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The Third School Nutrition Dietary Assessment Study: Findings and Policy Implications for Improving the Health of US Children

      Introduction

      Transformative Milestones in School Nutrition

      In 1995, Johanna Dwyer, DSc, RD, wrote the editorial for the first School Nutrition Dietary Assessment (SNDA-I) study (
      • Dwyer J.
      The School Nutrition Dietary Assessment Study [editorial].
      ). She noted that over the past century, school nutrition policies and practices were affected by four “revolutions”: (a) the realization in the late 19th century that poor children were in need of school meals; (b) the passage of the National School Lunch Act of 1946 that created the National School Lunch Program (NSLP) both to ensure that school meals would help protect against dietary deficiency diseases and to provide an outlet for surplus agricultural commodities; (c) the passage of the Child Nutrition Act of 1966, which established the School Breakfast Program (SBP) to help meet the nutritional needs of children from low-income families; and (d) in the mid-1990s, the application of the Dietary Guidelines for Americans as a standard for ensuring that schools meals would help minimize risk of chronic diet-related diseases. Today, in the early 21st century, we find ourselves in the midst of a fifth era in school nutrition. The obesity epidemic has heightened concerns about the quality of school meals, and foods and beverages sold and provided throughout the school: in vending machines, school stores, cafeterias, for fundraising, and for use as rewards for good behavior. The increasing national concern about obesity and the role of school foods in affecting children's health provides an unparalleled opportunity to advocate for policies and practices to create more healthful school meals and school food environments to improve children's diets and weights. This new era is about balancing needs for healthy nutrition with needs to prevent excess energy intake, especially through reduction of high-calorie, low-nutrition foods and beverages.

      Diets of US Children and Adolescents

      Studies have consistently shown that the diets of US children and adolescents do not meet current national dietary recommendations for good health (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ,
      • Gleason P.M.
      • Suitor C.
      Children's Diets in the Mid-1990s: Dietary Intake and Its Relationship with School Meal Participation.
      ). Nutrients of concern include higher-than-recommended intakes of total fat, saturated fat, and sodium. Moreover, dietary intakes of calcium, potassium, fiber, magnesium, and vitamin E are sufficiently low to warrant concern (
      Institute of Medicine. Committee on Food Marketing and the Diets of Children and Youth
      Food Marketing to Children and Youth: Threat or Opportunity?.
      ). Teenage girls are at especially high risk of inadequate vitamin and mineral intakes (
      • Gleason P.M.
      • Suitor C.
      Children's Diets in the Mid-1990s: Dietary Intake and Its Relationship with School Meal Participation.
      ,
      • Devaney B.
      • Kim M.
      • Carriquiry A.
      • Camano-Garcia G.
      Assessing the Nutrient Intakes of Vulnerable Subgroups: Final Report Submitted to the USDA, Economic Research Service.
      ,
      • Cole N.
      • Fox M.K.
      Diet Quality of American School-Age Children by School Lunch Participation Status: Data from the National Health and Nutrition Examination Survey, 1999-2004.
      ,
      • Clark M.A.
      • Fox M.K.
      Nutritional quality of the diets of US public school children and the role of the school meal programs.
      ). Children from low-income families are less likely to have a healthful diet (
      Institute of Medicine. Committee on Food Marketing and the Diets of Children and Youth
      Food Marketing to Children and Youth: Threat or Opportunity?.
      ). Overall, youth today have dietary patterns that are low in fruits and vegetables, whole grains, and dairy foods, and are high in fat and added sugars. Only one in four youth age 9 to 18 years eat an average of five or more half-cup servings of fruits and vegetables per day (
      • Guenther P.M.
      • Dodd K.W.
      • Reedy J.
      • Krebs-Smith S.M.
      Most Americans eat much less than recommended amounts of fruits and vegetables.
      ). Almost one third of all vegetables eaten are potatoes, and only 7% of vegetables eaten are dark green or orange, whereas the recommendation is that one third of all vegetable servings should be dark green or orange. The 2005 Dietary Guidelines (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ) recommends that Americans consume half of their grains as whole grains, but currently only 7% of children ages 2 to 19 years meet this recommendation (
      US Department of Health and Human Services
      Healthy People 2010: Midcourse Review–Nutrition and Overweight.
      ).
      Data also clearly show that youth consume a large proportion of total energy from high-calorie and low-nutrient foods and beverages (
      Institute of Medicine. Committee on Food Marketing and the Diets of Children and Youth
      Food Marketing to Children and Youth: Threat or Opportunity?.
      ). Total energy intake by children and adolescents has increased substantially since the mid 1980s (
      Institute of Medicine. Committee on Food Marketing and the Diets of Children and Youth
      Food Marketing to Children and Youth: Threat or Opportunity?.
      ). Mean energy intake for all Americans age 2 and older has increased by 150 to 300 calories per day during the past 20 to 30 years. Approximately 50% of this increase is attributed to the consumption of sugar-sweetened beverages (
      • Popkin B.M.
      • Armstrong L.E.
      • Bray G.M.
      • Caballero B.
      • Frei B.
      • Willett W.C.
      A new proposed guidance system for beverage consumption in the United States.
      ). In 1999-2004, US youth consumed a mean of 224 calories per capita per day from sugar-sweetened beverages, representing approximately 11% of their daily energy intake (
      • Wang Y.C.
      • Bleich S.N.
      • Gortmaker S.L.
      Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004.
      ). Increasing energy intake coupled with a reduction in everyday physical activity has created an energy imbalance, resulting in a steady increase in rates of childhood obesity (
      • Bleich S.
      • Cutler D.
      • Murray C.
      • Adams A.
      Why is the developed world obese?.
      ,
      • Sturm R.
      Stemming the global obesity epidemic: What can we learn from data about social and economic trends?.
      ,
      • Wang Y.C.
      • Gortmaker S.L.
      • Sobol A.M.
      • Kuntz K.M.
      Estimating the energy gap among US children: A counterfactual approach.
      ).

      The Childhood Obesity Epidemic

      Over the past four decades, obesity rates in the United States have more than quadrupled among children ages 6 to 11 years, more than tripled among adolescents ages 12 to 19 years, and more than doubled among children ages 2 to 5 years (
      Institute of Medicine, Committee on Prevention of Obesity in Children and Youth
      Preventing Childhood Obesity: Health in the Balance.
      ). Today, almost one third of US children and adolescents—nearly 23 million children and teens—are either overweight or obese (
      • Ogden C.L.
      • Carroll M.D.
      • Flegal K.M.
      High body mass index for age among US children and adolescents, 2003-2006.
      ). Preventing obesity during childhood is critical because habits formed during childhood and adolescence frequently persist into adulthood. Overweight children and adolescents are more likely to become overweight adults. Obesity is strongly associated with cardiovascular disease risk, hypertension, type 2 diabetes, and dyslipidemia (
      Institute of Medicine, Committee on Prevention of Obesity in Children and Youth
      Preventing Childhood Obesity: Health in the Balance.
      ). In addition to the toll on our nation's health, obesity also poses a tremendous financial burden on our economy and our health care system. The estimated cost of obesity to the United States was $177 billion in 2000 (
      US Department of Health and Human Services
      Healthy People 2010: Midcourse Review–Nutrition and Overweight.
      ).
      The prevalence of childhood overweight and obesity is highest among certain ethnic and racial groups such as African Americans, Latinos, and American Indians and Alaska Natives, and among low-income youth. In 2006, 16% of youth 6 to 17 years of age lived in poverty (
      Federal Interagency Forum on Child and Family Statistics
      America's Children in Brief: Key National Indicators of Well-Being.
      ). Approximately 17% of youth (12.6 million) lived in households that were food insecure (lack of access at times to enough food) (
      Federal Interagency Forum on Child and Family Statistics
      America's Children in Brief: Key National Indicators of Well-Being.
      ). Obesity and hunger may co-exist in low-income families, presenting a challenge for school nutrition programs to balance both preventing hunger and preventing overweight.

      Children's Food Environments

      Children's eating behaviors are strongly influenced by the foods available in their immediate environments. Two key settings that impact children's diets are home and school. Approximately 50 million 5- to 19-year-olds attend elementary and secondary schools, a number that represents more than 80% of all youth in the United States (
      Institute of Medicine
      Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth.
      ). Most children attend school for approximately 9 months per year. Because children spend a large amount of time each day at school, they consume a substantial portion of their daily food intake there. Thus, it is critical to assess what foods are available at school and what children are eating.

      Importance of the SNDA Studies

      The role of the NSLP and SBP are uniquely assessed by the national SNDA studies, supported by the USDA, which provide a comprehensive picture of the food and nutrient content of school meals, provide national benchmarks for determining how well school meals meet nutrition-related standards, and examine trends over time. The first SNDA study (SNDA-I) was conducted in 1991-1992, SNDA-II was conducted in 1998-1999, and SNDA-III in 2004-2005. SNDA-III provides the most comprehensive and up-to-date information about school meal programs, competitive foods, and the overall school food environment for elementary, middle, and high schools. SNDA-III was the first SNDA study to collect in-depth, in-person observational information about the types of foods available from vending machines, school stores, and à la carte (
      • Gordon A.R.
      • Cohen R.
      • Crepinsek M.K.
      • Fox M.K.
      • Hall J.
      • Zeidman E.
      The third School Nutrition Dietary Assessment Study: Background and study design.
      ). Measured heights and weights of schoolchildren also were collected for the first time, allowing exploration of the relationship between overweight and obesity and competitive foods and NSLP/SBP meals.
      The study design and data collection methods used in SNDA-III are impressive (
      • Gordon A.R.
      • Cohen R.
      • Crepinsek M.K.
      • Fox M.K.
      • Hall J.
      • Zeidman E.
      The third School Nutrition Dietary Assessment Study: Background and study design.
      ). The study sample represents all public schools participating in the NSLP in the 48 contiguous states and Washington, DC, based on a complex multistage sampling frame that selected school food authorities, then schools served by these school food authorities, and then children attending these schools. Data were collected from 130 school food authorities in 36 states, 398 schools in those school food authorities, and approximately 2,300 students in 287 of those schools. Detailed menu data about meals offered and meals served, and data about the types and sources of competitive foods were collected. Twenty-four–hour dietary recalls were collected in person with approximately 2,300 students, which had not been done since SNDA-I. In-person or telephone interviews were conducted with 2,300 parents of those students. The purpose of this editorial is to review SNDA-III findings and policy implications for improving school foods, food environments, and the diets and weights of America's youth.

      SNDA-III Study Findings and Policy Implications for Improving the Health of US Children and Adolescents

      School Meals

      What do we know about the meals offered and served in the National School Lunch Program and how can they be improved?
      The NSLP has enormous impact in terms of program reach (the number of students participating, particularly low-income youth) and contribution to children's daily nutrition needs. More than 101,000 US schools (99% of all public schools and 83% of all public and private schools combined) participate in the NSLP. In 2007, a mean of 30.6 million children participated in the program each school day, representing approximately 60% of all children in NSLP schools. Almost half (49%) of school lunches served were provided free to low-income students and another 10% were provided at a reduced price (
      USDA Economic Research Service
      The food assistance landscape: FY 2007 annual report.
      ). SNDA-III found that NSLP participants consumed a mean of more than one third (35%) of their total daily energy intake from foods and beverages obtained and consumed at school (for all students, including both NSLP and non-NSLP, mean energy intake of these foods was 26%) (21). For students participating in both the NSLP and SBP, as much as 47% of daily energy intake comes from foods obtained at school.
      The good news from SNDA-III is that more than 85% of schools offered reimbursable lunches that met the School Meals Initiative for Healthy Children (SMI) standards (US Department of Agriculture's [USDA's] current regulatory standard) for each of the key target nutrients: protein, vitamin A, vitamin C, calcium, and iron. Assessing what students actually selected, more than 70% of schools met the USDA standards for these target nutrients (
      • Crepinsek M.K.
      • Gordon A.R.
      • McKinney P.M.
      • Condon E.M.
      • Wilson A.
      Meals offered and served in US public schools: Do they meet nutrient standards?.
      ).
      However, there are areas of concern. Only 6% of schools offered lunches that met all of the SMI standards, and essentially none of the schools served lunches that met the sodium benchmark based on the 2005 Dietary Guidelines. In fact, the mean sodium content of lunches offered was almost twice the recommended level (
      • Crepinsek M.K.
      • Gordon A.R.
      • McKinney P.M.
      • Condon E.M.
      • Wilson A.
      Meals offered and served in US public schools: Do they meet nutrient standards?.
      ). Only approximately one in five schools served lunches that met the total fat standard. USDA nutrition regulations for the NSLP and SBP meals are being reviewed and updated, but currently are based on the 1995 Dietary Guidelines, which recommend fat intake at or less than 30% of energy. The new 2005 Dietary Guidelines recommend fat intake between 25% to 35% of energy. Based on this benchmark in the 2005 Dietary Guidelines, 60% of schools met the total fat recommendation (
      • Crepinsek M.K.
      • Gordon A.R.
      • McKinney P.M.
      • Condon E.M.
      • Wilson A.
      Meals offered and served in US public schools: Do they meet nutrient standards?.
      ). It is concerning that 40% of schools still provide lunches with more than 35% from energy from fat.
      In SNDA-III, only 30% of schools met the saturated fat standard (<10% of energy) (
      • Crepinsek M.K.
      • Gordon A.R.
      • McKinney P.M.
      • Condon E.M.
      • Wilson A.
      Meals offered and served in US public schools: Do they meet nutrient standards?.
      ). Between SNDA-II and SNDA-III, some progress was made in reducing the average energy from saturated fat in lunches served. However, more than two thirds of schools (66% of elementary schools and 76% of secondary schools) still serve meals that do not meet the standards for saturated fat. The importance of saturated and trans fat in the development of elevated cholesterol and subsequent cardiovascular disease and other cardiovascular risk factors is well-established (
      • Gidding S.S.
      • Dennison B.A.
      • Birch L.L.
      • Daniels S.R.
      • Gillman M.W.
      • Lichtenstein A.H.
      • Rattay K.T.
      • Steinberger J.
      • Stettler N.
      • Van Horn L.
      Dietary recommendations for children and adolescents: A guide for practitioners.
      ). The major sources of saturated fat in children's diets are full-fat milk, cheese, and fatty meats (
      • Gidding S.S.
      • Dennison B.A.
      • Birch L.L.
      • Daniels S.R.
      • Gillman M.W.
      • Lichtenstein A.H.
      • Rattay K.T.
      • Steinberger J.
      • Stettler N.
      • Van Horn L.
      Dietary recommendations for children and adolescents: A guide for practitioners.
      ). A surprising finding in SNDA-III was that whole milk was available in almost one third (31%) of school lunch menus (
      • Condon E.M.
      • Crepinsek M.K.
      • Fox M.K.
      School meals: The types of foods offered to and consumed by children at lunch and breakfast.
      ). Almost all schools offered nonfat or low-fat milk, and there is no need to offer whole milk in school meals. The 2005 Dietary Guidelines recommend that children older than 2 years of age consume nonfat or low-fat milk. To help reduce saturated fat and extra calories, Congress should remove the current requirement specifying that schools offer milk at various fat levels and require schools only to serve nonfat (skim) or 1% low-fat milk.
      According to SNDA-III, the top sources of total fat in NSLP lunches were: salad dressings, condiments/spreads, pizza products, peanut butter sandwiches, and french fries (
      • Crepinsek M.K.
      • Gordon A.R.
      • McKinney P.M.
      • Condon E.M.
      • Wilson A.
      Meals offered and served in US public schools: Do they meet nutrient standards?.
      ). Top sources of saturated fat were pizza products, condiments/spreads, 2% milk, salad plates/salad bars, and hamburgers/cheeseburgers. Use of reduced-fat salad dressings and spreads, low-fat dairy products, and lean cuts of meats in appropriate portion sizes and lower fat commodity meats will be critical in reducing saturated fat and total fat in reimbursable school lunches. Reducing the frequency of offering fried potatoes and higher-fat baked goods in school meals may help reduce fat and calories in the diets of children (
      • Briefel R.R.
      • Wilson A.
      • Gleason P.M.
      Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants.
      ).
      The food groups most lacking in children's diets are fruits and vegetables, whole grains, and nonfat or low-fat milk products (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ). SNDA-III provides important documentation on the extent to which these foods are offered. Although almost all schools offered some type of vegetable, fruit, or juice, it is concerning that 42% of schools did not offer any fresh fruit or raw vegetables in the reimbursable school lunch on a daily basis (
      • Gordon A.
      • Crepinsek M.K.
      • Nogales R.
      • Condon E.
      School Nutrition Dietary Assessment Study-III: Volume 1: School Food Service, School Food Environment, and Meals Offered and Served.
      ). Fresh fruit was available in only 50% of the reimbursable lunch menus (
      • Condon E.M.
      • Crepinsek M.K.
      • Fox M.K.
      School meals: The types of foods offered to and consumed by children at lunch and breakfast.
      ). Salad bars were offered every day in 18% of secondary schools and 13% of elementary schools. Fresh fruits and raw vegetables in NSLP lunches were significantly less common in schools with a higher percentage of low-income students (
      • Finkelstein D.M.
      • Hill E.L.
      • Whitaker R.C.
      School food environments and policies in US public schools.
      ). Only 5% of breads and rolls not part of an entrée were made from whole grains (
      • Condon E.M.
      • Crepinsek M.K.
      • Fox M.K.
      School meals: The types of foods offered to and consumed by children at lunch and breakfast.
      ).
      These findings have important policy implications. Given the serious and persistent budget constraints many school foodservice administrators face, it is not surprising that fresh fruits, vegetables, and whole grains are not offered daily. The fact is that fresh fruits and vegetables and whole-grain products cost more (
      • Weber J.A.
      Increasing food costs for consumers and food programs straining pocketbooks.
      ). There is a need, especially with increasing food prices, to look closely at increasing reimbursement rates for school meals to help schools serve meals that meet the current Dietary Guidelines. In addition, other strategies need to be explored, such as increasing the funding for the Department of Defense Fresh Fruit and Vegetable Program, providing more fresh and fresh-cut fruits and vegetables through the USDA commodity program, and expanding the USDA Fresh Fruit and Vegetable Program.
      However, just increasing fruits, vegetables, and whole grains on school menus alone will not ensure that children will eat them. These efforts need to be combined with training and technical assistance for foodservice managers and cooks on food preparation techniques and promotion strategies. Experiential classroom nutrition education for students focused on healthful eating needs to be strengthened and expanded.
      Clark and Fox (
      • Clark M.A.
      • Fox M.K.
      Nutritional quality of the diets of US public school children and the role of the school meal programs.
      ) found that participation in the NSLP was related to excessive sodium intakes. Reducing sodium intake in school meals is important but will be a challenge. Providing processed commodity foods lower in sodium and products reformulated to be lower in sodium will help schools reduce the sodium content of school meals.
      In SNDA-III, elementary schools were significantly more likely than middle and high schools to meet the SMI standards for reimbursable lunches served (
      • Crepinsek M.K.
      • Gordon A.R.
      • McKinney P.M.
      • Condon E.M.
      • Wilson A.
      Meals offered and served in US public schools: Do they meet nutrient standards?.
      ). Compared to SNDA-II, there were few improvements in the proportion of secondary schools meeting SMI standards for key nutrients served at lunch (other than the reduction in energy from saturated fat), and significantly fewer schools met the vitamin A standard in SNDA-III (
      • Gordon A.
      • Fox M.K.
      Mathematica Policy Research Inc
      School Nutrition Dietary Assessment Study-III: Summary of Findings.
      ). SNDA-III found that whereas the majority of elementary and secondary schools offer low-fat meals and low-fat items, more high-fat options are available and children tend to choose them most often. This highlights the need for more focused attention in improving school lunches, especially in secondary schools.
      What is the relationship between NSLP participation and children's diets and weight?
      A key finding from SNDA-III was that NSLP participants consumed more nutrients at lunch than matched nonparticipants, even after adjusting for differences in observable characteristics (
      • Clark M.A.
      • Fox M.K.
      Nutritional quality of the diets of US public school children and the role of the school meal programs.
      ). Intake of protein, vitamin A, vitamin B-12, riboflavin, calcium, phosphorus, potassium, and zinc were among the nutrients that were significantly higher compared with intake by nonparticipants. In general, lunches consumed by NSLP participants and nonparticipants provided similar amounts of energy (
      • Gordon A.
      • Fox M.K.
      • Clark M.A.
      • Nogales R.
      • Condon E.M.
      • Gleason P.M.
      • Sarin A.
      School Nutrition Dietary Assessment Study-III: Volume II: Student Participation and Dietary Intakes.
      ). However, lunches consumed by high school NSLP participants were significantly higher in calories than those consumed by high school nonparticipants (733 vs 661 calories), but were still lower than the USDA energy standard for NSLP high school lunches (787 calories) (
      • Gordon A.
      • Fox M.K.
      Mathematica Policy Research Inc
      School Nutrition Dietary Assessment Study-III: Summary of Findings.
      ). A recent analysis using the National Health and Nutrition Examination Survey (1999-2004) also examined nutrient intake and dietary quality of children who participated and did not participate in the NSLP (
      • Cole N.
      • Fox M.K.
      Diet Quality of American School-Age Children by School Lunch Participation Status: Data from the National Health and Nutrition Examination Survey, 1999-2004.
      ). The results were consistent with SNDA-III findings; lunches consumed by NLSP participants had higher dietary quality and were more nutrient-dense than lunches consumed by nonparticipating children. NSLP participation was associated with increased prevalence of excessive sodium intakes in mean 24-hour intakes among high school students (
      • Clark M.A.
      • Fox M.K.
      Nutritional quality of the diets of US public school children and the role of the school meal programs.
      ). Unlike SNDA-I, school meal participation was not associated with an increase in mean 24-hour intake of excessive fat or saturated fat (
      • Clark M.A.
      • Fox M.K.
      Nutritional quality of the diets of US public school children and the role of the school meal programs.
      ).
      Critics of school meals have expressed concern that the NSLP may be contributing to childhood obesity. Studies in the past that did not correct for selection bias found that NSLP participants were more likely than nonparticipants to be overweight (
      • Fox M.K.
      • Hamilton W.
      • Lin B.-H.
      Effects of Food Assistance and Nutrition Programs on Nutrition and Health: Volume 4, Executive Summary of the Literature Review.
      ). When examining the relationship among food assistance programs and overweight/obesity, selection bias (which is a result of the systematic error in creating or defining comparison groups that differ in observed and nonobserved measures) is a critical methodological issue that needs to be addressed and controlled for (
      • Linz P.
      • Lee M.
      • Bell L.
      Obesity, Poverty, and Participation in Nutrition Assistance Programs.
      ). Participation is also an important issue that needs to be accurately defined. In analyzing SNDA-III data, Gleason and Dodd (
      • Gleason P.M.
      • Dodd A.H.
      School breakfast program but not school lunch program participation is associated with lower body mass index.
      ) used two approaches to address selection bias, and in the regression model controlled for a large set of student-level factors and school-level factors. They found no evidence that usual NSLP participation was related to students' body mass index or risk of overweight or obesity. However, specific characteristics of NSLP lunches may be associated with increased likelihood of obesity (
      • Fox M.K.
      • Dodd A.H.
      • Wilson A.
      • Gleason P.M.
      Association between school food environment and practices and body mass index of US public school children.
      ). Among elementary school children, children who attended schools where french fries were offered more than once per week in NSLP lunches were significantly more likely to be obese than children who attended schools where french fries were offered less frequently. A comparable association was noted for elementary children who attended schools where desserts were offered more than once per week in NSLP lunches (
      • Fox M.K.
      • Dodd A.H.
      • Wilson A.
      • Gleason P.M.
      Association between school food environment and practices and body mass index of US public school children.
      ). Thus, although participation in the NSLP overall is not associated with students' risk of overweight or obesity, specific menu planning practices may increase these risks.
      It should be noted that the cross-sectional design of the SNDA-III study makes it impossible to determine causality. Longitudinal studies will provide the best possible evidence of the timing and direction of any relationship between school foods and beverages, program participation, and obesity.
      What do we know about the meals offered and served in the School Breakfast Program and how can they be improved?
      An average of 10.1 million children per day participated in the SBP in 2007, which accounts for approximately 24% of all children attending a participating school. The SBP is primarily used by children from low-income families; 71% of breakfasts were provided free to students and another 10% were provided at a reduced price (
      USDA Economic Research Service
      The food assistance landscape: FY 2007 annual report.
      ). School breakfasts were more likely to meet SMI standards for target nutrients including fat and saturated fat than were NSLP lunches. Moreover, significantly more schools served breakfasts meeting SMI standards for saturated fat and total fat in SNDA-III than in SNDA-II, indicating that progress has been made in a relatively short time (
      • Gordon A.
      • Fox M.K.
      Mathematica Policy Research Inc
      School Nutrition Dietary Assessment Study-III: Summary of Findings.
      ). Although fruit juice was offered on almost all of the breakfast menus, fresh fruit was only offered in 26% of school breakfast menus and canned fruit on 14% of the menus (
      • Condon E.M.
      • Crepinsek M.K.
      • Fox M.K.
      School meals: The types of foods offered to and consumed by children at lunch and breakfast.
      ). Sausage was more likely to be offered on the menu (40%) as were sweet rolls, doughnuts, and pastries (29%), than were whole fruits (26%) (25). Breads, rolls, or bagels made with whole grains were relatively rare and appeared in fewer than 5% of breakfast menus. As with school lunches, more attention and financial resources are needed to increase fruits and whole grains in school breakfasts and to promote these foods to children.
      Although 1% milk was the most common type of milk offered on elementary and middle school menus, 2% milk was most common in high schools (
      • Condon E.M.
      • Crepinsek M.K.
      • Fox M.K.
      School meals: The types of foods offered to and consumed by children at lunch and breakfast.
      ). The majority of the ready-to-eat cereals were sugar-sweetened, with only 27% of menus offering an unsweetened cereal (
      • Condon E.M.
      • Crepinsek M.K.
      • Fox M.K.
      School meals: The types of foods offered to and consumed by children at lunch and breakfast.
      ). These represent other areas for improvement.
      Evidence suggests that breakfast consumption may improve cognitive function, test grades, and school attendance, and that breakfast eaters are less likely to be overweight (
      • Rampersaud G.C.
      • Pereira M.A.
      • Girard B.L.
      • Adams J.
      • Metzl J.D.
      Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents.
      ). Using data from SNDA-III, Gleason and Dodd (
      • Gleason P.M.
      • Dodd A.H.
      School breakfast program but not school lunch program participation is associated with lower body mass index.
      ) found that school breakfast participation may be a protective factor in obesity because school breakfast participation was associated with significantly lower body mass index, particularly among non-Hispanic white students. A key issue for the SBP is reducing barriers and increasing student participation rates. SBP participation rates are much lower than NSLP participation rates, with only approximately one in five students participating in the program.

      Competitive Foods

      To what extent are competitive foods available in US schools?
      The wide availability of competitive foods—foods and beverages sold on an à la carte basis in school cafeterias or through vending machines, snack bars, school stores, or fundraising—in US public schools is disconcerting. In the 2004-2005 school year, almost two thirds of elementary schools (64%) and roughly nine in 10 middle and high schools had foods or beverages other than milk for sale à la carte during lunch. Vending machines were available in 27% of elementary schools, 87% of middle schools, and 98% of high schools (
      • Fox M.K.
      • Gordon A.
      • Nogales R.
      • Wilson A.
      Availability and consumption of competitive foods in US public schools.
      ). Food and beverage fundraisers occurred in more than one third (37%) of elementary schools and more than half (50% to 60%) of middle and high schools (
      • Gordon A.
      • Fox M.K.
      Mathematica Policy Research Inc
      School Nutrition Dietary Assessment Study-III: Summary of Findings.
      ). SNDA-III also documented that the availability of vending machines increased dramatically from the early 1990s when SNDA-I was conducted; the percentage of vending machines doubled during this time in middle schools and increased approximately 25% in high schools (
      • Gordon A.
      • Fox M.K.
      Mathematica Policy Research Inc
      School Nutrition Dietary Assessment Study-III: Summary of Findings.
      ).
      SNDA-III inventoried the types of competitive foods and beverages that students could purchase. Overall, vending machines at schools offered either 100% juice or water just as often as other beverages, such as carbonated sweetened soft drinks or energy and sport drinks (approximately 43% for each category). Although no elementary schools had snack items in vending machines, 34% of middle schools and 60% of high schools did (
      • Gordon A.
      • Crepinsek M.K.
      • Nogales R.
      • Condon E.
      School Nutrition Dietary Assessment Study-III: Volume 1: School Food Service, School Food Environment, and Meals Offered and Served.
      ). Lower-fat snack foods were available, but they were less prevalent than higher-fat versions. For example, in high schools, 34% offered chips but only 6% had lower-fat versions; 23% had cake-type baked goods, but only 9% were lower-fat versions (
      • Gordon A.
      • Crepinsek M.K.
      • Nogales R.
      • Condon E.
      School Nutrition Dietary Assessment Study-III: Volume 1: School Food Service, School Food Environment, and Meals Offered and Served.
      ). In a previous SNDA-III analysis of the secondary schools that had vending machines, only 15% had no access to machines containing low-nutrient, energy-dense foods and beverages (
      • Finkelstein D.M.
      • Hill E.L.
      • Whitaker R.C.
      School food environments and policies in US public schools.
      ).
      At lunch, more secondary schools offered students à la carte side dishes or snack items that were relatively high in fat and calories than offered lower-fat or lower-calorie options. More than half of secondary schools made chips and cookies available to students, and between 33% and 38% offered fried potatoes, ice cream, and cake-type desserts. Only 21% of schools did not offer any à la carte items (
      • Finkelstein D.M.
      • Hill E.L.
      • Whitaker R.C.
      School food environments and policies in US public schools.
      ).
      The wide availability of competitive foods in schools, with many of these foods and beverages being low-nutrient and energy-dense, is consistent with other recent national studies such as the School Health Polices and Programs Study (
      • O'Toole T.P.
      • Anderson S.
      • Miller C.
      • Guthrie J.
      Nutrition services and foods and beverages available at school: Results from the School Health Policies and Programs Study 2006.
      ) and the School Health Profiles survey with secondary schools (
      Centers for Disease Control
      Competitive Foods and Beverages Available for Purchase in Secondary Schools–Selected Sites, United States, 2006.
      ). The School Health Profiles survey found that during 2004-2006, the availability of some less-nutritious competitive foods and beverages at secondary schools decreased, but availability did not decrease before school or during school hours when meals were not being served. Collectively, these findings indicate that much more effort is needed to improve the school food environment.
      What is the role of competitive foods in schoolchildren's diets?
      An important finding in SNDA-III was that NSLP participants were significantly less likely than nonparticipants to consume competitive foods and beverages (
      • Fox M.K.
      • Gordon A.
      • Nogales R.
      • Wilson A.
      Availability and consumption of competitive foods in US public schools.
      ). Overall, almost half (40%) of school children consumed one or more competitive foods on a typical school day, with competitive food consumption increasing from elementary school to middle school to high school (
      • Fox M.K.
      • Gordon A.
      • Nogales R.
      • Wilson A.
      Availability and consumption of competitive foods in US public schools.
      ). Competitive foods were most often consumed at lunch, and the most common items were dessert and snack items and beverages other than milk and 100% fruit juice. Fox and colleagues (
      • Fox M.K.
      • Gordon A.
      • Nogales R.
      • Wilson A.
      Availability and consumption of competitive foods in US public schools.
      ) found that competitive food consumers in elementary and secondary schools obtained 277 calories, on average, from competitive foods and beverages and almost two thirds (177 calories) of these calories were from low-nutrient, energy-dense sources. The amount of daily energy from low-nutrient, energy-dense foods and beverages consumed in elementary schools, middle schools, and high schools, was 135, 171, and 219 calories, respectively. Among all children, low-nutrient, energy-dense foods and beverages obtained and consumed at school contributed 89 calories to daily energy intake at school (
      • Briefel R.R.
      • Crepinsek M.K.
      • Cabili C.
      • Wilson A.
      • Gleason P.M.
      School food environments and practices affect dietary behaviors of US public school children.
      ).
      Briefel and colleagues (
      • Briefel R.R.
      • Wilson A.
      • Gleason P.M.
      Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants.
      ) found that overall 68% of all schoolchildren consumed sugar-sweetened beverages at some location during the day, half (50%) consumed them at home and one fourth (25%) at school. Sugar-sweetened beverages obtained at school contributed a daily mean of 29 calories in middle schools and 46 calories in high schools across all schoolchildren. Among soft-drink consumers, sugar-sweetened beverages obtained and consumed at school contributed a daily mean of 170 calories among high school students, 136 calories for middle school students, and 100 calories for elementary school students (
      • Briefel R.R.
      • Crepinsek M.K.
      • Cabili C.
      • Wilson A.
      • Gleason P.M.
      School food environments and practices affect dietary behaviors of US public school children.
      ). Among secondary school children who consumed sugar-sweetened beverages at school, energy intake over the entire day averaged 229 calories more than those who did not consume sugar-sweetened beverages at school (
      • Briefel R.R.
      • Wilson A.
      • Gleason P.M.
      Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants.
      ). Briefel and colleagues' analyses of SNDA-III data (
      • Briefel R.R.
      • Wilson A.
      • Gleason P.M.
      Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants.
      ) found that school food policies and practices that limited the availability of competitive beverages were associated with reduced consumption of energy from sweetened beverages at secondary schools. Further, there was no evidence that students “made up” for consuming fewer sugar-sweetened beverages at school by consuming more of these beverages outside of school (
      • Briefel R.R.
      • Wilson A.
      • Gleason P.M.
      Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants.
      ). In analyzing SNDA-III data, Fox and colleagues (
      • Fox M.K.
      • Dodd A.H.
      • Wilson A.
      • Gleason P.M.
      Association between school food environment and practices and body mass index of US public school children.
      ) found that among middle school children, the availability of low-nutrient, energy-dense foods in vending machines in or near the foodservice area was associated with a higher BMI z score. More than half of all middle schools have vending machines available in or near the cafeteria (
      • Fox M.K.
      • Gordon A.
      • Nogales R.
      • Wilson A.
      Availability and consumption of competitive foods in US public schools.
      ).
      A new and important concept introduced in the 2005 Dietary Guidelines was discretionary calorie allowance—the balance of calories remaining in a person's energy allowance after accounting for the number of calories needed to meet recommended nutrient intakes through healthful foods (
      US Department of Health and Human Services and US Department of Agriculture
      Dietary Guidelines for Americans, 2005.
      ). Only a relatively small amount of discretionary calories are available to be consumed as high-energy, low-nutrient foods. At 1,600, 2,000, and 3,000 calories per day, the discretionary calories would be 130, 265, and 510 calories, respectively. For sedentary school-aged children and adolescents, the discretionary calorie allowance ranges from 130 to 290 calories per day. For youth who are inactive, only small amounts of discretionary calories can be consumed before energy intake becomes excessive and weight gain results (
      • Sturm R.
      Stemming the global obesity epidemic: What can we learn from data about social and economic trends?.
      ,
      Institute of Medicine
      Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth.
      ). Estimating that approximately 25% of daily energy intake is consumed at breakfast, 33% at lunch, and 33% at dinner, this leaves only approximately 9% of total daily energy intake for discretionary calorie consumption during the day. Briefel and colleagues (
      • Briefel R.R.
      • Wilson A.
      • Gleason P.M.
      Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants.
      ) found that on average, 25% of daily calories (527 of 2,109) were classified as “empty calories.” The 177 calories consumed on average daily from low-nutrient, high-calorie competitive foods and beverages at school is a cause for concern.
      What are the policy implications?
      In SNDA-III, consumption of competitive foods that are low-nutrient and energy-dense was widespread, especially in secondary schools (
      • Briefel R.R.
      • Crepinsek M.K.
      • Cabili C.
      • Wilson A.
      • Gleason P.M.
      School food environments and practices affect dietary behaviors of US public school children.
      ). The amount of energy consumed at school from low-nutrient, energy-dense foods is not trivial. An analysis by Wang and colleagues (
      • Wang Y.C.
      • Gortmaker S.L.
      • Sobol A.M.
      • Kuntz K.M.
      Estimating the energy gap among US children: A counterfactual approach.
      ) quantified the magnitude of energy imbalance responsible for the increase in body weight among US children during 1988-1994 and 1999-2002. Their results suggested that a population-wide mean reduction in the energy gap of 110 to 165 calories/day could have prevented this increase. Reducing low-nutrient, energy-dense foods and beverages at school needs to be part of a comprehensive strategy for population-based obesity prevention because it could help reduce children's total energy intake. Combined with similar efforts to reduce energy from sugar-sweetened beverages and high-calorie, low-nutrient foods in other settings (such as after-school activities, home, and fast-food restaurants) could help reduce obesity. The recent School Health Policies and Programs Study (
      • O'Toole T.P.
      • Anderson S.
      • Miller C.
      • Guthrie J.
      Nutrition services and foods and beverages available at school: Results from the School Health Policies and Programs Study 2006.
      ) and School Health Profiles (
      Centers for Disease Control
      Competitive Foods and Beverages Available for Purchase in Secondary Schools–Selected Sites, United States, 2006.
      ) surveys indicate that the nation's schools have made progress in restricting access to unhealthful competitive foods, but much more work is needed.
      Given SNDA-III results showing the widespread availability of competitive foods and beverages, a critical issue is whether schools need to offer any competitive foods at all. The 2007 Institute of Medicine report, Nutrition Standards for Healthy School Meals, concluded that federally reimbursable school nutrition programs should be the main source of nutrition at school, and opportunities for competitive foods should be limited (
      Institute of Medicine
      Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth.
      ). If competitive foods are available, they should consist of only nutritious foods, specifically fruits, vegetables, whole grains, and nonfat or low-fat milk and dairy products, consistent with the Dietary Guidelines, to help children and adolescents develop healthful lifelong eating patterns.
      The USDA sets standards for the nutrient content of the meals provided through the NSLP and SBP. However, the USDA has almost no authority over competitive foods. The current federal regulations governing the nutrient content of competitive foods and beverages that are not part of the reimbursable school meals are minimal and outdated. The only nutritional criteria for competitive foods are that foods of minimal nutritional value (foods providing less than 5% of the Reference Daily Intake for key nutrients) may not be sold in the foodservice area during meal times. Many low-nutrition foods, despite their high content of calories, saturated fat, added sugars, and sodium, can be sold anywhere, anytime on school campuses. As of June 2008, 27 states have adopted competitive school food and beverage policies that are more restrictive than the existing USDA federal regulations (
      Trust for America's health
      F as in Fat: How obesity policies are failing in America.
      ). However, in spite of more access to competitive foods in secondary schools, state policies for competitive foods tend to be most restrictive for elementary schools and least restrictive for high schools. SNDA-III findings indicate that as children advance to higher grade levels, their school food environments become less healthful, which suggests that increased attention is needed to improve the food environments in secondary schools by limiting access to competitive foods, especially those that are low-nutrient and energy-dense.
      In 2004, Congress passed legislation requiring all school districts to develop a Wellness Policy by the beginning of the start of the 2006 school year that includes nutrition guidelines for competitive foods. However, the language in the policies often lacks specificity, and implementation across the country has not been uniformly strong, with considerable variation across school districts. Local school wellness policies hold promise for improving school food environments, but efforts and resources are needed to help school districts develop and implement stronger wellness policies.

      Conclusions

      Results of SNDA-III show that many schools have improved the nutritional quality of the NSLP and SBP school meals and foods sold outside of the reimbursable meal programs (competitive foods). However, there is much more room for improvement. Schools need to do even more to reduce the availability of high-calorie, low-nutrient foods and make school meals more nutritious. Although the majority of US schools offer breakfasts and lunches that meet the standards for key nutrients (such as protein, vitamins A and C, calcium, and iron), reimbursable school meals remain too high in saturated fat and sodium, and children are not consuming enough fruits, vegetables, and whole grains. Many public schools are constrained in providing better meals because of limited funds. It is time to reexamine the formulas used to set national reimbursement rates with reference to the costs of producing and serving school meals that meet the Dietary Guidelines.
      The competitive food environment in schools is in dire need of improvement, especially in high schools. Competitive foods are currently the chief source of the low-nutrient, energy-dense foods that children and teens consume in school. Therefore, policies restricting access to these foods are an especially important strategy for addressing childhood obesity and improving the nutritional health of children and youth. Policy solutions include establishing nutrition standards for competitive foods and beverages, limiting access to low-nutrient, energy-dense foods, and broadening the definition of foods of minimal nutritional value. If competitive foods are available during the school day, they should include only fruits, vegetables, whole grains, and nonfat and low-fat dairy products as recommended by the Institute of Medicine (
      Institute of Medicine
      Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth.
      ). Because local education agencies receive substantial amounts of federal aid each year—$10 billion in fiscal year 2007—to run their food programs, there is little doubt that the federal government could rule that schools that do not comply with these requirements are ineligible to receive federal dollars for their school lunch or breakfast programs. If Congress or the Department of Agriculture enacted such a rule, competitive foods and beverages would instantly change in almost every school in the nation (
      • Haskins R.
      • Paxson C.
      • Donahue E.
      Fighting obesity in the public schools The Future of Children. 2006.
      ). Such actions could lead directly to improved child nutrition and health.
      In 1995, the USDA launched the SMI. This initiative was designed specifically to address nutritional shortcomings identified in SNDA-I. As a result of this and other parallel efforts, the nutritional quality of reimbursable school meals has been improving. Given that the “fifth revolution” in school nutrition policies and practices is about balancing needs for healthful nutrition with needs to prevent excess energy intake, it is hoped that SNDA-III findings will spur actions to further improve the nutritional quality of the reimbursable school meals and catalyze effective efforts to limit access to energy-dense, nutrient-poor competitive foods and beverages during the school day. Continued national action at the federal, state, and local level is essential to promote healthful diets among youth and reverse the trend in increased rates of overweight and obesity. There is an inherent challenge for schools in meeting children's energy needs while minimizing both hunger and obesity (
      • Miller C.H.
      A practice perspective on the third School Nutrition Dietary Assessment Study.
      ,
      • Johner N.M.
      Evaluation's vital role in healthier school meals.
      ). However, reducing energy-dense, nutrient-poor foods and high-fat foods, and increasing fruits, vegetables, and whole grains will serve the health of all children well.
      STATEMENT OF CONFLICT OF INTEREST: The author has no conflict of interest to report with the sponsor of this supplement article or products discussed in this article.

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      Biography

      M. Story is a professor, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis