Many changes have been made over the past decades that have an impact on understanding the importance of nutrition in the health and well-being of school-age children and adolescents. Obesity is increasing among this population, putting children at greater risk for other health concerns such as diabetes, hypertension, and cardiovascular disease. Although food choices and eating habits derive from many sources, school environments can have a significant influence on children’s diets and play an important role in teaching and modeling appropriate health behaviors.
In addition to providing meals through federally reimbursable school nutrition programs, schools have become venues for “competitive” foods and beverages, those that compete with the traditional school lunch as a nutrition source. These foods and beverages are obtained from a variety of sources including à la carte service in the school cafeteria, school stores and snack bars, and vending machines.
The Child Nutrition and WIC (Women, Infants, and Children) Reauthorization Act of 2004 required each local education agency to develop a wellness policy by 2006. These policies must include nutrition guidelines, nutrition education and physical activity goals, and other school-based activities. Although school districts across the country have taken steps toward meeting these requirements, implementation is inconsistent and in some cases incomplete. In addition, given that each local education agency establishes its own local wellness policy, there is great variety, with policies ranging from very detailed and well-defined, to less detailed and more vague. To augment the local wellness policies and other federally directed
initiatives, Congress directed the Centers for Disease Control and Prevention (CDC) to undertake a study with the Institute of Medicine (IOM) to make recommendations about nutrition standards for foods offered in competition with federally reimbursable meals and snacks. An ad hoc committee of the IOM was thus convened and charged to
draw on literature regarding the availability, nutritional profile, and risks (including substitution) of school foods and beverages, including recent work by the Government Accountability Office, as appropriate;
synthesize lessons learned from relevant research, development of federal nutrition standards for the National School Lunch and Breakfast Programs, and experience from the development of state- and local-based standards for foods and beverages offered outside federally reimbursable meals and snacks;
consider whether a single set of nutrition standards is appropriate for elementary, middle, and high schools, or if more than one set is needed;
develop nutrition standards based on nutritional science for foods and beverages, other than federally reimbursable meals and snacks, offered in school;
consider how to ensure that foods and beverages offered in schools contribute to an overall healthful eating environment; and
develop benchmarks to guide future evaluation studies of the application of the standards.
APPROACH TO DEVELOPING NUTRITION STANDARDS
To initiate the study process, the committee developed a set of guiding principles to support the creation of a healthful eating environment for children in U.S. schools and to guide the deliberations and development of standards (Box S-1).
The committee also reviewed pertinent evidence, guided principally by the 2005 Dietary Guidelines for Americans (DGA). The DGA provides the most comprehensive science-based advice to promote health and reduce risk for major chronic diseases through diet and physical activity for the U.S. population two years of age and above. Although the scope of the DGA is quite broad, it does not cover all areas of importance to the committee’s work on nutrition standards for schools—for example, it lacks recommendations concerning caffeine and nonnutritive sweeteners. However, the DGA are diet-based recommendations, and competitive foods and beverages must be regarded individually. Thus standards were set for individual foods to increase the likelihood that students meet overall DGA recommendations.
The committee recognizes that:
The committee intends that:
The committee systematically organized foods and beverages offered separately from federally reimbursable school nutrition programs into two tiers according to the extent of their consistency with the DGA. Tier 1 foods and beverages are consistent with “foods to be encouraged” as defined in the DGA. Tier 1 foods and beverages are those that provide at least one serving of fruit, vegetable, whole grain, or nonfat/low-fat dairy. Tier 2 foods and beverages fall short of Tier 1 criteria, but they do not fall outside of
the intake recommendations of the DGA for other nutrients such as fat and sodium. Examples of Tier 2 foods include processed foods such as baked potato chips, low-sodium whole wheat crackers, graham crackers, or animal cracker cookies. Foods and beverages that are not consistent with the DGA do not meet the standards defined for Tier 1 and Tier 2 items. The committee developed specific nutrient standards for both Tier 1 and Tier 2 foods and beverages, discussed below. Table S-1 shows Tier 1 and 2 foods and beverages.
The committee’s Guiding Principles and the concept of Tier 1 and Tier 2 foods form the basis of its recommendations for nutrition standards for competitive foods offered in schools. These standards have two major objectives: first, to encourage children to consume foods and beverages that are healthful—fruits, vegetables, whole grains, and nonfat or low-fat dairy products—and second, wherever possible in all competitive foods and beverages offered at schools, to limit food components that are either not healthful when consumed at levels exceeding the DGA or fall outside DGA recommendations. Standards that contain specified ranges for fats, energy, added sugars, and sodium are the committee’s best judgment based on its interpretation of limited available evidence.
Standards for Nutritive Food Components
Standard 1: Snacks, foods, and beverages meet the following criteria for dietary fat per portion as packaged:
No more than 35 percent of total calories from fat
Less than 10 percent of total calories from saturated fats
Zero trans fat
Americans, including children, consume too much fat, especially saturated fat. Although some fat intake is needed to meet requirements for essential fatty acids and to utilize fat-soluble vitamins, fats are energy dense, and a high fat intake contributes to the high caloric intake of overweight and obese individuals. Consistent evidence shows that diets high in saturated fat are associated with increased risk and higher rates of coronary heart disease. Like saturated fats, trans fats found in hydrogenated oils increase low-density lipoprotein (LDL) cholesterol; trans fats also decrease high-density lipoprotein (HDL) cholesterol.
TABLE S-1 Foods and Beverages That Meet Tier 1 and Tier 2 Standards
Tier 1 for All Students
Tier 1 foods are fruits, vegetables, whole grains, and related combination products* and nonfat and low-fat dairy that are limited to 200 calories or less per portion as packaged and:
Tier 1 beverages are:
À la carte entrée items meet fat and sugar limits as listed above and:**
*Combination products must contain a total of one or more servings as packaged of fruit, vegetables, or whole-grain products per portion
**200-calorie limit does not apply; items cannot exceed calorie content of comparable NSLP entrée items
*1-percent milk fat
Tier 2 for High School Students After School
Tier 2 snack foods are those that do not exceed 200 calories per portion as packaged and:
Tier 2 beverages are:
Standard 2: Snacks, foods, and beverages provide no more than 35 percent of calories from total sugars per portion as packaged.
Sugars contribute calories without substantial amounts of micronutrients. Limiting foods high in added sugars is recommended because high levels of added sugars are associated with increased calorie and decreased micronutrient consumption. Decreases in micronutrient intake are greatest when added sugars exceed 25 percent of the total caloric intake. However, the committee decided that a 35 percent limit on total sugars (for non-dairy products) would be achievable while contributing to improvement in the eating patterns of school-age children.
Recent data show that added sugars from soft drinks, fruitades, and other sweetened fruit drinks contribute from 35 to more than 50 percent of the total intake of added sugars in children’s diets. Decreases in allowable added sugars are intended to provide an incentive for food manufacturers to develop an array of acceptable products that contain less than 35 percent of calories from total sugars. Many food products already in the marketplace approach this limit, and through modest reformulation will conform to the committee’s recommendation. With the exceptions noted, the recommendation of 35 percent of calories from total sugars is viewed by the committee as an interim recommendation until added sugars information is more readily available to school foodservice operators.
Exceptions to the standard are
100 percent fruits and fruit juices in all forms without added sugars;
100 percent vegetables and vegetable juices without added sugars; and
unflavored nonfat and low-fat milk and yogurt. Flavored nonfat and low-fat milk can contain no more than 22 grams of total sugars per 8-ounce portion, and flavored nonfat and low-fat yogurt can contain no more than 30 grams of total sugars per 8-ounce serving.
Dairy product exception Dietary intake of calcium-rich foods and beverages is very important throughout the school years, but many of the dairy products popular among school-age children that can make a positive contribution contain added sugars in excess of the recommended limit set by the committee. To avoid elimination of these dairy products due to sugar content, the committee made an exception to the recommended limit on added sugars.
In setting the proposed higher standards for these foods and beverages, the committee sets limits that are both attainable and maintain product palatability, while still reducing intake of added sugars. In making the
recommendations, the committee is also mindful of the positive efforts of some states and school districts, sometimes working together with the dairy industry, to successfully develop products lower in added sugars.
Standard 3: Snack items are 200 calories or less per portion as packaged and à la carte entrée items do not exceed calorie limits on comparable National School Lunch Program (NSLP) items.
Entrée items served à la carte are exempt from the 200-calorie limit; their caloric content does not exceed that of comparable NSLP entrée items.
Most U.S. children consume at least one snack per day, and children consume nearly one quarter of their dietary energy intake as snacks. Energy intake should be commensurate with energy expenditure in order to achieve energy balance in adults and avoid overweight and obesity; only a small positive energy balance is required for growth in school-age children. The energy density of foods is higher for snacks compared to meals, and excess weight gain may develop over time from a relatively small daily excess of calories consumed.
The committee determined that discretionary energy consumption from snacks should represent no more than about 9 percent of total daily energy intake. A 200-calorie maximum limit per portion for snacks may be high for some younger or smaller children, but it is assumed that variations in other daily energy intake will compensate for shortfalls or excesses. Furthermore, à la carte entrée items should not provide more calories than the comparable NSLP entrée items they replace. The standard is established for whole servings rather than half servings because, in the committee’s judgment, a whole serving of fruit, vegetable, or whole grain per portion would contribute to the goal of helping school-age children meet DGA recommendations in a portion size that food manufacturers can achieve in formulating new products.
Standard 4: Snack items meet a sodium content limit of 200 mg or less per portion as packaged or 480 mg or less per entrée portion as served à la carte.
Although sodium is an essential dietary mineral, it is widely overconsumed. Research evidence in adult subjects strongly supports a correlation between higher salt intake and increased blood pressure, although associations in children and adolescents are not as well documented.
The exception to the sodium recommendation for federally reimbursable school meal entrée items purchased à la carte reflects the fact that they generally represent greater energy value than the recommended limit for snacks (Standard 3 above). These entrée items are components of meals that meet U.S. Department of Agriculture school meal nutrition standards
and their inclusion allows greater flexibility for students with higher energy needs.
Standards for Nonnutritive Food Components
Standard 5: Beverages containing nonnutritive sweeteners are only allowed in high schools after the end of the school day.
In considering nonnutritive sweeteners in competitive foods and beverages for school-age children, four related issues were evaluated: safety; displacement effect on intake of other foods and beverages to be encouraged (fruits, vegetables, whole grains, and nonfat or low-fat dairy products); efficacy for maintenance of healthy weight; and the role of choice and necessity.
Safety The Food and Drug Administration (FDA) sets safety standards for food additives, including nonnutritive sweeteners. Those that are approved for use have been evaluated extensively and have met the standards. Yet there is still uncertainty, particularly about long-term use and about low-level exposure effects on the health and development of children.
Displacement Nonnutritive-sweetened beverages may be chosen instead of nutrient-dense beverages. Nutrient displacement occurs when a beverage or food of lesser nutritional value is substituted for one of greater nutritional value, resulting in reduced intake of nutrients.
Efficacy The DGA states that reduction of calorie intake is important in weight control. Nonnutritive sweeteners are used to replace sugars in foods and beverages and provide lower calorie choices to consumers.
Choice and necessity Beverages that meet Tier 2 standards make no caloric contribution and increase the variety of choices. These additional choices may be useful for those who wish to control or maintain body weight. The use of nonnutritive sweeteners to provide lower calorie foods and beverages, however, is not necessary to achieve the goal of weight control.
The committee considered these issues in the context of development in school age children and the public health concern of childhood obesity. Given the lack of clear evidence to evaluate their efficacy in weight control, intending to maintain clarity and avoiding complexity of standards across age groups and times of day, the committee took a cautious approach in its recommendations for the use of nonnutritive sweeteners in competitive foods and beverages.
Because of the uncertainties and limitations in evidence, especially concerning the safety and benefits for weight control, the committee does not recommend a standard for nonnutritive sweeteners in foods.
Safety Nonnutritive sweeteners meet the safety standards set by the FDA; however, there is no long-term evidence addressing their safety when consumption begins in early childhood, and in relation to a broader range of health and developmental outcomes. The committee also considered the limitations in testing and lack of evidence concerning the benefits or necessity for use of nonnutritive sweeteners in foods.
Displacement Displacement was not an important issue for nonnutritive sweeteners in foods that otherwise met the recommended standards.
Efficacy Based on the principle of energy balance, nonnutritive sweeteners in foods might provide a tool for weight management; however, studies to test this in children are not conclusive and the complexities of the relationship between nonnutritive sweeteners and appetite have not been studied in this age group.
Choice and necessity Although nonnutritive sweeteners may increase palatability, thereby increasing consumption of healthful foods, the potential increase in consumption may not be sufficient justification to include them in foods. There was also concern that children may not be able to distinguish between a food with nonnutritive sweeteners and a similar full-calorie food, which might encourage unintentional overconsumption. Improving dietary patterns and maintaining healthy weight in children does not require foods with nonnutritive sweeteners.
Standard 6: Foods and beverages are caffeine-free, with the exception of trace amounts of naturally occurring caffeine-related substances.
The evidence for adverse health effects, other than physical dependency and withdrawal, from caffeine consumption varies in severity of effects and consistency of results among studies (see discussion in Chapter 2) except for the two health effects mentioned. Tolerance and dependence on caffeine have been identified in all ages, including school-age children, and withdrawal from regular caffeine intake is followed by generally mild effects such as moodiness, headache, and shakiness.
Although there may be some benefits associated with caffeine consumption (see Chapter 2), the committee did not support offering products containing significant amounts of caffeine for school-age children because of the potential for adverse effects, including physical dependency and withdrawal (described in Chapter 2). Thus the committee judged that caf-
feine in significant quantities has no place in foods and beverages offered in schools. The committee recognized that some foods and beverages contain trace amounts of naturally occurring caffeine and related substances and did not intend to exclude such foods or beverages if the amounts of caffeine consumed are small and the product otherwise complies with the recommended nutritional standards.
Standards for the School Day
Standard 7: Foods and beverages offered during the school day are limited to those in Tier 1.
Because of their nutritional attributes, consumption of Tier 1 foods and beverages is to be encouraged. Thus it is appropriate to make them available as competitive foods during the school day. Evidence supports the use of Tier 1 foods and beverages to increase consumption of fruits, vegetables, whole grains, and nonfat and low-fat dairy products by school-age children, and to reinforce innovation by industry to create products more consistent with the DGA, thereby increasing healthful competitive food choices for school-age children.
Standard 8: Plain, potable water is available throughout the school day at no cost to students.
Water is essential to health, and is naturally calorie free with few known negative health consequences. Either tap or bottled water or water from fountains or other sources represents a safe, desirable way of maintaining hydration during the school day, and is therefore included as a Tier 1 beverage. The committee’s interpretation of limited available evidence is that carbonated water, fortified water, flavored water, and similar products are excluded because such products are associated with displacement of more healthful beverages (see Chapter 2); they are unnecessary for hydration purposes; and the increasing variety of products increases the difficulty of making clear distinctions among them. In addition, if flavored or fortified waters are included, they may serve, in the committee’s judgment, as implicit encouragement to produce more foods with nonnutritive components for children at the expense of more healthful foods.
Standard 9: Sports drinks are not available in the school setting except when provided by the school for student athletes participating in sport programs involving vigorous activity of more than one hour’s duration.
The committee concluded that, in most contexts, sports drinks are equivalent to flavored water, and because of their high sugar content it is appropriate that they be excluded from both Tier 1 and 2 beverages. However, for students engaged in prolonged, vigorous activities on hot days, evi-
dence suggests sports drinks are useful for facilitating hydration, providing energy, and replacing electrolytes. The committee’s recommended standard is consistent with conclusions of expert panels who considered this issue in adults. The committee suggests that the individual athletic coach determine whether sports drinks are made available to student athletes under allowable conditions to maintain hydration.
Standard 10: Foods and beverages are not used as rewards or discipline for academic performance or behavior.
Some schools have reported the use of foods and beverages as an aid in managing behavior. In the committee’s judgment, such use of foods and beverages in schools is inappropriate. Establishing an emotional connection between food and acomplishment encourages poor eating habits, and in the committee’s judgment should not be allowed.
Standard 11: Minimize marketing of Tier 2 snacks, foods, and beverages in the high school setting by
locating Tier 2 food and beverage distribution in low student traffic areas; and
ensuring that the exteriors of vending machines do not depict commercial products or logos or suggest that consumption of vended items conveys a health or social benefit.
The presence in some high schools of vending machines or other mechanisms to market Tier 2 snacks, foods, and beverages after school leaves open an opportunity to promote products during the regular school day, even if these vending machines operate only after the end of the regular school day. In making this recommendation, the committee concurs with the recommendations of the recent IOM report on food and beverage marketing to children.
Standards for the After-School Setting
Standard 12: Tier 1 snack items are allowed after school for student activities for elementary and middle schools. Tier 1 and Tier 2 snacks are allowed after school for high school.
The committee’s recommended standard applies specifically to after-school activities that are attended mainly by students and thus represent an extension of the regular school day.
Many school-related activities that take place in the late afternoon and evening involve both students and adults or, in some instances, mainly adults. These include interscholastic sporting events, back-to-school nights,
parent-teacher association meetings, and use of the school for adult activities such as adult athletic leagues.
Some students remain on the campus and proceed directly to their after-school activities, while others leave campus and return for these activities. Some food consumed during the after-school period is provided by the school, while in other cases it is provided by students or others.
Given that high school students are often expected to decide what to eat, it is appropriate to give them more choice in the less formal environment after the school day ends. Tier 2 foods and beverages provide for an expanded variety while maintaining nutritional standards.
Standard 13: For on-campus fund-raising activities during the school day, Tier 1 foods and beverages are allowed for elementary middle, and high schools. Tier 2 foods and beverages are allowed for high schools after school. For evening and community activities that include adults, Tier 1 and 2 foods and beverages are encouraged.
Fund-raising or evening and community activities that include the use of foods and beverages should emphasize nutritious choices such as fruits or juices, vegetables, nuts, grain products, and nonfat or low-fat dairy products. The committee recognizes that attempting to regulate foods and beverages sold for fund-raising or offered at evening events attended by both students and adults is not practical and may not be desirable. The committee urges that when foods and beverages are used for such activities they be limited to items that meet Tier 1 and Tier 2 standards.
IMPLEMENTING THE RECOMMENDED STANDARDS
The recommended nutrition standards are among several elements of a school policy that could significantly improve the nutritional quality of foods offered in schools. While proposing a complete implementation and evaluation plan is beyond the scope of the study, the committee developed a framework and set of benchmarks on which such a plan can be developed. The key elements for success in implementing standards for competitive foods in schools are summarized in Box S-2, and recommended actions follow.
Action 1: Appropriate policy-making bodies ensure that recommendations are fully adopted by providing
regulatory guidance to federal, state, and local authorities;
designated responsibility for overall coordination and oversight to federal, state, and local authorities; and
Key Elements for Success
performance-based guidelines and technical and financial support to schools or school districts, as needed.
Implementing the recommended nutrition standards for competitive foods and beverages offered in schools will require policy changes. These changes may occur at multiple levels, such as local, state, and/or national levels, and may combine policy guidance, regulations, and/or legislative action. In order for the recommended standards to be implemented, an authoritative agency must be designated to coordinate and monitor progress.
Action 2: Appropriate federal agencies engage with the food industry to
establish a user-friendly identification system for Tier 1 and 2 snacks, foods, and beverages that meet the standards per portion as packaged
provide specific guidance for whole-grain products and combination products that contain fruits, vegetables, and whole grains
Implementing the standards recommended in this report for Tier 1 and 2 snacks, foods, and beverages will only be accomplished with coordination and cooperation among federal agencies and the food industry. Product information currently available to foodservice operators is not always sufficient to determine whether products meet nutrition standards. In order for school foodservice operators to identify and evaluate foods and beverages that meet specified standards, detailed product information must be provided by manufacturers.
The federally reimbursable school nutrition programs are traditionally an important means to ensure that students have access to fruits, vegetables, whole-grain-based foods, and nonfat and low-fat dairy products during the school day. These programs are the main source of nutrition provided at school. However, there are increasing opportunities for students to select competitive snacks, foods, and beverages through à la carte services, vending machines, school stores, snack bars, concession stands, classroom or school celebrations, achievement rewards, after-school programs, and other venues. Schools are encouraged to limit these opportunities. When such opportunities arise, they should be used to encourage greater consumption of fruits, vegetables, whole grains, and nonfat or low-fat dairy products. The recommendations in this report are intended to ensure that competitive foods and beverages offered in schools are consistent with the DGA and, in particular, to encourage children and adolescents to develop healthful lifelong eating patterns.