Policy and Position Statements

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Healthy Eating Position Statement

I. ASTHO Supports State Efforts to Increase the Availability of Healthy Foods:

 
The Association of State and Territorial Health Officials (ASTHO) supports state and territorial health agencies in taking actions that change the norms in the United States to promote healthier eating and lifestyles, reduce healthy food disparities by increasing availability and access, and make the healthy choice the possible choice, or the easier choice for everyone.

National and federal reports that describe strategies, such as the Dietary Guidelines for Americans,1 Food Service Guidelines for Federal Facilities,2 National Prevention Strategy,3 and the National Academies’ Accelerating Progress in Obesity Prevention report,4 serve as a roadmap for state health agencies to address healthy eating and active living policies and programs across various sectors. Programs, such as the Preventive Health and Health Services Block Grant and chronic disease prevention and health promotion programs, can provide some of the funding and infrastructure needed to support healthy and safe communities with access to healthy foods for all populations. 

II. Within This Context, ASTHO Supports the Following Recommendations for State and Territorial Public Health Agencies:

 
Establish infrastructures for state and territorial health agencies to address healthy eating:

  • Support state leadership in the adoption of healthy eating policies at the workplace, within health agencies and throughout state government by implementing healthy food procurement policies that include agency food purchasing, events and meetings, vending machines, and cafeterias.
  • Support state health agency leadership and infrastructure that fosters engagement of the multiple sectors needed to provide comprehensive, systems change.
  • Support state health agency programs that have the ability to address healthy eating policies and programs with an effective, coordinated, sustainable infrastructure.
  • Promote partnerships across government entities, community groups, and healthcare systems that provide safe, culturally competent, and appropriate programs.
  • Affect policy change, implement initiatives and cross-cutting programs with consistent targeted messages to transform communities.
  • Foster collaboration within state and territorial health agencies to support coordination among public health programs.
  • Promote collaboration across state and territorial health agencies that support healthy eating in cooperation with agencies overseeing education, agriculture, healthcare, transportation, economic development, and other sectors.
  • Coordinate chronic disease programs that support infrastructure, to have adequate and synchronized leadership that supports communications, evaluation, surveillance, and management of related programs.
  • Prepare laboratories, businesses, healthcare, and community partners to respond to outbreaks of foodborne disease.5

Promote efforts to improve the nutritional environment for infants and children:

  • Collaborate with leaders and staff in hospitals, early learning centers, healthcare practices or clinics, worksites, government agencies, and community-based organizations to implement policies and programs that support breastfeeding.6
  • Encourage breastfeeding policies that support the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Title V Maternal and Child Health Services Block Grant programs.
  • Support hospitals in implementing evidence-based breastfeeding best practices and following the WHO International Code of Marketing of Breastfeeding-Milk Substitutes.7
  • Limit the distribution of marketing materials, samples, or gift packs including breast milk substitutes, bottles, nipples, pacifiers or coupons to pregnant women, mothers and their families by healthcare providers, hospitals, and healthcare practices or clinics, unless medically indicated.
  • Support adequate time and space for breastfeeding or expressing milk in the workplace.
  • Support paid family leave which has been shown to enhance the initiation and continuation of breast feeding in addition to other health benefits to mother and infant.
  • Encourage Early Childcare Center (ECE) policies that support access to healthy foods and beverages.
  • Support and strengthen state licensing standards for ECE that include nutrition and wellness guidelines and serving meals, snacks, and beverages that meet nutrition guidelines.
  • Support child day care centers and homes to provide a comfortable space for mothers to breastfeed, and to provide expressed breast milk to infants and children in their care.8
  • Encourage education policies that support healthy students through coordinated school health programs; support adequate access to and promotion of healthy foods and beverages through the National School Lunch and Breakfast Programs, and throughout the school day that meet updated standards developed through the Healthy and Hunger Free Kids Act of 2010; and promote the implementation of school wellness policies, Smarter Lunchroom,9 and farm to school programs.
  • Develop food marketing guidelines that limit the marketing of energy dense foods and sugar-sweetened beverages to children under the age of 18, near schools or other places where youth gather.

Support policy and environmental changes across various sectors:

Agriculture Policies

  • Encourage agriculture policies that shift federal subsidy support from highly processed foods and beverages to less processed foods, especially fruits and vegetables, that are low in saturated and trans fats, cholesterol, sodium, and added sugars.
  • Increase access to affordable fresh fruits and vegetables through commodity programs, and support healthy foods in food assistance programs.
  • Expand farmers markets and encourage the use of electronic benefit transfer at farmers markets.
  • Support fresh fruit and vegetable distribution to schools; and address the problem of food deserts.

Healthy Food in Public Places

  • Encourage that foods and beverages served or sold in government facilities and government-funded programs and institutions (e.g., schools, child care centers, parks, prisons, juvenile correctional facilities) meet nutrition standards consistent with the Healthy and Hunger Free Kids Act and DGA 2015-2020 limiting saturated fat, sodium and added sugars; and promote whole grain rich foods.10
  • Ensure that nutrition labeling in cafeterias and similar establishments, and healthy vending and concession policies provide consumers with appropriate information at the point of purchase.
  • Support state health agencies to provide the regulatory structure to enforce healthy eating and active living policies.11

Healthy Retail

  • Support grants, zoning regulations, and other incentives to attract full-service grocery stores, supermarkets, and farmers markets to underserved neighborhoods; and use zoning codes and disincentives to discourage a disproportionately high availability of unhealthy foods, especially around schools.12

Menu Labeling

  • Support regulations requiring fast food and other chain restaurants to provide calorie information at the point of decision-making, and other information about saturated and trans fats, cholesterol, sodium, and sugar content of standard menu items in an easily readable format.
  • Provide federal funding and resources to state and territorial health agencies, if they have responsibility to enforce menu labeling policies.

Restaurants/Food Industry

  • Foster partnerships with the restaurant industry and support restaurant efforts to improve nutritional quality, make smaller portion options available,13 and provide education and guidance about saturated and trans fats, cholesterol, sodium, and added sugars.14
  • Foster partnerships with food and beverage companies to lower sodium and added sugar content of processed, manufactured, and restaurant food and beverages over the next decade; and increase the selection of low-sodium, no-added sugar foods and beverages.15
  • Encourage warning labels on high-sodium foods or sugar-sweetened beverages located on supermarket shelves or on placards.
  • Address inequitable unhealthy food and beverage marketing practices on children and underserved communities.

Schools and Worksite Wellness

  • Support worksite wellness policies and accreditation programs that promote a healthy work environment, including healthy foods at meetings, events, cafeterias, and vending machines; and encourage breastfeeding or expressing milk in the workplace.
  • Support comprehensive policies and programs that promote wellness on college and university campuses.
 

Educate providers, other professionals and the general public to promote healthy eating and active living outreach activities:

  • Identify opportunities to assist and promote financial incentives for healthcare professionals and institutions to offer evidence-based nutrition counseling.
  • Develop targeted and culturally appropriate interventions; teach people how to use nutrition information to make healthier choices; and provide leadership in community-based healthy eating efforts.16
  • Support state provisions for training, educational materials, and technical assistance to communities, worksites, and schools interested in implementing healthy eating policies and programs, especially those targeting health disparities and other social determinants of health.
  • Support and promote opportunities to educate the public about the sodium content of processed foods and the effects of excessive salt consumption.

Support the evaluation of healthy eating efforts:

  • Encourage routine collection and use of public health surveillance data, including BRFSS, YRBS, e-codes, and hospital discharge data to identify jurisdictions’ most pressing needs and efficiently target scarce resources.
  • Collect community design data as communities alter environments to promote access to nutritious foods.
  • Support state leadership in the development of robust health information exchange with the clinical sector to improve public health and clinical services.
  • Develop clear benchmark goals and measurement of healthy eating according to the best attainable average level of “goodness” and the smallest feasible differences in rates among individuals and groups or “fairness.”
  • Harmonize state data collection with HHS data collection on race, ethnicity, sex, primary language and disability status as required by Section 3101 of the Public Health Services Act.
  • Track consumption patterns over time to ensure that other unhealthy oils and shortenings are not substituted for trans fats.
  • Evaluate the success of trans fat, sodium, and added sugars reduction efforts in states.

III. Background: Improving States’ and Territories’ Healthy Eating Efforts

 
Chronic diseases are now the leading causes of morbidity and mortality in the United States. They are also the primary drivers of healthcare expenditures. Currently, over one third of adults in the United States are obese.17 Obesity and unhealthy diets are also major contributors to chronic diseases like diabetes, cancer, hypertension, and heart disease.18 The environments we live in contribute to unhealthy eating, as it is difficult to make healthy choices if there is a lack of available healthy foods. Social determinants of health, including economic and social conditions such as poverty, also influence access to healthy foods and health of populations. In the United States, over 23 million people live in “food deserts” – low-income neighborhoods that are more than one mile from a supermarket or large grocery store.19 Oftentimes, lower income neighborhoods also have limited healthy foods choices and instead tend to have fast-food restaurants and other unhealthy, inexpensive food choices.20 Policies regulating sodium, trans fatty acids (trans fat), menu labeling, added sugars, and food marketing/behavioral design21 standards make it easier for individuals to make healthy decisions about the food they consume, and reduce harmful food additives.

Sodium Reduction

Heart disease and stroke are the first and fifth leading causes of death in the United States, respectively. High blood pressure leads to more than half of all heart attacks and strokes. Only one in 10 American adults consumes an amount of sodium within the recommended limits, and many consume more than double the recommended daily limit for sodium.22 Higher consumption of salt, along with age, obesity, and family history, leads to higher blood pressure. The age-adjusted prevalence of high blood pressure is nearly 50 percent greater among African Americans than the rest of the population.23 The Dietary Guidelines for Americans 2015-2020 (DGA 2015-2020), states that the major source of excess dietary sodium is the consumption of processed foods.24 Reducing sodium levels in packaged foods and restaurant foods by half would likely result in a 20 percent reduction in the prevalence of hypertension and 150,000 fewer deaths.25

Trans Fatty Acids (Trans Fat) Regulations

Artificial trans fat is the most harmful fat in the food supply. It is linked to about 50,000 fatal heart attacks annually and may also increase the risk for diabetes.26 In November 2013, the FDA issued a preliminary determination that partially hydrogenated oils (PHOs), the primary dietary source of trans fat in processed foods, are not “generally recognized as safe” for use in food. In June 2015, the FDA set a compliance period of three years allowing companies to either reformulate products by removing PHOs and/or petition the FDA to permit their specific uses. As many companies have already been working to remove PHOs from processed foods, the FDA anticipates that many may eliminate them before the end of the three-year compliance date.27

Added Sugars

According to the 2015-2020 DGA, added sugars account on average for almost 270 calories, or more than 13 percent of calories per day in the U.S. population.28 Excessive consumption of sugars is linked to obesity and lower intake of essential nutrients.29 There is also a relationship between consumption of added sugars and cardiovascular disease risk in adults.30 Sugar-sweetened beverages account for almost half (47%) of all added sugars consumed by the U.S. population.31 Children and adolescents consume an average of 365 calories per day from added sugars, with an average of 173 calories per day from sugar-sweetened beverages (soda, sweetened coffees and teas, energy drinks, flavored waters, and sugary fruit drinks).32 Although a decrease in daily soda consumption among U.S. high school students (from 33.8% to 20.4%) between 2007 and 2015 suggests that interventions encouraging reduced consumption of soda are working, overall prevalence of daily soda consumption remains high.33

Menu Labeling and Nutrition Fact Labeling

Menu labeling provides critical information to consumers so that they can make decisions about the foods they eat. Americans spend almost half of their food dollars at restaurants and eat about a third of their calories away from home.34 Approximately half of chain restaurants do not provide any nutrition information about their foods to their customers.35 Consumers cannot make informed choices about what to order in a restaurant unless they have adequate information about what they are choosing. Most Americans support menu labeling for nutritional information such as calories, fat, sugar, and salt content.36 Menu labeling can also lead to product reformulation as manufacturers compete to meet the demands of health-conscious consumers. Federal legislation mandated that many chain restaurants and other food establishments list the calorie count of the food they sell, note that the average daily intake is 2,000 calories, and let customers know that more nutritional information is available upon request.37 In 2016, the requirement took effect and the FDA issued new proposed changes to the nutrition facts label on packaged foods, including the addition of information about the type of fat (trans fat, saturated fat), and updated serving sizes to more closely reflect the amounts of food that people currently eat.38

Food Marketing/Behavioral Design Strategies

In 2014, nearly one in five children aged 6-11 years in the United States were obese.39 A contributor to the epidemic of childhood obesity is marketing of unhealthy foods to children. Children in the U.S. view an average of 2.8-4.8 fast food ads on television every day.40 The foods most frequently marketed to children are unhealthy. One study found that 98 percent of food advertisements viewed by children are high in fat, sugar, or sodium.41 Communities of racial and ethnic minorities, and low-income populations, also experience higher rates of targeted marketing of less nutritious foods. Outdoor advertisements featuring foods of low nutritional value are up to 32 times denser in predominantly African American neighborhoods and six times the density in Latino and Asian neighborhoods than high-income White neighborhoods.42 In 2012, the fast food industry spent over $4 billion in advertising.43 Forty-eight major food companies spent nearly $150 million alone on food marketing within schools in 2009.44 To reduce exposure to unhealthy food advertisements and provide consistent nutrition messaging in K-12 schools, the U.S. Department of Agriculture released the final rule for local school wellness policy implementation under the Healthy Hunger-Free Kids Act of 2010, effective Sept. 27, 2016. The final rule only permits in-school marketing of foods and beverages that meet the competitive foods (Smart Snacks in Schools) nutrition guidelines/standards.45 Behavioral design strategies such as promotion, placement, pricing and presentation, can encourage consumption of specific foods and beverages.46 The USDA provides tools and training to schools to create “smarter lunchrooms” by using these strategies to encourage consumption of healthy foods and beverages.47


Approval History

ASTHO position statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Board of Directors. Position statements are not voted on by the full ASTHO membership.

Board of directors review and approval on Dec. 6, 2017. Policy expires on Dec. 6, 2020. This position statement supersedes the healthy eating position statement which expired on Sept. 8, 2017.

For further information about this position statement, please contact ASTHO Prevention Policy Staff at prevention@astho.org. For ASTHO policies and additional publications related to the position statement, please visit http://www.astho.org/Policy-and-Position-Statements/.


ADDITIONAL RESOURCES

  • Child and Adult Food Care Program: CACFP provides aid to child and adult care institutions and family or group day care homes for the provision of nutritious foods that contribute to the wellness, healthy growth, and development of young children, and the health and wellness of older adults and chronically impaired disabled persons. 
  • Caring For Our Children: These are national standards that represent the best evidence, expertise, and experience in the country on quality health and safety practices and policies that should be followed in today’s early care and education settings.
  • Quality Rating Improvement Systems for childcare: A QRIS is a systemic approach to assess, improve, and communicate the level of quality in early and school-age care and education programs. Similar to rating systems for restaurants and hotels, QRIS award quality ratings to early and school-age care and education programs that meet a set of defined program standards. By participating in their State’s QRIS, early and school-age care providers embark on a path of continuous quality improvement. Even providers that have met the standards of the lowest QRIS levels have achieved a level of quality that is beyond the minimum requirements to operate.

REFERENCES

1 U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans 2015-2020. December 2015. Available at: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed 02-03-2017.

2 Food Service Guidelines Federal Workgroup. Food Service Guidelines for Federal Facilities. Washington, DC: U.S. Department of Health and Human Services; 2017.

3 National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.

4 IOM (Institute of Medicine). Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies Press, 2012.

5 Adapted from: National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.

6 Ibid.

7 Center for Disease Control and Prevention. The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Available at https://www.cdc.gov/breastfeeding/pdf/bf-guide-508.pdf. Accessed 04-24-2017.

8 QRIS National Learning Network. Quality Rating and Improvement Systems Framework. Available at: http://qrisnetwork.org/our-framework. Accessed 03-21-2017

9 US Department of Agriculture/Food and Nutrition Service website. USDA Helps Schools Make Lunchrooms “Smarter” as Students Head Back to Class. Release Number FNS 0006.14, 2014; http://www.fns.usda.gov/pressrelease/2014/fns-000614. Accessed 03-10-2017.

10 Ibid.

11 United States Department of Agriculture. Enhancing Retailer Standards in the Supplemental Assistance Program (SNAP). Available at http://www.sciencedirect.com/science/article/pii/S149940461600018X. Last published 5-17-2017.

12 Ibid.

13 Sliwa, Sarah; Anzman-Frasca, Stephanie; Lynskey, Vanessa; Washburn, Kyle; Economos, Christina. “Assessing the Availability of Healthier Children's Meals at Leading Quick-Service and Full-Service Restaurants. Journal of Nutrition Education and Behavior, Volume 48, Issue 4, April 2016, Pages 242-249.e1. Available at http://www.sciencedirect.com/science/article/pii/S149940461600018X.

14 Performance Standards for Restaurants: A New Approach to Addressing the Obesity Epidemic. Santa Monica, CA: RAND Corporation, 2013. Available at https://www.rand.org/pubs/conf_proceedings/CF313.html.

15 Kids’ Meals II: Obesity and Poor Nutrition on the Menu, 3-28-2013. Center for Science in the Public Interest. Available at https://cspinet.org/sites/default/files/attachment/cspi-kids-meals-2013.pdf.

16 The Guide to Community Preventative Services. Task Force Findings. Available at https://www.thecommunityguide.org/task-force-findings. Accessed on 04-20-2017.

17 Centers for Disease Control and Prevention. Adult Obesity Facts. Available at: www.cdc.gov/obesity/data/adult.html. Updated 09-01-2016. Accessed 02-03-2017.

18 Ward, Brian W. "Multiple chronic conditions among US adults: a 2012 update." Preventing chronic disease 11 2014. Available at https://www.cdc.gov/PCD/issues/2014/13_0389.htm. Accessed 04-06-2017

19 United States Department of Agriculture. Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences, United States Department of Agriculture, Economic Research Service. June 2009. Available at: https://www.ers.usda.gov/webdocs/publications/ap036/12716_ap036_1_.pdf. Accessed 02-03-2017.

20 Harding, Lauren. "Food Deserts: Low Income Communities and their Lack of Adequate Nutrition." 2012. Available at http://sophia.stkate.edu/msw_papers/34/.  Accessed 04-06-2017

21 Kaplan, Robert M., Michael L. Spittel, and Daryn H. David, eds. Population health: Behavioral and social science insights. Government Printing Office, 2015. Pp 112-114. Available at https://www.ahrq.gov/sites/default/files/publications/files/population-health.pdf. Accessed 04-24-2017

22 Gunn JP, Keenan NL, Labarthe DR. Sodium intake among adults—United States, 2005-2006. MMWR 59(24);746-749.

23 Yoon SS, Fryar CD, Carroll MD. Hypertension Prevalence and Control Among Adults: United States, 2011–2014. Available at: www.cdc.gov/nchs/data/databriefs/db107.htm. NCHS Data Brief. November 2015; 220:1-8.

24 U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans 2015-2020. December 2015. Available at: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed 02-03-2017.

25 Havas S, Roccella EJ, Lenfant C. Reducing the public health burden from elevated blood pressure levels in the United States by lowering intake of dietary sodium. Am J Public Health. Jan 2004; 94(1):19-22.

26 Center for Science in the Public Interest: "About Trans Fat." Available at: www.cspinet.org/transfat/about.html. Accessed 03-10-2014.

27 United States Food and Drug Administration: “FDA Takes Step to Remove Artificial Trans Fats from Processed Foods.” Available at: www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm373925.htm. Accessed 02-03-2017.

28 U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans 2015-2020. December 2015. Available at: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed 02-03-2017.

29 Johnson R, Appel L, Wylie-Rosett J, et al. Dietary Sugars Intake and Cardiovascular Health A Scientific Statement From the American Heart Association. Circulation. 2009;120(11):1011-1020.

30 Yang Q, Zhang Z, Gregg E, Flanders W, Merritt R, Hu F. Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults. JAMA Internal Medicine. 2014;174(4):516-524.

31 Johnson R, Appel L, Wylie-Rosett J, et al. Dietary Sugars Intake and Cardiovascular Health A Scientific Statement From the American Heart Association. Circulation. 2009;120(11):1011-1020.

32 Reedy J, Krebs-Smith S. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. Journal of the American Dietetic Association. 2010;110(10):1477-1484.

33 Miller G, Merlo C, Demissie Z, Sliwa S, Park S. Trends in Beverage Consumption among High School Students —   United States, 2007–2015. MMWR Morb Mortal Wkly Rep 2017;66:112–116. Available at http://dx.doi.org/10.15585/mmwr.mm6604a5. Accessed 02-03-2017.

34 Center for Science in the Public Interest. Anyone’s Guess: The Need for Nutrition Labeling at Fast-Food and Other Chain Restaurants. Available at: http://www.cspinet.org/restaurantreport.pdf. November 2003. Accessed 03-10-2014.

35 Center for Science in the Public Interest. Anyone’s Guess: The Need for Nutrition Labeling at Fast-Food and Other Chain Restaurants. Available at: http://www.cspinet.org/restaurantreport.pdf. November 2003. Accessed 03-10-2014.

36 Center for Science in the Public Interest. Summary of Polls on Nutrition Labeling in Restaurants. http://www.cspinet.org/new/pdf/census_menu_board_question.pdf. Accessed 03-10-2014.

37 Robert Wood Johnson Foundation: Health Affairs. Health Policy Brief: The FDA’s Menu-Labeling Rule. July 2015.  Available at http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_140.pdf. Accessed 04-06-2017.

38 FDA. FDA modernizes Nutrition Facts label for packaged foods. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm502182.htm. Accessed 02-03-2017.

39 Ogden, Cynthia L., et al. "Prevalence of obesity among adults and youth: United States, 2011–2014." NCHS data brief 219.219; 2015: 1-8.

40 Harris JL, Schwarts MB, Munsell CR, et al. Yale Rudd Center for Food Policy & Obesity. Fast Food F.A.C.T.S. 2013: Measuring Progress in Nutrition and Marketing to Children and Teens. November 2013. Available at: http://www.fastfoodmarketing.org/media/FastFoodFACTS_Report.pdf. Accessed 03-11-2014

41 Powell L, Szczypka G, Chaloupka F, Braunschweig C. Nutritional Content of Television Food Advertisements Seen by Children and Adolescents in the United States. Pediatrics. 2007;120(3):576-583.

42 Cassady, Diana L., Karen Liaw, and Lisa M. Soederberg Miller. "Disparities in Obesity-Related Outdoor Advertising by Neighborhood Income and Race." Journal of Urban Health 92.5; 2015: 835-842. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608936. Accessed 03-11-2014

43 Harris JL, Schwarts MB, Munsell CR, et al. Yale Rudd Center for Food Policy & Obesity. Fast Food F.A.C.T.S. 2013: Measuring Progress in Nutrition and Marketing to Children and Teens. November 2013. Available at: http://www.fastfoodmarketing.org/media/FastFoodFACTS_Report.pdf. Accessed 03-11-2014.

44 Federal Trade Commission. A Review of Food Marketing to Children and Adolescents: Follow Up Report. December 2012. Available at: http://www.ftc.gov/reports/review-food-marketing-children-adolescents-follow-report. Accessed 03-11-2014.

45 U.S. Department of Agriculture. Final Rule: National School Lunch Program and School Breakfast Program: Nutrition Standards for All Foods Sold in School as Required by the HHFKA of 2010. Available at: https://www.fns.usda.gov/school-meals/fr-072916d. Updated 07-29-2016. Accessed 05-25-2017.

46 Cohen D, Babey S. Contextual influences on eating behaviors: Heuristic processing and dietary choices. Obes Rev. 2012;13(9):766-779.

47 US Department of Agriculture/Food and Nutrition Service website. USDA Helps Schools Make Lunchrooms “Smarter” as Students Head Back to Class. Release Number FNS 0006.14, 2014. Available at http://www.fns.usda.gov/pressrelease/2014/fns-000614. Accessed 03-10-2017.