Informing the Future: Critical Issues in Health: Fourth Edition (2007)

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Children and Youth: A Healthy Start Children and Youth: A Healthy Start Few topics in health care are more emotionally charged than the health of America’s youth. The patterns that children establish early in life—diet, exercise, good habits, and an appreciation for their own well-being—give them the best chance for a lifetime of good health. The Institute of Medicine (IOM) approaches the issue of keeping the nation’s children healthy by looking at the health conditions of children and young adults as well as the world in which they live. The IOM’s work covers topics as broad as basic health and nutrition, as timely as childhood obesity, and as specific as teen driving. The good news is that, in general, the health of children and youth has improved considerably over the past several decades. Still, the challenges that remain involve biological, behavioral, social, and physical environments alike. Ef- fectively tackling these issues is a complex and multifaceted task and includes analyzing prevention and intervention strategies in addition to treatment. The IOM has helped to foster the idea that childhood health is about context and not just conditions. This concept requires a significant change in the way that the health care community thinks about disease. Food for Thought The foremost challenge to the long-term health of our children is clear: Chil- dren in the United States today are more overweight and obese than at any time in history, putting them at risk for serious health problems such as diabetes, cardiovascular disease, elevated cholesterol, and Any competitive foods that are high blood pressure—diseases that most people available should consist of fruits, still consider “adult” conditions. In addition to vegetables, whole grains, and nonfat obesity-related health concerns, poor food choic- or low-fat milk and dairy products, es can also lead to long-term health issues such consistent with the 2005 Dietary as osteoporosis from inadequate calcium intake Guidelines for Americans. or chronic iron deficiency. In response to growing concerns over obesity and other nutritional con- cerns, national attention has focused on the need to establish school nutrition 19 

Informing the Future: Critical Issues in Health standards. Children today spend the majority of their day at school and often stay for after-school activities. All together, the foods and beverages available both during and after school can contribute a significant number of calories to total daily consumption. Some improvements have been made in the food choices available in schools: General school nutrition policies have been put in place at the federal, state, and local levels, including a federally mandated wellness policy initiative. Furthermore, there has been increased recognition of the need to limit access to unhealthy foods such as those currently sold in vending machines in a school environment that otherwise offers federally reimbursable school nutrition programs. Despite some progress, however, the response of school districts to meeting wellness policy requirements has been inconsistent. To augment local wellness policies, Congress directed the Centers for Disease Control and Prevention (CDC) to undertake a study with the IOM to make recommendations about appropriate nutritional standards for the availability, sale, content, and consumption of foods at school, with particular attention to competitive foods that are offered outside the school meal program. The resulting report, Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth (2007), concluded that • federally-reimbursable school nutrition programs should be the main source of nutrition at school; • opportunities for competitive foods should be limited; and • any competitive foods that are available should consist of fruits, veg- etables, whole grains, and nonfat or low-fat milk and dairy products, consistent with the 2005 Dietary Guidelines for Americans. These standards should apply to à la carte cafeteria items, products sold in vending machines and at school stores, and other foods and drinks that are avail- able outside of the school meals that are required to conform to federal nutrition guidelines. The committee proposed two grade-level-based tiers of competitive foods and beverages that could be made available in schools. Marketing Weighs In Creating an environment in which U.S. children and youth can grow up healthy should be a high priority for the nation. Yet the prevailing pattern of food and beverage marketing to children and youth in America represents, at best, a missed opportunity. At worst, the status quo is a direct threat to the health pros- pects of the next generation. 20 

Children and Youth: A Healthy Start School lunch line Cafeteria Gym À la cartea Vending machines ? Vending machinesb Fund-raiserd School storec Vending machines High school at a À la carte: school food authority. b Vending machines: school food authority, vending operator, school official or administra- tor, physical education department, student association or club. c fig 3-1 School store: school official or administrator, student association or club. d Fund-raisers: physical education department, music or art department, business teacher, student association or club, booster groups. Groups most frequently involved in various competitive food venues commonly available in high schools. SOURCE: Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth, p. 70. 21 

Informing the Future: Critical Issues in Health 20 6–11 years 16 16 16 12–19 years Percentage 12 11 11 8 7 6 5 5 4 4 4 0 1963–1970 1971–1974 1976–1980 1988–1994 1999–2002 Year Prevalence of obesity among U.S. children and adolescents by age group and selected period, 1963– 2002. SOURCE: Food Marketing to Children and Youth: Threat or Opportunity?, p. 42. 2-1 Current food and beverage marketing targeted at children ages 12 years and under leads them to request and consume high-calorie, low-nutrient products. A broad effort, not just in schools, is needed to restore the knowledge balance and promote healthier habits. Current food and beverage marketing The IOM report Food Marketing to Children and targeted at children ages 12 years Youth: Threat or Opportunity? (2006) looked at how and under leads them to request and marketing influences children and youth. The re- consume high-calorie, low-nutrient port provided the most comprehensive review to products. A broad effort, not just date of the scientific evidence on the influence in schools, is needed to restore the of food marketing on diets and the diet-related knowledge balance and promote health of U.S. children and youth. healthier habits. The report found, quite simply and perhaps unsurprisingly, that current food and beverage marketing practices put children’s long-term health at risk. If America’s children and youth are to develop eating habits that will help them avoid early onset of diet-related chronic diseases, they must reduce their intake of high-calorie, low-nutrient snacks, fast foods, and sweetened drinks. Yet these very products make up the majority of those marketed to them. Companies spent an estimated $10 billion to market foods, 22 

Children and Youth: A Healthy Start beverages, and meals to U.S. children and youth in 2004, most of which were products high in calories and low in nutrients. Unfortunately for children, the marketing works. The report provided a set of policy and program recommendations to devel- op common standards and labeling policies for defining healthy foods, beverages, and meal options—a dramatic shift toward marketing and advertising strategies that promote these healthier foods. This would include both prohibiting the use of licensed cartoon characters on foods that are high in calories and low in nutri- ents and promoting a sustained social marketing program. Specific recommenda- tions were offered for • food, beverage, and restaurant industries; • food retailers and trade associations; • entertainment and media industries; • parents and caregivers; • schools; and • government. The report also offered guidance on additional research that is necessary to chart the path of future improvements and improve the ability to monitor and track changes in marketing practices that have an influence on children’s diets and diet-related health. Collectively, these recommendations reflect the spectrum of current knowledge and understanding in a rapidly changing environment, and they need to be implemented as a package in order to support and complement one another. The IOM report sparked several actions, including announcements by the soft drink industry of changes in their school marketing policies, by several large food companies of their plans to alter their products and marketing to children, and by Disney to prohibit the use of their characters for marketing products of concern. Reviews were also triggered by the board responsible for industry mar- keting guidelines, which is leading to a tightening of the standards, and by the Kaiser Family Foundation, who examined the even broader exposure of children to televised ads. Furthermore, policy makers in Congress and the Federal Trade Commission called for changes in corporate marketing strategies to make them consistent with IOM recommendations. 23 

Informing the Future: Critical Issues in Health 14 PREVENTING TEEN MOTOR CRASHES TABLE 2-4 Fatal Crash Characteristics, 16-Year-Old Driver Alone or with Teen Passengers (percentage) Driver 1 Teen 2 Teen 3+ Teen Alone Passenger Passengers Passengers Driver error 72a 82 83 90 Speeding 30 45 50 59 Single vehicle 36 51 59 72 0.08+ blood alcohol level 9 8 10 12 aTotals may exceed 100% because crashes may involve more than one characteristic. SOURCE: Insurance Institute for Highway Safety. Unpublished analysis of 2004 data from the Fatality Analysis Reporting System, National Highway Traffic Safety Administration. Fatal Crash Characteristics, 16-Year-Old Driver Alone or with Teen Passengers (percentage). SOURCE: Preventing Teen Motor Crashes: Contributions from the Behavioral and Social Sciences, p. 12. Bad Driving = Bad Health Unlike the long-term effects of poor nutrition, motor vehicle crashes present an immediate and violent risk to far too many youth. Over the past decade, there have been significant decreases in the rate of motor vehicle crashes involving teens, but teen drivers and passengers remain at substantial risk: motor vehicle crashes remain the leading cause of death for young people in the United States, and they constitute a critical public health problem. The IOM conducted a workshop and subsequently published Preventing Teen Motor Crashes: Contributions from the Behavioral and Social Sciences (2007). This proj- ect was a collaboration of the Transportation Research Board and the National Research Council/IOM Board on Children, Youth, and Families. The workshop explored how knowledge from the behavioral and social sci- ences could contribute to the development of new prevention strategies to re- duce the incidence of and injury from teen motor vehicle accidents. Workshop speakers identified opportunities to apply new research and knowledge to driving practices, especially in areas such as coaching, novice driving practices, parental supervision, error detection, peer interactions, adolescent decision making, and the development of incentives to foster safe driving skills. Workshop participants also examined the social context of teen driving that influences cognitive devel- 24 

Children and Youth: A Healthy Start opment and the acquisition of driving expertise—two areas that have received scarce attention in prior attempts to craft prevention strategies. A collection of papers presented at the May 2006 workshop is now being prepared for publication in a supplemental issue of the American Journal of Pre- ventive Medicine. The papers seek to provide useful, actionable educational and research materials to support the next phase of prevention strategies. Injuries and fatalities from teen motor crashes are preventable. Road acci- dents are not diseases or disorders that require scientific breakthroughs and mas- sive research grants. Behaviors must be changed, training must be provided, and concrete actions must be taken by administrators, parents, teachers, and policy makers. 25