Background: Schools can play a major role in prevention and intervention for childhood obesity. We describe changes in elementary school cafeteria lunch sales patterns resulting from nutritional improvements in menu offerings that were part of a community-wide focus on health. Methods: Elementary school lunch sales data were collected for 1 week in each of 7 years in a district serving a predominantly poor, rural, and Caucasian student population, with high rates of obesity. "Post hoc" data analyses described lunch sales patterns and related food service costs over the project years. Results: The percentage of high calorie/low nutrition foods sold decreased from 22% of all sales in 2005 to 0% in 2011. High-calorie snack purchases decreased from 535 items to 0 items. The sale of fresh fruits increased by 12%. There was only a slight decline in the percentage of children who purchased cafeteria lunches over the years and a 15.2% cost increase for purchasing healthier food supplies. Conclusions: Elementary school children purchased healthier lunches when healthier menu items were offered and when less healthy foods were eliminated from the menu. There was no significant decline in the number of students who purchased lunches as nutritional improvements were made.