Public Policy to Improve Child Nutrition and Health - Children's ...

Public Policy to Improve Child Nutrition and HealthChallenges and OpportunitiesBarbara A. Dennison, MDArch Pediatr Adolesc Med. 2012;166(5):485-487. doi:10.1001/archpediatrics.2012.196You are what you eat. An old adage that recognizes the critical role that diet has on health. With the goal ofimproving the nutrition and health of targeted populations, federal, state, and local governments havedeveloped and implemented public health policies and programs to prevent nutritional deficiencies byproviding nutritious foods, fortifying foods or beverages, and, more recently, limiting the calorie, fat, or sugarcontent of high-calorie, low-nutrient foods. Two articles 1-2 in this issue of the Archives contribute to thegrowing evidence base that public health nutrition policies can favorably impact children's diets and theirhealth.The obesity epidemic, one of the most important public health crises in the United States, is much more thana nutritional problem, but poor nutrition contributes to its development and improved dietary intakes andeating behaviors, to its prevention and treatment. While individual knowledge, skills, motivation, andsocioeconomic factors play a role, consensus is building that the food and physical activity environmentssignificantly contribute to the obesity epidemic. 3 As the prevalence of obesity and obesity-related diseases,such as type 2 diabetes mellitus, have increasingly affected children and adolescents, calls for policy, system,and environmental approaches to improve school foods by mandating nutritional standards for foods availablein school settings have become louder, more salient, and accepted. 4-5Schools are politically complicated institutions. While the US Department of Agriculture (USDA)–reimbursableschool lunch and breakfast are required to meet certain nutrition standards, other foods, without suchstandards, can be sold by the school food service in competition with school lunch and breakfast. The profit ormarkup on these competitive foods is usually substantively higher and often helps to subsidize school lunchand/or the food service program. Profits from vending machines or school stores frequently support sportsteams or other school activities. Changes can be resisted because of the potential or feared funding loss.Legislation to implement stricter nutritional standards for school lunch and breakfast and/or competitive foodshas been led by the states. 6California was an early regulator of competitive foods, limiting the amounts of total fat, saturated fat, sugar,and total calories per item. In this issue of theArchives, Taber and colleagues 1 report that, followingimplementation of the competitive food legislation in California, high school students consumed significantlyfewer calories and less sugar and fat at school than students in 14 other states with no competitive foodstandards. Previous studies found that, following the California competitive food legislation, the availability ofsodas and other sweetened beverages, regular chips, and candy was reduced, and the availability of healthierfoods was increased. 7 The Taber et al study, however, is the first to assess students' dietary intakes at schooland over the entire day. 1 The students in California consumed significantly fewer calories (156.5 calories) atschool compared with students in other states. The reduction in calories consumed over the entire day by theCalifornia students compared with the students in other states, while nearly identical (153.3 fewer calories),was of borderline statistical significance. The California students, compared with students in other states, alsotended to consume less total sugars, added sugars, and total fat during the entire day. 1California has also implemented nutritional standards for school meals that are stricter than the USDA federalguidelines. There is no mention whether any of the 14 comparison states have implemented stricter standardsfor school meals, but a report contemporaneous to the study's time frame 6 finds that only 2 of the 23 states

with no standards for competitive foods had standards for school meals stricter than the USDA requirements.Thus, the differences in the school dietary intakes between the California students and the students in thecomparison states reflect the impact of both school meals and competitive foods standards. It is also likelythat states that have passed legislation to require healthier foods may also be more supportive of othernutrition policies and have different levels of concern about child obesity and in the roles of schools andgovernment in addressing the school food environment.This study supports and contributes to the emerging public health evidence base that students' dietaryintakes will improve if less healthful foods and beverages are not permitted in schools. More studies such asthis are needed to understand the myriad of existing state competitive food legislation already implementedto help inform the federal competitive food legislation currently in development. These studies need tomeasure change in students' dietary intakes but also changes in nutritional quality, weight status, growth,and health measures. Public health evaluations such as this are hard to do, as reflected in the relatively lowparticipation rate of 24.7%.Of greater concern, however, are the students' low reported caloric intakes. The students' average caloricintakes at school (353 calories in California and 509 calories in the comparison states) are much lower than anational study of school lunch (733 calories for high school national school lunch participants and 661 caloriesfor nonparticipants). 8 The average daily caloric intakes (1639 calories/d in California and 1792 calories/d inthe comparison states) are also much lower than a national study (National Health and Nutrition ExaminationSurvey 1999-2000: average daily intake was 2700 calories/d for males aged 12-19 years and 2000 calories/dfor females aged 12-19 years). 9 These low reported intakes most likely represent underreporting; whether theunderreporting differs between California and the other states is not known. Nonetheless, if the 150-kcal/ddifference between students in California and other states is "real" and not compensated on nonschool days,the accumulated deficit over the typical 180-day school year would translate to a difference of about 7.7pounds/y. Anthropometric measures were not part of this study but in the future need to be included, asreducing excess weight gain and obesity are primary targets of school policy and environmental changes.With passage of the federal Healthy, Hunger-Free Kids Act of 2010, schools are required to adhere to newstandards to improve the quality of school meals, and schools that comply will be eligible for increased federalreimbursements for school meal programs. 10 Beginning with the 2012-2013 school year, the USDAreimbursableschool lunch will need to include more fruits and vegetables, whole grains, and reduced-fat milk.In addition to standards for school meals, the USDA is required to establish nutritional standards for all otherfoods and beverages (ie, competitive foods) served or sold in schools at any time during the day throughoutthe school campus, including vending machines, school stores, and à la carte in the cafeteria. An expertcommittee has recommended that if competitive foods are available in schools, they should be limited tofoods that youth need to consume more, ie, fruits, vegetables, whole grains, and nonfat or low-fat milk anddairy products. 4 However, as was demonstrated in developing the new nutritional standards for school lunchand breakfast, the interests of industry and advocates can influence the interpretation of science, translationinto specific rules, and implementation time frames.As pointed out by Robinson, 11 we need to build the evidence about what policy changes will work under whatcircumstances and in which types of schools or populations. As exciting as the thought of randomizing states,cities, or school districts in a policy change trial, it is incredibly unlikely that states, cities, or school districtswould ever agree to be randomized to test the implementation and impact of a new policy. Perhaps funding orthe provision of training and technical assistance could be randomized or staggered. A robust, comprehensiveevaluation plan needs to be in place to document the implementation and fidelity and to measure the processand outcome changes. Nonetheless, we are at the cusp of widespread implementation of major nutritionpolicies. As these policy changes are implemented in schools, it is essential to have a better understanding ofwhat policies are currently in place in different schools and states; what are students' current diets andweight status; what policy changes are being implemented; what is the effect on the school food environmentand students' dietary intakes in school, outside of school, and over a longer period; and what is the impact on

children's nutrition, growth, weight status, and health.A separate study 2 in the Archives reports additional benefits among those participating in the federally fundedpublic health nutrition program the Special Supplemental Nutrition Program for Women, Infants, and Children(WIC). Among 26 950 low-income primary caretakers of young children (

implementation and guide further recommendations. Our children deserve nothing less.AUTHOR INFORMATIONCorrespondence: Dr Dennison, Health Policy and Research Translation Unit, Division of Chronic DiseasePrevention, New York State Department of Health, Corning Tower, Ste 515, Empire State Plaza, Albany, NY12237 (bad10@health.state.ny.us).Financial Disclosure: None reported.Author Affiliations: Department of Epidemiology and Statistics, School of Public Health, University atAlbany, State University of New York, and Health Policy and Research Translation Unit, Division of ChronicDisease Prevention, New York State Department of Health, Albany.REFERENCES1. Taber DR, Chriqui JF, Chaloupka FJ. Differences in nutrient intake associated with state laws regarding fat,sugar, and caloric content of competitive foods. Arch Pediatr Adolesc Med.2012;166(5):452-458. FREE FULL TEXT2. Black MM, Quigg AM, Cook J; et al. WIC participation and attenuation of stress-related child health risks ofhousehold food insecurity and caregiver depressive symptoms. Arch Pediatr Adolesc Med. 2012;166(5):444-451. FREE FULL TEXT3. Story M, Kaphingst KM, Robinson-O’Brien R, Glanz K. Creating healthy food and eating environments:policy and environmental approaches. Annu Rev Public Health. 2008;29:253-272.FULL TEXT | WEB OFSCIENCE | PUBMED4. Stallings VA, ed, Yaktine AL, ed. Institute of Medicine. Nutrition Standards for Foods in Schools: Leadingthe Way Toward Healthier Youth. Washington, DC: The National Academies Press; 2007.5. Mello MM, Studdert DM, Brennan TA. Obesity: the new frontier of public health law. N Engl JMed. 2006;354(24):2601-2610. FULL TEXT | WEB OF SCIENCE | PUBMED

6. Levi J, Vinter S, Richardson L; et al. F as in fat: how obesity threatens America's future2009. http://healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf. Accessed February 10, 2012.7. Woodward-Lopez G, Gosliner W, Samuels SE, Craypo L, Kao J, Crawford PB. Lessons learned fromevaluations of California's statewide school nutrition standards. Am J Public Health.2010;100(11):2137-2145. FULL TEXT | PUBMED8. Gordon A, Fox MK, Clark M; et al. School Nutrition Dietary Assessment Study III. Volume II: StudentParticipation and Dietary Intakes. Alexandria, VA: USDA, Food and Nutrition Service;2007:154. http://www.fns.usda.gov/ora/menu/published/CNP/FILES/SNDAIII-Vol2.pdf. Accessed February10, 2012.9. Centers for Disease Control and Prevention. Intake of calories and selected nutrients for the United Statespopulation, 1999-2000.http://www.cdc.gov/nchs/data/nhanes/databriefs/calories.pdf. Accessed February 10,2012.10. Healthy, Hunger-Free Kids Act of 2010. USDAwebsite. http://www.fns.usda.gov/cnd/Governance/Legislation/CNR_2010.htm. Accessed February 10, 2012.11. Robinson TN. Solution-oriented policy research: using research to drive obesity prevention and controlpolicies. Arch Pediatr Adolesc Med. 2012;166(2):189-190. FREE FULL TEXT12. Black MM, Cutts DB, Frank DA; et al, Children's Sentinel Nutritional Assessment Program Study Group.Special Supplemental Nutrition Program for Women, Infants, and Children participation and infants' growthand health: a multisite surveillance study. Pediatrics. 2004;114(1):169-176. FREE FULL TEXT13. US Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis. National andState-Level Estimates of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)Eligibles and Program Reach, 2000–2009. Alexandria, VA: US Department of Agriculture, Food and NutritionService, Office of Research and Analysis; 2011.

Department of Agriculture, Economic Research Service; 2009. Report 73.15. Committee to Review the WIC Food Packages, Institute of Medicine. WIC Food Packages: Time for aChange. Washington, DC: The National Academies Press; 2005.16. US Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis. WICBreastfeeding Peer Counseling Study, Final Implementation Report. Alexandria, VA: US Department ofAgriculture, Food and Nutrition Service, Office of Research and Analysis; 2010. WIC-10-BPC.CiteULike Connotea Delicious Digg Facebook Reddit Technorati Twitter What's this?RELATED ARTICLESWIC Participation and Attenuation of Stress-Related Child Health Risks of Household FoodInsecurity and Caregiver Depressive SymptomsMaureen M. Black, Anna M. Quigg, John Cook, Patrick H. Casey, Diana Becker Cutts, Mariana Chilton, AlanMeyers, Stephanie Ettinger de Cuba, Timothy Heeren, Sharon Coleman, Ruth Rose-Jacobs, and Deborah A.FrankArch Pediatr Adolesc Med. 2012;166(5):444-451.ABSTRACT | FULL TEXTDifferences in Nutrient Intake Associated With State Laws Regarding Fat, Sugar, and CaloricContent of Competitive FoodsDaniel R. Taber, Jamie F. Chriqui, and Frank J. ChaloupkaArch Pediatr Adolesc Med. 2012;166(5):452-458.ABSTRACT | FULL TEXT