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TENESTRANTE, GRACYL P. SECTION-3 Healthier School Meals The IOM recommends new requirements for school meal programs.

Many children receive up to half of their daily caloric intake from school meals. The National School Lunch Program and School Breakfast Program provide low-cost and free meals to tens of millions of children every day. For schools to receive federal reimbursement, these meals must meet nutritional standards and meal requirements established in 1995 by the U.S. Department of Agriculture (USDA). The USDA asked the Institute of Medicine (IOM) to recommend revisions of these standards and requirements to reflect the 2005 Dietary Guidelines for Americans ( The IOM committee recommends the adoption of nutrient "targets" instead of nutrient-based "standards" for menu planning. This approach results in food-based menu planning and will meet the needs of more children. Recommended changes include the following:

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Fruits and vegetables: Increase variety and amount of fruit and vegetables offered. Offer fruit at breakfast and lunch with no more than half of fruit offered as juice. At least half of the daily vegetables offered are orange or green leafy vegetables or legumes. Decrease use of starchy vegetables. A meal must include a fruit at breakfast and either a fruit or vegetable at lunch to be reimbursable. Grains: Increase amount of whole grains. At least half of grains and breads offered should be whole-grain rich. Calories: Add maximum calorie levels to existing minimum calorie requirements. For breakfast and lunch, respectively, maximum calorie levels are 500 and 650 calories for grades kindergarten to 5, 550 and 700 calories for grades 6 8, and 600 and 850 calories for grades 9 12. Fat: The upper limit of total fat increased from 30% to 35% of calories. Increase focus on reducing saturated fat to <10% of total calories. Eliminate trans fat. Offer fat-free or 1% milk at each meal. Sodium: Decrease sodium content of meals from approximately 1600 mg per meal to no more than 740 mg per meal. This goal will be approached incrementally between now and 2020 to give the food industry time to develop good-tasting meals with low sodium content.

REACTION: Healthier School Meals

For all of us frustrated with the quality of food that children eat at school, this is welcome news. The IOM committee made similar recommendations in 2007 about so-called "competing foods" offered to students through la carte cafeteria services, school stores, snack bars, and vending machines. The National Alliance for Nutrition and Activity is spearheading the call for adequate funding to support nutrition education, monitor changes in school meals, and guarantee adequate reimbursement rates for these healthier (and more costly) meals. Careful implementation, adequate funding, and food industry involvement are needed to ensure that children will actually eat these healthier meals. Pediatricians can

be aware of the new recommendations, advocate for legislation to fund promotion and evaluation of these changes, and explain to patients and families how these school meal changes could improve health.

Can Seafood Consumption Help Reduce Childhood Depression? Significantly more depressed children who received omega-3 fatty acids achieved remission than those who received placebo. The prevalence of major depression in school-age children is 2% to 4%. Clinicians and parents would welcome a natural therapeutic intervention for childhood depression. Studies in adults with mood disorders have shown a beneficial effect of omega-3 fatty acids found in fish (see Am J Psychiatry 2006; 163:969). Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are the primary marine-based long-chain polyunsaturated fatty acids in the omega-3 group. To assess the potential therapeutic benefits of omega-3 fatty acids in childhood depression, 28 children with their first major depression (mean age, 10 years) were randomized to receive either omega-3 or placebo capsules daily for 16 weeks. The average duration of depression prior to study entry was 3.4 months. Data from the 10 children in each group who completed at least 1 month of the study revealed significant improvements in the omega-3 group compared with the control group on three standardized depression rating scales. A greater than 50% reduction in depression symptoms was seen in seven children in the omega-3 group and none in the placebo group. Similarly, four children in the omega-3 group, but none in the control group, had a complete remission. The beneficial effect in the omega-3 group was statistically significant at weeks 8, 12, and 16. Clinically important side effects were not reported. REACTION: The findings of this preliminary study are encouraging and reflect the results of most adult studies in this area. Also, a large international study found a strong negative correlation between fish consumption and major depression. One possible explanation for this relation is that omega-3 fatty acids reduce inflammatory mediators from arachidonic acid and help maintain CNS membrane integrity. As with all small studies, pediatricians should interpret these results with caution. It would be a major breakthrough to discover that specific fatty acids found in seafood can treat (and potentially prevent) mood disorders in children. We need much more research in this area in order to establish clinical recommendations.

Obesity: New Information, Surprising Findings Although numerous studies have linked various risk factors with obesity in childhood and adulthood, many were retrospective and inadequately controlled for confounding variables. Two new studies add to our understanding of factors associated with obesity. As part of the Avon Longitudinal Study of Parents and Children, a prospective birth cohort study, U.K. investigators assessed potential risk factors for obesity (>95% BMI) in 7758 sevenyear-old children. After adjustment for confounding variables, the following factors were associated with obesity: maternal BMI >30 (odds ratio, 4.25), paternal BMI >30 (OR, 2.54), and both parents BMI >30 (OR, 10.44); maternal smoking during pregnancy ( 20 cigarettes/day; OR, 1.80); birth weight (OR, 1.05/100 g); TV viewing (>8 hours/week; OR, 1.55); and duration of nighttime sleep (<10.5 hours/night; OR, 1.45). Neither duration of breast-feeding nor timing of introduction of solid foods was protective against obesity at age 7. In a subgroup of 909 children for whom additional early-life data were available, further risk factors were identified: weight gain at 8 months and 18 months of age (ORs for highest quartile by age, 3.13 and 2.65, respectively); catch-up growth between birth and 2 years (OR, 2.60); adiposity rebound (increase in BMI after reaching its lowest point) by 43 months of age (OR, 15.00); and weight gain in the first 12 months of life (OR, 1.06/100 g). In another study, investigators analyzed data from the 1970 British Cohort Study to examine adult outcomes of childhood obesity. Of the 8490 participants, 4% had been obese at age 10 years, and 16% were obese at 30 years. In nonobese adults, the researchers found no relation between obesity at 10 years (BMI >95%) and self-reported adult socioeconomic, educational, social, or psychological outcomes. Obesity at 30 years (BMI >28.5) had a mild effect on such outcomes, but obesity in women that persisted from childhood was associated with lack of gainful employment (OR, 1.9) and not having a current partner (OR, 2.0).

REACTION: Clearly, many environmental factors influence childhood obesity. Early childhood diet and nutrition, including adiposity rebound, is an important risk factor for later obesity. Also, parental obesity, which remains the single most important risk factor, is probably the most difficult to change. Surprisingly, the results from the long-term outcome study are less alarming than expected, demonstrating that childhood obesity has little effect on future economic, educational, and social well-being. However, the results might be different in the U.S. and in a contemporary cohort.