As a Stanford Impact Labs postdoctoral fellow working closely with Dr. Anisha Patel at the Stanford School of Medicine, I focus my research on understanding how policies that facilitate a healthy food environment improve health and prevent the onset of noncommunicable diseases, with the potential to reduce health disparities.
When the U.S. Department of Agriculture (USDA) announced its current proposal to limit added sugars in school meals, I sat down with Stanford Impact Labs’ Kate Green Tripp to discuss the implications.
In early February 2023, the USDA announced new nutrition standards for school meals. What is important to understand about this?
School meals currently serve about 30 million children between the ages of 5 and 18 in the U.S. The majority of these kids are low-income or at increased risk of food and nutrition insecurity. School meals were first introduced in 1946 with the aim of improving food security, which simply means access to food.
In 2010, the Healthy, Hunger-Free Kids Act strengthened nutrition standards for school meals to improve not only food security but also nutrition security — in other words, access to healthy and nutritious food. These standards limit the amount of salt, fat, and calories in school meals and standardize other requirements, such as ensuring that meals include whole grains, fruit, and vegetables. Yet no standard currently limits added sugar in school meals. The need for such a check has become urgent because research shows that school meals exceed the daily limit recommendation of added sugars per day.
The Dietary Guidelines for Americans (DGA) recommend consuming less than 10% of total daily calories from added sugar, and the American Heart Association recommends limiting added sugar to less than 25 grams (~6 teaspoons) per day. On Feb. 3, 2023, the USDA announced a new proposed rule on nutrition standards for school meals, which established a reduction of sodium and the first-ever limit on added sugars in school meals, in alignment with the DGA. If these new nutrition standards are implemented, school meals will be required to limit added sugar to less than 10% of total calories per day.
What does the average school meal look like now, specifically when it comes to sugar content?
Anecdotally, we know school meals have a lot of sugar, though few studies have evaluated the added sugar content. One study that assessed the amount of added sugars in school meals in 2014-2015 found that 92% of schools exceeded the limit recommendation (less than 10% of calories) in school breakfasts. The same study found that 67% of schools exceeded the limit recommendation in school lunches.
At the end of 2020, Dr. Anisha Patel, associate professor at Stanford — in partnership with Cultiva La Salud, the Dolores Huerta Foundation, and the UC Nutrition Policy Institute — performed a photovoice study to evaluate the perception of school meals among parents in elementary schools in the San Joaquin Valley.
At that time, schools were operating virtually because of the COVID-19 pandemic, but parents were allowed to pick up meals for their kids. For this study, parents were asked to take photos of the foods they received, and then in focus groups, they discussed their perception of the meals. One topic parents discussed was the healthfulness of the meals. In particular, parents perceived that school meals were “full of sugar.¨ Working alongside two student interns in Dr. Patel’s lab — Jonathan Tyes, a medical student at the University of Louisville, and Brandon Cortes, a high school student — I used the photographs that parents provided to quantitatively evaluate the amount of added sugar in school meals.
We found that parents’ instincts were right: School meals are high in added sugar, and on average, school meals contain eight teaspoons (33 grams) of added sugars per day, which is two more teaspoons than the American Heart Association recommends as a daily limit. Like the previous study, we identified that the top sources of added sugar were items that are commonly consumed at breakfast, such as flavored milk, yogurt, pastries, bread, and dry fruit. We discovered some cases in which a single breakfast of a blueberry muffin, dry fruit, and low-fat milk provided up to 10 teaspoons of added sugar — almost twice the daily limit, all in one dose as a child’s start to the day.
What do we know about the health effects of sugar on school-age kids?
Added sugar is associated with many adverse health outcomes. For example, in the short term, sugar increases the risk of tooth cavities. Added sugar is the leading cause of tooth decay in children, and high added sugar consumption in children is associated with excess weight gain, which increases the risk of being overweight or obese. Added sugar is also associated with cardiovascular risk factors in children, such as lipid alterations, non-alcoholic fatty liver disease, and high blood pressure. In overweight or obese children, a high intake of added sugar is also associated with insulin resistance.
A closer look at nutrition in American kids reveals alarming numbers:
- Children in the U.S. consume an average of 17 teaspoons (70.8 grams) of added sugar per day.
- About 8 in 10 school-age children in the U.S. consume more than 10% of calories from added sugar.
- More than one-third of children in the U.S. meet the definition of overweight or obese.
- 1 in 5 adolescents have pre-diabetes.
- 1 in 5 children ages 6-11 and more than half of adolescents have experienced dental caries.
What will it take for the proposed standards to be implemented?
It is important to note that the USDA's proposed rule is simply that: a proposal. The USDA will receive public comments for 60 days before developing the final rule. If the proposed rule doesn’t change, the policy will not be fully implemented until the 2027-2028 school year to allow schools to adjust to the necessary changes. In the meantime, in the 2025-2026 school year, the amount of added sugar will be limited on items that are the primary sources of added sugars in school meals, such as grain-based desserts (no more than 2 oz equivalents/week), breakfast cereals (no more than 6 grams/oz), yogurt (no more than 12 grams/6 oz), and flavored milk (no more than 10 grams/8 oz).
I would like to see this policy be implemented sooner rather than later with stricter standards, but I am hopeful and recognize this as a huge step in the right direction. However, I anticipate the proposal will see a lot of pushback from the food industry, which is known for using a variety of tactics to prevent and delay health policies that could affect their economic interests. That makes this a particularly critical moment for children's health advocates to submit comments supporting these standards and to remain vigilant until the standards are fully implemented.
In other exciting news, California is also considering passing a bill that would limit added sugar in school meals based on the American Heart Association recommendation of less than 25 grams/day. If this bill passes, California will be the first state to have stricter added-sugar criteria, and this measure will likely be implemented sooner than the USDA standard.