NUTRITION STANDARDS FOR FOODS IN SCHOOLS

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Committee on Nutrition Standards for Foods in Schools Food and Nutrition Board Virginia A. Stallings and Ann L. Yaktine, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by grant number H75/CCH324857-01 between the National Academy of Sciences and the Centers for Disease Control and Preven- tion. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the sponsoring agency that provided support for the project. Library of Congress Cataloging-in-Publication Data Nutrition standards for foods in schools : leading the way toward healthier youth / Committee on Nutrition Standards for Foods in Schools, Food and Nutrition Board ; Virginia A. Stallings and Ann L. Yaktine, editors. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-309-10383-1 (hardbound : alk. paper) ISBN-10: 0-309-10383-5 (hardbound : alk. paper) 1. School children—Nutrition—Government policy—United States. 2. School lunchrooms, cafeterias, etc.—Management—United States. 3. Nutrition policy—United States. I. Stallings, Virginia A. II. Yaktine, Ann L. III. Institute of Medicine (U.S.). Committee on Nutrition Standards for Foods in Schools. LB3479.U6N88 2007 371.7´160973—dc22 2007023350 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2007. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: The National Academies Press.

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

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

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COMMITTEE ON NUTRITION STANDARDS FOR FOODS IN SCHOOLS VIRGINIA A. STALLINGS (Chair), Joseph Stokes Jr. Research Institute, Children’s Hospital, University of Pennsylvania School of Medicine, Philadelphia DENNIS M. BIER, Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX MARGIE TUDOR BRADFORD, School Board, Bardstown Independent School District, Bardstown, KY CARLOS A. CAMARGO, JR., Massachusetts General Hospital and Brigham & Women’s Hospital, Harvard Medical School, Boston ISOBEL R. CONTENTO, Teachers College, Columbia University, New York THOMAS H. COOK, Vanderbilt University’s School of Nursing, The Monroe Carroll Children’s Hospital, Vanderbilt University, Nashville, TN ERIC A. DECKER, Department of Food Science, University of Massachusetts, Amherst ROSEMARY DEDERICHS, Food Services Department, Minneapolis Public School District, MN JAY T. ENGELN, National Association of Secondary School Principals, Reston, VA BARBARA N. FISH, West Virginia Board of Education, Parkersburg, WV TRACY A. FOX, Food, Nutrition, and Policy Consultants, LLC, Bethesda, MD JAMES C. OHLS, Mathematica Policy Research, Inc., Princeton, NJ (retired) LYNN PARKER, Food Research and Action Center, Washington, DC DAVID L. PELLETIER, Division of Nutritional Sciences, Cornell University, Ithaca, NY MARY T. STORY, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis Staff ANN L. YAKTINE, Senior Program Officer (from July 2006) JANICE RICE OKITA, Study Director (until July 2006) AMIN AKHLAGHI, Research Associate (until October 2006) ALICE VOROSMARTI, Research Associate HEATHER B. DEL VALLE, Senior Program Assistant 

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FOOD AND NUTRITION BOARD* DENNIS M. BIER (Chair), Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX MICHAEL P. DOYLE (Vice Chair), Center for Food Safety, University of Georgia, Griffin DIANE BIRT, Center for Research on Dietary Botanical Supplements, Iowa State University, Ames YVONNE BRONNER, School of Public Health and Policy, Morgan State University, Baltimore, MD SUSAN FERENC, Chemical Producers and Distributors Association, Alexandria, VA NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver REYNALDO MARTORELL, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA J. GLENN MORRIS, JR., Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu JOSE M. ORDOVAS, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA JIM E. RIVIERE, College of Veterinary Medicine, North Carolina State University, Raleigh NICHOLAS J. SCHORK, Scripps Genomic Medicine and The Scripps Research Institute, LaJolla, CA REBECCA J. STOLTZFUS, Division of Nutritional Sciences, Cornell University, Ithaca, NY JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison WALTER C. WILLETT, Department of Nutrition, Harvard School of Public Health, Boston, MA Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ANTON BANDY, Financial Associate *IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the report rests with the authoring committee and the institution. i

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with pro- cedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Dorothy R. Caldwell, School Health Consultant, Raleigh, North Carolina Susan Crockett, General Mills, James Ford Bell Technical Center Barbara Devaney, Human Services Research, Mathematica Policy Research Adam Drewnowski, Center for Public Health Nutrition, Professor of Epidemiology and Medicine, University of Washington Deanna Hoelscher, School of Public Health, University of Texas Health Science Center, Houston Francine R. Kaufman, The Keck School of Medicine, University of Southern California, Center of Endocrinology, Diabetes and Metabolism, Children’s Hospital, Los Angeles Ronald E. Kleinman, Pediatric Gastroenterology and Nutrition Unit, Massachusetts General Hospital, Boston ii

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iii REVIEWERS Michael I. McBurney, Department of Nutrition and Food Science, Texas Agricultural Experiment Station, Texas Cooperative Extension, Texas A&M University Theresa A. Nicklas, Baylor College of Medicine Connie M. Weaver, Department of Foods and Nutrition, Purdue University Margo G. Wootan, Nutrition Policy, Center for Science in the Public Interest Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Johanna T. Dwyer, Tufts University School of Medicine and Tufts–New England Medical Center and Neal A. Vanselow, Tulane University, Professor Emeritus. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface My memories of food at school are many, starting with cafeteria lunch provided after we presented our green lunch token and without discus- sion of choices or options. Everyone had a lunch token, so no one knew that there was a free or reduced-price lunch and no one went off campus for lunch unless you lived in the neighborhood. Bigger or maybe hungrier students got larger portions. A few students brought lunch in cool lunch boxes, and we envied what was assumed to be a better lunch. There were no vending machines until high school, and then the beverages were milk (full-fat chocolate and regular), orange juice, and a few candy and cracker snacks. I think the only soda machine was in the gym lobby. Hallway or homeroom bake sales provided great homemade cookies, cupcakes, fudge, and brownies. I recall that the school band had the rights to the chocolate bar sale, complete with our school colors and mascot on the label. Birthdays were not celebrated in school. The Halloween carnival was all about food, fun, and homeroom pride for all, from first graders to seniors. Dedicated parents and friends were the band and sport team boost- ers, and loyally staffed the concession stand for the football and basketball games. I don’t remember many students taking time from the action of the game to eat, and we did not want to spend our allowance on food. This was a time when childhood nutrition issues were iron deficiency and undernutrition, when few were concerned about fat or sugar in child- hood diets, and when most meals were consumed at home or school. I now know that some children were hungry and the school lunch was an important source of food. Interestingly, the key stakeholders have not ix

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x PREFACE changed—the children, families, school administrators, teachers, nurses, coaches, food service team, and food industry. The local and state school authorities implement federal policy and make many food and health deci- sions at their levels. In the background, nutritionists, health-care provid- ers, and other child advocates influence both policy and implementation. We now clearly recognize the importance of food and nutrient intake on child health and on lifelong adult health. All stakeholders are concerned about diet quality, emerging food and health habits, and maintaining a pat- tern of healthy childhood growth. Today overweight children outnumber undernourished children, and yet normal or overweight status does not guarantee food security and a healthful diet for many children. Our inex- pensive, abundant food supply, and innovative food industry provide highly palatable foods and beverages for children. School foods and beverages, once almost limited to school lunch, now often include many choices in addition to the federally supported school breakfast and lunch programs. The calories and nutrients consumed at school and school-related activities are an important component of dietary intake of all school-age children. Childhood obesity is often referred to as an epidemic in both the medical and community settings. It is within this scientific and social environment that our committee established our guiding principles and made recommendations for competi- tive foods and beverages provided outside of the federally funded school programs. The goal is for schools to employ their unique, long-term rela- tionship with children and their families to support child health and pro- vide a healthful school eating environment. Our committee is a dedicated group of remarkable people from diverse backgrounds and experiences. We quickly recognized that this was not an easy task. Over nearly 2 years, we learned and debated together, and developed this set of food and beverage standards for competitive foods and beverages, if they are offered. Sincere appreciation is extended to the many individuals and groups who were instrumental in the development of this report. First and fore- most, many thanks are due to the committee members, who volunteered countless hours to the research, deliberations, and preparation of the re- port. Their dedication to this project was outstanding and the basis of our success. Many individuals volunteered significant time and effort to address and educate our committee members during the workshops and public meet- ings. Workshop speakers included Richard Black, Karen Cullen, Robert Eadie, Stanley Garnet, Harold Goldstein, Nancy Green, Hope Hale, Mary Kay Harrison, Jay Hirschman, Mary McKenna, Clare Miller, Derek Miller, Alicia Moag-Stahlberg, Susan Neely, John Perkins, Michael Rosenberger, Barbara O. Schneeman, Jonathan Shenkin, Susan Waltman, Shirley Watkins,

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xi PREFACE Marilyn Wells, Melanie White, Kathy Wiemer, Gail Woodward-Lopez, and Margo Wootan. In addition, representatives from many entities provided oral testimony to the committee during public meetings that were held on October 26, 2005, December 5, 2005, February 13, 2006, and April 21, 2006. They represented the Action for Healthy Kids, Albert Einstein College of Medi- cine, American Academy of Pediatrics, American Beverage Association, American Dietetic Association, American Heart Association, Baylor College of Medicine, Boston University, The California Center for Public Health Advocacy, The Centers for Disease Control and Prevention, The Center for Science in the Public Interest, Coca-Cola North America, ConAgra Foods, Inc., The Food and Drug Administration, Food Products Association, Gen- eral Mills Bell Institute of Health and Nutrition, Grocery Manufacturers Association, International Dairy Foods Association, Irving Independent School District, Kraft Foods Inc., Los Angeles Unified School District, The National Association of State Boards of Education, National Dairy Council, National Medical Association, PepsiCo, The Physician’s Committee for Re- sponsible Medicine, School Nutrition Association, Schwan Food Company, The Texas Department of Agriculture, University of California–Berkeley, The United States Department of Agriculture, Westchester Coalition, and the West Virginia Department of Education. It is apparent that many organizations and individuals from a variety of school and scientific backgrounds provided timely and essential support for this project. Yet we would have never succeeded without the efforts, skills, and grace that were provided in large measure by Janice Okita, Ph.D., R.D. (8/05–7/06) and Ann Yaktine, Ph.D. (7/06–8/07), our Senior Program Officers and Study Directors for this project; Amin Akhlaghi, Research Associate (09/05–10/06); Alice Vorosmarti, M.S.P.H., Research Associate; Heather Del Valle, B.S., B.A., Senior Program Assistant; and Linda Meyers, Ph.D., Food and Nutrition Board Director. Thanks also to Hilary Ray for technical editing. Last, as chair, I express my sincere appreciation to each member of this committee for their extraordinary commitment to the project and the wonderful opportunity to work with them on this important task for the nutrition and school communities and for the school children whose health and future we were asked to consider. Virginia A. Stallings, Chair Committee on Nutrition Standards for Foods in Schools

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Contents SUMMARY 1 1 Committee Task and Guiding Principles 15 2 Nutrition-Related Health Concerns, Dietary Intakes, and Eating Behaviors of Children and Adolescents 29 3 The School Environment 73 4 Foods and Beverages Sold Outside the School Meal Program: Federal, State, Local, and Industry Initiatives 103 5 Recommended Standards and Actions for Competitive Foods in Schools 117 6 Next Steps 141 7 References 151 APPENDIXES A Acronyms and Glossary 171 B Energy Requirements 179 C Nutrition Standards for Competitive Foods Sold in Elementary, Middle, or High School Set by States 183 D Guidelines for Competitive Foods and Beverages 257 E Open Sessions 263 F Committee Member Biographical Sketches 267 Index 275 xiii

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