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Thinking Outside the (Lunch) Box

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FULL TEXT ALSO AVAILABLE AT: http://jama.jamanetwork.com/article.aspx?articleid=2480490 ... When I see a young boy for a checkup and his mother has provided him with chips, candy, and a sugary drink as an examination room snack, I am affected by the image. I too have a son, but my son eats differently. His whole environment is different. At least, so I thought ... ... Who should decide what a child eats at school? Other children’s parents? A teacher? What about the child’s parents? ... ... When food provision does occur, is it defensible to operate by an opt-out model (relying on vulnerable children to decline unhealthy items—engineered to be desirable, craveable, and arguably even addicting—offered by trusted adults, at school events, especially in the context of peers saying “yes”)? ... ... As of this writing, the school administration is considering our policy proposal ... ... If we can have nut-free schools, we can have junk-free schools—or at least schools that make less-healthy foods less ubiquitous and routine and healthier foods more available, accessible, and acceptable for all. Issues related to school food extend well beyond the lunchroom; addressing the is- sues will require thinking outside the lunch box.
Copyright 2016 American Medical Association. All rights reserved.
Thinking Outside the (Lunch) Box
I am a family physician in the Bronx, New York. My pa-
tients are predominantly lower-income minorities who
face many obstacles to healthy eating. During patient vis-
its, I have seen Coca-Cola in baby bottles and french fries
as infant food. A common theme in my patients’ diets is
a paucity of whole foods and a preponderance of ultra-
processed products.
Certainly, education plays a role; my patients gen-
erally have lower levels of schoolingand lower health lit-
eracy. Part of my job as a physician is to educate. Given
that nutrition impacts general health and wellness and
the management of virtually all disease states, I find my-
self counseling on diet at most patient visits.
When I see a young boy for a checkup and his mother
has provided him with chips, candy, and a sugary drink
as an examination room snack, I am affected by the im-
age. I too have a son, but my son eats differently. His
whole environment is different. At least, so I thought.
A Healthy Environment
MyfamilyandIliveoutside the Bronx—in an upper-middle-
class suburb bordering an affluent community. Access
to healthy food is not an issue, making our area very
much unlike the neighborhoods where my patients live.
The area is home to the school where my son
entered first grade last year. I was pleased to learn the
school supported a Healthy Snack Program (in which
parents take turns providing wholesome foods for chil-
dren in a class to share). For my son, these snacks
would supplement a healthy parent-packed lunch he
would bring from home every day. At least, that was
the plan.
But shortly after the school year began, I started to
notice some of my son’slunchbox favorites coming back
home, unfinished or uneaten. Something was up.
Unhealthy School Food
Ultimately,I discovered what was displacing items from
my son’slunch box was other foods. Some of these foods
were the “healthy” snacks provided by other parents—
snacks like Mott’s Apple Sauce and Go-Gurt.It would
hardly be a stretch to characterize Mott’s Apple Sauce
as a fruit-added corn syrup or Go-Gurt as a sugary blend
of suspicious synthetics with a modicum of milk to con-
note actual fermented dairy.
Nonetheless, “healthy” may have been a relative dis-
tinction, differentiating classroom snacks from other
foods at school. For instance, birthday parties occurred
with regular frequency in a class with just under 20 stu-
dents. Cupcakes, cookies, ice cream, and/orsugary drinks
almost inevitably defined these events.
Then there were the parities to recognize different
cultural holidays (Diwali, Hanukkah, Kwanza,Christmas,
Lunar New Year, etc) and to mark other events
(Halloween, Children’s Day, Valentine’s Day, last day of
classes, etc). These celebrations (often multiple per
holiday/event) frequently had sign-ups up for “salty
snacks” (various chips), “sweet snacks” (cakes and
candies), and “drinks” (inevitably sugared).
Then there were field trips (with, for example,
snack stops at McDonald’s) and “bake”sale s (often fea-
turing less-“baked”-than-assembled ultraprocessed
standards like Rice Krispies Treats and Jell-O concoc-
tions). Although field trips and bake sales were not
frequent, they added to other school-sanctioned food
provision that was more common (eg, teachers using
candy as incentive or reward in the classroom or as ma-
terial for in-class projects—eg, making “snowmen” from
marshmallows or doing math with Skittles).
And there were still other items to displace healthy
foods from a lunchbox. The after-school program made
Goldfish (an industrial amalgam of artificial ingredients
and refined starch) and animal and Graham “crackers”
(ie, animal and Graham cookies) regular offerings,
as well as other substantively synthetic starchy and
sugary snacks. Had my son been old enough to partici-
pate in activities of the middle school, similar items
from vending machines might have also contributed to
the mix.
Addressing the Situation
I gleaned from orientation events at the school that
other parents were well educated and quite comfort-
able financially. Certainly other parents were invested—
and had invested—in their children’s futures. Likewise
the school seemed dedicated to healthy child develop-
ment, and teachers and administrators seemed com-
mitted to an overall goal of building healthy minds
and bodies. Perhaps these well-intended, informed,
and well-resourced people just didn’t see the connec-
tion between food, education, and broader child
wellness?
I sent an observational email about school foods to
my son’s teacher and the parent representative for his
class. I was referred to the school nurse, who in turn re-
ferred me to the head of the lower school.
The lower-school head invited me in for a chat
and ultimately thought a wider conversation was in
order. She suggested a “coffee talk” (a morning ses-
sion where I could present to teachers, administra-
tors, and parents).
Making a Case
I opened the “coffee talk” by sharing my experience as
a family physician. I described seeing first-hand the bur-
den of largely preventable diet- and weight-related
chronic conditions across generations, and the appear-
ance of diseases in childhood once thought to be adult-
onset only. I reviewed diet’s links to attention and aca-
demics, to dental caries and digestive issues, and to
A PIECE OF MY
MIND
Sean C. Lucan, MD,
MPH, MS
Department of Family
and Social Medicine,
Albert Einstein College
of Medicine, Bronx,
New York.
Corresponding
Author: Sean C. Lucan,
MD, MPH, MS
(slucan@yahoo.com).
Section Editor:
Roxanne K. Young,
Associate Senior Editor.
>
Opinion
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overall health and longevity. I expressed concern about food provi-
sion and food lessons coming from the school.
A central thrust of my message was that children are what
they eat—literally; what we put in their bellies becomes the actual
substance of their bodies and brains. I used an analogy I use in
clinic: “If you were erecting a building, would you allow shoddy
materials?”
I stressed that any absence of apparent obesity should not at
all be reassuring: “Tallslender buildings are no less prone to crumble
when weak at their bases, and when we feed our kids junk, we build
a foundation of poor health,” with tastes, preferences, habits, and
behaviors that set children on a path toward unwell adulthoods.
I emphasized that the healthiest foods come from botanical
plants, not processing plants.
1
Several attendees nodded, which I
interpreted as agreement. But one dad worried about becoming a
“food Nazi.” Was I proposing no cookies, candy, or celebratory
treats for our kids? A childhood of deprivation was not a child-
hood as far as he was concerned. He had a point. But that wasn’t
my point.
Refining the Message
The message I wanted to convey was not one of deprivation but of
quality, quantity, and control.
First, it’s not that children should be disallowed treats. But there
is huge difference, for example, between a frozen treat made from
smashed-up whole fruit and an alternative engineered from “sugar,
dextrose, partially hydrogenated coconut oil, corn syrup solids,
maltodextrin, sodium caseinate, salt, guar and xanthan gums, natu-
ral and artificial flavor, monoglycerides and diglycerides, dipotas-
sium phosphate, and yellow dyes 5 and 6” (actual ingredients from
an actual “food” for kids).
Second, a “treat” is only a treat (by definition) if it is rare or out
of the ordinary.With snack programs, teachers’ rewards, in-class proj-
ects, vending machines, class parties, and various other school events
including the occasional field trip or bake sale, unhealthy products
a school may try to frame as “treats” are neither rare nor out of the
ordinary. They are ubiquitous and routine, being regularly en-
dorsed and provided—even celebrated! Given that a single drink box
and cupcake could provide more sugar than the World Health
Organization recommends even a moderately active 7-year-old con-
sume over an entire day (or even, ideally, over two days),
2
the regu-
larity of such consumption is alarming.
Third, and perhaps most important, who should decide what a
child eats at school? Other children’sparents? A teacher? What about
the child’s parents? Or someone else only with parental consent?
Schools need parental permission—and physician authoriza-
tion—to administer even a single dose of medication, but some-
how feel free to administer regular doses of other substances that
may affect physical and mental wellness (ie, various foodstuffs) with-
out even so much as parent notification.
The fact is, schools do not need to provide food for many of
the occasions they do today (eg, why not have fun activities
instead of sweets for birthdays?). When food provision does occur,
is it defensible to operate by an opt-out model (relying on vulner-
able children to decline unhealthy items—engineered to be
desirable, craveable, and arguably even addicting
3
—offered by
trusted adults, at school events, especially in the context of peers
saying “yes”)?
Policy and Precedent
Some of the parents who attended my “coffee talk” resonated with
my message. Weeks after the talk, we connected over email and to-
gether decided to draft a proposal for school-level policy.
In our proposal, we argued that nutrition is a critical determi-
nant of academic performance, child development, and broader well-
ness. More broadly, foodis a central concern of our time, with food
production and consumption having implications for personal, popu-
lation, and planetary health.
We proposed a standard for foods provided or sanctioned by
the school: real whole foods with minimal processing or packaging
(eg, fruits, vegetables, seeds, and whole grains), and restricted pro-
vision of ultraprocessed products (ie, items with refined starches,
added sugars, hydrogenated oils, or any ingredient that an adult
reader of the ingredient list [1] cannot pronounce, [2] does not
know what it is, or [3] would not recognize as actual food). Parents
would still be able to provide whatever items they feel are best for
their own children (but not for other people’s children).
We placed our proposal within the context of the school’s
existing food policy: an outright ban on nuts. We argued that the
“nut-free” policy has only a small chance of benefiting a tiny
minority of students, although science does not clearly support
the strategy and experts do not espouse it.
4
Moreover, the cost is
an inconvenience to all families and possible nutritional compro-
mise for unaffected students (ie, through vastly inferior chips,
crackers, and cookies officially recommended as alternatives
5
and
by removing nutritious staples from options available to possibly
picky eaters). By comparison, our proposed new policy could
benefit nearly all students, might improve nutrition broadly, and
would inconvenience only families wishing to provide their own
children with the kind of unhealthy “treats” the school would no
longer provide. We also noted that children exposed to healthier
food at school might bring healthy lessons home to their
families,
6
improving the quality of the foods in the house (and
possibly then sent back to school).
Of course, we anticipated that cost would be a concern. But
healthy food need not be more expensive.
7
Indeed, one parent
involved in our effort was able to negotiate with a nearby food
store and local farm (businesses seeing potential customers in the
school’s families and staff) to get fresh whole fruits and minimally
processed vegetables for classrooms at steep discounts. On aver-
age, these snacks would cost less than the $0.30 per student per
day that the school historically budgeted for its less-healthy
snacks.
We also anticipated that kids’ acceptance of new foods, par-
ticularly vegetables, would be a concern. But a pilot test of new pro-
duce offerings in some classrooms (lasting a few weeks and predat-
ing the new policy proposal) showed that children ate them—and
liked them! To kids, novel snacks (eg, vegetables cut into fun shapes)
can be bona fide “treats.”Healthy snacks can be festive and fun, just
as they can be financially feasible.
Hope for the Future
As of this writing, the school administration is considering our policy
proposal. And parents involved in writing the proposal are reach-
ing out to other parents and teachers for support. But I am sure the
issue of unhealthy food is not unique to my son’s school (nor to the
city or state in which it is located, nor to private schools in general).
Opinion A Piece of My Mind
28 JAMA January 5, 2016 Volume 315, Number 1 (Reprinted) jama.com
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Given part of a doctor’s job is to teach, I hope other physi-
cians will likewise bring lessons about healthy eating to schools in
their own communities. Other parents can get involved too and
need not be physicians to educate or advocate. Indeed, more
critical skills for effecting change—like in finance, negotiation,
organizing, and change management—might come from parents
outside medicine.
Schools afford multiple opportunities to positively influence
nutrition and broader wellness. If we can have nut-free schools,
we can have junk-free schools—or at least schools that make
less-healthy foods less ubiquitous and routine and healthier foods
more available, accessible, and acceptable for all. Issues related to
school food extend well beyond the lunchroom; addressing the is-
sues will require thinking outside the lunch box.
Conflict of Interest Disclosures: The author has
completed and submitted the ICMJE Form for the
Disclosure of Potential Conflicts of Interest.
Dr Lucan serves as a member of the Scientific and
Nutritional Advisory Board for Epicure. No other
disclosures were reported.
Funding/Support: Dr Lucan is supported by the
Eunice Kennedy Shriver National Institute of
Child Health and Human Development of the
National Institutes of Health under award
K23HD079606. The content is solely the
responsibility of Dr Lucan and does not
necessarily represent the official views of the
National Institutes of Health.
Additional Contributions: Special thanks to
Danielle Bocchino and Ivana and Jon Rustin for
contributing ideas and enthusiasm to the draft
school-food policy and for commenting on an
early version of this essay.Special thanks too to
Lenard Lesser for reviewing a later version of the
manuscript and for providing critical comments.
1. Lesser LI, Mazza MC, Lucan SC. Nutrition myths
and healthy dietary advice in clinical practice.
Am Fam Physician. 2015;91(9):634-638.
2. World Health Organization. WHO calls on
countries to reduce sugars intake among adults and
children. http://www.who.int/mediacentre/news
/releases/2015/sugar-guideline/en/. Accessed
August 20, 2015.
3. Moss M. The extraordinary science of addictive
junk food. New York Times. February 20,
2013:MM34.
4. Sicherer SH, Mahr T;American Academy of
Pediatrics Section on Allergy and Immunology.
Management of food allergy in the school setting.
Pediatrics. 2010;126(6):1232-1239.
5. SnackSafely website. Safe Snack Guide.
http://snacksafely.com/download/. Accessed
August 20 2015.
6. Lytle LA, Kubik MY, Perry C, Story M, Birnbaum
AS, Murray DM. Influencing healthful food choices
in school and home environments: results from the
TEENS study.Prev Med. 2006;43(1):8-13.
7. McDermott AJ, Stephens MB. Cost of eating:
whole foods versus convenience foods in a
low-income model. Fam Med. 2010;42(4):280-284.
The time indeed is at hand when systematic lectures
on food will be part of medical education, when the
value of feeding in disease is admitted to be as
important as the administration of medicines.
John Milner Fothergill (1841-1888)
A Piece of My Mind Opinion
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Purpose – The purpose of this paper is to identify patterns of medium preference for loyalty programs (LPs) among members to support the case for segmenting customers based on their medium preference. Design/methodology/approach – A survey of nearly 2,000 customers who are enrolled in at least one supermarket LP was employed. LP members are segmented based on a latent class clustering model and then profiled in terms of socio-demographic variables by means of a multinomial logit regression model. Findings – Medium preference is heterogeneous and differs at the customer segment and at the LP touchpoint level. Five segments emerge which display different medium preference patterns. LP medium preference is associated with age, gender, affluency and number of different LPs the customer is enrolled in. Practical implications – Retailers, e-tailers and brands can benefit from this customer segmentation when faced with the challenges of adding online features or migrating their LPs online. Marketers should differentiate their investment in online and offline LP touchpoints according to the medium preference for each LP touchpoint of the customer segments of interest. Originality/value – Retailers, e-tailers and brands are today introducing online marketing strategies and tactics, such as LPs, that have been traditionally used offline. So far, however, they have failed to answer the question whether online and offline LPs and related touchpoints have the same preference among consumers. Literature on LPs has not explored customer preference for the LP medium or the consumer characteristics related to medium preference. This work is unique in providing an overview of medium preference for LPs and their touchpoints.
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Full-text available
Healthy dietary intake is important for the maintenance of general health and wellness, the prevention of chronic illness, the optimization of life expectancy, and the clinical management of virtually all disease states. Dietary myths (i.e., concepts about nutrition that are poorly supported or contradicted by scientific evidence) may stand in the way of healthy dietary intake. Dietary myths exist about micronutrients, macronutrients, non-nutrients, and food energy. Representative myths of each type include that patients need to focus on consuming enough calcium to ensure bone health, dietary fat leads to obesity and is detrimental to vascular health, all fiber (whether naturally occurring or artificially added) is beneficial, and food calories translate to pounds of body weight through a linear relationship and simple arithmetic. A common theme for dietary myths is a reductionist view of diet that emphasizes selected food constituents as opposed to whole foods. Healthy dietary advice takes a more holistic view; consistent evidence supports recommendations to limit the consumption of ultraprocessed foods and to eat whole or minimally processed foods, generally in a form that is as close to what occurs in nature as possible. Family physicians can help dispel myths for patients and give sound nutritional advice by focusing on actual foods and broader dietary patterns. (Am Fam Physician. 2015;91(9):634-638. Copyright © 2015 American Academy of Family Physicians.)
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Food allergy is estimated to affect approximately 1 in 25 school-aged children and is the most common trigger of anaphylaxis in this age group. School food-allergy management requires strategies to reduce the risk of ingestion of the allergen as well as procedures to recognize and treat allergic reactions and anaphylaxis. The role of the pediatrician or pediatric health care provider may include diagnosing and documenting a potentially life-threatening food allergy, prescribing self-injectable epinephrine, helping the child learn how to store and use the medication in a responsible manner, educating the parents of their responsibility to implement prevention strategies within and outside the home environment, and working with families, schools, and students in developing written plans to reduce the risk of anaphylaxis and to implement emergency treatment in the event of a reaction. This clinical report highlights the role of the pediatrician and pediatric health care provider in managing students with food allergies.
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Financial limitations in low-income populations, those at highest risk for poor health outcomes, may preclude adherence to recommended dietary guidelines. We examine the financial burden of shopping for foods to meet national dietary recommendations in a supermarket compared to eating primarily in a fast-food restaurant. Using a single-parent, low-income model, we obtained whole food costs (healthy) from local supermarkets and from fast-food outlets (convenient). Using cost per calorie as a metric for comparison, we used estimated single-parent, low-income living expenses to determine the relative costs of meeting national dietary guidelines. Average food costs for healthy and convenience diets accounted for 18% and 37% of income, respectively. Dairy products and vegetables accounted for the largest cost percentages of diet costs (36% and 28%, respectively). The cost per calorie of a convenience diet was 24% higher than the healthy diet. Both models resulted in net financial loss over the course of a year for a single-parent, low-income family. Food costs represent a significant proportion of annual income. Diets based heavily on foods from convenient sources are less healthy and more expensive than a well-planned menu from budget foods available from large supermarket chains.
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The purpose of this research is to examine the effects of an intervention designed to increase the availability of fruits, vegetables and lower fat foods in homes and schools. This research is part of the TEENS study, a school-based intervention study. Sixteen schools in Minnesota were recruited to be in the study, and approximately 3600 middle school students in the eight intervention schools were exposed to a multi-component intervention. The TEENS intervention included classroom-based curricula, family newsletters, and changes in the school food environment including increasing more healthful options on a la carte and on the school lunch line. In addition to student-level outcomes, changes in availability of fruits, vegetables, and lower fat snacks in home and school environments were evaluated. The TEENS study was conducted from 1997 to 2000. Parents of students in intervention schools reported making healthier choices when grocery shopping as compared to parents of students in control schools (P = 0.01). No intervention effects were evident from a home food inventory. Compared to control schools, intervention schools offered (P = 0.04) and sold (P = 0.07) a higher proportion of healthier foods on a la carte, but no effects were seen for fruit and vegetables sales as part of the regular meal pattern lunch. Our results show mixed results for positively influencing adolescents' school and home environments.
American Academy of Pediatrics Section on Allergy and Immunology. Management of food allergy in the school setting
  • Sh Sicherer
  • T Mahr
Sicherer SH, Mahr T; American Academy of Pediatrics Section on Allergy and Immunology. Management of food allergy in the school setting. Pediatrics. 2010;126(6):1232-1239.