TY - JOUR
AU1 - Lucan, Sean C.
AB - I am a family physician in the Bronx, New York. My patients are predominantly lower-income minorities who face many obstacles to healthy eating. During patient visits, I have seen Coca-Cola in baby bottles and french fries as infant food. A common theme in my patients’ diets is a paucity of whole foods and a preponderance of ultraprocessed products. Certainly, education plays a role; my patients generally have lower levels of schooling and lower health literacy. Part of my job as a physician is to educate. Given that nutrition impacts general health and wellness and the management of virtually all disease states, I find myself counseling on diet at most patient visits. When I see a young boy for a checkup and his mother has provided him with chips, candy, and a sugary drink as an examination room snack, I am affected by the image. I too have a son, but my son eats differently. His whole environment is different. At least, so I thought. A Healthy Environment My family and I live outside the Bronx—in an upper-middle-class suburb bordering an affluent community. Access to healthy food is not an issue, making our area very much unlike the neighborhoods where my patients live. The area is home to the school where my son entered first grade last year. I was pleased to learn the school supported a Healthy Snack Program (in which parents take turns providing wholesome foods for children in a class to share). For my son, these snacks would supplement a healthy parent-packed lunch he would bring from home every day. At least, that was the plan. But shortly after the school year began, I started to notice some of my son’s lunchbox favorites coming back home, unfinished or uneaten. Something was up. Unhealthy School Food Ultimately, I discovered what was displacing items from my son’s lunch box was other foods. Some of these foods were the “healthy” snacks provided by other parents—snacks like Mott’s Apple Sauce and Go-Gurt. It would hardly be a stretch to characterize Mott’s Apple Sauce as a fruit-added corn syrup or Go-Gurt as a sugary blend of suspicious synthetics with a modicum of milk to connote actual fermented dairy. Nonetheless, “healthy” may have been a relative distinction, differentiating classroom snacks from other foods at school. For instance, birthday parties occurred with regular frequency in a class with just under 20 students. Cupcakes, cookies, ice cream, and/or sugary drinks almost inevitably defined these events. Then there were the parties to recognize different cultural holidays (Diwali, Hanukkah, Kwanzaa, Christmas, Lunar New Year, etc) and to mark other events (Halloween, Children’s Day, Valentine’s Day, last day of classes, etc). These celebrations (often multiple per holiday/event) frequently had sign-ups up for “salty snacks” (various chips), “sweet snacks” (cakes and candies), and “drinks” (inevitably sugared). Then there were field trips (with, for example, snack stops at McDonald’s) and “bake” sales (often featuring less-“baked”-than-assembled ultraprocessed standards like Rice Krispies Treats and Jell-O concoctions). Although field trips and bake sales were not frequent, they added to other school-sanctioned food provision that was more common (eg, teachers using candy as incentive or reward in the classroom or as material for in-class projects—eg, making “snowmen” from marshmallows or doing math with Skittles). And there were still other items to displace healthy foods from a lunchbox. The after-school program made Goldfish (an industrial amalgam of artificial ingredients and refined starch) and animal and Graham “crackers” (ie, animal and Graham cookies) regular offerings, as well as other substantively synthetic starchy and sugary snacks. Had my son been old enough to participate in activities of the middle school, similar items from vending machines might have also contributed to the mix. Addressing the Situation I gleaned from orientation events at the school that other parents were well educated and quite comfortable financially. Certainly other parents were invested—and had invested—in their children’s futures. Likewise the school seemed dedicated to healthy child development, and teachers and administrators seemed committed to an overall goal of building healthy minds and bodies. Perhaps these well-intended, informed, and well-resourced people just didn’t see the connection between food, education, and broader child wellness? I sent an observational email about school foods to my son’s teacher and the parent representative for his class. I was referred to the school nurse, who in turn referred me to the head of the lower school. The lower-school head invited me in for a chat and ultimately thought a wider conversation was in order. She suggested a “coffee talk” (a morning session where I could present to teachers, administrators, and parents). Making a Case I opened the “coffee talk” by sharing my experience as a family physician. I described seeing first-hand the burden of largely preventable diet- and weight-related chronic conditions across generations, and the appearance of diseases in childhood once thought to be adult-onset only. I reviewed diet’s links to attention and academics, to dental caries and digestive issues, and to overall health and longevity. I expressed concern about food provision and food lessons coming from the school. A central thrust of my message was that children are what they eat—literally; what we put in their bellies becomes the actual substance of their bodies and brains. I used an analogy I use in clinic: “If you were erecting a building, would you allow shoddy materials?” I stressed that any absence of apparent obesity should not at all be reassuring: “Tall slender buildings are no less prone to crumble when weak at their bases, and when we feed our kids junk, we build a foundation of poor health,” with tastes, preferences, habits, and behaviors that set children on a path toward unwell adulthoods. I emphasized that the healthiest foods come from botanical plants, not processing plants.1 Several attendees nodded, which I interpreted as agreement. But one dad worried about becoming a “food Nazi.” Was I proposing no cookies, candy, or celebratory treats for our kids? A childhood of deprivation was not a childhood as far as he was concerned. He had a point. But that wasn’t my point. Refining the Message The message I wanted to convey was not one of deprivation but of quality, quantity, and control. First, it’s not that children should be disallowed treats. But there is huge difference, for example, between a frozen treat made from smashed-up whole fruit and an alternative engineered from “sugar, dextrose, partially hydrogenated coconut oil, corn syrup solids, maltodextrin, sodium caseinate, salt, guar and xanthan gums, natural and artificial flavor, monoglycerides and diglycerides, dipotassium phosphate, and yellow dyes 5 and 6” (actual ingredients from an actual “food” for kids). Second, a “treat” is only a treat (by definition) if it is rare or out of the ordinary. With snack programs, teachers’ rewards, in-class projects, vending machines, class parties, and various other school events including the occasional field trip or bake sale, unhealthy products a school may try to frame as “treats” are neither rare nor out of the ordinary. They are ubiquitous and routine, being regularly endorsed and provided—even celebrated! Given that a single drink box and cupcake could provide more sugar than the World Health Organization recommends even a moderately active 7-year-old consume over an entire day (or even, ideally, over two days),2 the regularity of such consumption is alarming. Third, and perhaps most important, who should decide what a child eats at school? Other children’s parents? A teacher? What about the child’s parents? Or someone else only with parental consent? Schools need parental permission—and physician authorization—to administer even a single dose of medication, but somehow feel free to administer regular doses of other substances that may affect physical and mental wellness (ie, various foodstuffs) without even so much as parent notification. The fact is, schools do not need to provide food for many of the occasions they do today (eg, why not have fun activities instead of sweets for birthdays?). When food provision does occur, is it defensible to operate by an opt-out model (relying on vulnerable children to decline unhealthy items—engineered to be desirable, craveable, and arguably even addicting3—offered by trusted adults, at school events, especially in the context of peers saying “yes”)? Policy and Precedent Some of the parents who attended my “coffee talk” resonated with my message. Weeks after the talk, we connected over email and together decided to draft a proposal for school-level policy. In our proposal, we argued that nutrition is a critical determinant of academic performance, child development, and broader wellness. More broadly, food is a central concern of our time, with food production and consumption having implications for personal, population, and planetary health. We proposed a standard for foods provided or sanctioned by the school: real whole foods with minimal processing or packaging (eg, fruits, vegetables, seeds, and whole grains), and restricted provision of ultraprocessed products (ie, items with refined starches, added sugars, hydrogenated oils, or any ingredient that an adult reader of the ingredient list [1] cannot pronounce, [2] does not know what it is, or [3] would not recognize as actual food). Parents would still be able to provide whatever items they feel are best for their own children (but not for other people’s children). We placed our proposal within the context of the school’s existing food policy: an outright ban on nuts. We argued that the “nut-free” policy has only a small chance of benefiting a tiny minority of students, although science does not clearly support the strategy and experts do not espouse it.4 Moreover, the cost is an inconvenience to all families and possible nutritional compromise for unaffected students (ie, through vastly inferior chips, crackers, and cookies officially recommended as alternatives5 and by removing nutritious staples from options available to possibly picky eaters). By comparison, our proposed new policy could benefit nearly all students, might improve nutrition broadly, and would inconvenience only families wishing to provide their own children with the kind of unhealthy “treats” the school would no longer provide. We also noted that children exposed to healthier food at school might bring healthy lessons home to their families,6 improving the quality of the foods in the house (and possibly then sent back to school). Of course, we anticipated that cost would be a concern. But healthy food need not be more expensive.7 Indeed, one parent involved in our effort was able to negotiate with a nearby food store and local farm (businesses seeing potential customers in the school’s families and staff) to get fresh whole fruits and minimally processed vegetables for classrooms at steep discounts. On average, these snacks would cost less than the $0.30 per student per day that the school historically budgeted for its less-healthy snacks. We also anticipated that kids’ acceptance of new foods, particularly vegetables, would be a concern. But a pilot test of new produce offerings in some classrooms (lasting a few weeks and predating the new policy proposal) showed that children ate them—and liked them! To kids, novel snacks (eg, vegetables cut into fun shapes) can be bona fide “treats.” Healthy snacks can be festive and fun, just as they can be financially feasible. Hope for the Future As of this writing, the school administration is considering our policy proposal. And parents involved in writing the proposal are reaching out to other parents and teachers for support. But I am sure the issue of unhealthy food is not unique to my son’s school (nor to the city or state in which it is located, nor to private schools in general). Given part of a doctor’s job is to teach, I hope other physicians will likewise bring lessons about healthy eating to schools in their own communities. Other parents can get involved too and need not be physicians to educate or advocate. Indeed, more critical skills for effecting change—like in finance, negotiation, organizing, and change management—might come from parents outside medicine. Schools afford multiple opportunities to positively influence nutrition and broader wellness. If we can have nut-free schools, we can have junk-free schools—or at least schools that make less-healthy foods less ubiquitous and routine and healthier foods more available, accessible, and acceptable for all. Issues related to school food extend well beyond the lunchroom; addressing the issues will require thinking outside the lunch box. Section Editor: Roxanne K. Young, Associate Senior Editor. Back to top Article Information Correction: This article was corrected for typographical errors on January 19, 2016. Corresponding Author: Sean C. Lucan, MD, MPH, MS (slucan@yahoo.com). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest. Dr Lucan serves as a member of the Scientific and Nutritional Advisory Board for Epicure. No other disclosures were reported. Funding/Support: Dr Lucan is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award K23HD079606. The content is solely the responsibility of Dr Lucan and does not necessarily represent the official views of the National Institutes of Health. Additional Contributions: Special thanks to Danielle Bocchino and Ivana and Jon Rustin for contributing ideas and enthusiasm to the draft school-food policy and for commenting on an early version of this essay. Special thanks too to Lenard Lesser for reviewing a later version of the manuscript and for providing critical comments. References 1. Lesser LI, Mazza MC, Lucan SC. Nutrition myths and healthy dietary advice in clinical practice. Am Fam Physician. 2015;91(9):634-638.PubMedGoogle Scholar 2. World Health Organization. WHO calls on countries to reduce sugars intake among adults and children. http://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/. Accessed August 20, 2015. 3. Moss M. The extraordinary science of addictive junk food. New York Times. February 20, 2013:MM34. 4. Sicherer SH, Mahr T; American Academy of Pediatrics Section on Allergy and Immunology. Management of food allergy in the school setting. Pediatrics. 2010;126(6):1232-1239.PubMedGoogle ScholarCrossref 5. SnackSafely website. Safe Snack Guide. http://snacksafely.com/download/. Accessed August 20 2015. 6. Lytle LA, Kubik MY, Perry C, Story M, Birnbaum AS, Murray DM. Influencing healthful food choices in school and home environments: results from the TEENS study. Prev Med. 2006;43(1):8-13.PubMedGoogle ScholarCrossref 7. McDermott AJ, Stephens MB. Cost of eating: whole foods versus convenience foods in a low-income model. Fam Med. 2010;42(4):280-284.PubMedGoogle Scholar
TI - Thinking Outside the (Lunch) Box
JF - JAMA
DO - 10.1001/jama.2015.15971
DA - 2016-01-05
UR - https://www.deepdyve.com/lp/american-medical-association/thinking-outside-the-lunch-box-Un0chXr5Fe
SP - 27
EP - 29
VL - 315
IS - 1
DP - DeepDyve
ER -