Academy Comments to USDA re Child Nutrition Programs: Flexibilities for Milk, Whole Grains, and Sodium Requirements

January 29, 2018

School Programs Branch
Policy and Program Development Division
Food and Nutrition Service
3101 Park Center Drive
Alexandria, Virginia 22302

Re: Child Nutrition Programs: Flexibilities for Milk, Whole Grains, and Sodium Requirements (Docket No. FNS-2017-0021)

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the U.S. Department of Agriculture (USDA) related to its interim final rule (IFR) "Child Nutrition Programs: Flexibilities for Milk, Whole Grains, and Sodium Requirements" (Docket No. FNS-2017-0021) published in the Federal Register (82 FR 56703) on November 30, 2017. Representing over 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, including by ensuring America's children are fed safe, nutritious, and appealing meals in school.

A. Overview of Recommendations

1. Sodium

Nine out of ten children consume too much sodium,2 which studies show may increase their risk of high blood pressure, heart disease, and stroke.3 The Academy strongly supports reducing students' overconsumption of sodium in total and particularly their overconsumption of sodium in their school meals. We are concerned that ongoing delays may lead to a final regulation that would lock in unsafe levels of sodium for children, or even result in an eventual, unacceptable roll-back of the sodium standards. However, the Academy recognizes the merits of the proposed three-year delay (from School Year 2017-2018 to School Year 2021-2022) of the second sodium reduction targets (Target 2) for school meals in that it would allow more time for industry to reformulate products and provide additional time for students' palates to adapt to changes.

2. Low-Fat Flavored Milk

The Academy does not oppose providing schools with additional flexibility by allowing flavored low-fat (1 percent) milk for school meals and as a competitive food , and we note that reformulation of flavored milk and conscientious meal planning has enabled some schools to successfully include low-fat flavored milk without exceeding the calorie maximum.

3. Whole Grains

The Academy recognizes the success of most schools in meeting the whole grain requirements and urges USDA to ensure that any additional flexibility provided to those not yet meeting the standards is temporary and robust, reflecting a commitment to uniform adoption and compliance as soon as practicable.

B. Value of Ongoing Commitment to Improved School Nutrition Standards

Virtually all schools (99 percent) participating in the National School Lunch and Breakfast Programs are making great progress toward serving healthier meals for low-income children with less sodium; more whole grains, fruits, and vegetables; and no trans-fat; and removing sugary drinks and unhealthy snack food.4 The 2012 updates to school nutrition standards reflect sound science, support children's health, and are consistent with the 2015-2020 Dietary Guidelines for Americans (DGA)5 and the National Academies of Science, Engineering, and Medicine (formerly, Institute of Medicine ; hereinafter NASEM) 2009 report School Meals: Building Blocks for Healthy Children.6

The Harvard University T.H. Chan School of Public Health concluded that the update to school nutrition standards is "one of the most important national obesity prevention policy achievements in recent decades."7 Researchers estimate that these improvements prevent more than 2 million cases of childhood obesity and save up to $792 million in health-care related costs over ten years. Improved school nutrition is critical given that one out of three children and adolescents aged 2 to 19 years is overweight or obese8,9 and children consume one-third to one-half of daily calories during the school day.10 Contrary to supporting schools and children's health, our nation's substantial progress to date will be jeopardized if the delays go beyond that contemplated in the IFR or are made permanent.

C. Sodium

We appreciate USDA's efforts thus far to decrease the sodium content of school meals. The sodium reduction guidelines in the 2012 final rule (77 FR 4088) are aligned with the 2010 and 2015 DGAs and expert recommendations from the National Academy of Medicine's 2009 report.11 Nine out of ten children consume more sodium than is recommended for good health.12 Excess sodium consumption is strongly associated with the development and worsening of high blood pressure and an increased risk of coronary heart disease, stroke, heart failure, kidney failure, gastric cancer, and osteoporosis.13 A substantial number of studies show that as dietary sodium intake rises, so does blood pressure.14 Studies show a link between high blood pressure in childhood and high blood pressure in adulthood, and high blood pressure in childhood is linked to early development of heart disease and risk for premature death.15

Of concern, the prevalence of high blood pressure is increasing in American children.16 Already about one in six children aged 8-17 have raised blood pressure.17 Children may be at higher risk of developing heart disease and elevated blood pressure at earlier ages if they have obesity or eat too much sodium.18 Children who eat higher-sodium diets are about 40 percent more likely to have elevated blood pressure than children who eat lower-sodium diets.19

The good news is that lowering sodium consumption can have a tremendous impact on public health. Studies show that reduced sodium intake can lower blood pressure, control hypertension, and prevent cardiovascular disease.20,21 In addition, lowering sodium consumption, and thereby lowering blood pressure, can reduce medical costs. From 2012 to 2013, high blood pressure cost the United States an estimated $51.2 billion in direct and indirect costs.22

Emphasizing the alignment and strength in the science, the 2015 DGA reaffirmed the need to bring sodium consumption levels down to at least 2,300 mg a day. The 2015 DGA recommends that children consume no more than 1,900 to 2,300 mg of sodium per day.23 Unfortunately, children on average consume substantially more than that—between 2,500 to 4,200 mg of sodium per day—well over safe levels.24 Along with the DGAs, the Centers for Disease Control and Prevention, the World Health Organization, the American Heart Association, and other experts all recommend limiting sodium intake to less than 2,300 mg.25 At the current levels (Target 1), an elementary school lunch has on average 1,230 mg, or about two-thirds a day's worth of sodium for a child in one meal. Similarly, a high school lunch has on average 1,420 mg, or about half a day's worth.

Appealing products with safe levels of sodium are now more readily available and demand for these products has grown. For example, food companies such as Revolution Foods provide school meals that already meet the Target 3 sodium levels. Schwan's Company—the largest producer of school pizza—produces the pizza for Revolution Foods and has already invested in the technology and resources to make appealing school pizzas that meet Targets 2 and 3. In addition, many companies —including Aramark,26 ConAgra Foods,27 Domino's Pizza (Smart Slice),28 General Mills,29 Kellogg's,30 Kraft Foods,31 Mars,32 Nestlé,33 PepsiCo,34 and Unilever35—are engaged in voluntary sodium reduction across their full lines of consumer products, which should aid school sodium reduction efforts. This also complements state and local efforts such as New York City's National Salt Reduction Initiative.36 A variety of methods and technologies are available to help reduce levels of sodium in many food categories.37

While we are not aware of USDA collecting data on implementation beyond Target 1, we know that many schools have been working hard and are at or very close to meeting Target 2 levels. For example, the school meals program in Elbert County Schools, Georgia has done tremendous work to get their menus down to safe levels of sodium. They have employed tactics such as training staff to analyze sodium content in their menus; educating students on nutrition and menu changes; working with local and regional companies to find alternative products that met their sodium needs; and re -working their recipes to keep their foods with less sodium appealing to students.38 Other schools have also lowered sodium by using spice bars and salad bars that gives students more options to provide flavor with less salt. Schools all around the country—from Virginia to California, Indiana to Kansas, Oklahoma to New York, and Georgia to North Dakota —have successfully used these best practices to meet the Target 1 and Target 2 sodium levels. USDA should put greater effort into elevating and sharing these methods and encouraging their adoption by other schools around the country.

USDA programs like "Team Up for School Nutrition Success" and the "What's Shaking?" initiative have been beneficial, and we are pleased to read that USDA will continue these important initiatives. However, USDA needs to focus on targeted technical assistance that delivers more intensive and personalized training for those programs that may still have difficulties lowering sodium. In addition, while the USDA Foods (commodities) program has set a good example for schools by providing more moderate-sodium options, that work should continue.

The Academy agrees that USDA should re-evaluate the sodium reduction targets with the release of the 2020 DGA and encourages USDA to continue to support schools' efforts to work toward meeting existing DGA recommendations. USDA should address remaining challenges through enhanced training and technical assistance. If additional resources are required to provide technical assistance to ensure our students are receiving nutritious, appealing school meals, USDA should specify the amount and seek appropriations for this critical initiative. If a delay is deemed necessary for reformulation, we note that a delay in the second phase of sodium reduction would result in children consuming an extra 84 to 98 teaspoons of salt (over the course of the three -year delay).39 Further, we reiterate our concern that the delay contemplated in this IFR may be used to effectuate an eventual, unacceptable rollback or elimination of the third and final phase of sodium reduction for school meals (Target 3 which is supposed to go into effect School Year 2022-2023). The Academy is committed to the gradual reduction of sodium in school meals, and urges USDA to make clear its commitment to this shared endeavor.

D. Low-Fat Flavored Milk

As part of the Academy's commitment to meeting nutrition needs across the lifecycle, we are supportive of efforts to improve calcium intake and bone health by increasing milk consumption as recommended in the Dietary Guidelines, in particular consumption b y school-aged children. The 2015 DGA provides that "Some sweetened milk and yogurt products may be included in a healthy eating pattern as long as the total amount of added sugars consumed does not exceed the limit for added sugars, and the eating pattern does not exceed calorie limits."40 Unfortunately, "average intakes of dairy for most age-sex groups are far below recommendations of the Healthy U.S.-Style Pattern. Average dairy intake for most young children ages 1 to 3 years meets recommended amounts, but all other age groups have average intakes that are below recommendations."41 Flavored milk has been shown to be an effective tool in encouragi ng milk consumption by school-aged children; studies have demonstrated that school-aged children who drink flavored milk meet more of their nutrient needs, do not consume more added sugar, fat, or calories, and are similar in weight to non-milk drinkers.42 Flavored milk is not a major source of added sugars for children (major sources include soda, fruit drinks, grain desserts, candy, dairy desserts, and cold cereals).43

The Academy does not oppose providing schools with additional flexibility by allowing flavored low-fat (1 percent) milk for school meals and as a competitive food. Recognizing that the current standards that allow plain or flavored fat -free milk and plain low-fat milk are based on expert recommendations focused on the obesity epidemic from the National Academy of Medicine's 2009 report,44 and that the recommendations disallowed flavored low-fat milk because it would provide more calories and likely exceed the calorie maximum for school meals, Academy members report that reformulation of flavored milk and conscientious meal planning has enabled some schools to successfully include low - fat flavored milk without exceeding the calorie maximum. Should USDA seek an explicit standard for low-fat flavored milk, we note that the Robert Wood Johnson Foundation's Healthier Beverage Guidelines recommended that if schools offered flavored low-fat milk, it should be no more than 130 calories per 8 ounces.45

In addition, the Academy applauds virtually all SFAs (over 90 percent) that have employed strategies to encourage milk consumption, such as displaying plain milk in all-milk coolers, having plain milk account for at least one-third of the drinks displayed in each cooler, and placing plain milk in front of or before flavored milk or other sugary beverages.46 USDA should encourage these strategies and address any remaining challenges for the few SFAs through training and technical assistance.

E. Whole Grains

The Academy recognizes the success of most schools in meeting the whole grain requirements and urges USDA to ensure that any additional flexibility provided to those not yet meeting the standards is temporary and robust, reflecting a commitment to uniform adoption and compliance as soon as practicable. Temporary accommodation cannot result in permanent or long-term waivers or eventual rollback of the whole grain standards.

The 2015 DGA recommends making at least half of grains whole grain.47 Children aged 4 to 18 do not meet the recommended intake for whole grains and exceed the recommended limit for refined grains.48 Eating more whole grains is associated with reduced risk of heart disease, stroke, and diabetes, provides more nutrients, and are a healthful source of fiber.49

Whole grain-rich products are widely prevalent in the marketplace. As of December 2017, the Alliance for a Healthier Generation's Smart Food Planner, an online database that features food and beverage products that align with the school nutrition standards, shows that approximately 874 whole grain-rich products are currently available for purchase by schools.50 Further, USDA Foods provides more whole-grain products and has developed a number of resources that list whole grain-rich options.51

Many schools across the U.S. are offering whole grain-rich products on their menus that students enjoy. Academy members report whole grain rich buns are sold to students who consume them happily, with taste and texture regarded as at least as good as traditional refined grain buns. Successful strategies for encouraging students to eat more whole grains include student surveys, samples and taste tests, experimenting with new products and recipes, and peer-to-peer sharing of food preparation techniques. These techniques have also been successful in sodium reduction efforts.

USDA concedes in the IFR that 85 percent of schools have not requested waivers and are providing children with appealing whole-grain options. Some states do not have any schools requesting waivers such as Alabama, Idaho, and Montana, and others do not allow waivers such as Arkansas, Maryland, and Rhode Island.52 Some states have multiple waivers for only one type of product (e.g., pasta) like South Dakota, while North Dakota does not. We encourage USDA to provide additional training and technical assistance to the minority of school districts that currently are asking for waivers and are having difficulty meeting the whole grain-rich requirements.

F. Estimates of Benefits and Burdens to Children

USDA states in the IFR that, "…we expect the health benefits in this rule to be similar to the overall benefits of improving the diets of children cited in the RIA [regulatory impact analysis] for the final meal standard rule." However, the proposed three -year delay of the second sodium reduction targets keeps school meals at high levels of sodium, reducing the health benefit children would have had under the original timeline established by the 2012 final rule. USDA goes on to state that, "Further, we do not anticipate this interim final rule will deter the significant progress made to date by State and local operators, USDA, and industry manufacturers to achieve healthy palatable meals for students." We are concerned that further or permanently delaying sodium reduction levels could lead to industry halting efforts to innovate and reformulate, and halting school efforts that would otherwise have met the targets. The RIA does not provide a sufficiently thorough assessment of lost benefits. USDA cites the RIA for the 2012 final rule which indicated that, "…the likelihood is reasonable that the benefits of the rule exceed the costs, and that the final rule thus represents a cost-effective means of conforming NSLP [National School Lunch Program] and SBP [School Breakfast Program] regulations to the statutory requirements for school meals." In the final rule, the Academy stresses that USDA must calculate the reduced benefit to children for any changes it makes to the school nutrition standards related to sodium, whole grains, or flavored milk.G. Progress on Healthier School Foods

Schools have made extraordinary progress toward serving healthier meals with less sodium; more whole grains, fruits, and vegetables; and no trans fat, and removing soda, other sugary drinks, and unhealthy snack foods.53

1. Participation

The Academy has concerns about claims in the IFR related to changes in participation and specifically whether any changes are the result of changes to the nutrition standards. We note that in many respects and in many schools, participation is increasing. USDA correctly states that the decline in participation is among students purchasing full-priced meals and this decline began in 2008 (five years before the updated school nutrition standards went into effect in September 2012). However, USDA did not state that participation among students receiving free meals has dramatically increased (from 15.4 million children in 2008 to 20 million children in 2017) and remains the largest category (about two -thirds of participating students in 2017).54 Overall participation remains high with more than 30 million students participating in 2017. Many other factors impact participation, such as sales of competitive foods, increased charges for paid meals, an unacceptably short time allotted for students to eat, long lunch lines, and school closures and consolidations.

2. Reducing Health Disparities

Improvements in school foods have been critical to reducing health disparities and stigma for low-income children. According to research by Bridging the Gap, prior to the updated school nutrition standards, students in more affluent and larger schools wer e more likely to have access to healthier foods than those in lower-income and smaller schools.55 Another study found that improved school nutrition standards are associated with a decrease in obesity among low-income students.56 While USDA claims that the IFR provides flexibility and that it is up to schools whether to use them —such as not meeting the second phase of sodium reduction until SY 2021-2022—in reality this could negatively impact the progress to close health disparities. For instance, the IFR may result in low- income students in poorer schools having decreased access to healthier school meals with less sodium—which may be the only meals they consume that day—than students in more affluent schools that are already meeting or working toward the second phase of sodium reduction.

3. Increased Consumption; Same or Decreased Plate Waste

Students are eating more healthy food and studies show that plate waste has either remained the same or decreased since the updated school nutrition standards. A May 2014 Harvard School of Public Health study shows that children are now eating 16 percent more vegetables and 23 percent more fruit at lunch.57 A study released in March 2015 by the University of Connecticut's Rudd Center for Food Policy & Obesity found that students are eating more nutritious foods and discarding less of their lunches under the healthier standards.58 Children ate 13 percent more of their entrees, nearly 20 percent more vegetables, and chose 12 percent more fruit in 2014 compared to 2012, which means that students threw away less food than in the past.

4. Increasing Revenue

School lunch revenue can also increase with healthier school food. A study by the Robert Wood Johnson Foundation found that schools that implemented healthier nutrition standards for meals and snacks reported revenues rebounding to original profits two years after the updated standards went into effect (in 2014) and participation in the school meals program rose significantly among students from low-income families during the same period.59

Overwhelming Bipartisan Support for Healthy School Meals

The Academy notes that the public overwhelmingly supports healthier school meals. Nine out of ten Americans support the school nutrition standards.60 Nearly 70 percent believe school meals are excellent or good, compared to just 26 percent in 2010, before schools implemented the updated school nutrition standards. Students also like the taste of the healthier school meals. A September 2014 poll released by The Pew Charitable Trusts, the Robert Wood Johnson Foundation, and the American Heart Association shows that 72 percent of parents favor strong nutrition standards for school meals and 91 percent support serving fruits or vegetables with every meal.61 According to an August 2014 survey by the Robert Wood Johnson Foundation, the majority of school leaders nationwide reported that students liked the new lunches.62 Many statewide polls have demonstrated overwhelming support for the updated school nutrition standards. For instance, in Alabama,63 Kentucky,64 Louisiana,65 and North Carolina,66 more than 70 percent of parents support the standards. In addition, support for healthier school meals is bipartisan: the majority of registered voters with children in public schools are supportive of healthier school meals.67

H. Conclusion

Together, we have made substantial progress in developing, testing, and serving nutritious, palatable, and appealing school meals that children want to buy and consume. The Academy is emphatic that we cannot go backwards. To the extent that temporary accommodations are essential to effectuate long term compliance with school nutrition standards by all schools, we understand the need for flexibility insofar as it does not result in a weakening or rollback or permanent waiver of the achievable targets. Rather than weakening school nutrition standards, we urge the administration to stand firm and provide needed technical assistance that supports efforts to continue the progress made to- date in improving school food.

The Academy appreciates the opportunity to comment on t he IFR “Child Nutrition Programs: Flexibilities for Milk, Whole Grains, and Sodium Requirements,” which will help determine the future healthfulness of our children’s school meals. The Academy will continue to be at the forefront of child nutrition, from researching healthy practices and product reformulation to meal planning and direct engagement with students, parents, and policymakers. Please contact either Jeanne Blankenship at 312-899-1730 or by email at ptuma@eatright.org or Pepin Tuma at 202-775-8277 ext. 6001 or by email at <jblankenship@eatright.org> </jblankenship@eatright.org>

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 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 credenti als have identical meanings and legal trademark definitions.

2 Jackson SL, King SM, Zhao L, Cogswell ME. Prevalence of Excess Sodium Intake in the United States—

NHANES, 2009-2012. MMWR Morb Mortal Wkly Rep. 2016;64:1393-7. doi:10.15585/mmwr.mm6452a1.

3 Appel LJ, Lichtenstein AH, Callahan EA, Sinaiko A, Van Horn L, Whitsel L. Reducing Sodium Intake in

Children: A Public Health Investment. J Clin Hypertens. 2015;17:657-62. doi:10.1111/jch.12615.

4 U.S. Department of Agriculture. School Meal Certification Data (as of September 2016). Washington, DC: USDA; 2017.

5 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary

Guidelines for Americans, 8th Edition. Washington, DC: U.S. Government Printing Office, 2015.

6 Institute of Medicine. School Meals: Building Blocks for Healthy Children. Washington, DC: The National

Academies Press; 2010.

7 Gortmaker SL, Wang YC, Long MW, et al. Three Interventions that Reduce Childhood Obesity Are Projected to Save More Than They Cost to Implement. Health Aff. 2015;34:1932-9.  doi:10.1377/hlthaff.2015.0631.

8 Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of Obesity Among Adults and Youth: United States,

2011-2014. NCHS Data Brief. 2015;219:1-8.

9 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Childhood and Adult Obesity in the United States,

2011-2012. JAMA. 2014;311:806-14.

10 U.S. Department of Agriculture. School Nutrition Dietary Assessment Study-III. Washington, DC: USDA; 2007.

11 Id., Institute of Medicine. School Meals: Building Blocks for Healthy Children.

12 Id., Jackson SL.

13 Lawes CM, Vandler HS, Rodgers A. Global Burden of Blood-Pressure-Related-Disease, 2001. Lancet.

2008;371:1513-8.  doi: 10.1016/S0140-6736(08)60655-8.

14 Whelton PK, Appel LJ, Sacco RL, et al. Sodium, Blood Pressure, and Cardiovascular Disease: Further

Evidence Supporting the American Heart Association Sodium Reduction Recommendations. Circulation.

2012;126:2880-89.  doi:10.1161/CIR.0b013e318279acbf.

15 Id., Appel LJ.

16 Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction: The American Heart Association's Strategic Impact Goal through 2020 and Beyond. Circulation. 2010;121:586-613. doi:10.1161/CIRCULATIONAHA.109.192703.

17 Rosner B, Cook NR, Daniels S, Falkner B. Childhood Blood Pressure Trends and Risk Factors for High Blood Pressure: the NHANES Experience 1988–2008. Hypertension. 2013;62:247–54. doi:10.1161/HYPERTENSIONAHA.111.00831.

18 Yang Q, Zhang Z, Kuklina EV, et al. Sodium Intake and Blood Pressure Among US Children and Adolescents.

Pediatrics. 2012;130:611-9. doi:10.1542/peds.2011-3870.

19 Id., Rosner B.

20 Lichtenstein AH, Appel LJ, Brands M, et al. Diet and Lifestyle Recommendations Revision 2006: A Scientific

Statement from the American Heart Association Nutrition Committee. Circulation. 2006;114:82-96.

21 Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected Effect of Dietary Salt Reductions on Future

Cardiovascular Disease. N Engl J Med. 2010;362:590-9.  doi:10.1056/NEJMoa0907355.

22 Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart Disease and Stroke Statistics—2017 Update: A Report from the American Heart Association. Circulation. 2017;135. doi: 10.1161/CIR.0000000000000485.

23 Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: The National Academies Press; 2005. Tolerable Upper Intake Levels (UL): children aged 4 -8: UL 1,900 mg; children aged 9-13: UL 2,200 mg; children aged 14-18: UL 2,300 mg.

24 U.S. Department of Agriculture and U.S. Department of Health and Human Services. What We Eat in America, NHANES 2007-2010. Beltsville, MD: USDA, 2010. Average intake for males: children aged 4-8: 2,710 mg; children aged 9-13: 3,505 mg; children aged 14-18: 4,272 mg. Average intake for females: children aged 4-

8: 2,576 mg; children aged 9-13: 2,962 mg; children aged 14-18: 3,030 mg.

25 Institute of Medicine. Sodium Intake in Populations: Assessment o f Evidence. Washington, DC: The National

Academies Press; 2013.

26 American Heart Association. More Companies Lowering Sodium. https://sodiumbreakup.heart.org/more- companies-lowering-sodium. Published August 6, 2015. Accessed January 2018.

27 Soderlin B, Ruggles R. ConAgra Foods Cuts Sodium, But How Much Salt Is Too Much? Omaha World-Herald. May 15, 2013.  http://www.omaha.com/money/conagra-foods-cuts-sodium-but-how-much-salt-is- too/article_5390515d-3a44-571d-9260-949221613e9e.html.  Accessed January 2018.

28 Domino's Pizza. Smart Slice. https://biz.dominos.com/web/public/school -lunch. Accessed January 2018.

29 General Mills. Reducing Sodium. https://www.generalmills.com/en/Health/improving-health/reducing- sodium. Accessed January 2018.

30 Kellogg's. Continuing to Achieve Our 2020 Goals. http://www.openforbreakfast.com/en_US/content/nutrition/Kelloggs-progress-on-2020-goals.html. Accessed January 2018.

31 PRNewswire/Kraft Foods Inc. Kraft Foods On Track to Meet Sodium Reduction Goals Across Nor th American Product Portfolio. September 26, 2012.  https://www.prnewswire.com/news-releases/kraft-foods- on-track-to-meet-sodium-reduction-goals-across-north-american-product-portfolio-171344191.html. Accessed January 2018.

32 Giammona C. Mars Becomes First Food Giant to Call for FDA Salt Guidelines. Bloomberg. April 13, 2016. http://www.bloomberg.com/news/articles/2016-04-13/mars-becomes-first-food-giant-to-call-for-fda-salt- guidelines. Accessed January 2018.

33 PRNewswire/Nestlé. Nestlé Announces Support for Lower Sodium Targets. May 5, 2016. https://www.prnewswire.com/news-releases/nestle-announces-support-for-lower-sodium-targets-

300263325.html. Accessed January 2018.

34 Jones C. PepsiCo Pledges to Cut the Fat, Salt and Sugar by 2025. USA TODAY. October 17, 2016. https://www.usatoday.com/story/money/2016/10/17/pepsico-pledges-cut-fat-salt-and-sugar-

2025/92295106/.  Accessed January 2018.

35 Unilever. Reducing Salt. https://www.unilever.com/sustainable-living/improving-health-and-well- being/improving-nutrition/contributing-to-heart-health/reducing-salt/. Accessed January 2018.

36 New York City Department of Health and Mental Hygiene. National Salt Reduction Initiative. https://www1.nyc.gov/site/doh/health/health-topics/salt-initiative-restaurantfood.page. Accessed January

2018.

37 Antman EM, Appel LJ, Balentine D, et al. Stakeholder Discussion to Reduce Population-Wide Sodium Intake and Decrease Sodium in the Food Supply: A Conference Report from the American Heart Association Sodium Conference 2013 Planning Group. Circulation. 2014;129:660-79. doi:10.1161/CIR.0000000000000051.

38 U. S. Department of Agriculture. Training the Teachers in Our Biggest Classrooms. https://www.usda.gov/media/blog/2016/03/8/training-teachers-our-biggest-classrooms. Published March

2016. Accessed December 2017.

39 Difference between Target 1 and Target 2 sodium levels: grades k-5: 350 mg/day; grades 6-8: 390 mg/day; grades 9-12: 410 mg/day. Three-year delay is equivalent to mg/day x 185 school days x 3 school years (1 teaspoon = 2,325 mg): grades k-5: 194,250 mg (84 teaspoons); grades 6-8: 216,450 mg (93 teaspoons); grades

9-12: 227,550 mg (98 teaspoons).

40 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. Ch.2 at 49.  December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/.

41 Ibid.

42 Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth ("IOM Report"), Institute of Medicine, page 58.  Available at http://www.nationalacademies.org/hmd/Reports/2007/Nutrition-Standards-for-Foods-in-Schools-Leading-the-Way-toward-Healthier-Youth.aspx.  Accessed 27 January 2018. See also, Mary M. Murphy et al., Drinking Flavored or Plain Milk is Positively Associated wit h Nutrient Intake and Is Not Associated with Adverse Effects on Weight Status in U.S. Children and Adolescents, 108 J. Am. Diet. Assoc. 631, 631 (2008).

43 Fitch, C., & Keim, K. S. (2012). Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. Journal of the Academy of Nutrition and Dietetics, 112(5), 739–758; 744.

44 Id. Institute of Medicine. School Meals: Building Blocks for Healthy Children.

45 Healthy Eating Research. Recommendations for Healthier Beverages. Durham, NC: Robert Wood Johnson Foundation, 2013.  http://healthyeatingresearch.org/wp-content/uploads/2013/12/HER -Healthier-Bev-Rec- FINAL-3-25-13.pdf.

46 Id., Murdoch J.

47 Id., U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary

Guidelines for Americans.

48 Males (grains in ounce-equivalents): aged 4 to 8: average whole grains 0.7, average refined grains 5.4, recommended range for whole or total grains 2.0–3.0; aged 9 to 13: average whole grains 0.7, average refined grains 6.6, recommended range for whole grains 2.5–4.5; aged 14 to 18: average whole grains 0.8, average refined grains 7.5, recommended range for whole grains 3.0–5.0. Females (grains in ounce-equivalents): aged 4 to 8: average whole grains 0.5, average refined grains 5.0, recommended range for whole grains 2.0–3.0;

aged 9 to 13: average whole grains 0.6, average refined grains 6.0, recommended range for whole grains 2.5–

3.5; aged 14 to 18: average whole grains 0.5, average refined grains 5.5, recommended range for whole grains

3.0–4.0. Data source: U.S. Department of Agriculture and U.S. Department of Health and Human

Services. What We Eat in America, NHANES 2007-2010. Beltsville, MD: USDA, 2010.

49 U.S. Department of Agriculture. Why is it Important to Eat Grains, Especially Whole Grains?

https://www.choosemyplate.gov/grains-nutrients-health. Published June 2015. Accessed December 2017.

50 Alliance for a Healthier Generation. Smart Food Planner.  https://foodplanner.healthiergeneration.org. Accessed December 2017.

51 U.S. Department of Agriculture. Tools for Schools: Serving Whole Grain-Rich. https://www.fns.usda.gov/healthierschoolday/tools-schools-serving-whole-grain-rich. Published October

2017. Accessed December 2017.

52 Id., U.S. Department of Agriculture (unpublished). Whole Grain-Rich Exemption Take-Up by States: October

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53 Id., U.S. Department of Agriculture. School Meal Certification Data (as of September 2016).

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