No Free Lunch? Current Challenges Facing the National Bac kg ro u n d School Lunch and School Breakfast Programs P a p e r No. 72 Eileen Salinsky, Consultant December 11, 2009 OVERVIEW — This background paper describes important characteristics of the National School Lunch Program and the School Breakfast Program, reviews U.S. Department of Agriculture rules regarding the nutritional content of school meals, and examines compliance with current nutrition standards. It also considers the dietary status and obesity risk of meal program participants, discusses proposed improve- ments to nutritional standards and meal requirements, and highlights key legislative issues. Related Materials — A companion paper “Got Junk? The Federal Role in Regulating 'Competitive' Foods” (Issue Brief No. 835, December 11, 2009) explores proposals to increase federal regulation of competitive foods. December 11, 2009 National Health Policy Forum National Health Policy Forum Contents 2131 K Street, NW Suite 500 Washington, DC 20037 Overview of School Meal Programs........................................................5 Eligibility and Certification of Students For Subsidized Meals........6 T 202/872-1390 F 202/862-9837 Figure 1: School Meal Recipients.................................................7 . E nhpf@gwu.edu www.nhpf.org Figure 2: USDA Study of Eligibility Certification and .................... Certification Error Rates, 2005–2006 School Year........................9 Judith Miller Jones Federal Financial Assistance.........................................................10 Director Sally Coberly, PhD Cash Reimbursements for Meals Served......................................11 Deputy Director Figure 3: Federal Reimbursement Rates for School Meals Monique Martineau (Per Meal, 2009–2010 School Year).............................................11 Director, Publications and Online Communications Agricultural Commodities............................................................12 Program Costs. ...........................................................................12 . Nutritional Value of School Meals..........................................................14 . Current Nutrition Standards and Meal Requirements...................14 . Table 1: Current Nutrition Standards for School Meals.................15 Table 2: Lunch Requirements for Alternative Menu Planning Approaches...................................................................16 Compliance with Existing Federal Nutrition Standards..................17 Raising the Bar for the Nutritional Quality of School Meals.....................19 Nutritional Status of Participating Students .................................19 Call for Revised Nutrition Standards ............................................21 Table 3: Recommended Quantitative Specifications for School Meal Standards (as offered). ............................................23 . Barriers to Healthier School Meals...............................................24 Conclusion. ...........................................................................................26 . Endnotes...............................................................................................27 The National Health Policy Forum is a nonpartisan research and public policy organization at The George Washington University. All of its publications since 1998 are available online at www.nhpf.org. 2 Bac kg ro u n d www.nhpf.org P a p e r No. 72 A s the nation confronts an alarming epidemic of child- hood obesity, Congress is now considering modifica- tions to the National School Lunch Program and the School Breakfast Program administered by the U.S. Department of Agriculture (USDA). The programs have tremendous reach, with virtually all public and private schools participating and most children eating a school meal on a regular basis. The Na- tional School Lunch Program, the School Breakfast Program, and the Child and Adult Care Food Program are permanently authorized. However, reauthorization of related child nutri- tion programs (such as WIC [Women, Infants, and Children] and the Summer Food Service Program) occurs every five years and has historically provided an opportunity to con- sider improvements to the school-based nutrition programs. School nutrition policymakers face increasingly complex and far- reaching challenges. Historically in the United States, childhood malnutrition was characterized by dietary deprivation and hunger leading to a range of negative health outcomes for afflicted children, including stunted growth, compromised intellectual functioning, and life-long vulnerability to disease. While starvation continues to be a threat in much of the developing world, the food and beverage intake of most American children meets or exceeds energy needs. Despite this caloric abundance, nutritional deficiencies are not un- common and hunger persists for some low-income children. The typical diet of most American school children represents a para- dox: it provides a surplus of energy, yet a deficit of important nutri- ents. The average school-age child consumes too much sugar, fat, and sodium and not enough fruit, vegetables, whole grains, milk, and lean protein.1 Malnutrition—the excess or deficient intake of food energy, protein, or nutrients—can lead to a wide variety of de- velopmental, cognitive, behavioral, social, and academic problems in children. Excessive intake of food energy, perhaps the most ap- parent form of malnutrition today, clearly contributes to obesity and the many health problems associated with excess body fat. Physi- cal activity levels play an important role in determining the energy 3 December 11, 2009 National Health Policy Forum needs of individual children, and the precise causal relationships among diet, body weight, and health risks are not fully understood. However, the association between unhealthy dietary choices, obe- sity, and poor health outcomes is strong.2 Childhood obesity has been linked to a range of immediate health concerns (including elevated blood cholesterol levels, high blood pressure, asthma, and diabetes), as well as an increased risk for diseases (such as cancer and cardiovascular disease) in adulthood. Obese children also experience increased psychological stress and low self-esteem that can affect their mental and social well-being. A limited body of evidence suggests that obesity is associated with higher rates of school absenteeism and diminished academic per- formance.3 Misguided attempts to address overweight and obesity can also have negative repercussions on health. Weight-loss efforts among adolescents have been linked to higher rates of smoking ini- tiation, unsafe food restriction practices, and, in rare instances, eat- ing disorders, such as bulimia.4 The negative consequences of improper nutrition extend far beyond those related to overweight and obesity. For example, iron deficiency anemia can cause fatigue, shortened attention spans, reduced resis- tance to infection, and impaired cognitive function. Inadequate in- take of calcium during childhood and adolescence hinders healthy bone development and increases the risk of osteoporosis later in life. Diets high in sugary food and beverages promote dental caries, which affect over half of all school age children.5 Low-income children are particularly vulnerable to the prevailing nutritional paradox. Obesity is more prevalent among children liv- ing in poverty, yet these children are also more likely to face peri- odic food shortages and hunger due to economic constraints. Food insecurity (limited access to enough food for an active, healthy life) has been demonstrated to increase the risk of childhood obesity.6 Although the evidence base is still developing, cyclical periods of “feast” and “famine” appear to prime the body metabolically for weight gain. When food is available, the diets of low-income chil- dren are particularly likely to rely on less expensive, energy-dense, nutritionally deficient foods.7 Competitive foods (food and beverage items, like snacks or sodas, offered by schools in addition to school meals) are now in the spot- light,8 but the need to improve the nutritional quality of school meals 4 Bac kg ro u n d www.nhpf.org P a p e r No. 72 has also been raised. This background paper summarizes the Na- tional School Lunch Program and the School Breakfast Program and examines policy-relevant concerns regarding the impact and opera- tion of these programs, including the criteria and processes used to determine eligibility for free and reduced-price meals, the adequacy of federal financial assistance, the relationship between school meals and childhood obesity, and proposed changes to nutritional stan- dards for school meals. Ov erv ie w o f Sch o o l M e a l P ro g r a ms The school meal programs represent a long-standing federal com- mitment to childhood nutrition. The National School Lunch Program (NSLP) was established in 1946 “as a measure of national security, to safeguard the health and well-being of the Nation’s children and to encourage the domestic consumption of nutritious agricultural commodities and other food.”9 Although legislative authority for the program has been amended many times, the primary purpose has not been changed since it was first established. The NSLP was ex- panded in 1998 to include after school snacks offered to students in educational or enrichment programs. The School Breakfast Program (SBP) was piloted in 1966 and authorized in 1975. The programs provide federal financial assistance for meals served in participating schools (in the form of both cash reimbursements and donated agricultural commodities) and also establish nutrition- al requirements for those meals.10 While USDA provides funding for all meals served in participating schools, schools receive significant- ly higher levels of reimbursement for breakfasts and lunches served to children who qualify for free or reduced-price meals on the basis of family income. The programs have tremendous reach and exert a significant influ- ence on children’s nutritional status. Nearly all schools participate in the programs (83 percent of public and private schools for lunch, 99 percent of public schools for lunch, and 85 percent of public schools for breakfast),11 and lunches are available to nearly 92 percent of all students.12 Over 70 percent of all students consume a school lunch three or more days per week, and approximately 20 percent consume a school breakfast three or more days per week.13 School meals repre- sent approximately half of total daily caloric intake during the school 5 December 11, 2009 National Health Policy Forum year for students participating in both meals, with lunch representing 30 percent of total intake and breakfast 20 percent of total intake.14 The programs are implemented through a collaborative effort by federal, state, and local agencies. The Food and Nutrition Service within USDA reimburses states for meals served in schools, coor- dinates policy, provides technical assistance, and oversees the work of the states. State agencies, usually state departments of education, administer the programs through agreements with local school food authorities, manage the fiscal aspects of the program, monitor local performance and compliance with federal and state standards, and provide technical assistance. Local school food authorities (which usually correspond to school districts but can represent individual schools or groups of districts) serve school meals, certify students eligible to receive free and reduced-price meals, verify eligibility sta- tus for a sample of certified students, and maintain program data for reporting and reimbursement claims. Eligibility and Certification of Students For Subsidized Meals Eligibility for free and reduced-price meals is based on family in- come. In participating schools, free meals must be provided to chil- dren in households with income equal to or less than 130 percent of the federal poverty level or in households that are categorically eligible for school meal benefits. Categorical eligibility is provided to children in households that participate in Temporary Assistance for Needy Families (TANF), the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program), Head Start, or the Food Distribution Program on Indian Reservations (FDPIR) or to children who are homeless, runaway, or migrant. Reduced-price meals (sold for a maximum of 40 cents for lunch and 30 cents for breakfast) must be provided to children in households with income between 130 and 185 percent of poverty. The majority of school meals are served to the students eligible for free or reduced-price meals, but students who pay full price repre- sent a significant proportion of meal recipients. Of the 31.2 million school lunches served to students daily in 2009, approximately 52 percent were free to students, an additional 10 percent were provid- ed at reduced price, and 38 percent were paid for by students.15 Of the 11 million school breakfasts served daily, approximately 82 per- cent were free or reduced-price (Figure 1, next page). 6 Bac kg ro u n d www.nhpf.org P a p e r No. 72 Students who qualify for free or re- FIGURE 1 School Meal Recipients duced-price lunch are more likely to consume school meals than students Proportion of Meals Served, 2009 who pay full price. Nearly 90 percent of Lunches 31.2 million Breakfasts 11 million students qualifying for free or reduced- served daily served daily price meals consume school lunch three or more days per week compared with 38% 10% 18% 10% Reduced-Price Full-Price Reduced-Price 60 percent of the students who pay full Full-Price Meal Meal Meal Meal price. These differences in participa- 72% 52% tion rates are even more pronounced Free Meal Free Meal for breakfast, with about 45 percent of students qualifying for free or reduced- price meals usually consuming break- Participation Rates, 2004–2005 School Year fast compared with 10 percent of stu- dents who pay full price. Lunches* Students Eligible for Free or The process used to determine eligibil- Reduced-Price Meal 89% ity for free and reduced-price meals is Students Who Pay Full Price 60% known as certification. Most students certified for subsidized meals submit Breakfasts* applications indicating either their Students Eligible for Free or Reduced-Price Meal 45% household size and income level or their inclusion in one of the programs Students Who Pay Full Price 10% or populations that confer categorical eligibility for meal benefits. Approxi- mately 25 percent of students receiving free meals are directly certi- * Students consuming school meals three or more times per week. fied, meaning that some categorically eligible children are certified without submitting an application because some state agencies share Source: USDA, "National School Lunch information and directly verify the child’s categorical eligibility. Di- Program: Participation and Lunches Served," December 3, 2009, available at www.fns. rect certification for families participating in the SNAP became man- usda.gov/pd/slsummar.htm; USDA, "School datory in the 2008–2009 school year. States may use direct certifica- Breakfast Program: Participation and Meals Served," November 2, 2009, available at www. tion for other categorically eligible programs at their discretion. fns.usda.gov/pd/sbsummar.htm; and USDA, School Nutrition Dietary Assessment In certain high-poverty schools, all students may receive free meals Study III—Volume II: Student Participa- without applying for benefits or being directly certified. These spe- tion and Dietary Intake, November 2007, pp. 39–40, available at www.fns.usda.gov/ORA/ cial provisions (known as Provision 2 and Provision 3) reduce the menu/Published/CNP/cnp.htm. application processing burdens of high-poverty schools. Approxi- mately 7 percent of students receiving free meals qualify through these provisions. Relative to other public assistance programs that target low-income families, certification for free or reduced-price school meals is a 7 December 11, 2009 National Health Policy Forum low-burden process. The programs do not require applicants to sub- mit income documentation, apply in person, or meet any kind of as- set test. Approximately two-thirds of children receiving free lunches come from families whose income appears to be low enough to qual- ify for TANF or SNAP but do not participate in these programs.16 Schools are only required to verify the eligibility of a very small pro- portion of applications (typically 3 percent or less). These streamlined certification processes are credited with ensur- ing high rates of certification among eligible children, but have also raised concerns regarding program integrity. A USDA study con- ducted in the 2005–2006 school year suggests that certification errors are not uncommon. Approximately 22.5 percent of all certification de- terminations for subsidized meals (including both certified students and denied applicants) result in an erroneous certification status. Over-certification, that is certification granted to children actually ineligible for that level of meal benefits, is more common (15 per- cent of determinations) than under-certification (7 percent of deter- minations). These under-certifications include children certified for reduced-price meals who are actually eligible for free meals, as well as those erroneously denied school meal benefits. While only 5 per- cent of determinations result in denials, nearly 35 percent of denied applicants were erroneously rejected for free or reduced-price meals. According to a USDA study, about half of all certification errors among certified students represent misclassifications between the free and reduced-price lunch categories. Errors were most likely among children certified for reduced-price meals. Errors were least likely among children certified for free lunch, with only about 6 per- cent of students certified for free meals actually ineligible for any type of meal subsidy and 8 percent eligible for reduced-price meals, as shown in Figure 2, next page. However, because the majority of determinations result in certification for free lunch (78 percent), er- rors within this category account for about half of all certification errors made. The USDA study of certification errors focused solely on certification determinations made; it did not seek to identify the proportion of children eligible for school meal subsidies who did not submit applications for these benefits.17 In response to concerns about certification errors, some have pro- posed that more rigorous verification processes be imposed, such as increased requirements for income documentation and in-person 8 Bac kg ro u n d www.nhpf.org P a p e r No. 72 applications. A pilot test of “up front” documentation found that certification error rates did not decline significantly, but did decrease program participation rates among low-income children. Others be- lieve greater reliance on direct certification for children in categori- cally eligible households will allow school districts to concentrate their integrity control efforts on income-based applications. Some advocates have proposed eliminating the reduced-price meal category and raising eligibility for free meals to 185 percent of pover- ty, a threshold consistent with WIC eligibility. Error concerns center FIGURE 2 USDA Study of Eligibility Certification and Certification Error Rates, 2005–2006 School Year Certification Status Percent of all determinations 5% Full-Price Meal Free Meal 17% Reduced-Price Meal 78% Free Meal 40.9% 86% Reduced-Price 64.4% Free Meal Meal Full-Price Meal Certification Error Rate Accurately Certified 34% 25.1% 16.6% 19.0% Over-certified Under-certified 5.9% 8.1% Free Meal Full-Price Meal Reduced- Free Meal Full-Price Meal Reduced- Price Meal Price Meal Source: Michael Ponza et al., NSLP/SBP Access, Participation, Eligibility, and Certification Study – Errone- ous Payments in the NSLP and SBP, Vol. I: Study Findings, USDA, Report No. CN-07-APEC, November 2007, available at www.fns.usda.gov/ORA/menu/Published/CNP/FILES/apecvol1.pdf. 9 December 11, 2009 National Health Policy Forum on the reduced-price meal category and often reflect misclassification across subsidy categories. Proponents argue that creating a single benefit level could simplify certification procedures and encourage higher participation rates among eligible children.18 Raising the in- come level used to determine eligibility for free meals would also increase program costs, however. A recent study estimates that the additional cost to the federal government of eliminating the reduced- price meal category would be $477 million based on both higher re- imbursement rates and increased participation.19 F e d e ral Fina n cial A s s i s t a n ce Federal costs for the school meal programs have increased substan- tially since the program was last reauthorized. Between 2004 and 2008 federal spending for the school meal programs increased near- ly 25 percent, rising from $9.4 billion to $11.7 billion.20 In inflation- adjusted dollars, federal funding has increased approximately 10 percent during this time period, driven largely by increases in the number of meals served. While student participation rates have remained relatively stable in recent years, rising school enrollment and expansions in the break- fast program have resulted in an increased number of meals served. The number of lunches served increased by nearly 8 percent be- tween 2004 and 2008.21 During the same time period, the number of breakfasts served increased by nearly 20 percent.22 While the pro- portion of lunches served to students certified for free and reduced- price lunches increased slightly, rising from 59.1 percent to 60.1 per- cent between 2004 and 2008, the proportion of breakfasts served to students certified for free and reduced-price breakfasts decreased, falling from 82.4 percent to 80.6 percent. USDA support accounts for approximately half of all revenues re- ceived by school food authorities.23 The following summarizes the two major types of federal financial assistance (cash reimburse- ment for meals served and donated agricultural commodities) and describes the major components of program-related costs borne by school districts. 10 Bac kg ro u n d www.nhpf.org P a p e r No. 72 C a s h Re im b u r s e m e n t s fo r M eal s S e r ve d Most federal funding for school meal programs is provided in the form of cash reimbursement to participating schools for all meals that meet USDA’s nutritional standards. Nearly 91 percent of fed- eral funding is distributed through cash reimbursements for meals served. The majority of reimbursement expenses (nearly 78 percent) are for school lunches. Reimbursement rates are established in stat- ute that ties annual updates made to the Consumer Price Index Food Away from Home for Urban Consumers, set by the Bureau of Labor Sta- tistics each July. Maximum rates for lunches are also set, which limit the amount states can redistribute to individual school food authori- ties to ensure equitable distribution of federal funds. Reimburse- ment rates for the 2009–2010 school year are summarized in Figure 3. FIGURE 3 Federal Reimbursement Rates for School Meals (Per Meal, 2009–2010 School Year)* LUNCH BREAKFAST High Need School** High Need School** $ 2.70 $ 1.74 $ 2.30 $ 1.44 $ 0.27 $ 0.26 Non-High Need School Non-High Need School $ 2.68 $ 1.46 $ 2.28 $ 1.16 $ 0.25 $ 0.26 Maximum Per-Meal Reimbursement Maximum rate N/A $ 2.85 $ 2.45 $ 0.33 Meal Type *Excludes Alaska and Hawaii which receive higher reimbursement rates. Free Meal * *High-need schools are defined differently under the National School Lunch Program (NSLP) and the Reduced-Price Meal School Breakfast Program (SBP). The NSLP provides enhanced reimbursement for meals served by school food authorities that serve 60 percent or more free and reduced price meals. The SBP provides enhanced Full-Price Meal reimbursement for meals provided in “severe need” schools which serve 40 percent or more free and reduced-price meals. Source: Federal Register, vol. 74, no. 134, July 15, 2009. 11 December 11, 2009 National Health Policy Forum Ag ri cul tu ral C o m m o di tie s In addition to cash reimbursement for meals served, states also re- ceive federal financial support through donations of agricultural commodities, commonly referred to as USDA foods. These USDA foods represent an important source of food for school meals. In 2008, USDA provided the child nutrition programs with agricultur- al commodities valued at more than $1 billion. About 20 percent of foods acquired by schools were USDA foods.24 Schools receive USDA foods through two mechanisms: entitlements and bonus purchases. Entitlements guarantee each state an allot- ment for commodity purchases. The dollar amount of this allotment is based on the number of lunches served the previous year with per-meal rates updated annually on the basis of the Bureau of Labor Statistic’s Producer Price Index for Foods Used in Schools and Institutions. In 2008–2009, each state’s USDA foods entitlement allotment equaled 20.75 cents for every lunch served the prior year.25 States order products from a list of available offerings published by USDA until their entitlement allotment is depleted. Each state has a fair amount of flexibility in determining how to distribute USDA foods to schools. Some operate in a centralized fashion, with USDA foods delivered to a common warehouse. Others allocate the dol- lar value of the entitlement to districts, allowing districts to choose products from available offerings and delivering products directly to those districts. USDA makes bonus purchases specifically to relieve market surplus- es of, and provide price supports for, agricultural products. These bonus purchases are offered to states throughout the year on a fair- share basis proportionate to the state’s share of total meals served. In 2008, bonus purchases accounted for less than 6 percent of the total cost of USDA foods in the school meal programs.26 P ro g ra m C o s t s School food authorities have raised concerns that federal reim- bursement for free meals is not adequate to cover the costs of pre- paring and serving reimbursable meals. A recent study of meal costs sponsored by the USDA found that the average full cost of producing a reimbursable lunch was $2.79 in the 2005–2006 school year, compared with a federal reimbursement rate for free lunch 12 Bac kg ro u n d www.nhpf.org P a p e r No. 72 at that time of $2.51 (90 percent of average full costs covered by reimbursement). The study found that 72 percent of reimbursable lunches were produced at a cost greater than the subsidy rate for a free meal.27 Similar discrepancies between cost and reimburse- ment were found for school breakfasts, with the mean full cost of breakfast ($1.81) found to be considerably higher than the prevail- ing reimbursement rate ($1.27). While differences between funding and costs varied, costs exceeded reimbursement in a majority of school food authorities. Approxi- mately 68 percent of school food authorities had lunch costs that ex- ceeded reimbursement, and 82 percent of authorities had breakfast costs that exceeded reimbursement. The USDA study was based on a nationally representative sample and did not document regional variation in costs. Such regional variations are likely, as labor costs are known to vary across states and regions. The full cost of school meals is largely dominated by labor expenses. Nearly half of the average full cost of a reimbursable school lunch can be attributed to labor. In contrast, food costs (including the value of donated commodities) account for just over one-third of full costs. Other costs, including supplies, contracted services, and indirect charges from school districts (such as facility and utility costs) ac- counted for approximately 15 percent of full costs. The full cost of producing reimbursable meals include costs directly incurred by food service departments within schools or districts (such as food costs and staff salaries), as well as additional costs in- curred at the district level to support the programs (such as adminis- trative costs associated with certification processes and costs related to employee benefits and facility operations). These additional costs, which do not directly accrue to the food service authority’s budget and are typically not included in routine reports to USDA, account for approximately 20 percent of full meal costs. Although schools have taken action to reduce their budgets, the dis- parity between full meal costs and reimbursements has increased slightly since the USDA meal cost study was completed. The School Nutrition Association reports that, in the 2008–2009 school year, the average full cost of a school lunch was estimated to be $2.90, while the free lunch reimbursement rate that year was $2.57 (89 percent of full costs covered by reimbursement).28 Most school food authori- ties have taken steps to supplement revenues and decrease costs in 13 December 11, 2009 National Health Policy Forum response to budgetary pressure, such as increasing the price of full price student meals (73 percent), reducing staff (60 percent), cutting training (26 percent), and making menu substitutions (75 percent). Some argue that updates to meal reimbursement rates should be based on an index other than the current Food Away from Home for Urban Consumers. Proponents of a revised update mechanism note that most “away from home” food venues often do not provide ben- efits (such as health insurance and leave) to employees. Such benefits are common, and often generous, in school districts. Therefore, the labor cost increases experienced by schools are not likely to be re- flected in the update index currently used. N u t ri t i o n a l Va lu e o f S c h o o l M e a ls The content and quality of school meals have a significant impact on children’s dietary intake due to the high rates of participation in the NSLP and SBP by both schools and students. All meals provided by schools participating in NSLP and SBP must conform to the nutri- tion standards and meal requirements established by USDA. There- fore, these standards influence the diets of all children who consume school meals—those who qualify for free and reduced-price meals and those who pay full price. Cu r re n t N u tri tio n St a n d a rd s a n d M eal Re q uire m e n t s Current nutritional requirements for school meals reflect policies es- tablished by the USDA under the School Meal Initiative for Healthy Children (SMI) in 1995. These rules require that school meals: • Adhere to the then-current 1995 Dietary Guidelines for Americans • Provide specified proportions of the 1989 Recommended Dietary Allowances (RDAs) for select nutrients • Limit amounts of total and saturated fats to specified maximums • Provide a minimum number of calories based on Recommended Energy Allowances (REAs), which vary across age-grade groups Standards apply to the average content of meals over one school week (five days). USDA also recommends that school meal programs reduce the level of cholesterol and sodium in meals and increase the level of dietary fiber, whole grains, vegetables, and fruit. However, 14 Bac kg ro u n d www.nhpf.org P a p e r No. 72 Table 1 Current Nutrition Standards for School Meals S ta n da r d f o r M e a l Nutrient Lunch Breakfast Calories ⅓ of the REA* ¼ of the REA* Calories (minimums for school meals) Protein Grades Lunch Breakfast Calcium Preschool 517 388 Iron ⅓ of the RDA** ¼ of the RDA† K–3 633 N/A ‡ Vitamin A K–6 664 N/A ‡ Vitamin C K–12 N/A 554 4–12 785 N/A ‡ Total Fat ≤ 30% of Calories ≤ 30% of Calories 7–12 825 618 Saturated Fat < 10% of Calories < 10% of Calories Recommended but not required *REA – Recommended Energy Allowance †RDA – Recommended Dietary Allowance Cholesterol ‡N/A – Not Applicable Decrease level in meals and Sodium Source: USDA, School Nutrition Dietary Dietary fiber, Assessment Study III—Volume I: School whole grain Increase level in meals Foodservice, School Food Environment, products, fruits and Meals Offered and Served, November and vegetables 2007, p. xxxii, available at www.fns.usda.gov/ ORA/menu/Published/CNP/cnp.htm; and IOM, Nutrition Standards and Meal Require- program requirements do not specify or suggest measurable targets ments for National School Lunch and Breakfast Programs: Phase I. Proposed for these recommendations. A more detailed description of current Approach for Recommending Revisions nutrition standards for school meals is provided in Table 1. (Washington, DC: National Academies Press, 2008) p. 39. Program regulations allow schools some flexibility in achieving the nutrition standards established for school meals. Schools may choose one of four USDA-defined approaches to menu planning— Traditional Food-Based Menu Planning, Enhanced Food-Based Menu Planning, Nutrient Standard Menu Planning, or Assisted Nu- trient Standard Menu Planning—or they may identify and imple- ment a reasonable alternative. USDA has established different meal requirements for each of the menu planning approaches the agency has defined. Traditional Food-Based Menu Planning (used by approximately half of all schools),29 identifies the types and amounts of foods to be included in each meal. Enhanced Food-Based Menu Planning (used by 22 per- cent of schools) is similar to the traditional approach, but requires increased servings of fruits and vegetables. Nutrient Standard Menu Planning (used by 30 percent of schools) is more flexible in terms of the composition of the meal, but requires schools to calculate the 15 December 11, 2009 National Health Policy Forum nutritional content of meals offered to ensure compliance with nu- trition standards. (Assisted Nutrient Menu Planning has the same nutrition requirements as Nutrient Standard Menu Planning but al- lows the school food authority to receive analytic assistance from the state or an outside consultant.) Existing meal requirements distinguish between the meal that must be “offered” (that is made available to students for selection) and “served” (that is the meal that is actually provided to students). This “offer versus serve” provision was mandated by law for senior high school students in 1976 to reduce plate waste and was also offered as an option for lower grades.30 Meal requirements for lunch are sum- marized in Table 2. TABLE 2 Lunch Requirements for Alternative Menu Planning Approaches Menu Planning Traditional Food-Based Enhanced Food-Based Nutrient Standard* Approach Minimum quantities established for Minimum quantities Food items selected by menu planner specific food items established for specific to meet nutrition standards based on food items nutrient content analysis. Requirements A minimum of five food items in Increased quantities Meal must contain: for Meals specific quantities must be offered: of vegetable, fruit, or —Fluid milk Offered — ­ One serving of fluid milk grain (in a variety of fat-content levels) (in a variety of fat-content levels) —Entrée —One serving of meat or meat —Side dish alternative —Two servings of vegetable or fruit —One serving of bread or grain Requirements High school students must select at Same as traditional If three items are offered, students for Meals Served least three of the five items offered may decline one (Required for high Option for lower grades: schools may If four or more items are offered, school students; require students to select at least students may decline two Option for lower three or four of the five items Students must always take the entrée grades) * Includes Assisted Nutrient Standard Menu Planning Source: IOM, Nutrition Standards and Meal Requirements for National School Lunch and Breakfast Programs: Phase I. Proposed Approach for Recommending Revisions (Washington, DC: National Academies Press, 2008) p. 39. 16 Bac kg ro u n d www.nhpf.org P a p e r No. 72 Although states and school districts may impose additional nutri- tional requirements on school meals beyond those mandated by USDA, relatively few have done so. Many states have laws and regu- lations that govern the operation of school meal programs or place limits on competitive foods. However, these rules typically do not dictate the nutritional content of reimbursable school meals beyond reinforcing compliance with federal standards. Only a few states have established requirements for school meals that exceed those set by USDA. For example, North Carolina prohibits schools from us- ing cooking oils that contain trans fat; Rhode Island requires that all milk sold in schools be 1 percent fat or less; and West Virginia bans the use of trans fat in school meals and limits the sugar content of cereal products offered in school breakfasts.31 The number of schools or districts that have established school meal standards more rigorous than federal requirements is difficult to as- certain, but such standards do not appear to be widely prevalent at the local level. USDA has recognized nearly 600 schools in about 80 districts that have implemented voluntary nutrition standards for school meals which are more stringent than existing program requirements. These voluntary standards surpass federal rules in that they guarantee more offerings of fruits, vegetables, and whole grains and limit milk selections to 1 percent or nonfat options. These schools have been recognized as high performers by USDA through the HealthierUS School Challenge (see text box, next page). C o m p lia n ce w i th E x i s tin g F e d e ral N u tri tio n St a n d a rd s While some high-performing schools have surpassed program re- quirements, most school meals available in districts across the coun- try do not fully comply with USDA nutrition standards and the 1995 Dietary Guidelines. A national evaluation of school meals offered and served during the latter half of the 2004–2005 school year found that most schools comply with the current federal standards related to caloric minimums, protein, vitamin A, vitamin C, calcium, and iron. However, few met the mandated limits for fat and saturated fat, and none met the recommended (but not required) guidelines for sodi- um.32 Breakfasts were more likely to meet limits for fat and sodium, but less than one-third of schools offered or served breakfast that met the calorie minimum. 17 December 11, 2009 National Health Policy Forum For lunches, both offered and served, calorie and nutrient content tend to increase with grade level. Notable exceptions to this rule include higher average levels of vitamin A and calcium in the lunches served to elementary school children, presumably because younger students are more likely to select milk than older students. Also, while the lunches served in high schools and middle schools contained more Team N u tritio n an d th e H ealthie rU S S cho ol s Challe n g e : Volunt ar y Ef fo r t s to I m p rove S cho ol M eal s USDA has pursued a variety of voluntary activities to im- Team Nutrition and receive resource kits to guide their prove the quality of meals offered and served in schools. nutrition education efforts. A key contributor to these efforts is Team Nutrition which Despite these efforts to disseminate resources and ma- was launched in 1995 prior to the implementation of re- terials, implementation of Team Nutrition does not ap- vised nutrition standards and meal requirements under pear widespread. Nearly all schools provide some type the School Meal Initiative (SMI.) Team Nutrition provides of nutrition education to students, although nutrition training and technical assistance to school nutrition, food education is not required under the school meals pro- service, and teaching staff; supplies model curricula and grams. However, less than 6 percent of schools report us- materials for student nutrition education; and assists in ing Team Nutrition as a source for that education. More the development of school policies and community envi- schools (nearly 25 percent of all schools) use Team Nutri- ronments that support healthy eating and active living. tion resources for meal planning.* A rigorous evaluation of the pilot found that a comprehen- Schools that participate in Team Nutrition are also eligible sive program containing all the above elements positively for recognition under the HealthierUS School Challenge, influenced children’s nutritional knowledge and motiva- which acknowledges schools that demonstrate superior tion to eat a healthy diet. Team Nutrition also had a posi- performance in creating healthier school environments tive, yet small, effect on actual food choices, with educa- by awarding four levels of certification (Bronze, Silver, tional efforts leading to an increase in the diversity of foods Gold, and Gold with Distinction). Criteria vary by award selected and tasted. Increased selection and consumption level, but all certified schools must achieve certain levels of fruits, vegetables, and low-fat milk by students were of average daily school meal program participation and also observed in pilot sites, but these changes were not meet school meal standards that are more rigorous than statistically significant. Participating staff and adminis- mandated program requirements. Enhanced standards trators were generally very supportive of Team Nutrition relate to availability of fruits, vegetables, whole grains, activities, but noted that the comprehensive intervention and low-fat milk in reimbursable meals; competitive food requires a significant commitment of staff time and energy. policies; nutrition education; and opportunities for physi- Each year USDA spends approximately $10 million in cal education and physical activity. Nearly 600 schools na- support of Team Nutrition implementation. Approxi- tionwide have achieved some level of certification. mately half of these annual expenditures support state agencies in their efforts to implement Team Nutrition, * USDA, School Nutrition Dietary Assessment Study III—Vol- with about 20 state training grants awarded each year ume I: School Foodservice, School Food Environment, and on a competitive basis. However, any school can enroll in Meals Offered and Served, November 2007. 18 Bac kg ro u n d www.nhpf.org P a p e r No. 72 calories relative to those served in elementary schools, high school lunches were less likely to comply with calorie minimums for that age-grade group. Older students have more freedom to refuse com- ponents of the school lunch and have greater access to competitive food and beverages to supplement the reimbursable meal.33 The menu planning approach used by schools does not appear to have a significant influence on compliance with program require- ments, but does influence available food options somewhat. Lunch- es planned with the Nutrient Standard approach were more likely to offer deep yellow or dark green vegetables and less likely to of- fer deep-fried potatoes (which qualify as a vegetable choice) than lunches planned with the Traditional Food-Based method. However, schools using the Nutrient Standard approach were also more like- ly than those using one of the Food-Based systems to offer dessert, snacks, or juice as part of the school lunch.34 R a i si n g t he Ba r f o r t he N u t ri t i o n a l Qua l i t y o f Sc h o o l M e a ls Some parents and nutrition experts have questioned the extent to which existing nutrition standards and meal requirements suffi- ciently ensure healthy school breakfasts and lunches, even when fully implemented. While school meals are widely viewed as more nutritious than competitive food offerings, concerns about the nu- tritional quality of school meals are frequently raised. Critiques of- ten focus on inadequate offerings of fresh produce and low-fat dairy options, as well as an over-reliance on highly processed foods with added sugar and salt. Starchy vegetables (such as potatoes and corn) and canned fruits are the most common form of produce available in school lunches. Fresh fruits, non-starchy vegetables, and nonfat milk are often not available on a daily basis. French fries are more likely to be available (offered on 29 percent of school menus) than carrots (offered on 20 percent of school menus).35 N u tri tio nal St a tu s of Pa r ti cip a tin g Stu d e n t s In some respects the dietary intake patterns of school meal partici- pants appear better than those of non-participants. Studies have demonstrated that program participants are more likely to consume milk, fruit, and vegetables at lunch than non-participants. However, 19 December 11, 2009 National Health Policy Forum much of the difference in vegetable consumption is due to increased consumption of French fries and other potato-based products. Pro- gram participation has also been linked to increased intake of vita- mins, calcium, fiber, and (less desirably) sodium. Although there is little evidence that participation in the school meal programs contributes to obesity, USDA has not ruled out an association.36 The most inclusive study of food intake found no dif- ference in calorie consumption, at lunch or over a 24-hour period, between lunch program participants and non-participants. Several studies have shown that program participants are more likely to be overweight than non-participants, but these studies generally did not control for other differences between these populations, such as income levels. Only two studies have fully controlled for such dif- ferences between participant and nonparticipant populations, and these studies yielded conflicting results. One of these studies did find a link between school meal partici- pation and obesity for children ineligible for free or reduced-price meals.37 The study analyzed longitudinal data which followed a co- hort of children beginning in kindergarten and found that at the end of first grade program participants were both more likely to ex- perience an increase in BMI and more likely to be overweight than nonparticipants. This study did not document food intake differ- ences, and other studies have been unable to demonstrate significant differences in calorie consumption between participants and non- participants. However, one theory is that small differences in daily calorie intake (which are difficult to document through food intake studies) aggregate over time, leading to weight gain. The researcher who conducted the analysis estimated that the difference in BMI observed between participants and nonparticipants could be attrib- uted to a daily energy imbalance of as little as 40 calories. USDA views these findings as significant enough to raise concern and has called for additional research to examine the relationship between school meals and childhood obesity. Concerns have been raised that large studies which report the average experience of participants versus nonparticipants may mask important variations in student intake patterns and food service practices. For example, there is some evidence that the quality of school meals offered may influence student obesity. One study found that elementary school children attending schools where French fries were available more than once per week were more likely to be obese than children who 20 Bac kg ro u n d www.nhpf.org P a p e r No. 72 attended schools where French fries were available less frequently. It is unclear if such differences in school menus truly contribute to obesity or if they simply reflect broader variations in community di- etary norms and food environments. C all fo r Rev i s e d N u tri tio n St a n d a rd s While there is no evidence that school meal programs are driving childhood obesity, policymakers have sought to make the programs more effective in responding to the epidemic. Due in part to con- cerns about rising rates of obesity among children, in 2004 Congress mandated USDA to update program nutrition standards and meal requirements to reflect the most recent Dietary Guidelines. The most current version of the Dietary Guidelines was released in 2005, and they differ from the 1995 recommendations (which dictate existing school meal program requirements) in a number of important ways. Current recommendations: • Explicitly cite the need to balance energy consumed against ener- gy expended and establish a small “discretionary” calorie allotment for food and beverages with little nutritional value • Establish limits for trans fats, cholesterol, added sugars, and salt • Increase the emphasis on fruit, vegetable, and whole grain con- sumption • Encourage nonfat or low-fat milk consumption for children • Set total fat consumption target for children at 25 to 35 percent of total calories • Express reference values for nutrients in Dietary Reference In- takes (DRIs) rather than Recommended Daily Allowances (RDAs) USDA has yet to promulgate formal rules to integrate the updated Dietary Guidelines into mandated38 nutrition standards and meal re- quirements. In 2007 USDA issued general guidance for school meals to increase fruit, vegetable, whole grain, and fiber consumption; en- courage low-fat or nonfat milk selections; and decrease sodium, cho- lesterol, and trans fat intake. However, the Department deferred for- mal rule-making and commissioned an Institute of Medicine (IOM) study to advise on changes needed to bring nutrition standards and meal requirements in accordance with the current Dietary Guidelines. 21 December 11, 2009 National Health Policy Forum USDA commissioned the IOM’s Committee on Nutrition Standards for National School Lunch and Breakfast Programs (the Committee) to consider a variety of possible modifications to existing require- ments to school meals. Requests to the expert panel included: • Recommendations on appropriate calorie requirements for di- verse age-grade groupings (both changes to existing calorie mini- mums and possibly the creation of calorie maximums not currently required) • Clear specifications for the sodium, cholesterol, and fiber content of school meals • Advice on how best to increase fruit, vegetable, and whole grain consumption under the existing menu planning options, as well as consideration of the need for novel approaches to menu planning USDA recognized that developing these recommendations would involve a number of difficult and complex decisions. The Depart- ment urged the Committee to consider variability in student nutri- ent and calorie needs, particularly with regard to low-income, food- insecure students, as well as variability in the quality and amount of foods consumed outside of school meals. USDA also cited the impor- tance of creating feasible program standards and explicitly asked the Committee to factor potential barriers to implementation into their decision-making processes. The Committee released its final report in October 2009 and pro- posed substantial changes to the way USDA regulates the nutrition- al quality of school meals.39 Recommendations suggested that USDA should: • Rely on evidence-based Nutrient Targets to guide the formulation of meal requirements, without using the target specified for each vi- tamin and nutrient level as a compliance standard • Adopt a single approach to meal planning based on foods with quantitative specifications for calories (minimum and maximum), saturated fat (maximum), and sodium (maximum) (summarized in Table 3, next page) • Establish meal requirements using both Standards for Menu Plan- ning and Standards for Meals Selected by Students • Conduct a broad range of technical assistance and evaluative ac- tivities to support and monitor the implementation of proposed pro- gram changes 22 Bac kg ro u n d www.nhpf.org P a p e r No. 72 Table 3 Recommended Quantitative Specifications for School Meal Standards (as offered) S ta n da r d f o r M e a l Nutrient Lunch Breakfast Calories (minimum–maximum kcal) K–5 550–650 350–500 6–8 600–700 400–550 9–12 750–850 450–600 Saturated Fat (% of total calories) All Grades < 10% < 10% Sodium (mg) K–5 ≤ 640 ≤ 430 6–8 ≤ 710 ≤ 470 9–12 ≤ 740 ≤ 500 Source: Institute of Medicine, School Meals: Building Blocks for Healthy Children (Washington, DC: The National Academies Press, 2009), p. S-9. The meal requirements recommended by the IOM Committee differ from current program requirements in a number of ways, including: Calories — Specifications for the maximum calories in school meals are only slightly higher than current minimums. The Committee recognized that some children with limited access to food or rela- tively high calorie needs might benefit from additional calories in school meals. However, the Committee concluded that alternative mechanisms exist for ensuring that children’s daily food needs are met and did not feel that higher calorie maximums in school meals were warranted. Fruits and vegetables — The proposed requirements double the amount of fruit and vegetables to be included in school meals, set separate requirements for fruits and vegetables (which are treated interchangeably under current rules), limit juice to no more than half of the required fruit offerings, specify the types of vegetables that must be offered, and limit starchy vegetables to once per week. Over a five-day period, vegetables offered at lunch must include at least one-half cup equivalent of each of the following: dark green veg- etables, bright orange vegetables, and legumes. 23 December 11, 2009 National Health Policy Forum Grains — The amount of grains in school meals do not change signifi- cantly under the IOM Committee’s proposal, but the recommended meal requirements specify that at least half of the bread/grain of- ferings must be “whole grain–rich.” The Committee established cri- teria for identifying whole grain–rich foods, requiring at least half the total grain content be whole grain. Current requirements only encourage whole grains, without setting specific requirements for whole grain offerings. Milk — The proposed requirements do not change the amount of milk offered in school meals, but limit offerings to fat-free (plain or flavored) or plain low-fat (1 percent milk fat or less). Trans fats — The Committee recommends that trans fats be eliminated from school meals. For food items purchased commercially, the food labeling or manufacturer’s specification must indicate that the prod- uct contains zero grams of trans fat per serving. Sodium — The Committee recommends that sodium levels be re- duced gradually, with specified targets reached by the year 2020. Current requirements recommend that sodium levels be decreased but do not specify target levels. Selection of foods by students — Two options for standards for meals as selected by students were proposed for USDA consideration. The Committee’s preferred option would allow two items to be declined at lunch, but requires students to select at least one fruit or vegetable. The alternative option would allow for an additional item to be declined. Ba r rie r s to H eal thie r S ch o o l M eal s The Committee recognized that schools would likely face challenges in implementing the recommended meal requirements. An interim report explored numerous factors that have hindered past efforts to improve school meals, many of which had been previously identi- fied by USDA as important concerns. Key considerations include the cost implications of more rigorous nutrition standards and the foods available through commodities, as well as other practical realities that confront school food service operators. Healthy school meals can be more costly to produce than less healthy alternatives. Fresh fruit, vegetables, and meats are often more ex- pensive than processed food options due to differences in purchase 24 Bac kg ro u n d www.nhpf.org P a p e r No. 72 price, as well as food inventory management and preparation costs. Canned foods, frozen products, and dry mixes keep for longer time periods, reduce spoilage waste, and require less storage space. Some schools also find it more economical to purchase fully or semi- prepared foods from commercial food vendors rather than incur the labor and benefit costs that would be required to prepare fresh foods on-site. While some healthy options may be available from commercial vendors, in general processed foods tend to have higher fat, salt, and sugar content than recipes prepared from minimally processed ingredients. Historically some food service managers have expressed concerns that the USDA food items constrained their ability to improve the nutritional quality of school meals. The types of commodities available to schools have changed significantly over the years and school meal I m p rove m e nt s in U S DA Fo o d s programs can now choose Availability of fruits and vegetables through the USDA commodities programs from over 180 different (sometimes called USDA foods) has increased significantly. Between fiscal types of food items. USDA years 1995 and 2008, the value of fruits and vegetables made available to child has invested significant nutrition programs through the commodities programs nearly doubled, rising resources into improving from $135 million to $236 million. Fruits and vegetables now represent roughly the commodities programs one-quarter of the total value of commodities used in schools. About 20 percent (see text box for additional of all commodity fruits and vegetables used in schools are acquired through details). Despite these im- the U.S. Department of Defense’s Fresh Fruit and Vegetable Program. This pro- provements, advocates call gram utilizes the military’s extensive food purchasing and distribution system for additional changes to to provide a wider range of fresh produce than would normally be available ensure that commodities through the USDA’s traditional commodity purchases. A related effort, the fully contribute to healthier Farm to School Initiative, encourages small farmers to sell fresh fruits and veg- school meals. etables to schools and help schools establish the structures needed to promote these purchasing relationships. A major concern focuses USDA has made other efforts to improve the quality of commodities provided on the 50 percent of USDA to schools. For example: foods that are diverted to • Canned fruits can be packed only in light syrup, water, or natural juice commercial food proces- • Tropical oils (most of which contain trans fat) have been eliminated from sers who convert the raw commodity products bulk foods into ready-to-use • The allowable fat content of commodity meats, cheeses, bakery product products for school districts. mixes, and processed potatoes has been lowered For example, school dis- • Sodium levels in all canned vegetables have been lowered tricts may choose to further Future plans include continuing to bring commodities into alignment with the process poultry provided 2005 Dietary Guidelines and increasing whole grain offerings. through the commodity 25 December 11, 2009 National Health Policy Forum program into nuggets or sandwich patties. Although such diversion offers convenience to schools and reduces their labor costs, commer- cial processing can be a significant source of added salt and sugar. A broad range of other pragmatic concerns are perceived to hinder improvements in the nutritional quality of school meals. The lack of appropriate training for food service staff, inadequate equipment and facilities, skepticism regarding student receptivity to healthier meals, and limitations in existing food labeling requirements40 have all been cited as problems that must be addressed. The importance and extent of these issues is likely to vary by school district, depending on the organization and structure of their food service operations. The IOM Committee recognized that implementation of its recom- mendations for improving the nutritional quality of school meals would raise costs. Cost estimates suggest that the new meal require- ments will increase the food-related costs of school meals by 20 to 25 percent for breakfast and 4 to 9 percent for lunch, largely due to increases in fruit, vegetable, and whole grain offerings. The Commit- tee also acknowledged that the proposed meal requirements have the potential to increase labor and facility costs, in addition to food costs. However, the Committee did not feel that enough information was available to accurately estimate the magnitude of these impacts. The Committee concluded that most school food authorities would not be able to absorb the increases in food costs likely to result from the proposed meal requirements and recommended higher feder- al rates for meal reimbursement, along with capital investment in equipment and facilities, and resources to train school food service operators. Specific recommendations regarding the level of increase needed for reimbursement rates or the amount of infrastructure and training support were not provided. Co n c lu s i o n Much of the legislative policy debate surrounding school-based nu- trition is now focused on the “competitive” foods and beverages sold alongside reimbursable school meals, but Congress is also concerned with the quality and accessibility of the school meal programs. While USDA prepares for future regulatory changes regarding school meal nutrition standards, some advocates believe that statutory changes may also be necessary to expedite improvements. Proposals have 26 Bac kg ro u n d www.nhpf.org P a p e r No. 72 been made for legislative intervention to ensure more timely up- dates of nutrition standards on the basis of the evolving scientific evidence. Some have suggested statutory language that would estab- lish mandatory timelines for regulatory changes based on release of current, and future, Dietary Guidelines. Others have proposed that additional nutritional standards be in- cluded in legislative text. Congress has generally delegated author- ity over the nutritional content of school meals to USDA, but some aspects of meal composition are now defined by legislation. For ex- ample, legislation explicitly requires participating schools to offer fluid milk in a variety of fat contents. Some advocates would like to see broad directives for other nutritional improvements proscribed in statute. Arguments against legislative proscriptions focus on con- cerns regarding the timeliness of future changes, as well as the pos- sibility that political influence could encourage a departure from evidence-based standards. Similar to the debate regarding competitive foods, legislative and reg- ulatory efforts to improve the nutritional quality of school meals will be considered in light of the effect these improvements could have on childhood obesity, as well as the likely fiscal impact of changes. Any policy to significantly enhance nutrition standards for school meals will undoubtedly raise questions about the adequacy of federal fund- ing for the school meal programs. The perceived adequacy of federal financial support will be informed by a variety of factors, including the proportion of children eligible for free or reduced-price meals, meal reimbursement rates, the value and utility of donated com- modities, program costs, and the availability of alternative revenue sources. Policy changes in these areas may be needed to complement enhanced nutrition standards for school meals. En dn ot es 1. Institute of Medicine (IOM), Nutrition Standards and Meal Requirements for Na- tional School Lunch and Breakfast Programs: Phase I. Proposed Approach for Recommend- ing Revisions (Washington, DC: The National Academies Press, 2008) pp. 67–72. 2. IOM, Committee on Prevention of Obesity in Children and Youth, Preventing childhood obesity: Health in the balance, Jeffrey P. Koplan, Catharyn T. Liverman, Vivi- ca I. Kraak, Eds. (Washington, DC: The National Academies Press, 2005) pp. 66–73. 3. Action for Healthy Kids, “The Learning Connection: The Value of Improving Nutrition and Physical Activity in Our Schools,” October 2004, p. 15; available at www.actionforhealthykids.org/resources/files/learning-connection.pdf. 27 December 11, 2009 National Health Policy Forum 4. Centers for Disease Control and Prevention (CDC), “Guidelines for School Health Programs to Promote Lifelong Healthy Eating,” Morbidity and Mortality Weekly Report, 45, No. RR-9 (June 14, 1996): p. 4. 5. CDC, “Guidelines for School Health Programs to Promote Lifelong Healthy Eating,” pp. 3–4. 6. P. Casey et al, “The Association of Child and Household Food Insecurity With Childhood Overweight Status,” Pediatrics, 118 (2006): pp. e1406–e1413; available with subscription at http://pediatrics.aappublications.org/cgi/content/abstract/118/5/e1406. 7. Food Research and Action Center, Obesity, Food Insecurity, and the Federal Child Nutrition Programs: Understanding the Linkages, October 2005, p. 12; available at www.frac.org/pdf/obesity05_paper.pdf. 8. A companion Issue Brief by the National Health Policy Forum, “Got Junk? The Federal Role in Regulating ‘Competitive’ Foods” (Issue Brief No. 835, December 11), explores proposals to increase federal regulation of competitive foods. 9. P.L. 79-396, National School Lunch Act, Stat. 281 (June 4, 1946). 10. In addition to nutrition standards, USDA has established other requirements related to the operation of school meal programs. For example, all participating school food authorities must operate on a nonprofit basis and comply with food safety rules. 11. IOM, Nutrition Standards and Meal Requirements, p. 16. 12. U.S. Department of Agriculture (USDA), Effects of Food Assistance and Nutrition Programs on Nutrition and Health, ch. 5, February 2002, p. 175; available at www.ers.usda.gov/publications/FANRR19-1. 13. USDA, School Nutrition Dietary Assessment Study III—Volume II: Student Partici- pation and Dietary Intake, November 2007, p. 37; available at www.fns.usda.gov/ORA/ menu/Published/CNP/cnp.htm. 14. USDA, School Nutrition Dietary Assessment Study III—Volume II, pp. 157 and 232. 15. USDA, “National School Lunch Program: Participation and Lunches Served,” USDA Web site, updated December 3, 2009; available at www.fns.usda.gov/pd/ slsummar.htm. 16. USDA, “The National School Lunch Program: Background, Trends, and Is- sues”, ERR-61, Economic Research Service/USDA, July 2008, p. 3; available at www.ers.usda.gov/publications/err61. 17. One analysis suggests that 85 percent of all eligible children are certified for free or reduced-price meals based on certification records in the 1998–1999 school year and the Census Bureau’s Survey of Income and Program Participation in Au- gust and September 1998. Zoё Neuberger and Robert Greenstein, “New Analysis Shows ‘Overcertification’ for Free or Reduced-Price School Meals Has Been Over- stated,” Center on Budget and Policy Priorities, July 15, 2003; available at www.cbpp.org/archiveSite/7-15-03wic.pdf. 28 Bac kg ro u n d www.nhpf.org P a p e r No. 72 18. U.S. Government Accountability Office, “School Meal Programs: Experiences of the States and Districts That Eliminated Reduced-price Fees,” GAO-09-584, July 2009; available at www.gao.gov/new.items/d09584.pdf. 19. Quinn Moore, Laura Hulsey, and Michael Ponza, ”Factors Associated With School Meal Participation and the Relationship Between Different Participation Measures,” Mathematica Policy Research, Inc., Contractor and Cooperator Report No. 53, June 2009, p. 57; available at www.ers.usda.gov/Publications/CCR53/CCR53.pdf. 20. USDA, “Federal Cost of School Food Programs,” USDA Web site, updated De- cember 3, 2009; available at www.fns.usda.gov/pd/cncosts.htm. 21. USDA, “National School Lunch Program: Participation and Lunches Served.” 22. USDA, “National School Lunch Program: Participation and Lunches Served.” 23. USDA, Food and Nutrition Service, School Lunch and Breakfast Cost Study-II, Fi- nal Report, CN-08-MCII, April 2008, p. xii; available at www.fns.usda.gov/ORA/menu/ Published/CNP/FILES/MealCostStudy.pdf. 24. USDA, “USDA Foods in the National School Lunch Program,” updated March 2009, p. 3; available at www.fns.usda.gov/fdd/foods/healthy/WhitePaper.pdf. 25. Federal Register, vol. 73, no. 130, July 7, 2008, Notices 38391. 26. USDA, “Federal Cost of School Food Programs.” 27. USDA, School Lunch and Breakfast Cost Study-II, Final Report, p. vii. 28. School Nutrition Association, “Heats On: School Meals Under Financial Pressure,” September 2008, p. 2; available at www.schoolnutrition.org/uploadedFiles/ School_Nutrition/101_News/MediaCenter/PressReleases/Press_Release_Articles/Press_Releases/ HeatsOn(1).pdf. 29. USDA, School Nutrition Dietary Assessment Study III—Volume I: School Foodser- vice, School Food Environment, and Meals Offered and Served, November 2007, p. xxvii; available at ; available at www.fns.usda.gov/ORA/menu/Published/CNP/cnp.htm. 30. Ninety-three percent of middle schools and 78 percent of elementary schools elected the offer versus serve option for the 2004–2005 school year. USDA, School Nutrition Dietary Assessment Study III—Volume I, p. xxviii. 31. School Nutrition Association, “Summary of State Nutrition Standards,” January 14, 2008; available at www.asfsa.org/uploadedFiles/School_Nutrition/16_LegislativeAction/ Summary_of_State_Nutrition_Standards_April_2008.pdf. 32. USDA, School Nutrition Dietary Assessment Study III—Volume I, p. xxviii. Pro- gram nutrition requirements do not set a firm target for sodium content, assess- ment based on benchmarks included in the 1995 Dietary Guidelines. 33. USDA, School Nutrition Dietary Assessment Study III—Volume I, p. 168. 34. USDA, School Nutrition Dietary Assessment Study III—Volume I, p. 142. 29 December 11, 2009 National Health Policy Forum 35. USDA, School Nutrition Dietary Assessment Study III—Volume I, p. 136 36. USDA, “The National School Lunch Program: Background, Trends, and Is- sues,” pp. 23–24. 37. Diane Whitmore Schanzenbach, “Do School Meals Contribute to Childhood Obesity?” Harris School Working Paper, Series 05.13, University of Chicago, Har- ris School of Public Policy Studies, 2005; available at http://harrisschool.uchicago.edu/ about/publications/working-papers/pdf/wp_05_13.pdf. 38. The 2005 Dietary Guidelines are reflected in the criteria used to recognize HealthierUS Challenge Schools. 39. IOM, School Meals: Building Blocks for Healthy Children (Washington, DC: The National Academies Press, 2009). 40. For example, whole grains are not addressed in existing food labeling regula- tions enacted by the U.S. Food and Drug Administration. Because the whole grain content of foods cannot be readily determined through the label, it may be diffi- cult for establish a measurable standard for whole grain inclusion in school meals. 30