School Lunch Program: Efforts Needed to Improve Nutrition and	 
Encourage Healthy Eating (09-MAY-03, GAO-03-506).		 
                                                                 
Recent trends in children's health and eating habits are	 
alarming. Over 15 percent of children are overweight--double the 
rate in 1980. Children's diets are high in fat but low in fruits,
vegetables, and other nutritious foods. The National School Lunch
Program has had a continuing role in providing students with	 
nutritious meals. However, serving the meals is only the first	 
step. Students must choose to eat the nutritious food and limit  
the less healthful choices. GAO was asked to report on the extent
to which school lunches, nationwide, were meeting nutrition	 
standards, and schools were encouraging healthy eating, what	 
barriers selected schools faced in accomplishing this, and what  
innovative steps they had taken to overcome the barriers.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-506 					        
    ACCNO:   A06861						        
  TITLE:     School Lunch Program: Efforts Needed to Improve Nutrition
and Encourage Healthy Eating					 
     DATE:   05/09/2003 
  SUBJECT:   Children						 
	     Food programs for children 			 
	     Food services					 
	     Nutrition research 				 
	     Schools						 
	     Students						 
	     National School Lunch Program			 

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GAO-03-506

Report to Congressional Requesters

United States General Accounting Office

GAO

May 2003 SCHOOL LUNCH PROGRAM

Efforts Needed to Improve Nutrition and Encourage Healthy Eating

GAO- 03- 506

Schools are moving toward meeting school lunch nutrition requirements, but
more improvements are needed. According to national studies, lunches meet
requirements for nutrients such as protein, vitamins, calcium, and iron,
but do not meet the required 30 percent limit for calories from fat. Also,
efforts to encourage healthy eating could be increased. Students may need
more exposure to nutrition education to effect positive changes in their
behavior,

and most students have access to foods of little nutritional value, such
as soft drinks and candy, at school.

In schools we visited, barriers to providing nutritious meals and
encouraging healthy eating included budget pressures and competing time
demands. Regarding providing nutritious food, officials said when they
introduce healthier foods, they take the risk that students will buy fewer
school lunches resulting in loss of needed revenue. Regarding encouraging
healthy eating, officials said the focus on meeting state academic
standards limited time to teach nutrition. Also, schools paid for special
activities or other items not covered in the school*s budget with profits
from vending machines and snack bar sales.

Schools had taken a variety of innovative steps to overcome barriers. With
respect to providing nutritious food, while minimizing the risk students
might reject healthier choices, schools modified recipes to lower the fat
content of popular foods such as pizza and conducted taste tests before
adding healthier choices. To encourage healthy eating, schools found time
to teach nutrition by integrating nutrition lessons into reading and math
classes, and some established school food policies to restrict unhealthy
choices. Some schools enlisted help from parents, community organizations,
and businesses. Officials noted that overcoming barriers required strong
and persevering leadership.

Some Schools Encourage Healthy Eating Source: GAO . Recent trends in
children*s health and eating habits are alarming. Over 15 percent of
children are

overweight* double the rate in 1980. Children*s diets are high in fat but
low in fruits, vegetables, and other nutritious foods. The National School
Lunch Program has had a continuing role in providing students with
nutritious meals. However, serving the meals

is only the first step. Students must choose to eat the nutritious food
and limit the less healthful choices. GAO was asked to report on the
extent to which school lunches, nationwide, were meeting nutrition
standards, and schools were encouraging healthy eating, what barriers
selected schools faced in

accomplishing this, and what innovative steps they had taken to overcome
the barriers. GAO recommends that the

Secretaries of Agriculture, Health and Human Services, and Education work
together to identify specific strategies to help schools promote nutrition

education while meeting the demands of state academic standards and to
encourage each

state to identify a focal point to promote collaborative efforts that
would further develop nutrition education activities for schools.

www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 506. To view the full report,
including the scope and methodology, click on the link above. For more
information, contact David D. Bellis at (415) 904- 2272. Highlights of
GAO- 03- 506, a report to

Congressional Requesters

May 2003

SCHOOL LUNCH PROGRAM

Efforts Needed to Improve Nutrition and Encourage Healthy Eating

Page i GAO- 03- 506 School Lunch Program Letter 1 Results in Brief 3
Background 5 Schools Moving Toward Meeting Nutrition Requirements, but

Improvements Needed 9 Barriers Exist to Providing Nutritious Food and
Encouraging Healthy Eating Choices 15 Schools Have Implemented Approaches
to Overcome Barriers 18 Conclusions 24 Recommendations for Executive
Action 26 Agency Comments 26 Appendix I Comments from the Department of
Health and

Human Services 29

Appendix II Comments from the Department of Education 33

Appendix III GAO Contacts and Staff Acknowledgments 36 GAO Contacts 36
Staff Acknowledgments 36 Tables

Table 1: Mean Nutrient and Caloric Content of School Lunches Offered in
School Year 1998- 99 and School Year 1991- 92 Compared with NSLP Standards
11 Table 2: Percentage of Schools Offering Selected Foods in

Competition with School Lunches 14 Contents

Page ii GAO- 03- 506 School Lunch Program Abbreviations

CDC Centers for Disease Control and Prevention MOU Memorandum of
Understanding NSLP National School Lunch Program SFA School Food Authority
SNDA School Nutrition Dietary Assessment Study SHPPS School Health
Policies and Programs Study USDA United States Department of Agriculture

This is a work of the U. S. Government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. It may contain
copyrighted graphics, images or other materials. Permission from the
copyright holder may be necessary should you wish to reproduce copyrighted
materials separately from GAO*s product.

Page 1 GAO- 03- 506 School Lunch Program

May 9, 2003 The Honorable Tom Harkin Ranking Minority Member Committee on
Agriculture, Nutrition, and Forestry United States Senate

The Honorable Richard G. Lugar United States Senate

The nation faces a complex challenge in addressing recent trends in
children*s health and eating habits. The percentage of children ages 6 to
19 who are overweight has more than doubled to over 15 percent since

1980, and the incidence of Type II diabetes* closely associated with
obesity* has also increased in the past decade. Children*s diets are too
high in fat but low in fruits, vegetables, and other foods that provide
needed nutrients, according to the U. S. Department of Agriculture (USDA).
At the same time, a recent study reported that, in 2001, nearly one- half
million children lived in households in which one or more children were
hungry at some time during the year because the household lacked money
enough for food. 1 Healthy eating patterns in childhood are important to
promote optimal intellectual development and prevent health problems.

The National School Lunch Program has played a continuing role in school-
based efforts to provide students with nutritionally balanced meals at low
or no cost. In fiscal year 2002, about 28 million children each day at
about 99,000 public and nonprofit schools and residential child care
institutions received meals through this program. USDA*s Food and
Nutrition Service administers the program at the federal level, and state
education agencies typically administer and monitor the program through
agreements with local school food authorities* offices responsible for
managing the school meals program in one or more schools. School food
authorities that choose to participate are federally subsidized for each
meal they serve. To be reimbursable, meals must meet certain nutritional

1 Mark Nord, Margaret Andrews, and Steven Carlson, Household Food Security
in the United States, 2001 Washington, D. C.: U. S. Department of
Agriculture, Economic Research Service, 2002.

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 03- 506 School Lunch Program

requirements. However, serving nutritious lunches and other meals is only
the first step in promoting a healthy school food environment. Students
must choose to eat the nutritious meals as well as limit the other less
healthful food they may eat during the day.

Because of your concern about the serious diet- related health problems
faced by the nation*s children and the role of school lunches in
addressing the problems, you asked us to answer the following questions:
(1) What is known nationally about the extent to which schools and school
food authorities are meeting USDA nutrition requirements and promoting
healthy eating among students? (2) What barriers do schools and school
food authorities face in serving nutritious food and encouraging students
to make healthy eating choices? (3) What steps have schools and school
food authorities taken to overcome the barriers to serving nutritious food

and encouraging students to make healthy eating choices? We are also
issuing two other related reports* one concerns keeping school meals safe
from food borne illness and the other addresses the cost of school meals.
2 To report on the extent to which schools are meeting USDA nutrition

requirements and promoting healthy eating among students, we relied
primarily on the findings of three national studies 3 considered to be
authoritative by researchers and other experts in the field. A
statistician and a social scientist examined each study to assess the
adequacy of the samples and measures employed, the reasonableness and
rigor of the statistical techniques used to analyze them, and the validity
of the results and conclusions that were drawn from the analyses. To
report on the barriers schools face and the efforts schools and districts
have made to

2 U. S. General Accounting Office, School Meal Programs: Few Instances of
Food Borne Outbreaks Reported, but Opportunities Exist to Enhance Outbreak
Data and Food Safety Practices, GAO- 03- 530 (Washington, D. C.: May 9,
2003) and School Meal Programs: Revenue and Expense Information from
Selected States, GAO- 03- 569 (Washington, D. C.: May 9, 2003).

3 (1) U. S. Department of Agriculture, Food and Nutrition Service, Office
of Analysis, Nutrition and Evaluation, School Nutrition Dietary Assessment
Study II, Final Report

(SNDA- II), July 2001. For subsequent references to the same work: SNDA-
II; (2) Centers for Disease Control and Prevention, School Health Policies
and Programs Study 2000: A Summary Report, (SHPPS 2000) Journal of School
Health, Volume 71, Number 7, September 2001. For subsequent references to
the same work: SHPPS 2000; and (3) U. S.

Department of Agriculture, Food and Nutrition Service, Office of Analysis,
Nutrition and Evaluation, The School Meals Initiative Implementation
Study, Third Year Report, June 2002.

Page 3 GAO- 03- 506 School Lunch Program

overcome the barriers to serving nutritious food and encouraging healthy
eating choices, we reviewed the literature and consulted with experts in
the school lunch program and child nutrition area. On the basis of
recommendations from these sources, we identified and selected states for
site visits that were recognized leaders in the area, schools that had
approaches already in place, and schools that had not yet fully
implemented such efforts. We selected schools for site visits that
represented a range of the following characteristics: school district
size, locale (rural, urban, or suburban), type of school (elementary and
secondary), and percent of students eligible for free or reduced price
meals. We conducted on- site reviews of school lunch activities at 22
schools in California, Kentucky, Michigan, Rhode Island, and Texas. 4 We
discussed state operations and activities with officials in each state. In
each school district, we discussed efforts and barriers to providing

nutritious food and encouraging healthy eating choices with school food
authority officials, food service site managers, school principals, and
teachers. At some locations, we also discussed efforts with students and
parents. We conducted our study from August 2002 to March 2003 in
accordance with generally accepted government auditing standards.

Schools have made significant progress in meeting USDA nutrition
requirements since the mid- 1990s but need to make improvements both in
meeting the nutrition requirements and in promoting students* healthy
eating choices, according to national studies of school lunches. Regarding
nutrition requirements, the studies found that in 1991- 92 and 1998- 99,
the

average school lunch exceeded the required amount of nutrients, such as
protein, vitamins A and C, and calcium. Additionally, schools have reduced
the average proportion of calories from fat in lunches from 38 to 34
percent, nationwide, during this period. However, more than threequarters
of schools have not yet achieved the required rate of no more than 30
percent. Regarding encouraging healthy eating, a national study of
nutrition education in kindergarten through fifth grade found that
nutrition

is taught by most teachers. However, studies suggest, not enough to show
an impact on children*s behavior. Moreover, national studies also noted
that even when at school, students had access to food from a number of
sources other than the meals that are regulated by USDA*s programs. For
example, students at most secondary schools and many elementary

4 In addition, we visited one school and talked with a school food
official in both Virginia and Washington State. Results in Brief

Page 4 GAO- 03- 506 School Lunch Program

schools can purchase foods and beverages of limited nutritional value from
vending machines and school stores. Some school and school food authority
officials in the 22 schools we visited cited barriers they faced in
improving the nutritional quality of their lunches; however, many we spoke
with expressed greater concern over the barriers to promoting healthy
eating among students. In regard to improving the nutritional quality of
lunches, many officials cited a barrier that was financial rather than
dietary. They said that when school food authorities introduce healthier
foods with lower fat content they take the risk that students will not
like the menu changes and will buy fewer school lunches. Because school
food authorities operate their programs on a break- even financial basis,
and student meal payments make up a large part of their revenue, a
decrease in meals purchased can throw their budget out of balance,
officials said. With respect to encouraging healthy student eating habits,
many teachers and school officials told us that their ability to place
more emphasis on teaching nutrition and good dietary

habits was limited by the increased focus on devoting class time to the
subject matter needed to meet state academic standards. Officials also
said that they face barriers to restricting student in- school access to
foods of limited nutritional value. For example, many school principals
and organizations told us they receive money from vending machines and
sales of other food and beverages that may be of limited nutritional
value. They said it is difficult to limit these sales because the funds
are often used to

pay for special activities or items not covered in the school*s budget.
Similarly, school food authority officials told us that to help manage
their budgets, they have chosen to sell less healthful items in the
cafeteria, in competition with the USDA reimbursable meals.

Many of the schools and districts we visited had taken steps to overcome
such barriers. To improve nutritional quality while minimizing the risk
that students would reject healthier choices, some schools developed
recipes and techniques that lowered the fat and sodium content of popular
foods such as pizza and enchiladas without sacrificing the appeal of these
items. Some schools conducted student taste tests before they added new
and healthier choices such as yogurt and salads. To encourage healthy
eating, some schools changed their cafeteria layout and offered more
healthy

choices* for example, offering lunch stations or lines with different
themes, such as soup and salad or deli sandwich selections. To expand
students* opportunities to learn about healthy eating despite limited
class time, some schools integrated nutrition education into the existing
reading and math curricula and displayed nutrition bulletin boards. To
restrict other, less healthy food choices, a few schools had established a
school

Page 5 GAO- 03- 506 School Lunch Program

food policy that, for example, limited certain vending machine items or
improved the nutritional quality of foods on school grounds. Finally, some
schools had devised a broader approach that reached beyond the school to
enlist help from parents, community organizations, and businesses.
Together, they sponsored health fairs and organized health- related family
activities to raise nutrition awareness. Officials told us that their
efforts to overcome barriers and make any change* particularly involving
collaboration on a school or community wide level* required strong and
persevering local leadership with a focus on nutrition and healthy eating.
Leadership at the state level was also viewed as valuable.

In support of such efforts, USDA and the Departments of Health and Human
Services and Education have recently signed a memorandum of understanding*
an important step in establishing a partnership to address student
nutrition and other health- related issues. We recommend that the
agencies, using the partnership as a foundation, identify specific
strategies and develop materials to help schools promote nutrition
education while also meeting the requirements of state academic standards.
We further recommend that the agencies, working together through the
memorandum of understanding, encourage states to identify a focal point in
each state to promote collaborative efforts that would further develop
nutrition

education activities for the schools. We received oral comments on this
report from USDA and written comments from the Departments of Health and
Human Services and Education. The agencies generally agreed with the
report and recommendations. However, the Department of Education expressed
concern that the information we present appears to imply that
accountability provisions in the No Child Left Behind Act may contribute
to compromising a healthy eating environment in schools. We believe that
nutrition education and other components of a healthy eating environment
can and should be compatible with schools* efforts to meet the
requirements of state academic standards. It is for this reason that we
recommended that federal agencies work together to help schools promote
nutrition education and healthy eating among students. See appendixes I
and II for the written comments.

The National School Lunch Program (NSLP), established in 1946 and amended
many times, provides nutritionally balanced, low- cost or free meals to
children throughout the United States. Over 180 billion lunches have been
served since the program*s inception. USDA*s Food and Nutrition Service,
state agencies* usually departments of education* and Background

Page 6 GAO- 03- 506 School Lunch Program

school food authorities (SFAs) all play a role in managing the program.
SFAs that choose to take part in the program are reimbursed with cash
subsidies and receive donated commodities from USDA. In return, they must
serve lunches that meet federal requirements and offer free or reduced
price lunches to eligible children. The federal government reimburses the
states, which in turn reimburse SFAs for each meal served. 5 In fiscal
year 2001, the federal government spent over $6 billion in cash

reimbursements and commodities for school lunches. To ensure nutritional
quality, regulations developed under the National School Lunch Act
initially required schools to include specific serving sizes of food such
as fruits, vegetables, and whole milk in school lunches. In 1994, Congress

amended NSLP requirements with the Healthy Meals for Healthy Americans Act
6 to require schools to serve meals that adhere to Dietary Guidelines for
Americans, which include limits on total fat and saturated fat.
Additionally, school meals must meet one- third the recommended daily
allowance for calories and for nutrients such as protein, calcium, iron,
and vitamins A and C. Compliance with the standards is determined by
averaging the nutritional content of the lunches offered over a school
week.

SFAs have flexibility in operating their school meal programs. They may
operate the programs themselves or contract with food service management
companies to perform functions such as planning and preparing menus and
selecting and buying food. All or some food preparation may occur at on-
site school kitchens or at central kitchens, which distribute food to
satellite schools. In addition, SFAs select one of five menu- planning
approaches they use to comply with nutritional requirements: two food-
based, two nutrient- based* as well as a fifth option for *any reasonable
approach.* In a food- based approach, SFAs plan meals to include minimum
quantities of five meal pattern items (i. e., milk, meat or meat
alternative, two different servings of vegetables and/ or fruits, and
bread or grain products). In a nutrient- based approach, SFAs prepare a
computerized nutritional analysis of the week*s menu to ensure that the
meals meet nutritional requirements. Schools that use a nutrient

5 In school year 2002- 03, USDA reimbursed participating schools $2.14 for
every free lunch meal provided, $1.74 for every reduced price lunch meal
sold, and $0. 20 for every other lunch meal sold. The rates are the
minimum cash amounts reimbursed. USDA also provides higher amounts for
districts with 60 percent or more children approved for free and

reduced- price meals, districts in Hawaii and Alaska, and districts
identified by states as having critical needs in order to ensure equitable
distribution.

6 P. L. No. 103- 448, sec. 106 (1994).

Page 7 GAO- 03- 506 School Lunch Program

based approach are required to serve milk and to offer at least one entree
and one side dish.

To increase student participation and reduce waste, an *offer vs. serve*
provision in NSLP was introduced. Previously, for reimbursable lunches,
the entire meal package was served to students. Under the new provision,
schools offer foods that meet nutrient requirements and encourage students
to take them. Students are not required to take all menu items, but must
select specific menu items for a meal to be reimbursed. For example, in
SFAs that use a food- based menu planning system, students must take a
full portion of a least three of five meal- pattern items offered for a
lunch to be reimbursable. In SFAs that use a nutrient- based system and
offer the minimum of three menu items, students must select at least two
of the USDA meal- pattern items offered, one of which must be an entree.
If more than three menu items are offered, students may decline a maximum
of two menu items, however, the entree may not be declined. SFAs are
required to use the offer vs. serve provision for senior high school
students, and they have the discretion to use the provision for elementary
and middle school students.

NSLP requires state agencies to conduct periodic evaluations of SFA
compliance with nutritional and other requirements. State agencies often
review SFA compliance with the School Meals Initiative in conjunction with
the broader- based administrative reviews called Coordinated Review
Efforts that are conducted every 5 years. The procedures followed in
conducting School Meals Initiative reviews depend upon the menu planning
system used by the SFA. For SFAs using food- based menu planning systems,
the state agency must conduct its own nutrient analysis of the menu served
during the review period. For SFAs using nutrientbased systems, the state
agency reviews the menus and production records and assesses the SFA*s
nutrient analysis for a 1- week period, which can be any week of the
current school year prior to the period of review.

SFAs and schools may allow the sale of food in addition to meals served
through NSLP. Under USDA regulations, these foods are considered
*competitive foods* if they are sold in competition with lunches served
under the program in food service areas during the lunch periods.
Competitive foods may also include foods and beverages purchased from
vending machines, school stores, and snack bars. The regulations provide
the states and SFAs with discretion as to whether to impose restrictions
on the sale of all foods, such as by limiting the time or locations of the
sales. However, under the regulations, the schools must prohibit the sale

Page 8 GAO- 03- 506 School Lunch Program

of *foods of minimal nutritional value* in the school cafeteria during
meal periods. The federal regulations do not, however, prohibit the sale
of foods of minimal nutritional value outside the cafeteria any time
during the school day. 7 Foods of minimal nutritional value are defined in
federal regulations and include, for example, carbonated soft drinks,
chewing gum, and marshmallow candies.

In addition to providing assistance in meeting nutrition requirements,
USDA*s Food and Nutrition Service established the Team Nutrition
initiative in 1995 to develop and disseminate a package of materials that
encourage healthy eating and physical activity among students. These
materials focus on the benefits of good nutrition and motivating students
to change their behavior. Additionally, Team Nutrition provides grants to
states and technical assistance materials for school food service
personnel and classroom nutrition education materials as well as guidance
and materials on how to build school and community support for healthy
eating, physical activity, and a healthy school nutrition environment. The
initiative has its own Web site and recently began an electronic
newsletter to food service personnel as another channel to share ideas for
implementing activities and concepts at state and local levels. Changing
the Scene and Eat Smart- Play Hard, two additional USDA initiatives that
provide resources to promote healthy eating and physical activity are also
available to schools. Additionally, the Department of Health and Human
Services* Centers for Disease Control and Prevention (CDC) has developed
and disseminated a variety of materials and information to help schools
implement efforts to address health issues, including nutrition and

physical activity. CDC has also provided funding to promote healthy eating
and physical activity. For example, in 2000, CDC initiated a grant program
to support state health departments in developing and implementing

nutrition and physical activity interventions. In 2003, CDC provided
support for coordinated school health programs in 22 states that focused
on promoting healthy eating behaviors, physical activity, and tobacco use
prevention among students. Finally, the role of schools and the community

in addressing the national problem of child obesity is underscored in *The
7 In National Soft Drink Ass*n. v. Block, 721 F. 2d 1348 (D. C. Cir.
1983), the Court of Appeals for the District of Columbia overturned the
federal regulation in effect at the time prohibiting the sale of foods of
minimal nutritional value anywhere in the school from the beginning of the
school day until the last meal period. The court construed a 1977
amendment to the Child Nutrition Act as allowing USDA to regulate the sale
of competitive foods only in food service areas during meal periods.
Following this decision, USDA amended its regulation to limit the
prohibition of these foods to food service areas during meal periods.

Page 9 GAO- 03- 506 School Lunch Program

Surgeon General*s Call to Action to Prevent and Decrease Overweight and
Obesity.* This document* published in December 2001* emphasizes the
seriousness of the health problems associated with being overweight or
obese and outlines strategies that communities can use to address
overweight and obesity by focusing on both improved nutrition and
increased physical activity. The document also recommends providing more
healthful food options on school campuses as well as requiring physical
education in all school grades. USDA officials reported that Team
Nutrition and CDC collaborate on an ongoing basis and are currently
developing implementation materials for schools to use to improve their
school nutrition environment. The materials address issues such as
offering and promoting nutritious food and beverage options in vending
machines, school stores, and a la carte. The officials said they will also

report on case studies of schools that have made successful changes.
Schools have made measurable progress, nationwide, in meeting USDA
nutrition requirements and other guidelines over the past decade.
Additional improvement, however, is needed not only in meeting the
nutrition requirements, but also in encouraging students to eat more
healthfully. With respect to nutritional quality, on average, schools are
exceeding the requirements for a variety of nutrients. However, while most
schools have reduced the average percent of calories from fat in school
lunches, few have met the required goal for fat content. Regarding
promoting healthy eating, nutrition education is taught at most schools,
but studies suggest it may not be enough to show an impact on student
behavior. Moreover, students at most secondary schools and many elementary
schools nationwide have access to a variety of food and beverages from
vending machines, school stores, and other sources that is of little
nutritional value* for example, high in fat, sodium, and/ or added

sugars, but low in nutrients such as vitamins or minerals. In school year
1991- 92, a USDA national study to determine the nutritional quality of
school meals found that schools were generally meeting standards for
nutrients, including protein, vitamins A and C, calcium, and iron. 8 The
average calorie content of elementary school lunches was

8 Mathematica Policy Research, Inc., The School Nutrition Dietary
Assessment Study, School Food Service, Meals Offered, and Dietary Intakes,
(SNDA- 1), Oct. 1993. For subsequent references to the same work: (SNDA-
I). Schools Moving

Toward Meeting Nutrition Requirements, but Improvements Needed

School Lunch Nutrition Improving but Still Not Meeting Requirements

Page 10 GAO- 03- 506 School Lunch Program

somewhat higher than the standard, and the calorie content of secondary
school lunches was slightly lower than the standard. However, the study
also found that levels of fat, saturated fat, and sodium 9 in school
lunches were not consistent with the standards set out in the *Dietary
Guidelines for Americans.* 10 As a result of those findings, USDA
developed the School

Meals Initiative to improve the nutritional quality of school meals
through, for example, changes in meal menu planning requirements and
enhanced training and technical assistance for school food service
personnel. 11 In school year 1998- 99, a USDA follow- up study provided an
updated

national picture of the nutrient profile of school meals. 12 According to
this study, schools across the nation have, on average, continued to meet
or exceed required nutrient standards for protein, vitamins A and C,
calcium, and iron. The average calorie content of elementary school
lunches continued to be somewhat higher than the standard and that of
secondary school lunches, slightly lower. The study also reported a
significant trend

toward lower total fat levels in school lunches from nearly 38 percent of
total lunch calories in 1991- 92 down to about 34 percent in 1998- 99,
however, still above the required 30- percent standard. Additionally,
according to the study, while the number of schools meeting the 30-
percent standard had increased substantially, more than three- quarters of
elementary and secondary schools still had not yet achieved that goal.

Sodium levels had also declined significantly in both elementary and
secondary schools but were still considerably higher than the 800- mg.
standard. Table 1 compares the nutritional content standards with findings
from these two studies.

9 According to USDA officials, the standard for sodium level used in SNDA-
II is based on National Research Council recommendations. 10 U. S.
Department of Agriculture and U. S. Department of Health and Human
Services,

Nutrition and Your Health: Dietary Guidelines for Americans, 3rd edition,
Washington, D. C. (1990).

11 At the time SNDA- I was conducted, schools were not required to offer
meals that were consistent with the Dietary Guidelines for Americans. 12
SNDA- II.

Page 11 GAO- 03- 506 School Lunch Program

Table 1: Mean Nutrient and Caloric Content of School Lunches Offered in
School Year 1998- 99 and School Year 1991- 92 Compared with NSLP Standards
NSLP standard SY 1991- 92 a, b SY 1998- 99 a, b Percent change (SY

1991- 92 vs. SY 1998- 99) Elementary schools

Protein (gm) 10 30 30 0 Vitamin A (mcg RE) 224 397 491 +24 d Vitamin C
(mg) 15 28 37 +32 d Calcium (mg) 286 483 505 +5 d Iron (mg) 3.5 4.1 4. 6
+12 d Sodium (mg) 800 1,399 1,285 -8 d Cholesterol (mg) 100 84 68 -19 d
Total calories 664 715 738 +3 % Calories from fat 30% 37.5% 33.5% -11

% Calories from saturated fat 10% 15.2% 11.9% -22 d Secondary schools
Protein (gm) 16 33 33 0 Vitamin A (mcg RE) 300 418 519 +24 d Vitamin C
(mg) 18 34 42 +24 d Calcium (mg) 400 518 542 +5 d Iron (mg) 4.5 4.8 5. 0
+4 c Sodium (mg) 800 1,641 1,502 -8 d Cholesterol (mg) 100 95 75 -21 d
Total calories 825 820 798 -3

% Calories from fat 30% 37.5% 33.7% -10 d % Calories from saturated fat
10% 14.6% 11.8% -19 d Source: SNDA- II pp. 148- 155. Note: NSLP Standards
reflect minimums defined in current program regulations for grades K- 6
(elementary schools) and grades 7- 12 (secondary schools). NSLP standards
for the percentage of calories from fat and saturated fat were not in
effect during SY 1991- 92. NSLP standards reflect minimum content
requirements for total calories, protein, vitamins A and C, calcium, and
iron and maximum content limitations for sodium, cholesterol, calories
from fat, and calories from saturated fat. a Data for all public schools
in the first School Nutrition Dietary Assessment Study (SNDA- I).

b Data from the second School Nutrition Dietary Assessment Study (SNDA-
II). c Difference between SY 1991- 92 and SY 1998- 99 is statistically
significant at the 0.01 level. d Difference between SY 1991- 92 and SY
1998- 99 is statistically significant at the 0.001 level.

The 1998- 99 study also points out that schools may also offer low fat
menu options that allow students to choose menu items that provide a lunch
that meets the standard, even when the average lunch offered exceeds the
30- percent standard for calories from fat. The percentage of elementary
schools that provided such low- fat options increased from 34 percent to
82 percent and for secondary schools, from 71 percent to 91 percent
between school years 1991- 92 and 1998- 99. The study further reported
that

Page 12 GAO- 03- 506 School Lunch Program

99 percent of elementary schools and 96 percent of secondary schools were
meeting the cholesterol standard of 100 mg. or less. However, only 1
percent of elementary schools and less than 1 percent of secondary schools
were meeting the sodium content standard of 800 mg. or less.

In addition to making progress in serving nutritious meals, schools have
made a variety of efforts to encourage healthy eating among students.
However, such efforts remain limited in many locations, according to
national studies. Nutrition education is one way to promote good dietary
habits among youth, and a Department of Education study found that in
school year 1996- 97, 88 percent of kindergarten through fifth- grade
teachers presented lessons about nutrition. 13 According to that study,
the average total amount of time teachers devoted to nutrition education
was 13 hours per school year. Further, a CDC study found that most
schools, at all grade levels, require some nutrition to be taught,
however, the median amount of time spent on nutrition education as part of
schools* health education classes was 5 hours during the elementary years,
5 hours during the high school years, and 4 hours during the middle school
years. 14 A 1995 report summarizing the research on nutrition education
for school age children concluded that time and intensity of the
instruction offered do matter. Programs with longer durations, more
contact hours, and more components, such as parent involvement and changes
in school meals, result in more positive outcomes. 15 Additionally, the
study emphasizes the importance of focusing on student behavior* an
approach also supported by the Department of Education report. The study
concludes that, given the limited amount of time available, those
interventions that focus on specific student behaviors, such as reduced
fat intake or use of salt, result in more behavioral change than do
general nutrition education programs. Finally, the study underscores the
importance of providing a healthy school environment to reinforce and
encourage students to make healthy eating choices.

13 U. S. Department of Education, Office of Educational Research and
Improvement, National Center for Education Statistics, Nutrition Education
in Public Elementary School Classrooms, K- 5, (Feb. 2000).

14 SHPPS 2000. 15 Leslie A. Lytle, Nutrition Education for School- aged
Children, Journal of Nutrition Education, Vol. 27, No. 6, (Dec. 1995).
Efforts to Encourage

Healthy Eating Could be Increased at Many Schools

Page 13 GAO- 03- 506 School Lunch Program

The school environment* both inside and outside the cafeteria* is
important in encouraging healthy eating by providing students with access
to healthful food choices and models of healthful food practices. The 2000
CDC study highlights the need to address those aspects of the school
nutrition environment that are not regulated by USDA, such as a la carte
cafeteria items and food and beverages in vending machines, school stores,
and snack bars. 16 The study reports that while many schools offered low
fat foods and fruits and vegetables, many also offered foods and beverages
of limited nutritional value that competed with the healthful food for
student selection. For example, while 36 percent of elementary school SFAs
served low- fat baked goods a la carte in the cafeteria, nearly 49 percent
served baked goods that were not low in fat. Additionally,

about 43 percent of elementary schools, 74 percent of middle schools, and
98 percent of high schools have vending machines, school stores, canteens,
or snack bars, according to the study, which often offered foods high in
fat, sodium, or added sugars. Table 2 shows the percentage of schools that
offer various foods for sale to students in competition with school
lunches both within the cafeteria as a la carte selections and outside the
cafeteria.

16 SHPPS 2000.

Page 14 GAO- 03- 506 School Lunch Program

Table 2: Percentage of Schools Offering Selected Foods in Competition with
School Lunches

Numbers in percent Schools offering food or beverage a la carte Schools
where students can purchase food or beverage in vending machines, school
store,

canteen, or snack bar

Type of food or beverage Elementary schools Middle/ Junior high schools
Senior high

schools Elementary schools a Middle/ Junior high schools b Senior high

schools c

Low in fat 100% fruit or vegetable juice 57.8 63.9 77.4 49.4 53.1 65.0
Fruits or vegetables 68.1 74.0 90.4 20.0 11.8 22.0 Low- fat cookies,
crackers, pastries 36.1 40.8 48.0 26.4 37.7 49.6 Low- fat salty snacks
29.5 42.6 58.3 44.5 54.5 65.0 High in fat, sodium, or added sugars Soft or
sports drinks or fruit drinks not 100% juice

19.0 40.3 57.2 58.1 83.5 93.6 Chocolate candy 2.4 8.9 23.7 29.2 46.6 72.2
Cookies, crackers, pastries not low- fat 48.8 66.8 79.9 52.6 61.2 80.7
Salty snacks not lowfat 25.8 40.6 57.8 51.0 62.4 83.0

Source: School Health Policies and Programs Study, 2000. a Among the 43.0
percent of elementary schools with a vending machine, school store,
canteen, or snack bar. b Among the 73.9 percent of middle/ junior high
schools with a vending machine, school store, canteen, or snack bar.

c Among the 98.2 percent of high schools with a vending machine, school
store, canteen, or snack bar. According to the study, a relatively small
percentage of school districts have policies in place that require the
sale of healthy choices or that restrict the sale of foods with little
nutritional value. For example, only about 19 percent of districts require
schools to offer fruit and vegetables as a la carte items, and 23 percent
of districts require schools to prohibit the sale of foods that have
little nutritional value as a la carte items. Furthermore, about half of
school districts have a contract that gives a company rights to sell soft
drinks at schools in the district. Most of those districts receive a
percentage of sales receipts or other incentives. 17 Finally, in most
schools, organizations such as student clubs, sports teams, 17 For more
information on commercial activities in schools, see U. S. General
Accounting

Office, Public Education: Commercial Activities in Schools, GAO/ HEHS- 00-
156 (Washington, D. C.: Sept. 8, 2000).

Page 15 GAO- 03- 506 School Lunch Program

and parent- teacher associations sell food to raise money, and the food
sold is typically high in fat and added sugars, according to the study.

School and SFA officials in the 22 schools in 13 school districts that we
visited cited a number of barriers to meeting nutrition requirements and
improving school lunch nutritional quality. However, many officials we
spoke with were more concerned with the barriers they faced in encouraging
healthy eating among students and establishing a broader community
approach. Regarding improving nutritional quality and meeting USDA
requirements, SFA officials said that the pressure to balance their
budgets could affect the food served in the school. 18 Also, according to
state officials we spoke with, they have limited ability to enforce the
nutrition requirements. Regarding encouraging healthy eating, school
officials said that they have limited time and resources available to
teach nutrition education. Additionally, school principals and
organizations are reluctant to limit the sale of food and beverages of
limited nutritional value at the schools that we visited because they use
the money to support student activities not covered in the school budget.

SFA officials we talked with cited financial barriers to providing
nutritious meals. Many officials said that they are under pressure to
balance their budgets, while at the same time provide meals that meet USDA
nutrition guidelines and appeal to students. Some officials said that
providing a lunch that meets USDA*s guidelines for nutrition and comes in
under budget is achievable, but the challenge is in preparing healthful
foods that are also appealing to the students and that students will
select and eat.

Many SFA officials said that when they make changes in the menu items
offered, such as lowering the fat content or introducing new items, they
run the risk that students will not like the changes and will decline to
participate. They noted that because food service programs are typically
required to operate on a break- even basis, and student meal payments make
up a large part of their revenue, a decline in participation could have a
negative effect on the budget. For example, in Rhode Island, an official
told us that several years ago SFA officials decided to no longer offer
deep- fried French fries to the students. Disappointed by this decision,
the

18 For more information on school meal revenues compared to expenses in
school years 1996- 97 through 2000- 01, see U. S. General Accounting
Office, School Meal Programs: Revenue and Expense Information from
Selected States, GAO- 03- 569 (Washington, D. C.: May 9, 2003). Barriers
Exist to

Providing Nutritious Food and Encouraging Healthy Eating Choices

Budget Pressures Can Affect Nutritional Quality of Food

Page 16 GAO- 03- 506 School Lunch Program

students boycotted the entire school lunch program. Within a week the
school restored them to the menu* but as an a la carte item. Some SFA
officials mentioned that the school food service staff has sometimes been
reluctant to adopt standardized recipes that did not include bacon fat,
butter, cream, or other ingredients that made their recipes popular with

the students. When schools serve meals that do not comply with federal
nutrition requirements, enforcement options are limited, according to
state and federal officials. If the state School Meals Initiative review
reveals noncompliance, the state agency works with district officials to
develop a plan to correct deficiencies and follows up to monitor the
progress of the plan. Although regulations allow for withholding of
federal meal reimbursements if the SFA has not been acting in good faith
to meet the terms of the corrective action plan, state and USDA officials
questioned whether this offers a practical or realistic solution because
of the possibility of program cutbacks or closure and the effect on the
students, especially those receiving free or reduced price lunches.

Efforts to meet various school and district financial pressures have led
SFAs to serve less healthful a la carte items in the cafeteria in
competition with school lunches. While a la carte items can include such
things as fruit and milk, they may also include cookies, candy, ice cream,
and deep- fried French fries. One SFA director said that a la carte sales
help her balance

the budget. She said the SFA probably sells about $600 a day in a la carte
items, such as pudding, toaster pastry, beef jerky, and cheese sticks.
Less healthful a la carte items may be sending a mixed nutrition message
to students, according to officials. SFA officials said that they
recognize that some of the a la carte items offered are less nutritious or
healthful, but said they need the revenue the items generated to help
balance their budgets.

School and SFA officials we spoke with said that time constraints and
financial needs within the school sometimes compromise efforts to
encourage healthy eating choices among students. Principals, teachers, and
other officials said that classroom time is focused almost entirely on
making sure that students meet state academic standards, and little time
is left to include subjects or information not included on the state
academic Competing Time and

Budget Pressures May Compromise Healthy Eating Environment in Schools

Page 17 GAO- 03- 506 School Lunch Program

standards test. 19 One SFA director said that state testing is leading the
curriculum* social skills, nutrition education, and other subjects are
being left out. As another official said, *If you want it taught, get it
on the test.* Three states we visited required students to take nutrition
education as part of a health class at the secondary level, but only one
state included it when preparing for a required statewide health test.
Several schools we

visited taught some nutrition education* often as part of a consumer and
family sciences course, health, or physical education at the secondary
level (middle, junior, and senior high schools). These classes were
usually elective and taken by only a few students. Some districts we
visited included nutrition as part of their health curriculum at various
grade levels, but typically limited it to a few hours class time. Finally,
while a variety of materials and information is available to assist
teachers in presenting nutrition information to both elementary and
secondary students, some teachers said they were not aware of, or did not
have time to locate and utilize these resources.

Students at the schools we visited also had access to soft drinks, candy,
and other foods of limited nutritional value elsewhere in the school
because, according to officials, the school relies on the revenue. For
example, at several schools we visited the profits from soda vending
machines generated several thousand dollars over a year*s time to be used
at the discretion of the principal. Some principals said that it was their

only funding source for expenditures such as awards for students* academic
and athletic achievements, for school or class fieldtrips, and for other
educational opportunities. One principal bought a bassoon for the school
orchestra because a particularly promising low- income student musician
needed it. Officials said that finding another source of funding to
replace that generated by these machines would be difficult, and as one
principal said, *It would be World War III if the machines were removed.*

19 In 1994, Congress mandated major changes to Title I of the Elementary
and Secondary Education Act in response to concerns that Title I funding
was not significantly improving the educational achievement of at- risk
students. Under the 1994 reauthorization, states

were required to adopt or develop challenging curriculum content and
performance standards, assessments aligned with content standards, and
accountability systems to assess schools* and districts* progress in
raising student achievement. The No Child Left Behind Act of 2001
augmented the assessment and accountability requirements that states

must implement and increased the stakes for schools that fail to make
adequate progress. For more information on state implementation of these
requirements see U. S. General Accounting Office, Title I: Education Needs
to Monitor States* Scoring of Assessments, GAO- 02- 393, (Washington, D.
C.: April 1, 2002).

Page 18 GAO- 03- 506 School Lunch Program

Many schools that we visited also sold food and beverages as part of
Parent Teacher Association or athletic team fundraisers or other school
club sales. They acknowledged that often these items sold outside of the
cafeteria* such as candy and cookies* are of limited nutritional value.
However, officials said that the profits made from these sales provide
funds for school activities or projects that would otherwise not be
funded, so officials say they are reluctant to restrict or prohibit them.
Additionally,

in some schools that we visited, a healthy nutrition environment was
compromised by teachers and others using foods of limited nutritional
value, such as candy and cookies, as a reward for good classroom or
hallway behavior, scoring well on a test or project, or from even bus
drivers for good conduct on the bus. Some school or PTA activities also
included refreshments that were of limited nutritional value. Officials
said that foods of limited nutritional value were often less expensive and
more convenient. The schools and SFAs that we visited had established a
variety of

approaches to overcome the barriers they face in providing nutritious food
and encouraging students to make healthy eating choices. Nearly all the
visited schools had taken actions to improve the nutritional quality of
the food served to students and at the same time help ensure that the food
would be appealing to the students. To promote healthy eating habits among
their students, some schools offered nutrition education both in and
outside the classroom. Some had taken steps to limit students* access to
foods of limited nutritional value at school. A number of schools had
enlisted community organizations and businesses for assistance and
resources to help sponsor activities outside the classroom such as health
fairs, family events, and nutrition awareness campaigns. Additionally,
state and federal agencies had a number of efforts in place to support
local initiatives and community- wide collaborations.

In most of the SFAs that we visited, officials had taken a number of steps
to improve the nutritional quality of the food. For example, some food
service officials had modified the recipes of several foods that are
popular with students, such as enchiladas and macaroni and cheese, to make
them more nutritious yet still appealing to student palates. Their
techniques

included baking rather than frying, reducing salt usage, and substituting
low- fat ingredients wherever possible, such as in gravies, cheese sauces,
and salad dressings. At one high school in Kentucky, the food service
replaced the nacho cheese sauce with a low- fat substitute, and students
told us they were not aware of the change. Several SFA directors said that
Schools Have

Implemented Approaches to Overcome Barriers

A Variety of Efforts Are in Place to Improve Nutritional Quality of School
Meals

Page 19 GAO- 03- 506 School Lunch Program

they worked with vendors of prepared food to provide items that had
healthier nutritional specifications and lower fat content. For example,
an SFA in Washington State negotiated with a vendor to supply French fries

with less fat and sodium. In Kentucky, an SFA worked with venders to
provide low- fat pizza and chicken nuggets.

School food service managers and school officials found that expanding the
number and variety of healthy food choices increased the likelihood that
students would select them. Two of the schools that we visited were

part of a six- school research project that focused on increasing the
number of healthy lunch options available to students. Researchers
reported that when the number of healthy entrees was increased, the
percent of students purchasing them increased and has stayed higher than
pre- intervention levels. Also, several SFAs periodically provided free
taste testing or samples of proposed new additions to the school lunch.
SFA directors considered the student preferences and made changes in the
menu as long as their food service operation broke even financially as
required. We visited an elementary school in northern Virginia when
students were participating in a taste test. The students said that they
enjoyed the opportunity to taste the new items. Students filled out an
evaluation form, after they ate each sample, providing comments and
indicating how much they liked or disliked the item. The SFA director said
that the tastings increased student awareness of healthier food items and
induced them to taste items that they may not have normally chosen on
their own.

The schools and SFAs we visited had efforts in place to overcome the
barriers to encouraging healthy eating. They initiated changes in the
cafeteria and education activities in the classroom and beyond. Some
actions extended throughout the school and to the local community. Efforts
to support school activities are also taking place at the state and
federal levels.

SFAs in the districts that we visited had introduced a variety of
approaches in their cafeterias to make healthier school food more
appealing to students. One approach was to package the food in a manner
similar to what students find in fast- food restaurants. For example, a
high school in Washington State modeled its salads on those found in a
leading chain restaurant. A Kentucky high school served its reduced- fat
pizzas in small boxes imprinted with a brand name logo; and a Rhode Island
high school used colorful wrappers for its sandwiches. In another
approach, a California SFA found that vegetable consumption increased when
kitchen Schools Have

Implemented Activities to Promote Healthy Eating Choices

Efforts in the Cafeteria

Page 20 GAO- 03- 506 School Lunch Program

staff let the students serve themselves from the garden bar rather than
take vegetables served in individual bowls. 20 In addition, one district
we contacted increased the appeal of healthier food by reducing the
selling price of items such as string cheese, fresh fruit, and sunflower
seeds.

Some schools and SFAs we visited had taken actions to make their
cafeterias more attractive to students. In several districts, schools
tried to recreate, to some degree, the experience students find in popular
restaurants and food courts. They configured school cafeterias with
multiple serving lines, each with a different theme. For example, at a
high school in Kentucky, one line served the standard school lunch
entrees, while other lines were for salads and submarine sandwiches. A
high school in Michigan added an area that sold just soup, salad, and
delisandwiches. Several schools made cafeterias more inviting places to
eat by incorporating colorful decor. For example, the cafeteria manager at
a

Texas high school installed red and white awnings above the doorways into
the food area to make it look more like a cafe. One SFA in Rhode Island
had decorated school cafeterias with specific themes. For example one
junior high school cafeteria had a nautical decor, and a high school
cafeteria had murals of maps and flags representing each of the countries
of origin represented in the student body.

In several districts, SFAs used the monthly school menu to reach out
beyond the cafeteria and focus attention on nutrition. Some menus
contained items of nutritional interest or facts such as the calories and
fat content in the various school foods. School food service managers said
that since the students often took the menus home, it helped them reach
parents and guardians with their message of healthy eating choices. In a
related example, a Texas school district reported putting a new nutrition
article on their website every month.

Many schools had identified opportunities to instruct students about
nutrition both in the classroom and in other school activities. One SFA in
California had a nutritionist visit fourth grade classrooms to explain the
food pyramid and the importance of fruits and vegetables in their diet. As
part of her presentation, she gave the students samples of different
fruits. At a Rhode Island middle school, we watched a family and consumer

20 USDA cautions that schools must take other issues into account when
considering adding a salad bar including food safety practices associated
with preparing and storing the salad bar items as well as proper student
use. Educational Efforts

Page 21 GAO- 03- 506 School Lunch Program

science class prepare a raspberry ice yogurt as a healthful alternative to
the traditional milk shake. The teacher said she used USDA nutrition
education materials as well as those from food industry associations. She
also had class visits to farms, a farmers* market, and restaurant
kitchens. An SFA in California reported a noticeable change in what
students chose and ate after providing students with more information
about fruits and vegetables. Its schools placed nutrition- themed posters
in hallways and the cafeterias and started teaching nutrition in the
classroom. With the help of a Team Nutrition grant, a Michigan elementary
school integrated nutrition education into existing reading and math
curriculum. The project helped the school overcome the difficulty of
finding time to teach nutrition, a

subject with less priority to teachers because it is not included in state
academic standards assessments. The school was also using the School
Health Index for Physical Activity and Healthy Eating, a self- assessment

and planning guide developed by CDC, to assess its nutrition and physical
activity policies and create a healthy school environment. Some schools
and districts had adopted new policies or practices to restrict or replace
food of limited nutritional value sold in schools. These policies and
practices varied widely in their scope from those limited to a single
classroom to school and districtwide efforts. For example, at the
classroom level, in several elementary schools we visited, teachers said
that they no longer used candy as a reward in the classroom as a means of
supporting the healthy eating message. Instead, they substituted healthful
snacks, stickers, or extra minutes for recess as incentives. One teacher
in a Rhode Island elementary school rewarded her students with pennies for

demonstrating good health habits. Students could later exchange the
pennies for healthful snacks.

At the school level, some schools that sold competitive foods through
vending machines or in a cafeteria a la carte line, regulated the type of
items that could be sold. For example, at one Rhode Island elementary

school, at the principal*s request, the food service manager replaced
school snack bar items, such as candy bars and potato chips, with
healthier choices, such as rice cereal cookies and raisins. According to
the food service manager, students accepted the new selections with
minimal controversy, sales rebounded, and other elementary schools in the
district adopted the same changes. A Texas school district had a similar
experience when it revised its vending machine policy to include only
healthier items. An elementary school principal in California said her
school made more money selling healthier snacks than the limited
nutritional value items previously sold in the school. One district that
we School Policies, Practices, and

Community Activities

Page 22 GAO- 03- 506 School Lunch Program

visited in Michigan allows middle school students to make snack purchases
only after they have eaten their regular lunch.

At the district level, one large urban SFA that we visited was beginning
to implement a broad districtwide food policy that set multiple goals
focusing on improving the nutritional quality of school food, serving
enjoyable foods from diverse cultures, and improving the quality of food
service jobs. The policy also established a Nutrition Advisory Board that
includes teachers, principals, students, parents, and community
representatives in addition to district administration and SFA staff.
Several districts that we visited had established policies that prohibited
candy and soft drink machines at elementary schools and some regulated a
la carte sales in their secondary schools. A number of districts focused
on increasing the offerings of healthier items such as milk, water, and
juices. In addition to efforts in the cafeteria, educational efforts, and
changes in policies and practices to encourage healthy eating, several
schools that we

visited had taken steps to establish a broader more systematic healthy
school environment that includes both healthy eating and physical
activity. Two elementary schools in Texas* as part of a university and
state health department study funded by CDC* were working closely with
their SFAs

to increase low- fat choices in the cafeteria, were providing more
nutrition education to students, and were increasing students* physical
activity through physical education and other activities. These schools
had established a school committee of faculty, staff, students, and
parents to plan many of the school activities. Also, one elementary school
that we visited in Rhode Island had established a comprehensive school
health initiative that included both nutrition and physical activity
efforts. The school nurse taught health and was working on integrating
nutrition education into classroom lessons. She recently taught a lesson
on comparing the nutritional information on cereal boxes. The school had
established a healthy schools committee which meets twice a month and was
using a $1,000 grant to set up a walking program. Last year, the school
held a heart health fair for students and parents that included healthful

snacks and group exercise. Several school districts had expanded their
nutrition education efforts beyond the school by collaborating not only
with families, but also with community organizations and businesses to
raise healthy nutrition and lifestyle awareness. Several districts held
health fairs for families of students in which nutrition was a central
theme. For example, a fair at one Rhode Island school had restaurant chefs
speak to parents, demonstrate healthful food preparation, and provide
samples of healthful snacks. Three

Page 23 GAO- 03- 506 School Lunch Program

schools in another Rhode Island district also had a health fair that had
the sponsorship of organizations such as the local police department. A
health insurance company sponsored a pilot project at two middle schools
in

Grand Rapids, Michigan, in the spring of 2001. The *Trek Around the World*
encouraged students to increase their physical activity and eat more fresh
fruits and vegetables.

Many SFA officials, principals, and other officials that we contacted said
leadership makes a difference in the success of nutrition and healthy
eating efforts. They emphasized the importance of local leadership in

implementing and sustaining a successful child nutrition and health
program in the school and community. For example, one elementary school
principal made a point of frequently eating fresh fruit in front of her
students. A middle school administrator roamed the cafeteria at lunchtime
encouraging students to eat healthful foods. In some schools we visited,
other people such as a teacher, a physical education teacher, the school
nurse, or the local parent- teacher association president had taken a
leadership role in implementing and sustaining efforts to encourage good
nutrition and create a healthy school environment.

State efforts to support local leaders in improving school meal nutrition
and encouraging healthy eating among students in the states we visited
included a variety of approaches. For example, in Rhode Island, a private
nonprofit organization facilitated Team Nutrition efforts, providing a
focal point for assistance and outreach to schools and districts. In
Michigan, the Michigan State University Extension and the Michigan
Department of Education worked as a team to promote Team Nutrition. The
extension service provided materials, information, and assistance to
schools and SFAs. The state department of education and the extension
service have a history of collaboration to address a variety of state
issues, according to state officials. In Kentucky, Rhode Island, and
Texas, state departments of education and health have also established
ways to collaborate to address student health issues, including nutrition.
In California, the state passed legislation that will take effect in 2004
that establishes restrictions on beverages sold in elementary and middle
schools and places nutritional standards on the type of foods that can be
sold* including in vending machines. State education department officials
in California report that they are working with school districts to
promote districtwide healthful food policies. School and SFA officials
acknowledged that state assistance and leadership was valuable in
implementing local activities. However, USDA officials report that not all
states have established a state focal point for leadership or have begun
collaboration among state agencies to address nutrition education. State
Efforts to Support School

Activities

Page 24 GAO- 03- 506 School Lunch Program

A growing support structure for these local efforts is in place at the
federal level. According to USDA officials, the agency will continue and
expand its nutrition and healthy eating efforts through the Team Nutrition
initiative. According to officials from USDA and CDC, they collaborate on
a number

of health efforts to avoid duplication and ensure a single message is
communicated. Additionally, USDA, CDC, and the Department of Education
partnered with a number of national organizations to sponsor a Healthy
Schools Summit in October 2002. The conference emphasized collaboration to
foster change at the state, district, and local levels and launched the
establishment of Action for Healthy Kids teams in 50 states

and the District of Columbia. Further, in June 2002, the Secretaries of
the Departments of Agriculture, Health and Human Services, and Education
signed a memorandum of understanding to strengthen and promote the
education and health of school- age children. The memorandum specifies the
types of activities the departments will conduct over 5 years. For
example, USDA will develop and distribute grade- specific materials to
schools to use in the classroom, and Health and Human Services will
provide technical assistance to help state education agencies support
schools in selecting or developing effective physical education and
nutrition education curricula. Additionally, the Department of Education
will encourage schools to participate in Team Nutrition and encourage
state boards of education to develop policies that will provide healthy
school environments. However, the memorandum does not identify specific
strategies to address how schools will find time to use the materials and
technical assistance provided by federal agencies given the time
requirements for meeting state academic standards* for example, by
facilitating the integration of nutrition education into the existing
curricula and activities and by focusing on student behavior. Furthermore,
the

memorandum does not specifically address the importance of leadership and
agency collaborations at the state level in addressing nutrition and
healthy eating in schools.

With an urgent health problem threatening the well being of the country*s
youth, it is important that actions be taken to reverse current trends
toward obesity and related physical problems. While schools and the school
lunch program cannot be expected to solve these problems alone, they are
well positioned to positively influence what children eat and what they
know about the importance of good nutrition. However, many schools are
sending a mixed message when they provide nutritious meals and encourage
healthy choices, but at the same time rely on the sales of foods of
limited nutritious value to fund school and student activities. Despite
the difficulties of making significant changes in the foods sold at
Federal Efforts to Support

School Activities Conclusions

Page 25 GAO- 03- 506 School Lunch Program

schools, a number of schools and districts have shown that healthful food
policies and practices can be put in place. These policies not only help
ensure that the food children eat at school is healthful; they also
provide a positive model within the school and an opportunity to learn
about healthy eating outside the classroom. Many schools, however,
continue to face challenges to providing nutrition education in the
classroom, in part, because of the need to focus on subject matter covered
to meet state academic standards.

Federal efforts to promote and support local initiatives, including
increasing collaboration among agencies, show promise. The recent
memorandum of understanding signed by USDA, the Department of Health and
Human Services, and the Department of Education underscores the

importance of agencies working together and contributing what they do
best. This federal partnership could be fruitful in increasing the
emphasis on, and resources available for, encouraging healthy eating and
the integration of nutrition education into schools* existing curriculum
in ways that would meet state academic standards requirements while
advancing students* awareness of the importance of healthy eating.

The state role in promoting nutrition education* both in the classroom and
beyond* is also seen as an important part of the nutrition and healthy
eating equation. Efforts in some states are promising. However, not all
states appear to have established the focused and coordinated effort among
appropriate state agencies that could facilitate active partnering with
the federal agencies that provide resources and assistance.

Providing healthful food and encouraging healthy eating among students is
a complex undertaking and schools differ in their needs and capabilities
so that no single program can be appropriate for all. Moreover, healthy
eating

is only one of the changes needed to address the growing overweight and
health problems among our nation*s youth. Ultimately, a more comprehensive
program that addresses students* entire environment, and one that provides
multiple exposures to nutritious food and information

on healthy eating* as well as promoting appropriate physical activity*
appears to offer the most hope of success. The Surgeon General*s office
has emphasized the importance of individuals and groups, across all
settings, working in concert to educate people about health issues related
to overweight and obesity and to promote balancing healthy eating with
regular physical activity. A number of models have already been developed
for schools to use in that endeavor, including USDA*s Changing the Scene
and East Smart- Play Hard and CDC*s School Health Index. However,
nationwide progress could be facilitated by enhanced and continuing

Page 26 GAO- 03- 506 School Lunch Program

collaboration among officials and organizations at the federal, state, and
local level to inform, promote, and help sustain efforts.

We recommend that the Secretaries of Agriculture, Health and Human
Services, and Education use their recently signed memorandum of
understanding as a vehicle to

 identify specific strategies and develop materials to help schools
promote nutrition education while still meeting the requirements of state
academic standards and

 encourage states to identify a focal point in each state to promote
collaborative efforts that would further develop nutrition education
activities for the schools. We requested comments on a draft of this
report from the Secretary of

Agriculture or her designee. On April 11, 2003, officials from USDA*s Food
and Nutrition Service, Child Nutrition Division, provided us with the
following oral comments on the draft. The officials said that they were in
general agreement with the findings and recommendations as presented in
the report. However, they said that targeted nutrition education training

funds, which were provided to states in the past, are no longer available,
and they believe that, without additional funding, states are unlikely to
implement our recommendation that each state identify a focal point to
promote collaborative efforts to develop nutrition education activities
for schools. We recognize that states are currently facing budget
shortfalls and may find it difficult to create new staff positions at this
time. However, we believe that states, at a minimum, can identify a focal
point from among existing positions to promote a focused and coordinated
effort

among appropriate state agencies. The officials also noted that they
believe their major school nutrition initiatives* which are Team
Nutrition, Changing the Scene, and Eat SmartPlay Hard* all play an
important role in encouraging schools to serve nutritious food and in
encouraging children to eat well. We agree that such initiatives can play
an important role in improving the school nutrition environment in schools
where they are implemented; however, not all schools participate in the
initiatives. Our recommendations focus on the need for various federal and
state agencies to work together as a next step to help focus resources and
activities on nutrition education and other efforts to encourage children
to eat healthy foods. Regarding this need for collaboration, Food and
Nutrition Service officials said that they would like to be more active in
their support for, and collaboration with, CDC. Recommendations for

Executive Action Agency Comments

Page 27 GAO- 03- 506 School Lunch Program

However, they believe USDA is not always in a position to support CDC as
much as they would like and would need additional resources to do so. In
our review, we did not analyze funding levels of the different agencies.
Finally, in addition to these observations, USDA provided technical
comments that we have incorporated as appropriate.

The Department of Health and Human Services provided written comments on a
draft of this report. (See app. I.) Health and Human Services generally
agreed with our findings and recommendations and provided information on
the Steps to a Healthier US initiative. It also provided technical
comments that we have incorporated as appropriate. Along with the
technical comments, the department provided a table summarizing the
strategies for improving school nutrition that were presented in the
report. We have included the table in appendix I.

The Department of Education also provided written comments on a draft of
this report. (See app. II.) Education said that the report provides a
review of the many issues facing schools in their efforts to meet USDA
nutrition requirements and promote healthy eating among students and they
also provided additional information on department initiatives that
support student health and nutrition. However, Education expressed concern
that the information we present appears to imply that accountability
provisions in the No Child Left Behind Act may contribute to compromising
a healthy eating environment in schools, and it raised questions about the
support for our finding that school officials have difficulty finding the
time to incorporate nutrition education into every day lessons because of
pressures to meet state academic standards. Our findings are based on the
views expressed by school and SFA officials we interviewed, and we believe
we have fairly reflected the views of those officials. We believe that
nutrition education and other components of a healthy eating environment
can and should be compatible with, and complementary to, schools* efforts
to meet the requirements of state academic standards. It is for this
reason that we have recommended that federal agencies partner and work
with states to help schools find ways to

promote nutrition education and healthy eating among students. Education
suggested that we acknowledge other provisions of the No Child Left Behind
Act that can support nutrition and also suggested that we include more
examples of physical activity programs in our report. It specifically
noted the Carol M. White program, which includes elements that address
both physical activity and healthy eating. We recognize that there may be
a number of programs that have the potential to contribute to nutrition
and healthy eating efforts, and we agree that physical activity

Page 28 GAO- 03- 506 School Lunch Program

programs could be an important component of a healthy school environment.
However, the scope of our study did not include a comprehensive review of
initiatives that support nutrition or physical activity. Also, the
department recommended that we include the Action For Healthy Kids
Initiative with our examples of community collaborations to promote
children*s nutrition as well as physical activity. We have done so.

Education also provided us with technical comments, which we have
incorporated as appropriate.

We will send copies of this report to the Secretaries of Agriculture,
Health and Human Services, and Education, appropriate congressional
committees, and other interested parties. In addition, the report will be
available at no charge on GAO*s Web site at http:// www. gao. gov.

If you or your staff have any questions or wish to discuss this material,
please call me at (415) 904- 2272 or Kay E. Brown at (202) 512- 3674.

David D. Bellis Director, Education, Workforce,

and Income Security Issues

Appendix I: Comments from the Department of Health and Human Services Page
29 GAO- 03- 506 School Lunch Program

Appendix I: Comments from the Department of Health and Human Services

Appendix I: Comments from the Department of Health and Human Services Page
30 GAO- 03- 506 School Lunch Program

Appendix I: Comments from the Department of Health and Human Services Page
31 GAO- 03- 506 School Lunch Program

Appendix I: Comments from the Department of Health and Human Services Page
32 GAO- 03- 506 School Lunch Program

Appendix II: Comments from the Department of Education

Page 33 GAO- 03- 506 School Lunch Program

Appendix II: Comments from the Department of Education

Appendix II: Comments from the Department of Education

Page 34 GAO- 03- 506 School Lunch Program

Appendix II: Comments from the Department of Education

Page 35 GAO- 03- 506 School Lunch Program

Appendix III: GAO Contacts and Staff Acknowledgments

Page 36 GAO- 03- 506 School Lunch Program

Kay E. Brown (202) 512- 3674 (brownke@ gao. gov) Susan J. Lawless (206)
287- 4792 (lawlesss@ gao. gov)

In addition to the individuals named above, Robert B. Miller, Dianne L.
Whitman- Miner, Shana B. Wallace, Tamara L. Fucile, Daniel A. Schwimer,
Karyn I. Angulo, and Stanley G. Stenersen made key contributions to this
report. Appendix III: GAO Contacts and Staff

Acknowledgments GAO Contacts Staff Acknowledgments

(130184)

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