The purpose of this project is to assess breakfast and lunch programs in Minnesota schools and identify ways to improve nutrition, specifically where it impacts childhood caries (cavities) and obesity. Our objectives were to survey the snacks and beverages being sold to elementary school children in Minnesota and gather data related to the funding of school lunches. The survey was sent to all public school districts in the state, resulting in a response rate of 63%. Our results show that more than 91% of the responding school districts in the state of Minnesota serve chocolate milk five or more days a week, with one serving equaling 22 grams of sugar. According to current guidelines, children should have no more than 25 grams of added sugar in a day. Seventy-seven percent of respondents indicated that students have the option of adding additional food via a la carte options that meet Smart Snacks requirements. More than 53% of responding schools reported the use of meal accounts to help pay for these options. Sixty-five percent of respondents reported that 31-60%o of their children are on free or reduced lunches. Seventy-eight percent of respondents reported that 61-90% of their children eat school lunch.
Background
To meet our purpose of assessing meals served in Minnesota school districts and suggesting improvements to reduce childhood caries and obesity, we initially wanted to determine how often chocolate milk was served. The survey widened to include questions related to all food and beverages available during the course of a day, how many children eat school lunches, and how many receive reduced lunches. The surveyors were Katie Ask and Dr. Sarah Magnuson. Katie Ask is a student at the University of Minnesota Dental Therapy Program with a background in nutrition; Sarah Magnuson is a 2008 University of Minnesota School of Dentistry graduate who is in private practice as a general dentist, and has also worked in the public health field since 2009. Dr. Magnuson has seen an increase in childhood caries among patients with state insurance, and is concerned about improving their overall oral health. We are providing this information to the Minnesota Dental Association in response to their September 2016 resolution to learn more about school lunches.
A Brief History of School Lunches in the United States
Informal school lunch programs date back to the beginning of the 20th century when volunteer groups who were concerned for the health and well-being of children began providing meals. (1) Prior to this, students lived close enough to travel home during the lunch hour. In the beginning, these volunteer groups lacked guidelines or regulations related to the populations they served. These programs originally started in larger cities such as Boston and Philadelphia. (2) As these programs gained in popularity, they became harder to fund, creating a need for more formal structure. In 1946, the Nutrition School Lunch Act was instituted by President Harry Truman, (3) an act that made it possible for schools to receive federal aid for providing school lunches to all children as long as the following guidelines were followed:
1. Serve lunches meeting the minimum nutritional requirements prescribed by the Secretary.
2. Serve meals without cost or at reduced cost to children who were determined by local school authorities to be unable to pay the full cost of the lunch, and not to segregate or discriminate against such children in any way.
3. Operate the program on a nonprofit basis.
4. Utilize as far as practicable the commodities declared by the Secretary to be in abundance and to utilize commodities donated by the Secretary.
5. Maintain proper records of all receipts and expenditures and submit reports to the State agency as required. (4)
This was the first time that school lunch programs were made to regulate the types of foods they could serve. Over time, changes have been made to schools and to the meal programs. As popularity continued to grow and people were traveling further from home, institutions developed cafeterias. A school breakfast program was also developed, this in 1975. (5) Major changes occurred in 1980, when the first dietary guidelines for healthy Americans were published. Dietary guidelines are published every five years, and provide important nutrition information that allows organizations to construct policy (6) Since the guidelines were initially set, the government has been more stringent on the foods that are allowed to be served, focusing on limiting macronutrients (e.g., fat, protein, carbohydrate). These changes are grounded in evidence-based nutrition, establishing the healthiest possible diet for Americans at that time. Another addition is a school nutrition dietary assessment that is used to see how well schools are meeting these guidelines.
Q1 How many days of the week do you serve chocolate milk? Answered: 210 Skipped 1 Q1 Answer Choices 1 day a week 2.86% 2 days a week 0.95% 3 days a week 1.9% 4 days a week 2.38% 5 days a week 66.19% 10 days a week (both breakfast/lunch) 25.71% Total responses 210 Note: Table made from pie chart. Q2 Does your school participate in a Special Milk Program (SMP) and/or Minnesota Kindergarten Milk Program (MKMP)? (Please select all that apply) Answered: 180 Skipped 31 Q2 Answer Choices Special Milk Program 26.67% Minnesota Kindergarten Milk Program 74.44% No 18.33% Total responses 210 Note: Table made from bar graph.
School Lunch Funding and Student Participation
As of 2012, the National School Lunch Program had served 31 million school-aged children lunches each day, and more than 224 billion lunches since the program started. (7) Children qualify for free lunches by being below 130% of the poverty level; they qualify for reduced price lunches if they fall below 150% of the poverty level. (7) These programs function by receiving cash subsidies from the government to help cover the price of providing these lower cost meals. In addition to subsidies, schools can also receive money for participating in different reimbursement programs such as the following.
Q3 Do middle schoolers have access to vending machines during the school day? Answered: 180 Skipped 31 Q3 Answer Choices Yes 26.67% No 73.33% Total responses 180 Note: Table made from bar graph. Q4 Do high schoolers have access to vending machines during the school day? Answered: 181 Skipped 30 Q4 Answer Choices Yes 50.28% No 49.72% Total responses 181 Note: Table made from bar graph.
SMP--Special Milk Program is a national program that provides milk to children in schools, child care institutions, and eligible camps, with a reimbursement of 19.75 cents per half pint of pasteurized types of fat free or low fat (1%) milk. Regulated by state agencies, participating schools must sell milk at a reduced rate, and the schools cannot participate in any other federal child nutrition meal service programs. (8)
MKMP--Minnesota Kindergarten Milk Program is a state funded program that provides cash reimbursement for milk at a rate of 20 cents per half pint per day per child served at low or no cost to kindergarten students. The program may operate in public and private nonprofit schools and boarding schools. Schools that participate in the SMP may also participate in the MKMP. (9)
Smart Snacks were implemented in July 2014. Smart Snacks are defined as follow. (10)
* Must be a grain product that contains 50% or more whole grains by weight (have a whole grain as the first ingredient); or
* Have as the first ingredient a fruit, a vegetable, a dairy product, or a protein food; or
* Be a combination food that contains at least 1/4 cup of fruit and/or vegetable: and
* The food must meet the nutrient standards for calories, sodium, sugar, and fats
A snack is defined as being 200 calories or less, 200 mg or less sodium, 35% of calories or less total fat, and less than 10% of calories saturated fat.
An entree is defined as being 350 calories or less, 480 mg or less sodium, 35% of calories or less total fat, and less than 10% of calories saturated fat.
Methods
We created a list of all 331 public school districts in the state of Minnesota using the website www.mngeo.state.mn. us/maps/schooldistricts. An excel spreadsheet was created, and we attempted to get contacts from the state government. After visiting each school's website, we located email contacts for either the nutritionist, principal, or superintendent when feasible. When an email address was located on their websites, we called the schools directly asking for the best contact. A survey was created on surveymonkey.com with the following 10 questions.
Q5 Please select all beverages you have available in your vending machines (before and after school)? Answered: 184 Skipped 27 Q5 Answer Choices White milk 10.33% Chocolate milk 12.50% Juice 52.72% Soda pop 26.63% Power drink Gatorade, Powerade, etc.) 64.13% Water 80.43% None, does not apply 19.02% Total responses 184 Note: Table made from bar graph. Q6 Does your school have an a la carte option? Answered: 184 Skipped 27 Q6 Answer Choices Yes 77.72% No 22.28% Total responses 184 Note: Table made from bar graph.
* How many days of the week do you serve chocolate milk?
* Does your school participate in a Special Milk Program (SMP) and/or Minnesota Kindergarten Milk Program (MKMP)?
* Do middle schoolers have access to vending machines during the school day?
* Do high schoolers have access to vending machines during the school day?
* Please select all beverages you have available in your vending machines (before and after school).
* Does your school have an a la carte option?
* If yes to a la carte, how is it funded?
* Does your school have the ability for parents to see what their children are purchasing?
* What percentage of children receive free or reduced lunches?
* What percentage of children eat school lunch?
Results were exported from Survey Monkey including charts/graphs for Question 1-8. Question 9 and 10 were not multiple choice and were grouped by percentages.
Q7 If yes to a la carte, how is it funded? Answered: 86 Skipped 14 Q7 Answer Choices Cash 31.14% Meal account 53.89% Does not apply, we don't have an a la carte 14.97% Total responses 187 Note: Table made from bar graph. Q8 Does your school have an ability for "parents to see what they are purchasing? Answered: 85 Skipped 12 Q8 Answer Choices Yes 76.97% No 23.03% Total responses 178 Note: Table made from bar graph.
Results
Two hundred ten of 331 schools responded to our electronic survey. Please see attached graphs for results, and note that some schools chose to skip some of the questions.
Discussion
The results show that more than 91% of schools in the state of Minnesota serve chocolate milk five or more days a week. Seventy-four percent of schools participate in the MKMP, encouraging children to drink milk in the schools. Middle schoolers have limited access to vending machines compared to that of high schoolers. Power drinks, juice, and water are more likely to be found in the schools that have vending machines. A la carte options including Smart Snacks, general snacks, and second meal options are found in 77% of our schools in Minnesota, and 53% of schools use meal accounts to help pay for this option. We have a list of foods served in our Excel spreadsheet for reference upon request. Seventy-six percent of schools report that parents can see what their children are purchasing. Seventy-eight percent of school districts report that 61-90% of their students eat school lunch, which emphasizes the importance of healthy food choices. Of those students who eat school lunches, 31-60% of their children report receiving free or reduced lunches. Minnesota has a high population of children on assistance in some way or form. We were surprised that 91% of children have access to chocolate milk on a daily basis. A single serving of chocolate milk contains more than 22 grams of sugar, while the American Heart Association recommends that children should consume fewer than 25 grams of added sugar a day. Chocolate milk, juice, soda, and power drinks also have high levels of sugar and can cause dehydration by pulling nutrients from the tooth structure.We attached an article for reference about children's sugar consumption. We hope this paper can encourage further research and investigation to help with the oral of health of children in the state of Minnesota.
Q9 What percentage of children are on free or reduced lunches?
Answered: 166 Skipped 160
Percentage of Reduced Lunches
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80
Percent Range 1% 7% 17% 26% 23% 16% 4% 2%
Percentage of Reduced Lunches
81-90 91-100
Percent Range 0% 3%
Note: Table made from bar graph.
10 What percentage of children eat school lunch?
Answered: 166 Skipped 160
Persentage of Lunches per
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80
Percent Range 12% 0% 0% 19% 2% 8% 21% 30%
Persentage of Lunches per
81-90 91-100
Percent Range 27% 0%
Note: Table made from bar graph.
Conclusion
With the state of Minnesota being responsible for providing free or reduced meals to children who may have barriers to oral health, it is important that we provide the best choices. Replacing chocolate milk with white milk in schools would reduce the sugar content, which will help reduce obesity and dental caries risks. Evidence shows that children adjust to dietary changes. Further evaluation of beverages within schools is highly recommend as students have more choices that negatively impact their oral health.
We were overwhelmed by the support provided by school districts, and we thank them for their help in providing this data. With this document, we are happy to share our results with each district. Please know that we are available to answer any questions readers may have regarding this study, and we are happy to be a resource for other information relating to dentistry.
Article Summaries
An article on "Children's Sugar Consumption: Obesity and Dental Caries" (11) was recently published in Pediatric Dentistry stating a need to look at children's consumption of food and beverages, being mindful of the amount of sugar that they consume. (Readers are directed to the table on page 13 of that article). The American Heart Association recommends fewer than 25 grams of added sugar a day. The U.S. Department of Agriculture recommends no flavored milk be given to children birth to five years old; those six years old and older should consume unflavored fat-free, skim, or low fat milk. If flavored milk is given, it should contain no more than 22 grams of sugar per 8 fluid ounces. U.S. Department of Health and Human Services and U.S. Department of Agriculture want children to limit sugar consumption to less than 10% of their diets, and they encourage lower intake of sugar-sweetened foods, particularly beverages.The World Health Organization follows the same suggestion of less than 10% sugar consumption, and they also state that intake of free sugar should be less than 5% of total energy intake per day to reduce the risk of weight gain and dental caries--i.e., children four to eight years old would need fewer than 16 grams! (11)
Acknowledgments
We thank Dr. Karl Self from the University of Minnesota for his guidance with this research project. Thanks as well to all the school districts who helped out, and to the Minnesota Dental Association for approving the resolution in 2016.
References
(1.) files.eric.ed.gov/fulltext/ED502404.pdf
(2.) http://www.pbs.org/food/the-history-kitcheny history-school-lunch/
(3.) https://www.fns.usda.gov/sites/default/files/NSLA.pdf
(4.) https://www.fns.usda.gov/nslp/history
(5.) https://www.fns.usda.gov/sites/default/files/BR-REPSummary.pdf
(6.) http://www.health.gov/dietaryguidelines/
(7.) https://www.fns.usda.gov/sites/default/files/NSLPFactSheet.pdf
(8.) Special Milk Program--https://www.fns.usda.gov/smp/special-milk-program
(9.) Minnesota Milk Programs--https://educar.ion. state.mn.us/MDE/dse/FNS/Milk/index.htm
(10.) Smart Snacks--http://www.pewtrusts.org/~/media/assets/2015/06/smart__snacks_proceedings.pdf https://www.fhs.usda.gov/sites/default/files/tn/USD ASmartSnacks.pdf
(11.) Children's sugar consumption: obesity and dental caries. Ped Dent 39;1:12-13.
Katie Ask, B.S., (*) and Sarah Magnuson., D.D.S. (**)
(**) Dr. Magnuson is a Minneapolis District delegate for the Minnesota Dental Association. She is a general dentist in private practice in Greenfield, Minnesota. Email is smagnuson@lakesarahdental.com
(**) Ms. Ask is a senior Master of Dental Therapy student at the University of Minnesota School of Dentistry. Email is askxx010@umn.edu