Proposed Nutrition Standards for Competitive Foods and Beverages in Massachusetts Public Schools

July 13, 2011

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Outline

• Brief review of statute• Summary of regulatory process to date• Review of comments and DPH responses• Proposed guidance document• Implementation and next steps

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• Law signed on July 10, 2010• Development of draft regulations

– Interagency workgroup with Department of Elementary and Secondary Education, John Stalker Institute, Boston Public Health Commission, Harvard School of Public Health

• Presentation to PHC February 9th

• Public comment period through April 8, 2011• Public hearings March 28 and April 5, 2011 • Revision and finalization of regulations• Approval by EOHHS and Governor’s Office • Presentation to PHC for final promulgation

Development of NutritionRegulations for Massachusetts Schools

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Overview of Key Elements of Bill

• Requires DPH to establish nutritional standards for “competitive foods and beverages” in public schools sold up to 30 minutes before or 30 minutes after the school day

• Update standards every 5 years

• Plain water readily available during school day at no cost

• Offer fresh fruits/non-fried vegetables wherever food is sold (except vending machines)

• Make nutrition info available for non-prepackaged foods (except fresh fruits/vegetables, food/beverages sold at booster sales and other school sponsored events)

• Prohibit use of fryolators in preparing competitive foods

• Ensure food preparation and all foods/beverages meet state and federal food safety guidelines

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Overview of Key Elements of Bill

• Requires regulations to promote school wellness advisory committees

• Requires training of public school nurses in screening and referral for obesity, diabetes and eating disorders

• Establishes Commission on School Nutrition and Childhood Obesity

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Public Comment

• 2 public hearings: March 28 in Boston and April 5 in Springfield – More than 60 people attended these hearings– 19 parties submitted oral testimony

• 91 written responses received

• Testimony and written comments were reviewed by interagency workgroup.

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Public Health Organizations

• 8 organizations strongly supported the regulations as presented

– BPHC

– Everett Community Health Partnership

– Springfield Wellness Leadership Council

– American Diabetes Association

– Voices for a Healthy SouthCoast

– Service Employees International Union

– Healthy Foods in Northampton Schools Coalition

– Massachusetts Dietetic Association

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Public Health Organizations

• 8 organizations supported the regulations with stronger qualifications (add fiber requirement, lower sugar content, extend to 24/7, etc.):

– Western Massachusetts Center for Healthy Communities

– Massachusetts Public Health Association– Project Bread– Cambridge Public Health Department– Hunger-Free and Healthy Worcester– American Academy of Pediatrics – Massachusetts

Chapter– Harvard School of Public Health Prevention Research

Center– Act FRESH Campaign

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Comments on Juice – Portion Size Limit

Comments were received

• requesting an increase in the size limit for juice for middle and high schools.

• requesting the elimination of juice altogether.

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DPH Response

Juice – Portion Size Limit

Proposed:

No more than 4-ounce servings for elementary/middle schools No more than 8-ounce servings for high schools

Final Recommendation:

Revise the standard to servings of juice shall be no more than 4 ounces.

Rationale:

Dietary Guidelines for Americans 2010 and National School Meals Program serving size for juice is 4 oz.

American Dietetic Association advises “whenever possible to replace these drinks with plenty of water.”

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Comments on Milk – Portion Size Limit

• Comments were received requesting to allow 10-ounce servings of milk for middle and high schools.

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DPH Response

Milk – Portion Size Limit(Including alternative milk beverages such as lactose-free and soy)

Proposed:

No more than8-ounce servings

Final Recommendation:

Maintain standard

Rationale:

National School Meals Program portion size is 8 ounces

DGA 2010 recommends: “3 cups/day fat-free or low-fatmilk and milk products for adults and children andadolescents ages 9 to 18 years, 2½ cups/day for children4 to 8 years, and 2 cups for children 2 to 3 years.”

Plastic containers are now available in 8 ounce sizes.

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Comments on Beverages with Added Sugar or Sweeteners

Comments were received - • From organizations (School Nutrition

Association, Dairy Council and the MA Nutrition Board) and individuals regarding allowing flavored milk.

• Recommending the exclusion of flavored milk in the regulations.

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DPH Response

Beverages with Added Sugar or Sweeteners

Proposed:

Any beverages withadded sugar orsweeteners notalready prohibited willbe phased out byAugust 1, 2013.

A school may provideor sell flavored milk ormilk substitutes thatcontain the sameamount or less sugarthan plain, fat-free orlow-fat milk.

Final Recommendation:

Maintain current standard

Rationale:

Limiting the availability and accessibility of sugar-sweetened

beverages can decrease consumption of sugar-sweetened

beverages and increase the consumption of more healthful

drinks. Adding sugar to plain milk (flavored milk contains at

least 2.5 teaspoons of added sugar per 8 ounce serving) can

substantially increase the calories per serving without increasing

overall nutrient value. Schools have an important opportunity to

restrict the availability of sugar-sweetened beverages, and to

educate and model healthy behavior (CDC).

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Comments on Sugar

• Comments were received requesting that the amount of sugar allowed in each product be decreased from 35% to 20% or 25%.

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DPH Response

Sugar

Proposed:

No more than 35percent totalcalories fromsugars

Final Recommendation:

Maintain current standard

Rationale:

There was not enough evidence to support this recommendedrevision.

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Comments on Sugar Exemptions

• Recommendations were received to decrease the amount of sugar in yogurt from 30 grams to 20 grams of sugar per 8 ounce serving.

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DPH Response

Sugar Exemptions(All other categories apply, e.g., fat and calories.)

Proposed:

Low-fat or non-fatyogurt (includingdrinkable yogurt)with no more than30 grams of totalsugars, per 8-ounceServing

Final Recommendation:

Maintain current standard

Rationale:

Currently there is no product except for plain yogurt that would meet this recommended revision.

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Comments on Artificial Sweeteners

Comments were received from - • organizations (AHA and MA Beverage

Association) and individuals requesting that artificial sweeteners be allowed.

• Requesting that artificial flavors and colors be excluded along with artificial sweeteners.

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DPH Response

Artificial Sweeteners

Proposed:

No artificial sweeteners

Final Recommendation:

Maintain current standard

Rationale:

There is incomplete evidence on the long-term health effects ofnon-nutritive sweeteners, particularly from exposure initiated inchildhood. Some research suggests that non-nutritivesweeteners can increase preference for sweet foods and leadto increased calorie consumption. Additionally, the objectiveis to encourage children to enjoy natural flavors of foods andbeverages – not artificially enhanced with a sweet taste.

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Comments on Fiber

• Comments were received requesting the addition of a fiber requirement to supplement the current whole grains requirement.

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DPH Response

Fiber

Final Recommendation:

Do not add an additional standard.

Rationale:

IOM did not specifically mention a fiber requirement becauseof the emphasis on fruits, vegetables and whole grains, all ofwhich contain a significant amount of fiber.

A few work group members also warned that fiber was addedto many products that were not whole grain so adding thisguideline could be confusing.

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DPH Response - Definitions

There were several public comments askingfor clarification of proposed definitions

– Added: “An item is one serving of a product; packaged items can contain no more than one serving per package.”

– Added: “When applying the nutrition standards of 105 CMR 225.000, the food product should be analyzed as a whole, not by the individual ingredients that make up the product.”

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DPH Response - Definitions

– Revised (to include Healthier US terminology):

“Whole grains mean grains or the foods made from

them that contain all the essential parts and naturally

occurring nutrients of the entire grain seed. For

purposes of these regulations, whole grain should be

the primary ingredient by weight, (i.e., whole grain

listed first in the ingredient statement).”

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DPH Response - Definitions

– Revised (to clarify that guidelines apply to ALL

the locations in and around the school) – food

and beverages offered, sold or provided in:

• school cafeterias offered as à la carte items• school buildings, including classrooms and hallways• school stores• school snack bars• vending machines• concession stands• booster sales• fundraising activities• school-sponsored or school-related events• any other location on school property

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DPH Response - Definitions

– Revised (for feasibility of implementation):

“Fresh” means fresh, frozen, dried or canned without

added sugar, fat, or sodium, for the purpose of these

regulations.”

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Concerns Beyond DPH Authority: Proposed Guidance Document Topics

• Restricting of marketing to students• Not using food as a reward• Limiting access of outside vendors to students• Nutrition education for parents/students• Monitoring the regulations• Applying the regulations 24/7• Lunch duration• Scheduling recess before lunch

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Other Proposed Guidance Document Topics

• Easy-to-read chart of the guidelines with examples for each category

• Links to resources, such as the MA Action for Healthy Kids “A List” of approved foods and beverages

• Alternatives for successful school fundraising activities• Alternatives for healthy celebrations • Implementing the water regulation• Implementing nutrition information regulation• Implementing financially successful school nutrition

standards

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Implementation and Next Steps

• Regulations go into effect August 1, 2012, except for following provisions which go into effect August 1, 2013

• eliminating beverages with added sugar or sweeteners• making nutritional information available

• DPH guidance documents currently being prepared by interagency workgroup to facilitate policy implementation and share best practices

• Training programs and technical assistance for school nutrition directors and other appropriate school personnel are being prepared by DESE and John Stalker Institute

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Acknowledgements

• Internal DPH work group– Laura York– Chris Nordstrom– Cynthia Bayerl– Diana Hoek– Cheryl Bartlett– Howard Saxner– Lauren Smith

• John Stalker Institute– Karen McGrail

• Boston Public Health Commission– Kathy Cunningham

• DESE staff – John Bynoe– Katie Millett– Carol Goodenow– Linda Fischer– Mary Anne Gilbert– Rita Brennan Olson

• Harvard School of Public Health– Eric Rimm– Juliana Cohen– Jessica Garcia