How a Public Health Goal Became a National Law

Abstract

This case study provides insights into policy strategy and advocacy best practices that resulted in passage of the Healthy, Hunger-Free Kids Act of 2010, a public health law that resulted in improvements to school foods and beverages across the country. Congress reauthorizes child nutrition programs such as the National School Lunch Program and School Breakfast Program every 5 years. The Healthy, Hunger-Free Kids Act of 2010 is the legislation that reauthorized the child nutrition programs through September 30, 2015, and continues in effect today. We conducted stakeholder interviews and reviewed the legislative and regulatory history of the Healthy, Hunger-Free Kids Act of 2010 and advocates’ files. We formed an external advisory committee which helped to develop the interview questions and list of interviewees and reviewed the content of the case study. This case study focuses on the provisions that address the nutritional quality of school meals, snacks, and beverages and covers the period from 2004 to 2016. Overall, the case study demonstrates a number of key lessons to help inform other nutrition and public health policy initiatives, as well as continued implementation and defense of school nutrition. For instance, how advocates used research to develop and advocate for policy change, compromises that were needed to advance the policies, changes in attitudes about school food policy over time, framing and messaging, the role of state and local policy that contributed to national change, and how challenges were resolved between stakeholders.

LESSONS FROM THE FRONTLINES OF THE FIGHT TO IMPROVE SCHOOL FOODS

In the early 2000s, making full use of the school lunch program to improve the health of millions of American school-age children seemed a distant vision. Political and practical barriers appeared insurmountable, and many key stakeholders lacked a common plan for how and what could be improved.

A decade later, Congress passed the Healthy, Hunger-Free Kids Act of 2010 (HHFKA), which has resulted in healthier snacks, beverages, and meals in schools, with more than 98% of school districts serving healthier lunches with more whole grains, fruits, and vegetables and less salt and trans fat.1

The Healthy, Hunger-Free Kids Act of 2010 addresses disparities in access to healthy food for low-income children.2 Prior to the updated school nutrition standards, students in higher-income communities were more likely to have healthier school foods than those in lower-income communities.3 The Healthy, Hunger-Free Kids Act of 2010 also increased universal school meal access in high-poverty schools and expanded the afterschool meal program nationwide.

How did advocates and policymakers achieve such a fundamental shift in the nutritional quality of food in schools? This case study tells the story. These insights may help to inform the push for other nutrition and public health policy initiatives and provide context for efforts to continue the implementation of and support for school nutrition.

SPOTTING AN OPPORTUNITY FOR BETTER NUTRITION IN SCHOOLS

School policies can play a critical role in addressing both nutrition and childhood obesity. Children consume up to one-half of daily calories during the school day.4 Most public schools (95%) participate in the US Department of Agriculture’s (USDA’s) National School Lunch Program (NSLP), with nearly half of all children in the United States (>30 million) eating school lunch daily.5,6 Most public schools (90%) also participate in the USDA School Breakfast Program (SBP), which provides food for more than 14 million children.7 Taxpayer investment in both programs was $16.9 billion in fiscal year 2015.8

Congress permanently established the NSLP in 1946, to address childhood malnutrition given the number of young men rejected from the World War II draft, and the SBP in 1975, and reauthorizes key child nutrition programs every 5 years. Although the NSLP and SBP are permanently authorized, during the Child Nutrition Reauthorization (CNR) process, there is an opportunity to review the programs and consider improving them. The Healthy, Hunger-Free Kids Act of 2010 is the 2010 CNR legislation. While Congress did not pass a 2015 CNR, HHFKA continues in effect today.9

As early as the 1990s, research indicated the need to update school nutrition standards for meals, snacks, and beverages. The USDA’s first School Nutrition Dietary Assessment revealed that school meals in school year 1991 to 1992 met USDA requirements for vitamins, minerals, and protein, but were too high in saturated fat and sodium.10

Since 1979, the national standards for snacks and drinks (called “competitive foods”) prohibited sales of foods and beverages with less than 10% of the Recommended Daily Allowances of key vitamins, minerals, or protein (so-called foods of minimal nutritional value) and did not address the full range of nutritional concerns such as calories, saturated fat, or sodium.11 This allowed schools to sell high-calorie and low-nutrient-density foods such as pizza, candy bars, and french fries and caused nutritional inconsistencies. While Skittles and sugary juice drinks could be sold (because they were fortified with vitamin C), jelly beans and seltzer water were not permitted to be sold because they were devoid of nutrients.12

National policy change takes time and is full of stops and starts. The Healthy, Hunger-Free Kids Act of 2010 is the culmination of more than 20 years of advocacy (Figure 1). As described below and by those interviewed, stepwise change in the quality of school foods moved from local to state and finally to national standards and from weaker to stronger school food standards. In achieving this forward momentum, most also noted that timing played a role. Interviewees described the passage of HHFKA as a moment when they saw “all the stars aligning,” referring to a confluence of factors that included concern about childhood obesity, state and local momentum, the support of both effective coalitions and nontraditional partners, and a favorable political climate. However, they cautioned, enacting the legislation was only 1 step of the process: implementing and preventing the law from being weakened continue to be essential to its ongoing success in achieving its important aims.

FIGURE 1.

How advocates improved school foods.

This case study provides insights into policy strategy and advocacy best practices from stakeholders directly involved in passage of HHFKA (Table 1). The case study focuses on the provisions that address the nutritional quality of school meals, snacks, and beverages and covers the period from 2004 to 2016 (Figure 2).

TABLE 1.

Key Insights and Best Practices

FIGURE 2.

Timeline: key school nutrition policy milestones, 2004 to 2016.

This case study was prepared by the Center for Science in the Public Interest (CSPI), which since 2003 helped coordinate the activities of many national, state, and local organizations working on school foods through the National Alliance for Nutrition and Activity (NANA) coalition. Efforts were made to get a broad and representative viewpoint by forming an external advisory committee and conducting more than 20 in-depth stakeholder interviews. The 6-member advisory committee included researchers and nutrition and antihunger advocates, who helped to develop the interview questions and list of interviewees and reviewed the content of the case study. We conducted telephone interviews in October and November of 2016 with key stakeholders from Congress, USDA, administration officials under both the George W. Bush and Barack Obama Administrations, researchers, and health and antihunger organizations.

We reviewed legislative and regulatory history from the 2004 and 2010 CNRs for school meals and competitive foods. We also examined peer-reviewed research and advocates’ files, which included summaries of coalition meetings, strategy documents, notes from meetings with congressional and USDA staff, correspondence between advocates and policymakers, fact sheets, press releases, and other materials.

STATES AND LOCALITIES LAY THE GROUNDWORK FOR CHANGE TO SCHOOL FOODS

In the early 1990s, there were efforts to improve school meals, including in the 1994 CNR the requirement for meals to be based on the Dietary Guidelines for Americans (DGA).13 The DGA is updated every 5 years, and HHFKA updated school nutrition standards based on the 2010–2015 DGA.

In the early 2000s, momentum was building at the state and local level. More than 20 states across the country, as diverse as Arkansas, California, Kentucky, Mississippi, and Texas, adopted policies setting nutrition standards for foods and beverages in vending machines, a la carte items in cafeterias, and other foods sold outside school meals.14,15 In a number of politically conservative states where passing legislation might have been challenging, officials took steps to improve the quality of school foods and beverages through regulation and administrative action. For example, former Texas State Commissioner of Agriculture Susan Combs (1999–2007) moved the school meal programs from the Texas Education Agency to the state department of agriculture and made key improvements to school meals, snacks, and beverages, such as removing deep-fat fryers and reducing portion sizes and calories for snacks and beverages. While the NSLP and SBP are federal programs, they are implemented by states and localities, which have the authority to adopt stronger nutrition standards.

A common concern raised by policymakers was that students would not purchase healthier options and schools would lose revenue. But the successes of schools in states that had adopted stronger standards, as well as those recognized by programs that rewarded nutritionally exemplary schools (such as USDA’s HealthierUS School Challenge16 and the Alliance for a Healthier Generation’s Healthy Schools Program17), provided numerous real-world examples of schools that successfully changed to healthier foods and beverages without losing revenue, making the case that national reform was feasible.

Local and state experiments also influenced the opinions of key lawmakers from those states. For example, school food improvements in Arkansas helped to cultivate support from Democratic Senator Blanche Lincoln, who became a champion for healthier school foods. Senator Lincoln (who left the Senate in 2011) chaired the critical Senate committee having jurisdiction during the 2010 CNR. Many interviewees noted that while research provided key support for the adoption and defense of policy, the examples of real-life successes, personal stories of constituents, and direct experiences among legislators and their staff are often more influential than data.

THE 2004 CHILD NUTRITION REAUTHORIZATION TO THE 2010 HHFKA

Work to Get Less Healthy Food Out of Schools, 2004–2007

During the 2004 CNR (which was enacted on June 30, 2004), nutrition advocates prioritized removing sugar-sweetened beverages and unhealthy snacks from school vending machines, a la carte offerings in cafeterias, school stores, and other venues that were outside the school meal programs nationwide.

Effective and united coalition strategy was essential. A diverse group of advocates worked together on school foods through NANA, a large coalition that now has more than 500 national, state, and local organizations, including the American Public Health Association, American Heart Association, Academy of Nutrition and Dietetics (then the American Dietetic Association), and School Nutrition Association (then the American School Food Service Association). The Center for Science in the Public Interest cofounded NANA in 1999 and facilitates the coalition.

A key lesson is that advocates can make the most of limited resources by forming coalitions that capitalize on different organizations’ connections and expertise. Acting alone, most nonprofits lack the staff or resources to persuade Congress to pass monumental policies that are opposed by well-funded industries.

Through a well-coordinated strategy, the groups in NANA helped to increase lawmakers’ awareness of the problem of unhealthy snacks and beverages sold in schools during the 2004 CNR; however, they were unable to secure additional authority for USDA to regulate competitive foods nationwide. As a compromise, Rep John Boehner (R-Ohio) (who was then the chair of the House of Representatives’ Committee on Education and the Workforce) agreed to a local approach that was favored by some school officials and conservative politicians. The 2004 CNR required school districts that participated in child nutrition programs to develop and implement a Local Wellness Policy that included provisions to address competitive foods and other school nutrition and physical activity issues.

Local Wellness Policies proved to be an important stepping stone, leading more school districts to adopt and strengthen school nutrition policies. Along with the growing number of state policies, it also contributed to a profusion of different standards in school districts around the country, making school food requirements more logistically challenging and expensive for beverage and snack food companies. Such variances led to the suppliers of school foods becoming more amenable to national standards. A key lesson is that national nutrition policy can be easier and less expensive for industry to implement than a variety of policies in different states and localities (in addition to HHFKA, examples include the national menu labeling law and the Nutrition Facts Label on packaged foods). A desire for uniformity can be a powerful driver of industry support for national policy.

Advocates worked closely at the national level with a select group of congressional champions to build support for national standards for snacks and beverages outside the meal programs. Sen Tom Harkin (D-Iowa) and Rep Lynn Woolsey (D-California) introduced competitive foods bills each congressional session from 2005 to 2010. One congressional staffer noted, “When Senator Harkin started in school nutrition and competitive foods reform, he was totally out on his own.” Advocates also built bipartisan support, including adding lead Republican cosponsors Rep Chris Shays (R-Connecticut) and Sen Lisa Murkowski (R-Alaska).

National Alliance for Nutrition and Activity organizations worked with Sen Harkin to secure funds for a National Academy of Medicine (NAM; formerly Institute of Medicine) study on competitive foods, which resulted in the 2007 report, Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth.18 Another federal report by the USDA and Centers for Disease Control and Prevention, Making It Happen, highlighted a widely cited set of case studies showing that schools could successfully switch to healthier options without losing money.19 Data from the Centers for Disease Control and Prevention showed that the majority of a la carte items in school cafeterias and vended foods were of poor nutritional value.20 Advocates also conducted research on competitive foods to make the case for national reform. For example, CSPI prepared state report cards that “graded” states based on competitive foods policies and revealed that two-thirds of states had no or weak competitive foods policies (Figure 3).15

FIGURE 3.

Advocates conducted targeted research on competitive foods to show the need for the Healthy, Hunger-Free Kids Act of 2010. For example, the Center for Science in the Public Interest released state “report cards” in 2006 and 2007 to make the case for the need for national policy; two-thirds of states had no or weak competitive foods policies.

By 2006, advocates had secured considerable bipartisan and industry support for making changes on the national level to competitive foods policy. A key milestone was a voluntary agreement between public health advocates and industry.

A group of nutrition and tobacco advocates and attorneys threatened to sue the American Beverage Association, Coca-Cola, and PepsiCo and were nearing a settlement to remove most sugary drinks from schools in 2006. Instead of settling, the beverage companies brokered an agreement with the Alliance for a Healthier Generation (children’s health nonprofit founded by the American Heart Association and Clinton Foundation) that limited full-calorie soda in schools.21

Then in 2007, the American Beverage Association and several food and beverage companies reached an agreement with CSPI, other health groups, and Sen Harkin (which he planned to offer as an amendment to the 2007 farm bill) to adopt a set of national standards for competitive foods that would have prohibited candy, snack cakes, and full-calorie soda in schools.

One barrier to passage were allies in support of healthier school foods who were concerned that the amendment would have preempted state and local competitive foods laws. Although prospects for passage looked promising, the amendment was not filed in time for a vote and therefore was not included in the 2007 farm bill.22

Improving School Meals, 2005–2009

In 2005, following publication of the new DGA, USDA sent nonbinding recommendations to schools, encouraging them to align school meals with the 2005 DGA.23 Advocates used the update to the DGA to push for updating school meal standards.24 National Alliance for Nutrition and Activity members (including the American Heart Association, National Parent Teacher Association, Academy of Nutrition and Dietetics, Produce for Better Health Foundation, and CSPI) worked together to develop a set of shared recommendations to bring school meals in line with the 2005 DGA, met with USDA, and sent a letter from 50 organizations urging the Bush Administration to update school meal nutrition standards. In 2007, the Administration contracted with NAM for recommendations to update school meal nutrition standards, resulting in the 2009 report, School Meals: Building Blocks for Healthy Children.25 Interestingly, while some politically conservative politicians inaccurately characterized HHFKA as wholly new and unprecedented, the process to improve school foods began under the Bush Administration several years before debate over HHFKA.

The Fight for Passage of HHFKA, 2009–2010

At the national level, diverse coalitions representing nutrition, public health, antihunger, child-focused, and faith-based groups provided resources, staff capacity, diverse congressional relationships, grassroots reach, and expertise. According to the interviews, a collection of nontraditional and new partners, including some food and beverage companies, industry trade associations, and retired military leaders, helped to attract additional bipartisan support. The report, Too Fat to Fight, from the Mission: Readiness organization—a group of top military leaders committed to improving children’s health and wellbeing—brought retired generals and admirals into school food advocacy. The report generated significant publicity and was cited regularly by policymakers and advocates.26 One industry representative noted, “Stranger the bedfellows, the stronger the coalition.”

When the debate began over the 2010 CNR, major food and beverage companies and the School Nutrition Association, a group representing school food manufacturers and professionals, supported updating the national competitive foods standards. One industry representative noted, “We made the case that this is a common-sense approach and age-appropriate and advocated for a nationwide system over a patchwork approach.”

In addition, enacting legislation was, at that moment, easier: for a narrow window of 2 years, a Democratic president coincided with a Democratic majority in both chambers of Congress. First Lady Michelle Obama championed improving school foods through her “Let’s Move” initiative, launched in February 2010, which increased media and public attention to childhood obesity and nutrition.

Contrary to widely prevalent views that HHFKA was exclusively an Obama Administration victory, some interviewees considered the campaign to remove sugary drinks and unhealthy snacks from schools already near completion when President Obama took office. Others also expressed concern that the First Lady’s engagement contributed to making school nutrition, which long had a bipartisan tradition, into a more partisan issue.

How Did Advocates Push for HHFKA Passage?

Throughout the CNR, advocates used a full slate of tools to emphasize the need for and feasibility of updates to school food policies. For example, they created PubMed alerts to identify new research on school foods and shared those developments with their networks, reporters, the Administration, and Congress. In addition, advocates worked with prominent and reputable researchers to highlight studies that were needed to support their policy goals, such as studies of the impact on school revenue of switching to healthier school foods. Polls conducted by the organizations demonstrated public support for removing soda and unhealthy food from schools.27 Advocates developed fact sheets with general background on each CNR policy priority and rebutted concerns that improving competitive foods would reduce school revenue. Materials included videos, infographics, and quizzes, which were distributed via email to and in meetings with congressional staff. Advocates also increased public support by engaging celebrities, including actors Scarlett Johansson, Andrea Bowen (“Desperate Housewives”), Deidre Hall (“Days of Our Lives”), Chevy Chase, and chefs Tom Colicchio and Rachel Ray.

Another key tactic to build congressional support was to mobilize members of the public in key districts and states. Grassroots involvement was essential to passing state and local school food policies, securing cosponsors for the national competitive foods bill, and passing HHFKA. Innovative strategies included dressing children as fruits and vegetables and distributing messages on plates, school lunch trays, seltzer water bottles, and stress balls to Congress.

Funders also played a critical role. In addition to financial support, some provided essential tactical help. For example, the Child Nutrition Initiative funded a communications firm to work closely with advocates during the final year of work to pass HHFKA (Figure 4).

FIGURE 4.

Ad placed in newspapers widely read by congressional members and staff to urge the House of Representatives to pass the Healthy, Hunger-Free Kids Act of 2010.

Importantly, advocates reworked their message to have wider political appeal for removing sugary drinks and unhealthy snacks from schools. Up through the 2004 CNR, advocates had asked Congress to give USDA additional authority to regulate all school foods. Toward the end of the 2004 CNR, advocates reframed both the text of the competitive foods legislation and their talking points to emphasize that USDA’s competitive foods standards were no longer consistent with science. This was a critical change because revising outdated standards was more appealing to conservative politicians than expanding government authority.

Challenges From Within the Community of Allies

A major hurdle to passage of HHFKA turned out to be a disagreement among allies. Initially, antihunger and nutrition groups tried to coordinate activities for the 2010 CNR. But a major challenge was a disagreement over the appropriate “offset” (funds designated as paying for the legislation) in the Senate bill. The Senate CNR bill (HHFKA) moved up the date to end a temporary increase to Supplemental Nutrition Assistance Program monthly benefits by 5 months to help pay for the new investments in child nutrition programs.28 While most advocates would have preferred a different means of paying for HHFKA, some antihunger groups opposed passage of the bill if it included this funding approach.

After the 2010 midterm elections, when Democrats lost the majority in the House and prospects for a better CNR bill in the next Congress looked dim, Feeding America, along with groups such as the National WIC Association, bridged the impasse between antihunger and nutrition groups. Such groups made the case that HHFKA included important improvements to addressing both hunger and nutrition and worked alongside NANA to pass the Senate version of the CNR bill in the House. The White House and advocacy groups continued to reassure a number of House Democrats, who remained concerned about how HHFKA was funded, that passing the Senate bill was the only way to get a strong bill passed before the congressional session ended.

On August 5, 2010, the Senate passed HHFKA (S. 3307) unanimously, and on December 2, 2010, the House passed the Senate bill with bipartisan support by a vote of 264-157. President Obama signed HHFKA into law on December 13, 2010.

Interviewees had a range of views on how antihunger and nutrition groups work together today. In general, the groups work more closely together every 5 years when legislation requires it, such as with CNR and the farm bill. The groups largely work together well when faced with cuts or rollbacks to nutrition programs. They face challenges when Congress uses some groups’ priority (such as the temporary increase in Supplemental Nutrition Assistance Program benefits) to subsidize another group’s priority (such as increased funding for healthier school lunches). Looking forward to future CNRs and farm bills, interviewees expressed a desire to avoid the kind of bifurcation that occurred during the 2010 CNR.

HHFKA: A Major Advance for Child Nutrition

The Healthy, Hunger-Free Kids Act of 2010 and its implementing regulations improved school nutrition in key ways. For competitive foods, updated standards removed full-calorie soda and placed limits on calories, sodium, saturated fat, and sugars for snacks, in effect prohibiting candy and many snack cakes and other sweet baked goods. Snacks must be at least 51% whole grain (“whole-grain rich”), or the first ingredient a fruit, vegetable, dairy, or protein food. School meals must now include a fruit or vegetable, more and a greater variety of vegetables must be offered, meals must be whole-grain rich, meet limits on saturated fat, must be within healthy calorie ranges, and must reduce sodium gradually in over time.

IMPLEMENTING HHFKA: 2011–2015

Although passing HHFKA took more than a decade of tremendous and focused effort, it was not enough to pass a national law to update and strengthen school nutrition. Advocates needed to mount a coordinated effort to protect the standards from being weakened in subsequent years by Congress. One advocate noted wryly, “You think that you passed this bill and you’re done. You can retire and achieve what you wanted to achieve. But the next 5 years are almost harder than the previous 10 in fighting back and in implementation.”

A month after HHFKA passed, USDA proposed new school meal regulations (January 13, 2011), which were finalized 1 year thereafter (January 26, 2012). The speed of the rulemaking was unusual. One industry interviewee noted, “I have never seen such a comprehensive response from the Administration.”

Many diverse organizations supported the adoption of the updated school food regulations.29 National Alliance for Nutrition and Activity coordinated development of model comments for the rules, circulated sign-on letters in support of a common set of recommendations, and mobilized groups to submit comments. A majority of comments to USDA (135 000 of the 138 000 comments on the meal standards and 240 000 of the 247 800 comments on competitive foods) were submitted by organizations based on the model NANA comment.

The earlier work to build the case for healthy school foods was essential to informing USDA’s new rules. Proposed school meal changes were based on recommendations from the 2009 NAM report, School Meals: Building Blocks for Healthy Children.25 Proposed competitive foods changes were grounded in the 2007 NAM report, Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth,18 as well as nutrition standards developed by states and localities, organizations, and the beverage and food companies’ agreements with the Alliance for a Healthier Generation.

Defending School Nutrition

The first major pushback to implementing HHFKA came in 2011 after the proposed school meal regulations were published. The American Frozen Food Institute lobbied to credit a half serving of tomato paste as a full serving of vegetables. Advocates countered that industry was trying to count “pizza as a vegetable” in the school lunch program.30,31 At the same time, the National Potato Council fought to prevent USDA from limiting how frequently schools could include french fries in school meals. In response to that lobbying, Congress required, through a policy rider added to the fiscal year 2012 Agriculture Appropriations Act, that USDA allow tomato paste to be overcredited and also prevented USDA from adopting limits on french fries or other starchy vegetables.32

Another effort to weaken school nutrition came in 2014, pushed in part by the Schwan Food Company (the largest provider of school pizza) and the School Nutrition Association. They opposed the whole grain–rich requirement and sodium reduction targets for school meals.33 Advocates worked with Sen Tom Harkin (D-Iowa) and Sen John Hoeven (R-North Dakota) on a bipartisan compromise that allowed states to offer waivers for specific products (like tortillas) from the whole grain–rich requirement and delayed the second phase of sodium reduction targets.

How Did Advocates Defend HHFKA?

Advocates used strategic research and other tactics to counter opposition to the school nutrition standards. To respond to opponents’ claims that children would go hungry under the updated school nutrition standards, advocates cited a USDA study showing that children would have access to a similar number of calories from school lunches before and after the law.4 In addition, plate-waste studies showed that school food waste had not increased since implementation of the new school meal standards.34,35 Pew Charitable Trusts conducted a health impact assessment to show that school revenue did not decrease with stronger snack and beverage standards.36 Groups also used the science base on sodium to reinforce the need for sodium reduction in school meals.37,38

As had been the case throughout the campaign, advocates enlisted examples from successful schools, including Bridging the Gap data on local wellness policies,14 and relied upon models from schools that had already implemented stronger nutrition standards through state or local policies or voluntary programs, such as USDA’s HealthierUS School Challenge16 and the Alliance for a Healthier Generation’s Healthy Schools Program.17 Advocates used pictures of school meals from before and after HHFKA to show how appealing healthy school lunches could be and that meals still had plenty of food. Pew conducted polls that showed that greater than 90% of parents supported improved school meals.39

Advocates countered arguments that the updated school nutrition standards were an overreach by the federal government, arguing that the regulations were a responsible use of taxpayer dollars, ensuring that a national nutrition program serves nutritious food. Advocates reminded policymakers that school foods had long been a bipartisan issue and that the updated meal standards process began under the Bush Administration. Rather than weaken them, advocates pushed for additional technical assistance for schools (such as through USDA’s Team Up for School Nutrition Success program), to help schools meet the standards.

Allies also worked collaboratively with supportive companies to make the case that national regulations were easier and less expensive for the food industry. The food industry is not monolithic. Advocates may find sympathetic companies to partner with even if other companies or influential trade associations are not supportive. While public health organizations typically have different motives than industry, the 2 groups can often still find ways to work together on common goals, and over time, public policy can drive changes to products that benefit both public health and the marketplace. For example, as schools demand more whole-grain and lower-sodium products, the food industry is developing (and profiting from) a greater variety of healthy and delicious products.40

CONCLUSION: AN UPHILL CLIMB TO A HEALTHIER RESULT FOR AMERICAN SCHOOLCHILDREN

Prior to the mid-2000s, getting unhealthy food out of school was enormously controversial. Advocates faced opposition by many school officials, food and beverage companies, conservative politicians, and others. Yet, HHFKA passed unanimously in the Senate and with strong bipartisan support in the House of Representatives. Eventually, after years of work, even the beverage industry and many food companies came around to support a robust national school food policy. As one federal employee said, “Change is hard. If it was easy it would have been done years ago.”

The transformation was well worth the years of efforts. Remarking on the change in school foods, one advocate said, “I graduated from the same school district my kids go to now. I was eating Pizza Hut pizza, fruit punch, and Funyuns. Today, my kids are eating star fruit, whole-grain macaroni and cheese with low-fat cheese, baby carrots, and low-fat milk, in the same cafeteria.”

Major wins for public health are often a result of untold stories. This story, which we have sought to tell thus far, is far from over. Although healthy school foods are now well supported by the public and much of industry, it is equally true that the issue is more partisan in tone than before the reforms. Since Congress did not pass a 2015 CNR bill and the opposition from conservative politicians and some industry groups continues, it is unclear the degree to which attacks will be mounted in the coming years. Advocates may need to use many of the successful advocacy tactics described in this case study to counter the ongoing opposition and to protect the continued and critical progress on healthy school foods.