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Introduction

The National School Lunch Program (NSLP) and the School Breakfast Program (SBP) are large and important child nutrition programs overseen by the U.S. Department of Agriculture (USDA). The department has requested that the Institute of Medicine (IOM) of the National Academies review and recommend revisions to the Nutrition Standards and the Meal Requirements that are currently used to plan these school meals. Under the auspices of the Food and Nutrition Board of the IOM, an expert committee was convened to study the issues and make recommendations.

This committee has undertaken the study in a two-phase process. This report, which describes Phase I of the study, focuses largely on the development of plans that will be used to make sound recommendations for the revision of the Nutrition Standards and Meal Requirements. Topics related to the competitive foods offered in schools (e.g., foods available in vending machines, at snack bars, and á la carte) are outside the scope of this report. Throughout the report, children and adolescents in the United States who are of school age (4–18 years) are referred to as “schoolchildren.”

Chapter 1 includes background information about the school meal programs and reasons that revisions in standards and requirements are needed. Chapter 2 provides detailed information about the current Nutrition Standards and Meal Requirements. Chapter 3 covers the committee’s working principles and study criteria and then introduces the approach that it plans to use to develop its recommendations. Chapter 4, which addresses the first step in the committee’s approach, provides an overview of the food and nutrient needs of schoolchildren. Chapter 5 presents the committee’s proposed planning model for the approach to be used to develop Nutrition Standards, and Chapter 6 describes analyses that will be conducted in the course of developing final recommendations. Appendix A identifies the many abbreviations, acronyms, and specific terms that are included in this report.

This introductory chapter provides an overview of the NSLP and the SBP, addresses the reasons that the Nutrition Standards and the Meal Requirements for these programs need to be updated and revised, describes the committee’s task, and briefly summarizes findings from a selection of large-scale evaluations that the committee may need to consider as it develops recommended revisions to the standards.



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1 Introduction The National School Lunch Program (NSLP) and the School Breakfast Program (SBP) are large and important child nutrition programs overseen by the U.S. Department of Agriculture (USDA). The department has requested that the Institute of Medicine (IOM) of the National Academies review and recommend revisions to the Nutrition Standards and the Meal Requirements that are currently used to plan these school meals. Under the auspices of the Food and Nutrition Board of the IOM, an expert committee was convened to study the issues and make recommendations. This committee has undertaken the study in a two-phase process. This report, which describes Phase I of the study, focuses largely on the development of plans that will be used to make sound recommendations for the revision of the Nutrition Standards and Meal Requirements. Topics related to the competitive foods offered in schools (e.g., foods available in vending machines, at snack bars, and à la carte) are outside the scope of this report. Throughout the report, children and adolescents in the United States who are of school age (4–18 years) are referred to as “schoolchildren.” Chapter 1 includes background information about the school meal programs and reasons that revisions in standards and requirements are needed. Chapter 2 provides detailed information about the current Nutrition Standards and Meal Requirements. Chapter 3 covers the committee’s working principles and study criteria and then introduces the approach that it plans to use to develop its recommendations. Chapter 4, which addresses the first step in the committee’s approach, provides an overview of the food and nutrient needs of schoolchildren. Chapter 5 presents the committee’s proposed planning model for the approach to be used to develop Nutrition Standards, and Chapter 6 describes analyses that will be conducted in the course of developing final recommendations. Appendix A identifies the many abbreviations, acronyms, and specific terms that are included in this report. This introductory chapter provides an overview of the NSLP and the SBP, addresses the reasons that the Nutrition Standards and the Meal Requirements for these programs need to be updated and revised, describes the committee’s task, and briefly summarizes findings from a selection of large-scale evaluations that the committee may need to consider as it develops recommended revisions to the standards. 15

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16 NUTRITION STANDARDS AND MEAL REQUIREMENTS OVERVIEW: PROGRAMS AND PARTICIPANTS Operating under the aegis of the Food and Nutrition Service of USDA, the NSLP and the SBP play key roles in ensuring the nutrition and health of children in the United States. The NSLP offers nutritious lunches in 99 percent of U.S. public schools and in 83 percent of private and public schools combined (USDA/ERS, 2004). The SBP offers breakfasts in approximately 85 percent of public schools (USDA, 2007a). With about 95 percent of U.S. children eating one or two meals at school on school days (including children who bring their lunches from home), the school cafeteria holds the potential to promote sound dietary habits among all schoolchildren, regardless of whether they participate in the school meal programs (Kennedy and Davis, 1998). Purpose, Brief History, and Description of the Programs Purpose The purpose of the NSLP, as summarized in the enabling legislation, is “as a measure of national security, to safeguard the health and well-being of the Nation’s children and to encourage the domestic consumption of nutritious agricultural commodities and other food” (National School Lunch Act, P.L. 79-396, Stat. 281 (June 4, 1946): §2). This section of the National School Lunch Act has not been changed over the life of the program—more than six decades. Congress authorized the SBP as a pilot program in 1966 (Child Nutrition Act, P.L. 89- 642, (October 11, 1966)). When Congress permanently authorized the SBP in 1975 under an amendment to the Child Nutrition Act (P.L. 94-105, (October 7, 1975)), it stated “it is the purpose and intent of the Congress that the school breakfast program be made available in all schools where it is needed to provide adequate nutrition for children in attendance” (Martin, 2008a). Brief History—Federal Reimbursement Linked to Regulations From the onset, federal reimbursement for school meals has been linked to specific regulations. The NSLP was required to operate on a nonprofit basis and to serve meals at no cost to children who were determined to be unable to pay (National School Lunch Act, P.L. 79-396, Stat. 281 (June 4, 1946): §2). In addition, Section 9 of the National School Lunch Act gave the Secretary of Agriculture the authority to prescribe the minimum nutritional requirements for school lunches. In 1946, the secretary prescribed three food-based meal patterns (USDA, 2008a): 1. Type A lunches, which consisted of 8 ounces of whole milk, 2 ounces of protein-rich food, ¾ cup of vegetables or fruit, one portion of a bread product, and 2 teaspoons of butter or fortified margarine; 2. Type B lunches, which had the same specification for bread and milk and half the portion of the other food groups as Type A lunches and which were devised for schools where facilities were not available to provide a Type A lunch; and 3. Eight ounces of whole milk, which supplemented lunches brought from home. The SBP initially had a meal pattern similar to that of the Type A school lunch but was adapted for a smaller meal size (Martin, 2008b). Meals that conformed to the meal patterns were eligible for some degree of federal reimbursement. Initially, the federal reimbursement for meals was much lower than their cost (Martin, 2008b).

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INTRODUCTION 17 Laws and regulations governing the school meal programs have evolved over the years (see Appendix B). Much of the basis for the current Nutrition Standards and Meal Requirements is a function of work undertaken by USDA in 1995 and known as the School Meals Initiative for Healthy Children (SMI) (USDA, 1995), as well as legislation passed by Congress in 1996 (Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L. 104-193 (August 22, 1996): §702). Brief Program Description Currently, the school meal programs must provide meals at no cost (free) or at a reduced- price for children certified by the school food authorities to be eligible for them. Others may purchase the meals at full price. Schools must offer meals whose food components are consistent with program regulations, but a meal qualifies for federal reimbursement even if a student accepts fewer food items, as long as the number of items meets the minimum specified by the as served standard (National School Lunch and Child Nutrition Act Amendments, P.L. 94-105, 1975). Current USDA subsidies for the cost of these meals are described in detail in Chapter 2. As illustrated in Figure 1-1, the current standards and requirements comprise many elements. As a first step, a planning model guides the development of the Nutrition Standards and Meal Requirements. The current planning model uses the 1995 Dietary Guidelines for Americans (HHS/USDA, 1995) and the 1989 Recommended Dietary Allowances (RDAs) (NRC, 1989), as prescribed by law. USDA established specific minimum standards for the levels of calories, protein, vitamins A and C, calcium, and iron as well as specified levels of calories from total fat and saturated fat to be included in school meals 1 (USDA, 1995). These specifications now constitute the Nutrition Standards for school meals. As part of the Nutrition Standards specification, calculations are carried out to develop the quantitative amounts of nutrients for relevant age-grade groups. These calculated amounts are currently referred to as “nutrient standards.” The right-hand side of Figure 1-1 shows how the elements are connected to provide a pathway to a nutritious school breakfast or lunch. The child’s consumption of the foods he or she has selected is shown at the end of the path. Consumption of the food is a key part of ensuring the health of children, but it is out of the direct control of the meal’s providers. However, standards will be most effective if they result in nutritious foods that appeal to children. The left- hand side of the figure provides a brief description of each of the elements. The standards and requirements outlined in Figure 1-1 are described in detail in Chapter 2. 1 Although there is not a required mandate for the levels of sodium, cholesterol, and dietary fiber in school meals, the amounts of these nutrients are required to be calculated in the nutrient analysis as carried out by school food programs and state agencies during SMI reviews.

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18 NUTRITION STANDARDS AND MEAL REQUIREMENTS Planning Model NUTRITION STANDARDS • Nutrition Standards – Goals for School Meals – —Foundation of school meals —Established by USDA and specified in regulation “Nutrient Standards” for —Nutrient Standards currently reflect age-grade groups required nutrients as calculated quantities for age-grade groups • Meal Requirements implement the Nutrition Standards MEAL REQUIREMENTS —Established by USDA and specified in regulation • Meal Requirements consist of Meal Standards Meal Standards standards for two types of menu for for planning approaches Food-Based Nutrient-Based Menu Planning Menu Planning • Menu planning approach is selected by the school food authority and menus are developed at the local level Meal Meal • Meal—as offered—to the student Offered Offered must meet the as offered standard for the menu planning approach • Meal selected by student—as Meal Meal served—must meet the as served Served Served standard for the menu planning approach Reimbursability of Meal • Components of child’s meal Established checked by cashier Child Consumes Meal FIGURE 1-1 Current path to a nutritious school lunch and breakfast.

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INTRODUCTION 19 For this report, the general term “standards” is occasionally used and is intended to be a comprehensive term for the Nutrition Standards and Meal Requirements. In the case of Meal Requirements, the “meal standards” for each of the menu planning approaches encompass the specifications for the amounts of the food items (food-based menu planning) as well as the specifications for the food components or menu items that are designated for a meal as offered and for a meal as served. Program Size and Student Participation The potential reach of the school meal programs is very large: during the 2005–2006 school year, more than 49.1 million children were enrolled in U.S. public schools (U.S. Department of Education, 2007). If a school participates in one or both of the school meal programs, any child who attends the school may obtain the school meal. On average, about 60 percent of children in schools that offer school meals eat a school lunch (USDA, 2007a). In fiscal year (FY) 2007, an average of 30.6 million schoolchildren participated in the NSLP on each school day. About 24 percent of children in schools that offered the SBP participated in the program, on average, equaling 10.1 million children each school day. In FY 2007, the participating schools served about 5.1 billion lunches at a cost of approximately $8.7 billion to USDA and 1.7 billion breakfasts at a cost of $2.2 billion to USDA (USDA/ERS, 2008). Figure 1-2 shows how the average rate of student participation in the NSLP and the SBP has changed over the past 40 years. The sharp dip in student participation that occurred between 1981 and 1982 was triggered by provisions in the Omnibus Reconciliation Act of 1981 (P.L. 97- 35, Stat. 95 (August 13, 1981): §357–933) that substantially reduced financial support for the school meal programs and resulted in a decrease in the number of students purchasing lunches at full price. From 1985 to 2000, the rate of growth in school lunch participation was about equal to the rate of growth in school enrollment (USDA, 2008b).

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20 NUTRITION STANDARDS AND MEAL REQUIREMENTS 35 NSLP SBP 30 Omnibus Reconciliation Act of 1981 Average Participation (in millions) 25 20 15 10 5 0 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 Year FIGURE 1-2 Change in average student participation in the National School Lunch Program and the School Breakfast Program, 1969–2007. SOURCE: USDA, 2008c,d. Diversity of the School Population The U.S. school-age population is highly diverse both across the nation and within many individual schools. Table 1-1 shows the distribution of enrollment in public schools by race and ethnic background for fall 1995 and fall 2005. Notably, diversity is increasing: the Hispanic and Asian/Pacific Islander populations are growing at a rapid rate. TABLE 1-1 Distribution of Enrollment in Public Schools by Race and Ethnic Background, Fall 1995 and Fall 2005 Percent Enrollment Asian/Pacific American Indian/ Year White Black Hispanic Islander Alaska Native 1995 64.8 16.8 13.5 3.7 1.1 2005 57.1 17.2 19.8 4.6 1.2 SOURCE: U.S. Department of Education, 2008a.

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INTRODUCTION 21 Differences in the racial and ethnic compositions of school districts in different parts of the United States are not readily revealed by the information in Table 1-1. However, Figure 1-3 illustrates the diversity present in the five largest school districts in the 50 states during the 2005–2006 school year. White, non Hispanic Black, non Hispanic 70 Hispanic Asian/Pacific Islander 60 American Indian/Alaska Native 50 Percentage of Students 40 30 20 10 0 New York City Los Angeles Unified City of Chicago Dade County, FL Clark County, NV School District FIGURE 1-3 Racial and ethnic compositions of public elementary and secondary schools in the five largest school districts of the 50 states. SOURCE: U.S. Department of Education, 2008b.

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22 NUTRITION STANDARDS AND MEAL REQUIREMENTS Immigration is likely responsible for a portion of the changes shown in Table 1-1 and will probably contribute to future changes (U.S. Department of Education, 2000a). Data from the 2006 Annual Social and Economic Supplement to the Current Population Survey indicate that, for all children under the age of 18 years, about 21 percent have a foreign-born parent or parents, are foreign-born themselves, or both (U.S. Census Bureau, 2006). Low-Cost Meals for Schoolchildren The school meal programs provide children with access to nutritious, low-cost food to support their growth, development, and health. Both the NSLP and the SBP can provide a safety net for children in need, given the provisions that make school meals available free or at a reduced cost to eligible participants. If the child lives in a household whose income is at or below 130 percent of the federal poverty level (or if the household receives food stamps, 2 Temporary Assistance for Needy Families, or assistance from the Food Distribution Program on Indian Reservations), the child is eligible for a free school lunch and a free school breakfast. The McKinney-Vento Homeless Assistance Act (P.L. 100-77, 1987), as amended by the No Child Left Behind Act (P.L. 107-110, 2001), states that students who are identified by a school district as homeless or highly mobile automatically qualify for free meals and do not need to complete the full application process (U.S. Department of Education, 2004). If the household income is between 130 percent and 185 percent of the poverty level, the child is eligible for a reduced-price meal (USDA, 2008b). Ordinarily, children from households with incomes over 185 percent of the poverty level pay full price. Even full price meals, however, are subsidized by the government to a small extent through both cash reimbursements and the provision of USDA food commodities (see School Food Purchasing Data Illuminate the Usage of Major Types of Food later in this chapter and USDA Commodities in Chapter 2). Figures 1-4 and 1-5 show the changes in student participation from 1969 to 2007 by payment type for the NSLP and the SBP, respectively. For the NSLP, the percentage of students obtaining meals in the full-price category has decreased over time (USDA, 2008c). 2 As of October 1, 2008, the new name for the Food Stamp Program is the Supplemental Nutrition Assistance Program (SNAP).

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INTRODUCTION 23 35 Free Reduced Price Full Price Total 30 25 Average Participation (in millions) 20 Omnibus Reconciliation Act of 1981 15 10 5 0 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 Year FIGURE 1-4 Change in student participation in the NSLP by meal cost category, 1969–2007. SOURCE: USDA, 2008c. 35 Free Reduced Price Full Price Total 30 25 Average Participation (in millions) 20 15 10 5 0 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 Year FIGURE 1-5 Change in student participation in the SBP by meal cost category, 1969–2007. SOURCE: USDA, 2008d.

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24 NUTRITION STANDARDS AND MEAL REQUIREMENTS Currently, more children receive free meals than meals in the other two price categories. On average, 59 percent of the NSLP lunches served in FY 2007 were served to students who received their meals free or at a reduced price (USDA, 2008c). In the SBP, 81 percent of the meals were served free or at a reduced price (USDA, 2008d). Notably, approximately 10 percent of schools now serve breakfast free of charge to any child who wishes to participate (universal- free breakfast) (SNA, 2007). Given the current provisions, children who participate in both the NSLP and the SBP are offered at least 58 percent of the 1989 RDAs (NRC, 1989) for selected vitamins and minerals (at least 25 percent at breakfast and 33 percent at lunch). Thus, for the 36 weeks, on average, that children are in school, school meals may be the source of more than 40 percent of their weekly intakes of these nutrients. Therefore, school meals clearly have the potential to make a valuable contribution to the food intake and nutritional health of children, especially if their other meals and snacks are of poor nutritional quality or are unavailable. WHY IS THERE A NEED FOR UPDATING AND REVISIONS? Congress has recognized the need to update and revise the Nutrition Standards and Meal Requirements for the school meal programs. In 2004, Congress passed the Child Nutrition and WIC 3 Reauthorization Act (P.L. 108-265), which required USDA to issue guidance and regulations to promote the consistency of the standards for school meal programs with the standards provided in the most recent Dietary Guidelines for Americans and the Dietary Reference Intakes (DRIs) (IOM, 1997, 1998, 2000a, 2001, 2002/2005, 2005). Reasons for the current call for updates and revisions are shown in Box 1-1. The first two bullets in Box 1-1 represent the major reasons that Congress called for the revisions. BOX 1-1 Rationale for the Call to Revise the Current Nutrition Standards and Meal Requirements • Current Nutrition Standards and Meal Requirements are inconsistent with current Dietary Guidelines for Americans, especially with regard to meeting recommended intakes within energy needs by following a balanced meal pattern; increasing intake of fruits, many types of vegetables, and whole grains; minimizing intake of trans fat; a 25 to 35 percent range of total fat intake as a percentage of calories, limiting sodium intake to 2,300 mg per day.a • They are inconsistent with current nutrient reference values and were developed without the benefit of new understandings regarding how such values should be applied in assessing and planning diets for groups of people. • They may be contributing to the increased prevalence of childhood obesity in the United States. • Their implementation poses challenges for many school food operators. _____________________________ a See Appendix C for specifics. 3 WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children.

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INTRODUCTION 25 The last major change to the standards and requirements for school meals went into effect in 1995 (see Appendix B). Since then, authoritative dietary guidance and recommended nutrient intakes have changed, the prevalence of obesity has increased substantially, and stakeholders have voiced concerns and implemented some initiatives for change. Some of the relevant developments and changes that have occurred since 1995 are discussed below. Dietary Guidelines for Americans Has Changed Dietary Guidelines for Americans, first issued in 1980 (HHS/USDA, 1980) and revised every 5 years since then, provides the public with authoritative guidelines on diet and health. Moreover, according to law (National Nutrition Monitoring and Related Research Act, P.L. 101- 445 (October 22, 1990): §301), these guidelines form the basis of federal food, nutrition education, and information programs, including the school meal programs. Currently, the Nutrition Standards for school meals reflect the applicable recommendations of the 1995 Dietary Guidelines for Americans. The recommendations provided in the latest edition of Dietary Guidelines for Americans, issued in 2005 (HHS/USDA, 2005), are more extensive and specific than those presented in 1995, as shown in more detail in Appendix C. Furthermore, many of the key elements of the most recent nutrient reference values—Dietary Reference Intakes (DRIs), issued between 1997 and 2005—are incorporated in the 2005 Dietary Guidelines for Americans, as discussed in the text below. Reference Values for Nutrients Have Changed Public law and regulations enacted in the mid-1990s specified the use of the 1989 RDAs (NRC, 1989) to set the nutritional parameters for the NSLP and the SBP (USDA, 1994a). However, beginning in 1997 and continuing through 2005, the IOM developed an expanded set of reference values called the DRIs (IOM, 1997, 1998, 2000a, 2001, 2002/2005, 2005). In addition to more specifically incorporating chronic disease end points into considerations of the establishment of DRIs, the DRIs differ from the 1989 RDAs, in that • DRIs cover a more extensive list of nutrients, one of which is fiber; • DRIs include several types of reference values in addition to the RDAs, including Estimated Average Requirements (EARs), Adequate Intakes (AIs), Tolerable Upper Intake Levels (ULs), and Acceptable Macronutrient Distribution Ranges (AMDRs) (see Chapter 5 for further details); • DRIs use different age-gender groups, different units for vitamins A and E, and a different method for handling estimated energy needs; and • The DRI process established recommendations concerning total fat and saturated fat, as recommendations for those two nutrients were not available in 1989. The IOM also developed methods for the use of the EARs, AIs, ULs, and AMDRs to assess nutrient intakes by particular groups of individuals (IOM, 2000b) and to plan intakes for particular groups (IOM, 2003). Such changes are relevant to the task of making recommendations to revise the school meal programs. Notably, the use of RDAs for assessing or planning intakes for groups of people is no longer recommended.

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26 NUTRITION STANDARDS AND MEAL REQUIREMENTS The Prevalence of Obesity Among Schoolchildren Has Increased Much concern has been raised about the increasing prevalence of obesity among U.S. children, as indicated by the age- and gender-specific body mass indexes (BMIs) at the 95th percentile or higher (CDC, 2008a). Between 1976 and 2006, striking increases in the percentages of obese children occurred, as shown in Figure 1-6. 20 18 Ages 6-11 Ages 12-19 16 Percentage with BMI >95th Percentile 14 12 10 8 6 4 2 0 1976-1980 1988-1994 2003-2006 NHANES Survey Period FIGURE 1-6 The increasing prevalence of obesity (BMIs ≥95th percentile of Centers for Disease Control and Prevention growth charts, calculated as weight [in kilograms] divided by height [in meters squared]) among schoolchildren, 1976–2006. NOTE: NHANES = National Health and Nutrition Examination Survey. SOURCES: CDC, 2008a; Ogden et al., 2008.

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INTRODUCTION 27 Table 1-2 presents recent data on three categories of high BMIs among U.S. children. Notably, nearly one-third of all children are overweight or obese (BMI ≥85th percentile). Specifically, close to 17 percent of children are obese and another 16 percent are overweight. In all three BMI categories and for each age group, the prevalence is higher among males than among females and is higher among non-Hispanic blacks and Mexican Americans than among non-Hispanic whites (data not shown) (Ogden et al., 2008). Despite the limitations in the use of BMI as a measure of pediatric obesity (Ebbeling and Ludwig, 2008), the prevalences of obesity shown in Table 1-2 indicate that large numbers of children and adolescents are at increased risk for chronic disease: type II diabetes (Messiah et al., 2008), hypertension (Jago et al., 2006), and metabolic syndrome (De Ferranti et al., 2006) in the short term and cardiovascular disease in the long term (Baker et al., 2007). TABLE 1-2 Prevalence of High BMIs Among U.S. Children, by Age, 2003 to 2006 Age group, yr (both Percentage of children (SE) with the Following BMIs according genders) CDC Growth Charts: ≥97th Percentile ≥95th Percentile ≥85th Percentile 6–11 11.4 (0.9) 17.0 (1.3) 33.3 (2.0) 12–19 12.6 (1.0) 17.6 (1.2) 34.1 (1.5) NOTE: Data come from the National Health and Nutrition Examination Survey (NHANES). Pregnant adolescents were excluded. Values for BMIs were rounded to one decimal place. CDC = Centers for Disease Control and Prevention; SE = standard error. SOURCE: Derived from Ogden et al., 2008. Reprinted, with permission, from Journal of the American Medical Association. May 28, 2008. 299(20):2403. Copyright © (2008) American Medical Association. All rights reserved.

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28 NUTRITION STANDARDS AND MEAL REQUIREMENTS No studies have been found that link the school meal programs with obesity. However, because of the substantial contribution of school meals to total intake, revision of the Nutrition Standards and Meal Requirements might hold potential for reducing the possible contribution of the school meal programs to childhood obesity. Stakeholders Are Calling for Change Concomitantly with the developments mentioned above, stakeholders have actively sought to make changes to the school meals programs. The committee held an open meeting with representatives from professional organizations, associations, the food industry, and state and county agencies and food service operations at which the participants shared information and viewpoints concerning the need for revision to the Nutrition Standards and Meal Requirements for the school meal programs (Appendix D provides the workshop agenda). Several associations have initiatives that include actions to promote the application of the 2005 Dietary Guidelines for Americans to school meals. An important emphasis of food service operators and representatives of the food industry is that the recommendations for change need to be feasible and that cost, ease of preparation and service, and acceptance of the foods by the students be considered. They also encouraged authorities to make changes on a gradual basis. In addition to calling for revision of the Nutrition Standards and Meal Requirements, the Child Nutrition and WIC Reauthorization Act of 2004 (P.L. 108-265: §204) mandated that local wellness policies be developed in all school districts by the 2006–2007 school year. As a result, the level of involvement at the local level (by parents, students, representatives of the school food authority, the school board, the school administrator, and other members of the public) has increased substantially. Thus, additional calls for change are originating at the local level THE COMMITTEE’S TASK To help respond to the Congressional requirement that USDA issue new guidance and regulations for the Nutrition Standards and Menu Requirements of the school meal programs, the USDA has sought the assistance of the Institute of Medicine (IOM) to provide recommendations to update and revise the nutrition- and food-related standards and requirements for the school lunch and breakfast programs. The last revisions to these meal programs took place in 1995. The specific charge to the committee is shown in Box 1-2.

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INTRODUCTION 29 BOX 1-2 Charge to the Committee • Specify a planning model for school meals (including targets for intake) as it may relate to nutrients and other dietary components for lunch and breakfast; • Recommend revisions to the Nutrition Standards and, in consideration of the appropriate age- grade groups for schoolchildren, provide the calculations that quantify the amounts of nutrients and other dietary components specified in the Nutrition Standards; • Recommend the Meal Requirements necessary to implement the Nutrition Standards on the basis of two existing types of menu planning approaches (i.e., the food-based menu planning [FBMP] approach and the nutrient-based menu planning [NBMP] approach); for this task, the committee was asked to recommend Meal Requirements that include o standards for a food-based reimbursable meal by identifying the food components for as offered and as served meals and the amounts of food items per reimbursable meal by age-grade groups and o standards for a nutrient-based reimbursable meal by identifying the menu items for as offered and as served and the 5-day average amounts of nutrients and other dietary components per meal; and • Illustrate the practical application of the revised Nutrition Standards and Meal Requirements by developing menus for a 4-week cycle that will meet the recommended standards for the age-grade groups. The committee’s work has been divided into two phases. For the phase of the work reported here (Phase I), the committee was asked to identify and review the available data and information, formulate criteria, carry out an assessment of the food and nutrient intakes by schoolchildren, and describe its planning model and the analytic methods that it plans to use to develop recommendations for revising the standards. As specified in the committee’s task, at the time that this Phase I report is released, comments from interested parties will be accepted and the report will be discussed during a public forum carried out as part of the next scheduled committee meeting. 4 The input received will be taken into account during the Phase II activities, which will specify the recommendations for revisions. The committee’s overall task is to review and assess the food and nutritional needs of schoolchildren in the United States on the basis of the 2005 Dietary Guidelines for Americans (HHS/USDA, 2005) and the DRIs and to use that review as a basis for recommending revisions to the Nutrition Standards and Meal Requirements for the NSLP and the SBP. As part of its task, the committee has been asked to consider the critical issues described in Appendix E. The goal is 4 More information about committee meetings can be found by visiting the IOM website for this study: http://www.iom.edu/fnb/schoolmeals.

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30 NUTRITION STANDARDS AND MEAL REQUIREMENTS the development of a set of well-conceived, practical, and economical recommendations that reflect current nutrition science, increase the meals’ contents of the key food groups (as appropriate), improve the ability of the school meal programs to meet the nutritional needs of children, foster healthy eating habits, and safeguard children’s health. Furthermore, the request to the committee specifies that the recommendations be designed to be economical and keep program costs as close as possible to current levels adjusted for inflation. The committee intends to identify recommendations based on the best available nutrition science and will take cost into account. Finally, current law requires the programs to provide meals containing one-third of the RDA for lunch and one-fourth of the RDA for breakfast. This language was adopted before the new conceptual approach related to DRIs was developed and could be incorporated into legislation. Therefore, this Phase I report describes the planned approach to use DRIs and the Phase II report will compare differences (with examples and rationale) between basing standards on the RDA approach and basing the standards on the DRI methodology. RELEVANT FINDINGS FROM LARGE-SCALE EVALUATIONS OF SCHOOL MEAL PROGRAMS The committee has conducted an initial examination of large-scale evaluations of school meal programs to identify information that may be useful in revising the Nutrition Standards and Meal Requirements. Beginning in 1983, USDA funded numerous large-scale studies to evaluate the school meal programs and selected components of the programs (Appendix F). The topics of the evaluations have included the nutrient contents of the meals, the effects of the meals on the participants’ nutritional status, operational issues, and costs. The studies not only identified a number of strengths of the programs but also identified a number of areas for improvement. This section provides a brief summary of findings that the committee may review as it considers possible revisions it will propose. During Phase II, the committee will conduct targeted literature searches to determine whether additional studies may provide information useful to the process of developing recommendations for revisions to the Nutrition Standards and Meal Requirements. School Nutrition Dietary Assessment Studies Provide Data on Program Compliance and Students’ Intake All three studies in the School Nutrition Dietary Assessment (SNDA) series, SNDA-I (USDA, 1993), SNDA-II (USDA, 2001a), and SNDA-III (USDA, 2007a) provide data on the extent to which schools were in compliance with standards that were current at the time. All three studies showed that the lunches provided through the NSLP provided one-third or more of the 1989 RDAs for the required vitamins, minerals, and nutrients and that the breakfasts provided through the SBP provided one-fourth or more of the RDAs, on average. Based on data collected from nearly 400 elementary, middle, and high schools during the 2004–2005 school year (USDA, 2007a), compliance with the standards for key nutrients ranged from 71 percent for energy to more than 98 percent for calcium and protein. Compliance for cholesterol and dietary fiber exceeded 90 percent. However, all the lunches exceeded the sodium recommendation and few met the standards for total fat (19 percent) and saturated fat (28 percent). In the same study, compliance with current standards was less favorable for the SBP.

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INTRODUCTION 31 While nearly 66 percent of schools met the standard for vitamin C, less than 50 percent of schools met the standards for protein, vitamin A, calcium, and iron. Less than 25 percent of schools offered meals that complied with the standards for energy and total fat, and less than 10 percent complied with the saturated fat standard. The three SNDA studies also indicate change over time. SNDA-II (1998–1999 school year) found that school meals were lower in fat, on average, than they had been in 1991–1992 (SNDA- I) and that the percentage of schools that met the Nutrition Standards for total fat and saturated fat in meals as offered had increased from about 0 percent to 15 to 20 percent. SNDA-III (2004– 2005 school year) found no increase in the percentage of schools serving lunches that met the Nutrition Standard for total fat compared with the percentage found in SNDA-II but a significant increase in the percentage of schools that met the Nutrition Standard for saturated fat. In all three SNDA studies, breakfast was more likely than lunch to meet the dietary recommendation for total fat. On average, school lunches and school breakfasts remain high in sodium. Revenues Cover Reported Costs but Not Full Costs Using reported costs (not necessarily actual total costs), both the 1994 and the 2008 cost studies (USDA, 1994b, 2008e) found that school food authorities operated at a break-even level, on average. Reimbursable lunches generated a revenue surplus that many schools used to offset SBP losses, and in some cases, the surplus was used to reduce losses from non-program-related food services, such as à la carte food services. Notably, however, revenues fell short of covering full costs. The reported costs often excluded such costs as indirect costs, equipment depreciation, utilities, fuel (for off-site delivery), all of which contribute to the full cost. Revenues covered about 92 percent of reimbursable meals but only 61 percent of nonreimbursable meals (à la carte food services, adult meals, food services from vending machines, and catering) (USDA, 2008e). Nutrient-Based Menu Planning Poses Challenges but Offers Flexibility The Nutrient Standard Menu Planning approach (called Nutrient-Based Menu Planning for the purposes of this report) is described in more detail in Chapter 2. The two evaluations of this menu planning approach (USDA, 1997, 1998a) revealed a number of challenges related to staff resources, time requirements, and the software used but reported that the approach offered increased flexibility in menu planning. The resulting menus tended to be lower in total fat and saturated fat than they were before this approach was initiated and had comparable abilities to meet the RDAs. The rates of student participation in the meal programs and costs remained about the same. School Food Purchasing Data Illuminate the Usage of Major Types of Food The School Food Purchasing Study (USDA, 1998b) obtained national estimates of food purchases made in the 1996–1997 school year by public school districts participating in the NSLP and the SBP. That study included all food purchases, not only those that related to reimbursable meals served under the NSLP and the SBP. Other food purchases may have included à la carte foods, foods for staff meals, and foods served though USDA food assistance programs (Child and Adult Care, Summer Food Services, and the Nutrition Program for the Elderly).

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32 NUTRITION STANDARDS AND MEAL REQUIREMENTS On the basis of the findings of that study, in the 1996–1997 school year, school districts purchased 83 percent of their food commercially, received 13 percent of their food as donated commodities, and obtained 4 percent of their food in the form of processed foods containing donated commodities. The five leading food categories in terms of total value of the food donated were fluid milk, pizza, ground beef, cheese, and potato products. USDA donations were the primary source of the supply of peanuts and peanut butter, turkey products, beef products, vegetable oils and shortening, cheese, flour, and eggs. In an examination of purchasing practices, no one method produced the best cost per pound for all food items. Since the 1984–1985 school year, there had been large changes in the use of a number of foods, as briefly summarized below. • Higher rates of use: Breakfast cereals, prepared foods, yogurt, and fruit drinks • Lower rates of use: Fluid milk, butter, salad dressing, vegetable oils and shortening, lard, and other animal fats (consistent with recommendations to reduce total and saturated fat in meals) • Increased volumes: Fresh fruits and vegetables, with a much larger variety of these foods being donated Higher Calorie Level and Universal-Free School Breakfast Program Increase Program Participation The first evaluation of the School Breakfast Program (USDA, 1998c) found that the calorie content of breakfast affects participation. In particular, when the standards for breakfast specify that the meal is to contain a level of calories greater than 10 percent of the RDA, the likelihood that low-income elementary school students will eat breakfast increases. In a more recent 3-year pilot study (USDA, 2004), a universal-free school breakfast program resulted in a substantial increase in school breakfast participation (for all children), especially in the schools that served breakfast to students in the classroom. The School Meals Initiative Has Led to Several Operational Improvements The School Meals Initiative (SMI) aims to achieve far-reaching reform of the school meal programs relative to upgrading the nutritional content of school meals. It was finalized as a regulation in 1995 (USDA, 1995). The three SMI implementation studies (USDA, 2000a, 2001b, 2002a) addressed operational topics but not the extent to which schools met the SMI standards. In particular, the three SMI studies showed increasing and substantial progress in the implementation of menu planning approaches. In the 1999–2000 school year, nearly two-thirds of all school districts reported that they had fully implemented their chosen approach to menu planning, and many more were far along in the process. Menu changes, if any, tended to be modest, however. The SMI implementation studies found that the percentage of school districts that adopted nutrient-based menu planning remained stable at about 25 percent, but there was evidence that those that used this system of menu planning became more efficient at doing so. Nonetheless, key elements of nutrient-based menu planning (entering and analyzing recipes, entering and analyzing menus, and obtaining missing nutrient information) have remained challenging for many districts. The Team Nutrition Pilot Study (USDA, 1999), which preceded the SMIs, provided some data on how broad-scale nutrition education efforts may positively affect children’s food consumption behaviors, including the acceptance of menu choices.

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INTRODUCTION 33 Salad Bars Are More Prevalent in the Upper Grades and in Affluent Schools A review of salad bars in schools (USDA, 2002b) was based on SNDA-II data collected during the 1998–1999 school year. The review found that salad bars are more likely to be available in high schools than in elementary schools and in more affluent schools than in schools with a high percentage of children who receive free or reduced-price meals. Schools with salad bars may offer a wider variety of vegetables and fruits than other schools. The presence of a salad bar was associated with student participation in the NSLP in middle and high schools, but the study lacked data with which it could be determined whether the salad bars increased participation rates or with which the quantities of fruits and vegetables served to or consumed by students could be estimated. Few Peer-Reviewed Studies Address Program Impact Literature searches for relevant publications in peer-reviewed journals has not yet identified large-scale studies using data collected after the implementation of the SMI in 1995, the date of the most recent change in the Nutrition Standards and Meal Requirements. Gleason and Suitor (2003) used data from the 1994–1996 Continuing Survey of Food Intakes by Individuals to examine the impact of participation in the NSLP on children’s dietary intake at lunchtime and over 24 hours. By controlling for selection bias with a fixed-effects model, the investigators found that the NSLP was associated with an increased 24-hour intake of calcium, magnesium, phosphorus, zinc, vitamin B12, riboflavin, and fiber. Participants had lower intakes of added sugars than did non-participants, but higher intakes of total fat and saturated fat. In earlier peer- reviewed studies that used SNDA data, NSLP participation was positively related to the intake of selected nutrients at lunch (Burghardt et al., 1995; Gordon et al., 1995) and to daily dietary fat intake; but the other effects of program participation on 24-hour intakes were smaller, and fewer findings were statistically significant (Burghardt et al., 1995). IMPLICATIONS The NSLP and the SBP have a long and impressive history of providing nutritious low-cost meals to schoolchildren. Over time, efforts have been made to update the programs’ Nutrition Standards and Meal Requirements to keep pace with the changing understandings of children’s nutritional needs. There have been major developments in dietary guidance and nutrient reference standards and their application to programs since the last major revisions to the Nutrition Standards and Meal Requirements. It is now time to develop recommendations for further revisions to the Nutrition Standards and Meal Requirements of the school meal programs so that the program can achieve greater benefits for the nation’s children. Chapter 2 helps to clarify the nature of the charge to the committee by describing the current standards that are the subject of the committee’s review and subsequent recommendations, along with topics that may be important to the committee as it considers recommendations.

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