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4 Food and Nutrient Needs of Schoolchildren The committee’s charge included a requirement to “review and assess the food and nutritional needs of school-aged children in the United States based on the 2005 Dietary Guidelines and the Dietary Reference Intakes.” Findings from this review are to form the basis for recommended revisions to existing nutrition standards and meal requirements. In its review, the committee considered recent published data on schoolchildren in the United States covering the children’s dietary intakes, weight status, and biochemical indicators of nutritional status. This chapter describes the data used in the committee’s review, including details about the methods for assessing the apparent adequacy of children’s food and nutrient intakes. Then it summarizes the committee’s key findings in two sections. The first section addresses the children’s reported food intakes, and the second addresses children’s estimated energy and nutrient intakes. The chapter concludes with the identification of food groups and nutrients under consideration for special attentions during Phase II of the study. DATA SOURCES The data considered by the committee came primarily from two published studies that included nationally representative samples of schoolchildren in the United States: • Diet Quality of American School-Age Children by School Lunch Participation Status (USDA, 2008l). This report, hereafter referred to as the 2008 Diet Quality Report, used data from the National Health and Nutrition Examination Survey (NHANES). NHANES is conducted by the National Center for Health Statistics and is designed to provide national estimates of the health and nutrition status of the civilian, noninstitutionalized population in the 50 states. Since 1999, NHANES has been a continuous annual survey, and data from the survey are released in public data files every 2 years. The 2008 Diet Quality Report provides data on children’s 1-day (24-hour) intakes of MyPyramid food groups (USDA, 2008n), on the basis of data from 61

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62 NUTRITION STANDARDS AND MEAL REQUIREMENTS NHANES 1999–2002, 1 and on children’s usual nutrient intakes 2 and body weight distributions, on the basis of data from NHANES 1999–2004. • School Nutrition Dietary Assessment Study–III (SNDA-III) (USDA, 2007a). SNDA-III was sponsored by the U.S. Department of Agriculture (USDA) and collected data from a nationally representative sample of public school children in grades 1–12. The study’s multistage sampling approach first sampled school food authorities (SFAs) in the 48 contiguous states, then the schools served by those SFAs, and then the children who attended those schools. SNDA-III provides data on children’s usual nutrient intakes. Data were collected during the 2004–2005 school year. Table 4-1 summarizes information about each of these main data sources and how they were used in the committee’s review. Additional details about the data collection methods, the samples analyzed, and the analysis methods are provided in Appendix I. Neither of the two main data sources included information about trans fat or vitamin D intakes, but the committee briefly addressed these two topics in its review. To supplement the available data, the committee reviewed published reports of NHANES data on (1) body mass index and the prevalence of obesity, and (2) biochemical indicators of nutritional status. TABLE 4-1 Key Data Sources Used to Assess Food and Nutrient Needs of Schoolchildren 2008 Diet Quality Reporta SNDA-IIIb Data reviewed by the Committee One-day food group ⎯ √ intakes based on MyPyramid* Usual nutrient intakes √ √ ⎯ BMI Distribution √ • Children (ages 5–18 years) Sample 2,314 children (ages 6–18 years) • One-day intakes of MyPyramid food groups: 2,597 children • Usual nutrient intakes: 3,546 children • BMI distribution: 3,495 children • One-day intakes of MyPyramid food Data collection period 2004–2005 school year groups: 1999–2002 • Usual nutrient intakes and BMI distribution: 1999–2004 NOTE: — = data not included; √ = data included; SNDA=School Nutrition Dietary Assessment. *Data on food group intakes were based on a single 24-hour recall and were not adjusted to reflect usual food intakes. Analysis was limited appropriately to estimates of group means. SOURCES: a USDA, 2008l; b USDA, 2007a. 1 MyPyramid intakes could not be estimated for children in the NHANES 2002–2004 sample because a companion database that is needed to generate these estimates (the MyPyramid Equivalents Database for USDA Food Codes [version 1.0; USDA, 2006b]), provides data only for NHANES 1999–2000 and 2001–2002. 2 “Usual nutrient intakes” refers to 24-hour recall data that have been statistically adjusted, following methods recommended by the IOM, to better estimate long-run (usual) intakes (ISU, 1997; Nusser et al., 1996); for this report, reference to nutrient intake includes energy (calories).

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 63 DATA LIMITATIONS Dietary intake data played a central role in the committee’s review and assessment of children’s food and nutrient needs, as shown in Table 4-1. The available data have four important limitations that the committee acknowledged in its review. Each of these limitations is described below. Underreporting and Overreporting of Food Intakes It is well recognized that individuals responding to dietary surveys may underreport or overreport their intakes. Underreporting may result in overestimates of the prevalence of inadequate intakes or in underestimates of excessive intakes; and overreporting may result in overestimates of excessive intakes (Briefel et al., 1997). Underreporting tends to be greatest among adolescents, especially females; people who are overweight or obese; and people who have low incomes (Bandini et al., 1997; Braam et al., 1998; Little et al., 1999; Livingstone et al., 1992; Pryer et al., 1997; Stallone et al., 1997; Ventura et al., 2006). For elementary school-age children, the opposite problem may occur, with food intakes being overreported by the children themselves, by their parents, or by both (Basch et al., 1990; Baxter et al., 2002; Lytle et al., 1993). Some researchers have reported that there may be differences in children’s under- and overreporting by meal (Baxter et al., 2007; Guinn et al., 2008). Problems of underreporting in the data reviewed by the committee may have been mitigated to some extent by the data collection processing techniques used: • Both NHANES and SNDA-III used the Automated Multiple-Pass Method (AMPM) which limits the underreporting of food intakes (Johnson et al., 2008) and improves the accuracy of estimated energy intakes in normal weight adults (Moshfegh et al., 2008). • SNDA-III used several data collection strategies to minimize reporting errors among children (USDA, 2007a) that included two-part interviewing and parental assistance for elementary school children, aids for the interviews such as copies of school menus, and a listing of all potential locations in a school where food or beverages could be obtained. • SNDA-III incorporated data provided by school foodservice managers about portion sizes used and energy and nutrient content of foods offered in reimbursable school meals before processing the 24-hour recall data. Although the above techniques may have acted to reduce reporting errors in the NHANES and SNDA-III dietary intake data, there is evidence to suggest that some level of under- or overreporting remains. Moshfegh et al. (2008) found that, even with use of the AMPM protocol, individuals who were overweight or obese underreported their energy intakes. Moreover, as discussed later in this chapter, the SNDA-III data provide suggestive evidence that the intakes of children ages 6–8 years and females ages 9–13 years may have been overreported and that intakes of adolescents ages 14–18 years, particularly males, may have been underreported. It is likely that comparable over- and underreporting occurred in the NHANES data used in the 2008 Diet Quality Report; however the committee did not have access to data that would elucidate this issue. 3 The major implications of the apparent over- and underreporting of food intakes is that 3 The SNDA-III report included comparisons of reported energy intakes and Estimated Energy Requirements (EERs). These comparisons suggest come misreporting of usual food (energy) intakes. Because the 2008 Diet

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64 NUTRITION STANDARDS AND MEAL REQUIREMENTS the prevalence of nutrient inadequacy may be underestimated for children ages 6–8 years and for females ages 9–13 years, but it may be overestimated for adolescents ages 14–18 years. Despite these limitations, the dietary intake data are an important source of information for the committee’s work. The method recommended by the Institute of Medicine (IOM, 2000b) to assess the adequacy of diets consumed by population groups requires the use of 24-hour recall data. The committee agrees with the Institute of Medicine that “comparing high-quality intake data with tailored requirement data to assess intakes is a meaningful undertaking and can, at a minimum, identify nutrients likely to be either under- or overconsumed by the … group of interest” (IOM, 2000b, p. 161). The committee recognizes that estimates of the prevalence of inadequate nutrient intakes are imprecise, providing general information about nutrients that are most likely to be of concern rather than precise estimates of the proportions of children with definitive nutrient inadequacies. The committee also examined anthropometric data and biochemical data to obtain additional perspective on children’s usual intakes of energy and micronutrients, respectively. One-Day Data on Food Group Intakes Rather Than Usual Intakes The available data on children’s food group intakes are based on a single 24-hour recall, whereas data on nutrient intakes reflect children’s usual intakes. Although data from a single 24- hour recall do not provide a reliable estimate of an individual’s usual intake or the usual intake distribution of a population group, these data do provide reliable estimates of mean intakes at the group level. Consequently, the committee’s use of the food intake data is limited to examination of mean intakes relative to MyPyramid recommendations. Lack of Data on Supplement Intake Nutrient intakes from both the 2008 Diet Quality Report and SNDA-III are based on intakes from food and beverages only. They do not include intakes from dietary supplements or over- the-counter medicines. The 2008 Diet Quality Report indicated that 29 percent of all schoolchildren took some type of dietary supplement (most commonly multivitamin- multimineral preparations) during the preceding month, and SNDA-III found that more than half of all schoolchildren used vitamin supplements at some level. Given that sizeable proportions of schoolchildren used supplements, nutrient intake data from both SNDA-III and the 2008 Diet Quality Report may overestimate the prevalence of nutrient inadequacy. In addition, it was generally not possible to determine whether nutrients were consumed in amounts that were higher than the Tolerable Upper Intake Level (UL). Lag in Reflecting Changes in the Marketplace Recent changes in food fortification and in other aspects of the marketplace may have changed the availability and the consumption of some types of food and some nutrients and other food components. For example, the availability of whole grain products and of calcium-fortified foods has been increasing, and the trans fat content of foods has been decreasing. However, the impacts of marketplace changes on consumption among schoolchildren is unknown. Quality Report did not include comparisons of usual energy intakes and EERs, it was not possible to assess the likelihood of over- or underreporting.

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 65 ASSESSMENT OF FOOD INTAKES To assess children’s food intakes, the committee relied on data from the 2008 Diet Quality Report. These data are based on single 24-hour recalls collected in NHANES 1999–2002. The MyPyramid food guidance system (USDA, 2008n) provided the recommended levels of intake that the committee used to assess food intakes (see Appendix J). The committee used the MyPyramid food guidance system because it translates the 2005 Dietary Guidelines for Americans (HHS/USDA, 2005) into recommendations about the types and amounts of food that should be consumed to promote health and maintain weight (Marcoe et al., 2006). The MyPyramid Food Guidance System The MyPyramid food guidance system (USDA, 2008n) includes MyPyramid food intake patterns. These patterns provide specific food-based dietary guidance that is consistent with the recommendations in the 2005 Dietary Guidelines for Americans. The system also incorporates the nutrient-based recommendations made in the Dietary Reference Intakes (DRIs). USDA used an iterative process to develop the food intake patterns for MyPyramid. This process identified appropriate energy levels and nutritional goals for the patterns, established food groupings, determined the amounts of nutrients that would be provided by consuming different combinations of foods, and evaluated the nutrient levels in each pattern against specific goals. With the exception of sodium, nutrient goals were set by using the Recommended Dietary Allowances (RDAs) or Adequate Intakes (AIs). For sodium, the goal was less than the UL. USDA used a weighted average to estimate the amounts of nutrients that each food group would contribute. The assigned weights were based on the level of consumption of each food item, as determined from national food consumption surveys (Marcoe et al., 2006). Appendix J presents tables from MyPyramid that provide the food intake patterns (recommended types and amounts of foods) for various calorie levels suitable for schoolchildren. The MyPyramid food intake patterns provide at least 90 percent of the goals for all nutrients except vitamin E and potassium. The amounts of vitamin E and potassium provided by the patterns are larger, however, than the typical intakes by children (Marcoe et al., 2006). The major food groups in MyPyramid are fruits, vegetables, grains, milk products, meat and meat alternates, and oils. 4 To promote the intake of the recommended amounts of nutrients, food intake patterns specify five subgroups for vegetables (dark green vegetables, orange vegetables, legumes, starchy vegetables, and other vegetables) and two subgroups for grains (whole grains and other grains). The foods used to develop the food patterns are the forms of each food in the food group that are the lowest in fat (e.g., lean meat and fat-free milk) and that are free of added sugars (e.g., water-packed canned fruit). Thus, the patterns assume the consumption of the most nutrient- dense forms of foods in each food group. The MyPyramid food guide also includes a discretionary calorie allowance, that is, the amount of calories from any source (often added sugars or solid fats) that can be used flexibly. For the purposes of this Phase I report and its related analyses, considerations concerning added sugars are included as a component of the discretionary calorie allowance. During Phase II, issues related to added sugars in school meal programs will be considered more specifically. 4 Oils and trans-free soft margarines are included to provide vitamin E and essential fatty acids.

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66 NUTRITION STANDARDS AND MEAL REQUIREMENTS Table J-2 in Appendix J provides detailed information about the food items included in each food group and subgroup 5 ; the equivalent quantities for each food group; and explanations of the recommended amounts for the vegetable and grain subgroups, oils, and the discretionary calorie allowance. The explanations are key to understanding new concepts that were introduced on the basis of the work of the 2005 Dietary Guidelines Advisory Committee (HHS/USDA, 2004). MyPyramid includes food intake patterns for a wide range of calorie levels to accommodate the needs of different individuals. (Appendix J shows only the intake patterns that are suitable for children ages 2–18 years.) The recommended amounts of foods from the major food groups and from the food subgroups differ with differences in nutrient and energy needs, which are based on a person’s age, gender, and activity level. Mean food group intakes that are below MyPyramid recommendations do not necessarily indicate inadequate nutrient intake, but they do suggest improvements to the diet that would achieve greater consistency with Dietary Guidelines for Americans and recommended intakes for individuals. Estimating Intakes of MyPyramid Food Groups The committee relied on published estimates of children’s one day intakes of MyPyramid food groups. Estimation of the intakes of MyPyramid food groups is a complex process for several reasons: (1) a large percentage of the foods eaten in the United States represent a combination of ingredients from two or more food groups, (2) many of the foods consumed are not lean or fat-free forms of the food, and (3) many foods contain added solid fats or added sugars, or both. Cleveland and colleagues (1997) developed a method that can be used to analyze food intake data to estimate the number of Food Pyramid servings for comparison with Pyramid recommendations. (The Food Pyramid was an earlier version of the MyPyramid food guidance system.) The method involves the disaggregation of food mixtures into their component parts so that each ingredient can be credited to a specific food group. For example, the ingredients in pizza are credited to the grains, milk, vegetable, and (if meat is present) the meat and meat alternates groups. 6 If the meat is not lean, the number of grams of fat in excess of a lean meat ounce equivalent would be considered discretionary calories. The grain in a sweetened ready-to- eat cereal would be credited to the grains group and the sugar would be credited (in teaspoon equivalents) to added sugars under discretionary calories. With this system, some food mixtures make small contributions to one or more food groups and make proportionately larger contributions to discretionary calories. Peach pie, for example, provides fruit that is credited to the fruit group and flour that is credited to the grains group, but the sugar and shortening would be credited to discretionary calories. To obtain the disaggregated food-level data needed to estimate MyPyramid food group intakes, the authors of the 2008 Diet Quality Report linked the foods reported in NHANES 24- hour recalls to the MyPyramid Equivalents Database for USDA Survey Food Codes (USDA, 2006b). That database contains values for the MyPyramid food groups and subgroups (as described above) for every food reported in NHANES 1999–2002, as well as values for oils, solid fats, and added sugars. 7 The values for fruit, vegetables, milk, and milk products are reported in cup equivalents; and those for grains and for meats and beans are reported in ounce 5 Note the emphasis on foods with no added sugars or fats, lean meats, and fat-free milk. 6 Hereafter, the meat and meat alternateves group is called the meat and beans group for convenience. 7 Alcohol is also counted under discretionary calories but is omitted from this report on the Nutrition Standards for school meals.

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 67 equivalents. Discretionary calories are reported in grams of solid fats and teaspoons of added sugars. The committee compared the published values for children’s mean intakes of MyPyramid food groups to MyPyramid food intake patterns for specific calorie levels. The calorie levels chosen (1,600 calories for children ages 6–8 years, 2,000 calories for children ages 9–13 years, and 2,400 calories from children ages 14–18 years) were based on the Estimated Energy Requirements (EERs) reported in SNDA-III. These requirements are discussed under Energy later in this chapter. Results and Discussion Figure 4-1 illustrates graphically how children’s one day intakes compared with the MyPyramid food guidance system recommendations. For all age groups, the level of consumption of total grains was high and the level of consumption of whole grains and the three types of vegetables combined was very low. 140 4-8 years, 1,600 calories 9-13 years, 2,000 calories 14-18 years, 2,400 calories 120 Percentage of MyPyramid Recommendation Consumed 100 80 60 40 20 0 Total fruit Total vegetable Dark green and Total grain Whole grain Total milk group Total meats and orange veg, and beans legumes MyPyramid Recommended Foods FIGURE 4-1 Percentages of MyPyramid recommended food groups or food components consumed, by age group, based on the recommended daily amounts for the specified level of calories. NOTE: veg = vegetable. SOURCE: USDA, 2008l.

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68 NUTRITION STANDARDS AND MEAL REQUIREMENTS Tables 4-2 through 4-4 compare the reported mean daily amounts of each MyPyramid food group consumed with the MyPyramid pattern for the specified calorie level. Data are presented in the three tables for the following age groups, respectively: 5–8 years, 9–13 years, and 14–18 years. Data are not presented by gender because these data were not available in the 2008 Diet Quality Report. Also in that report, the data for three vegetable subgroups (dark green vegetables, orange vegetables, and legumes) were combined; therefore, the analysis reflects these vegetables as one group. For children ages 5–8 years, the mean level of grain consumption reported was 38 percent higher than the MyPyramid recommendation. However, few of the grains that children consumed were whole grains. The mean level of consumption of whole grains was less than one-fourth of the MyPyramid recommendation. The mean intakes reported were about 80 percent of the amounts recommended for the fruit and milk groups and 70 percent of the amounts recommended for the meats and beans group. The mean level of intake of vegetables was low— less than half the recommended amount—and the levels of consumption of dark green and orange vegetables and legumes were especially low. TABLE 4-2 Mean Daily Amounts of MyPyramid Food Groups Consumed Compared with a 1,600- Calorie MyPyramid Food Intake Pattern, Children Ages 5–8 Years Percentage of the MyPyramid MyPyramid Food Recommendation Food Group or Food Intake Pattern Mean Daily of 1,600 Calories Consumed Component Consumption Total fruit (cup equiv) 1.5 1.2 80 Total vegetables (cup 2 0.9 45 equiv) 0.86a Dark green and orange 0.1 12 vegetables and legumes Total grains (oz equiv) 5 6.9 138 Whole grains (oz 2.5b 0.6 24 equiv) Total milk group (oz 3 2.4 80 equiv) Total meats and beans (oz 5 3.5 70 equiv) NOTE: The sample (n = 578) included schoolchildren, and weekday food consumption recalls were obtained during periods when school was in session. Estimates are based on a single 24-hour recall per child. The MyPyramid food intake pattern used is from the Dietary Guidelines for Americans (HHS/USDA, 2005). equiv = equivalent; oz = ounces. a Based on the recommendation of 6 cup equivalents per week. b Based on the recommendation that half of all grain equivalents be whole grains. SOURCE: Weighted tabulations of data from NHANES 1999–2002, as reported in Diet Quality of American School-Age Children by School Lunch Participation Status (USDA, 2008l); adapted from Table C-20.

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 69 The mean intakes of vegetables, grains, and meats and beans reported by children ages 9–13 years were comparable to those reported by younger children (Table 4-3). However, the mean intake of fruits was considerably lower, and the mean intake of milk and milk products was somewhat lower. Children ages 9–13 years consumed less than half (45 percent) the recommended amount of fruit and 71 percent of the recommended amount of milk and milk products. TABLE 4-3 Mean Daily Amounts of MyPyramid Food Groups Consumed Compared with a 2,000- Calorie MyPyramid Food Intake Pattern, Children Ages 9–13 Years Percentage of the MyPyramid MyPyramid Food Recommendation Food Group or Food Intake Pattern of Mean Daily 2,000 calories Consumed Component Consumption Total fruit (cup equiv) 2 0.9 45 Total vegetables (cup 2.5 1.1 44 equiv) Dark green and orange 1.14a 0.1 9 vegetables and legumes Total grains (oz equiv) 6 7.1 118 3b Whole grains (oz equiv) 0.6 20 Total milk group (oz 3 2.2 73 equiv) Total meat and bean (oz 5.5 3.9 71 equiv) NOTE: The sample (n = 998) included schoolchildren, and weekday food consumption recalls were provided during periods when school was in session. Excludes pregnant and breast-feeding females. Estimates are based on a single 24-hour recall per child. The MyPyramid food intake pattern used is from the Dietary Guidelines for Americans (HHS/USDA, 2005). equiv = equivalent; oz = ounce. a Based on the recommendation of 6 cup equivalents per week. b Based on the recommendation that half of all grain equivalents be whole grains. SOURCE: Weighted tabulations of data from NHANES 1999–2002, as reported in Diet Quality of American School-Age Children by School Lunch Participation Status (USDA, 2008l); adapted from Table C-20.

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70 NUTRITION STANDARDS AND MEAL REQUIREMENTS Finally, the findings for children ages 14–18 years were similar to those reported for younger children, but the mean intakes generally represented somewhat smaller percentages of the recommended amounts (Table 4-4). The only food group for which the mean intake exceeded 80 percent of the recommendation was grains. TABLE 4-4 Mean Daily Amounts of MyPyramid Food Groups Consumed Compared with 2,400- Calorie MyPyramid Food Intake Pattern, Children Ages 14–18 Years Percentage of the MyPyramid MyPyramid Food Food Group or Food Intake Pattern of Mean Daily Recommendation Consumed Component 2,400 calories Consumption Total fruit (cup equiv) 2 1 50 Total vegetables (cup 3 1.3 43 equiv) Dark green and orange 1.14a 0.2 18 vegetables and legumes Total grains (oz equiv) 8 7.6 95 Whole grains (oz 4b 0.4 10 equiv) Total milk group (oz 3 2 66 equiv) Total meats and bean (oz 6.5 4.9 75 equiv) NOTE: The sample (n = 1,021) included schoolchildren, and weekday food consumption recalls were obtained during periods when school was in session. Excludes pregnant and breast-feeding females. Estimates are based on a single 24-hour recall per child. The MyPyramid food intake pattern used is from the Dietary Guidelines for Americans (HHS/USDA, 2005). equiv = equivalent; oz = ounce. a Based on the recommendation of 6 cup equivalents per week. b Based on the recommendation that half of all grain equivalents be whole grains. SOURCE: Weighted tabulations of data from NHANES 1999–2002, as reported in Diet Quality of American School-Age Children by School Lunch Participation Status (USDA, 2008l); adapted from Table C-20.

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 71 The Dietary Guidelines for Americans recommend that the majority of fruit intake come from whole fruits (fresh, frozen, canned, or dried) rather than fruit juice. Data presented in the 2008 Diet Quality Report indicate that whole fruits accounted for about 40 to 50 percent of children’s total fruit intakes (USDA, 2008l). Children consumed excessive amounts of discretionary calories from solid fats and added sugars, 8 as shown in Table 4-5. On average, the food intakes reported by schoolchildren included 2.6 to 5.5 times the recommended number of discretionary calories from these sources. The top five contributors to discretionary solid fat in the diets of schoolchildren were sandwiches (other than burgers), french fries and other fried potato products, pizza with meat, whole milk, and hamburgers and cheeseburgers (USDA, 2008l). The leading contributors to added discretionary sugars were regular sodas, noncarbonated sweetened drinks, candy, ready-to-eat breakfast cereals, and ice cream. TABLE 4-5 Mean Daily Intakes of Discretionary Calories from Solid Fats and Added Sugars, by Age Group 5–8 years 9–13 years 14–18 years (n = 578) (n = 998) (n = 1,021) Parameter 1,600 2,000 2,400 Calorie level for age group MyPyramid discretionary calorie 132 267 362 allowance Mean intake of discretionary solid fat 44.4 47.4 51.2 Grams 400 427 461 Caloriesa Mean intake of discretionary added sugars 19 22.8 28.9 Teaspoons 319 383 486 Caloriesb Total discretionary calories 719 810 947 Mean Mean percent of discretionary calorie 545 303 262 allowance NOTE: n = sample size. a Estimated on the basis of the number of grams (g) of discretionary solid fat (fat g × 9 calories/g). b Estimated on the basis of the number of teaspoons (tsp) of added sugars (tsp × 4.2 g/tsp × 4 calories/g). SOURCES: Weighted tabulations of data from NHANES 1999–2002, as reported in Diet Quality of American School-Age Children by School Lunch Participation Status (USDA, 2008l); adapted from Table C-20. Sample includes schoolchildren with weekday recalls during periods when school was in session. Excludes pregnant and breastfeeding females. Estimates are based on a single 24-hour recall per child. MyPyramid discretionary calorie allowance used was from Dietary Guidelines for Americans (HHS/USDA, 2005). 8 Discretionary calorie intake is also influenced by the consumption of more than the recommended amounts of MyPyramid food groups, as was observed for grain intakes of children ages 5–8 years and 9–13 years (Tables 4-2 and 4-3).

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78 NUTRITION STANDARDS AND MEAL REQUIREMENTS Nutrients with Adequate Intakes For calcium, potassium, fiber, and vitamin D, the DRIs specify AIs rather than EARs. Table 4-7 presents data on the schoolchildren’s mean intakes of all of these nutrients except vitamin D, which is discussed later in this section. As emphasized by the Institute of Medicine (IOM, 2000b), inherent limitations in the AI reference value affect conclusions that can be drawn about nutrient adequacy. If the usual mean intake is equal to or higher than the AI, the prevalence of inadequacy is likely to be low. If the usual mean intake is less than the AI, no firm conclusions can be drawn about the adequacy of usual intakes. However, when mean intakes are substantially lower than the AIs, there may be reason to be concerned about inadequacy. TABLE 4-7 AIs and Mean Reported Usual Intakes of Calcium, Potassium, and Fiber of Schoolchildren on the Basis of Usual Nutrient Intakes from SNDA-III 6–8 yr, both 9–13 yr, 14–18 yr, 14–18 yr, genders 9–13 yr, males females males females Nutrient (n = 343) (n = 469) (n = 484) (n = 506) (n = 512) Calcium (mg) AI 800 1,300 1,300 1,300 1,300 Mean usual 1,093 1,213 1,050 1,248 847 intake Potassium (mg) AI 3,800 4,500 4,500 4,700 4,700 Mean usual 2,415 2,662 2,370 3,004 2,084 intake Fiber (g) AI 25 31 26 38 26 Mean usual 13.9 15 13.3 16.2 12 intake Fiber (g/1,000 kcal) AI 14 14 14 14 14 Mean usual 7.1 6.8 6.9 6.2 6.9 intake NOTE: g = grams; kcal = calories; mg = milligrams; n = sample size. SOURCES: Weighted tabulations of data from the SNDA-III (USDA, 2007a); adapted from Table VI.16 in Volume II. Dietary intake data (24-hour recalls) were collected during the 2004–2005 school year and do not include intakes from dietary supplements (e.g., multivitamin-multimineral preparations). The personal computer version of the Software for Intake Distribution Estimation (PC-SIDE; ISU, 1997) was used to estimate usual nutrient intake distributions. The AIs used in the analysis were from the DRI reports (IOM, 1997, 2002/2005, 2005).

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 79 Calcium For calcium, the mean usual intake by children ages 6–8 years was higher than the AI, indicating that the prevalence of inadequate calcium intakes in this age group is likely to be low. The mean usual intakes of calcium for all groups of older children were lower than their respective AIs. The gap between the mean usual intake and the AI of calcium was larger for females than for males. Inadequate calcium intake can constitute a notable health concern for schoolchildren. Peak bone mass is largely accrued during adolescence, and may not be achieved if optimal calcium intake is not reached. On average, the age of peak calcium accrual for females is reached at 12.5 years, while the age of peak accrual for males is 14 years old. Several studies support a potential relationship between low calcium intakes and fractures during adolescence (Goulding et al., 1998, 2001; Wyshak and Frisch, 1994). The risks of not attaining peak bone mass during adolescence include osteoporosis and bone fractures later in life (Greer et al., 2006; IOM, 1997). Potassium For potassium, the mean usual intakes by all groups of children were lower than their respective AIs. Direct evidence on the potassium requirements of children is lacking (IOM, 2005). Because the conditions resulting from inadequate potassium intake are chronic and likely to result from inadequate intake over an extended period of time, there may be good reasons for concern about the current levels of potassium intake by children even in the face of limited data. Fiber The level used to establish AIs for fiber was 14 grams per 1,000 calories (IOM, 2002/2005), which is based on the median energy intake of specific age-gender subgroups, as estimated from the 1994–1996, 1998 Continuing Survey of Food Intakes by Individuals. On a gram-per-1,000 calorie basis, children’s usual daily fiber intakes were generally less than half of the 14 grams assumed in setting the AI. For all groups, even the 95th percentile of the distribution of usual fiber intake was less than the AI (see http://www.fns.usda.gov/oane). Part of the discrepancy is due to the fact that AIs are defined for total fiber (dietary fiber plus functional fiber), but food composition databases include values only for dietary fiber and do not include all sources of functional fiber. Thus, fiber intakes are underestimated, but not to an extent that would alleviate the marked disparities between the AIs and the usual intakes apparent in these data. 10 For this reason, some have suggested that the methods used to establish the AIs for fiber may need to be reexamined, especially for children and adolescents (USDA/ERS, 2007b). 11 The Institute of Medicine (IOM, 2002/2005) has concluded that the consumption of fiber should be increased to promote normal laxation, help prevent diet-related cancer, help reduce serum cholesterol concentrations and therefore the risk of coronary heart disease, and help prevent obesity and the risk of adult-onset diabetes. Vitamin D Data on the vitamin D intake of schoolchildren are not available. Neither of the published analyses of usual nutrient intakes reviewed by the committee includes data on vitamin D intakes. Release 20 of USDA’s National Nutrient Database for Standard Reference, the authoritative source of food composition data in the United States, contains vitamin D contents of only about 600 foods, whereas the vitamin C content of about 1,100 foods is listed (USDA/ARS, 2008). That database does not yet include the vitamin D contents of foods that have recently been fortified with vitamin D or the contents of specific forms of vitamin D. The challenges associated with the estimation of vitamin D intakes have been described by Yetley 10 It is estimated that adults consume about 5.1 more grams per day of fiber than the amount estimated from current food composition databases (IOM, 2002/2005). 11 The data used to establish AIs are drawn from studies of coronary heart disease risk among adults. Moreover, the AIs for children are two to three times higher than the standard previously used to assess fiber intake in this age group (USDA/ERS, 2007b).

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80 NUTRITION STANDARDS AND MEAL REQUIREMENTS (2008). Yetley (2008) has reviewed the results of selected vitamin D status assessments that were based on NHANES data. Those data have included serum 25-hydroxyvitamin D concentrations since 1988. Using existing reference values, the prevalence of low 25-hydroxyvitamin D (≤25.5 nanomoles per liter) for children was ≤1 percent for children ages 5–11 years and 5 percent for children ages 12–19 years. Nonetheless, the committee is aware of recent interest in reviewing and, if needed, updating the reference values associated with vitamin D as well as reviewing discussions about the appropriateness of 25-hydroxyvitamin D as a biomarker for vitamin D status. In September 2008, the Institute of Medicine put in place a new DRI study to review emerging data about vitamin D requirements and health. The relevance of newer information on vitamin D to the school meal programs must await the outcome of this important work. Energy The adequacy of usual energy intake may be evaluated by comparing energy intake estimates derived from self-reported food intake with EERs. Adipose tissue stores may also be used to evaluate the adequacy of usual energy intake, with excessive stores a marker for excessive energy intake and low stores indicative of chronic insufficient energy intake. This can be assessed by examining the prevalence of obesity and underweight, as discussed in Chapters 1 and 2, respectively. The assessment of self-reported energy intakes is challenging. In theory, populations that are in energy balance (not gaining or losing weight) should have average usual energy intakes that are roughly equivalent to their corresponding EERs. However, as noted earlier, it is well recognized that children or their caregivers tend to misreport food intake in dietary surveys. The accurate estimation of EERs also requires accurate information about customary levels of physical activity. Rather than collecting detailed data about physical activity, SNDA-III assumes a “low active” level of physical activity for all children. The study’s authors used this assumption because data from the Youth Media Campaign Longitudinal Survey indicate that relatively few children are engaged in regular physical activity (USDA, 2007a). The survey found that more than 60 percent of children ages 9 through 13 years did not participate in any organized physical activity during their non-school hours and that about 23 percent did not engage in physical activity during their free time (CDC, 2003). Reported usual energy intakes and EERs for schoolchildren are shown in Table 4-8. 12 For children ages 6–8 years and females ages 9–13 years, both the mean and median reported usual energy intakes exceeded the mean and median EERs. The gap was approximately 400 calories for the youngest children and approximately 200 calories for the older females. Excess daily usual energy intakes in this range would lead to an annual weight gain of approximately 20 to 30 pounds. The magnitude of the difference between usual energy intake and the EER suggests that the food intakes for these age groups were overreported. However, an alternative explanation for the discrepancy between mean usual energy intakes and mean EERs is that EERs were underestimated because a low-active level of physical activity was assumed for all children (USDA, 2007a). In contrast, for adolescents ages 14–18 years, reported usual energy intakes were less than the EERs. For males, the mean reported energy intake was roughly 300 calories less than the 12 Compared with the findings from SNDA-III, the mean usual energy intakes reported in the 2008 Diet Quality Report, based on data from the NHANES 1999–2004 (USDA, 2008l), were comparable for the youngest children (mean of 1,912 calories for children ages 5–8 years) and somewhat lower for females ages 9–13 years (1,898 calories) (see http://www.fns.usda.gov/oane).

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 81 corresponding EER. The discrepancy was smaller for females (130 calories).13 These findings may reflect a tendency for adolescents to underreport food intakes. TABLE 4-8 Reported Usual Food Energy Intakes and EERs 6–8 yr, 9–13 yr, both 14–18 14–18 yr, 14–18 yr, 9–13 yr, 9–13 yr, both yr, males females both genders males females genders (n = 506) (n = 512) genders (n = 343) (n = 469) (n = 484) Parameter Usual energy intake (kcal/day) 1,944 2,203 1,923 2,060 2,570 1,772 2,129 Median 1,968 2,239 1,960 2,103 2,625 1,830 2,214 Mean EER (kcal/day) 1,527 2,117 1,724 1,873 2,782 1,923 2,261 Median 1,574 2,223 1,752 1,993 2,874 1,960 2,411 Mean NOTE: kcal = calories; n = sample size. SOURCES: Weighted tabulations of data from the SNDA-III (USDA, 2007a); adapted from Tables J.1a and J.1b in Appendix J to Volume II of the report. Dietary intake data (24-hour recalls) were collected during the 2004–2005 school year. The personal computer version of the Software for Intake Distribution Estimation (PC-SIDE; ISU, 1997) was used to estimate usual nutrient intake distributions. EERs were calculated by using algorithms defined in Dietary Reference Intakes: Applications in Dietary Assessment (IOM, 2000b) and by assuming a low-active level of physical activity. 13 Compared with the findings from SNDA-III, the mean usual energy intakes reported in the 2008 Diet Quality Report, based on data from NHANES 1999–2004 (USDA, 2008l), were comparable for males (mean equals 2,635 calories) and higher for females (mean equals 1,924 calories) ages 14–18 years (see http://www.fns.usda.gov/oane).

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82 NUTRITION STANDARDS AND MEAL REQUIREMENTS In any case, data in Chapter 1 make it clear that obesity is a growing concern for schoolchildren; and, therefore, excessive energy intake is a major concern. During Phase II, the committee will consider the levels of calories in the overall diet of schoolchildren and appropriate calorie levels for the Nutrition Standards and Meal Requirements for school meals. Macronutrients Information on macronutrient intake relative to the AMDRs is shown in Table 4-9. All schoolchildren had usual intakes of protein, as a percentage of total energy intake, that were consistent with the AMDR, which is 10 to 30 percent of total energy. With the exception of adolescent females, the same was true for usual intakes of carbohydrate. Five percent of adolescent females had usual carbohydrate intakes that exceeded the upper bound of the AMDR (which is 45 to 65 percent of total energy), and about 8 percent had usual carbohydrate intakes that fell below the lower bound of the AMDR. TABLE 4-9 Percentage of Schoolchildren with Reported Usual Intakes of Macronutrients Outside the AMDR Range, Based on Usual Nutrient Intakes from SNDA-III 6–8 yr, both 9–13 yr, 14–18 yr, 14–18 yr, genders 9–13 yr, males females males females (n = 343) (n = 484) (n = 506) (n = 512) Nutrient (n = 469) Carbohydrate Greater <3a <3 <3 <3 5 than AMDR Less than <3 <3 <3 <3 8.2 AMDR Protein Greater <3 <3 <3 <3 <3 than AMDR Less than <3 <3 <3 <3 <3 AMDR Total fat Greater than 18.6 <3 11 22.2 31.4 AMDR Less than <3 <3 <3 <3 9.3 AMDR NOTE: n = sample size; * = point estimate may not be reliable because of an inadequate cell size or a large coefficient of variation. a Less than 3 percent is reported in rare occurrences (less than 3 percent of students had usual intakes in this range, but the specific point estimates was statistically unreliable). SOURCES: Weighted tabulations of data from SNDA-III (USDA, 2007a); adapted from Tables J.3, J.15, and J.17 in Appendix J to Volume II. Dietary intake data (24-hour recalls) were collected during the 2004–2005 school year. The personal computer version of the Software for Intake Distribution Estimation (PC-SIDE; ISU, 1997) was used to estimate usual nutrient intake distributions and the percentage of children with usual intakes outside the reference value(s). The AMDRs used in the analysis were from the macronutrient DRI report (IOM, 2002/2005).

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 83 More than 60 percent of children in all age groups had usual fat intakes that were within the AMDR (25 to 35 percent of total calories). As shown in Table 4-9, the intakes for the majority of children whose usual fat intakes were outside the AMDR exceeded the upper bound of the range. During Phase II, the committee will consider both the total amount and the nature of the types of fats that are appropriate for the Nutrition Standards and Meal Requirements for the school meal programs. Excessive Intakes Nutrients with Tolerable Upper Levels of Intake Because supplement data were unavailable, it generally was not possible to determine whether nutrients were consumed in amounts that were higher than the UL. Sodium is the primary nutrient that the committee is considering with regard to the potential for exceeding the UL. The Institute of Medicine (IOM, 2005) has underscored the potential for excessive sodium intake to adversely affect blood pressure in children. However, overall, more than 90 percent of schoolchildren had usual sodium intake that exceeded the UL (see Table 4-10). TABLE 4-10 Percentage of Schoolchildren with Reported Usual Intakes of Sodium that Exceeded the UL, Based on Usual Nutrient Intakes from SNDA-III 6–8 yr, both 9–13 yr, 9–13 yr, 14–18 yr, 14–18 yr, genders males females males females (n = 343) (n = 469) (n = 484) (n = 506) (n = 512) Parameter Sodium UL (g/day) 1.9 2.2 2.2 2.3 2.3 >97a % Greater than UL >97 90 >97 75 NOTE: g/day = grams per day; mg = milligrams; n = sample size. a More than 97 percent is report for common occurrences (more than 97 percent of students had usual intakes in this range, but the specific point estimate was statistically unreliable). SOURCES: Weighted tabulations of data from SNDA-III (USDA, 2007a); adapted from Table J.33 in Appendix J to Volume II. Dietary intake data (24-hour recalls) were collected during the 2004–2005 school year and do not include intake from dietary supplements. The personal computer version of the Software for Intake Distribution Estimation (PC-SIDE; ISU, 1997) was used to estimate usual nutrient intake distributions and the percentage of children with usual intakes that exceeded the reference value. The ULs used in the analysis were from two DRI reports (IOM, 2002/2005, 2005).

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84 NUTRITION STANDARDS AND MEAL REQUIREMENTS The committee compared the usual nutrient intake distributions of calcium, iron, phosphorus, and zinc (see http://www.fns.usda.gov/oane) with the defined ULs. The risk of excessive intakes from foods and beverages alone appears to be low for all these nutrients except zinc. For all the age-gender subgroups examined, intakes at the 95th percentile of the distribution were well below the ULs for all but one of these nutrients. For zinc, more than 25 percent of children ages 6–8 years had usual intakes that exceeded the UL (the UL is 12 grams and the intake at the 75th percentile of the distribution was 12.6 grams). For older children, zinc intakes at the 95th percentile of the distribution were below the UL. Saturated fat and cholesterol Percentages of schoolchildren with reported usual intakes that exceed recommended limits for saturated fat and cholesterol, as specified by the 2005 Dietary Guidelines for Americans, are shown in Table 4-11. TABLE 4-11 Percentages of Schoolchildren with Reported Usual Intakes that Exceed Recommended Limits for Saturated Fat and Cholesterol,a Based on Usual Nutrient Intakes from SNDA-III 6–8 yr, both 9–13 yr, 14–18 yr, genders 9–13 yr, males females 14–18 yr, females (n Nutrient (n =343) (n =469) (n=484) males (n =506) =512) Saturated Fat >10% of total food >97b energy 78.7 89.5* 76.7 74.6 Cholesterol <3c > 300 mg 4.8* 15.6* 36.6 9.0* NOTE: * = point estimate may not be reliable because of an inadequate cell size or a large coefficient of variation. a The reference values used for saturated fat and cholesterol are taken from Dietary Guidelines for Americans (HHS/USDA, 2005). The DRI guideline for saturated fat is to consume amounts as low as possible while consuming a nutritionally adequate diet (IOM, 2002/2005). b More than 97 percent is report for common occurrences (more than 97 percent of students had usual intakes in this range, but the specific point estimate was statistically unreliable). c Less than 3 percent is reported in rare occurrences (less than 3 percent of students had usual intakes in this range, but the specific point estimates was statistically unreliable). SOURCES: Weighted tabulations of data from SNDA-III (USDA, 2007a); adapted from Tables J.5 and J.37 in Appendix J to Volume II. Dietary intake data (24-hour recalls) were collected during the 2004–2005 school year and do not include intake from dietary supplements. The personal computer version of the Software for Intake Distribution Estimation (PC-SIDE; ISU, 1997) was used to estimate usual nutrient intake distributions and the percentage of children with usual intakes that exceeded the reference value.

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FOOD AND NUTRIENT NEEDS OF SCHOOLCHILDREN 85 More than three-quarters of children in all age-gender subgroups had usual saturated fat intakes that exceeded the limit recommended in the 2005 Dietary Guidelines for Americans (HHS/USDA, 2005). More than 85 percent of all schoolchildren had usual cholesterol intakes that were consistent with the guidance. The prevalence of excessive cholesterol intakes was higher for males than for females and was highest among adolescent males. Appropriate amounts of these food substances will be considered during Phase II of this study. Trans fatty acids The DRIs do not include reference values for trans fatty acids, but the Institute of Medicine’s recommendation is to keep intake as low as possible while consuming a nutritionally adequate diet (IOM, 2002/2005). The DRIs do not include reference values for trans fatty acids. Dietary Guidelines for Americans recommend limiting the intake of fats and oils containing trans fat. The committee could not estimate trans fat intake, however, because neither of the published studies reviewed by the committee includes data on this food component. Trans fatty acids are not included in the food and nutrient database used to analyze dietary recalls collected in NHANES and SNDA-III (USDA/ARS, 2004). Nonetheless, the requirement (as of January 1, 2006) that the trans fat content be listed on Nutrition Facts Labels would enable the committee to make feasible recommendations concerning the trans fat content of school meals. Other Substances found in food ranging from additives to contaminants to caffeine are often cited as factors to consider in planning meals for children. While not addressed specifically in this Phase I report, such substances may be considered during the Phase II deliberations, as appropriate and as feasible. Summary of Nutrient Assessment The findings presented in this chapter provide a picture of the prevalence of apparent nutrient inadequacies, the prevalence of the risk of excessive intakes, and dietary imbalances among schoolchildren. Although the data are based on estimates of intake and have important limitations, as described here, they provide a foundation for identifying those nutrients in the diets of schoolchildren that merit consideration during the Phase II deliberations. On the basis of the available intake data, concerns about inadequate intakes are the greatest for older children. However, the low prevalence of inadequacy estimated for younger children could be influenced by overreported food intakes. For adolescent females, the data suggest that the intakes of virtually all vitamins and minerals merit attention. However, the high prevalence of inadequate intakes estimated for adolescent females could be influenced by underreported food intakes. The calcium intakes by children ages 6–8 years appear to be adequate. The mean and median calcium intakes by older children are less than the AI, and the gap is the highest for adolescents ages 14–18 years, especially females. The mean and median intakes of potassium and fiber were substantially lower than the AI for all groups of children. These findings suggest the potential for inadequate intakes of these nutrients. The total intakes of fiber are underestimated because of limitations in food composition data, and there may be problems with the existing AIs for fiber. However, the magnitude of the gap between the usual intakes and the AIs for fiber suggests that children’s fiber intakes are inadequate. The intakes of saturated fat are a major concern. More than three-quarters of children in all age and gender groups had usual saturated fat intakes that exceeded the recommendation of the

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86 NUTRITION STANDARDS AND MEAL REQUIREMENTS Dietary Guidelines for Americans of less than 10 percent of total energy. Total fat intake is of less concern. Nonetheless, the usual fat intakes by some children were excessive. Finally, children’s sodium intakes merit close attention. Three-quarters or more of children in all age groups had usual intakes of sodium that exceeded the UL, and in most cases, the prevalence of excessive intakes exceeded 90 percent. SUMMARY AND CONCLUSIONS This review has identified a number of foods and nutrients for which a notable proportion of children have intake levels inconsistent with recommended intake levels (Table 4-12). During Phase II of this study, the committee will consider these foods and nutrients further and will identify priority foods and nutrients for the Nutrition Standards and Meal Standards of the school meal programs.

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TABLE 4-12 Foods and Nutrients Under Consideration in Children’s Diets Foods for Which Intakes Are Inadequate, Nutrients for Which Intakes Are Excessivea Age Category Male and Female Nutrients for Which Intakes Are Inadequate Male Female Male Female Ages 6–8b Fruit Sodium Potassium Potassium Sodium Total vegetables Saturated fat Fiber Fiber Saturated fat Dark green and orange vegetables and Total fat Total fat Energyc Energyc legumes Whole grains Total meat and beans Milk Ages 9–13 Fruit Magnesium Calcium Sodium Sodium Energyc Total vegetables Potassium Magnesium Cholesterol Dark green and orange vegetables and Total fat Vitamins A and E Phosphorus Saturated fat legumes Saturated fat Fiber Potassium Whole grains Zinc Total meat and beans Vitamins A, C, E Milk Fiber Ages 14–18 Fruit Calcium Sodium Sodium Magnesium Total vegetables Iron Cholesterol Cholesterol Potassium Dark green and orange vegetables and Magnesium Saturated fat Saturated fat Vitamins A, C, E Energyc legumes Phosphorus Total fat Total fat Fiber Whole grains Potassium Total meat and beans Zinc Milk Vitamins A, C, E, B6, B12 Folate Thiamin Energyc Fiber NOTE: Excessive energy intakes for some age-gender groups may not have been identified because of underreporting. a Excessive amounts of discretionary calories were consumed from solid fat and added sugars; this also constitutes concern relative to recommendations to be made by the committee. Usual intakes of added sugars could not be estimated because relevant data were not available in SNDA-III. The committee notes the quantitative amounts of added sugars in Table 4-5. Furthermore, while intakes of trans fatty acids also could not be measured, trans fatty acids will be considered as appropriate by the committee during Phase II. b Data for children age 5 years were included in the food intake data. c It is difficult to accurately estimate energy intakes because of under- and overreporting of food intake and a lack of accurate information about customary levels of physical activity 87

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