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9
Projected Impact of the Recommended Nutrient Targets and Meal Requirements

The committee considered its four criteria (see Box 2-2 in Chapter 2) in evaluating the projected impact of its recommendations for the School Breakfast Program and the National School Lunch Program (NSLP). The recommendations considered here are those for the revision of the current Nutrition Standards (to Nutrient Targets) and of the Meal Requirements (the standards for menu planning and the standards for meals as selected by the student). The purpose of this evaluation is to critically examine the committee’s recommendations with respect to likely benefits and negative consequences. Thus, the results may be interpreted as a sensitivity analysis. The committee notes, however, that evidence on which to base predictions of many of the effects is severely limited.

CRITERION 1:
ALIGNMENT WITH DIETARY GUIDELINES FOR AMERICANS AND THE DIETARY REFERENCE INTAKES

The committee considered the alignment of the Meal Requirements with dietary guidance solely on the basis of the meals as offered. The committee recognizes that it is the food that is consumed that affects nutritional status, and it developed the standards for menu planning with student acceptability in mind. Because effective implementation of the standards will be crucial to improving student’s actual consumption, Chapter 10 addresses that topic.



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9 Projected Impact of the Recommended Nutrient Targets and Meal Requirements The committee considered its four criteria (see Box 2-2 in Chapter 2) in evaluating the projected impact of its recommendations for the School Breakfast Program and the National School Lunch Program (NSLP). The recommendations considered here are those for the revision of the current Nutrition Standards (to Nutrient Targets) and of the Meal Requirements (the standards for menu planning and the standards for meals as selected by the student). The purpose of this evaluation is to critically examine the committee’s recommendations with respect to likely benefits and negative consequences. Thus, the results may be interpreted as a sensitivity analysis. The committee notes, however, that evidence on which to base predictions of many of the effects is severely limited. CRITERION 1: ALIGNMENT WITH DIETARY GUIDELINES FOR AMERICANS AND THE DIETARY REFERENCE INTAKES The committee considered the alignment of the Meal Requirements with dietary guidance solely on the basis of the meals as offered. The com- mittee recognizes that it is the food that is consumed that affects nutritional status, and it developed the standards for menu planning with student ac- ceptability in mind. Because effective implementation of the standards will be crucial to improving student’s actual consumption, Chapter 10 addresses that topic. 

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 SCHOOL MEALS Methods of Evaluating Alignment with Dietary Guidance The committee examined how well the recommended standards for menu planning and the menus themselves aligned with Dietary Guidelines and the Dietary Reference Intakes (DRIs). To examine the change in align- ment of the standards with food-specific Dietary Guidelines, the committee compared the recommended meal patterns with those specified in the cur- rent Meal Requirements (see Tables 8-1 and 8-2 in Chapter 8), reviewed the food items in the modified baseline and sample menus to verify their correspondence with the Dietary Guidelines, and also compared the rec- ommended standards with recommendations for children in the Dietary Guidelines (see Appendix P). Examination of the alignment with the DRIs included analysis of the breakfast and lunch menus for each age-grade group, using the School Meals Menu Analysis program (Appendix K), to determine their consis- tency with the recommended Nutrient Targets. (The Nutrient Targets were largely based on the DRIs.) The analysis covered 6 sets of modified baseline menus (5 menus for each meal and age-grade group) and 24 sets of sample menus (20 menus for each meal and age-grade group. The committee had written these menus using the new standards for menu planning. The committee recognizes a number of limitations of the nutrient analy- ses of the sample menus, as identified below, and emphasizes that operators should not be asked to conduct comparable analyses. • The list of foods in the School Meals Menu Analysis program was limited in that it did not include a number of products with improved fat profiles that became available after the third School Nutrition Dietary As- sessment study (SNDA-III). • When exact matches for the newer foods were not found, other foods were selected to provide as close a match as possible. • Commercial products listed in the database may not offer the same nutrient content of similar items specifically created for Child Nutrition (CN) programs, such as CN-labeled products. • Similar items from different manufacturers may differ slightly in nutrient content; for example, sodium content may vary in different brands of chicken patties. • Industry partners frequently adjust ingredients and recipes to meet customer requests. Nonetheless, the committee considers the analysis adequate to show approximately how well the standards for meal planning lead to menus that come close to the Nutrient Targets. Using existing USDA-approved software, operators will be able to obtain very good estimates of the calorie,

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 PROJECTED IMPACT saturated fat, and sodium content of their menus; but the software would not provide information on all the nutrients. The software the committee used is not suitable for use by school food service operators. This analysis was done only to show the correspondence of the standards for meal plan- ning with the Nutrient Targets. The committee also considered data on nutrient contents for meals as offered by the school, using averages from SNDA-III (USDA/FNS, 2007a) and from the representative baseline menus described in Chapter 6. (These averages were from menus that had been planned under the existing Meal Requirements.) Findings Regarding Alignment with Dietary Guidance Alignment with Dietary Guidelines for Americans The use of the recommended Meal Requirements clearly improves alignment with the Dietary Guidelines. Tables 8-1 and 8-2 in Chapter 8, which compare current food-based menu standards with the committee’s recommendations, shows that the amounts of fruits, total vegetables, and whole grain-rich foods are substantially higher in the new meal patterns. In addition, milk products are the types encouraged in the Dietary Guidelines. Appendix P shows how the recommended Meal Requirements respond to each of the relevant recommendations in the Dietary Guidelines. The com- mittee’s review of the modified baseline menus and sample menus (which gave special attention to the inclusion of a variety of fruits and vegetables, whole grain-rich products, and fat-free or low-fat milk products) found that these menus are consistent with the food-specific Dietary Guidelines. The committee’s recommendation that students be required to select at least one fruit at breakfast and at least one fruit or vegetable at lunch (see Table 7-4 in Chapter 7) may contribute to an increase in the consumption of foods from these important food groups. Notably, the meals contain relatively high amounts of most nutrients for the calories, as explained in the sec- tion “Effects of Nutrient Intake Contributions from School Meals on Total Daily Nutrient Intakes.” For the menus written by the committee, analysis shows that the satu- rated fat content as a percentage of calories (shown in Tables 9-1 through 9-3) is less than the maximum amount recommended in the Dietary Guide- lines. Moreover, options that are high in saturated fat are minimized, mean- ing that students would be unable to choose higher fat forms of milk and seldom would have an option for an entrée that is high in saturated fat. In its review of data from SNDA-III (USDA/FNS, 2007a), the committee had observed that the percentage of schools sering meals (as selected by students) that met the standard for saturated fat (less than 10 percent of

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 SCHOOL MEALS TABLE 9-1 Comparison of Nutrient Values for Menus from SNDA-III Dietary Data and from Menus Planned by the Committee with Recommended Nutrient Targets for the National School Breakfast and Lunch Programs, Elementary School (children ages 5–10 years) Breakfast Content Based on As Offered Menu Plans SNDA-III Rep. Baseline Modified Sample Nutrient Meana* Menub* Baseline Menuc Menusd Targetse Nutrient (unit) Calories (kcal) 463 493 452 458 350–500 Saturated Fat (g) 4 5.4 3.4 3.1 < 10 Saturated Fat (% of kcal) 8.6 9.9 6.7 6.0 Protein (g) 15 18 21 18 10 Vitamin A (µg RAE) 242 272 268 251 129 Vitamin C (mg) 30 25 46 41 16 Vitamin E (mg αT) 0.9 0.9 2.0 . . Thiamin (mg) 0.5 0.44 0.41 0.39 0.25 Riboflavin (mg) 0.8 0.87 0.84 0.87 0.31 Niacin (mg) 5.0 4.2 4.5 3.8 3.2 Vitamin B6 (mg) 0.5 0.40 0.56 0.59 0.27 Folate (µg DFE) 173 166 161 170 91 Vitamin B12 (µg) 1.9 1.7 2.1 2.4 0.8 Iron (mg) 4.3 4.5 4.5 3.6 2.3 Magnesium (mg) 63 69 98 87 49 Zinc (mg) 3.0 3.1 3.9 3.5 2.0 Calcium (mg) 409 464 560 529 223 Phosphorus (mg) 397 493 523 496 242 Potassium (mg) 711 757 973 957 909 ≤ 430 643 478 Sodium (mg) 575 699 Linoleic Acid (g) 2.0 1.7 2.2 . . α-Linolenic Acid (g) 0.2 0.20 0.21 0. 0. Fiber (g) 3 4 6 6  NOTES: αT = α-tocopherol; DFE = dietary folate equivalent; g = gram; mg = milligram; RAE = retinol activity equivalent; SNDA-III = third School Nutrition Dietary Assessment study; µg = microgram. Italic font indicates values that do not meet the Nutrient Targets. Bold font indicates values that exceed the maximum Nutrient Target. aThe menus reported in SNDA-III had been developed using the existing Nutrition Standards (covering only eight nutrients), the nutrient values of which are lower than those of the recom- mended Nutrient Targets. 109 schools provided the menus for breakfast, 126 for lunch. bRepresentative baseline menus were chosen from menus available in SNDA-III, using the process described in the section “Testing of Revisions of Standards for Menu Planning” in Chapter 5, but the nutrient values of those menus were calculated by the committee. N = 5 menus.

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 PROJECTED IMPACT Lunch Content Based on As Offered Menu Plans SNDA-III Rep. Baseline Modified Sample Meana* Menub* Baseline Menuc Menusd Nutrient Targetsf 741 694 635 569 550–650 9 7.3 6.1 6.0 < 10 10.9 9.5 8.6 9.5 30 28 27 27 15 294 248 439 394 192 32 24 51 38 24 2.5 2.3 3.0 3.0 . 0.5 0.51 0.41 0.40 0.37 0.9 0.95 0.81 0.80 0.46 7.0 6.2 5.3 5.3 4.7 0.5 0.55 0.62 0.52 0.40 160 137 136 0  1.9 1.8 2.0 2.0 1.2 4.5 4.4 4.1 3.6 3.4 102 95 120 103 72 3.8 3.7 3.8 3.7 2.9 531 520 498 486 332 571 542 592 559 361 1,124 1,179 1,353 , , ≤ 640 1,564 1,491 1,377 1,409 6.0 4.2 6.4 4.1 3.3 0.7 0.46 0.58 0.37 0.31 7 6 10 9  cThe committee developed the modified baseline menus by revising the representative baseline menus to meet the recommended standards for menu planning, while keeping the adjustments to a minimum. N = 5 menus. dThe committee developed the sample menus to meet the recommended standards for menu planning and to illustrate a number of different types of menus. N = 20 breakfast menus and 20 lunch menus for each age-grade group. eTargets based on 21.5 percent of the daily School Meal-Target Median Intake (School Meal-TMI) for age-grade group. fTargets based on 32 percent of the daily School Meal-TMI for the age-grade group. SOURCE: *USDA/FNS, 2007a.

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0 SCHOOL MEALS TABLE 9-2 Comparison of Nutrient Values for Menus from SNDA-III Dietary Data and from Menus Planned by the Committee with Recommended Nutrient Targets for the National School Breakfast and Lunch Programs, Middle School (children ages 11–13 years) Breakfast Content Based on As Offered Menu Plans SNDA-III Rep. Baseline Modified Sample Nutrient Meana* Menub* Baseline Menuc Menusd Targetse Nutrient (unit) Calories (kcal) 501 450 510 532 400–550 Saturated Fat (g) 5 4.1 3.3 3.6 < 10 Saturated Fat (% of kcal) 9.2 8.1 5.8 6.0 Protein (g) 16 15 22 0 0 Vitamin A (µg RAE) 257 227 251 284 162 Vitamin C (mg) 32 33 67 43 20 Vitamin E (mg αT) 1 0.85 2.7 .0 . Thiamin (mg) 0.5 0.41 0.45 0.52 0.32 Riboflavin (mg) 0.9 0.79 0.88 1.00 0.41 Niacin (mg) 5.0 3.9 4.7 5.8 4.0 Vitamin B6 (mg) 0.5 0.43 0.50 0.78 0.36 Folate (µg DFE) 191 186 185 248 114 Vitamin B12 (µg) 2.0 2.1 2.1 2.9 0.9 Iron (mg) 4.6 3.6 4.6 5.1 3.5 Magnesium (mg) 64 64 83 105 66 Zinc (mg) 3.2 3.0 3.7 4.8 2.5 Calcium (mg) 432 384 468 580 296 Phosphorus (mg) 416 402 493 572 362 Potassium (mg) 730 678 1,047 1,023  ≤ 470 685 605 Sodium (mg) 629 591 Linoleic Acid (g) 3.0 2.1 2.5 . . α-Linolenic Acid (g) 0.2 0.24 0.25 0. 0. Fiber (g) 3 3 6 6  NOTES: αT = α-tocopherol; DFE = dietary folate equivalent; g = gram; mg = milligram; RAE = retinol activity equivalent; SNDA-III = third School Nutrition Dietary Assessment study; µg = microgram. Italic font indicates values that do not meet the Nutrient Targets. Bold font indicates values that exceed the maximum Nutrient Target. aThe menus reported in SNDA-III had been developed using the existing Nutrition Standards (covering only eight nutrients), the nutrient values of which are lower than those of the recom- mended Nutrient Targets. 109 schools provided the menus for breakfast, 126 for lunch. bRepresentative baseline menus were chosen from menus available in SNDA-III, using the process described in the section “Testing of Revisions of Standards for Menu Planning” in Chapter 5, but the nutrient values of those menus were calculated by the committee. N = 5 menus.

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 PROJECTED IMPACT Lunch Content Based on As Offered Menu Plans SNDA-III Rep. Baseline Modified Sample Meana* Menub* Baseline Menuc Menusd Nutrient Targetsf 816 757 592 640 600–700 10 10.0 5.9 5.9 < 10 10.9 11.9 8.9 8.3 32 30 33 32  300 369 301 401 241 34 33 31 43 30 2.8 2.7 4.0 . . 0.6 0.57 0.49 0.47 0. 1.0 0.91 0.84 0.85 0.61 7.0 6.0 6.9 6.5 6.0 0.6 0.62 0.63 0.65 0.54 180 196 169   2.0 1.7 2.1 1.9 1.3 5.0 4.9 5.2 . . 110 109 126 123 98 4.2 4.0 4.8 4.3 3.7 549 532 478 517 440 606 589 608 618 538 1,249 1,296 1,523 , ,00 ≤ 710 1,558 1,593 1,520 1,602 7.0 6.5 4.5 5.2 3.6 0.8 0.93 0.45 0.52 0.36 8 6 10 9 9 cThe committee developed the modified baseline menus by revising the representative baseline menus to meet the recommended standards for menu planning, while keeping the adjustments to a minimum. N = 5 menus. dThe committee developed the sample menus to meet the recommended standards for menu planning and to illustrate a number of different types of menus. N = 20 breakfast menus and 20 lunch menus for each age-grade group. eTargets based on 21.5 percent of the daily School Meal-Target Median Intake (School Meal-TMI) for age-grade group. fTargets based on 32 percent of the daily School Meal-TMI for the age-grade group. SOURCE: *USDA/FNS, 2007a.

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 SCHOOL MEALS TABLE 9-3 Comparison of Nutrient Values for Menus from SNDA-III Dietary Data and from Menus Planned by the Committee with Recommended Nutrient Targets for the National School Breakfast and Lunch Programs, High School (children ages 14–18 years) Breakfast Content Based on As Offered Menu Plans SNDA-III Rep. Baseline Modified Sample Nutrient Meana* Menub* Baseline Menuc Menusd Targetse Nutrient (unit) Calories (kcal) 519 513 574 567 450–600 Saturated Fat (g) 5 4.9 3.5 4.3 < 10 Saturated Fat (% of kcal) 9.3 8.6 5.4 6.8 Protein (g) 17 15 26 24 22 Vitamin A (µg RAE) 256 256 266 265 186 Vitamin C (mg) 37 35 63 42 26 Vitamin E (mg αT) 1.0 1.3 3.7 . . Thiamin (mg) 0.5 0.43 0.63 0.51 0.37 Riboflavin (mg) 0.9 0.78 1.09 0.99 0.45 Niacin (mg) 5.0 3.8 5.8 5.3 4.9 Vitamin B6 (mg) 0.5 0.42 0.68 0.72 0.42 Folate (µg DFE) 179 162 221 207 138 Vitamin B12 (µg) 1.9 1.9 2.7 2.7 1.1 Iron (mg) 4.5 4.6 5.9 4.3 4.0 Magnesium (mg) 67 64 107 105 99 Zinc (mg) 3.1 2.3 4.3 4.3 2.9 Calcium (mg) 431 398 591 600 323 Phosphorus (mg) 427 381 589 592 384 Potassium (mg) 779 718 1,169 , ,0 ≤ 500 838 669 Sodium (mg) 686 659 Linoleic Acid (g) 3.0 3.4 3.0 . .0 α-Linolenic Acid (g) 0.2 0.4 0.30 0. 0. Fiber (g) 3 2 7   NOTES: αT = α-tocopherol; DFE = dietary folate equivalent; g = gram; mg = milligram; RAE = retinol activity equivalent; SNDA-III = third School Nutrition Dietary Assessment study; µg = microgram. Italic font indicates values that do not meet the Nutrient Targets. Bold font indicates values that exceed the maximum Nutrient Target. aThe menus reported in SNDA-III had been developed using the existing Nutrition Standards (covering only eight nutrients), the nutrient values of which are lower than those of the recom- mended Nutrient Targets. 109 schools provided the menus for breakfast, 126 for lunch. bRepresentative baseline menus were chosen from menus available in SNDA-III, using the process described in the section “Testing of Revisions of Standards for Menu Planning” in Chapter 5, but the nutrient values of those menus were calculated by the committee. N = 5 menus.

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 PROJECTED IMPACT Lunch Content Based on As Offered Menu Plans SNDA-III Rep. Baseline Modified Sample Meana* Menub* Baseline Menuc Menusd Nutrient Targetsf 857 913 845 789 750–850 10 9.2 7.1 6.8 < 10 10.6 9.1 7.5 7.8 33 33 34 35 32 299 252 397 377 277 39 20 63 52 39 2.8 2.9 5.4 . . 0.6 0.73 0.63 0.60 0.56 1.0 1.12 1.00 0.94 0.67 8.0 9.1 7.4 7.3 7.3 0.6 0.63 0.71 0.71 0.63 184 243 205   2.0 2.0 2.0 2.0 1.6 5.2 6.0 5.9 . . 113 115 169 156 147 4.3 4.1 5.4 5.0 4.3 547 551 576 559 481 623 607 732 704 572 1,309 1,187 1,740 , , ≤ 740 1,988 1,693 1,588 2,082 7.0 7.7 6.1 7.0 4.5 0.9 0.91 0.51 0.66 0.45 8 8 15 13 11 cThe committee developed the modified baseline menus by revising the representative baseline menus to meet the recommended standards for menu planning, while keeping the adjustments to a minimum. N = 5 menus. dThe committee developed the sample menus to meet the recommended standards for menu planning and to illustrate a number of different types of menus. N = 20 breakfast menus and 20 lunch menus for each age-grade group. eTargets based on 21.5 percent of the daily School Meal-Target Median Intake (School Meal-TMI) for age-grade group. fTargets based on 32 percent of the daily School Meal-TMI for the age-grade group. SOURCE: *USDA/FNS, 2007a.

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 SCHOOL MEALS the calories from saturated fat) was considerably lower than the percentage of schools offering meals that met the standard. Limiting certain options, such as entrées that are high in saturated fat, should help to reduce this problem. Alignment with Dietary Reference Intake Tables 9-1 through 9-3 for the three age-grade groups compare data from four groups of menus with the recommended Nutrient Targets for school meals. (As described in Chapter 3, the Nutrient Targets were derived from the DRIs.) The tables show that the menus written by the commit- tee, which follow the recommended standards for menu planning, meet or nearly meet the Nutrient Targets in almost all cases, especially at break- fast; and many of the nutrient values are more favorable than the averages derived from menus written under the current Meal Requirements (that is, the menus used to obtain the SNDA-III means and the representative baseline menus). For the menus written by the committee, examination of the tables il- lustrates a number of points: • The amounts of protein; vitamins A, C, riboflavin, B6, and B12; magnesium; zinc; calcium; and phosphorus all compare favorably with the Nutrient Targets for both breakfast and lunch for all three age-grade groups. (Minor deviations are considered to be within the expected limits of accuracy of the data.) • The amounts of potassium and fiber are higher than the SNDA- III mean and the amounts in the representative baseline menus. Although some of them do not meet the Nutrient Target, some of them compare very favorably (e.g., potassium values of the sample menus actually exceed the Nutrient Target for elementary and middle school breakfast). • As expected, the amount of vitamin E was consistently below the Nutrient Target, the amount of iron was below the iron target for middle and high school lunch, amounts of linoleic and α-linolenic acid were below the breakfast target for all three age-grade groups (amounts of these fatty acids exceeded the targets at the lunch meal), and the amount of sodium consistently was above the target maximum. • Folate values at lunch tended to be lower than in the menus based on existing standards, and they did not meet the target for middle or high school lunch. In a few cases, the contents of thiamin and niacin were slightly below the target for lunch—the deviations may be within the limits of accuracy of the data.

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 PROJECTED IMPACT Based on the above analyses, it appears prudent to make gradual changes to serve more foods that are rich in vitamin E and linoleic and α- linolenic acid (such as vegetable oils; nuts, seeds, and nut butters; and whole grains). The foods that are offered for this purpose need to be affordable, well accepted, and tolerated by the students, and they need to fit within the calorie allowance. Although peanut butter is an example of a good source of vitamin E and the unsaturated fatty acids, it is a food that many school districts omit from school meals because of concerns about allergy. Three nutrients merit special attention: 1. Vitamin E. Although the vitamin E content of the menus is much lower than the target values and low vitamin E intakes are reported for schoolchildren, the committee notes that no health consequences have been associated with these reported vitamin E intakes. Moreover, evidence suggests that vitamin E intakes are underestimated in survey data because of four types of measurement errors (IOM, 2000). Nonetheless, efforts to increase vitamin E intake, such as those suggested above, are warranted. 2. Folate. The substitution of 1 ounce of 100 percent whole wheat bread for 1 ounce of enriched white bread (which is fortified with folic acid) decreases the amount of folate by 34 µg of Dietary Folate Equivalents (DFE)1 (but increases the amount of several other nutrients). In some of the menus, the committee substituted 2 ounces of 100 percent whole grain foods for 2 ounces of refined enriched grain foods, thus decreasing the amount of folate in the meal by approximately 70 DFE. Selecting fruits and vegetables (e.g., orange juice, spinach) that are especially rich in folate may help make up the difference. 3. Iron for middle school and high school meals. The use of the nutrient density Target Median Intake approach (described in Chapter 4) resulted in relatively high Nutrient Targets for iron for the middle school and high school meals. The targets were set to cover 95 percent of the most vulnerable group (the females who were assumed to be menstruating), thus taking into account those with the highest need for iron. Although some attention to the selection of iron-rich foods may be merited within the rec- ommended standards for menu planning, the committee did not consider it necessary to make further changes in amounts specified from the meat and meat alternates group—the food group that provides the most iron—or to place extra emphasis on the richest sources of iron within that group. 1 Value based on computing the difference between the two folate values taken from the USDA National Nutrient Database for Standard Reference, Release 21: http://www.nal.usda. gov/fnic/foodcomp/search/.

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 SCHOOL MEALS Possible Negatie Consequences Amounts of food offered may be too large for some of the younger elementary school children because they are more likely to have lower en- ergy needs than the older children in the same age-grade group. The use of the offer ersus sere (OVS) provision of the law in all elementary schools might help offset this problem by allowing the children to decline a speci- fied number of foods. CRITERION 3: SIMPLIFIED MENU PLANNING AND MONITORING AND STUDENT ACCEPTANCE OF SCHOOL MEALS This criterion covers a number of topics. Student participation in school meals, which the committee’s criteria do not address directly, is covered in this section because of its overall importance to school meal programs and its close linkage with student acceptance of school meals. Menu Planning Process The committee worked to develop the least complex approach to menu planning that would be consistent with Dietary Guidelines. Although the recommended standards for menu planning are not as simple as the current food-based standards, it was essential to introduce new elements to con- form to Dietary Guidelines. The committee ruled out making recommenda- tions for nutrient-based menu planning because there was not a practical way to do so that would cover the full array of nutrients and also ensure consistency with Dietary Guidelines. Adantages The recommended standards for menu planning provide a single, pri- marily food-based approach to meal planning that covers breakfast and lunch for the three age-grade groups. Once training materials and methods are developed, focusing on a single menu planning method could streamline training across school districts. Required food composition data are limited to calories, saturated fat, and sodium—each of which is readily available on nutrition facts panels or from manufacturers. The approach has a strong scientific foundation that helps ensure healthy school meals for the nation’s children. Potential Negatie Consequences The committee recognizes that the menu planning process is always a complex task, especially under any set of standards for menu planning

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 PROJECTED IMPACT designed to be consistent with the DRIs and the Dietary Guidelines. Devel- oping food-based menu plans that also meet the specifications for calories and saturated fat, that gradually reduce the sodium content of the meals, and that are operationally realistic will present challenges for many school food service directors. Menu planning to meet the 2005 Dietary Guidelines requires changing the menu-planning mindset from meeting daily minimums to achieving a healthy balance of planned food items within an appropriate meal calorie range for the week. Previously, the focus was on meeting minimum amounts (except for saturated fat), and there was considerable leeway for offering extra menu items (such as condiments) and foods high in added sugars. A challenge for menu planners who have not used the Enhanced Food-based Menu Planning Approach is having weekly amounts that cannot be evenly distributed over the school days (e.g., eight grains per week means that the menu would include options with two grains 3 days per week and only one grain the other 2 days). However, meeting the Meal Requirements is only one of many aspects of the menu planning process. Time, training, and new resource materials will be required for operators to learn the new approach to meal planning. Chapter 10 identifies measures that will aid in the implementation of new menu planning methods. Monitoring of Meal Quality The current method of monitoring by state agencies and the committee’s suggestions for the monitoring of school meals are covered in Chapter 10. Adoption of the approaches suggested there would simplify the monitor- ing process and be more likely to facilitate effective implementation of the recommended Meal Requirements. Student Acceptance of Changes in School Meals Student acceptance of changes in school meals is correlated with stu- dent participation rates. A number of changes in the Meal Requirements could influence both. Based on information about foods commonly eaten by schoolchildren and a few reports in the literature, the committee identi- fied as follows how it anticipates that students will initially accept specific menu changes. Potential Positie Effects on Acceptance • More fruit at breakfast. The committee received suggestions from students to add fruit at breakfast, to use as a “topping,” for example, on cereal or yogurt (USDA, 2009).

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0 SCHOOL MEALS • Greater choice at some schools. This could improve acceptance, especially by better meeting the needs of students with religious and cultural preferences. Potential Negatie Effects on Acceptance • Dark green and orange egetables and legumes on menu each week. Few students report eating these vegetables (USDA/FNS, 2008c). Although students in schools that have the OVS provision in effect would not be required to select those vegetables, the implementation of effective educational, marketing, and food preparation strategies could improve student acceptance of these nutritious foods (see Chapter 10). • More egetables at lunch but starchy egetables sered less often. Data from the National Health and Nutrition Examination Survey 1999–2002 (USDA/FNS, 2008c) indicate that vegetable consumption by children is very low, with the exception of potato consumption (see Chap- ter 3). However, the committee anticipates that parents and students will ultimately appreciate the value of nutritionally improved school meals and that, with repeated exposures and high-quality food preparation, students will learn to value the vegetable items offered. Anecdotal reports from food service supervisors and newspaper articles suggest that this outcome is likely. • Proposed requirements to select a fruit or egetable for a reim- bursable meal. (see section “Options for Standards for Meals as Selected by Students” in Chapter 7). Currently, students in most schools operating under OVS are not required to take a fruit or vegetable. The committee anticipates that the proposed requirement will become reasonably well ac- cepted because the student has a choice of fruits at breakfast and a choice of at least three fruit and vegetable items at lunch. • Milk choices limited to fat-free (plain or flaored) and plain low- fat ( percent milk fat or less). Currently, a majority of students consume plain milk with a fat content of 2 percent or more or flavored milk with at least 1 percent milk fat (USDA/FNS, 2008c). Although the lower fat milks may not be well accepted initially, using methods described in Chapter 10 may facilitate student acceptance. In addition, the committee anticipates that the inclusion of flavored fat-free milk among the milk options will help promote the consumption of milk by students. • More whole grain-rich food products, fewer refined grain prod- ucts. Data from 1999–2002 (USDA/FNS, 2008c) indicate that children’s consumption of whole grains is very low (see Chapter 3). This is likely to be, in large part, a function of the availability of suitable and appetizing products, and the committee expects that the availability and acceptance of these products will increase with time.

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 PROJECTED IMPACT • Nearly all entrées, cheese, and grain products low in saturated fat. There may be some initial negative response because most schoolchildren are accustomed to the taste and texture of foods high in saturated fat. (See also the section “Student Participation” that follows.) • Little to no trans fat in the meals. Increasingly, trans fat is being greatly reduced in the food supply. • Fewer desserts. Anecdotal evidence and evidence from SNDA-I (USDA/FNS, 1993) and from an early study by Dillon and Lane (1989) indicate that desserts are very popular when served. • Less sodium in the meals. This is probably the most worrisome of the recommended changes, because the sodium intake of U.S. children is very much above recommended levels and most schools serve meals that are high in sodium. Eidence Related to Acceptance of Foods with Lower Sodium Content There is only limited evidence by which to predict the acceptance of lower-sodium products by children, especially when they are introduced gradually. It is well established that taste is one of the most important fac- tors related to food acceptability (IFIC, 2008) and that lowering the salt (sodium chloride) content of foods has a negative impact on the taste and flavor of food (Kilcast and Angus, 2007). When people undertake a low- sodium diet, observations suggest that the immediate response is a strong dislike for the foods that are reduced in salt (Beauchamp and Engelman, 1991). Although the lower sodium diet eventually may be acceptable, espe- cially if steps are taken to enhance the flavor of food with other ingredients such as herbs and spices, this occurs under circumstances in which the study participant (an adult) is highly motivated to continue the diet. To the extent that there are any data for children, the observations sug- gest that, compared with adults, children have a higher preference for salt taste (Beauchamp and Cowart, 1987; Desor et al., 1975). Thus, children may react even more strongly than adults to reduced salt taste in foods. It is unlikely that children will be easily motivated to continue to eat foods that do not taste appealing, especially if foods that contain more salt are available. Given the importance of taste in food acceptance, rapid and no- ticeable reductions in the sodium content of school meals would jeopardize the success in offering meals that the students will find satisfactory. Lack of satisfaction, in turn, would increase the likelihood of a decrease in student participation in the school meal programs. On the other hand, perceptual studies on taste show that people are generally unable to detect differences between two concentrations of a taste substance when the difference is less than 10 percent (Pfaffmann, 1971). On this basis, small reductions in sodium chloride instituted regularly, perhaps

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 SCHOOL MEALS only at the beginning of the school year, may be expected to accomplish a reduction in sodium intake over time without risking a decrease in food acceptability and, in turn, student participation. Overall, the choice to move slowly but systematically in reducing sodium in school meals seems prudent. Analysis of the sample school breakfast menus indicates that school breakfasts can be planned with sodium levels close to the recommended amounts with little change of commonly used products. (See Tables 9-1 through 9-3 for the analysis and Appendix M for the menus.) Gaining student acceptance of lower sodium lunches is more problematic and is part of the reason for setting the year 2020 as the target for achieving full implementation of the sodium recommendation (see Chapter 10). Aoiding or Addressing Decreased Student Acceptance Decreased student acceptance could lead to the consumption of poorer quality diets by students, either by eating less of the food that is offered or by switching from school meals to à la carte meals, food from vending ma- chines or school stores, off-campus meals, or food from home. Over time, initial negative effects on student acceptance could become positive, given appropriate measures to encourage the acceptance of less familiar foods. With regard to increasing whole grains and especially to reducing the sodium content of meals, the committee acknowledges the need for a gradual phase-in to accustom children to the changes in school meals and also to give the market time to respond to changes in demands (expressed as purchase specifications) from school food service directors. While caution demands that the possibility of decreased student acceptance be acknowl- edged, the committee is optimistic that students, teachers, and particularly parents will welcome the introduction of healthier school meals and that the ultimate impacts on acceptance and participation may actually be posi- tive. There is no evidence on which to base a prediction of the response to lower-sodium meals when offered at school without similar changes being made outside of school. Chapter 10 addresses aspects of implementation that may foster student acceptance of the changes. Student Participation Because the School Breakfast Program and the National School Lunch Program offer nutritious foods that promote schoolchildren’s growth, health, and readiness to learn, schools aim for high student participation rates in these programs. The available data on which to base confident predictions of any effects of the proposed changes on participation rates are limited. The committee anticipates that participation rates will be strongly

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 PROJECTED IMPACT affected by economic factors. It further anticipates that, overall, students and parents will value a change toward more healthful school meals. The most promising data related to student participation rates are found in a recent empirical analysis conducted in Minnesota (Wagner et al., 2007). These investigators present preliminary evidence that lunch sales do not decline when “healthier”3 meals are served. This finding suggests that participation rates are maintained with improvements in the nutritional quality of the meal. As described below, there is some evidence that changes toward reducing high-fat choices and increasing the availability of low-fat entrée choices in school lunch improve nutrient intakes and may increase participation in school lunch. One intervention to increase fruit and vegetable availability in school breakfasts resulted in increased participation (Woodward-Lopez and Webb, 2008). Several evaluations of more comprehensive attempts to improve the nutritional value of school lunches—from San Francisco (Wojcicki and Heyman, 2006), Texas (Cullen et al., 2008), and California middle and high schools (Center for Weight and Health, 2006)—all have shown increases in participation. Several studies have examined the effects of increasing the frequency of offering lower fat entrées in school lunch. Whitaker et al. (1993, 1994) worked in elementary schools in Bellevue, Washington. The initial interven- tion was to offer low-fat entrées more often. Although the low-fat entrées were selected less frequently than the higher fat entrées (29 percent of students selected the lower fat entrées—without any further intervention or awareness of the intervention on the part of the students), there was no effect on participation rates (Whitaker et al., 1993). In a subsequent study, the same intervention was used in a randomized design, but the study was expanded by engaging parents at a low level as agents of change. This was accomplished by providing information: menus that emphasized (by bold font) the lower fat alternative entrées, facts about the fat content of both entrées, and menu nutrition information. The results were an increase in the selection of low-fat entrées and no change in school lunch participation (Whitaker et al., 1994). In a later study in central Texas elementary schools, an intervention was introduced to offer lower fat entrées more frequently, followed by a reduction in the frequency of offering higher fat alternative entrées (Bartholomew and Jowers, 2006). In this study, the percentage of students selecting the lower fat entrée increased, and there was a 20 percent reduction in selection of the higher fat entrée. School lunch participation increased slightly overall. 3 The scoring method described in the article relies on data obtained from the school district’s nutrition review regarding how well the school met the Nutrition Standards for the eight dietary components, and it considered the average calories per meal.

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 SCHOOL MEALS Data from the SNDA-I study, collected in 1992, indicate that participa- tion in the NSLP is less likely when the lunch that is offered contains less than 32 percent of calories from total fat (Gleason, 1995). Although that level of fat is lower than the 35 percent upper level in the recommended Nutrient Targets, it suggests that the methods used to reduce the saturated fat content of school meals, as emphasized in the committee’s recommen- dations, could be important to maintaining student participation rates. Low-fat and fat-free milk products, for example, may not be well accepted initially. Evaluations of salad bar programs in public schools indicate positive effects on fruit and vegetable consumption (Adams et al., 2005; Slusser et al. 2007), but they have not examined participation rates. A program in- troduced in 2006 in California (and subsequently discontinued because of a lack of funding) provided an increased reimbursement rate at the level of 10 cents for every breakfast served when an additional serving of fruit or veg- etable was offered. For participating schools, the impact on fresh fruit and vegetable consumption was significant. Importantly, participation in school breakfast increased enough to bring about $1 million in additional federal meal reimbursement to the state (Woodward-Lopez and Webb, 2008). Evaluations of more comprehensive changes to school meals are few, but those that are available are encouraging. In the examples that follow, community support and technical assistance contributed to the positive results. (See the section “Achieving Change” in Chapter 10 regarding the importance of these factors.) The San Francisco Unified School District first piloted new nutrition standards for school lunch in one large middle school in 2002–2003. Then, upon finding that revenues increased, the district scaled the changes up to include the entire district the following year (Wojcicki and Heyman, 2006). In this situation, the overall student participation in the lunch program increased in the academic year following implementation of the new standards. In total, 40 middle and high schools (almost all of those in the district) were included in the evaluation. The second available experience is from the state of Texas, where a statewide Public School Nutrition Policy was implemented in 2004. The policy incorporated a number of changes to improve the overall school nutrition offerings. An evaluation was conducted in several middle schools before and after the changed standards (Cullen et al., 2008). That study showed a substantial increase in participation from the year before the policy was implemented to 2 years following the change for all categories of school lunch (free, reduced-price, and paid meals). In California, the pilot test of a state law that focused on the restriction of competitive foods in schools led to a more comprehensive intervention. In participating schools, the intervention included improvement of variety and quality in school meals, improvement in cafeteria environments, and

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 PROJECTED IMPACT the adoption of nutrition and physical activity policies. The evaluation documented an increase in participation in the meal program and a decrease in the purchase of competitive foods. The increased student participation in the school lunch program resulted in financial benefits to the schools’ food service (Center for Weight and Health, 2006). It should be noted that all the evidence cited here is from repeat cross- sectional studies and that other factors that affect participation (most importantly, factors affecting the larger economy) were not controlled. However, the available evidence shows that schools that have implemented changes similar to those recommended by this committee have experienced neutral or positive changes in participation. A caveat is that no interven- tions have explicitly focused on substantially reducing the sodium content of school meals. Some of the interventions, by their restriction of snack foods, would have had some impact on sodium, however. The current economic situation in the United States has put an increas- ing proportion of families under economic stress. Data from SNDA-I show that students who were certified to be eligible for free or reduced-price meals had higher participation rates than noncertified students (Gleason, 1995). Since that time, the certification process has been simplified, suggest- ing that low-income schoolchildren may be even more likely to participate. The result is that school meals (especially for those who qualify for free or reduced-price meals) are becoming an increasingly important part of the safety net for food security for families with children. CRITERION 4: SENSITIVE TO COSTS AND ADMINISTRATIVE CONCERNS Costs As discussed in Chapter 8, the increases in fruits, vegetables, and whole grain-rich foods incur additional food costs. The expected increase is likely to exceed the amount that could be absorbed by school food authorities under current federal reimbursement levels, with certain exceptions as discussed in Chapter 8. Measures to help school food programs meet the Dietary Guidelines incur cost increases and an increased need for adminis- trative support. An overview of strategies to control the overall cost of food service operations appears in Chapter 10, Box 10-2. Administrative Concerns Change always leads to administrative concerns, and the committee lists a number of potential concerns below.

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 SCHOOL MEALS Purchasing In the short term, food service directors may face challenges in obtain- ing acceptable food products, especially ones that are reduced in sodium and saturated fat (and, in some areas, whole grain-rich foods). The new standards for menu planning will require greater attention to writing ap- propriate specifications for food processors or vendors. Preparation and Meal Serice The committee developed the standards for menu planning with the intent of making them adaptable to many types of food service operations. The sample menus in Appendix M illustrate this point. Nonetheless, the addition of food items, namely at least one more fruit at breakfast and (for some programs) one more vegetable at lunch, will increase time and space requirements at schools that have not already taken the initiative to make these increases. Data from SNDA-III (USDA/FNS, 2007a), however, indi- cate that many schools already offer an additional fruit, vegetable, or both over amounts specified in the current Meal Requirements. Equipment and Kitchen and Storeroom Space Improving the quality of school meals by adding fruits and vegetables and decreasing saturated fat and sodium may call for additional equipment and kitchen and storeroom space in many food service operations. The ex- tent of the need will depend on the current status and on decisions related to (1) the use of purchased entrées and ready-to-eat fruits and vegetables or (2) in-house preparation of those items. Some food service operations may need to add refrigerator or freezer space; fruit and vegetable preparation sinks; work table space; and special utensils to cut, dice, or chop fruits and vegetables for ready-to-eat portions. Some may need to replace fryers with steamers, microwave ovens, and combi ovens. To handle additional menu items, serving lines may need more refrigerated units, hot wells, and utility carts. Additional small serving and portioning equipment may be needed. Effects on Student Participation Rates Student participation rates are a major administrative concern because they affect revenue, as noted above, and thus are closely linked to the finan- cial viability of school meal programs. Because of the close link of participa- tion rates with student acceptance of school meals, the evidence concerning student participation rates was reviewed in the previous section.

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 PROJECTED IMPACT SUMMARY Apart from cost data (covered in Chapter 8), relatively little evidence is available on which to base predictions of the impact of implementing the recommended Meal Requirements for school meals. It is clear that the recommended standards for menu planning will result in menus that are much more consistent with the DRIs and the Dietary Guidelines than are the current standards for menu planning. In addition, the meals will provide more nutrients relative to calories, and the recommended option for meals as selected by the student may improve actual consumption of fruits and vegetables. In some school settings, the initial need (and therefore the cost) for equipment and/or training may be increased. The literature suggests that student acceptance can be achieved and participation rates maintained if appropriate methods are used for implementing change.

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