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SCHOOL MEALS

Building Blocks for Healthy Children

Committee on Nutrition Standards for National School Lunch and Breakfast Programs

Food and Nutrition Board

Virginia A. Stallings, Carol West Suitor, and Christine L. Taylor, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Committee on Nutrition Standards for National School Lunch and Breakfast Programs Food and Nutrition Board Virginia A. Stallings, Carol West Suitor, and Christine L. Taylor, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. AG-3198-C-08-0001 between the National Acad- emy of Sciences and the U.S. Department of Agriculture. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not neces- sarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Nutrition Standards for National School Lunch and Breakfast Programs. School meals : building blocks for healthy children / Committee on Nutrition Standards for National School Lunch and Breakfast Programs, Food and Nutrition Board ; Virginia A. Stallings, Carol West Suitor, and Christine L. Taylor, editors. p. cm. Includes bibliographical references. ISBN 978-0-309-14436-0 (pbk.) 1. School children—Food—United States. 2. School children—Nutrition—Government policy—United States. I. Stallings, Virginia A. II. Suitor, Carol West. III. Taylor, Christine Lewis. IV. Title. [DNLM: 1. Food Services—standards—United States. 2. Nutrition Policy—United States. 3. Adolescent—United States. 4. Child—United States. 5. Schools—United States. WA 350 I59s 2009] LB3479.U6I67 2009 371.7'16—dc22 2009049798 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. School Meals: Building Blocks for Healthy Children. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON NUTRITION STANDARDS FOR NATIONAL SCHOOL LUNCH AND BREAKFAST PROGRAMS VIRGINIA A. STALLINGS (Chair), The Children’s Hospital of Philadelphia, University of Pennsylvania KAREN WEBER CULLEN, Children’s Nutrition Research Center, Baylor College of Medicine, TX ROSEMARY DEDERICHS, Minneapolis Public Schools, Special School District No. 1, MN MARY KAY FOX, Mathematica Policy Research, Inc., Cambridge, MA LISA HARNACK, Division of Epidemiology and Community Health, University of Minnesota, MN GAIL G. HARRISON, School of Public Health, Center for Health Policy Research, University of California, Los Angeles MARY ARLINDA HILL, Jackson Public Schools, MS HELEN H. JENSEN, Department of Economics, Iowa State University, Ames RONALD E. KLEINMAN, Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA GEORGE P. McCABE, College of Science, Purdue University, West Lafayette, IN SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu ANGELA M. ODOMS-YOUNG, Department of Kinesiology and Nutrition, University of Illinois at Chicago, IL YEONHWA PARK, Department of Food Science, University of Massachusetts, Amherst MARY JO TUCKWELL, inTEAM Associates, Ashland, WI Study Staff CHRISTINE TAYLOR, Study Director SHEILA MOATS, Associate Program Officer JULIA HOGLUND, Research Associate HEATHER BREINER, Program Associate CAROL WEST SUITOR, Consultant Subject Matter Expert and Writer ANTON BANDY, Financial Officer GERALDINE KENNEDO, Administrative Assistant, Food and Nutrition Board LINDA D. MEYERS, Director, Food and Nutrition Board 

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with proce- dures approved by the National Research Council’s (NRC’s) Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Cheryl A. M. Anderson, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Janet Currie, Economics Department, Columbia University, New York, NY Barbara L. Devaney, Human Services Research, Research Division, Mathematica Policy Research, Inc., Boston, MA Deanna M. Hoelscher, School of Public Health, University of Texas Health Sciences Center at Houston Eileen T. Kennedy, Friedman School of Nutrition Sciences and Policy, Tufts University, Boston, MA Daryl Lund, Cottage Grove, WI Penny McConnell, Food and Nutrition Services, Fairfax County Public Schools, Vienna, VA Barry Sackin, B. Sackin & Associates, L.L.C., Murrieta, CA ii

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iii SCHOOL MEALS Sandra Schlicker, Wellness and Nutrition Services, Office of the State Superintendent of Education, Government of the District of Columbia, Washington, DC Frances H. Seligson, Independent Consultant, Hershey, PA Patricia Wahl, University of Washington School of Public Health and Community Medicine, Seattle Walter C. Willett, Department of Nutrition, Harvard School of Public Health, Boston, MA Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Elaine L. Larson, School of Nursing, Columbia University, and Joanna T. Dwyer, Tufts University School of Medicine & Friedman School of Nutrition Science & Policy, Frances Stern Nutrition Center, Tufts-New England Medical Centers. Ap- pointed by the NRC and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review com- ments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface My small southern town memories of food at school are many, starting with cafeteria lunch provided after we presented our green tokens and with- out discussion of choices or options except for the big decision of chocolate or plain milk. Everyone had a lunch token, so no one knew that there was a free or reduced-price lunch and no one went home or off campus for lunch unless you lived in the neighborhood. Bigger or maybe hungrier students got larger portions. A few students brought lunch in cool lunch boxes, and we envied what was assumed to be a better lunch. There were no vending machines until high school, and then the machine foods and beverages were few, and most students did not come to school with money or plans to purchase foods other than school lunch. We did not want to spend our allowance on food. This was a time when childhood nutrition issues were iron deficiency and undernutrition, when few were concerned about fat, sugar, or sodium in childhood diets, and when most meals were consumed at home with family members or at school. I now know that some children were hungry and the school lunch, and later school breakfast, was an important source of food. Interestingly, the key stakeholders have not changed—the chil- dren, families, school administrators, teachers, nurses, coaches, food service team, and food industry. The local and state school authorities implement federal policy and make many food and health decisions at their levels. In the background, nutritionists, health-care providers, and other child advo- cates influence both policy and implementation. We now clearly recognize the importance of food and nutrient intake on child health and on lifelong adult health. All stakeholders are concerned about diet quality and quan- ix

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x PREFACE tity, emerging food and health habits, and maintaining a healthy pattern of childhood growth. Today overweight children outnumber undernourished children, and childhood obesity is often referred to as an epidemic in both the medical and community settings. Nonetheless, normal or overweight status does not guarantee food security and a healthful diet for many chil- dren. Our inexpensive, abundant food supply and innovative food industry provide highly palatable foods and beverages for children. School foods and beverages, once almost limited mainly to school lunch, now often include many choices in addition to the meals offered by federally supported school breakfast and lunch programs. The calories and nutrients consumed at school and school-related activities are an important component of dietary intake of all school-age children. It is within this scientific and social environment that our commit- tee established criteria for nutrient targets and meal standards and made recommendations to revise the nutrition- and food-related standards and requirements for the National School Lunch Program and the School Break- fast Program. The recommended standards for menu planning lay out a school meal approach that results in the wide array of nutrients that chil- dren need and that reflect the Dietary Guidelines for Americans. Our committee is a dedicated group of remarkable people from diverse backgrounds and experiences. We quickly recognized that this was not an easy task. Over nearly 2 years, we learned and debated together, and de- veloped this set of recommendations for nutrition and food standards for schools meals. We recognized that the standards will be effective only to the extent that standards are implemented effectively and thus made recom- mendations related to technical support, developing foods that are reduced in sodium content, and taking measures to help schools incorporate more products that are rich in whole grains. The goal is for schools to employ their unique, long-term relation- ship with children and their families to support child health and provide a healthful school eating environment. This will require attention to many factors that go beyond the federally supported school meal programs: com- petitive foods (foods and beverages offered other than the meals provided under the National School Lunch and Breakfast programs), time and dura- tion of meal periods, activity level of children, and evaluation and research that address interactions of such factors with the success of the school meal programs. The involvement of students, parents, schools, and the food industry is important to the success of implementing the recommended revisions. Support from state and federal agencies and from professional organiza- tions and child advocacy groups will help to promote the acceptance of the recommended meals. Finally, the level of federal reimbursement for school meals needs to be sufficient to cover the cost of improvements in the meals

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xi PREFACE such as increased amounts of fruits and vegetables and the substitution of whole grain-rich foods for some of the refined grains. Sincere appreciation is extended to the many individuals and groups who were instrumental in the development of this report. First and fore- most, many thanks are due to the committee members, who volunteered countless hours to the research, deliberations, and preparation of the re- port. Their dedication to this project was outstanding and is the basis of our success. Many individuals volunteered significant time and effort to address and educate our committee members during our two public workshops on July 8, 2008, and January 28, 2009. Workshop speakers included: Tom Baranowski, Kimberly Barnes-O’Connor, Jessica Donze Black, Helene Clark, Adalia Espinosa, Joanne F. Guthrie, Jeanne Harris, Geraldine Henchy, Fred Higgens, Jay Hirschman, Lynn Hoggard, Sue E. Holbert, Leonard Marquart, Cathie McCullough, Celeste Peggs, Matt Sharp, Ted Spitzer, Kimberly Stizel, Katie Wilson, and Margo Wootan. In addition representatives from many entities provided oral testimony to the committee during the public workshops that were held on July 8, 2009, and January 28, 2009. They represented the Action for Healthy Kids, Alliance for a Healthier Generation, American Academy of Pediatrics, American Dietetic Association, Apple Processors Association, ARMARK Education, Baylor College of Medicine, Food Research and Action Center, California Food Policy Advocates, Charterwells School Dining Services, Economic Research Service, Food Distribution Program and Food and Nu- trition Service of United States Department of Agriculture, General Mills, Grocery Manufacturers Association, International Dairy Foods Associa- tion, Local Matters, National Alliance for Nutrition and Activity, National Dairy Council, National Pork Board, Nemours Division of Health and Prevention Services, School Nutrition Association, Soyfoods Association of North America, Sunkist Taylor LLC, United Egg Producers, United Fresh Produce Association, University of Minnesota, U.S. Apple Association, and Wellness in American Schools. It is apparent that many organizations and individuals from a variety of school and scientific backgrounds provided timely and essential support for this project. Yet we would have never succeeded without the extensive contributions of Carol West Suitor, ScD, as Consultant Subject Matter Ex- pert and Writer to the project. Furthermore, it is important to recognize the efforts, skills, and grace that were provided in large measure by Christine L. Taylor, PhD, RD, Study Director for this project; Sheila Moats, BS, As- sociate Program Officer; Julia Hoglund, MPH, Research Associate; Heather Breiner, BS, Program Associate; and Linda Meyers, PhD, Director, Food and Nutrition Board. I also want to thank Todd Campbell from Iowa State Uni- versity for developing the software used by the committee to analyze menus

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xii PREFACE for cost and nutrient analyses, and Mathematica Policy Research, Inc. for providing data analyses. Last, as chair, I express my sincere appreciation to each member of this committee for their extraordinary commitment to the project and the wonderful opportunity to work with them on this important task for the nutrition and school communities and for the schoolchildren whose health and future we were asked to consider. Virginia A. Stallings, Chair Committee on Nutrition Standards for National School Lunch and Breakfast Programs

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Contents Summary 1 1 Introduction and Background 19 2 Foundation for Revising Nutrition Standards and Meal Requirements 33 3 Schoolchildren’s Food and Nutrient Intakes and Related Health Concerns 47 4 Process for Developing the Nutrient Targets 69 5 Process for Developing the Meal Requirements 91 6 Iterations—Achieving the Best Balance of Nutrition, Student Acceptance, Practicality, and Cost 107 7 Recommendations for Nutrient Targets and Meal Requirements for School Meals 115 8 Food Cost Implications and Market Effects 131 9 Projected Impact of the Recommended Nutrient Targets and Meal Requirements 155 10 Implementation, Evaluation, and Research 179 11 References 209 xiii

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xi CONTENTS APPENDIXES* A Acronyms, Abbreviations, and Glossary 221 B Biographical Sketches of Committee Members 229 C Critical Issues for Consideration by the Committee on Nutrition Standards for National School Lunch and Breakfast Programs, as Submitted by the U.S. Department of Agriculture 237 D January 2009 Workshop Agenda and Summary of Public Comments 245 E Standards for the Current Food- and Nutrient-Based Menu Planning Approaches 255 F Data Used to Calculate Estimated Energy Requirements 259 G Data Tables Containing Examples of New SNDA-III Analyses 263 H Uses of MyPyramid Food Groups and the MyPyramid Spreadsheet 269 I Dietary Intake Data and Calculation of the Target Median Intake for Iron 285 J Target Median Intake (TMI) Tables 293 K Use of the School Meals Menu Analysis Program 297 L Baseline Menus 305 M Sample Menus 331 N Evidence Considered Related to the Definition for Whole Grain-Rich Foods 363 O Comparison of Recommended Nutrient Targets to Various Nutrition Standards for School-Aged Children 367 P Comparison of Dietary Guidelines for Americans with Recommended Meal Requirements 373 Q Regulations Related to the Sodium Content of Foods Labeled “Healthy” 379 *Appendixes C through Q are not printed in this book, but can be found on the CD at the back of the book or online at http://www.nap.edu.