Background: Health literacy and food perceptions influence health knowledge, behaviors, and subsequent health status. Improving health literacy and modifying food perceptions through social marketing nutrition messaging may prove beneficial, particularly in youth. Presently, schools are sending youth mixed messages. Healthful eating behaviors are taught and promoted in the classroom, but not modeled in the school nutrition environment; items sold in competitive food venues (i.e. vending, ala carte, school stores) are typically energy dense, nutrient poor. Thus, the purpose of this study was to improve student health literacy and food perceptions through social marketing nutrition messaging and improving the quality and composition of items offered in competitive food venues.

Methods: Students completed health literacy (N=255) and food perception assessments (N=253) in fall 2008 and spring 2010. The Newest Vital Sign assessment includes questions about a Nutrition Facts Panel and categorizes individuals into three health literacy categories. The food perceptions assessment consisted of an unstructured line (0-15 cm) gathering students' perceptions on six items typically sold in vending machines, ala carte, and school stores relative to six food attributes (expensive, tastes good, healthy, boosts energy, improves mental performance and improves physical performance). All competitive food venues available to students were inventoried at baseline and endpoint. Intervention schools (n=3) were provided social marketing nutrition messages over the course of the study in addition to training and technical assistance. They were also required to make three changes relative to competitive foods. Each school's Local Wellness Policy was gathered and scored at baseline and endpoint relative to competitive foods guidelines.

Results: Few changes were seen from the intervention, indicating health literacy, food perceptions and competitive foods are difficult to change. Taste was identified as a potent motivator in student food selection, while nutrition was a low motivator. Local Wellness Policies did not change over the course of the study and did not reveal any significant relationships with the data. Lastly, gender appears to play an important role in food perceptions.

Conclusions: Foodservice directors should focus on taste in marketing `healthy' items to adolescents and less on nutrition. Free taste-testing of `healthy' items in the cafeteria will likely influence students' perception and is encouraged. A focus for competitive food venues should be incorporating novel, `healthy' options rather than solely focusing on removing `unhealthy' items. School nutrition professionals should also consider gender differences to create more effective gender-specific marketing of nutrition programs. Finally, school foodservice directors have an important role to ensure their school's nutrition guidelines are rigorous and adequately implemented.