POLICY STATEMENT Organizational Principles to Guide and Define the Child HealthCare System and/or Improve the Health of all Children

Snacks, Sweetened Beverages,Added Sugars, and SchoolsCOUNCIL ON SCHOOL HEALTH, COMMITTEE ON NUTRITION

abstractConcern over childhood obesity has generated a decade-long reformation ofschool nutrition policies. Food is available in school in 3 venues: federallysponsored school meal programs; items sold in competition to school meals,such as a la carte, vending machines, and school stores; and foods available inmyriad informal settings, including packed meals and snacks, bake sales,

fundraisers, sports booster sales, in-class parties, or other school

celebrations. High-energy, low-nutrient beverages, in particular, contributesubstantial calories, but little nutrient content, to a student’s diet. In 2004, theAmerican Academy of Pediatrics recommended that sweetened drinks bereplaced in school by water, white and flavored milks, or 100% fruit andvegetable beverages. Since then, school nutrition has undergone a significanttransformation. Federal, state, and local regulations and policies, along withalternative products developed by industry, have helped decrease theavailability of nutrient-poor foods and beverages in school. However, regularaccess to foods of high energy and low quality remains a school issue, much ofit attributable to students, parents, and staff. Pediatricians, aligning withexperts on child nutrition, are in a position to offer a perspective promotingnutrient-rich foods within calorie guidelines to improve those foods broughtinto or sold in schools. A positive emphasis on nutritional value, variety,appropriate portion, and encouragement for a steady improvement in qualitywill be a more effective approach for improving nutrition and health thansimply advocating for the elimination of added sugars.

INTRODUCTION

The rising rate of obesity in the United States has resulted in increasedattention on nutrition and long-term health. Not only have children andadolescents become overweight from consuming excess calories relativeto activity, but their diets have also become inadequate or deficient inseveral crucial nutrients.1,2 Consistently, 30% to 40% of daily energy ofchildren and adolescents is consumed as energy-dense, nutrient-poorfoods and drinks.1,3 More than 55 million children and teenagers attendthe nation’s 105 000 schools and consume 35% to 40% of their daily

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, policy statements from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The recommendations in this statement do not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

All policy statements from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

DISCLOSURES: Dr Murray receives support from the National DairyCouncil and the American Dairy Association for serving on speakers’bureaus. Dr Bhatia receives support from the Nestle Nutrition Institutefor serving as workshop faculty and an advisor.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-3902

DOI: 10.1542/peds.2014-3902

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energy in those schools.4 The intentof the present statement is to updateprogress since the Council on SchoolHealth issued its policy statement“Soft Drinks in Schools” in 2004 andto highlight new opportunities forimproving diet quality in schools.

Foods and beverages are available tostudents in schools through 3 venues:

1. The School Breakfast, NationalSchool Lunch, and After-SchoolPrograms, sponsored by the USDepartment of Agriculture (USDA);

2. Competitive items sold outside ofthe USDA school meals; and

3. Items available from other sources(packed meals or snacks, in-classparties, rewards, sporting events,and other such occasions).

This third source of foods consumed inschool, brought in for many differentreasons by many different individuals,is unregulated. It represents anopportunity for pediatricians to joinwith parents and students, as well asother advocates for child nutrition, toraise an awareness of the importanceof nutritional choices for children andadolescents.

OPTIMAL NUTRITION FOR CHILDRENAND ADOLESCENTS

Optimal nutrition for individualsolder than 2 years is described by the2010 Dietary Guidelines forAmericans (DGAs), based on therecommendations of an independentexpert advisory committee.2,5 Thecommittee recommendedconsumption of a diverse, nutrient-dense diet based on 5 food groups:vegetables, fruits, grains and wholegrains, low-fat or no-fat milk and dairy,and quality protein sources. Theprimary directive of the DGAs was forindividuals to obtain nutrition froma variety of whole foods based ona sound dietary pattern of appropriateservings from each food group thatmeets, but not exceeds, caloric needs. Asexemplars, the 2010 DGAs referencedthe USDA Food Patterns (http://www.cnpp.usda.gov/USDAFoodPatterns.htm),

the DASH diet (Dietary Approaches toStop Hypertension; http://www.nhlbi.nih.gov/health/health-topics/topics/dash/), and the vegetarianeating pattern because of theirestablished health benefits. The DGAsidentified 4 nutrients (potassium,fiber, vitamin D, and calcium), ofwhich Americans have consistentlylow consumption, resulting in a highrisk of chronic diseases.5 The DGAAdvisory Committee, recognizing thechallenge of energy balance, proposedthat all Americans cut their intake ofsolid fats and added sugars as aneffective strategy to pare calories thatcontribute little to a nutrient-richdiet.2 The Academy of Nutrition andDietetics has long espoused theperspective that “all foods fit”; that is,a balanced, nutrient-rich dietarypattern still can accommodate all thetypes of foods, when foods withadded sugars and fats are consumedjudiciously. Discretionary calories(ie, calories remaining after fulfillingthe body’s nutrient needs from the5 food groups) may include addedsugars, which can heighten thepalatability and enjoyment of foodand play a role in food safety andquality.6,7

THE NATIONAL SCHOOL MEALPROGRAMS: STEADY IMPROVEMENT

USDA meal programs in schoolrepresent a national investment of$13.7 billion in cash reimbursementand commodity costs annually. Schoolmeal programs have a profound effecton the diet quality of the nation’schildren, in particular children at riskfor food insecurity.8–12 Participatingschools serve more than 31 millionlunches and 11 million breakfasts perday, of which approximately one-halfof the participants in the NationalSchool Lunch Program and three-quarters in the School BreakfastProgram fit the eligibility criteria forfree or reduced-price meals (fiscalyear 2010 data: http://www.fns.usda.gov/pd/sbsummar.htm and http://www.fns.usda.gov/pd/slsummar.htm). Two-thirds of children and

teenagers from female-headedhouseholds (among the highest riskfor food insecurity) benefit from freemeals (http://www.fns.usda.gov/cnd/governance/notices/iegs/iegs.htm).13 Schools saw a sharp rise inmeal program enrollment after thesevere economic downturn in 2007.Collectively, the following school-based and auxiliary programs forma nutrition safety net for children(http://www.fns.usda.gov/cnd/):

• The National School LunchProgram

• The School Breakfast Program

• After School Snacks

• The Special Milk Program

• The Fresh Fruit and VegetableProgram

• The Child and Adult Care MealProgram

• The Seamless Summer Program

Data from 3 School Nutrition DietaryAssessment (SNDA) surveys between1995 and 2009 showed rapidimprovements in nutrition quality,increasingly aligned with DGArecommendations.8,14,15 Consistently,children consuming school meals hadbetter nutrition than thoseconsuming alternative meals, withhigher intake of protein, vitamins Aand B12, riboflavin, calcium,phosphorus, potassium, and zinc.Approximately two-thirds of schoolsoffered students a choice each day forlunch of 1 of 2 or more types of fruitor 100% fruit juice, 1 of 2 or moreentrees or main courses, and 1 of 2 ormore vegetables. Most schools limitedmilk to either low-fat or nonfatmilk.8,9,16

However, the latest SNDA report(2009) noted that improvementswere needed in several areas. Forinstance, only 9 of 22 specific foodpreparation practices recommendedby nutritionists as strategies forreducing the total fat, saturated fat,sodium, and added sugar content ofschool meals had been implemented“almost always” or “always” by mostdistricts and schools.11 Only 6%

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offered lunches that met all of thestandards of the School MealsInitiative (http://www.fns.usda.gov/cnd/guidance/default.htm). Althoughapproximately 60% met the fatstandard (25%–35% of totalkilocalories), only 30% kept saturatedfat under 10% of kilocalories. Diversesources of saturated fats in schoolswere still prevalent in school meals inthe 2007 SNDA. Almost no school metthe goals for sodium; meeting thesegoals will require not only betterpreparation techniques but also manynew low-sodium products before theproposed 50% cuts in sodium can berealized over the next 10 years.8,10,11

It was revealed that raw or freshvegetables and fresh fruits wereunavailable in 42% and 50% ofschools, respectively. Because ofhigher costs, only 5% of the breads orrolls offered were whole grain.16

These findings prompted the Instituteof Medicine (IOM) to recommendincorporation of more lean meats,lower fat milks (nonfat or 1% only),fruits, vegetables, and whole grains,along with age-appropriate servingsizes.10 An IOM report, “School Meals:Building Blocks for Healthy Children,”formed the basis for new mealpatterns from the USDA, which werefinalized in January 2012. Whena series of school meal menus weretested that met IOM criteria, the datashowed that their system would meetthe Recommended Dietary Allowancefor 24 nutrients, based solely onserving frequencies of the 5 foodgroups and age-appropriate servingsizes. This finding has 3 importantimplications. One, it representsa strong confirmation of the conceptof food patterns, as espoused by the2010 DGAs. Two, it supports movingaway from using individual nutrientsas markers for nutritional sufficiencyin school meals. Three, it should serveto caution those who wish to revise orrevoke individual recommendationswithin the proposed meal patterns.Clearly, the proposed servings-basedmeal patterns can work.Discretionary calories remained

within the IOM plan, recognizing thatschool food service directors oftenuse these limited, but popular,discretionary calories to enticeparticipation in the meal program.

Higher quality school meals engendersubstantial costs. Despite anadditional $0.06 per meal allocatedby the 2010 Child NutritionReauthorization, reimbursement forfood service over the past 20 yearshas never kept pace with risingexpenses or inflation.17 The NationalSchool Boards Association cited thefact that, even by the USDA’sconservative estimates, the recentreimbursement rates (2010) willcover less than one-half the costs ofimplementing the new nutritionstandards over the next 5 years(http://www.nsba.org/Advocacy/Key-Issues/SchoolNutrition/NSBAsIssueBriefonSchoolNutrition.pdf). If the price of nonreimbursedmeals increases as a result, morechildren may bring meals from home,purchase food from other sources, orskip meals altogether, each of whichwill be detrimental to achievingbetter diet quality. Additional federaland state budget cuts in the near-term threaten many aspects of ourchild nutrition strategy, an importantpoint of advocacy for the AmericanAcademy of Pediatrics (AAP).

ITEMS SOLD IN COMPETITION TOSCHOOL MEALS: NEW NATIONALSTANDARDS

Competitive foods sold in vendingmachines and a la carte linesrepresent a far less nutritious optionthan the USDA-sponsored schoolmeals.18 Until 2010, federal lawrestricted the sale of carbonateddrinks, candies, and other “foods ofminimal nutritional value” only in thecafeteria during meal service hours,leaving many nutrient-poor productsavailable for sale with laxoversight.9,19,20 Access to “emptycalories” has been associated withhigher daily energy intake andgreater BMI and, equally important,

with displacement of more nutrient-rich alternatives.1,21–23 Competitivefoods are a double-edged sword forthe school food service. On the onehand, they subtract consumers fromthe school meals, robbing the schoolof valuable federal reimbursements.On the other hand, a la carte andvending sales are attractive tostudents and can be lucrative forschools. However, many schools thathave taken steps to improve thenutritional quality of competitivefoods have not reported subsequentlosses in total revenue, and in somecases, have even increased revenueand school meal participation,contrary to widely heldexpectations.24,25

In 2004, the AAP published a policystatement (“Soft Drinks in Schools”)in response to a growing trendtoward contracts for exclusive right ofsale between school districts andtheir beverage distributors.26 Thevoice of the AAP was just one ina chorus of concern about poornutrition and child health. TheAlliance for a Healthier Generationwas formed as a collaborative to helpaddress childhood obesity. Itpublished “School BeverageGuidelines” in 2007.27 In theseguidelines, the beverage industrycommitted to altering the availabilityand mix of beverages offered inschools. Their self-imposedregulations were not withoutskeptics.28 Of greatest concern wasthe likelihood that innovations byindustry would usher in new butsimilar alternatives. To some extent,this prediction has been borne out.Fruit drinks, sports rehydrationdrinks, energy drinks, sweetenedteas, and coffees have joined water,milks, and fruit juice as replacementsfor more traditional soft drinks.

However, substantial progress wasmade after the voluntary Alliance fora Healthier Generation agreement.27

A report from the alliance issued in2010 cited an 88% decrease in totalcalories shipped to schools, a 95%

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decrease (in ounces) of full-caloriecarbonated soft drinks, anda corresponding increase in moreacceptable alternatives, such as water,100% fruit juice, and rehydrationdrinks in smaller portion sizes.Nevertheless, school-based surveysstill recorded widespread availabilityof sweetened beverages in US schools,at least partly because of suppliersoperating outside of exclusive orformal contracts, as addressed by thealliance agreement.19,20,29

Other forms of sweetened drinkshave become popular in schools aswell, replacing carbonated softdrinks. The AAP issued a policystatement in 2011 on the role ofrehydration drinks among childrenand adolescents, warning that theiruse outside of prolonged, vigorous-intensity physical activity involvingfluid and electrolyte depletiondelivered unwarranted energy andadded sugar. Water is the appropriatesource of hydration for nearly alltypes of less vigorous activities. Thestatement also raised concerns aboutcaffeine and other additives inpopular energy drinks.30

The New Nutrition Standards

For the first time since 1970 whenthe obesity epidemic took root,Congress recently gave the USDAauthority to establish nutritionstandards for foods sold on campusduring the school day. Lacking federalstandards, a patchwork of state andlocal regulations of varying strengthhave been put in place over the pastdecade.29,31 The new federal nutritionstandards for competitive foods sold inschools, titled “Smart Snacks in School,”were proposed in February 2013 andadopted in June 2013 after receivingmore than 250 000 comments from thepublic (http://www.gpo.gov/fdsys/pkg/FR-2013-06-28/pdf/2013-15249.pdf). These standards wereimplemented in 2014.

The USDA Food and Nutrition Serviceformulated the nutrition standardsfrom several sources. Most prominent

was an IOM report titled “NutritionStandards for Foods in Schools:Leading the Way Toward HealthierYouth.”32 The IOM concluded that toachieve dietary stability for childrenand at the same time maintaina financial footing for the school foodservice, competitive foods of lownutrient value should be significantlycurtailed. USDA review of existingstate and local standards, as well as ofvoluntary standards (eg, thosedeveloped by the Alliance fora Healthier Generation), augmentedthe IOM recommendations.

Food Requirements

Under the new standards (http://www.fns.usda.gov/cnd/governance/legislation/allfoods_flyer.pdf), foodssold in schools must have a fruit,a vegetable, a dairy product, ora protein food as its first ingredient;be a whole grain–rich product(.50% whole grain or have wholegrain as first ingredient); bea “combination food” containing atleast one-quarter cup fruit orvegetable; or contain 10% of the DailyValue of a nutrient of concernoccurring naturally (calcium, vitaminD, potassium, or fiber). In this way,the standards directly support the2010 DGAs. In addition, all foods soldmust meet a range of calorie andnutrient requirements. Total fat mustbe#35% of kilocalories, saturated fatmust be ,10% of kilocalories, andtrans fat must be 0 g, as listed onthe nutrition facts label. Snack itemsmust contain #200 mg of sodium,and entrée items from the schoolmeal programs that are sold as snacksmust contain #480 mg of sodium perportion. Snack items must contain#200 kcal, and entrée items mustcontain #350 kcal per portion. Totalsugar content (inherent plus addedsugars) is limited to #35% of weightper portion as sugars.

Beverage Requirements

Schools may sell plain or carbonatedwater, unflavored low-fat milk,unflavored or flavored fat-free milk

and milk alternatives (as permittedby the school meal programs), and100% fruit and/or vegetable juice,with or without carbonation ordilution with water but containing noadded sweeteners. Except for water,portion sizes are limited to 8 oz inelementary schools and 12 oz inmiddle and high schools. High schoolsmay sell additional beverage options,such as calorie-free, flavored, orunflavored carbonated waters orother calorie-free drinks (#5 kcal per8-oz serving and up to 10 kcal per20-oz serving size). In addition, thestandards offered 2 alternatives forother beverages in #12-oz servings:one is beverages with ,40 kcal per 8oz or #60 kcal per 12 oz.

Although most fluids containingadded sugars have been curtailed bythe new standards, not all addedsugars were eliminated. After softdrinks, perhaps the mostcontroversial use of added sugar inschools is in flavored milk, which thenew standards allowed, matching thestipulations of the National SchoolLunch Program and the SchoolBreakfast Program. Consideration ofa beverage such as flavored milkprovides a good example of thebalance needed to limit added sugarsand yet promote nutrient-rich foods.Many school districts have chosen toban flavored milk and opt solely forlower fat nonflavored milks.Consumption patterns of milksamong children suggest caution,however.33 Eliminating the addedsugars from milk may increase milkwastage, resulting in fewer ouncesconsumed per day.34,35 Outside ofschool, whole and 2% milk varietiescomprise nearly three-quarters of themilk consumed by children, whereas1% and nonfat milk combinedaccount for only 20%.33 Insideschools, flavored milk representsmore than 70% of all milk consumed;38.5% of milk, however, is nonfat and51% is 1% fat, a substantial decreasein saturated fat and calories relativeto consumption patterns outside ofschool.36 Milk consumption at the

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noon meal is critical and is correlatedwith overall diet quality as well ascalcium intake.37 Studies have shownthat flavored milk consumption is notassociated with weight gain or evena higher total daily sugar intake inchildren.38,39 The 2007 IOMrecommendations set a lowerstandard for the fat and sugar contentof flavored milk. Since then, the addedsugar content of flavored milks inschools has been reduced by morethan 30%, approaching the levels IOMsuggested (ie, a maximum of 22 g oftotal sugars/8 oz, containing 12 g ofinherent lactose and 10 g of addedsugar).32 Instead of prohibiting sugar-sweetened flavored milk, the newUSDA standards direct schools tooffer only a nonfat variety, thuscutting calories and saturated fat butstill encouraging consumption. Thisbalanced approach recognizes thecontribution of fluid milk as theprimary source of 3 of the 4 nutrientsof concern cited by the 2010 DGAs(calcium, vitamin D, and potassium).

Concerted public and industry efforts,grassroots advocacy, local schoolwellness polices, and state andfederal regulations have resulted ingreat improvements in nutritionquality in schools. For these efforts toachieve their full potential, however,technical assistance and training (aswell as public discussion, ongoingsurveillance, regular reappraisal, andcontinued advocacy) will be required,particularly at the local level.

INFORMAL SOURCES OF FOODS ANDBEVERAGES—A NEED FOR IMPROVEDQUALITY

As much as 40% of the daily energyconsumed by 2- to 18-year-olds is inthe form of “empty calories” (energy-dense, nutrient-poor), most of itconsumed away from school.1,3

However, a substantial portion of low-quality foods make their way intoschools from parents, students,teachers, and staff. Packed lunchesand snacks, bake sales and boostersales, fundraisers, and class birthdays

and holiday parties traditionallyfeature candy, sweet or fried desserts,chips, and other snack-type foods andsweetened beverages. Such foodsare common rewards forachievement. Sports venues oftenhave refreshments for the players aswell as items vended for spectatorsthat are high in calories but low innutrient value. Although fundraisersdo come under the mandate of thenew standards for competitive foodssold in schools, the USDA left much ofthe detail to the discretion of stateagencies. Fundraisers occurringduring nonschool hours, off campus,or on the weekends are exempt fromthe new standards. Furthermore, thestandards offer an exemption forinfrequent fundraisers but left thecriteria to state discretion.

Some schools with strong nutritionpolicies that limited items brought infrom home have successfully lessenedthe likelihood of high consumption ofempty calories amongstudents.22,23,40 Nutrition educationin school and at the point of sale mayhelp students become more savvyconsumers. Utilization of research onbehavioral economics, whichdescribes the factors that influence anindividual’s food selection, may helpoptimize the presentation of nutrient-rich foods, relative to fewer nutrientoptions (http://www.ers.usda.gov/publications/err-economic-research-report/err68.aspx). Offeringalternatives (eg, nonfood items forfundraisers, foods of higher quality)as substitutions for traditionalfundraising fare represents anopportunity for pediatricians to joinwith other child health professionalsto influence everyday food choices inlocal schools (http://www.actionforhealthykids.org/component/content/article/39-step-3-challenges/636-healthy-a-active-classroom-parties; www.eatright.org;http://www.cspinet.org/new/pdf/schoolfundraising.pdf).

Added sugars offer no nutritionalbenefits. At the same time, sugars

themselves are not necessarilyharmful. Used along with nutrient-rich foods and beverages, sugar canbe a powerful tool to increase thequality of a child’s diet. Used inexcess, added sugars can addsubstantially to daily calories. Used atextreme levels (ie, more than 25% to30% of total calories), sugars candisplace other nutrients, resulting innutrient deficiencies. Although addedsugars are often presumed to be anindependent cause of overweight, thisclaim has not been proven in studies.The DGA Advisory Committee foundthat “a moderate body of evidencesuggests that under isocaloriccontrolled conditions, added sugars,including sugar-sweetened beverages,are no more likely to cause weightgain than any other source ofenergy.”2 Furthermore, thecommittee’s evidence review failed tofind a causative connection betweensugar consumption and type 2diabetes mellitus, heart disease, orbehavioral disorders. Similarly, recentreviews of the relationship betweensugar consumption and the nutrientcontent of the diet found that theassociation was nonlinear. Evena moderately high intake of addedsugars was not necessarily associatedwith decrements in dietary nutrientintake.41–46 Care should be takenwhen prohibiting sugar-containingproducts to avoid compromisingoverall nutrition among children. Forexample, the American HeartAssociation, in taking its strongstance against overconsumption ofadded sugars to ensure diet qualityand lessen obesity, qualified itsrecommendations by stating that,“The form in which added sugars areconsumed appears to be an importantmodifier of the impact of [nutrient]dilution. Soft drinks, sugar, andsweets are more likely to havea negative impact on diet quality,whereas dairy foods, milk drinks, andpresweetened cereals may havea positive impact.”47 Sugarsconsumed in nutrient-poor foods andbeverages are the primary problem to

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be addressed, not simply the sugarsthemselves.

Registered dietitians, school nurses,and school food service directors arenatural collaborators with whompediatricians can work in advancinga unified perspective on increasingnutrient density (the nutrient-to-calorie ratio of a product) whilelimiting caloric excess. Often, all 4professional groups can berepresented on a school district’swellness council. The Healthy,Hunger-Free Kids Act of 2010 (Pub LNo. 111-296) requires schools toinform and update students, parents,and the public about the content andimplementation of local wellnesspolicies and to periodically measurewhether their schools are incompliance and making progresstoward meeting wellness policy goals.Pediatricians seeking an avenue to beinvolved in their local communityschool’s nutrition can providea unique perspective on childnutrition, physical activity, and childdevelopment (www.fns.usda.gov/tn/Healthy/wellnesspolicy_tools.html;http://www.actionforhealthykids.org;and http://www.cdc.gov/healthyyouth/npao/strategies.htm).

Thoughtful guidance for families,students, and school staff should aimto establish a practical perspective onnutrition that avoids both prohibitionand overconsumption of addedsugars when planning packedlunches, school parties andcelebrations, booster sales, and othersuch occasions. It has been wellestablished and repeatedlydemonstrated, particularly by thefood industry, that sugars canincrease the palatability anddesirability of foods. Children, inparticular, have a strong liking formore intense sweet.48 Consumedwithin recommended calorieamounts, sweetness can offer aneffective tool to promoteconsumption of nutrient-dense foodsand beverages.49 To help move allschool food items in line with the

2010 DGAs, these attributes shouldbe considered:

• Selected from the fundamental 5food groups: vegetables, fruits,grains (whole grains), low-fat milkand dairy, and quality proteinsources (eg, lean meats, fish, nuts,nut butters, seeds, eggs)

• Promotes a broad variety of foodexperiences for children andadolescents

• Avoids highly processed foods (ie,energy dense with a high caloriecontent per weight of food), relyinginstead on fresh components highin water content whenever possible

• Uses the minimum amount ofadded sugar necessary to promotethe palatability, enjoyment, andconsumption of nutrient-rich fooditems

• Adheres to the directives and por-tion size recommendations offeredin the recent USDA nutritionstandards for competitive foods, asdiscussed previously

Additional improvements in nutrientdensity of sweet-tasting productscould be obtained if nonnutritivesweeteners are used as a tool toreplace added sugars and help lowercaloric intake. Several nonnutritivesweeteners have been accepted bythe US Food and Drug Administrationas safe and have shown good safetyover time. However, data are scarceon long-term benefits for weightmanagement in children andadolescents or on the consequencesof long-term consumption.50

Continued research is needed.

CONCLUSIONS

Pediatricians can influencenutritional quality in schools directlythrough their participation asparents, as members of the school’swellness council, as consultants, assports team physicians, as membersof the school board, as communityadvocates for child nutrition, orthrough the AAP or their statechapters.51 In addition, physicians

can encourage local schools toachieve national or state recognitionfor their wellness efforts, asexemplified by the USDA’s HealthierUS Schools Challenge (http://www.fns.usda.gov/tn/healthierus/index.html). Counseling families andschools to seek a higher diet qualityfirst, then to use the limited amountsof acceptable discretionary calories ina thoughtful way, offers an effectivetool to achieve the goals of the DGAsin school.

RECOMMENDATIONS

1. Pediatricians should offer a clearperspective for students, parents,and school officials, based on na-tional nutrition goals, the evidencereview of the 2010 DGAs, and therecent nutrition guidelines forschools. The primary objectiveshould be to maximize nutrientdensity (nutrients consumed perkilocalorie) within recommendedcalorie ranges, which representsa balance between reducing ex-cess calories, solid fats, addedsugars, and sodium while usingavailable discretionary calories toencourage greater consumption ofnutrient-rich foods andbeverages.

2. Particularly at the local level,pediatricians should acknowledgethe substantial gains made by theschool nutrition staff on schoolmeals while supporting the fullimplementation of the recentUSDA guidelines both for schoolmeals and for competitive foodssold in schools.

3. Pediatricians should focus partic-ular attention on counseling fami-lies and local school staff aboutimproving the quality of selectionsbrought into schools for packedlunches and snacks, fundraisers,sporting events, in-class parties,and school celebrations. By iden-tifying the attributes of nutrient-rich foods, pediatricians caninfluence food choices and, at thesame time, offer families and

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schools a practical, holistic per-spective on child nutrition.

4. In schools, pediatricians shouldconsider wellness councils orschool health advisory councils asa unique opportunity for influenc-ing student nutrition through col-laboration with otherprofessionals invested in childnutrition, especially registereddietitians, school nurses, andschool food service directors. De-velopment of policies and prac-tices with the involvement ofstudents and staff can be a potentform of education about qualitynutrition.

5. Advocacy efforts of the AAP and itsmember pediatricians within theirstate chapters and local schooldistricts should continue to sup-port the efforts of the USDA toimprove the school nutrition en-vironment as the best means toensure the nutritional adequacy ofall school-aged children andadolescents.

LEAD AUTHORS

Robert Murray, MD, FAAPJatinder J. S. Bhatia, MD, FAAP

COUNCIL ON SCHOOL HEALTH EXECUTIVECOMMITTEE, 2013–2014

Jeffrey Okamoto, MD, FAAP, ChairpersonMandy Allison, MD, MSPH, FAAPRichard Ancona, MD, FAAPElliott Attisha, DO, FAAPCheryl De Pinto, MD, MPH, FAAPBreena Holmes, MD, FAAPChris Kjolhede, MD, MPH, FAAPMarc Lerner, MD, FAAPMark Minier, MD, FAAPAdrienne Weiss-Harrison, MD, FAAPThomas Young, MD, FAAP

PAST EXECUTIVE COMMITTEE MEMBERS

Cynthia Devore, MD, FAAP, Immediate PastChairpersonStephen Barnett, MD, FAAP†

Robert Murray, MD, FAAP, Past Chairperson

LIAISONS

Linda Grant, MD, MPH, FAAP – American School

Health Association

Veda Johnson, MD, FAAP – School-Based Health

Alliance

Elizabeth Mattey, MSN, RN, NCSN – National

Association of School Nurses

Mary Vernon-Smiley, MD, MPH, MDiv – Centers for

Disease Control and Prevention

PAST LIAISONS

Carolyn Duff, RN, MS, NCSN – National Association of

School of Nurses

STAFF

Madra Guinn-Jones, MPH

COMMITTEE ON NUTRITION, 2013–2014

Stephen R. Daniels, MD, PhD, FAAP, ChairpersonSteven A. Abrams, MD, FAAPMark R. Corkins, MD, FAAPSarah D. de Ferranti, MD, FAAPNeville H. Golden, MD, FAAPSheela N. Magge, MD, FAAPSarah Jane Schwarzenberg, MD, FAAP

ADDITIONAL CONTRIBUTOR

Jatinder J. S. Bhatia, MD, FAAP, Past Chairperson

LIAISONS

Jeff Critch, MD – Canadian Pediatric Society

Laurence Grummer-Strawn, PhD – Centers for

Disease Control and Prevention

Rear Admiral Van S. Hubbard, MD, PhD, FAAP –

National Institutes of Health

Benson M. Silverman, MD† – Food and Drug

Administration

Valery Soto, MS, RD, LD – US Department of

Agriculture

STAFF

Debra L. Burrowes, MHA

†Deceased.

REFERENCES

1. Williams C; Dietary Guidelines AdvisoryCommittee. Children’s Dietary Intakes.Available at: www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/DGAC/Report/Resource1-Children.pdf.Accessed June 4, 2013

2. US Department of Agriculture, Center forNutrition Policy and Promotion. Report ofthe Dietary Guidelines AdvisoryCommittee on the Dietary Guidelines forAmericans, 2010. Available at: www.cnpp.usda.gov/dgas2010-dgacreport.htm.Accessed June 4, 2013

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