Academy Comments to Council of Better Business Bureaus re: Children's Food and Beverage Advertising Initiative's Nutrition Criteria

July 22, 2016

Joan Rector McGlockton, JD
Director, Children’s Food and Beverage Advertising Initiative
Council of Better Business Bureaus
4200 Wilson Boulevard, Suite 800
Arlington, VA 22203

Dear Ms. McGlockton,

The Academy of Nutrition and Dietetics (the "Academy") is pleased that the Children's Food and Beverage Advertising Initiative (the CFBAI) is updating the Category-Specific Uniform Nutrition Criteria (the "uniform criteria") for food marketing to children to be consistent with the current Dietary Guidelines for Americans and the latest nutrition science. Representing more than 100,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. Every day we work with Americans in all walks of life — from prenatal care through end of life care — providing nutrition care services and conducting nutrition research.

The Academy has long been at the forefront of improving children's health by educating the public about child nutrition. Our Kids Eat Right initiative (www.eatright.org/kids) is a valuable resource of scientifically based health and nutrition information and turn key nutrition messaging that parents and caretakers use and trust to raise healthy children. The Academy strongly supports the CFBAI's work and respectfully offers the below comments and considerations as it updates the uniform criteria.

I. Value of the CFBAI in the Current Environment

It is absolutely critical for all stakeholders to continuously work together in a coordinated manner to fight the epidemic of child obesity. We are an increasingly overweight and undernourished nation. Over the past thirty years, the percentage of overweight children and adolescents in the United States has more than doubled, at an astronomical cost to our nation and families.2 Americans' diets simply do meet nutritional goals. Children and adolescents consume too many calories, too much saturated fat, trans fat, sodium, and added sugars, and too few nutrient dense foods such as fresh fruits and vegetables, whole grains and lean protein sources. Although many factors have led to the obesity epidemic, food marketing plays a substantial role in driving children's food choices and overall diet and in influencing purchasing decisions of parents and caregivers.3 One study indicated that the elimination of advertising of unhealthy foods and beverages to children on television alone could reduce childhood obesity by 18 percent, or approximately 2.8 million children.4

The commitment of the member companies to improving children's health in their marketing efforts by encouraging healthier dietary choices is thus laudable, and the Academy recognizes and appreciates these commitments that represent approximately 80 percent of child-directed television food advertising. Companies' commitments include reformulating food to fit within the uniform criteria, phasing out certain products, and developing new, enjoyable, and healthier options that appeal to both children and parents.

We are encouraged that the CFBAI program has continued to evolve over time. These advances include adding more member companies, covering 100 percent rather than 50 percent of advertising, inclusion of additional media approaches, adoption of uniform nutrition criteria, and the current update to those nutrition criteria. Adoption of uniform nutrition criteria was a positive step forward, helping to reduce unhealthy food marketing to children. The Academy is pleased that current CFBAI criteria are largely consistent with current evidence-based nutrition recommendations, and we strongly encourage maximum alignment with federal nutrition standards and recommendations going forward to promote consistency for consumers and industry alike.

II. Juice and Other Beverages

Juice can be an important and healthful addition to a child's diet and can make a meaningful contribution towards providing the recommended daily servings of fruits and vegetables. At the same time, evidence suggests that fruit juice is a top contributor to children's caloric intake.5 Children and adolescents are not consuming the recommended amounts or varieties of fruits and vegetables: they are consuming more fruit juice and less whole fruit, fewer dark green and orange vegetables and legumes than recommended.6 Studies show that people who eat whole fruits have a lower risk for type 2 diabetes compared to those who consume fruit juice.7 Juice intake has increased overall among children 5 years and younger compared to three decades ago,8 with the largest increases in Latino and African American children.9 Further, fruit juice has several nutritional disadvantages compared to whole fruit: juice has little or no dietary fiber and frequent, prolonged, and excessive exposure could lead to dental caries.10,11

The Academy is concerned that the uniform criteria calorie limit for juice may be too high. We understand that level was set to prevent exclusion of certain juices, such as grape juice. To address that competitive concern and keep liquid calories in check, we urge CFBAI to adopt the juice criteria from the Healthy Eating Research expert Recommendations for Healthier Beverages:12 0- to 6-ounce portions of 100 percent fruit or vegetable juice or fruit juice combined with water; no added sweeteners; and no more than 100 mg of sodium per portion.

In addition, we encourage CFBAI to update its criteria to communicate that to qualify for the meal criteria, soda and other sugary drinks (including imitation fruit drinks) should not be listed on a restaurant's children's menu or be offered as a default beverage with children's meals or be included in packaged children's meals sold in stores. Many major restaurants chains, including McDonald's, Burger King, Dairy Queen, Subway, Panera, Applebee's, and Jack in the Box, already exclude sugary drinks from their children's menus. Sugary drinks are the top sources of added sugars in children's diets and are linked to obesity, diabetes, and dental caries. For reference, twelve ounces of soda contains a whole day's added sugar for a child.

The Academy also supports the policy of disallowing beverages containing caffeine in the uniform criteria with the exception of beverages with trace amounts of naturally-occurring caffeine substances. We also emphasize the importance of distinguishing between coffee, soft drinks, or other drinks that contain caffeine, and energy drinks. The American Academy of Pediatrics states, "energy drinks pose potential health risks primarily because of stimulant content; therefore, they are not appropriate for children and adolescents and should never be consumed."13 An expert panel on caffeinated energy drinks recommended labels for "stimulant drug containing drinks," stating "that the product is NOT recommended for children or adolescents under the age of 18 years."14 The Sports Medicine Advisory Committee of the National Federal of State High School Associations (2011) "strongly recommends that energy drinks should not be used for hydration prior to, during, or after physical activity." Researchers have found that caffeine is the primary stimulant of concern in energy drinks,15 and emergency room visits due to energy drinks have increased over 13-fold between 2005 and 2011, with 1,499 visits reported in children aged 12 to 17 in 2011.16 The Academy does not support the sale of energy drinks in elementary, middle, or high schools and urges USDA to regulate differently the sale of energy drinks (often classified as supplements) from other beverages with caffeine.

III. Nutrients to Encourage, Fortification and Consumption of Nutrient Dense Foods

The Academy applauds the CFBAI for including criteria for "Nutrition Components to Encourage," but we strongly recommend the CFBAI synthesize those criteria with a food-based approach consistent with the 2015 Dietary Guidelines for Americans (DGA) recommending that nutrient needs be met primarily by consuming nutrient-dense food. The DGA consistently emphasizes the importance of consuming a diet rich in a variety of fruits and vegetables, as well as whole grains and low-fat dairy products. The nutrient-density of fruits, vegetables, whole grains, and low-fat dairy products cannot be duplicated by simply adding vitamins or minerals to nutrition-poor foods and beverages. Thus, the CFBAI nutrition guidelines should ensure that marketed foods make a meaningful contribution to a healthful diet. We note that this approach is also consistent with the U.S. Department of Agriculture's National School Lunch Program and School Breakfast Program meal patterns and Smart Snack competitive foods standards.

The Academy strongly supports efforts to ensure that all foods marketed to children must provide a positive nutritional benefit consistent with the DGA's intent that nutrient needs be met primarily by consuming nutrient-dense foods.17 The Academy agrees that there can be benefits from fortification, but notes the FDA's admonition that fortification can also "result in over- or under-fortification in consumer diets and create imbalances in the food supply."18 In short, the Academy believes that the uniform criteria should encourage whole, nutrient dense foods with naturally occurring nutrients of public health concern. Accordingly, we support a requirement that foods contain at least 10 percent of the Daily Value of a naturally occurring nutrient of public health concern (i.e., calcium, potassium, vitamin D, dietary fiber, and other nutrients of concern added per DGA updates).

The Academy appreciates that the use of functional foods can help individuals obtain some recommended nutrients. In general, functional foods have the potential to minimize health care costs while improving health and wellness and giving consumers greater control over their health by providing a convenient form of health-enhancing ingredients.19 It is the position of the Academy of Nutrition and Dietetics to recognize that, although all foods provide some level of physiological function, the term functional foods is defined as "whole foods along with fortified, enriched, or enhanced foods that have a potentially beneficial effect on health when consumed as part of a varied diet on a regular basis at effective levels based on significant standards of evidence."20

One consideration in defining whether a particular fortified food is actually a functional food is the question of replacement: comparison of the total nutritional and caloric value of one product (e.g., milk) with its possible replacement (e.g., a calcium-fortified cookie). In the above example, consideration must be given to the many different, additional nutrients present in milk not present in its replacement. Some have asserted that fortified foods even "have a ‘nutritional obligation' to be as nutritionally valuable as the food it is probably replacing."21 Marketing that touts the needs for a single nutrient in a replacement food often ignores the other important nutrients commonly associated with the touted nutrient in a whole food. Many touted nutrients are important not only individually, but and also as "indicator nutrients" that commonly indicate presence of a group of desirable nutrients occurring together in whole foods.

Further, the Academy is open to clarifying natural source of nutrients of concern versus fortified foods (e.g., "a source of added nutrients;" "a fortified food") in marketing initiatives consistent with National Academy of Medicine's concerns about over-fortification.22 The Academy concurs with the FDA that "[r]esearch suggests consumer product perceptions and purchase decisions can be influenced by labeling statements and different labeling statements may have different influences."23

IV. Whole Grains and Whole Grain Rich

The Academy supports CFBAI's commitment to improving the nutritional quality of grains marketed to children. Grains are important sources of many nutrients, including dietary fiber, B vitamins (thiamin, riboflavin, niacin, and folate), and minerals (iron, magnesium, and selenium). Dietary fiber from whole grains may help reduce blood cholesterol levels and is associated with lower risk of heart disease, obesity, and type 2 diabetes.24 Whole grains are notably under consumed among preschool children.25 According to research that evaluated NHANES 1999-2004 data, average consumption of whole grains in children 2 to 5 years of age was only 0.45 servings per day, and only 8.4 percent of study participants consumed the minimum recommended 1.5 servings per day.26 If parents and child care providers consumed more whole grains themselves, the grains would be more readily available as an option to serve children, and will also make whole grains more desirable as adults model healthy behaviors, making children more likely consume them as well.

CFBAI should add a definition for "whole grain rich" of at least 50 percent of the total grain ingredients as whole grains by weight, aligned with the criteria used in the National School Lunch Program. This consistent definition will help achieve the DGA's recommendation to consume one-half of all grains as whole grains.27>

While supporting the adoption of criteria consistent with federal guidelines, the Academy opposes defining whole grains as containing at least 8 grams (or any other gram amount of whole grains) as a standard if it does not ensure that grain products contain at least 50 percent whole grain. For example, 8 grams of whole grain in a 25 g serving of pasta would be only 32 percent whole grain. A 55 g serving of cereal with 8 grams of whole grain would be only 15 percent whole grain, and likely contain more refined grain than whole grain. The intention is to encourage consumption of 50 percent whole grains within the recommended portion and serving sizes for grains, not merely to increase consumption of all grains with a concomitant consumption of whole grains.

V. Added Sugars

It is the position of the Academy that consumers can safely enjoy a range of nutritive sweeteners and nonnutritive sweeteners (NNS) when consumed within an eating plan that is guided by current federal nutrition recommendations, such as the DGA and the DRIs, as well as individual health goals and personal preference.28 The difficulty, of course, is striking a balance by making sure one only consumes added sugars within recommended calorie limits (e.g., 2000 calories/day) while still making sure one consumes the recommended intake of nutrients. However, too many Americans are not striking the right balance in their overall diet and are consuming too much added sugar, with consumption of added sugars for youth and young adults typically well above 10% of calories.29 On average, youth consume 430 calories from added sugars each day,30 which is more than twice the total recommended intake for a moderately active 6-8 year old boy or 7-9 year old girl (10 percent calories from added sugars for a 1,600 calorie diet is 40 grams of added sugars per day). As a result, the 2015 DGAC Report31 repeatedly urged Americans to "consume dietary patterns . . . low in sugar-sweetened foods and beverages" (i.e., foods and beverages with low amounts of added sugars."32

The CFBAI uniform criteria regarding added sugars should be strengthened in several additional ways to more effectively promote marketing of nutritious food and beverages to children. The Academy encourages CFBAI to set the sugars standard based on added sugars, rather than total sugars, because added sugars are the focus of the scientific evidence of health harms and should be limited in children's diets. Added sugars, when considered with solid fats and excess energy intake, have been linked to health concerns, including overweight and obesity, type 2 diabetes or prediabetes, inflammation, and cardiovascular disease.33 In contrast, foods with naturally occurring sugars such as fruits and dairy products are not as concentrated as foods with added sugars and are often rich in multiple nutrients.

With the recent publication of the final rule updating the Nutrition Facts Panel, food manufacturers know the criteria by which added sugars are defined, enabling the CFBAI to update uniform criteria for added sugars prior to the implementation date of the final rule.34 For example, as required in the Nutrition Facts final rule, concentrated fruit juice when added as a sweetener to a product should count towards the added sugars content of the product.

If one snack food uses up a quarter of a child's day's limit for added sugars (the current CFBAI limit of 10 grams per serving out of a recommended limit of 40 grams per day) that would make it difficult for a child to stay under the recommended day's limit for added sugars. In addition, children served high-sugar cereals eat, on average, more than two servings (61 g) of cereal.35 Furthermore, the standard for cereal in the WIC food packages is no more than six grams of sugars per one-ounce dry cereal, and the Academy encourages the CFBAI to adopt criteria consistent with existing federal recommendations and standards.

VI. Sodium

The Academy wholeheartedly supports recommendations that make progress in reducing the amount of sodium Americans consume on a daily basis. High levels of salt in the diet are associated with high blood pressure, heart disease and stroke, particularly among certain vulnerable groups and individuals. It is critical that all school nutrition standards include limits on the amount of sodium in processed and prepared foods, a major source of students' sodium intake. The Academy supports the DGA recommendation that children should consume no more than 1,500 milligrams of sodium per day and has supported USDA's efforts to significantly reduce sodium in the school meal programs over the next 10 years. To achieve the DGA's goals, we support the existing sodium standard for snack items (<200 mg) and entrees (<480 mg) for competitive foods sold in schools. These proposed competitive foods sodium standards should contribute significantly to sodium reduction in children's diets and complement the gradual reduction that is already happening in the school meal programs.

Breads, cheeses, snacks, and mixed dishes (including sandwiches and pizza) are among the top sources of sodium in Americans' diets.36 Children are over-consuming sodium, far exceeding the National Academy of Medicine's maximum recommended levels.37,38 Eating more sodium is associated with increased blood pressure in children.39 High blood pressure in childhood often leads to high blood pressure in adulthood and is linked to early development of heart disease and risk for premature death.40 We encourage the CFBAI to ensure updates to the uniform criteria regarding sodium are aligned with existing federal recommendations and guidance.

VII. Brands

Companies should not market brands to children that include products that do not meet nutrition criteria. The updated CFBAI nutrition standards should apply to both individual products and to marketing that promotes an overall brand. Many marketing efforts aimed at children show only brief images of specific products and instead focus children's attention on larger brand-related messages.41,42 This strategy allows companies to advertise brands with both healthy and unhealthy versions of a product, provided that only products meeting nutrition criteria are depicted in the ads.

Brand marketing affects children's preferences and choices. Children are particularly brand sensitive and show preferences for brands at a young age,43 with food brand knowledge increasing significantly from 3 years of age. Children's brand knowledge is higher for unhealthy than for similarly advertised healthy foods. For example, children shown a random sample of McDonald's and Burger King children's ads were as likely to recall a toy premium/movie tie-in message as any food at all, even though the advertisements were supposed to emphasize food and make the premiums secondary. When children did recall food, they rarely mentioned the healthy foods, even though such images were included in all of the ads. In contrast, most children recalled food after watching adult fast food advertisements, which shows that they had the developmental capability of noticing food when it is the primary focus of the advertisement.44

VIII. Conclusion

The Academy sincerely appreciates the opportunity to offer comments on the updating of the uniform criteria, and we would welcome the opportunity to work with you on this significant initiative going forward. Please contact either Jeanne Blankenship by telephone at 312-899-1730 or by email at [email protected] or Pepin Tuma by telephone at 202-775-8277 ext. 6001 or by email at [email protected] with any questions or requests for additional information.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics


1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Chou, S, Rashad, I, Grossman, M. Fast-food restaurant advertising on television and its influence on childhood obesity. J. Law and Econ. 2008; 51(4): 599-600.

3 Institute of Medicine, Committee on Food Marketing and the Diets of Children and Youth. Food marketing to children and youth: threat or opportunity? Washington, DC: National Academies Press; 2006. Available at http://www.nap.edu/catalog/11514/food-marketing-to-children-and-youth-threat-or-opportunity.  Accessed July 12, 2016.

4 Chou S, Rashad I, Grossman M. Fast-food restaurant advertising on television and its influence on childhood obesity. J. Law and Econ. 2008; 51(4): 599-617.

5 Rader RK, Mullen KB, Sterkel R, et al. (2014). Opportunities to Reduce Children's Excessive Consumption of Calories from Beverages. Clinical Pediatrics, 1047-54.

6 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015 (Ch. 1 p. 47; Ch. 2 pp. 43-47; 50). Available at https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf.

7 Muraki I, Imamura F, Manson JE, Hu FB, Willett WC, van Dam RM, & Sun Q. (2013). Fruit Consumption and Risk of Type 2 Diabetes: Results from Three Prospective Longitudinal Cohort Studies. British Medical Journal, 347, f5001.

8 Fulgoni III VL & Quann EE. (2012). National Trends in Beverage Consumption in Children from Birth to 5 Years: Analysis of NHANES across Three Decades. Nutrition Journal, 1-11.

9 Beck AL, Patel A, & Madsen K. (2013) Trends in Sugar-Sweetened Beverage and 100% Fruit Juice Consumption among California Children. Academic Pediatrics, 364-370.

10 American Academy of Pediatrics: Committee on Nutrition. (2001). The Use and Misuse of Fruit Juice in Pediatrics. Pediatrics, 1210-1213.

11 Evans EW, Hayes C, Palmer CA, et al. (2013). Dietary Intake and Severe Early Childhood Caries in Low-Income, Young Children. Journal of the Academy of Nutrition and Dietetics, 1057-1061.

12 Healthy Eating Research:  Building evidence to prevent childhood obesity. Robert Wood Johnson Foundation. Available at http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404852.  Accessed July 10, 2016. 

13 Sports drinks and energy drinks for children and adolescents: are they appropriate?. Pediatrics. 2011;127(6):1182-9 (emphasis added).

14 Health Canada website. Report by the Expert Panel on Caffeinated Energy Drinks (2010).  Accessed July 10, 2016. Available at http://www.hc-sc.gc.ca/dhp-mps/prodnatur/activit/groupe-expert-panel/report_rapport-eng.php.

15 Clauson KA, Shields KM, Mcqueen CE, Persad N. Safety issues associated with commercially available energy drinks. J Am Pharm Assoc (2003). 2008;48(3):e55-63; Reissig CJ, Strain EC, Griffiths RR. Caffeinated energy drinks--a growing problem. Drug Alcohol Depend. 2009;99(1-3):1-10.

16 SAMHSA website. Update on Emergency Department Visits Involving Energy Drinks: A Continuing Public Health Concern (2013).  Accessed July 12, 2016.  Available at http://www.samhsa.gov/data/sites/default/files/DAWN126/DAWN126/sr126-energy-drinks-use.htm.

17 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015 (Ch. 3, p. 66). Available at https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf.

18 21 CFR 104.20(a).

19 Crowe KM, Francis C. Position of the academy of nutrition and dietetics: functional foods. J Acad Nutr Diet. 2013;113(8):1096-103, at 1097, citing Institute of Food Technologists. Functional foods: Opportunities and challenges.  March 2005. Accessed July 12, 2016.

20 Id., at 1096 (emphasis added).

21 Borenstein B, Lachance PA. Rationale and technology of food fortification with vitamins, minerals, and amino acids. C R C Critical Reviews in Food Technology. 1971;2(2):171-186 at 174.

22 National Research Council. Examination of Front-of-Package Nutrition Rating Systems and Symbols: Phase I Report. Washington, DC: The National Academies Press, 2010 at 11 (noting "concerns about encouraging overfortification or the addition of these nutrients to food systems in which the nutrient is unstable or not biologically available").

23 Experimental Studies on Consumer Responses to Nutrient Content Claims on Fortified Foods.  77 FR 48988 (Aug 15, 2012).

24 O'Neil, C. E., Nicklas, T. A., Zanovec, M., Cho, S. S., & Kleinman, R. (2011). Consumption of whole grains is associated with improved diet quality and nutrient intake in children and adolescents: the National Health and Nutrition Examination Survey 1999–2004. Public health nutrition, 14(02), 347-355.

25 Ball, S. C., Benjamin, S. E., & Ward, D. S. (2008). Dietary intakes in North Carolina child-care centers: Are children meeting current recommendations?.Journal of the American Dietetic Association, 108(4), 718-721.

26 Adams JF, Engstrom A. Helping consumers achieve recommended intakes of whole grain foods. J Am Coll Nutr 2000;19(3 Suppl):339S–344S.

27 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015 (Executive Summary at xiii).  Available at https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf.

28 Fitch C, Keim KS. Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. J Acad Nutr Diet. 2012;112(5):739-58.

29 Welsh J, Sharma A, Grellinger L,Vos M. Consumption of added sugar is decreasing in the United States. Am J Clin Nutr. 2011; 94: 726-34.

30 Reedy J, Krebs-Smith SM. "Dietary Sources of Energy, Solid Fats, and Added Sugars among Children and Adolescents in the United States." Journal of the American Dietetic Association 2010, vol. 110(10), pp. 477-484. Available at: http://riskfactor.cancer.gov/diet/foodsources/article/table1.html.

31 United States Department of Agriculture. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. http://www.health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf). February 2015 (Part D. Chapter 1, Page 17). 

32 See, Ibid, Part D. Chapter 2, Page 45.

33 US Departments of Agriculture and Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office; 2010.

34 US Department of Health and Human Services, US Food and Drug Administration.  "Food Labeling: Revision of the Nutrition and Supplement Facts Labels."  Federal Register 2016, vol. 81, pp. 33742-33999.

35 Harris JL, Schwartz MB, Ustjanauskas A, Ohri-Vachaspati P, Brownell KD. "Effects of Serving High-sugar Cereals on Children's Breakfast-eating Behavior." Pediatrics 2011, vol. 127, pp. 71-76.

36 Centers for Disease Control and Prevention. "Top 10 Sources of Sodium."  Available at http://www.cdc.gov/salt/sources.htm.  Accessed July 12, 2016.

37 Institute of Medicine (IOM). 2004. "Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate." Washington, DC: The National Academies Press.

38 U.S. Department of Agriculture, Agricultural Research Service. 2012. "Nutrient Intakes from Food: Mean Amounts Consumed per Individual, by Gender and Age, What We Eat in America, NHANES 2009-2010." Available: www.ars.usda.gov/ba/bhnrc/fsrg.

39 Yang et al. "Sodium Intake and Blood Pressure among US Children and Adolescents. Pediatrics. 2012, vol. 130, pp. 611-619.

40 Centers for Disease Control and Prevention website. Highlights: "Sodium Intake and Blood Pressure Among U.S. Children and Adolescents." September 17, 2012.  Accessed July 12, 2016. Available at http://www.cdc.gov/salt/pdfs/sodium_pediatrics_highlights.pdf.

41 Wilking, C. "Copycat Snacks in Schools." The Public Health Advocacy Institute.  2014.

42 Harris, JL, Kidd, B, LoDolce, M, Munsell, C, Schwartz, MB. "Food Marketing FACTS in Focus: Kraft Lunchables." Yale Rudd Center.  2014.

43 Tatlow-Golden, M, Hennessy, E, Dean, M, Hollywood, L. "Young Children's Food Brand Knowledge. Early Development and Associations with Television Viewing and Parent's Diet. Appetite 2014,