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Diane Harris Of The Centers For Disease Control And Prevention Speaks Out On Salad Bars: “Some Answers Won’t Be Entirely Satisfactory, But That’s Where We Are.”

Jim Prevor’s Perishable Pundit, March 18, 2013


Diane Harris, Ph.D., M.P.H., C.H.E.S.
Health Scientist
Division of Nutrition,
Physical Activity and Obesity

Centers for Disease Control and Prevention
Atlanta, Georgia

Q: Lorelie DiSogra recommended you as an excellent contact as the CDC lead for Let’s Move Salad Bars to Schools. We’re interested to learn more about any research or studies undertaken or in progress to monitor the success of the program as well as validate its expansion. What can you tell us based on the work you’ve done to increase produce consumption in children as a public health imperative to decrease risk of chronic disease and obesity?

A: Some answers won’t be entirely satisfactory, but that’s where we are. We published a report in August 2012 assessing the program as it relates to public health goals.

The best studies done so far are in the Los Angeles school district. Dr. Wendy Slusser, medical director, Fit for Healthy Weight Program, UCLA, is still working with the LA school district cooperatively as they change menus to comply with the new federal school nutrition mandates.

Q: How significant are these new mandates and their impact on schools?

A: This year is really a critical year when talking about school foods with the implementation of new school meal plans, finally. It’s been a long time coming. CDC changed components and increased requirements for the specific fruits and vegetables — the variety as well as the quantity for both breakfast and lunch. The USDA website has lots of information on the details. 

It is important to talk about salad bars in this context. Schools now have the obligation to increase fruits and vegetables, although it doesn’t say necessarily fresh produce.

Q: You’ve brought up a touchy subject in the fresh produce industry, where “frozen” can be viewed as a bad word…

A: From our perspective for public health, you have to be realistic on what’s available and affordable, comparable costs of fresh and frozen. I’ve had some difficulties in the redefining of certain categories in fresh, such as peas and lima beans. Schools also rely heavily on commodity products.

Basically from the school point of view, administrators are juggling entire food budgets and meeting new produce requirements. To get increased reimbursement rates, schools must demonstrate that the new meal patterns meet new guidelines.

Q: What are some of the key changes? The potato industry lobby, for instance, has vehemently opposed the re-categorizing of potatoes and French fries…

A: In the past, French fries were a vegetable. We were getting in trouble, so they were re-defined as starchy vegetables, along with lima beans and peas. It was unsettling for me to see lima beans and peas included, but the reality is there is no deficit of white starchy vegetable intake.

Legumes have gone over to protein. There’s a nice spread sheet showing the before and after. [Editor’s note: see comparisons of previous and current regulatory requirements under the Final Rule Nutrition Standards in the National School Lunch and School Breakfast Programs here.]

Q: Do salad bars generate significant movement toward satisfying those guidelines?

A: If schools offer salad bars, it moves this process along; you achieve automatic variety in the salad bar when looking at hitting all vegetable groups and the different colors and nutritional elements for the menu. It takes care of a range of requirements.

Q: What are the pros and cons schools must consider when deciding whether to implement a salad bar, such as labor, logistics, and food safety issues?

A: Jessica Shelly, foodservice director for the Cincinnati school district, has been a great advocate for salad bars. A couple of years ago, there was not a single salad bar in her schools, but working with Lorelei, she secured funding from six different organizations for 53 salad bars, affecting 34,000 Cincinnati public school students.

She comes from a food safety background and was a food safety inspector. At first blush, she had reservations in bringing self-serve salad bars to schools, but she did research and felt comfortable with the safety considerations. She calculated that it saved costs in labor, and it wasn’t necessary to have prepackage items.

She took steps to maximize the program’s reach and effectiveness by not only using the Cambro equipment we supply, but refurbishing other existing equipment. She also partnered with the National Dairy Council’s program, so her salad bars are also mobile breakfast kiosks serving fruit and other nutritious items to children in their classrooms.

Q: The mobile kiosks sound like they offer flexibility and convenience, but don’t they also come with logistical challenges and labor issues as well?

A: There are some operational issues. For example, where is the unit relative to the point of sale where the cash register is located? The foodservice register is where school administrators monitor the program for low income students.

Q: While there is much anecdotal evidence pointing to the success of salad bars in increasing produce consumption, isn’t it difficult to quantify?

A: The most rigorous research has come from Dr. Sussler’s work in the LA unified school district. An objective of her study was to measure change in fruit and vegetable consumption among elementary-school children after the introduction of a salad bar program as a lunch menu option in the USDA’s reimbursable lunch program.

Her results found a significant increase in the frequency of fruits and vegetables consumed, almost all due to an increase during lunch. Mean energy, cholesterol, saturated fat and total fat intakes were significantly lower in the children after the salad bar was introduced in the schools compared with the intakes in the children beforehand. She looked at third graders in largely low income Hispanic populations. These are kids who may not have as much access to fruits and vegetables at home.

Q: Did the research take into account what the children ate outside of school? And how was the information gathered?

A: She did a 24-hour recall, so kids basically told her what they ate, and she did comparative studies before and after the salad bar was introduced. In her study, she looked at the full diet quality and the change was pretty much accounted for by what they ate at school.

Q: Has the research looked into the staying power of these changed eating habits, monitoring long term consumption patterns?

A: Studies to track children’s eating behaviors over time are expensive and difficult to do. Realistically, I like to think of salad bars as a multipoint plan, when other things also go on to encourage produce consumption, which also complicates the process from a research perspective in isolating the impact of salad bars in particular.

Q: Could you elaborate on that?

A: From CDC’s vantage point, we believe in a comprehensive strategy. The Center of Excellence for Training and Research Translation at the University of North Carolina at Chapel Hill did an evaluation of the Riverside Unified School District farmer’s market salad bar, which is used in 29 elementary schools there.

Rodney Taylor, director of nutrition services for Riverside Unified School District, is full of passion and a great advocate for kids eating fresh fruits and vegetables. It’s a multifocal program with farm-to-school components and education. The Riverside program focuses on local food and includes hands-on educational activities, harvest of the month, taste tests, etc. It found that students who chose the salad bar ate more servings of fruits and vegetables than students who chose the hot bar.

Q: Is that really surprising? Perhaps those children heading to the salad bar were more health- or diet-conscious. And wouldn’t it be more likely that salad bars by their very nature would carry more fruits and vegetables?

A: The hot bar is main line, so it includes produce items like steamed broccoli. From qualitative work in the field, a lot of times foodservice people were surprised by these results.

I should also mention Whole Kids Foundation, a charitable arm of Whole Foods that focuses on childhood obesity initiatives. Main priorities are school gardens and salad bars and education. A school garden really brings an interactive experience to kids. They get involved in producing food, and they gain more of an appreciation of what good food tastes like. It is important to acculturate children to the taste of fresh produce when they are bombarded by junk food ads.

Q: Fascinating scientific research has been done on the need to intervene at an early age to recondition taste buds before eating behaviors and habits have become engrained… Professor Gabriella Morini of the University of Gastronomic Sciences in Pollenzo, Italy, gave a thought-provoking talk on this topic at the New York Produce Show & Conference last December…

A: I’m interested in preschool programs because the younger, the better. They see produce wrapped in plastic in the supermarket and think that’s where it comes from. Kids really react to interactive experiences and salad bars work in that way.

We don’t have empirical data that kids eat more from salad bars than when produce is prepackaged, but that’s my gut feeling and by talking to kids and school officials. There is a study in San Diego, California, schools that shows when offered more variety, kids will eat more fruits and vegetables.

We really emphasize the idea of choice and having that interactive experience, a full range of varieties and colors, and they love to dip, they love to feel; Even older kids like to have interactive experiences with food.

Q: If children pile their plates with produce, does it necessarily mean they eat it all? There are plenty of anecdotal stories, where children take a bite out of an apple and throw the rest in the garbage…

A: We don’t have a lot of data on waste. We’d like to know if eating from a salad bar results in less waste. Some complaints we’re hearing from the field in certain districts — since kids are required to eat more fruits and vegetables, they are throwing them away. Are these complaints from schools that have salad bars, or don’t provide any other incentives or education? These are questions we’d like to get answered.

I know of several studies happening right now to look at other data that support salad bars, such as promotional support posters on the wall; our partner The Lunch Box has curricular activities, Eat a Rainbow Today, which involves picking colors from the salad bar. It would be nice to know if that does work.

There’s nothing bad about encouraging schools to bring in salad bars and try these activities.

Q: With schools facing budget cuts and limited resources to allocate for different programs, do you find this presents some resistance?

A: There is so much that can be done with little cost. Often you can involve volunteers, parents, other farm-to-school volunteers, and chefs. There is this formal organization, Chefs Move to Schools.

Some school districts are uneasy about having other people in the lunch room for food safety reasons.

Q: Has CDC addressed food safety issues with salad bars?

A: One of the concerns raised frequently with salad bars is whether kids are potentially passing disease from one to another through the salad bar. We don’t have good data on that, but haven’t identified any outbreaks from school salad bars, yet that doesn’t mean it hasn’t happened.

We know of the foodborne illness potential carried through produce. There are safety programs in place, GAP certification and HACCP all along the supply chain. Schools have the opportunity to adopt Standard Operating Protocols. Lots of these resources are on the salad bar website.

Someone with eyes on it takes care of it. Food safety measures have been designed into the salad bar equipment. Tongues are long enough so when handled don’t fall in trays. All Cambro units have sneeze guards, and schools will follow a whole set of procedures. Cambro non-electric units hold temperatures for four hours. Cambro did an analysis on that.

There are a few school districts where their local public health departments say they want electrified units. Cost is substantially greater than the units we offer. We can’t get as many, but we do offer electric units to schools in New York City, Washington, D.C., and some schools in Minnesota, and other places, but it’s localized, not widespread.

In New York City particularly, there are a number of school sites that are so old they don’t have the capacity for power in the lunch room, so we face infrastructure issues in selected areas.

Mayor Bloomberg has made it part of his priority to have a salad bar in every school. Bloomberg did an announcement in front of a school salad bar about seeing decreased obesity rates in New York City.

We’re trying to seize the moment. We’re shooting for 4,000 salad bars this year. In the long run, it’s hard to project. We don’t know the sustainability of the program for the future.

Whole Kids Foundation recently launched Salad Bar Nation, and this will be a parallel campaign, raising awareness, a salad a day, working through social media outlets, looking for sponsorship and engagement from celebrities and chefs to promote 2,013 salad bars in 2013.

United Fresh as been great in getting a large number of smaller donations, and it has a powerful California campaign. Whole Foods and United Fresh operate differently, but both have been contributing in a significant way. It’s a lot of work and people invest extensive time that isn’t in their job description.

Q: PMA has also been dedicated to the cause, recently committing $100,000 to support the Let’s Move initiative and the Let’s Move Salad Bars to Schools campaign… What is CDC’s role as it relates to financial support for the program?

A: As government employees, CDC is not part of fundraising efforts.

All of the Let’s Move initiatives have some federal agencies attached. We’re unique because so much of Let’s Move Salad Bars to Schools is fundraising, but we work from a public health perspective.

We have funded studies and program activities in several different ways. CDC puts out requests for proposals for university work on researching salad bars. In New Orleans, The Prevention Research Center at Tulane University won a cooperative agreement to evaluate the public health impact of salad bars in New Orleans schools. Many of these salad bars were awarded by United Fresh when their conference was there.

We also have a partnership with another association of state and territorial public health and nutrition directors. These are the former 5 A Day coordinators in each state. We have a network in state health departments in each state that focus on health. They all have their own organizations, and we’ve provided funding for mini grant programs. Nine states have been funded with modest amounts of money for workshops, training videos, and documentation to help with food safety guidelines.

The State of Alaska set up a contest to elicit these grassroots videos.

The winning video was taken 30 miles north of the Arctic Circle in a native Alaskan community; first, highlighting the fact that you can do salad bars in a remote area and then showing how much the kids love it. This is an example of great state public health support to help propagate the salad bar message.

 

Q: What other research is in the pipeline? What are some of the key areas CDC is focusing on?

A: There is very preliminary work, which may be too early to talk about now. One of our concerns is the southeastern states, where there is much less interest from schools in getting salad bars. I can’t tell you exactly why that is, but we’ve tried to figure it out. Those are areas with some of the highest childhood obesity rates and some of lowest rates of kids eating fresh fruits and vegetables.

What are some school-based activities we can do, if it’s not salad bars, what else is there? We’re putting together some state-based teams to strategize action plans and how to implement them. We’ve put in money, and partnered with USDA in their southeast regional office, as well as the School Nutrition Association. We’ve talked conceptually to other organizations, who are interested in participating but this is all still in the planning stages.

These are the kinds of things we’re trying to do to think about schools and what they need. We’re really pushing salad bars and working to get quantifiable evidence to keep track of results.

Q: What follow up is done to make sure that schools who were given salad bars continue to use them? Do schools find the process challenging?

A: For some schools, it is kind of mindboggling… processing equipment, salad spinners, peelers, cutting boards, refrigeration. We’ve had a lot of distributors step up and support schools. Labor is a huge issue, with facilities not being able to do large scale food prep. So when distributors can do peeling, washing, and food prep, it has been a big boon for a lot of school districts.

A lot of times it takes the school district to just ask, but sometimes they don’t realize the capacity. It appears there is more cost in paying for this food prep, but schools need to do a cost benefit analysis to think this through because they are all under budget constraints.

Q: I imagine CDC feels the pinch as well…

A: What’s happening now with federal funding… we’ve had to drop initiatives. With the Sequester, every budget is going to be cut. This is not a time for us to be expanding research and surveillance. And a lot of this trickles down to states, which are also compromised.

Q: In what ways?

A: Researchers write their own questions or use standardized tools. With the 24-hour recall from Wendy Slusser’s research, you get granular breakdown. With national surveys, it gets more complicated; Youth Risk Behavior Surveillance System (YRBSS) collects data using certain parameters and measurements. It looks at consumption of total fruits and vegetables and gets to some of the subgroups; that’s times per day, but does not get into our requirements.

The recommendations for dietary guidelines for Americans are in cups, but the data is not collected that way. The difficulty of our surveillance systems is we can’t get state data on whether kids are meeting the requirements and eating the proper amount. There are other more intensive surveys one-to-one to learn what kids are actually eating, but because these are so intensive, the people conducting the studies can only meet with a few people. We’re trying to come up with statistical models to estimate numbers.

You asked about obesity rates. For those kinds of levels of research studies, this is a longer term enterprise to show outcomes in obesity. First, there are many things that effect obesity. It would require monitoring over a much longer timeframe than we have funded for.

I can’t answer whether children’s eating habits are sustained when they have salad bars in schools, but in our studies done so far, change in dietary habits is occurring, and in the works we have plans to re-survey schools that we provide salad bars. We have baseline information, which is part of the information-gathering process in the application stages to assess the capacity of schools to implement a salad bar; are they willing to buy the fruits and vegetables, and will they operate it and keep it indefinitely? We will go through our administrative partner that will do the follow-up surveys. Alas, I’m afraid our response rate won’t be great.

Right now, we’re very proud to have hit the one-million-kid mark on the number of children benefiting from the Let’s Move Salad Bars to Schools program. This is our third year working on this. We just wrote our strategic plan for the White House, and we’re looking forward to another year.

Another role of CDC is as liaison with the White House. The goal is to cross-promote among all the Let’s Move! initiatives, so were working together when it makes sense.

Q: On a personal note, how did you find yourself in this lead role? Is there an interesting back story?

A: I’m a health scientist at CDC. Before I moved into public health, I was a cancer researcher. My story came from doing bench research. I was finding biochemical affects of plant-based compounds to reduce cancer, but became concerned with statistics showing major deficiencies in people’s diets of plant-based vegetables.

Five years ago, I went back to school and got my masters in public health with a full focus on the possibilities of increasing intake of fruits and vegetables on a national scale. I finished my masters and came to CDC’s nutrition branch, and was lucky to land this position, with a particular focus on children, which is exactly in line with my objectives.

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