1. National Nutrition Standards In the Schools School Nutrition Association- USDA State Agency Conference November 27, 2007 Virginia A Stallings, MD Children’s Hospital of Philadelphia University of Pennsylvania School of Medicine

2. The most pressing challenge to nutritional health in this first decade of the 21 st century is obesity.

3. Competitive Foods are Widely Available in Schools Percentage of Schools Offering Competitive Foods Food VenueElementaryMiddleHigh A la carte678891 Vending Machines 468791 Snack Bars152554

4. School-Related Health Policy 2004 Child Nutrition and WIC Reauthorization Act Wellness Policy Required by 2006 –Nutrition education goals –Physical activity goals –Nutrition guidelines –Other school-based activities

5. Nutrition Guidelines All foods available on campus with objective of promoting health and reducing obesity FY 2005 Congress directed CDC to initiate an IOM study to review the evidence and make recommendations

6. Institute of Medicine National Academies chartered in 1863 to advise the government on scientific and technical matters National Research Council, 1916 National Academy of Engineering, 1964 Institute of Medicine, 1970 IOM for evidence-based info to support policies related to the health of the public

7. Committee’s Task Review evidence and make nutrition standard recommendations: –for availability of sale, content and consumption of foods and beverages at schools; –with attention to foods and beverages in competition with federally reimbursable meals and snacks.

8. Task Consider lessons learned –National School Lunch and Breakfast Program –State- and local-based standards One standard for all ages, or not?

9. Task Develop standards based upon nutrition and health science Ensure that foods and beverages offered in schools contribute to an overall healthful environment Develop benchmarks to guide evaluations of the standards

10. Committee on Nutrition Standards for Foods in Schools Virginia A. Stallings (chair) Children’s Hospital of Philadelphia, PA Dennis M. Bier Baylor College of Medicine, TX Margie Tudor Bradford, Bardstown Independent School Dist., KY Carlos A. Camargo, Jr. Massachusetts General Hospital, MA Isobel R. Contento Columbia University, NY Thomas H. Cook Vanderbilt University, TN Eric A. Decker Univ. of Massachusetts, Amherst, MA Rosemary Dederichs Minneapolis Public School District, MN Jay T. Engeln National Association of Secondary School Principals, VA Barbara N. Fish West Virginia Board of Educ., WV Tracy A. Fox Food, Nutrition & Policy Consultants, VA James C. Ohls Mathematica Policy Research Inc., NJ Lynn Parker Food, Research, and Action Center, Washington, DC David L. Pelletier Cornell University, NY Mary T. Story University of Minnesota, MN

11. Institute of Medicine Staff Ann Yaktine, Study Director (from July, 2006) Janice Rice Okita, Study Director (until July, 2006) Amin Akhlaghi, Research Associate (until Oct., 2006) Alice Vorosmarti, Research Associate Heather Del Valle, Senior Program Assistant

12. Process and Approach Ten Guiding Principles Tier 1: All students all day “F, V, WG, D” Tier 2: High school students after school Includes recommendations for: – Non-nutritive sweeteners – Caffeine – Water availability – Sport drinks – Food for student reward and punishment – Fund raising

13. The committee recognizes that: 1. The present and future health and well-being of school-age children are profoundly affected by dietary intake and the maintenance of a healthy weight. 2. Schools contribute to current and life-long health and dietary patterns and are uniquely positioned to model and reinforce healthful eating behaviors in partnership with parents, teachers, and the broader community. The Guiding Principles

14. 3. Because all foods and beverages available on the school campus represent significant caloric intake, they should be designed to meet nutritional standards. 4. Foods and beverages have health effects beyond those related to vitamins, minerals, and other known individual components.

15. 5.Implementation of nutrition standards for foods and beverages offered in schools will likely require clear policies; technical and financial support; a monitoring, enforcement, and evaluation program; and new food and beverage products.

16. The committee intends that: 6. The federally reimbursable school nutrition programs will be the primary source of foods and beverages offered at school. 7. All foods and beverages offered on the school campus will contribute to an overall healthful eating environment. 8. Nutrition standards will be established for foods and beverages offered outside the federally reimbursable school nutrition programs.

17. 9.The recommended nutrition standards will be based on the Dietary Guidelines for Americans, with consideration given to other relevant science-based resources. 10.The nutrition standards will apply to foods and beverages offered to all school-age children (generally ages 4 through 18 yrs) with consideration given to the developmental differences between children in elementary, middle, and high schools.

18. Calories Weight management Physical activity Food groups to encourage Fats Carbohydrates Sodium, potassium Alcoholic beverages Food safety U.S. Department of Health and Human Services U.S. Department of Agriculture www.healthierus.gov/dietaryguidelines

21. Dietary Intake Data <2% meet the Food Guide Pyramid recommendations 16% did not meet any of the Pyramid food group recommendations Too few fruits, vegetables, whole grains; not enough fiber- or calcium-rich foods Too much fat, sodium, added sugar Are children’s diets meeting the Dietary Guidelines for Americans?

22. Tier 1 for All Students All School Day: Foods Tier 1 foods are fruits, vegetables, whole grains, and related combination products and nonfat and low-fat dairy that are limited to 200 calories or less per portion as packaged and:  No more than 35% of total calories from fat  Less than 10% of total calories from saturated fats  Zero trans fat (≤0.5 g per serving)  35% or less of calories from total sugars, except for yogurt w/ no more than 30 g of total sugars, per 8-oz. portion as packaged  Sodium content of 200 mg or less per portion as packaged

23. Tier 1 for All Students: Foods Á la carte entrée items meet fat and sugar limits as listed above and: o are National School Lunch Program (NSLP) menu items o have a sodium content of 480 mg or less

24. Tier 1 for All Students All School Day: Beverages Tier 1 beverages are:  Water without flavoring, additives, or carbonation.  Low-fat (1%) and nonfat milk (in 8 oz. portions): o Lactose-free and soy beverages are included o Flavored milk with no more than 22 g of total sugars per 8-oz. serving  100-percent fruit juice in 4-oz. portion for elementary/ middle school and 8 oz. for high school.  Caffeine-free, with the exception of trace amounts of naturally occurring caffeine substances

25. Tier 1 Foods and Beverages Individual fruits: apples, pears, fruit cups packed in juice Vegetables - baby carrots Dried or dehydrated fruit - raisins, apricots, apples 100 percent fruit juice or low-salt vegetable juice Low-fat, low-salt whole-grain crackers or chips Whole-grain, low-sugar cereals 100 percent whole-grain mini bagels Whole grain granola bars w/ or w/out fruit (Total = 1 serving) 4, 6, or 8-oz low-fat fruit-flavored yogurt with no more than 15, 22.5, or 30 gm sugar accordingly 4, 6, or 8-ounce servings low-fat chocolate milk with no more than 11, 16.5 or 22 gm sugar accordingly

26. Tier 2 for High School Students After School Tier 2 snack foods are: those that do not exceed 200 calories per portion as packaged and:  No more than 35% of total calories from fat  <10% of total calories from saturated fats  Zero trans fat (≤0.5 g/portion)  35% or less of calories from total sugars  Sodium content, 200 mg or less per portion as packaged Tier 2 beverages are: Non-caffeinated, non- fortified beverages with less than 5 calories per portion as packaged: with or without: - nonnutritive sweeteners, - carbonation, - flavoring

27. Tier 2 Foods and Beverages Low-salt baked potato chips, crackers, and pretzels Animal crackers with no more than 35% of calories from sugar Graham crackers with no more than 35% of calories from sugar Caffeine-free, calorie-free, non-fortified soft drinks Frozen ice cream products that meet the standards for sugar and fat

28. Items that Do Not Meet the Standards Potato chips and pretzels with too much fat or sodium Cheese crackers with too much fat or sodium Breakfast or granola bars with too much fat or sugar Ice cream products with too much fat Cake, cupcakes, cookies with too much sugar or salt Fortified sports drinks or fortified water Gum, licorice, candy Fruit smoothies with too much added sugar Regular colas or sodas with sugar or caffeine

29. Nutritive Food and Beverages 1.Fat: < 35/10 / 0 2.Total sugars < 35% kcal 3.<200 kcal/portion 4.<200 mg sodium/portion STANDARDS:

30. Non-nutritive Food and Beverages 5.Nonnutritive sweetener in beverages in high school after school 6.Caffeine-free STANDARDS:

31. All Students During the School Day 7.Tier 1 foods and beverages 8.Water available and free 9.Sport drink limited to student athletes with >1 hr vigorous activity via coach 10.Not for reward or punishment for behavior or academic achievement 11.Minimize marketing of Tier 2 foods and beverages STANDARDS:

32. After-School Setting 12.Tier 1 for elementary and middle school Tier 1 and Tier 2 for high school STANDARDS:

33. Fund Raising 13.Tier 1 on campus during school day for all students Tier 1 and Tier 2 on campus after school for high school students Encourage Tier 1 and Tier 2 for evening and community events that include adults and students

34. Action for Implementation 1.Policy making bodies providing: Regulatory guidance Designate responsibility Performance guidelines Technical and financial support 2.Federal agencies and food and beverage industry Identification system for Tier 1 and Tier 2 Whole grain and combination products guidance

35. Key Elements for Success Awareness and understanding of the standards by schools, parents, students, and federal, state, and local as well as other private stakeholders. CDC Implementation Guide – under development

36. Concluding Remarks Federal school nutrition programs are the main source of nutrition provided at school. However, if opportunities for students to select competitive foods and beverages arise, they should be used to encourage greater consumption of fruits, vegetables, whole grains, and nonfat or low-fat dairy foods. The recommendations in this report ensure that competitive foods and beverages are consistent with the DGA and will help encourage students to develop healthful life-long eating patterns.

40. “Remember when we used to have to fatten the kids up first?”