Removing Junk Food and Beverages from School Vending Machines
We need to adopt policies that limit the sale of foods with little nutritional value in schools if we are to reduce the childhood obesity rate.
By Caleb R. Schultz, M.D.
Obesity rates in the United States are rapidly increasing among all age groups, making obesity a leading public health threat.1,2 Especially concerning are figures showing that one-third of children and adolescents are overweight or obese. These young people are at increased risk of developing numerous comorbidities including coronary artery disease and type 2 diabetes.2-4 Moreover, when an overweight or obese child becomes an overweight or obese adult, he or she can experience decreased quality of life, diminished productivity on the job because of increased rates of illness, and a shortened life- expectancy—all of which have deleterious economic effects.5,6
The reasons for the growing prevalence of obesity in the United States are multiple and varied. The obvious reason for weight gain is that the amount of energy consumed is greater than the amount of energy expended. Gaining small amounts of weight, year after year, is the way most people become overweight and obese. In fact, the average weight gain for adults is 0.5 to 1 kg/year.7 Often, the calories that lead to such small gains go unnoticed in daily diets. Many people consume energy-dense foods such as those that are high in fat and sugar and that are minimally or non-nutritious.8 In addition, adults and children have become more sedentary over the last several decades with the rise of personal computing, the increased mechanization of work duties, and the growth of screen-based entertainment.9-11
Because of limited funding, many schools have cut physical education programs and recess, and urban sprawl has produced communities in which driving, rather than walking, is required to get to work, school, stores, and other places.12-14 In low-income neighborhoods and minority communities, the lack of access to supermarkets and healthful foods has created “health-food deserts,” which contribute to obesity.15-17
Because the causes of overweight and obesity are numerous, the policies to combat the epidemic must be varied; no single solution alone will change the prevalence trends. Therefore, local communities, states, and the nation need to make numerous policy changes in order to begin bending the curve downward.
This article proposes one needed policy change regarding the nutritional quality of the foods offered in school vending machines. It presents the case for reducing access to non- nutritious foods and beverages in school vending machines, addresses arguments against removing these foods, and discusses issues that could hinder efforts to make such changes.
School Food Policy Overview
Policy initiatives related to preventing and reducing obesity generally have focused on either personal responsibility or environmental strategies. Policies aimed at personal responsibility have included encouraging individuals to eat better, decrease their calorie consumption, participate in nutrition education, and engage in physical activity.18 Strategies that focus on the environment have included subsidizing nutritious foods (fruits and vegetables); taxing foods and drinks that are low in nutrients; restricting marketing and advertising of foods that have little nutritional value; litigating against “dangerous” high-fat, high-calorie, minimally nutritious foods; banning the use of certain ingredients (eg, trans fats); requiring calorie labeling on menus; improving the nutritional content of foods sold in schools; and limiting or banning food or beverage advertisements within schools.18,19 Because foods provided at school are a big part of many children’s diets, policies that address food in schools are important for addressing the high rates of overweight and obesity in children.
The U.S. Department of Agriculture’s (USDA) Food and Nutrition Service administers the national school lunch and breakfast programs and subsidizes the foods served in schools that meet certain nutritional requirements.20 However, there is limited federal regulation of the nutritional content of competitive foods; these are foods sold in schools through vending machines, a la carte in lunch rooms, or through fundraisers that are in “competition” with foods provided by the national school lunch and breakfast programs. Federal regulations require that one segment of competitive foods—foods of minimal nutritional value—not be sold to students during the breakfast and lunch periods in food service areas.21 Foods of minimal nutritional value are those that provide less than 5% of the recommended daily requirements for each of eight specified nutrients (protein, vitamin A, vitamin C, niacin, riboflavin, thiamine, calcium, and iron) per serving and/or per 100 calories.22 However, included on a list of USDA exemptions are fruit roll-ups and other fruit snacks along with fruit-flavored waters and carbonated drinks that contain added sugar. The USDA’s allowing such exemptions has led many to call for a stricter definition of foods of minimal nutritional value.
Research has shown that competitive foods are widely available in schools and that many are of low nutritional quality.21, 23-27 Moreover, evidence suggests that the availability of competitive foods can have a negative impact on the healthfulness of children’s diets.28-31 For example, Kubik and colleagues found that the availability of competitive foods was associated with decreased consumption of fruits and vegetables and increased intake of total and saturated fat.29 According to national data from 2005, vending machines were available in 17%, 82%, and 97% of elementary, middle, and high schools, respectively.32,33 These and other reports underscore the widespread availability of vending machines in schools.34,35
Some school districts have policies limiting the amount of competitive foods and beverages that can be sold in schools; others ban them altogether. Numerous studies have shown that schools and school districts that have such policies regarding vending machine food see improved nutrition among students.36
The following is a proposed policy regarding beverages and foods in school vending machines that school boards and communities can use as a model as they take steps toward decreasing the availability of minimally nutritious foods and beverages. It reflects aspects of various competitive food policies used by school systems across the country or offered by nutrition and policy groups. The policy is based on nutritional guidelines from numerous sources including the American Dietetic Association, Centers for Disease Control and Prevention, Center for Science in the Public Interest, Institute of Medicine, and statutes within the Nutrition Labeling and Education Act; it incorporates the most stringent recommendations in order to maximize healthful food choices by students.37-45
Foods and beverages sold in school vending machines would meet the following nutrition and portion requirements:
Allowed: Water or seltzer water without added caloric sweeteners; 100% fruit and vegetable juices that do not contain additional high-calorie sweeteners; and unflavored or flavored low-fat (1%) or fat-free milk and nutritionally equivalent nondairy beverages
Prohibited: Soft drinks, sports drinks, and iced teas that contain caloric sweeteners; fruit-based drinks that contain less than 100% real fruit juice or that contain additional caloric sweeteners; beverages containing caffeine, except for low-fat (1%) or fat-free chocolate milk, which contains trivial amounts of caffeine.
Low-fat: 30% of calories or fewer from fat (excluding nuts, seeds, peanut butter, and other nut butters); 10% of calories or less from saturated fat; no amount of trans fat; less than 3 g of total fat per serving, and less than 1 g of saturated fat per serving
Low-sugar: 35% or less of an item’s weight from added sugar, excluding sugar that occurs naturally in fruit, vegetables, and dairy products Low-salt: 230 mg or less of sodium
Nutrient-rich: Provides at least 10% of one or more of vitamins A or C, iron, calcium, protein, or fiber; exempt are certain raw, canned, and frozen fruits and vegetables
Beverages: 12 oz.; no limit on water
Foods: Yogurt (not frozen) 8 oz., frozen desserts/ice cream 3 fl. oz., bakery items (pastries, muffins, etc.) 3 oz., cookies/cereal bars 2 oz., snacks/sweets (chips, crackers, popcorn, cereal, trail mix, nuts, seeds, dried fruit, jerky, etc.) 1.25 oz.
A school district’s nutrition services department would use this criteria to select the items that could be sold in their vending machines. Such items would only be available for sale after the final lunch period. The district superintendent would be responsible for overseeing the implementation and enforcement of the policy. Penalties for policy violation might include fines in the form of withheld vending machine revenue; these fines would increase incrementally per incident.
In Minnesota, a number of county public health departments; the Coordinated School Health Council within the Minnesota Department of Health; Action on Obesity Minnesota; the state chapters of the American Academy of Pediatrics, American Dietetic Association, American Public Health Association, and American Academy of Family Physicians; Rep. Tim Walz, a member of the House Agriculture Committee and former public school teacher; the Minnesota Obesity Center; and the Healthy Foods, Healthy Lives Institute at the University of Minnesota have supported raising nutrition standards in schools. Nationally, First Lady Michelle Obama, senators Tom Harkin (D-IA), Chris Dodd (D-CT), and Blanche Lincoln (D-AK); and the Society for Nutrition Education, American School Food Service Association, American Heart Association, William J. Clinton Foundation, and Center for Science in the Public Interest have supported improving the nutritional content of foods and beverages sold in schools and limiting access to foods that have little nutritional value. Last month, the U.S. Senate passed the Healthy, Hunger-Free Kids Act of 2010, which directs the USDA Food and Nutrition Service to increase meal reimbursements to school systems, offers schools enhanced training on preparation of healthier meals, and strengthens school wellness policies around nutrition and physical activity. The bill also requires that foods and beverages sold in schools, including competitive foods sold in vending machines and a la carte in cafeterias, meet the revised USDA nutritional standards. It will be imperative that the USDA ensure that the most stringent nutrition standards are adopted, not standards based on food and beverage industry “scientific” analysis and lobbying. In the U.S. House, the bill has passed out of committee and should come up for a vote in the next few months.
Those opposing school-based food policies are numerous, strong, and well-funded. Although at first glance surprising, local school boards and principals, the National School Boards Association, and National Association of Secondary School Principals have opposed efforts to offer healthful foods in vending machines because they fear revenue loss. Other groups opposing such policy changes include the American Beverage Association (formerly the National Soft Drink Association), the Snack Food Association, the Grocery Manufacturers of America, the Center for Consumer Freedom, and the Sugar Association.
Representatives from the snack food and beverage industries have argued that they already contribute to public health efforts. For example, McDonald’s vice president of social responsibility and communications Mike Riker was quoted in an article in BusinessWeek saying, “McDonald’s has sponsored physical fitness programs and nutrition education for decades. McDonald’s takes nutrition very seriously.”46 Moreover, food and beverage companies and the groups that represent them highlight their signing of a Memorandum of Understanding on School Competitive Foods and Beverages, an agreement to improve the nutritional value of competitive foods in schools.47 The memorandum was signed by the American Heart Association, the Alliance for a Healthier Generation, the William J. Clinton Foundation, and five food companies—Campbell Soup Company, Dannon, Kraft Foods, Mars, and PepsiCo. Representatives from the food and beverage industries say that this attempt at self-regulation makes legislation unnecessary. However, the guidelines in the memorandum are only recommendations, and they often are not enforced because the signatories (Pepsi, the American Beverage Association, and Campbell Soup, for example) do not directly provide competitive foods to schools and can only encourage distributors to support such nutrition changes. The only way to ensure that distributors offer healthful competitive foods is through legislation and regulation.
A key industry strategy is to emphasize the importance of physical activity, rather than food consumption, in obesity prevention. A spokesperson from the National Soft Drink Association once said that obesity “is about the couch and not the can.”48 Clearly, inactivity plays a role in the growing rates of obesity; however, the importance of increased calorie consumption, especially from non-nutritious, high-calorie foods, cannot be understated.
Opposition groups argue that there are no good or bad foods, implying that no foods or types of foods (such as soft drinks, candy, or snack foods) should be singled out and that programs aiming to change their consumption are unfair. Borrowing an argument from the tobacco industry, food industry leaders often note that attempts to limit access to certain foods and beverages are a threat to personal freedom. They further argue that consumers deserve choices; and they say that if children do not have choices, they will never learn how to make good decisions about nutrition.49 If access to junk food helped kids make more healthful food choices, which no reasonable person expects, then one could argue for placing cigarette vending machines in schools as well so that children could learn to make the right decision about tobacco.19
Another commonly heard argument against school policies that limit non-nutritious foods is that it is the responsibility of parents to teach healthful eating habits.50 In essence, this means that parents must overcome the influence of thousands of advertisements and famous endorsers touting products that may be harmful. In the end, such a singular approach places the blame for overweight kids on parents. Certainly, parents need to help their children make wise food choices; but this is only one part of a successful strategy for fighting obesity.
Finally, many school districts are hesitant to enact policies that restrict competitive food offerings, fearing that such actions will result in substantially decreased revenue. Studies from across the United States, however, have shown that offering healthful foods and beverages in vending machines allows for continued revenue generation; in some cases, profits increased after healthful foods replaced unhealthful options.36,51 The proposed policy would have no effect on a la carte food sales. And the limited data do not support the concern that improving the nutritional quality of competitive foods will hurt school revenue.
Issues that Affect Implementation
A potential hurdle in implementing this policy to decrease the availability of unhealthful foods may be finding products that meet the recommended nutritional criteria; finding ones in the portion sizes that meet the policy requirements may be even more challenging. This underscores the importance of enlisting the help of the food and beverage industry, as portion sizes may need to be altered.
Some may argue that the proposed policy does not go far enough in limiting the availability of competitive foods that have poor nutritional value. But this incremental approach to eliminating these foods would allow school districts to realize success and allay their fears about lost revenue. In order to accurately assess the results of such a policy, however, vending companies would have to be willing to offer data on the sale of products sold in their machines.52
To adequately address the epidemic of overweight and obesity in children in the United States, we will need to enact healthful food policies across all sectors of society. Changing school policies so that they support healthful eating is critical to this effort. The policy proposed in this article is one step toward that end. By selling healthful foods to students in vending machines, consumption of high-calorie junk foods with little nutritional value will decrease. Schools must offer children food choices, but it is important to make it easy for children to make healthful choices.
Improving the health of society requires the help of physicians, regardless of specialty, outside the clinic or hospital. Advocacy needs to go beyond guild-based specialty society interests or financial concerns and focus on local, state, and national policies that enhance the health and well-being of society. Publicly supporting improved school nutrition policies is one thing physicians can do to improve the well-being of the nation’s children. MM
Caleb Schultz is an anesthesiology resident at Mayo Clinic and is enrolled in the University of Minnesota’s Executive Master’s in Public Health Program. He served as the former health policy director for Rep. Tina Liebling.
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