Tracy A. Fox, MPH, RD President, Food, Nutrition & Policy Consultants, LLC Stepping Up for a Healthier School Environment Forum: Overview of Institute of Medicine School Foods Report NY State Education Department New York, NY April 16, 2008

U.S. Childhood Obesity Epidemic Trends Obesity prevalence in U.S. children and adolescents by age and time frame, Sources: CDC, 2005 and Ogden et al., 2002, 2006

Competitive Foods are Widely Available in Schools Percentage of Schools Offering Competitive Foods Food VenueElementaryMiddleHigh A la carte Vending Machines School Store/Canteen/ Snack Bars Ref: GAO 2005

% of schools where students could purchase items from vending, stores, canteens, snack bars: Ref: CDC School Health Policies and Programs Studies, 2000 and 2006

% of schools where students can still purchase junk food (vending, school stores, canteen, snack bars) Ref: CDC School Health Policies and Programs Study, 2006

Top 5 Items vending, stores, canteens, snack bars ESMSHS Bottled WaterBottled water 100% fruit juiceSports DrinksSports drinks Soda/high sugar drinks Sports Drinks100% fruit juice High fat cookies, cakes, baked goods Salty snacks, low fat Salty snacks, high fat Ref: CDC School Health Policies and Programs Study, 2006

-- Access: Majority of schools still allow junk food in ALL venues during school day (a la carte, vending, schools stores, concessions, student parties, fundraising) -- A la carte items generally healthier than other venues -- Fundraisers: over half schools still sell chocolate candy, cookies, sodas, other high fat/sugar/salt items Trends are positive – more work to do

Local Wellness Policies 2004 Child Nutrition and WIC Reauthorization Act Wellness Policy Required by 2006 –Nutrition education goals –Physical activity goals –Nutrition guidelines –Other school-based activities

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

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.

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

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

The Guiding Principles Support Healthy Eating Guide Committee Deliberations

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.

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. 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.

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.

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.

IOM Nutrition standards ACTIVELY support the positive messages in 2005 Dietary Guidelines for Americans Standards promote DGA “foods to encourage” throughout the school day, in all schools: –fruits –vegetables –whole grains –non- or low-fat dairy products

Promotion of Fruits, Veggies, WG and LF/NF Milk automatically places limits on other components Standards limit the amount of: –saturated fat –salt –added sugars –total calories

Tier 1 and Tier 2 Foods and Beverages Foods and beverages organized into 2 Tiers Foods/beverage categorized into tiers based on consistency with the DGA Tier 1 foods and beverages: “foods to be encouraged” (fruit, vegetable, whole grain, or nonfat/low-fat dairy) Tier 2 foods and beverages fall short of Tier 1 criteria but still within the DGA recommendations for nutrients such as fat, saturated fat, and sodium

Tier 1 for All Students All School Day: Foods Tier 1 foods contain one serving of 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 (smaller portions are permitted)  Sodium content of 200 mg or less per portion as packaged Tier 1 Foods

Tier 1 for All Students: Foods Á la carte entr é e 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 Entrée Items

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 (per 8 oz. portion): o Lactose-free and soy beverages are included o Flavored milk with no more than 22 g of total sugars per 8-oz. serving (smaller portions are permitted)  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. Tier 1 Beverages

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, or flavoring) Tier 2 Foods/Beverages

1.Kcal: <200/portion 2.Fat: < 35 total; 10% sat; 0 trans 3.Sugars: < 25% cal from ADDED sugar Interim sugar std: < 35% cal from TOTAL sugar Dairy exceptions per 8 oz: Flavored milk: 22 grams total sugar Flavored yogurt: 30 grams total sugar Smaller portions are permitted; sugar to be limited accordingly 4.<200 mg sodium/portion STANDARDS (in detail)

5.Nonnutritive sweetener in beverages in high school after school 6.Caffeine-free STANDARDS in detail (cont’d)

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

12.Tier 1 for elementary and middle school 13.Tier 1 and 2 for high school STANDARDS After-School Setting

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 with or without fruit (as long as one serving total is reached) 4, 6, or 8-ounce low-fat fruit-flavored yogurt (with no more than 15, 22.5, or 30 grams of sugars accordingly) 4, 6, or 8-ounce servings low-fat chocolate milk (with no more than 11, 16.5 or 22 grams of sugars accordingly)

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

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

Thoughts on Implementation of the Standards

Implementing the Recommended Standards The recommended nutrition standards are among several elements of a school policy that could significantly improve the nutritional quality of foods and beverages offered in schools

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 Reformulate/develop compliant items

Action for Implementation 3. State agencies and organizations: Legislation, guidance, direction Annual/periodic reporting from districts Technical and financial support 4.Local districts and organizations Identify mechanism for change (LWP) Communicate/raise awareness Implement change Monitor and evaluate

Challenges in Implementing IOM Standards Federal efforts underway – CN reauthorization (2009); revision of school meals Existing state/local guidelines and standards/LWP Need to develop healthier school foods that: –Taste good –Economical –Convenient Cost Motivation

Key Elements for Success Awareness and understanding of the standards by schools, parents, students, and federal, state, local, industry, as well as other stakeholders.

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, fruits, vegetables, whole grains, and nonfat or low-fat dairy foods and beverages should be available. The recommendations in this report ensure that competitive foods and beverages are consistent with the DGA and will encourage students to develop healthful life-long eating patterns. Changes will take time, dedication, leadership.

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, MD 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

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