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6
Iterations—Achieving the Best Balance of Nutrition, Student Acceptance, Practicality, and Cost

The development of the Nutrient Targets and Meal Requirements involved iterative processes (see Figure 2-2 in Chapter 2). The need for iteration was especially evident in the development of the recommendations for the standards for menu planning, which posed a number of major challenges. In many cases, the challenges related to the fact that menus that are based on nutrition science alone are not necessarily appealing to students, practical, or economical (or any combination of these). The challenges included finding ways to design standards for menu planning that balanced nutrition, student acceptance, practicality (including the consideration of equipment and facilities), and labor and food cost; setting the specifications for sodium; making recommendations for the definition of whole grain-rich foods; and addressing nutrient shortfalls and overages. The task of addressing standards for meals as selected by students under the offer versus serve provision of the law also posed challenges. Cost factors are addressed in Chapter 8.

NUTRIENT CONTENT, PRACTICALITY, AND APPEAL FOR THE STANDARDS OF MENU PLANNING

Amounts and types of foods specified in the initial revisions of the standards for menu planning made menu writing difficult. Challenges arose in determining the foods to include in the meat and meat alternates group; determining the amounts of certain food groups to include by meal, day, and week; and selecting acceptable forms of fluid milk. Some adjustment was needed in the calorie levels. These topics are addressed briefly below.



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6 Iterations—Achieving the Best Balance of Nutrition, Student Acceptance, Practicality, and Cost The development of the Nutrient Targets and Meal Requirements in- volved iterative processes (see Figure 2-2 in Chapter 2). The need for itera- tion was especially evident in the development of the recommendations for the standards for menu planning, which posed a number of major chal- lenges. In many cases, the challenges related to the fact that menus that are based on nutrition science alone are not necessarily appealing to students, practical, or economical (or any combination of these). The challenges in- cluded finding ways to design standards for menu planning that balanced nutrition, student acceptance, practicality (including the consideration of equipment and facilities), and labor and food cost; setting the specifications for sodium; making recommendations for the definition of whole grain-rich foods; and addressing nutrient shortfalls and overages. The task of address- ing standards for meals as selected by students under the offer ersus sere provision of the law also posed challenges. Cost factors are addressed in Chapter 8. NUTRIENT CONTENT, PRACTICALITY, AND APPEAL FOR THE STANDARDS OF MENU PLANNING Amounts and types of foods specified in the initial revisions of the standards for menu planning made menu writing difficult. Challenges arose in determining the foods to include in the meat and meat alternates group; determining the amounts of certain food groups to include by meal, day, and week; and selecting acceptable forms of fluid milk. Some adjustment was needed in the calorie levels. These topics are addressed briefly below. 0

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0 SCHOOL MEALS Foods in the Meat and Meat Alternates Group The meat and meat alternates group in the current Meal Requirements includes all the types of food listed in MyPyramid’s meat and beans group, and it also includes cheese and yogurt. MyPyramid categorizes cheese and yogurt in the milk group on the basis of nutrient content. Historically, these dairy foods have been counted as meat alternates in both school breakfast and lunch, and menu items such as a low-fat version of cheese pizza are very popular. It quickly became evident that counting cheese and yogurt as milk substitutes rather than meat substitutes would complicate menu planning. This method would either (1) result in a decrease in the amount of fluid milk offered if cheese or yogurt was served or (2) call for an increase in milk group servings in the meal pattern so that cheese and/or yogurt could be offered along with 8 ounces of fluid milk each day. Therefore, to test the effect on nutrient intake of using cheese or yogurt as a meat substitute, the committee added lines for low-fat cheese and yogurt to the MenuDevelop- ment spreadsheet (see Figure 5-1 in Chapter 5). The results indicated that the content of all nutrients (except vitamin E; potassium; and, for those ages 11 years and older, iron) were above the initial targets for the meal. These three exceptions are the same nutrients that are below the targets in the pattern that includes meat. These findings support the continuation of the current practice of allowing the substitution of low-fat cheese or yogurt for meat or beans. Determining Amounts of Food by Meal, Day, and Week Planning daily amounts of food to meet a specific weekly pattern poses challenges, especially for the meat and meat alternates group, the grain group, and the vegetable subgroups. (See Table H-1 in Appendix H for a list of foods in the various food groups.) By testing options and examining data using the MenuDevelopment spreadsheet, it was determined that some flexibility was possible without compromising the nutritional quality of the menus. Thus, the recommended meal patterns give a range for the numbers of servings of meats and meat alternates and for the grains. In addition, the committee determined that extra amounts of dark green or orange vegetables may be counted in the “other vegetable” sub- group. Fresh (not dried) lima beans and peas, which are both leguminous vegetables, may be counted as either a legume or a starchy vegetable. Al- though unsaturated vegetable oils are a MyPyramid food group, the com- mittee determined that it was not practical to include a specified amount of oil in the recommended meal patterns for three reasons: (1) it is difficult for operators to determine the amount of vegetable oil in commercial products,

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0 ITERATIONS—ACHIEVING THE BEST BALANCE (2) school breakfast options such as cold cereal are not served with an oil, and (3) the cashier could not easily verify if a vegetable oil was on the tray. Because unsaturated vegetable oils are an important source of vitamin E, linoleic acid, and α-linolenic acid, the inclusion of unsaturated vegetable oils is encouraged within calorie limits. Maximum calorie levels were in- creased by 50 calories at breakfast for elementary and middle school to accommodate the changes in the recommended meal patterns. Forms of Fluid Milk For consistency with Dietary Guidelines, the committee agreed to limit the fat content of the fluid milk offered to 1 percent (the fat content of low-fat milk).1 Knowing that Dietary Guidelines advises the consumption of foods and beverages with little added sugars, the committee considered advantages and disadvantages of retaining flavored milk as a milk option. The committee agreed to retain flavored fat-free milk. (Flavored low-fat milk would provide more calories and would be likely to result in menus that exceeded the calorie maximum.) Flavored milks are the predominant milk choice at school. The committee was concerned that eliminating all flavored milk would result in a substantial decrease in milk intake, espe- cially if plain reduced-fat (2 percent milk fat) and whole milk are eliminated from the menu. Murphy and colleagues (2008) provide evidence that drink- ing flavored milk is positively associated with nutrient intake but not with weight status in U.S. children and adolescents. The maximum calorie level for school meals places a limit on the amount of added sugars (and solid fats) that may be included in the foods offered. SETTING THE SPECIFICATIONS OF SODIUM The development of standards for menu planning to meet initial so- dium targets presented challenges. There are four types of major barriers to achieving substantial reductions in the sodium content of school meals: 1. Sodium in the food supply. The sodium content of many commer- cially prepared foods that are available to school meal programs is moder- ately high or high. For this reason, partnership by the food industry will be required to achieve substantial reductions of the sodium content of school meals. School lunches as offered have a mean sodium content that ranges 1 Afterconsidering practical reasons and the nutrient content of possible meal patterns for school meals, the committee specified 1 cup of milk at both breakfast and lunch for all age- grade groups even though Dietary Guidelines recommends 2 rather than 3 cups of milk daily for children younger than 9 years.

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0 SCHOOL MEALS from slightly less than 1,400 mg in elementary school to nearly 1,600 mg in high school (USDA/FNS, 2007a). Data from the third School Nutrition Dietary Assessment study (USDA/FNS, 2007a) also indicate that about 43 percent of the sodium in school lunches is provided by combination entrées, 17 percent by accompaniments, 12 percent by grains, and 11 percent by vegetables. 2. Preparation of foods from ingredients that are low in salt. If fea- sible, more local food preparation and the use of a greater proportion of fresh foods and frozen vegetables could result in acceptable school meals with a lower sodium content. However, many food production kitchens are designed to heat and hold food items rather than to prepare them. Additional equipment such as steamers, kettles, tilt skillets, combi ovens (combination steam and convection ovens), and perhaps refrigerators and freezers would be required to do food production. Initially, this would add to program costs. Also, switching from heat and hold to food production requires the addition of staff. Those districts that estimate meals per labor hour (MPLH) to monitor productivity may see an unfavorable decrease in their numbers.2 Moreover, the existing kitchen facility may not be able to handle any additional equipment. This may be the case where new con- struction has occurred, and it also applies to older schools where space and connections of equipment may be a cost issue. 3. Preference for salty foods. Most schoolchildren are accustomed to the taste of salty food and tend to prefer or expect it, regardless of their participation in school meal programs. This preference or expectation is likely to persist as long as the students are routinely exposed to salty foods at home and elsewhere. There are no data to show that salt preference will decrease if the consumption of salty foods is decreased at lunch but main- tained at meals outside of school. 4. Effects on participation in school meals. If schoolchildren are not satisfied with the taste of foods served in school meals, participation in school meal programs is likely to decrease. Children’s nutrient intake and dietary quality may be reduced if they consume foods that are relatively low in nutrients and high in calories from the snack bar or vending machines or from home instead of eating the school lunch (Briefel et al., 2009; Cullen et al., 2007, 2008; Templeton et al., 2005). Children who are eligible for free or reduced-price meals may be especially vulnerable to low nutrient intake if they choose not to participate in the school meal programs. In 2 In school food service operations, the determination of MPLH is the primary calculation used to measure labor productivity. The MPLH calculation involves equating a predetermined number of breakfast meals and snacks as well as a set dollar value of à la carte sales equal to the value of one lunch.

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 ITERATIONS—ACHIEVING THE BEST BALANCE addition, decreased participation threatens the financial integrity of school meal programs. These barriers are so broad in scope that school food programs, acting independently, will find it difficult to make rapid and large reductions in the sodium content of school meals. In the short term, the committee con- sidered it unrealistic for school food authorities (SFAs) to meet the initial sodium nutrient targets from Chapter 4, which are much lower than the current amount of sodium in school meals. Nonetheless, the committee used those same values in setting sodium specifications in the standards for menu planning (see Chapter 7) but set the year 2020 as the date to achieve full implementation, with suggestions for intermediate targets. DEFINING WHOLE GRAIN-RICH FOODS The 2005 Dietary Guidelines for Americans (HHS/USDA, 2005) rec- ommends consuming at least three 1-ounce servings of whole grains daily. It further states that, in general, half the total grain servings should be whole grains. Consequently, the standards for menu planning recommended in this report need to include specifications related to whole grains. Develop- ing such specifications is in line with the request from the study sponsors to recommend a definition that would help schools to “easily identify whole grain products that provide a significant level of whole grains” (see Ap- pendix C, “Critical Issues”). As a starting point, the committee noted that the grains group in MyPyramid, which is used as the basis for the meal patterns in the recom- mended standards for menu planning, includes two food subgroups: refined grains and whole grains. Foods in the whole grains subgroup “contain the entire grain kernel—the bran, germ, and endosperm” (USDA, 2008). Lists of whole grain ingredients appear in Appendix Table H-1 of this report and in the HealthierUS School Challenge Whole Grains Resource Guide (USDA/FNS, 2009b). It is essential to distinguish between the terms whole grains and whole grain-rich foods (or whole grain-rich products). The term whole grains applies to (1) grain foods whose grain ingredients are whole grains only (100 percent whole grain, such as whole wheat bread, and oatmeal) and (2) whole grain ingredients, such as rye flour. Whole grain-rich foods, on the other hand, may contain less than 100 percent whole grain. The committee recognized that it is not realistic to require that foods intended to increase the consumption of whole grains by children contain only whole grains as the grain ingredients for at least three reasons:

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 SCHOOL MEALS 1. Student acceptability is very low for many foods that contain whole grains as the only grain ingredients (e.g., whole wheat bread or 100 percent whole wheat hamburger buns) (Delk and Vickers, 2007). 2. The cost of some 100 percent whole grain foods may be too high to be covered by program income. 3. The availability of whole grain food selections may be limited, especially for some small school districts. The committee therefore focused on developing a definition of whole grain- rich foods that can be counted as meeting the specification for whole grains in the standards for the planning of school menus. It did so by specifying a temporary criterion that comprises two elements (one for portion size and the other for whole grain content). The criterion encompasses not only whole grains such as brown rice but also many foods that contain a mixture of whole and refined grains. (See the section “Recommended Standards for Menu Planning” in Chapter 7 for the criterion and related information.) In developing the criterion, the committee considered the strengths and limita- tions of various criteria that were established by different organizations (see Appendix N), while recognizing that the criterion must be relatively simple for SFAs to apply in menu planning. In designing the meal patterns, the committee recognized that the whole grain-rich food criterion might not result in a whole grain intake that makes up half of the total grain intake (because many whole grain- rich foods are only about 50 percent whole grain). Student acceptability and cost had a major impact on the committee’s recommendations related to whole grains. MODIFYING BASELINE MENUS TO ASSESS POSSIBLE STANDARDS FOR MENU PLANNING The committee tested the preliminary standards for menu planning in part through the process of developing modified baseline menus. In developing the modified menus, the objective was to retain as much of the original menu as possible, adding or substituting foods or changing portion sizes only as necessary to make the menus fit the initial menu plan- ning standards. Based on initial attempts, minor changes were made in the standards to make the approach to menu planning more practical. The modified baseline menus were reviewed to verify improved alignment with Dietary Guidelines. To illustrate, Appendix L shows representative baseline menus and the corresponding modified baseline menus. Among the changes that are the easiest to notice are the types of milk (to lower fat content); substitution of whole grain-rich foods for refined grains; omission of items

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 ITERATIONS—ACHIEVING THE BEST BALANCE such as saltines and salty snacks; and substitution of lower fat meats (e.g., turkey hot dogs for regular). To verify that the preliminary menu planning standards would lead to menus that meet or approach the preliminary nutrient targets, the com- mittee entered the modified baseline menus into the School Meals Menu Analysis program (see Appendix K), assigned as offered weights for the foods using the method specified by the U.S. Department of Agriculture (USDA/FNS, 2007a), calculated the daily averages for the 5-day school week, and compared those averages to the preliminary nutrient targets. Despite the finding that the menus provided a few nutrients in amounts that were lower than the preliminary nutrient targets and that the sodium content was undesirably high (see Chapter 9), no further adjustments in either the preliminary nutrient targets or the standards for menu planning were deemed appropriate. DETERMINATION OF STANDARDS FOR MEALS AS SELECTED BY STUDENTS The law that allows students to decline some food items in school meals has two conflicting goals: decreasing waste and preserving nutri- tional integrity. By conducting analyses and examining the results, the committee was able to comment mainly on the nutritional aspects of op- tions for standards for meals as selected by students. Because P.L. 94-102 specifies that a number of parties are to be involved in establishing the administrative procedures—that is, the standards for meals as selected by students—the committee considered it inappropriate to make a single recommendation for these standards. Thus, it developed two options, as discussed in Chapter 7. SUMMARY As guided by the experience of using the meal patterns for menu plan- ning and the review of menus and of analyses of initial and subsequent iterations, the committee adjusted its recommended standards for menu planning as necessary to achieve a satisfactory balance of nutrition, prac- ticality, student appeal, and cost. The initial nutrient targets were retained with the exception of calories, for which minor increases were made for some age-grade groups at breakfast. For reasons of practicality and student acceptance, the committee set a target date of the year 2020 to achieve the full implementation of the sodium specification in the meal standards but suggests the setting of intermediate targets (see Chapter 10). A temporary

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 SCHOOL MEALS criterion was developed for whole grain-rich foods. Chapter 7 presents the recommendations for Nutrient Targets and Meal Requirements, and Chap- ter 10 covers the recommendations for bringing sodium specifications and the whole grain-rich food definition into better alignment with the Dietary Guidelines.