.

^bIncludes toast, roll, bagel, and English muffin.

^cIncludes waffles, French toast, and pancakes.

^dIncludes doughnut, biscuit, pastry, cake, pie, and muffin.

^eIncludes milk, yogurt, and cheese.

^fSoda, lemonade, Capri Sun, Sunny D, Quarter Water, etc.

Calorie Analysis

In the base-case analysis, students offered BIC consumed an estimated average of 95 calories more than students in comparison schools during the morning (371 vs 276 kcal; P < .001). In sensitivity analyses, the finding that students offered BIC had greater estimated morning calorie intake than did comparison students was robust across the range of plausible values for calorie content of different foods in different settings. Estimated additional calorie intake among students offered BIC ranged from 65 to 112 calories (Figure B, available as a supplement to the online version of this article at http://www.ajph.org). For example, estimated additional calorie intake among BIC students increased with estimated increases in calories from classroom-provided cereal, from 65 additional calories (if cereal in the classroom was 60 cal) to 95 additional kilocalories (if cereal in the classroom was 130 cal). Conversely, estimated additional calorie intake among BIC students decreased with estimated increases in calories from outside-of-classroom cereal, from 99 additional calories (if cereal outside the classroom was 60 cal) to 77 additional kilocalories (if cereal outside the classroom was 412 cal). When students were stratified by grade level, students offered BIC consumed more calories than did students in comparison schools at each grade level (data not shown). Among students offered BIC, those actually eating BIC averaged 447 estimated morning calories, 151 more calories than students eating only in other locations, who averaged 296 estimated morning calories.

DISCUSSION

BIC was developed, in large part, to ensure that students who could not or did not take advantage of cafeteria breakfast had an additional opportunity to obtain sufficient nourishment. It attempts to prevent students from starting the school day without anything to eat by making food available to all children during the first class of the day. However, offering BIC in addition to universal free cafeteria breakfast by making food available to all children in the classroom setting also has the potential unintended consequence of increasing calorie consumption among children who have already eaten breakfast—at home, in a neighborhood bodega, in the school cafeteria, or in all of these locations. We found that offering BIC did appear to reduce the percentage of children who reported eating nothing in the morning by about 6%, although more than 8% of students offered BIC still reported not eating from any source in the morning. It is possible that no intervention will successfully increase breakfast consumption among children to 100%; reasons commonly given by children for skipping breakfast include lack of time, lack of hunger, and dieting to lose weight.⁸ BIC addresses only the first of these. Students offered BIC were more likely to eat more than once in the morning and, on average, ate an estimated 95 additional calories each morning. Among those offered BIC, those eating in the classroom consumed an estimated 151 more morning calories than did those who ate only in other locations. Thus, it appears that a modicum of success in reducing breakfast skipping may be achieved at the cost of increasing caloric consumption, which could contribute to the epidemic of overweight and obesity among children.

BIC could potentially improve the quality of children’s morning food intake and replace unhealthy snacks with foods that are likely to be missing from the diets of food-insecure children, such as fruits and vegetables. We found no apparent impact on consumption of items such as candy, doughnuts, and chips before children arrived at school or consumption of fruits and vegetables. Among students offered BIC, classrooms became the most common place for students to eat in the morning, apparently replacing some eating at home and in the school cafeteria, yet the percentage of students eating foods purchased at bodegas was the same in BIC and comparison classrooms.

The few published studies on BIC program nutritional outcomes are consistent with ours, suggesting that BIC does increase calorie intake, potentially beyond recommended levels. In a comparison of in-school options, in-classroom breakfast was associated with significantly greater calorie intake than cafeteria breakfast.²¹ In the School Breakfast Pilot Program, students who had breakfast available to them in the classroom were more likely to eat 2 or more breakfasts per day and had higher breakfast intakes of grain servings, food energy, total fat, and sodium than did students who had breakfast available to them in the cafeteria.²² In addition, students in the School Breakfast Pilot Program who ate 2 or more breakfasts per day in any location consumed more calories over 24 hours than did students who ate 1 breakfast (122% vs 101% of the recommended dietary allowance).²² This latter finding is particularly important because our study was limited to morning calorie intake and did not evaluate whether eating more in the morning was offset by eating less later in the day.

Given concerns about breakfast skipping and BIC’s success at reaching large numbers of children, the concept of BIC is not likely to be abandoned in the near future. BIC has been endorsed by many organizations, including the US Department of Agriculture,²³ and mandated (Chicago, IL; Washington, DC) or promoted (e.g., Dallas and Houston, TX; Newark, NJ; Prince George's County, MD) in several municipalities.^24–30 However, before considering large-scale expansion, it deserves additional evaluation to determine how offering BIC modifies overall daily caloric consumption over time (i.e., Do parents and students come to depend on it as the only source of breakfast over time? Do students consume more calories than they otherwise would? Do students eating it tend to gain more weight than those not eating it?). It is also possible that modifications could reduce any potential problems BIC may introduce. For example, low-calorie-density foods, such as whole fruit, that are likely to improve children’s nutrition could be offered to address food insecurity without exacerbating obesity and its associated health problems.

Strengths and Limitations

This study has several strengths. It was performed in classrooms in 3 of NYC’s high-need neighborhoods with high obesity levels, and it included sufficient numbers of BIC and comparison students to detect differences of less than 5% in the percentage of those eating in the morning. In addition, the survey was administered shortly after the start of the school day, minimizing potential recall problems. Finally, we examined BIC as a policy, evaluating average impact on all children offered breakfast in BIC classrooms rather than just examining food and calorie intake in those children who accepted classroom breakfast.

This study also has some important limitations. First, it was an observational study comparing students in classrooms in different schools, assuming they would be similar in the absence of BIC. Our comparison of students based on BIC status may have overestimated the significance of observed differences given correlation among students in the same classrooms and schools. Second, children’s self-report of items eaten in 1 day might not represent usual breakfast consumption. Third, BIC was a relatively new program. It is possible that, over time, students may decrease eating in other locations as they become accustomed to receiving BIC. Fourth, calories consumed in our study are estimates, assuming children ate a standard portion of any given item. We did not observe actual food intake. We compensated for this, in part, by establishing ranges of calories for foods and conducting sensitivity analyses using these ranges. Under different assumptions, children in BIC classrooms still consumed substantially more calories. Fifth, we limited our study to morning food intake. It is possible that BIC may be associated with less eating later in the day. Sixth, calorie content of food served in NYC classrooms was limited because of NYC agency nutrition guidelines. In jurisdictions without similar nutrition standards, breakfasts with higher calorie content may be served in classrooms, and calories added to children’s diets through BIC may be greater. For example, 1 provider of foods packaged specifically for BIC offers a breakfast package including Frosted Flakes with milk, an item such as Mini Animal Grahams, and juice.³¹ With 11 grams of sugars,³² Frosted Flakes does not meet NYC’s standard that cereals contain less than 10 grams of sugar.³³ Finally, this study was limited to urban elementary schools in low-income NYC neighborhoods. It is possible that morning food consumption patterns in these schools may be different than those in other communities and that older children exhibit different eating behaviors.

Conclusions and Summary

Because studies suggest breakfast consumption may improve memory and school performance, particularly among undernourished children,⁸ all children should have the opportunity to eat 1 healthy meal before the start of the school day. However, municipalities should be careful not to exacerbate one problem while attempting to solve another. In low-income NYC neighborhoods with high obesity rates, BIC appeared to achieve some success in reducing the percentage of children going without food in the morning. For every student who ate and otherwise would not have, however, 3 other students ate in 2 or more locations. Given that BIC may be contributing to excess calories, increasing the risk for obesity, it is essential that further evaluation be done before adopting it more widely.