Implementation, Evaluation, and Research
The effectiveness of recommended Nutrient Targets and Meal Requirements will be determined in large part by the extent to which the children consume appropriate amounts of the foods that are offered and the manner in which the targets and requirements are implemented, monitored, and evaluated. Monitoring refers to a review of how well the revised Meal Requirements are being implemented for the purpose of quality improvement at the local level. Evaluation refers to well-designed studies to examine the value of the Meal Requirements in meeting overall programmatic goals. Topics covered under implementation include key elements of achieving change, menu planning, school food service program operation, technical support for school food service operators, monitoring the quality of school meals, achieving long-term goals related to reducing sodium and increasing the whole grain content of meals, and the updating of the Nutrient Targets and Meal Requirements in response to future changes in Dietary Guidelines for Americans and the Dietary Reference Intakes (DRIs). Specific recommendations are given related to technical support for food service workers, procedures for monitoring, and measures related to the sodium and whole grain content of prepared foods. The chapter concludes with the committee’s recommendations related to evaluation and research.
Making a substantial change in menus for the school meal programs calls for a holistic approach to the entire food service operation. A strategic plan that introduces change incrementally over a realistic time frame—one developed with the involvement of key stakeholders—is desirable. The foremost concern of all operators is the possibility that modifications may negatively affect student participation. Especially in the current economy, any loss of revenue based on decreased participation presents a real threat to the financial stability of the program. Operators are acutely aware of student preferences; they know that students often decide whether or not to eat a school meal based on what is on the menu and not on hunger alone. Thus, careful consideration needs to be given to many aspects of implementing change.
Community-level strategies that can be used to promote change include engaging the school community, peer involvement, nutrition education, parental and community involvement, the training of food service workers and the involvement of the food industry. Brief summaries of these topics appear below. Some studies illustrate measures that improve the acceptance of more healthful foods outside the school setting. For example, Garey et al. (1990), Hinkle et al. (2008), and Wechsler et al. (1998) describe strategies for increasing the acceptance of milk products with lower fat content, several of which are similar to the strategies described below. Key factors that may be beyond the school food operators’ control but that influence student acceptance of the food offered include the time of the meal and the amount of time allowed for obtaining and eating the meal, the eating spaces available, the timing of recess, and access to competitive foods. “Making It Happen” (http://teamnutrition.usda.gov/resources/makingithappen.html), a joint project of USDA and Health and Human Services, is a source of locally tested ideas for improving the nutritional quality of all foods and beverages offered and sold on school campuses.
Engaging the School Community
Engaging the school community in the implementation of the new recommendations is essential. Several interventions noted the importance of formative research with the target audiences. For example, strategies that engage the school community include taste testing for the students to
improve preference for new items (Fulkerson et al., 2004; Snyder et al., 1999; Wechsler et al., 1998), signage on the food line (Fulkerson et al., 2004; Wechsler et al., 1998), product positioning (Goldberg and Gunasti, 2007; Wechsler et al., 1998), posters (Fulkerson et al., 2004; Snyder et al., 1999; Wechsler et al., 1998), media campaigns (Fulkerson et al., 2004; Goldberg and Gunasti, 2007), and celebrity endorsements (Wechsler et al., 1998).
Peer involvement is another strategy for promoting recommended meal changes (Fulkerson et al., 2004; Hamdan et al., 2005). Student advisory councils or other school-based student committees can work with the food service staff in the interval before new regulations need to be implemented, as well as during early implementation. Input from parents and school staff is also helpful.
Nutrition education can promote behavior change. In a study by Suarez-Balcazar and colleagues (2007), just providing a salad bar in elementary schools did not improve student fruit or vegetable selections. However, the addition of six nutrition classes in the intervention school resulted in greater student selection of fresh fruit and an item from the salad bar than occurred in the schools that only had the salad bar. Some promotion or education around these food groups will be needed because the new recommendations increase the fruit and vegetable offerings, emphasize vegetable subgroups to be offered, require that a fruit or vegetable be selected by the student, and increase the use of whole grain-rich products.
Parental and Community Awareness and Involvement
Keeping parents and the community aware of the changes also promotes acceptance. Suggested strategies include presentations at parent meetings (Wechsler et al., 1998), newsletters (Goldberg and Gunasti, 2007), and the use of local media (Goldberg and Gunasti, 2007). Districts are encouraged to form school-community advisory committees to develop implementation time lines in advance of the new regulations. These timelines can inform planning for menu revisions, training, and budgets so that all the pieces are in place when the new regulations are released.
Training and Equipment for School Food Service Staff
Adequate training for school food service staff is also essential to successful implementation, and the staff will need access to the necessary equipment (Goldberg and Gunasti, 2007; Snyder et al., 1999). (Further information on this topic appears later in this chapter under “School Food Service Operation” and “Technical Support for School Food Service Operators.”) In addition to learning the procedures to prepare the menu items, food service staff will need experiences to help them accept the new meal patterns and must be willing and able to give positive comments about the foods as the students pass through the cafeteria serving areas (Hendy, 1999; Perry et al., 2004; Schwartz, 2007). Training could include the use of step-by-step instructional materials—print, video, or web-based—and guided hands-on experiences.
Food Industry Involvement
The food industry needs to be a partner in achieving change because it is responsible for the diversity and quality of foods that are available for the school meal programs. Among the areas in which their partnership is essential are (1) producing appealing foods that are (a) lower in sodium, (b) lower in saturated fat, and (c) higher in the proportion of whole grains to refined grains; (2) identifying the whole grain content of foods on the label; and (3) producing foods in portion sizes that are compatible with the recommended standards for meal planning.
Regardless of the approach to menu planning that is used, menu items must be compatible with student preferences to promote the consumption of the foods by the participants and also to promote optimum student participation. School food authorities (SFAs) can take many steps to encourage the acceptance of foods by schoolchildren. Among the key factors that relate to menu planning are variety in flavors, textures, and food choices; repeated exposure to less familiar foods; eye appeal; food combinations that go well together; foods that are easy to eat in the available time and eating space; and consideration of regional, cultural, and religious food preferences. All these factors need to be considered in conjunction with strategies to implement the recommended standards for menu planning.
Meeting Challenges Related to Implementation of the Standards for Menu Planning
The recommended standards for menu planning pose new challenges that will call for menu planners to approach their task with a clear understanding of the nutritional goals to be achieved, which are based on the 2005 Dietary Guidelines.
Assistance will be needed to meet a number of anticipated menu planning challenges such as the following:
Planning within a calorie range that is different for each age-grade group;
Counting both daily servings and weekly servings for planned menu items;
Designing and grouping menu item choices to ensure that each student may select meals that meet the minimum amounts of each food group and subgroup during the week;
Developing or modifying food procurement specifications and recipes to meet the calorie, saturated fat, and sodium specifications;
Identifying food products in the marketplace that fit with the specifications for calories, saturated fat, and sodium and are also appealing to students;
Implementing incremental menu item changes (to permit food service staff to develop the skills and abilities to produce and serve the new items successfully);
Pre-costing menus and adjusting items as needed to stay within the targeted food cost; and
Identifying the most cost-effective and student-accepted items.
To achieve the desired calorie range, the menu planners will need to consider differences in quantities and combinations of items offered on each menu, adjust portion sizes for the specific grade group, and modify food purchasing specifications and recipes to meet the desired calorie level provided by a serving. To meet the meal pattern for each age-grade group, the menu planners may need to give thought to designing a base menu that permits ease and clarity in counting the number and type of required fruits, vegetables, and grains. Ideally the menu planner will standardize the daily choices available for each type of menu item and will group like-item choices in a way that aids students in selecting items of each type.
The committee recognizes that menu planners will need assistance in achieving incremental changes in their menus, food specifications, and recipes. See the section “Technical Support and Monitoring to Benefit School Food Operations” for more discussion of this topic.
Using Cycle Menus as a Menu-Planning Strategy
The development of a 2- to 3-week-cycle menu that repeats itself over the school year with optional seasonal changes would offer substantial benefits in the implementation of the recommended Meal Requirements. Advantages relate to reducing the total time required for menu planning, improving student acceptability, controlling cost, and improving food service operations. Box 10-1 highlights benefits of 2- to 3-week-cycle menus.
The sample menus that the committee wrote to illustrate the application of the standards for menu planning (see Appendix M) provide ex-
Benefits of 2- to 3-Week-Cycle Menus
amples of sound principles of menu planning. They were not designed to be cycle menus, however. Furthermore, they are not expected to be suitable for a particular school district without some adaptation to local food preferences, food availability, and the capabilities of the food service operation.
Variety and Choice
Operators are urged to offer students a choice of items within the food groups in the meal pattern, featuring foods known to appeal to their students. In some schools, foods that are healthy versions of popular fast foods and other familiar foods may improve student acceptance, especially if attractively prepackaged. In other schools, the Farm-to-School program and sustainable practices may foster student acceptance. Some schools provide free small samples of new items to encourage students to taste them. In many schools with limited eating space or very limited eating time (or both), the choices may need to be of suitable “grab and go,” quick-to-eat foods.
The acceptance of foods may be improved when the foods are served repeatedly (as is the case with cycle menus) and when children see their friends eat them. Birch (1987) and Birch and Marlin (1982) have documented that repeated exposures to foods (including fruits and vegetables) improve children’s preference for those foods. Among sixth and seventh grade children in Norway, home accessibility of and preferences for fruits and vegetables were significant predictors of intake at the beginning of the study (Bere and Klepp, 2004). After 8 months, changes in home and school availability and preferences were related to changes in fruit and vegetable intake (Bere and Klepp, 2005). Exposure to vegetables for 14 days in the home resulted in higher preference for those vegetables among children ages 2–6 years (Wardle et al., 2003). Similar results were found for children ages 5–8 years in a school-based study that provided the vegetables in eight sessions (Wardle et al., 2003). Several additional studies indicate that availability, exposure, and preferences are related to fruit and vegetable intake (Brug et al., 2008; Cooke, 2007; Cullen et al., 2003; Neumark-Sztainer et al., 2003). Offering some less-well-accepted foods, in addition to preferred foods, provides students with the opportunity to learn to like the items.
Student involvement in the development of school breakfast and lunch menus may contribute to the acceptance of school meals that are consistent
with the Dietary Guidelines. Students currently play an increasing role in various aspects of school governance, and their presence and participation are required on Wellness Committees for a school district (P.L. 94-105). The committee received limited but thought-provoking input from students in the process of developing its recommendations and has worked to incorporate their suggestions in the final recommendations. Student suggestions included offering colorful, attractive fruits; preparing foods with “fun” shapes (elementary school), substituting low-fat cheeses for full-fat cheeses; and using fresh ingredients to reduce the sodium content of foods while retaining good flavor.
In most school districts, some students prefer vegetarian meals or need them for religious reasons. In some schools, relatively high percentages of the students practice vegetarianism, but practices of vegetarians vary. For example, vegans exclude all animal products; lacto-ovo vegetarians exclude meat, fish, and poultry but consume dairy products and eggs; and semi-vegetarians occasionally eat meat, fish, and poultry along with dairy products and eggs (Craig and Mangels, 2009). Reasons for vegetarian practices include adherence to religious or cultural beliefs, health concerns, and concerns about animal welfare and the environment (Jabs et al., 1998; Lea and Worsley, 2002). Menu planners need to consider ways that vegetarians can be accommodated within the Meal Requirements.
Many SFAs currently include a variety of options that can accommodate vegetarian diets. The meat alternates (see listing in Appendix H, Table H-1) include soy protein products along with a variety of other options. Several manufacturers that produce meat alternates participate in Child Nutrition labeling (USDA/FNS, 2000b), which helps meal planners know how to include the products in school meals. Students who have special dietary needs are allowed to request a substitute for fluid milk, such as a fortified soy-based beverage (USDA/FNS, 2009d).
School Food Service Program Operation
It is essential to the success of a school food service program to have a qualified individual directing the program, especially during a period of transition. The person in charge of the program must have the education, knowledge, training, and experience to administer the entire food service operation. In particular, the complexities of a school food service program require strong skills in a wide variety of areas including nutrition, nutri-
tional analysis, food safety, sanitation, budget, public finance, purchasing, equipment, personnel management, relevant computer applications, and communication to a wide variety of audiences. All these skills will be very helpful in implementing the recommended standards. A mentoring program can be developed to help directors obtain needed skills.
Effective implementation of changes in standards also benefits when directors keep current with food service industry trends and student preferences and have a broad knowledge of the industry as a whole, including relevant roles of the manufacturers, vendors, and distributors. Partnerships with industry representatives will be a key ingredient to the successful implementation of recommendations related to sodium, saturated fat, and whole grains. Directors will need to keep up to date on the various federal, state, and local policies and regulations and be prepared to produce the appropriate documentation as proof of adherence to all requirements.
Experience with and use of menu planning software helps ensure that menus meet the standards for calories and saturated fat and that gradual reductions in the sodium content of menus occur. More complete nutrient analyses can provide information that is useful to parents of children with special dietary needs. The ability to use software to create daily production records and other reports makes it possible to stay informed about essential areas of the operation and to make adjustments in menus and other aspects of the operation as needed.
The expertise of the School Nutrition Association (SNA) and its members is a valuable resource to all levels of the school food service business, but particularly to the directors and leaders. SNA provides excellent resources for networking, mentoring, and continuing education. The U.S. Department of Agriculture (USDA) and the National School Food Service Management Institute are among the entities that provide training and learning opportunities.
Attention to succession planning as part of a long-term strategic plan helps ensure that school districts will continue to be led by highly skilled personnel in the future. Mentoring and internship programs may introduce qualified candidates to the challenges and opportunities of the positions.
Operators have had to make adjustments for the last several years to keep up with increasing costs that were not reflected in the USDA cost study (USDA/FNS, 2008f). Because of the high percentage of free and reduced-cost meals being served in many schools, a majority of their per meal revenue for school meals is obtained from federal reimbursement. Although students qualified for reduced meals pay a portion of their meal costs, the total amount received per meal by the school is capped at the free reim-
bursement level. Thus, only the total amount of revenue for each full paid meal is under the control of the school district. Some additional per meal revenue may be received from a state, however the level of funding and criteria for receiving state funds varies substantially among the states. Thus, many school food service operations have also subsidized program revenue with à la carte or catering sales. In many schools during the past few years, these combined sources of revenue many not have been adequate to support the meal programs, so they are now operating at a loss. An increase in cost of even a few cents per meal may threaten the financial viability of many school meal programs. At current federal reimbursement levels, many SFAs will be unable to meet the anticipated increase in food costs associated with the recommended changes in the Meal Requirements. Moreover, in view of expected increases in all program costs (both direct and indirect costs, some of which are associated with the committee’s recommendations), operators may need to strategically assess the entire operation to achieve maximum efficiency. Box 10-2 lists some of the strategies that can help control the overall cost of food service operations.
Use of USDA Foods
USDA offers USDA (commodity) foods to states for use in the National School Lunch Program.1 Because approximately 15 to 20 percent of the food served as part of the school lunch is donated USDA food (USDA/FNS, 2008a), these foods have an important influence on the quality and cost of school meals (see section “USDA Foods” in Chapter 8). The Commodity Program has made substantial improvements in its offerings in recent years to become better aligned with Dietary Guidelines for Americans and to be more responsive to its “customers.”
Types of USDA Foods Offered USDA offers both perishable and nonperishable products. The major types of foods are red meat, fish, poultry, egg products, fruits, vegetables, grains, peanut products, dairy products, and oils. Many of the perishable products are available in a processed form (e.g., fruits and vegetables may be fresh, canned, or frozen) (USDA/FNS, 2008h).
Most of the foods offered are purchased by USDA in the category called entitlement purchases (USDA/FNS, 2008a). USDA makes entitlement purchases based on nutritional and customer considerations. Bonus purchases by USDA relate to the purchase of surplus supplies of perishable foods and thus vary greatly from year to year with regard to both the type of food
Strategies to Help Control the Cost of Food Service Operations
and the amount available. In school year (SY) 2008, the bonus commodities included several fruits that were provided in canned or frozen form.
Working in conjunction with USDA, the Department of Defense Fresh Fruit and Vegetable Program (DOD Fresh Program) has made a wide variety of types of fresh produce available to many school districts across the United States. The DOD Fresh Program has increased the availability of fresh fruits and vegetables in schools, especially in schools with the highest proportion of children eligible for free or reduced-price school meals. However, because the Department of Defense has found it necessary to
restructure its operations and involve commercial distributors, the program is in a period of transition (FRAC, 2008; USDA/FNS, 2008a).
Processing Processing is an integral part of the Commodity Program—about half of all USDA foods are diverted to processing. Its purpose is to produce end products that are more usable by schools. To obtain a food processing contract, companies must agree to use USDA foods according to strict specifications. For example, they might use three USDA foods (tomato sauce, whole wheat flour, and low-fat cheese) in the manufacturing of pizza with a specified nutrient profile. Advantages of processed USDA foods include the (1) reduction of (a) labor costs, (b) other production costs, (c) storage requirements and costs, and (d) some food safety concerns; and (2) the availability of foods that the school would not have the capacity to prepare.
Important Changes in Food Offerings The Food and Nutrition Service has introduced a variety of changes in USDA food offerings to improve alignment with the 2005 Dietary Guidelines for Americans, as summarized in Box 10-3. Several of the prepared meat and meat alternate offerings (e.g., beef sloppy joe [A716], beef taco filling [A714], cooked beef patty [A706], and frozen breaded chicken pieces [A526]) provide 5 to 6 g of saturated fat per serving (USDA/FNS, 2008h). (Serving sizes differ for these products.) Much effort is being placed on testing new products for acceptability by food service operators and students in the schools (C. McCullough, http://www.iom.edu/Activities/Nutrition/SchoolMeals/2009-JAN-28.aspx).
Barriers to the Effective Use of USDA Foods State agencies serve as intermediaries between the SFAs and USDA in the procurement of USDA foods. Known as distributing agencies, the state agencies vary widely in operation (FRAC, 2008). In some cases, state policy and procurement stifle local efforts. For a variety of reasons, not all SFAs use USDA foods to maximum advantage (CFPA, 2008; FRAC, 2008). In response to criticisms of the entire commodity system (ordering, processing, delivery, etc.), in 1998 USDA’s Commodity Improvement Council requested a major project to find solutions to the identified problems. The USDA Commodity Program is now in transition and moving toward a system that will place more responsibility on the school districts and decrease the occurrence of unilateral state agency determinations on what foods to make available to the SFAs.
Technical Support and Monitoring to Benefit School Food Operations
According to the Healthy Meals for Healthy Americans Act (P.L. 103-448, Section 106(b)), USDA is to provide various types of assistance to
Examples of USDA Food Offerings that Are Consistent with Selected 2005 Dietary Guidelines for Americans
Low in Saturated Fat, trans Fat, Total Fat, or All Three
Reduced in Sodium
Reduced in Added Sugars
Fruits and Vegetables
SOURCE: USDA/FNS, 2008a.
schools related to the implementation of school meal programs. The listing includes “standardized recipes, menu cycles, and food product specification and preparation techniques” and information related to menu planning approaches.2 The new recommendations involve some major shifts in the approach to menu planning regardless of the approach currently being used
by an SFA. Thus, operators will need to be provided with specific strategies for meeting the recommended Meal Requirements.
Recommendation 4.3 The Food and Nutrition Service, working together with state agencies, professional organizations, and industry, should provide extensive support to enable food service operators to adapt to the many changes required by revised Meal Requirements. The types of support required include the following:
Technical assistance for developing and continuously improving menus, ordering appropriate foods (including the writing of specifications), and controlling costs while maintaining quality.
New procedures for monitoring the quality of school meals that (1) focus on meeting relevant Dietary Guidelines and (2) provide information for continuous quality improvement and for mentoring food service workers to assist in performance improvement.
To facilitate effective implementation of the recommended standards for menu planning, planners may need many forms of technical support. The earlier section “Menu Planning” identifies many of the areas in which technical assistance will be needed. One priority is collaboration with school food service directors to revise related menu planning guidance materials, including the Food Buying Guide for Child Nutrition Programs (USDA/FNS, 2009c) to make its content compatible with the recommended Meal Requirements. The committee encourages the simplification of procedures for selecting specific foods in amounts that will meet the standards. Emphasis should be placed on assisting operators to follow the meal patterns while keeping calories within the minimum and maximum levels, keeping saturated fat content below the maximum, and reducing sodium content. Many of the food items offered by some schools contain more solid fat or calories (often from high-fat entrées or bread products, added sugars, or both) than would be compatible with the recommended meal patterns.
As example of a potentially useful approach, the committee developed a prototype of a menu checking tool (see Appendix Table M-7), which might be developed further and tested in a variety of types of food service operations. The concept is that operators would use the tool to help in menu planning, either as a spreadsheet on the computer with formulas entered to automatically total amounts or by hand entry with simple counting. Once the daily values have been entered, the formulas in the spreadsheet option would automatically calculate average calories, sodium, and percentage of
Recommendations 1–3 are located in Chapter 7.
saturated fat over the 5-day week; and the spreadsheet would show how those values compare to the recommended specifications. Such a tool would provide a way to track the types of vegetables and grains that are offered and confirm that the menu pattern over the week meets the recommended standards. By entering the components, the operator would be able to identify shortfalls or overages that need correction to meet the recommended standards for menu planning.
Other important forms of technical support include guidance on the effective incorporation of USDA foods based on the new standards for menu planning; guidance on the use of production records to improve menu planning and monitor performance; and additional training and technical resources on topics such as food composition, applying nutrition and food behavior research to facilitate change, modifying standardized recipes, developing healthy cooking techniques, interpreting food labels, and developing food specifications for procuring healthier products.
Monitoring the Quality of School Meals
Because the committee determined that the Nutrient Targets are not appropriate for the monitoring of school meals, it considered elements of new approaches to monitoring. This section provides background information on the current approach to monitoring and then outlines possible elements of a two-stage approach: one targeted toward facilitating the transition to the new Meal Requirements and the second toward maintaining or achieving further improvements in quality.
Background Currently, federal regulations require that state agencies conduct two different reviews of each SFA once every 5 years. This includes Coordinated Review Effort (CRE) reviews and School Meal Initiative (SMI) reviews. The goals of CRE reviews are to determine if (1) free and reduced-price meal benefits are provided in accordance with the regulations, (2) proper meal counts are being taken at the point of service, and (3) complete reimbursable meals are being offered. Goals of SMI reviews are to ensure that (1) program meals meet the (current) Nutrition Standards and (2) SFAs receive the technical assistance and resources needed to meet the (current) Nutrition Standards. States may conduct CRE and SMI reviews independently, in any order, or concurrently. Many do so concurrently.
Under the current monitoring system, the SMI review is the mechanism used to monitor the quality of school meals. Each review covers a specific 5-day school week. During an SMI review, state agency staff members review menus, production records, standardized recipes, and nutrition facts and/or Child Nutrition labels. In addition, for schools that use nutrient-based menu planning, they review the nutrient analysis report for the specified week.
For schools that use food-based meal planning systems, the state agency completes a nutrient analysis. Results of the nutrient analysis are compared to nutrient standards and, depending on the results, state agency staff may make suggestions and/or assist SFA staff members in developing a Corrective Action Plan (CAP) to improve compliance with nutrient standards.
Current regulations require that, unless a waiver has been granted, the nutrient analysis evaluated during the SMI review be a weighted analysis. A weighted analysis incorporates data on how frequently each menu item was selected by students. These results are interpreted as representing the average nutrients in meals selected by students (as served). Many schools have had difficulty maintaining production records that are detailed enough to provide the data needed for a weighted nutrient analysis, especially if they offered food à la carte (not as part of reimbursable school meals) (Crepinsek et al., 2009).
In recent years, considerable attention has been focused on the CRE reviews because of concerns about improper payments made to SFAs because of errors in meal counting and claiming. The Access, Participation, Eligibility, and Certification Study (APEC) estimated that approximately $860 million in improper payments occurred during school year 2005–2006 (USDA/FNS, 2007c). Meal counting errors can occur because the planned menu does not meet the established Meal Requirements, a student’s specific meal selection does not include all the components required for a reimbursable meal, or a cashier incorrectly records the student’s categorical eligibility (that is, free, reduced price, or paid).
Possible New Approaches to the Monitoring of School Meals USDA could consider both a short-term approach to monitoring during the initial stage of implementation of the new Meal Requirements and a revised approach during the second stage, once implementation is well established. Both approaches would move away from the current emphasis on completing the detailed nutrient analysis and documenting compliance. The initial approach might address fewer elements at a time but occur on a more frequent basis.
During the first stage, at least for the next several years, monitoring would be directed toward facilitating the transition to the new Meal Requirements. The emphasis would be on examining progress in meeting the standards, especially those related to fruits, vegetables, whole grain-rich foods, calories, saturated fat, and sodium; identifying training needs for school food service operators; and providing needed technical assistance to improve the school meals (see the previous section for the types of technical assistance likely to be needed).
The subsequent approach to monitoring (the second stage) would continue to focus on gathering and using information to enhance the ability
of food service operators to plan and offer meals that are consistent with the new Meal Requirements. Focusing on the Meal Requirements rather than the Nutrient Targets in planning and assessing school meals fits with the goals of both CRE and SMI reviews. This second stage of monitoring would focus on documenting that planned menus are consistent with the recommended meal pattern (the first step in ensuring that meals that are counted or claimed for reimbursement are consistent with program requirements). The committee is aware that, in response to the APEC study mentioned above, USDA is currently working with the National Food Service Management Institute to develop technical assistance materials related to planning and recognizing reimbursable meals (GAO, 2009). These materials are intended to help food service staff members develop approaches to make it easier for students to choose a reimbursable meal and for cashiers to confirm that a reimbursable meal has been selected.
During both stages of monitoring, a variety of methods could be used to monitor how well the program has implemented the new Meal Requirements. For example, monitors could focus on whether schools are offering only low-fat and fat-free milks, at least half of the grains as whole grain-rich products, and the required numbers and types of fruits and vegetables. This level of review could include more than a single week’s menu; perhaps a full 2- or 3-week cycle. To address Meal Requirements for saturated fat and sodium, monitors could review, for a randomly selected week, nutrition facts labels for commercially prepared items (such as entrées and muffins) to ensure that the saturated fat and sodium content are consistent with targets established in a revised food buying guide. In addition, monitors could examine food production records to obtain information on the average number of fruit, vegetable, and whole grain servings being taken in reimbursable meals. This would involve calculating the total fruit (or vegetable or whole grain) servings divided by the total number of reimbursable meals.
All this information could be used to (1) establish a baseline for each SFA, (2) identify technical assistance needs, (3) prepare a plan, in cooperation with SFA staff, for addressing these needs, and (4) monitor progress over time. In addition to focusing on planned menus, the assessment would include a focus on children’s selection of vegetables, fruits, and whole grains, so that these patterns can be monitored over time.
Achieving Long-Term Goals
Two recommendations are made to promote the achievement of long-term goals related to reducing the sodium and increasing the proportion of whole grains in school meals, as presented below.
Meeting the Sodium Standard and Whole Grain-Rich Food Specifications
Recommendation 5. USDA should work cooperatively with Health and Human Services, the food industry, professional organizations, state agencies, advocacy groups, and parents to develop strategies and incentives to reduce the sodium content of prepared foods and to increase the availability of whole grain-rich products while maintaining acceptable palatability, cost, and safety.
The committee set the year 2020 as the goal for achieving the recommendations for sodium in school meals—sodium values that are based on the Tolerable Upper Intake Level by age-grade group (≤ 430 to ≤ 470 mg sodium for breakfast and ≤ 640 to ≤ 740 mg sodium for lunch). This is consistent with the limited data to indicate that small reductions in taste changes are undetected (Pfaffmann, 1971) and the conclusion that gradual stepwise reductions over time may be the most successful approach. Furthermore, it is unrealistic to expect that school food operators can immediately make substantial reductions in the sodium content of school meals given the amount of sodium in foods in school meals and in the market at this time. They may need time to develop acceptable recipes that are lower in sodium, and the food industry will need time to develop the technologies to offer acceptable food products with lower sodium content.
Information in the third School Nutrition Dietary Assessment study (SNDA-III) (USDA/FNS, 2007a) indicates that the amount of sodium in school lunch meals as offered was 1,377–1,580 mg. Student sodium consumption from meals was about 1,000 to 1,300 mg per lunch.
Reducing the intake of sodium has been the focus of Dietary Guidelines for Americans and of other national health initiatives; and they have directed most attention to the sodium that is provided by salt (sodium chloride) added in processing, cooking, and at the table. Efforts to reduce sodium intake have met with limited success. In fact, given the considerable challenges associated with these efforts in the United States, the Institute of Medicine is currently conducting a study to determine strategies for reducing intakes of sodium among Americans.4
Salt has a unique combination of properties that may affect the texture, safety, and shelf life of many food products—as well as their taste. Thus, the use of salt is a long-established and widespread practice for products such as breads, cheeses, and cured meats (Hutton, 2002). Other ingredients may fulfill some, but not all, of the functions of salt. Furthermore, other sodium-containing substances may serve important functions in foods, including extending their shelf life and retarding the growth of harmful organisms.
Limited available information (Beauchamp and Engelman, 1991) reveals that when people undertake a low-sodium diet they do not initially find it palatable. Over time, however, the lower sodium diet becomes more acceptable. Questions that remain are how long sensory preferences persist, whether the degree of saltiness preferred increases if other high-sodium foods are consumed, whether consumers can readily accept lower-sodium single food items or meals if the overall total dietary sodium intake is not reduced significantly, and to what extent knowledge concerning adults’ sodium preferences is applicable to children (Beauchamp and Engelman, 1991).
Attempts to reduce the sodium content of foods labeled “healthy” provide perspective on the challenge. In this example, the Food and Drug Administration proposed a two-tier process for defining and gradually reducing the sodium criterion for the use of the implied nutrient content claim “healthy” and its derivatives (e.g., “health” and “healthful”) on individual foods and on meal and main dish products. Despite publishing a final rule (59 FR 24232) with the specifications that appear in Table 10-1, the second-tier criteria were first stayed (enforcement was postponed to a later date) in response to numerous negative public comments. Then, in 2005, the second-tier criteria were dropped in response to comments documenting the substantial technical difficulties in finding suitable alternatives for sodium that would also be acceptable to consumers. (See Appendix Q for a brief history.)
Currently, many of the popular items (entrées, cheese, salad dressings, and dips) in school meals provide between 250 and 900 mg of sodium per serving. Therefore, keeping the sodium content of school meals (especially lunch) below the maximum recommended in Chapter 7 would require substantial reductions in sodium in the foods available to schools. Chapter 7 identifies some resources that describe initial steps that could
TABLE 10-1 Sodium Criteria in the Final Rule (September 29, 2005; 59 FR 24232) to Define the Term “Healthy” as an Implied Nutrient Content Claim Under Section 403(r) of the Federal Food, Drug, and Cosmetic Act, 1944
reduce the sodium content of school meals by perhaps 10 percent. However, these steps would result in reductions that are substantially less than those needed to meet the sodium target.
Various types of foods (some commercial products, USDA foods, and foods prepared by the school or school district) will require reformulation. As described in Chapter 6, if a school district elects to prepare a greater proportion of the food for school meals rather than buying commercially pre-prepared products, time will be required to develop the capacity to do so. To ensure student acceptance of lower sodium foods, the process for the development and/or for the reformulation of the foods needs to include input from SFAs and students.
The sponsor asked the committee (see Appendix C) to consider a recommendation that would allow for a gradual reduction of sodium levels in school meals to meet a new standard without adversely affecting student participation in school meals and to allow time for food products to be reformulated with lower sodium levels. Based on the FDA’s experiences (mentioned above), substantial technological challenges facing the food industry and school food operators, and lack of data relevant to achieving student acceptance of lower sodium foods in schools, the committee has set a 10-year window (by the year 2020) for achieving the sodium recommendation.
To ensure that action is taken to reduce the sodium content of school meals in a stepwise manner over the 10-year period while maintaining student participation rates, the committee suggests the setting of intermediate targets for each 2-year interval and the development of incentives for action. This stepwise approach is also consistent with the available data, suggesting that acceptance of diets with lower sodium content is more successful if carried out gradually as opposed to making radical reductions within short time frames. A reasonable immediate target would be to provide less than the mean sodium content of meals as reported in SNDA-III (Crepinsek et al., 2009). With this method for the elementary school lunch, for example, the immediate target would be less than 1,377 mg. A possible first intermediate target is a 10 percent reduction in the sodium content of the meals. For the elementary school lunch the value would be the SNDA-III mean for sodium minus 10 percent of the mean:
This value might be reconsidered based on information in the forthcoming Institute of Medicine report on strategies to reduce sodium. At the end of the 2-year interval, it would be appropriate to assess progress and effects of the actions on student participation rates, food cost, safety, and food service operations to determine a reasonable target for the next period.
The committee recognizes that reducing the sodium content of school meals as specified in Table 7-3 and in a way that is well accepted by students will present major challenges and may not be possible. All the elements of achieving change that were described at the beginning of this chapter will need to come into play. Nonetheless, assuming that participation in the school meal programs remains high, each reduction in the sodium content of school meals will be beneficial to the nation’s children.
Whole Grain-Rich Food Specifications
The committee recognizes that using the whole grain-rich food criterion (Box 7-1 in Chapter 7) is likely to result in a whole grain intake that is somewhat lower than is recommended in Dietary Guidelines. Although brown rice and whole wheat tortillas are 100 percent whole grain foods, for example, many of the foods that meet the whole grain-rich food definition contain approximately 50 percent whole grain and 50 percent enriched refined grain. Setting more stringent specifications is not reasonable at this time because of current student preferences and experiences with whole grains, differences in product availability across the United States and its territories, cost, and limited information on product packaging regarding the whole grain content of food products.
Although the recommended standards for menu planning that are related to whole grains fall somewhat short of recommendations in Dietary Guidelines, they are a great advance over current regulations, which have no requirements for whole grains.
To achieve greater alignment with Dietary Guidelines, the following approach is suggested:
Within approximately 3 years postimplementation of new Meal Requirements, it will be advisable to revise the standards for menu planning with regard to grains such that the proportion of whole grain (rather than whole grain-rich) to refined grain will exceed 50 percent. This objective may be attained by planning meals in which at least half of the grains on the menu are 100 percent whole grain products, increasing the percentage of whole grains required to qualify as a whole grain-rich food, increasing the proportion of grains served that are whole grain rich, or any combination of these. Product labeling with the whole grain content would be an important step.
Recommendation 6. The Food and Drug Administration should take action to require labeling for the whole grain content of food products.
Requiring manufacturers to provide information about the grams of whole grains provided per serving would enable operators to identify the
grain products that would allow them to meet the Dietary Guidelines recommendation for whole grains. Voluntary action by manufacturers to provide whole grain content information for their food products might be achieved within a few years. Regulatory action would be expected to take longer.
Other steps that would help implement the long-range goal of meeting the Dietary Guidelines recommendation for whole grains include the following:
Incrementally increase the ratio of whole grain-rich foods to refined grain foods in the meal patterns of the Meal Requirements (e.g., from one-half to three-fourths of the grains offered). Retaining some allowance for refined grain foods is likely to be needed to accommodate cultural and regional food preferences.
Encourage SFAs to increase specifications for the proportion of whole grain in whole grain-rich foods when soliciting bids from commercial bakeries, food vendors, and product manufacturers. The HealthierUS School Challenge Whole Grains Resource Guide (USDA/FNS, 2009b) provides guidance for writing appropriate specifications for food processors or vendors. Studies indicate that schoolchildren will accept increasing proportions of whole grain in many grain products, up to approximately 70 percent of the total (Chan et al., 2008; Rosen et al., 2008). A reasonable goal would be to increase the proportion of whole grain to 65 to 70 percent of the grain in selected products within 3 years of the announcement of the final regulations for the Meal Requirements for school meals.
When consumer acceptance of whole grains grows and label information includes the amount of whole grain in the product, revise the whole grain-rich food criterion so that grams of whole grain per ounce equivalent becomes the sole criterion; set the minimum number of grams of whole grain required for a food to be classified as a whole grain-rich food to a value greater than 8 g of whole grain per grain serving.
Updating Nutrition Standards and Meal Requirements in Response to Revisions of Dietary Guidelines or Dietary Reference Intakes
A revision of the Dietary Guidelines for Americans is expected in the year 2010, shortly after the release of this report, and at periodic intervals thereafter. Similarly, the DRIs for vitamin D and calcium currently are under review, and changes in the DRIs for various nutrients may be published over time. To keep the Nutrient Targets and Meal Requirements aligned with these key resources, periodic review is necessary, followed by revisions if needed.
If the current Nutrition Standards become Nutrient Targets, to be used only as the scientific basis for designing the standards for menu planning as part of the Meal Requirements, changes in the DRIs could be incorporated into the Nutrient Targets without the need for regulatory change, using the method described by the committee for setting the School Meal-Target Median Intakes (see Chapter 4). A higher target would be unlikely to affect the standards for menu planning because they were designed to balance nutrition, practicality, student appeal, and cost. A much lower target might open the way for relaxing those standards, however.
The committee anticipates that there will be little need for regulatory change in the Meal Requirements unless there are major changes in the Dietary Guidelines related to recommended meal patterns. The specification for saturated fat in the standards for menu planning could be tied to the Dietary Guidelines recommendation. That is, the regulation could state that the maximum amount of saturated fat is the percentage of calories specified by the most recent edition of the Dietary Guidelines for Americans (currently, less than 10 percent of total calories). If the recommended sodium intake is substantially decreased, it seems likely that the sodium specification in the standards for menu planning would be unaffected for some time: the committee’s recommendation is for a decrease in the sodium content of school meals to be achieved by the year 2020.
EVALUATION AND RESEARCH
The recommended Nutrient Targets and Meal Requirements for school meal programs call for numerous changes in the foods that are offered, and potentially in the selections made by the students. Because the food and nutrient intakes of schoolchildren are likely to change, the magnitude and direction of the changes should be evaluated. The revisions to the Meal Requirements may also have an impact on student acceptance and participation rates, school food service operations, and the cost of the program. All these outcomes should be carefully evaluated after implementation of the revisions. In addition, the committee agreed that research is needed in several areas to better revise and implement the recommended Nutrient Targets and Meal Requirements in the future.
Recommendations for Evaluation
Recommendation 7. Relevant agencies in USDA and other federal departments should provide support for the conduct of studies to evaluate the revised Meal Requirements for the School Breakfast Program and the National School Lunch Program.
USDA should continue funding for periodic School Nutrition Dietary Assessment studies, with the intermittent addition of a cost component.
USDA should take the lead in providing funding to conduct well-designed short-term studies in varied school settings to better understand how the new Meal Requirements change children’s total and school meal dietary intakes, student participation, food service operations, and cost.
The following sections illustrate the types of evaluations that fall under this recommendation.
Evaluation Using the School Nutrition Dietary Assessment Studies
Many of the changes resulting from the revised standards can be evaluated by the SNDA studies, and the committee urges continuation of these studies with the addition of a cost component. USDA has been funding evaluations of nutrients and costs, but in separate studies and sometimes at different points in time. The dovetailing of these efforts would allow nutrients and food groups to be examined jointly with costs. Specific questions of importance could be addressed by comparing the results of the next SNDA study with those from SNDA-III. Following are several topics of particular interest.
What is the effect of recommended changes in school Meal Requirements on children’s nutrient intakes, both from the school meals and across the day? How did the prevalence of nutrient inadequacy change? (The Nutrient Targets would be useful in such a study.)
How do changes in the Meal Requirements influence nutrient intakes from other meals?
Some of the assumptions that are inherent in the use of the Target Median Intake method to set the Nutrient Targets are untested in a school meals setting and should be evaluated:
How did the changes to the school meals affect intakes in the lower tails of the distribution? For example, how did the shape of the distributions change when the mean intake was increased or decreased?
For nutrients with an Adequate Intake, is it appropriate to set the Target Median Intake equal to the Adequate Intake, or do the distributions of intake indicate a concern about some groups of schoolchildren with very low intakes?
Nutrient Intakes above the Tolerable Upper Intake Level
Do the recommended changes in the school Meal Requirements result in an increase in the prevalence of intakes above the Tolerable Upper Intake Level for any of the age-gender subgroups? If so, are strategies needed to reduce the very high intakes?
Did the changes to the school Meal Requirements affect intakes in the upper tails of the distribution in the same way as intakes at the mean? If not, how did the distributions change?
Did sodium intakes decrease so that mean intakes are closer to the Tolerable Upper Intake Level?
Achievement of Appropriate Calorie Intakes at School Meals
Were the desired mean calorie intakes for each age-grade group achieved?
How did the distribution of energy intake per kilogram of body weight change?
Achievement of Consistency with the Dietary Guidelines
How do children’s food group intakes compare with the daily dietary patterns recommended by MyPyramid after the new Meal Requirements have been fully implemented for at least one year? Specifically, did consumption of fruits, vegetables, and whole grain-rich foods increase at the school meals and across the day?
What changes have occurred in children’s food group intakes from other meals?
What changes have occurred in children’s intake of discretionary calories, both at the school meals and throughout the day?
What changes have occurred in intakes of saturated fat?
Evaluation by Conducting Well-Defined, Short-Term Studies
The committee recommends that well-defined, short-term studies be conducted in a variety of settings to better understand the impact of the new Meal Requirements. These studies could address all the above measures, either separately or simultaneously, within a school or school district. A pre-post study design would be desirable, in which data on children’s intakes (both at school and throughout the day), meal participation rates, school food service operations, and school meal costs are collected at two time points: (1) prior to implementation of the revised Meal Requirements and (2) after implementation, allowing for a period of transition to fully adapt to the new requirements. With this design, changes in the measures could be evaluated within the same group of children. This type of short-term study would be conducted in different age-grade groups of students
(elementary school, middle school, high school) and in a variety of school settings (large, small, ethnically diverse, etc.).
Other Relevant Topics for Evaluation
In addition, the committee considers the following topics to be worthy of evaluation.
Acceptance of Meals and Participation in the Program
What is the effect of recommended changes in the Meal Requirements on school meal participation? Evaluate the impact on free and reduced-price participation and on paid-meal participation.
How does offering multiple choices of entrées, fruits, and vegetables affect student acceptance (and participation rates)?
What is the student acceptance of lower sodium foods?
What are the effects of new guidelines for the variety of vegetables to be offered?
What is the impact of the revised Meal Requirements under the offer versus serve provision of the law on student selection of vegetables and other meal components?
Challenges to School Food Service Operations
How do the recommended Meal Requirements affect food service operations; how can any problems be addressed?
To what extent have vendors responded to the changes by making recommended foods more available and in appropriate portion sizes?
How do the new Meal Requirements affect food waste?
How do the new Meal Requirements affect the ease of administration for state agencies? Are there differences across states based on foods available and ways of administering the program?
Changes to the Cost of the Programs How well do projected costs compare to the actual costs of implementing the changes, and how do costs vary by geographic location or size of the school district?
Child Health Outcomes It would also be desirable to conduct longer term studies of potential improvements in children’s health as a result of the new Meal Requirements. Such studies might have a cross-sectional design (for example, comparing participants and nonparticipants after adjusting for confounding factors) or a longitudinal design (for example, tracking changes in health outcomes over time). Of particular interest are studies that could evaluate the impact of the Meal Requirements on the prevalence of childhood overweight and obesity.
Recommendations for Research
The committee asked several questions for which scientific answers were unavailable. This lack of information led to uncertainty about the potential effectiveness of some of the recommendations for Meal Requirements for school meals.
Recommendation 8. The committee recommends that agencies of USDA, of other federal departments, and relevant foundations fund research studies on topics related to the implementation of the new Meal Requirements, children’s acceptance of and participation in school meals, and children’s health—especially the following:
Effects of the recommended range of calorie levels on the adequacy of energy intakes for individual children within each of the age-grade categories.
Impacts of various approaches to reducing the sodium content of school meals and student acceptance of reduced-sodium foods.
Impacts of various approaches to increase the acceptance of whole grain-rich products.
Fruit and vegetable options and preparation methods that will increase consumption and decrease waste.
Effects on cost, waste, and food and nutrient intakes of various options to govern the number and types of foods students must accept for a reimbursable meal under the offer versus serve provision of the law.
Targeted approaches to decreasing the prevalence of nutrient inadequacy that do not require increasing the intakes of all children.
Changes in child health as a result of the new standards.
The full set of recommended research topics appears below.
To what extent do the revised calorie standards for school meals provide adequate calories for all without providing excessive calories for some? For example, the recommended minimum and maximum calorie levels were set based on the average for males and females. Does this cause “hunger” issues with males or athletes (male and female) or both, especially among older students for whom the range of caloric needs is higher? Studies are needed that measure energy intakes relative to energy needs at the individual level, as well as satiety, across different strata of family food security and incomes.
How can sodium levels of school meals be reduced without adversely affecting student acceptance? What is the minimum sodium content for foods (such as an entrée) to be acceptable and safe? Is a stepped reduc-
tion in sodium levels more likely to result in student acceptance of low-sodium foods? What other strategies can help to reduce the sodium content in school meals (e.g., the use of salt substitute, herbs, pairing flavors such as citrus)?
What are strategies for achieving high student acceptance of 100 percent whole grain products (products with 16 g or more of whole grains per 1 ounce equivalent portion)?
How can the recommended changes in the school meals be complemented by other programs to increase fruit and vegetable consumption? For example, what is the effect of the USDA Fresh Fruit and Vegetable Program on children’s total daily intake of fruits, vegetables, and other foods? How does the provision of a fruit or vegetable snack in the morning affect lunch intake? What is the impact and cost of using salad bars?
To what extent can logistical strategies (such as holding recess before rather than after lunch or lengthening the lunch period) increase schoolchildren’s consumption of food groups encouraged in the Dietary Guidelines for Americans?
What guidelines would improve schoolchildren’s adherence to the Dietary Guidelines without increasing food waste? For example, what strategies would improve student selection of vegetables, particularly of dark green and orange vegetables?
The methods used to set the School Meal-Target Median Intakes assume it is necessary to shift the full distribution of intakes to reduce the prevalence of inadequacy, but there may be alternative methods of reducing the prevalence of inadequacy. For example, could subpopulations with the lowest intakes of nutrients be identified and specifically targeted (e.g., provide calcium-rich foods to children who avoid milk)? Such targeted approaches could reduce costs while contributing to increased nutrient intakes.
The committee notes that there are many interactions between the school meal programs and competitive foods in schools (for example, see the benchmarks in Chapter 6 [Next Steps] in Nutrition Standards for Foods in Schools [IOM, 2007]). Some of the benchmarks for an implementation and evaluation plan are relevant to the school meals programs.
Successful implementation of the recommended Nutrient Targets and Meal Requirements will require attention to key elements of achieving change, menu planning, school food service program operation, technical support for school food service operators, monitoring of the quality of
school meals, and achieving long-term goals related to reducing sodium and increasing the whole grain content of school meals. Acting on recommendations for evaluation and research will provide information needed for further improvements to standards for school meals and methods for planning intakes by groups.