5
Recommended Standards and Actions for Competitive Foods in Schools

INTRODUCTION

This chapter presents the committee’s recommended nutrition standards for competitive foods and beverages in schools. As will be discussed in detail below, the committee’s recommendations depend on the interactions of a number of important factors that describe competitive foods, including

  • types of foods;

  • nutrient content of foods and beverages;

  • type of schools to which a given standard applies (elementary, middle, or high);

  • time of day that a standard applies (school day, after school); and

  • competitive food and beverage venues in the school (including use of à la carte versus other sales locations).

To make it possible to develop recommendations in the context of this complexity, it is important to set up a clear framework for presenting detailed recommendations. First, two key underlying working principles on which the committee’s recommendations are premised are presented below. Next, a brief overview of the overall approach to the standards is discussed. This overview provides a useful context within which subsequent, more detailed material is presented and interpreted. Finally, a set of working definitions that are important in defining standards are developed, followed by the recommended standards.



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5 Recommended Standards and Actions for Competitive Foods in Schools INTRODUCTION This chapter presents the committee’s recommended nutrition standards for competitive foods and beverages in schools. As will be discussed in de- tail below, the committee’s recommendations depend on the interactions of a number of important factors that describe competitive foods, including • types of foods; • nutrient content of foods and beverages; • type of schools to which a given standard applies (elementary, middle, or high); • time of day that a standard applies (school day, after school); and • competitive food and beverage venues in the school (including use of à la carte versus other sales locations). To make it possible to develop recommendations in the context of this complexity, it is important to set up a clear framework for presenting de- tailed recommendations. First, two key underlying working principles on which the committee’s recommendations are premised are presented below. Next, a brief overview of the overall approach to the standards is discussed. This overview provides a useful context within which subsequent, more detailed material is presented and interpreted. Finally, a set of working definitions that are important in defining standards are developed, followed by the recommended standards. 

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 NUTRITION STANDARDS FOR FOODS IN SCHOOLS Two Key Premises To understand the committee’s proposed nutrition standards for com- petitive foods, it is useful to highlight 2 of the 10 Guiding Principles defined in Chapter 1 because they particularly direct the committee’s recommen- dations. These key premises, within the context of the Guiding Principles as a whole, are the necessity of using standards based on individual foods rather than the whole diet (Guiding Principle 8), and identification of the Dietary Guidelines for Americans (DGA) as the primary source informing the committee’s recommendations on specific food components (Guiding Principle 9). The Necessity of Using Food-Based Standards As noted in Guiding Principle 8, nutrient standards for competitive foods and beverages must be food based, rather than based on overall di- etary intake (diet based). This is in contrast to the context of other nutrition policies (e.g., the DGA), in which diet-based standards are the approach of choice. When feasible, a diet-based standard is preferred because this approach recognizes that an individual’s health is influenced by the over- all pattern of foods consumed, rather than just on individual foods and beverages. However, unlike the federally reimbursable school nutrition programs, which have some flexibility in meeting intake requirements over time, competitive foods are usually offered and purchased individually without taking into account other daily intake. In this context, each food and beverage must be regarded separately; thus the committee’s recommenda- tions set standards for the indiidual foods and beverages. Furthermore, the standards assure that each snack, food, and beverage item offered separately from the federally reimbursable school nutrition programs is consistent with the dietary pattern and specific nutrient recommendations of the DGA, and the committee’s rationale for its application of the DGA is explained in the relevant sections of the text. The recommended nutrition standards are based on the assumption that meals are the primary nutrient and calorie source for children for the day. Competitive foods are offered as discretionary calories. Reliance on the 00 Dietary Guidelines As noted in Guiding Principle 9, the majority of recommendations are derived from the summary volume of the DGA (DHHS/USDA, 2005). The committee identified the DGA as the primary resource for formulating

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS its recommendations because they provide the most current guidance for achieving a healthful diet for Americans over the age of 2 years. Although the scope of the DGA is quite broad, it does not cover all areas of importance to the committee’s work on nutrition standards for schools—for example, it lacks recommendations concerning caffeine and nonnutritive sweeteners. Accordingly, the committee supplemented infor- mation from the DGA with reviews of original literature and other relevant sources, including the U.S. Government Accountability Office Reports to Congress (GAO, 2003, 2004, 2005). The committee also sought compel- ling refutation of specific DGA guideline recommendations for school-age children; no such evidence was found. OVERVIEW OF APPROACH The following recommended nutrition standards have two major objec- tives. The first is to encourage the consumption of foods and beverages that are healthful for children, for example, fruits, vegetables, whole grains, and nonfat or low-fat dairy products. The second objective is to limit wherever possible, in all competitive foods and beverages offered at schools, food components that are not healthful when consumed in excess. Fats, sodium, added sugars, nonnutritive sweeteners, and caffeine were included. To achieve these parallel aims, three categories of competitive foods and beverages for school-age children were defined. Tier 1 foods and bever- ages are desirable to encourage; Tier 2 foods and beverages do not exceed an acceptable level of total, saturated, and trans fat; sugars; and sodium; and finally, the third category includes foods and beverages that do not meet the standards described in the DGA and are not allowed. Other approaches were also considered, such as a single tier rather than two, and including half servings of Tier 1 foods per portion as packaged. However, the com- mittee determined that the Tier system was preferable to achieve the goals of the Guiding Principles. The intended outcome of the committee’s recommendations is as follows: • Tier 1 foods may be offered throughout the school day at all school levels, if school administrators elect to make competitive foods and bever- ages available. • Tier 2 foods and beverages are available at limited times of the day at specified school levels. • All other competitive foods are not made available during the school day or at after-school activities for students. These competive foods may be offered at certain after-school acitivities, particularly on occasions

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0 NUTRITION STANDARDS FOR FOODS IN SCHOOLS such as school concerts or sporting events, when adults as well as students, are present. HIERARCHY OF FOODS To describe the standards, formal definitions of key concepts were de- veloped. These include specific definitions of the hierarchy of competitive foods and beverages. This hierarchy is called Tier 1 and Tier 2 to classify competitive foods and beverages by their compliance with DGA recom- mendations. The committee evaluated the nutrient content of food items to determine whether they conform to the nutrition standards in this report based on the recommendations of the DGA. Tier 1 Foods and Beverages Tier 1 foods and beverages provide important health benefits that war- rant encouraging consumption by school-age children, and do not exceed levels of certain nutrients and compounds that may be unhealthful for school-age children when consumed in excess. Types of Foods and Beerages Included in Tier  These food and beverage types listed as “foods to encourage” are derived from those with a similar definition described in the DGA (DHHS/ USDA, 2005): • Fruits and vegetables • 100-percent fruit and vegetable juices • Whole-grain products • Nonfat or low-fat dairy products Other foods and beverages are included as Tier 1: • Nuts and seeds (allowed as combination products as long as other nutrient standards are met; the fat content will not count against the total fat content of the product) • Entrée items included in the National School Lunch and School Program (NSLP) and School Breakfast Program (SBP) sold à la carte or entrée items comparable in portion size, calories, and nutritional value to NSLP/SBP entrées • Water

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS Fruits, vegetables, and whole grains Fruits, vegetables, and whole grains are Tier 1 foods because of the health benefits they provide. The DGA indicates that current evidence is sufficiently compelling to justify the use of a “Fruit, Vegetable, and Whole-Grain Focus” as a foundation for a healthful diet. Although the functions of individual nutrients, such as vita- mins and minerals, are well understood, many of the interactions between nutrients and other components found in whole foods are not, and remain to be elucidated. The following provide the foundation for the committee’s designation: • These foods are important sources of many of the nutrients iden- tified in Chapter 2 as those in which children’s diets tend to be deficient, including calcium, potassium, fiber, magnesium, and vitamin E. • Although the exact mechanisms are not fully understood, extensive epidemiological evidence shows that intake of generous amounts of these food groups is associated with reduced risk of chronic disease. • Fruits, vegetables, and whole grains are often lower-calorie alter- natives to foods and beverages also high in fats, sugar, and sodium. Thus, increased consumption of fruits, vegetables, and whole grains may be useful to achieve and manage a healthy weight. • Many 9- to 13-year-olds do not meet the DGA (DHHS/USDA, 2005) recommendations for fruit and vegetable consumption. For example, fewer than 4 percent of girls and about 1 percent of boys meet the recom- mendations; among older children, less than 1 percent of boys and 1.5 per- cent of girls ages 14 to 18 years meet current recommendations (Guenther et al., 2006). • The DGA (DHHS/USDA, 2005) recommends that half of daily grain consumption, or about three servings per day, be eaten as whole grains. A serving is defined as an ounce-equivalent, that is, a quantity of food containing 1 ounce of grain: one slice of bread, 1 ounce of dry cereal, or 1/2 cup of cooked rice, pasta, or cereal. Consumption of the equivalent of at least three 1-ounce servings of whole grains each day is recommended to help reduce the risk of several chronic diseases, and to help with weight maintenance. However, the average intake of whole grains is currently less than one serving per day, with less than 10 percent of all Americans con- suming three servings per day (Cleveland et al., 2000). To qualify as Tier 1 products, each item must contain at least one serv- ing of a fruit or vegetable, as defined by the U.S. Department of Agriculture (USDA) “MyPyramid” and/or one serving of whole grain, as discussed above. In the case of combination products, the product must contain an aggregate of at least one serving of qualifying ingredients (e.g., one-half

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 NUTRITION STANDARDS FOR FOODS IN SCHOOLS serving of fruit plus one-half serving of whole grain). A smaller portion size is acceptable for younger children as long as the constitution of the whole food component does not change. Tier 1 combination products can include additional ingredients that are consistent with the recommended nutrition standards. For example, a baked fruit bar containing one serving of fruit and made with refined white flour still qualifies as a Tier 1 food, based on its fruit content, although the use of whole grain would be even more desirable. The form of a food may affect its healthfulness. For example, it is likely that an apple eaten raw, with the peel on, may be more nutritionally beneficial than a highly processed apple juice. Components of Tier 1 prod- ucts should be kept as close to their natural state as can be achieved while maintaining palatability and affordability. Tier 1 foods consist of the following: • Fruits and vegetables offered as individual pieces (e.g., apples, pears, carrots) or as products as close as possible to their natural state (e.g., applesauce, dried fruit, diced pears). These products must meet all other nutrition standards as specified in the committee’s criteria. • Whole-grain products (e.g., bagels, crackers, whole-grain chips) provide at least one serving of whole grains per portion and meet all other nutrition standards in this report. • Combination products may take many different forms and must meet the following standards: —One portion of the product contains at least one serving of fruit, vegetable, or whole grain in any combination (e.g., ½ serving of fruit plus ½ serving of whole grain, or 2⁄3 serving of fruit and 1⁄3 serving of whole grain). —The number of servings (or fractions) of fruit and vegetable, and grams of whole grains in one portion, is clearly labeled or otherwise identifiable. —The product may contain ingredients in addition to the above quantities of fruits, vegetables, and whole grains (e.g., yogurt, cheese, re- fined grains, nuts and seeds), but must meet all other nutrition standards as recommended in this report. A special allowance is made for nuts and seeds when they occur in combination products. • Nonfat and low-fat yogurts may be offered, provided they contain no more than 30 grams of total sugars per 8-ounce serving (see “Added sugars information” below). Nuts and seeds The committee also supports the inclusion of nut and seed products in Tier 1, as long as the products meet other nutrition standards. In addition, the fat content of nuts and seeds will not count

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS against the total fat content of combination products. In particular, nuts and seeds, like fruits and vegetables, are whole foods (see Chapter 2) with complex nutrient structures. Although less research is available on the benefits of nuts and seeds, compared to fruits and vegetables, it is reasonable to accept that they may offer many of the same nutritional advantages noted for fruits and vegetables. Nuts are also specifically mentioned in the DGA as a source of beneficial fats for children (DHHS/USDA, 2005). Nuts and seeds are good sources of monounsaturated fatty acids (MUFAs) and polyunsaturated fatty acids (PUFAs), which are the types of fats that should make up most of the fat in the diet. Some PUFAs are essen- tial for health—the body cannot synthesize them from other fats. Some nuts and seeds (e.g., flax, walnuts) are excellent sources of essential fatty acids; and sunflower seeds, almonds, and hazelnuts are good sources of vitamin E. In addition, nuts and seeds may contribute to the overall compositional complexity of the diets with benefits as yet undocumented. In conjunction with their nutrient density, nuts and seeds are also energy dense, however nut and seed snack products are often high in sodium, and could contribute to excessive caloric and sodium intake. Nonfat and low-fat dairy products Nonfat and low-fat dairy products are Tier 1 foods because of the critical importance of calcium, particu- larly for adolescent girls for whom calcium consumption can have a criti- cal impact on the likelihood of developing osteoporosis later in life. The DGA (DHHS/USDA, 2005) recommends that children 4 to 8 years of age consume 2 cups of milk per day and those 9 to 18 years of age consume 3 cups per day. Milk consumption among children and adolescents is cur- rently below this level and has been declining over the past few decades (see Chapter 2). Juice One hundred-percent fruit and vegetable juices are both included in Tier 1 for reasons previously discussed for whole fruits and vegetables, although juices provide less dietary fiber than whole fruits or vegetables. This recommendation follows the Report of the Dietary Guidelines Advi- sory Committee (DGAC) in classifying juices as contributing to the rec- ommended servings for the fruits and vegetables group (DHHS/USDA, 2004). Because of concerns about excess juice consumption leading to excess energy intake, as well as certain other health issues such as displacing other more nutrient-dense foods, both the DGAC (DHHS/USDA, 2004) and the American Academy of Pediatrics (AAP, 2001) recommend that juice intake be limited. Consistent with this, the maximum juice portion sizes recommended are 4 and 8 ounces in elementary/middle and high schools, respectively.

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 NUTRITION STANDARDS FOR FOODS IN SCHOOLS Components of Federally Reimbursable Meals Also Sold as À La Carte As noted in Chapter 3, among the most popular competitive food and beverage items sold are entrée or side item foods and beverages, which are offered both in the reimbursable school meals and as individual à la carte items (e.g., fresh fruit and yogurt salad). Evidence from the most recent USDA School Nutrition and Dietary Assessment (SNDA-II) supports this by reporting that the offerings of the NSLP and SBP are reasonably nutritious and are improving in quality over time. The nutrient standards of the diet-based federally reimbursable school nutrition programs are not the same as those recommended in this report for individual competitive foods and beverages. However, the two sets of rules overlap, and the committee concluded that it is reasonable to include these NSLP/SBP items in the set of Tier 1 foods and beverages to be en- couraged when competitive foods are offered in schools, if they meet the nutrient standards as defined in this report. Tier 2 Foods and Beverages Tier 2 foods and beverages (allowed after school in high schools) fall short of Tier 1 standards, but are still consistent with the nutritional rec- ommendations of the DGA. One difference from this general definition of Tier 2 foods and beverages is that the committee proposes that, for high schools, nonnutritive-sweetened beverages containing less than 5 calories per serving are included in Tier 2, while use of nonnutritive sweeteners are not addressed in the DGA. The reason for the committee’s proposed standard is that these bever- ages may provide alternatives that can be useful in (1) providing additional dietary choices to high school students, reflecting their development and level of responsibility, and (2) helping these students limit caloric intake. The decision to include this exemption represented a complex weighting of several competing goals (for further discussion see Chapter 2). Foods and Beverages Not to Be Sold as Competitive Foods and Beverages Excluded from Tier 1 and Tier 2 foods and beverages are those that do not meet the DGA for total, saturated and trans fat, added sugars, and sodium. The standards for Tier 1, Tier 2, and à la carte foods and beverages are summarized in Table 5-1.

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS TABLE 5-1 Foods and Beverages That Meet Tier 1 and Tier 2 Standards Foods Beverages Tier 1 for All Students Tier 1 foods are fruits, vegetables, whole Tier 1 beverages are grains, and related combination products* • Water without flavoring, additives, or and nonfat and low-fat dairy that are carbonation limited to 200 calories or less per portion as • Low-fat* and nonfat milk (in 8 oz. packaged and portions): • No more than 35 percent of total calories —Lactose-free and soy beverages are from fat included • Less than 10 percent of total calories from —Flavored milk with no more than 22 g of saturated fats total sugars per 8-oz. portion • Zero trans fat (≤ 0.5 g per serving) • 100 percent fruit juice in 4-oz. portion as • 35 percent or less of calories from total packaged for elementary/middle school and sugars, except for yogurt with no more 8 oz. (two portions) for high school than 30 g of total sugars, per 8-oz. portion • Caffeine-free, with the exception of trace as packaged amounts of naturally occurring caffeine • Sodium content of 200 mg or less per substances portion as packaged À la carte entrée items meet fat and sugar limits as listed above and** —Are National School Lunch Program (NSLP) menu items —Have a sodium content of 480 mg or less *Combination products must contain a total *1-percent milk fat of one or more servings as packaged of fruit, vegetables, or whole-grain products per portion **200-calorie limit does not apply; items cannot exceed calorie content of comparable NSLP entrée items Tier 2 for High School Students After School Tier 2 snack foods are those that do not Tier 2 beverages are exceed 200 calories per portion as packaged • Non-caffeinated, non-fortified beverages and with less than 5 calories per portion as • No more than 35 percent of total calories packaged (with or without nonnutritive from fat sweeteners, carbonation, or flavoring) • Less than 10 percent of total calories from saturated fats • Zero trans fat (≤ 0.5 g per portion) • 35 percent or less of calories from total sugars • Sodium content of 200 mg or less per portion as packaged

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 NUTRITION STANDARDS FOR FOODS IN SCHOOLS Recommended Standards for Competitive Foods and Beverages Offered in Schools The committee’s Guiding Principles and the concept of Tier 1 and Tier 2 foods form the basis of its recommendations for nutrition standards for competitive foods offered in schools. These standards have two major ob- jectives. The first is to encourage children to consume foods and beverages that are healthful—fruits, vegetables, whole grains, and nonfat or low-fat dairy products. The second objective is, wherever possible in all competi- tive foods and beverages offered at schools, to limit food components that are either not healthful when consumed at levels exceeding the DGA or fall outside DGA recommendations. Standards that contain specified ranges for fats, energy, added sugar, and sodium are the committee’s best judgment derived from limited available evidence, and the rationale is explained in relevant portions of the text. Dietary Fats Standard 1: Snacks, foods, and beverages meet the following criteria for dietary fat per portion as packaged: • No more than 35 percent of total calories from fat • Less than 10 percent of total calories from saturated fats • Zero trans fats Rationale Americans, including children, consume too much total dietary fat, especially saturated fats. Although some fat intake is needed to meet re- quirements for essential fatty acids and to utilize fat-soluble vitamins, fats are energy dense, and a high fat intake is a major contributor to the high caloric intake of overweight and obese individuals. Data are consistently strong that diets high in saturated fat are associated with increased risk for and higher rates of coronary heart disease. Like saturated fats, trans fats, found in hydrogenated oils, increase low-density lipoprotein (LDL) choles- terol; trans fats also decrease high-density lipoprotein (HDL) cholesterol. The DGA recommends 25 to 35 percent of calories from total fat for all individuals over 2 years of age. The recommended standard for school-age children (4–19 years of age), is the upper end of an acceptable range in the DGA (and in the Dietery Reference Intakes, or DRIs), and allows for greater flexibility in choices while remaining within acceptable limits for a dietary pattern.

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS Added Sugars Standard 2: Snacks, foods, and beverages provide no more than 35 percent of calories from total sugars per portion as packaged. Exceptions include • 100-percent fruits and fruit juices in all forms without added sugars • 100-percent vegetables and vegetable juices without added sugars • Unflavored nonfat and low-fat milk and yogurt; flavored nonfat and low-fat milk with no more than 22 grams of total sugars per 8-ounce serving; and flavored nonfat and low-fat yogurt with no more than 30 grams of total sugars per 8-ounce serving Rationale Balancing food energy intake levels with energy expenditure is con- sistent with maintaining healthy weight. Sugars contain calories without substantial amounts of micronutrients. Limiting foods high in added sugars is recommended because of its association with increased calorie consump- tion and decreased intake of micronutrients. Decreases in micronutrient intake are strongest when added sugars exceed 25 percent of the total caloric intake. Although the committee concluded that the ideal recommendation for added sugars would be one that limits them to no more than 25 percent or less of total calories, such a recommendation for sugars could not be operationalized at this time because manufacturers are not required to list added sugars as part of the nutrition facts panel. The committee established the interim recommendation of 35 percent of calories from total sugars (with exceptions noted above) versus added sugars, because the total sugars information is part of the nutrition facts panel. A standard based on calories versus one based on weight is a reasonable calculation and will allow for a greater variety of products, such as cereals and granola bars, to be provided. Many of these products are important contributors of folate, vitamins A and C, iron, and zinc in children’s diets. It should be noted that the committee considered setting the added sugars limit at 10 percent for individual foods, but it was determined that a 25 percent limit, with the exception of dairy products, would be more easily achieved, while still contributing to improvement in the eating patterns of school-age children. Recently, the contribution of added sugars from soft drinks, fruitades, and other sweetened fruit drinks to the total intake of added sugars in children’s diets ranged from 35 to more than 50 percent. Other recom-

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0 NUTRITION STANDARDS FOR FOODS IN SCHOOLS servings because, in the committee’s judgment, a whole serving of fruit, vegetable, or whole grain per portion would contribute to the goal of help- ing school-age children meet DGA recommendations in a portion size that food manufacturers can achieve in formulating new products. Sodium Standard 4: Snack items meet a sodium content limit of 200 mg or less per portion as packaged or 480 mg or less per entrée portion as served for à la carte. Rationale Although sodium is an essential mineral, it is widely overconsumed. Research evidence in adult human subjects strongly supports an association between salt intake and increased blood pressure, although similar associa- tions in children and adolescents are not as well-documented. The exception to this recommendation for entrée items purchased à la carte reflects the fact that they generally represent greater portion sizes than the recommended calorie limit for snacks would allow; these entrée items are components of meals that meet USDA school meal nutrition standards and the FDA maximum sodium levels allowed for foods labeled as “healthy.” Their inclusion allows greater flexibility for students with greater energy needs. Nonnutritive Sweeteners Standard 5: Beverages containing nonnutritive sweeteners are only allowed in high schools after the end of the school day. Factors Considered for Use of Nonnutritie Sweeteners In consideration of nonnutritive sweeteners in competitive foods and beverages for school-age children, four related topics were evaluated: safety of nonnutritive sweeteners in children; displacement effect of intake of foods and beverages with nonnutritive sweeteners on intake of other foods and beverages to be encouraged (fruits, vegetables, whole grains, and non- fat or low-fat dairy products); efficacy of intake of foods and beverages containing nonnutritive sweeteners to contribute to maintaining a healthy weight in children; and the role of choice and necessity in the use of non- nutritive sweeteners in beverages and foods.

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS Safety The Food and Drug Administration (FDA) sets safety standards for food additives, including nonnutritive sweeteners. Those that are ap- proved for use have been evaluated extensively and have met FDA safety standards. Although safety standards are in place for food additives, there is still uncertainty, particularly about long-term use and about low-level exposure effects on health and development in children. Displacement of foods and beverages to be encouraged Nonnutritive- sweetened beverages may be chosen instead of nutrient-dense beverages. Nutrient displacement occurs when a beverage or food of lesser nutritional value is substituted for one of greater nutritional value, resulting in reduced intake of nutrients. Efficacy of nonnutritive sweeteners for weight control The DGA states that reduction of calorie intake is important in weight control. Nonnutritive sweeteners are used to replace sugars in foods and beverages and provide lower calorie choices to consumers. Choice and necessity Beverages that meet Tier 2 standards and have no caloric contribution increase the number of choices. Snack foods that meet Tier 1 and 2 requirements can meet calorie limits by substituting non- nutritive sweeteners for sugars. These additional choices may be useful for those who wish to control or maintain body weight; however, the use of nonnutritive sweeteners to provide lower calorie foods and beverages is not necessary to achieve weight control. The committee considered these issues in the context of developmental and social skills of school-age children and the public health concern of childhood obesity. Rationale for Nonnutritie-Sweetened Beerages Safety The FDA sets a safety standard for foods or food additives, regulated by the Federal Food, Drug, and Cosmetic Act, of “a reasonable certainty of no harm.” Prior to their approval for use, the FDA reviewed numerous safety studies on nonnutritive sweeteners in current use and has not, to date, found an associated safety risk. There is, however, a paucity of evidence on long-term health effects in humans from nonnutritive sweeten- ers, particularly exposure initiated in childhood. Displacement Soft drinks do not provide nutrients identified as lack- ing in the diets of U.S. children. These beverages could, if offered during the school day, displace more nutrient-rich products, such as nonfat and low-fat milk or 100-percent juice. The committee determined this was less

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 NUTRITION STANDARDS FOR FOODS IN SCHOOLS of a consideration outside meal times, when milk and juice consumption is believed to be relatively low. The committee found no evidence to evaluate the impact of nonnutritive-sweetened products to increase the consumption of foods and beverages to be encouraged (fruits, vegetables, whole grains, and nonfat or low-fat dairy products). Efficacy Evidence shows that diets that use nonnutritive-sweetened products can aid in weight loss and/or maintenance (i.e., weight control) in obese adult women. In these studies, nonnutritive sweeteners were generally consumed in beverages. No evidence is available to evaluate the efficacy of nonnutritive-sweetened foods for weight control. Preliminary evidence from a pilot study in adolescents indicated that replacing sugar-sweetened bever- ages with nonnutritive-sweetened beverages could help obese adolescents with weight control. Nonnutritive-sweetened beverages provide low-calorie choices that may effectively contribute to weight control. High school-age students may be better able to discriminate among more or less healthful choices and better prepared to make informed, individually appropriate beverage choices than younger school-age children. Necessity Although the DGA and the DGAC acknowledged that obe- sity is a major public health concern, they remained silent on the use of non- nutritive sweeteners as part of the strategy to maintain a healthy weight in Americans, including school-age children. The DGAC literature review did not include a review of the efficacy of nonnutritive sweeteners for weight loss and weight maintenance and the DGA did not address nonnutritive sweeteners as part of the strategy to maintain a healthy weight in Ameri- cans, including school-age children. The DGA does state that reduction of caloric intake is important in weight control; thus use of nonnutritive sweeteners could be a weight control strategy for some populations, but are not necessary to achieve this goal. Conclusion Based on the lack of evidence to evaluate efficacy and with an intention to avoid complexity of standards across age groups and times of day, the committee took a cautious approach in its recommenda- tions and determined that nonnutritive sweeteners are limited to beverages for high school students after school, thus avoiding competition with and potential displacement of nutrient-rich products as part of school meals and snacks.

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS Rationale on Nonnutritie-Sweetened Foods Because of the uncertainties and limitations in evidence, especially con- cerning the safety and benefits for weight control, the committee does not recommend a standard for nonnutritive sweeteners in foods. Safety Nonnutritive sweeteners have been evaluated and meet the safety standards set by FDA. However, there is no long-term evidence on the safety of nonnutritive sweeteners when consumption begins in early childhood and in relation to a broader range of health and developmental outcomes. The committee considered this in light of the limitations in test- ing and the lack of evidence concerning the benefits or necessity for use of nonnutritive sweeteners in foods. Efficacy Based on the energy balance principle, nonnutritive sweeteners in foods might provide a tool for weight management; however, studies to test this concept have not been conducted in children and the complexities of nonnutritive sweeteners and appetite have not been studied in this age group. Moreover, improving diet and maintenance of healthy weight in children does not require foods with nonnutritive sweeteners. There was a concern that children may not be able to distinguish between a nonnutri- tive sweetened food and a similar full-calorie food, which might encourage unintentional overconsumption of calories. Necessity Although nonnutritive sweeteners may increase palatability, thereby increasing the consumption of healthful foods, the potential in- crease in consumption may not be sufficient reason to include nonnutritive sweeteners in foods. Displacement Displacement was not an important issue for nonnutri- tive sweeteners in foods that otherwise meet the recommended standards. Conclusion Given these uncertainties and limitations, research is needed, particularly on safety and efficacy. Caffeine Standard 6: Foods and beverages are caffeine free, with the exception of trace amounts of naturally occurring caffeine-related substances.

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 NUTRITION STANDARDS FOR FOODS IN SCHOOLS Rationale The evidence for adverse health effects, other than physical dependency and withdrawal from caffeine consumption, varies in severity of effects and consistency of results among studies (see discussion in Chapter 2) except for physical dependency and withdrawal symptoms. Tolerance and dependence on caffeine have been identified in all ages, including school-age children, and withdrawal from regular caffeine intake is followed by generally mild effects such as moodiness, headache, and shakiness. Although there may be some benefits associated with caffeine consump- tion among adults (see Chapter 2), the committee did not support offering products containing significant amounts of caffeine for school-age children because of the potential for adverse effects, including physical dependency and withdrawal (described in Chapter 2). Thus the committee judged that caffeine in significant quantities has no place in foods and beverages offered in schools. The committee recognized that some foods and beverages con- tain trace amounts of naturally occurring caffeine and related substances. The intent of the committee was not to exclude such foods or beverages if the amounts of caffeine consumed are small and the product otherwise complies with the recommended nutrition standards. Foods and Beverages Offered in Schools Standard 7: Foods and beverages offered during the school day are limited to those in Tier 1. Rationale Tier 1 foods and beverages have particular attributes making them “foods and beverages to encourage.” Thus it is appropriate to make them available as snacks throughout the school day and as à la carte items dur- ing school meal periods. As discussed in Chapter 2, the evidence supports the use of Tier 1 foods to • increase the current consumption of fruits, vegetables, and whole grains by school-age children; • increase consumption of calcium-rich foods and beverages; • set standards for à la carte entrées that meet NSLP requirements or the recommended standards herein; and • reinforce innovation by industry to create food and dairy products more consistent with the DGA, thereby increasing healthful food choices for school-age children. The committee concludes that policies encouraging the sale of fruit-,

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS vegetable-, and whole grain-based foods and nonfat or low-fat dairy prod- ucts in à la carte lines, vending machines, school stores, snack bars, fund- raisers, and other venues will be nutritionally beneficial. Standard 8: Plain, potable water is available throughout the school day at no cost to students. Rationale Water is essential to health, and is naturally calorie-free with few known negative health consequences. Either tap or bottled water or water from fountains or other sources represents a safe, desirable way of main- taining hydration during the school day, and is therefore included as a Tier 1 beverage. The committee’s interpretation of limited available evidence is that carbonated water, fortified water, flavored water, and similar products are excluded during the school day, because such products are associated with displacement of more healthful beverages (see Chapter 2), they are un- neccessary for hydration purposes, and the increasing number of products increases the difficulty of making clear distinctions among them. In addi- tion, if flavored or fortified waters are included, they may serve, in the com- mittee’s judgment, as implicit encouragement to produce more foods with nonnutritive components for children at the expense of the more heathful fruits, vegetables, whole grains, and nonfat and low-fat dairy products. Standard 9: Sports drinks are not available in the school setting except when provided by the school for student athletes participating in sport programs involving vigorous activity of more than one hour’s duration. Rationale The committee concluded that, in most contexts, sports drinks are equivalent to flavored water, and because of their high sugar content it is appropriate that they be excluded from both Tier 1 and 2 beverages. How- ever, for students engaged in prolonged, vigorous activities on hot days, evi- dence suggests sports drinks are useful for facilitating hydration, providing energy, and replacing electrolytes. The committee’s recommended standard is consistent with conclusions of expert panels who considered this issue in adults. The committee suggests that the individual athletic coach determine whether sports drinks are made available to student athletes under allow- able conditions to maintain hydration. Standard 10: Foods and beverages are not used as rewards or discipline for academic performance or behavior.

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 NUTRITION STANDARDS FOR FOODS IN SCHOOLS Rationale Some schools have reported the use of foods and beverages as an aid in managing behavior. The committee has determined that such use of foods in schools is inappropriate; thus to avoid establishing an emotional connection between foods and beverages and acomplishment, they should not be allowed. Standard 11: Minimize marketing of Tier 2 foods and beverages in the high school setting by • locating Tier 2 food and beverage distribution in low student traffic areas; and • ensuring that the exterior of vending machines does not depict commercial products or logos or suggest that consumption of vended items conveys a health or social benefit. Rationale The presence in some high schools of vending machines used to sell Tier 2 foods and beverages after school leaves open a marketing opportu- nity for industry to promote their products during the regular school day, even if these vending machines are only turned on at the end of the regular school day. In making this recommendation, the committee concurs with the recommendations of the recent Institute of Medicine report on food and beverage marketing to children. Foods and Beverages Offered in the After-School Setting Standard 12: Tier 1 snack items are allowed after school for student activi- ties for elementary and middle schools. Tier 1 and 2 snacks are allowed after school for high school. Defining end of the regular school day Implementing the above concept will require that schools develop an operational definition of the time when the regular school day ends for high school. The committee has elected to leave the determination of the end of the school day to the local principal or other school administrator familiar with local circumstances. Some high schools may wish to define the end of the school day as the end of classes. This would make Tier 2 foods available to students as snacks while they are leaving school; other schools may wish to limit departing students to the most healthy foods by enabling the availability of only Tier 2 foods, after most students have left campus—perhaps one-half hour after the last class

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS has ended. Avoiding congestion as students seek to board buses or leave through a limited number of exits may be additional factors to consider. Rationale The committee’s recommended standard applies specifically to after- school activities that are attended mainly by students and thus represent an extension of the regular school day. Many school-related activities take place in the late afternoon and evening and involve both students and adults or, in some instances, mainly adults. These include interscholastic sporting events, back-to-school nights, parent-teacher assocation meetings, and use of the school for adult activities such as adult athletic leagues. Some students remain on the campus and proceed directly to their after- school activities, while others leave campus and return for these activities. Some food consumed during the after-school period is provided by the school, while in other cases it is provided by students or others. Given that high school students are often expected to handle more responsibility, it is appropriate to give them more choice in the less formal environment after the school day. Tier 2 foods and beverages provide for an expanded variety while still maintaining nutrition standards. Standard 13: For on-campus fund-raising activities during the school day, Tier 1 foods and beverages are allowed for elementary, middle, and high schools. Tier 2 foods and beverages are allowed for high schools after school. For evening and community activities that include adults, Tier 1 and 2 foods and beverages are encouraged. Rationale Fund-raisers that include the use of foods and beverages should em- phasize nutritious choices such as fruits or juices, vegetables, nuts, grain products, and nonfat and low-fat dairy products. The committee recognizes that there are many activities that involve both students and adults or, in some instances, mainly adults. These include interscholastic sport events, back-to-school nights, parent-teacher association meetings, and use of the school for specifically adult activities such as athletic leagues. The com- mittee recognizes that attempting to regulate foods and beverages sold for fund-raising or offered at evening events attended by both students and adults is not practical and may not be desirable. However, the committee urges that when foods and beverages are included in such activities they be limited to items that meet Tier 1 and 2 standards.

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 NUTRITION STANDARDS FOR FOODS IN SCHOOLS Actions for the Implementation of Nutrition Standards in Schools Action 1: Appropriate policy-making bodies ensure that recommendations are fully adopted by providing • regulatory guidance to federal, state, and local authorities; • designated responsibility for overall coordination and oversight to federal, state, and local authorities; and • performance-based guidelines and technical and financial support to schools or school districts, as needed. Rationale Policy changes will be required to implement these recommendations. These changes can be made at the local (school or school district) level, at the state level, or at the national level, using various combinations of policy guidance, regulations, legislation, etc. To implement these recom- mendations successfully, an agency with authority and capacity must be designated to coordinate and monitor the implementation. In addition, most potential implementing agencies will need assistance—in the form of information, advice, model strategies, and, in some cases, funding. The committee used this approach because not all schools require technical and financial support and because the type and amount of support needed will vary across districts. Action 2: Appropriate federal agencies engage with the food industry to • establish a user-friendly identification system for Tier 1 and 2 snacks, foods, and beverages that meet the standards per portion as pack- aged; and • provide specific guidance for whole-grain products and combina- tion products that contain fruits, vegetables, and whole grains. Rationale Implementing the standards recommended in this report for Tier 1 and Tier 2 foods and beverages and on other issues regarding food content will be accomplished only with coordination and cooperation among federal agencies and the food industry. If school food service operators are to identify and evaluate foods and beverages that meet certain standards, they will need detailed product information from manufacturers. Product infor- mation that is currently available to foodservice operators is not always sufficient to ensure that products meet nutrition standards. For example,

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 RECOMMENDED STANDARDS AND ACTIONS FOR COMPETITIVE FOODS although some product information is readily available, such as total and saturated fat and sodium, other information, such as added sugars, whole- grain status, and fruit content, may be more difficult to determine. The committee urges appropriate federal agencies and food manufac- turers to develop an identification system that will enable school foodser- vice operators to easily evaluate whether a product meets certain standards. The Centers for Disease Control and Prevention and the Produce for Better Health Foundation “Products Promotable” guidelines are excellent exam- ples of federal agencies working with the private sector to determine what fruit and vegetable products can bear the 5-A-Day logo. The committee recommends a similar approach that will require coordination among ap- propriate federal agencies as well as the private sector to establish a system to identify Tier 1 and Tier 2 foods as defined by the committee. The committee recognizes that the development of an identification system is a longer term goal. In the interim, the committee has provided information on areas such as whole grains and added sugars to assist stake- holders in implementing the recommendations in the short term. CONCLUSION The federally reimbursable school nutrition programs traditionally have been an important means for ensuring that students have daily access to fruits, vegetables, whole-grain-based products, and nonfat or low-fat dairy products during the school day. The committee’s view is that these programs should be the main source of nutrition provided at school. How- ever, the committee also recognizes that there is an increasing number of opportunities for students to eat and drink, including à la carte services, vending machines, school stores, snack bars, concession stands, classroom or school celebrations, achievement rewards, after-school programs, and other venues. Thus schools are encouraged to limit such additional oppor- tunities for students to eat and drink, but when they do arise in school, they should be used to encourage greater daily consumption of fruits, vegetables, whole grains, and nonfat or low-fat dairy products. The committee also acknowledges that implementing new standards for competitive foods offered in schools will incur a transition phase and that offering a competitive food program is elective, and additional costs likely will be passed on to purchasers. However, the committee’s reasoning is that increased market response with greater product availability will help diminish resistance to change. The recommendations in this report are intended to ensure that offer- ings in these venues are consistent with the DGA and, in particular, to help children and adolescents meet the guidelines for consumption of fruits, vegetables, whole grains, and nonfat or low-fat dairy products.

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