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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth 1 Committee Task and Guiding Principles BACKGROUND The dietary practices of children and adolescents are critical to their overall health and well-being. Unfortunately, children’s diets tend to be inadequate in fruits, vegetables, whole grains, and calcium-rich foods and too high in sodium, saturated fat, and added sugar. The School Nutrition Dietary Assessment Study II (SNDA-II) (Fox et al., 2001) reports that intake of total fat among school-age children makes up approximately 33–35 percent of caloric intake (upper limit of recommended level), and saturated fat intake is approximately 12 percent of total caloric intake (exceeding recommended levels). Although obesity increases health problems among U.S. school-age children and adolescents, the resulting greater risk that these health problems pose for other serious chronic conditions—including diabetes, cardiovascular disease, and elevated cholesterol and blood pressure levels—cannot be overlooked. Other nutrition and health issues that have an impact on children and adolescents include poor bone health, dental caries, and low iron intake. In addition to these issues of physical health, sociocultural issues are of concern, particularly the social discrimination against obese children and adolescents. Food choices and eating habits are learned from many sources. However, the school environment plays a significant role in teaching and modeling eating and health behaviors. For many children, foods consumed at school provide a major portion of their daily nutrient intake. Foods and beverages consumed at school come from three major sources: (1) federally
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth reimbursable school nutrition programs that include the National School Lunch Program (NSLP), the School Breakfast Program (SBP), and after-school snacks; (2) food and beverage sources that include items sold or offered through à la carte lines, snack bars, student stores, vending machines, or school activities such as special fundraisers, achievement rewards, classroom parties, school celebrations, classroom snacks, and school meetings; and (3) foods brought from home (“brown bag” lunches). Foods and beverages sold at school outside of the NSLP or SBP are referred to as “competitive foods” because they compete with the traditional school meals as a nutrition source (see Chapter 3 for detailed discussion). Such foods and beverages may include carbonated sodas, fruit-flavored drinks of low fruit content, snack foods high in added sugar or salt, and baked goods high in fat as well as healthier options such as small whole-grain bagels and fruit. A number of factors influence the decision to allow competitive foods in the school environment, including state and local policies, student preferences, commercial marketing strategies in the school, administrative and parental opinions, financial concerns, and time and space constraints affecting meal service in the school. Lunches brought from home are not included as they fall outside the scope of the report. There are important concerns about the contribution of nutrients and total calories from competitive foods to the daily diets of school-age children and adolescents. First, competitive foods tend to be calorie-dense rather than nutrient-dense and thus may contribute to the increasing problem of overweight and obesity among school-age children and adolescents (Kubik et al., 2003, 2005; Templeton et al., 2005). They may also contribute to other health conditions, including dental caries, poor bone health, and iron-deficiency anemia (Lytle and Kubik, 2003). Second, in contrast to meals served through the NSLP—which are generally consistent with national nutrition policy as delineated in the Dietary Guidelines for Americans (DGA)—competitive foods do not follow any federal nutrition guidelines and are not likely to conform to nutrient intake recommendations. Table 1-1 summarizes the recommendations from the DGA (DHHS/USDA, 2005). Third, these foods are increasingly available and consumed in a variety of venues across the school campus and throughout the school day. Given that children’s diets tend not to meet the DGA, and there is an abundance of often unhealthy food and beverage choices available at school, developing nutrient standards for individual products available outside the federally reimbursable school nutrition programs will make an important contribution toward improving the healthfulness of children’s diets. The public recognition of and attention to these issues has resulted in a call for effective solutions. In June 2004, Congress passed Section 204 of Public Law 108–265 of the Child Nutrition and WIC (Women, Infants, and Children) Reauthorization Act that required local education agencies to
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth TABLE 1-1 Key Recommendations for the General Population from the Dietary Guidelines for Americans 2005 Focus Area Key Recommendation Adequate nutrients within calorie needs Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol. Meet recommended intakes within energy needs by adopting a balanced eating pattern, such as the U.S. Department of Agriculture (USDA) Food Guide or the Dietary Approaches to Stop Hypertension (DASH) Eating Plan. Weight management To maintain body weight in a healthy range, balance calories from foods and beverages with calories expended. To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity. Physical activity Engage in regular physical activity and reduce sedentary activities to promote health, psychological well-being, and a healthy body weight. To reduce the risk of chronic disease in adulthood, engage in at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week. For most people, greater health benefits can be obtained by engaging in physical activity of more vigorous intensity or longer duration. To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood, engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements. To sustain weight loss in adulthood, participate in at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult with a health-care provider before participating in this level of activity. Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance. Food groups to encourage Consume a sufficient amount of fruits and vegetables while staying within energy needs. Two cups of fruit and 2 1/2 cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level. Choose a variety of fruits and vegetables each day. In particular, select from all five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times a week. Consume 3 or more ounce-equivalents of whole-grain products per day, with the rest of the recommended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains. Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products.
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth Fats Consume less than 10 percent of calories from saturated fatty acids and less than 300 mg/day of cholesterol, and keep trans fatty acid consumption as low as possible. Keep total fat intake between 20 to 35 percent of calories, with most fats coming from sources of polyunsaturated and monounsaturated fatty acids, such as fish, nuts, and vegetable oils. When selecting and preparing meat, poultry, dry beans, and milk or milk products, make choices that are lean, low-fat, or fat-free. Limit intake of fats and oils high in saturated and/or trans-fatty acids, and choose products low in such fats and oils. Carbohydrates Choose fiber-rich fruits, vegetables, and whole grains often. Choose and prepare foods and beverages with little added sugars or caloric sweeteners, such as amounts suggested by the USDA Food Guide and the DASH Eating Plan. Reduce the incidence of dental caries by practicing good oral hygiene and consuming sugar- and starch-containing foods and beverages less frequently. Sodium and potassium Consume less than 2,300 mg of sodium (approximately 1 teaspoon of salt) per day. Choose and prepare foods with little salt. At the same time, consume potassium-rich foods, such as fruits and vegetables. Alcoholic beverages Those who choose to drink alcoholic beverages should do so sensibly and in moderation—defined as the consumption of up to one drink per day for women and up to two drinks per day for men. Alcoholic beverages should not be consumed by some individuals, including those who cannot restrict their alcohol intake, women of childbearing age who may become pregnant, pregnant and lactating women, children and adolescents, individuals taking medications that can interact with alcohol, and those with specific medical conditions. Alcoholic beverages should be avoided by individuals engaging in activities that require attention, skill, or coordination, such as driving or operating machinery. Food safety To avoid microbial foodborne illness: Clean hands, food contact surfaces, and fruits and vegetables. Meat and poultry should not be washed or rinsed. Separate raw, cooked, and ready-to-eat foods while shopping for, preparing, or storing foods. Cook foods to a safe temperature to kill microorganisms. Chill (refrigerate) perishable food promptly and defrost foods properly. Avoid raw (unpasteurized) milk or any products made from unpasteurized milk, raw or partially cooked eggs or foods containing raw eggs, raw or undercooked meat and poultry, unpasteurized juices, and raw sprouts. SOURCE: DHHS/USDA, 2005.
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth develop wellness policies to address the problem of childhood overweight and obesity (Child Nutrition and WIC Reauthorization Act of 2004. Public Law 108–265. 108th Congress. 2004). The wellness policy contains four basic components: nutrition education goals, physical activity goals, nutrition guidelines, and other school-based activities. The law specifies that the wellness policy include “nutrition guidelines selected by the local education agency for all foods available on each school campus under the local education agency during the school day with the objectives of promoting health and reducing childhood obesity.” Although school districts across the country have taken steps toward meeting wellness policy requirements, these policies show great variability. Additionally, individual districts have expressed interest in being provided with information to enhance their understanding of nutrition and health issues and to assist them in developing strong wellness policies. THE COMMITTEE’S TASK In the FY 2005 Consolidated Appropriations, House Report 108–792, Congress directed the Centers for Disease Control and Prevention (CDC) to initiate a study with the Institute of Medicine (IOM) to review evidence and make recommendations about appropriate nutrition standards for the availability, sale, content, and consumption of foods at school, with attention to foods offered in competition with federally reimbursable meals and snacks. An ad hoc committee of the IOM was thus convened and charged to draw on literature regarding the availability, nutritional profile, and risks (including substitution) of school foods and beverages, including recent work by the Government Accountability Office, as appropriate; synthesize lessons learned from relevant research, development of federal nutrition standards for the National School Lunch and Breakfast Programs, and experience from the development of state- and local-based standards for foods and beverages offered outside federally reimbursable meals and snacks; consider whether a single set of nutrition standards is appropriate for elementary, middle, and high schools, or if more than one set is needed; develop nutrition standards based on nutritional science for foods and beverages, other than federally reimbursable meals and snacks, offered in school; consider how to ensure that foods and beverages offered in schools contribute to an overall healthful eating environment; and develop benchmarks to guide future evaluation studies of the application of the standards.
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth Approach to the Task To address its charge, the committee reviewed available evidence from the current literature and from public workshop presentations by recognized experts (see Appendix E), developed guiding principles, and deliberated on issues relevant to its charge. The committee reviewed literature, but did not conduct its own systematic, comprehensive evidence-based review. One challenge faced by the committee was interpreting limited evidence. Where evidence was inconclusive, the committee used its judgment to inform its interpretation of findings. An important starting point for the committee was the Dietary Guidelines for Americans (DHHS/USDA, 2005), together with the technical report of the Dietary Guidelines Advisory Committee (DHHS/USDA, 2004). The DGA is an evidence-based guideline that is a source of dietary health information for policymakers, nutrition educators, and health providers. For areas not addressed in the DGA, such as caffeine and nonnutritive sweeteners, the committee conducted searches of original literature and reviews of these topics, including reports from the Government Accountability Office (GAO) on competitive foods in schools (GAO, 2005). The committee also recognized the importance of cost, but did not conduct an economic analysis of the recommended standards because it is beyond the scope of the report. The committee was asked to provide benchmarks to evaluate programs. Because of the complexity of the issues, multiplicity of stakeholders, and lack of availability of data necessary to establish firm estimates and baselines, the committee lacked evidence and resources to address this task in detail with confidence. It did, however, put forward general guidelines for implementing the recommended standards and following up on the progress of implementation. Organization of the Report This report is organized into seven chapters. Chapter 1 describes the committee’s task and introduces its guiding principles. Chapter 2 reviews nutrition-related health concerns that involve school-age children and adolescents. Chapter 3 describes the school environment and organizational structure and how these relate to federally reimbursable school meals and snacks, and competitive foods and beverages. Chapter 4 provides an in-depth discussion of foods and beverages offered outside the federally reimbursable school meals and the role of industry in the design and distribution of competitive foods in schools. Chapter 5 provides the committee’s recommendations and Chapter 6 presents options for the implementation of the recommendations. The report references are listed in Chapter 7. Background and additional material are provided in the appendixes.
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth GUIDING PRINCIPLES In response to the statement of task, the committee produced a set of “Guiding Principles” to effect development of nutritional standards for foods offered outside federally reimbursable meals and snacks. These principles are highlighted in Box 1-1 and described in detail below. BOX 1-1 Guiding Principles To initiate the study process, the committee developed a set of principles to guide their deliberations. The committee recognizes that: The present and future health and well-being of school-age children are profoundly affected by dietary intake and the maintenance of a healthy weight. Schools contribute to current and lifelong health and dietary patterns and are uniquely positioned to model and reinforce healthful eating behaviors in partnership with parents, teachers, and the broader community. Because foods and beverages available on the school campus represent significant caloric intake, they should be designed to meet nutrition standards. Foods and beverages have health effects beyond those related to vitamins, minerals, and other known individual components. Implementation of nutrition standards for foods and beverages offered in schools will likely require clear policies; technical and financial support; a monitoring, enforcement, and evaluation program; and new food and beverage products. The committee intends that: The federally reimbursable school nutrition programs will be the primary source of foods and beverages offered at school. All foods and beverages offered on the school campus will contribute to an overall healthful eating environment. Nutrition standards will be established for foods and beverages offered outside the federally reimbursable school nutrition programs. The recommended nutrition standards will be based on the Dietary Guidelines for Americans, with consideration given to other relevant science-based resources. The nutrition standards will apply to foods and beverages offered to all school-age children (generally ages 4 through 18 years) with consideration given to the developmental differences between children in elementary, middle, and high schools.
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth The rationale for each Guiding Principle is presented below: 1. The present and future health and well-being of school-age children are profoundly affected by dietary intake and the maintenance of a healthy weight. Although a healthy diet is important throughout life, research indicates that many children and adolescents have poor eating habits that fall far short of meeting recommended dietary guidelines. Poor eating habits also result in increased lifelong health risks such as overweight and obesity, diabetes, high cholesterol, high blood pressure, lowered immune resistance, iron deficiency anemia, some types of cancer, osteoporosis, and dental caries. However, childhood offers an enormous opportunity to provide a solid foundation for establishing healthful lifelong eating patterns. Taking advantage of this opportunity to improve the quality of children’s diets is essential to the promotion of a healthier and more productive society. 2. Schools contribute to current and lifelong health and dietary patterns and are uniquely positioned to model and reinforce healthful eating behaviors in partnership with parents, teachers, and the broader community. Fifty million 5- to 19-year-old children attend elementary and secondary schools, a number which represents more than 80 percent of all children in the United States (Gerald and Hussar, 2003; U.S. Census Bureau, 2006). Most children attend school for about 9 months per year from kindergarten through 12th grade. Where preschool is offered, some begin school at 3 to 4 years of age. Because children spend a large amount of time each day at school, they also consume a significant portion of their daily food intake at school. Although schools alone cannot address all the nutritional needs of children, they nonetheless play an important role in establishing short- and long-term dietary habits. Therefore, it is imperative for schools to promote good nutrition through healthful school meals and by ensuring that other foods and beverages available to students throughout the school campus contribute to a healthy diet. Promoting children’s health through public health initiatives, from ensuring that students are immunized to improving their nutritional status through the NSLP, is and will continue to be a fundamental aspect of the U.S. public school system. This basic tenet has been confirmed in numerous federal agency reports and consensus documents such as Healthy People 2010 (DHHS, 2000), Preventing Childhood Obesity: Health in the Balance (IOM, 2005b), Food Marketing to Children and Youth: Threat or Opportunity? (IOM, 2006), and School Health Services and Programs (Lear et al., 2006). In addition, school food has been a concern of the federal government since the Depression era. Congress and the U.S. Department of Agriculture (USDA) set detailed standards for school lunch and breakfast
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth programs, and the federal government invests about $10 billion a year in them. In addition, the presence of children in a school setting for many hours each day provides a multitude of opportunities for modeling and reinforcing healthful eating behaviors. There are opportunities in formal classroom nutrition education programs as a component of other academic courses such as math, language arts, and science; and in classroom hands-on experiences with the preparation and consumption of food. Opportunities to model and reinforce healthful eating behaviors are also available through the offering of healthful foods and beverages in the school meal and snack programs as part of à la carte sales in the cafeteria and throughout the school campus (e.g., in vending machines, school stores and clubs, and in the classroom). Although there are many influences on students’ eating habits (both positive and negative) and numerous settings outside of school where children eat and drink, the school setting is the place in which the most curriculums are provided, and healthful behaviors and positive attitudes can be modeled and reinforced. This should apply to the healthfulness of foods and beverages as much as it does to the quality of curriculums, textbooks, science-based books, and rules of behavior. 3. Because foods and beverages available on the school campus represent significant caloric intake, they should be designed to meet nutrition standards. Because children spend a large amount of time at school, they often consume a large proportion of their foods and beverages there—estimates range from 19 to 50 percent or more of total calories (Gleason and Suitor, 2001). School meal programs have been increasingly successful (Fox et al., 2001), and are on a continuing trajectory to be even more successful in promoting healthful foods and beverages. However, schools today offer students many opportunities to consume foods and beverages outside the school meal programs and throughout the school day. For example, students have access to various other food and beverages sold as à la carte in the cafeteria, and other competitive foods and beverages available via vending machines, school stores, classroom parties, and fundraisers. The School Health Policies and Programs Study (SHPPS) found that 43 percent of elementary schools, 74 percent of middle schools, and 98 percent of high schools had vending machines, school snack bars, and other food and beverage sources outside of the school meal programs (Wechsler et al., 2001). A 2005 survey conducted by the U.S. Department of Education found that 94 percent of elementary schools offered foods and beverages for sale outside of school meal programs (Parsad and Lewis, 2006). The GAO found that nine out of ten schools offered competitive foods and beverages through à la carte cafeteria lines, vending machines, and school stores (GAO, 2005).
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth Although many schools and districts are improving competitive food and beverage offerings, they have a long way to go in promoting healthful choices. The SHPPS found that the most commonly consumed competitive foods and beverages were high in sugar, fat, and salt (Wechsler et al., 2001). Other studies also have found that à la carte offerings are of lesser nutritional quality (French et al., 2003; Harnack et al., 2000; Probart et al., 2005). 4. Foods and beverages have health effects beyond those related to vitamins, minerals, and other known individual components. The 2005 DGA (DHHS/USDA, 2005) and MyPyramid (USDA, 2005) provide advice to help Americans choose a healthful diet. As stated, “The intent of the Dietary Guidelines is to summarize and synthesize knowledge regarding individual nutrients and food components into recommendations for a pattern of eating that can be adopted by the public” (DHHS/USDA, 2005). The DGA further states, “A basic premise of the Dietary Guidelines is that nutrient needs should be met primarily through consuming foods. Foods provide an array of nutrients and other compounds that may have beneficial effects on health” (DHHS/USDA, 2005). This is especially important to consider in the school setting where lifelong habits will be encouraged and developed. A growing body of evidence suggests the important role that fruits, vegetables, whole grains, and nonfat and low-fat dairy play in our diet. The recommended standards comprise both nutrient- and food-based standards to remain consistent with the DGA and to recognize the importance of consuming nutrients through foods and beverages. 5. Implementation of nutrition standards for foods and beverages offered in schools will likely require clear policies; technical and financial support; a monitoring, enforcement, and evaluation program; and new food and beverage products. Currently, there are many school, school district, and state policies on foods and beverages available outside the federally reimbursable school nutrition programs. Some standards are detailed and others are more general. Moreover, in some settings where competitive foods and beverages are offered, and at some grade levels, there are no policies at all. Thus, for nutrition standards to be implemented in schools that choose to allow these foods and beverages, policy changes at the school and school district level, and sometimes at the state and federal level, may be necessary. In addition, school and school district staffs have varying levels of experience putting nutrition standards into practice. Some may require technical assistance and additional funding to implement these changes. They will also need the assistance of food and beverage suppliers to provide products that comply with the standards. Furthermore, to ensure that the standards are more than mere words on paper, responsibility must be assigned to personnel in the school or school district for monitoring the implementa-
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth tion and enforcement of the recommendations and for program evaluation. Finally, it will be important for school personnel, parents, and other parties to have access to information on implementation of the standards and patterns of food and beverage consumption in local settings. 6. The federally reimbursable school nutrition programs will be the primary source of foods and beverages offered at school. Current nutrition standards for school meals are based on the 1995 Dietary Guidelines and are being revised and updated to meet the 2005 guidelines (USDA, 2006). The standards require that breakfast and lunch menus, when averaged over a school week, meet the following: Limit total fat intake to no more than 30 percent of calories and saturated fat to less than 10 percent of calories Provide one-third of the Recommended Dietary Allowance for protein, iron, calcium, and vitamins A and C for lunch and one-fourth for breakfast Steadily decrease the level of sodium Provide a varied menu, abundant in fruits, vegetables, and whole grains School meals are evaluated according to these standards, and national studies show that schools are moving steadily toward compliance (Fox et al., 2001). Children who participate in the school meal programs consume more fruits, vegetables, and dairy products compared to those who do not (Gleason and Suitor, 2001). In addition, students participating in the school meal program are likely to have a better sense of what constitutes a nutritionally complete meal. Given the nutritional benefits of consuming school meals, they should serve as the main source of nutrition in school. The committee recognizes that some school children may depend on home food sources for some or all meals and snacks consumed during the day. 7. All foods and beverages offered on the school campus will contribute to an overall healthful eating environment. In addition to the prevalence of foods and beverages high in fat, sugar, and salt, evidence also suggests that the consumption of such products displaces the consumption of fruits, vegetables, and other healthful foods in children’s diets (Cullen and Zakeri, 2004; Kubik et al., 2003; Templeton et al., 2005). The current availability of foods and beverages sold outside the school meal programs (Wechsler et al., 2001) and their overall poor nutritional quality contribute to the increased consumption of less healthful foods and the overconsumption of calories (Cullen and Zakeri, 2004; Kubik et al., 2003; Templeton et al., 2005). For schools to take full advantage of their unique position to model
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth and reinforce healthy eating behaviors, the nutrition standards established consider foods and beverages offered in all venues and throughout the school day. 8. Nutrition standards will be established for foods and beverages offered outside the federally reimbursable school nutrition programs. In addition to the school meals, which are planned to achieve nutrition standards over a school week, students have opportunities within the cafeteria and throughout the school campus to consume a variety of foods and beverages. These widely accessible items are often high in fat, sugar, and salt, making it increasingly difficult for children to eat a healthful overall diet. Most children do not consume a diet consistent with the DGA and many have access, often unlimited and unsupervised, to a variety of items outside school meal programs. Therefore, it is essential to establish a set of nutrition standards for these competitive foods and beverages in order to increase a student’s likelihood of meeting the DGA recommendations. 9. The recommended nutrition standards will be based on the Dietary Guidelines for Americans, with consideration given to other relevant science-based resources. The DGA (DHHS/USDA, 2005) represents the most comprehensive U.S. evidence review of current scientific literature on diet and health, and it serves as the basis for federally funded school food and nutrition education programs. Other relevant resources considered included the IOM reports Preventing Childhood Obesity: Health in the Balance (IOM, 2005b), Food Marketing to Children and Youth: Threat or Opportunity? (IOM, 2006), Progress in Preventing Childhood Obesity: How Do We Measure Up? (IOM, 2007), the Dietary Reference Intake reports (IOM, 1997, 1998, 2000, 2001, 2002/2005, 2005a), and the report series on diet and health produced by the Food and Agriculture Organization of the United Nations/World Health Organization (WHO, 2003). In addition, position statements from professional nutrition and health associations, such as the American Academy of Pediatrics, also may be considered. Although contextual factors such as the ability of the marketplace and the school administration to respond to the recommendations may be weighed, the main objective is to improve the health of children. 10. The nutrition standards will apply to foods and beverages offered to all school-age children (generally ages 4 through 18 years), with consideration given to the developmental differences between children in elementary, middle, and high schools. The DGA (DHHS/USDA, 2005) applies to all adults and children over the age of 2 years. However, there are key developmental differences between elementary and secondary school children. These differences include higher requirements for calcium and energy during adolescence, a gap be-
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Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth tween requirements and actual consumption for several nutrients and food groups among adolescents, and the limited ability of elementary school children to make appropriate choices among multiple food and beverage offerings. Although the committee recognizes that there is individual variability among students even within a given educational level or grade, the standards are based on the DGA, which apply across the board to all Americans—regardless of weight status or activity level. Therefore, for students who are very active on most or all days of the week and who require more calories, the foods and beverages recommended are still appropriate. SUMMARY The quality of nutritional intake has a profound effect on a range of health issues. Improving childhood nutritional status improves the future health of the nation by diminishing individual risk factors for chronic diseases that include type 2 diabetes, cardiovascular disease, osteoporosis, and dental caries. These issues are examined in more detail in the following chapter.
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