title: A repeat cross-sectional study examining the equitable impact of nutritional standards for school lunches in England in 2008 on the diets of 4-7y olds across the socio-economic spectrum.
abstract: BACKGROUND
  The 2008 nutritional standards for primary school lunch in England improved nutritional content. The impact on socio-economic inequalities is unknown. We examine the impact of the nutritional standards on children's nutrient intake at lunchtime and in total diet by level of deprivation.
  
  
  METHODS
  We conducted cross-sectional studies in 12 English primary schools before and after legislation. Dietary intake was recorded for 4-7y olds using a validated, prospective four-day food diary. Socio-economic status was estimated using the Index of Multiple Deprivation; three groups of approximately equal sizes were created. Linear, mixed-effect models explored the effect of year, lunch type (school or home-packed lunch), level of deprivation and the interaction(s) between these factors on children's diets.
  
  
  RESULTS
  368 and 624 children participated in 2003-4 and 2008-9 respectively. At lunchtime, between 2003-4 and 2008-9, the increase in non-starch polysaccharide (NSP) intake was larger in the least compared to the most deprived group (difference in mean change 0.8 mg; 95% CI 0.4, 1.3). There were similar differences in mean changes for iron (0.3 mg; 0.2, 0.4) and zinc (0.3 mg; 0.1, 0.5). In total diet, differential effects were observed for NSP, iron and zinc; we found no evidence these changes were associated with lunch type. Lunch type was associated with changes in per cent energy from non-milk-extrinsic sugars (NMES) and vitamin C. Per cent energy from NMES was lower and vitamin C intake higher in school lunches in 2008-9 compared with 2003-4. The corresponding differences in home-packed lunches were not as marked and there were subtle but statistically significant effects of the level of deprivation.
  
  
  CONCLUSIONS
  By 2008-9, NMES at lunchtime and in total diet was lower for children consuming a school lunch; this change was equitable across the deprivation groups. Vitamin C intake increased more for children in the most deprived group, narrowing the socio-economic inequality. A range of significant differential effects of the nutritional standards were observed and important socio-economic inequalities in dietary intake remain. Additional interventions to promote equitable nutrition in children are needed to support legislative measures and maximise their impact.
authors.affiliation: Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. suzanne.spence@ncl.ac.uk.|Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK. suzanne.spence@ncl.ac.uk.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Spence
authors.affiliation: School of Mathematics and Statistics, Newcastle University, Newcastle upon Tyne, UK. john.matthews@ncl.ac.uk.
authors.forename: John N S
authors.initials: JN
authors.lastname: Matthews
authors.affiliation: Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. martin.white@ncl.ac.uk.|Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK. martin.white@ncl.ac.uk.|Fuse, UKCRC Centre for Translational Research in Public Health, Newcastle upon Tyne, UK. martin.white@ncl.ac.uk.
authors.forename: Martin
authors.initials: M
authors.lastname: White
authors.affiliation: Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. ashley.adamson@ncl.ac.uk.|Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK. ashley.adamson@ncl.ac.uk.|Fuse, UKCRC Centre for Translational Research in Public Health, Newcastle upon Tyne, UK. ashley.adamson@ncl.ac.uk.
authors.forename: Ashley J
authors.initials: AJ
authors.lastname: Adamson
mesh_terms: D001205:Ascorbic Acid / Q000008:administration & dosage / Q000032:analysis; D002241:Carbohydrates / Q000008:administration & dosage / Q000032:analysis; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D015930:Diet Records; D004043:Dietary Fiber / Q000008:administration & dosage / Q000032:analysis; D005260:Female; D005522:Food Services / Q000592:standards*; D006801:Humans; D019266:Iron, Dietary / Q000008:administration & dosage / Q000032:analysis; D062409:Lunch; D008297:Male; D018673:Nutrition Policy / Q000331:legislation & jurisprudence*; D009752:Nutritional Status; D012574:Schools; D012959:Socioeconomic Factors; D006113:United Kingdom; D015032:Zinc / Q000008:administration & dosage / Q000032:analysis
chemical_list: D002241:Carbohydrates; D004043:Dietary Fiber; D019266:Iron, Dietary; D015032:Zinc; D001205:Ascorbic Acid