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10
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.



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10 Implementation, Evaluation, and Research The effectiveness of recommended Nutrient Targets and Meal Require- ments 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 Re- quirements are being implemented for the purpose of quality improvement at the local level. Ealuation 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 increas- ing 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. 

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0 SCHOOL MEALS IMPLEMENTATION Achieving Change Background 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 strate- gies 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

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 IMPLEMENTATION, EVALUATION, AND RESEARCH 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 Inolement 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 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 Inolement 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.

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 SCHOOL MEALS Training and Equipment for School Food Serice 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 Opera- tors.”) 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 Inolement 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. Menu 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 par- ticipation. School food authorities (SFAs) can take many steps to encour- age 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 prefer- ences. All these factors need to be considered in conjunction with strategies to implement the recommended standards for menu planning.

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 IMPLEMENTATION, EVALUATION, AND RESEARCH 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 under- standing 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 plan- ning 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 stu- dent may select meals that meet the minimum amounts of each food group and subgroup during the week; • Developing or modifying food procurement specifications and reci- pes to meet the calorie, saturated fat, and sodium specifications; • Identifying food products in the marketplace that fit with the speci- fications for calories, saturated fat, and sodium and are also appealing to students; • Implementing incremental menu item changes (to permit food ser- vice 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 reci- pes. See the section “Technical Support and Monitoring to Benefit School Food Operations” for more discussion of this topic.

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 SCHOOL MEALS 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 ser- vice operations. Box 10-1 highlights benefits of 2- to 3-week-cycle menus. The sample menus that the committee wrote to illustrate the applica- tion of the standards for menu planning (see Appendix M) provide ex- BOX 10-1 Benefits of 2- to 3-Week-Cycle Menus • One set of menus allows the operator to feature items rated as highly acceptable by the students within daily choices consistent with the standards. This contributes to student satisfaction and may result in higher rates of student participation in the school meal programs. It also may lead to the selection and consumption of more fruits and vegetables by the students. • A 2- or 3-week-cycle menu aids the standardization and optimization of food procurement, inventory turnover, and daily production quantities—improving food service operations and helping control costs. Having a consistent inventory uses less storage space. • Accurate usage projections can be established, enabling vendors and manufacturers to project their production schedules and needs and often resulting in better pricing. • Delivery schedules can be easily set up and managed. • Food service employees can use the food production history as a way of becoming more adept at production planning. • Menu writing and costing need be done for only one cycle, with occasional market adjustments. • Employees can enhance their skills in producing, displaying, and garnish- ing similar item combinations within the time allotted. • Students and cashiers become more aware of what items must be selected to qualify for a reimbursable meal. • Analysis for calories, saturated fat, and sodium will need to be done for only one cycle, with optional seasonal adjustments. The same is true for more exten- sive nutrient analysis that may be requested in connection with special diets. • Health-care staff that work in schools become familiar with the nutrient contents of the meals, allowing easier control of diets for children with special needs (such as schoolchildren with diabetes for whom carbohydrate counts are requested). • Only one cycle menu needs to be communicated to families with a calendar of cycle weeks.

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 IMPLEMENTATION, EVALUATION, AND RESEARCH 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 prefer- ences, 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 pro- vide 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. Repeated Exposure 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 docu- mented 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 avail- ability, 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 Inolement Student involvement in the development of school breakfast and lunch menus may contribute to the acceptance of school meals that are consistent

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 SCHOOL MEALS 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 incor- porate 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. Vegetarian Options 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 prac- tices 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 accom- modate vegetarian diets. The meat alternates (see listing in Appendix H, Table H-1) include soy protein products along with a variety of other op- tions. 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 Program Direction 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-

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 IMPLEMENTATION, EVALUATION, AND RESEARCH 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 pref- erences 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 mem- bers is a valuable resource to all levels of the school food service business, but particularly to the directors and leaders. SNA provides excellent re- sources 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. Cost 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 rev- enue 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-

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 SCHOOL MEALS 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 nonper- ishable 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 pur- chases 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 1 The term offers applies because neither states nor school food service operations are re- quired to use any of the foods. The foods may be used in the School Breakfast Program as well.

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 IMPLEMENTATION, EVALUATION, AND RESEARCH BOX 10-2 Strategies to Help Control the Cost of Food Service Operations • Strategically assess all areas of the operation for processes that may be outdated or that can be streamlined. • Make data-driven decisions. Data on student participation, food cost, labor cost, equipment replacement cost, and training cost are needed to guide the operation in a strategic planning process. • Use computer hardware and software to assist in putting processes in place (e.g., production records). • Form a purchasing cooperative to maximize volume buying. • Use cycle menus throughout the year to streamline menu planning and costing and to offer valid usage numbers to vendors and suppliers to obtain better pricing. • Plan for the incorporation of the wide variety of healthy USDA foods (see “Use of USDA Foods”) into the cycle menu, thus capturing the maximum amount of the district’s entitlement allocation. • Perform a cost-benefit analysis before making any major decisions such as those related to the purchase of equipment or a change to or from the use of highly processed foods. • Make use of the local and national School Nutrition Association to brain- storm ideas and share methods. • Ask employees to present new ideas and processes for daily tasks, and reward innovation. • Conduct job safety analyses to reduce injuries and absenteeism. • Create benchmarks for the organization and make team decisions based on the goals. • Market the school meal programs to encourage student participation. • Importantly, all the benefits of a 2- to 3-week-cycle that were listed previ- ously increase operational efficiency. The more closely daily food production quantities match actual usage, the less waste in both food and staff time. These operational savings are essential to maximizing the percentage of revenue avail- able to cover the higher raw food costs associated with offering more fruits, veg- etables, and whole grain-rich foods. 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 vari- ety 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 high- est proportion of children eligible for free or reduced-price school meals. However, because the Department of Defense has found it necessary to

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 SCHOOL MEALS 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 rec- ommendation 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 achiev- ing 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 intermedi- ate 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 suc- cessful if carried out gradually as opposed to making radical reductions within short time frames. A reasonable immediate target would be to pro- vide 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: 1,377 mg – 138 mg = 1,239 mg of sodium This value might be reconsidered based on information in the forth- coming 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.

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 IMPLEMENTATION, EVALUATION, AND RESEARCH 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 crite- rion (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 defini- tion 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 re- lated 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 Require- ments, 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 combina- tion of these. Product labeling with the whole grain content would be an important step. Recommendation 6. The Food and Drug Administration should take ac- tion 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

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00 SCHOOL MEALS 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 meet- ing the Dietary Guidelines recommendation for whole grains include the following: • Incrementally increase the ratio of whole grain-rich foods to re- fined 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 commer- cial bakeries, food vendors, and product manufacturers. The HealthierUS School Challenge Whole Grains Resource Guide (USDA/FNS, 2009b) pro- vides guidance for writing appropriate specifications for food processors or vendors. Studies indicate that schoolchildren will accept increasing pro- portions 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 infor- mation 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 un- der 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.

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0 IMPLEMENTATION, EVALUATION, AND RESEARCH 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 Di- etary 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 (cur- rently, less than 10 percent of total calories). If the recommended sodium intake is substantially decreased, it seems likely that the sodium specifica- tion 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 partici- pation 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 de- partments 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.

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0 SCHOOL MEALS a. USDA should continue funding for periodic School Nutrition Dietary Assessment studies, with the intermittent addition of a cost component. b. USDA should take the lead in providing funding to conduct well-designed short-term studies in varied school settings to better un- derstand how the new Meal Requirements change children’s total and school meal dietary intakes, student participation, food service opera- tions, and cost. The following sections illustrate the types of evaluations that fall under this recommendation. Ealuation Using the School Nutrition Dietary Assessment Studies Many of the changes resulting from the revised standards can be evalu- ated 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 ques- tions 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. Nutrient Inadequacy 1. What is the effect of recommended changes in school Meal Re- quirements 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.) 2. How do changes in the Meal Requirements influence nutrient in- takes from other meals? 3. 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: a. 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 dis- tributions change when the mean intake was increased or decreased? b. For nutrients with an Adequate Intake, is it appropriate to set the Target Median Intake equal to the Adequate Intake, or do the distribu- tions of intake indicate a concern about some groups of schoolchildren with very low intakes?

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0 IMPLEMENTATION, EVALUATION, AND RESEARCH Nutrient Intakes above the Tolerable Upper Intake Level 1. Do the recommended changes in the school Meal Requirements result in an increase in the prevalence of intakes above the Tolerable Up- per Intake Level for any of the age-gender subgroups? If so, are strategies needed to reduce the very high intakes? 2. 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? 3. Did sodium intakes decrease so that mean intakes are closer to the Tolerable Upper Intake Level? Achievement of Appropriate Calorie Intakes at School Meals 1. Were the desired mean calorie intakes for each age-grade group achieved? 2. How did the distribution of energy intake per kilogram of body weight change? Achievement of Consistency with the Dietary Guidelines 1. How do children’s food group intakes compare with the daily dietary patterns recommended by MyPyramid after the new Meal Require- ments 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? 2. What changes have occurred in children’s food group intakes from other meals? 3. What changes have occurred in children’s intake of discretionary calories, both at the school meals and throughout the day? 4. What changes have occurred in intakes of saturated fat? Ealuation 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 mea- sures, 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

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0 SCHOOL MEALS (elementary school, middle school, high school) and in a variety of school settings (large, small, ethnically diverse, etc.). Other Releant Topics for Ealuation In addition, the committee considers the following topics to be worthy of evaluation. Acceptance of Meals and Participation in the Program 1. What is the effect of recommended changes in the Meal Require- ments on school meal participation? Evaluate the impact on free and re- duced-price participation and on paid-meal participation. 2. How does offering multiple choices of entrées, fruits, and veg- etables affect student acceptance (and participation rates)? 3. What is the student acceptance of lower sodium foods? 4. What are the effects of new guidelines for the variety of vegetables to be offered? 5. What is the impact of the revised Meal Requirements under the offer ersus sere provision of the law on student selection of vegetables and other meal components? Challenges to School Food Service Operations 1. How do the recommended Meal Requirements affect food service operations; how can any problems be addressed? 2. To what extent have vendors responded to the changes by making recommended foods more available and in appropriate portion sizes? 3. How do the new Meal Requirements affect food waste? 4. How do the new Meal Requirements affect the ease of administra- tion 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 com- pare 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.

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0 IMPLEMENTATION, EVALUATION, AND RESEARCH 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 Require- ments for school meals. Recommendation 8. The committee recommends that agencies of USDA, of other federal departments, and relevant foundations fund re- search 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: a. Effects of the recommended range of calorie levels on the ad- equacy of energy intakes for individual children within each of the age-grade categories. b. Impacts of various approaches to reducing the sodium content of school meals and student acceptance of reduced-sodium foods. c. Impacts of various approaches to increase the acceptance of whole grain-rich products. d. Fruit and vegetable options and preparation methods that will increase consumption and decrease waste. e. 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. f. Targeted approaches to decreasing the prevalence of nutrient inadequacy that do not require increasing the intakes of all children. g. Changes in child health as a result of the new standards. The full set of recommended research topics appears below. 1. 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, espe- cially 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. 2. How can sodium levels of school meals be reduced without ad- versely affecting student acceptance? What is the minimum sodium content for foods (such as an entrée) to be acceptable and safe? Is a stepped reduc-

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0 SCHOOL MEALS tion in sodium levels more likely to result in student acceptance of low-so- dium 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)? 3. 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)? 4. How can the recommended changes in the school meals be comple- mented 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? 5. 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? 6. 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? 7. 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 reduc- ing 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. SUMMARY 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

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0 IMPLEMENTATION, EVALUATION, AND RESEARCH school meals, and achieving long-term goals related to reducing sodium and increasing the whole grain content of school meals. Acting on recom- mendations for evaluation and research will provide information needed for further improvements to standards for school meals and methods for planning intakes by groups.

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