Academy of Nutrition and Dietetics: Revised 2021 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Management of Food and Nutrition Systems.

Management of food and nutrition systems (MFNS) encompasses the varied roles of registered dietitian nutritionists (RDNs) with administrative responsibilities for food and nutrition services within an organization. RDNs in MFNS are frequently employed in acute care, but also expand into a multitude of other settings in which management of nutrition and foodservice is required, for example, foodservice departments in assisted living and post-acute and long-term care; colleges and universities, kindergarten through grade 12 and pre-kindergarten schools and childcare; retail foodservice operations; correctional facilities; and companies that produce, distribute, and sell food products. RDNs in MFNS aim to create work environments that support high-quality customer-centered care and services, attract and retain talented staff, and foster an atmosphere of collaboration and innovation. The Management in Food and Nutrition Systems Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has revised the Standards of Professional Performance (SOPP) for RDNs in MFNS for 3 levels of practice: competent, proficient, and expert. The SOPP describes 6 domains that focus on professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Indicators outlined in the SOPP depict how these standards apply to practice. The standards and indicators for RDNs in MFNS are written with the leader in mind-to support an individual in a leadership role or who has leadership aspirations. The SOPP is intended to be used by RDNs for self-evaluation to assure competent professional practice.

Reducing the knowledge to action gap in hospital nutrition care - Developing and implementing nutritionDay 2.0.

BACKGROUND & AIMS: In hospital nutrition care the difficulty of translating knowledge to action often leads to inadequate management of patients with malnutrition. nutritionDay, an annual cross-sectional survey has been assessing nutrition care in healthcare institutions in 66 countries since 2006. While initial efforts led to increased awareness of malnutrition, specific local remedial actions rarely followed. Thus, reducing the Knowledge-to-action (KTA) gap in nutrition care requires more robust and focused strategies. This study describes the strategy, methods, instruments and experience of developing and implementing nutritionDay 2.0, an audit and feedback intervention that uses quality and economic indicators, feedback, benchmarking and self-defined action strategies to reduce the KTA gap in hospital nutrition care. METHODS: We used an evidence based multi-professional mixed-methods approach to develop and implement nutritionDay 2.0 This audit and feedback intervention is driven by a Knowledge-to-Action framework complemented with robust stakeholder analysis. Further evidence was synthesized from the literature, online surveys, a pilot study, World Cafés and individual expert feedback involving international health care professionals, nutrition care scientists and patients. RESULTS: The process of developing and implementing nutritionDay 2.0 over three years resulted in a new audit questionnaire based on 36 nutrition care quality and economic indicators at hospital, unit and patient levels, a new action-oriented feedback and benchmarking report and a unit-level personalizable action plan template. The evaluation of nutritionDay 2.0 is ongoing and will include satisfaction and utility of nutritionDay 2.0 tools and short-, mid- and long-term effects on the KTA gap. CONCLUSION: In clinical practice, nutritionDay 2.0 has the potential to promote behavioural and practice changes and improve hospital nutrition care outcomes. In research, the data generated advances knowledge about institutional malnutrition and quality of hospital nutrition care. The ongoing evaluation of the initiative will reveal how far the KTA gap in hospital nutrition care was addressed and facilitate the understanding of the mechanisms needed for successful audit and feedback. TRIAL REGISTRATION: Registration in clinicaltrials.gov: Identifier: NCT02820246.

Food Hygiene Practices at the Ghana School Feeding Programme in Wa and Cape Coast Cities.

Objective: The integrity and the wholesomeness of the food served to school pupils cannot be overlooked, especially when one considers the magnitude of health and sanitation issues that are plaguing the West African nations. This study aimed to investigate some of the personal hygiene practices by the pupils and the hygienic conditions in which food is cooked and served to these school-going children under the Ghana School Feeding Programme (GSFP). Design: A cross-sectional and descriptive survey research designs were used in the study. Purposive and simple random sampling techniques were employed in selecting participants. Participants. There were 720 respondents for the study, comprising 600 pupils, 60 teachers, and 60 kitchen staff members from 20 schools. Information was obtained using questionnaire, observation, and unstructured interview instruments. Results: Findings from the study revealed that the majority of pupils (92% in Wa and 65% in Cape Coast) did not wash their hands with soap under running water. No hand washing centers for pupils were also seen in most of the schools studied. Majority of the cooks did not have health certificate, and neither had attended any in-service training in two years. In both Wa and Cape Coast municipal schools, none of the kitchen staff admitted that pupils and teachers ever complained about the meals they served to the pupils. Conclusion: The GSFP in basic schools forms part of the integral diet of the school children; hence, provision of good quality food can affect the health, learning, and physical activities of these children. Observational checklist revealed that most of the kitchen staff do not strictly adhere to basic food hygiene practices, and this affects the wholesomeness of the food served to the children. There is, therefore, a need for kitchen staff training on hygiene and food preparation practices.

Hygienic-Sanitary conditions of Hospital Nutrition Services in Southern Brazil / Condições higienicossanitárias dos serviços de nutrição e dietética em hospitais do Sul do Brasil

This study evaluated the good handling practices in the ten Hospital Nutrition Services of the respective hospitals in the South of Brazil, classified as general hospitals. For data collection, there was used a Checklist for Good Handling Practices for Food Services based on current legislation. Among the results, the average of adequacy of the hospitals stand out, showing that the items related to responsibilities and edifications had the lowest adequacies, 67% and 73%, respectively, followed by the food handler block, with 76% of adequacies. The block referring to food handlers showed that few of them sanitize the hands during the change of activity. The classification of hospitals in relation to Good Handling Practices was satisfactory, however, greater failure was observed related to the practices of the food handlers, which are crucial for the safety of food produced in Hospital Nutrition Services.

Este estudo avaliou as boas práticas de manipulação em 10 serviços de nutrição e dietética de hospitais do Sul do Brasil, classificados como hospital geral. Para a coleta de dados, utilizou-se uma Lista de Verificação em Boas Práticas para Serviços de Alimentação baseada na legislação vigente. Dentre os resultados destacam-se a média de adequação dos hospitais, mostrando que os itens relacionados a responsabilidades e edificações apresentaram as menores adequações, 67% e 73%, respectivamente, seguidos com o bloco de manipuladores, com 76% de adequações. O bloco referente aos manipuladores de alimentos mostrou que poucos deles higienizam as mãos durante a troca de atividade. A classificação dos hospitais em relação à Boas Práticas de Manipulação foi satisfatória, no entanto, observou-se que falta o cumprimento de alguns itens, relacionados com as práticas dos manipuladores, que são cruciais para a segurança dos alimentos produzidos nos serviços de alimentação.

Position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior: Food and Nutrition Programs for Community-Residing Older Adults.

Given the increasing number and diversity of older adults and the transformation of health care services in the United States, it is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that all older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs. Programs must include food assistance and meal programs, nutritional screening and assessment, nutrition education, medical nutrition therapy, monitoring, evaluation, and documentation of evidence-based outcomes. Coordination with long-term care services and support systems is necessary to allow older adults to remain in their homes; improve or maintain their health and manage chronic disease; better navigate transitions of care; and reduce avoidable hospital, acute, or long-term care facility admissions. Funding of these programs requires evidence of their effectiveness, especially regarding health, functionality, and health care-related outcomes of interest to individuals, caregivers, payers, and policy makers. Targeting of food and nutrition programs involves addressing unmet needs for services, particularly among those at high risk for poor nutrition. Registered dietitian nutritionists and nutrition and dietetics technicians, registered must increase programmatic efforts to measure outcomes to evaluate community-based food and nutrition services.

Dietary Service Staffing Impact Nutritional Quality in Nursing Homes.

OBJECTIVE: To examine the relationship between dietary service staff and dietary deficiency citations in nursing homes (NHs). METHOD: 2007-2011 Online Survey and Certification and Reporting data for 14,881 freestanding NHs were used to examine the relationship between dietary service staff and the probability of receiving a dietary service-related deficiency citation. An unconditional logit model with random effects was employed. RESULTS: Findings suggest that higher staffing levels for dietitians (odds ratio [OR] = .955; p < .01), dietary service personnel (OR = .996; p < .01), and certified nursing assistants (CNAs; OR = .981; p < .05) decrease the likelihood of receiving a dietary service deficiency citation. CONCLUSION: Higher levels of dietary service and CNA staffing levels have the potential to improve the quality of nutritional care in NHs. Findings help substantiate the Centers for Medicare and Medicaid Services' proposed rules for more stringent Food and Nutrition Services in the NH setting and signify the need for further research relative to the impact of dietary service staff on nutritional and clinical outcomes.

[Differing dietary advice are given to gynaecological and prostate cancer patients receiving radiotherapy in Sweden]. / Stor variation i kostråden vid strålbehandling av lilla bäckenet - Kost har potential att förebygga följdsjukdomar till strålning och ge bättre tarmhälsa ­ men vetenskaplig evidens saknas.

Preclinical studies indicate that an optimal diet during pelvic radiotherapy may be able to prevent radiation-induced survivorship diseases that diminish cancer survivors' intestinal health. We do not yet know what this optimal diet might be because scientific studies needed to determine what dietary advice might best be given to patients during treatment. Oncology clinics in Sweden were contacted to determine the nature of dietary advice given to gynaecological and prostate cancer patients at each clinic before, during and after radiotherapy. Reports from these clinics revealed that dietary advice given to patients differs from one clinic to another. This was as expected, since it was known that the scientific evidence needed to identify the best possible diet is not yet available. Clinical studies of the effects of different diets are urgently needed if we are to prevent survivorship diseases that decrease intestinal health.

Position of the Academy of Nutrition and Dietetics, Society for Nutrition Education and Behavior, and School Nutrition Association: Comprehensive Nutrition Programs and Services in Schools.

It is the position of the Academy of Nutrition and Dietetics, School Nutrition Association, and Society for Nutrition Education and Behavior that comprehensive, integrated nutrition programs in preschool through high school are essential to improve the health, nutritional status, and academic performance of our nation's children. Through the continued use of multidisciplinary teams, local school needs will be better identified and addressed within updated wellness policies. Updated nutrition standards are providing students with a wider variety of fruits, vegetables, and whole grains, while limiting sodium, calories, and saturated fat. Millions of students enjoy school meals every day in the United States, with the majority of these served to children who are eligible for free and reduced-priced meals. To maximize impact, the Academy, School Nutrition Association, and Society for Nutrition Education and Behavior recommend specific strategies in the following key areas: food and nutrition services available throughout the school campus, nutrition initiatives such as farm to school and school gardens, wellness policies, nutrition education and promotion, food and beverage marketing at school, and consideration of roles and responsibilities.

Practice Paper of the Academy of Nutrition and Dietetics: Comprehensive Nutrition Programs and Services in Schools.

It is the position of the Academy of Nutrition and Dietetics, School Nutrition Association (SNA), and Society for Nutrition Education and Behavior (SNEB) that comprehensive, integrated nutrition programs in preschool through high school are essential to improve the health, nutritional status, and academic performance of our nation's children. To maximize impact, the Academy, SNA, and SNEB recommend specific strategies in the following key areas: food and nutrition services available throughout the school campus, nutrition initiatives such as Farm to School and school gardens, wellness policies, nutrition education and promotion, and consideration of roles and responsibilities. This paper supports the joint position paper of the Academy of Nutrition and Dietetics, SNA, and SNEB published in the May 2018 Journal of Academy of Nutrition and Dietetics. In alignment with the joint position paper, this practice paper provides registered dietitian nutritionists and nutrition and dietetics technicians, registered with an overview of current school nutrition services and opportunities for professional careers in school settings. The Academy of Nutrition and Dietetics has several position papers related to youth preschool through adolescence that cover specific nutrition needs in more detail at www.eatright.org.

Phenolic compounds content and antioxidant capacity of meals provided to elementary public schools in Chile during 2011 / Contenido de compuestos fenólicos y capacidad antioxidante de alimentos entregados a las escuelas públicas de enseñanza básica en Chile durante 2011

The Chilean National School Feeding Program (NSFP) delivers breakfast and lunch meals that supply 250 and 450 kcal, respectively, along the country. In the last decades, a significant increase of obesity has been observed in primary education children, and it involves risk factors of non-communicable diseases. The dietary intake of foods containing phenolic compounds (PC) exerts favorable effects on health by reducing risk factors of prevalent diseases. The aim of the study was to measure the PC content and antioxidant capacity (AC) [ORAC and DPPH] of meals provided by the NSFP in Quillota, Chile, in 2011. The PC supply of the whole meals served ranged from 362.7 to 1,730 mg GAE. The best breakfast foods include whole grain cookie (2.59±0.3 mg GAE/g), bread with avocado, quince jelly or strawberry jam (1.61±0.13 to 2.05±0.3 mg GAE/g); while the best lunch salads include beetroot, lettuce, and cabbage/fish (1.66±0.3 to 2.35±0.1 mg GAE/g), and main courses contain legumes, or mixed vegetables. The lowest PC contents were observed in pasta and rice preparations (p<0.05). Among desserts, the best source of PC is fruit (1.81±0.04 to 6.91±0.31 mg GAE/g). The correlation between PC and AC varied according to the type of meal. PC content and AC are additional criteria for selecting the best quality meals, in addition to the nutrients and energy content. The results support the recommendation to increase the supply of fruits and vegetable/legumes preparations and fruits instead of starchy foods to scholars.

El Programa de Alimentación Escolar (PAE) para enseñanza básica en Chile distribuye, en todo el país, desayunos y almuerzos que aportan 250 y 450 kcal, respectivamente. En las últimas décadas ha aumentado significativamente la obesidad en escolares, lo que induce factores de riesgo de enfermedades no transmisibles. La ingestión de alimentos que contienen polifenoles (PF) ejerce efectos beneficiosos al reducir factores de riesgo de enfermedades prevalentes. El objetivo del estudio fue determinar el contenido de PF y la capacidad antioxidante (CA) [ORAC y DPPH] de los alimentos entregados por el PAE en Quillota, Chile, en 2011. El aporte de PF en las raciones servidas fluctuó entre 362.7 y 1,730 mg EAG. El mejor desayuno contenía galletón con granos integrales (2.59±0.3 mg EAG/g), pan con palta, dulce de membrillo o de fresas (1.61±0.13 a 2.05±0.3 mg EAG /g) y el mejor almuerzo, ensaladas de remolacha, lechuga, o col/pescado (1.66±0.3 a 2.35±0.1 mg EAG /g), y un plato principal con leguminosas o vegetales mixtos. Los contenidos menores de PF se observaron en platos con pastas y arroz (p<0.05). Entre los postres, la mejor fuente de PF es la fruta (1.81±0.04 a 6.91±0.31 mg EAG/g). La correlación entre PF y CA fluctuó según el tipo de preparación. El contenido de PF y la CA son criterios de calidad adicionales al aporte de energía y nutrientes de las preparaciones. Los resultados apoyan la recomendación de aumentar el aporte a los escolares de frutas y vegetales/leguminosas en lugar de alimentos con alto contenido de almidones.

Microbiological quality of enteral feeding and infant formula produced in dietary units, according to the triad of Donabedian.

INTRODUCTION AND AIMS: Microbial contamination of enteral feeding and infant formulas can result in a risk of worsening of the clinical condition of the patients, who are already weakened and susceptible to pathogens. The objective was to evaluate aspects of the management of quality hygienic - sanitary of enteral feeding and infant formulas in hospitals, focusing on the structure, process and outcome. METHODS: An observational, descriptive, prospective, with quantitative and qualitative variables study was done. The survey was conducted for 12 months and 227 samples of enteral feeding and 176 of infant formula were collected in Nutrition and Dietetic Services of Health Secretary / Federal District. In evaluating the operating conditions, the Tool 2 was applied to: Enteral Nutrition Preparation. Data were analyzed from the unified Donabedian's triad for evaluation of health services. RESULTS: The results obtained with the Tool 2 demonstrated that the Storage Block complies with legal requirements. Moreover, Dressing Block is a risk factor for the contamination. From the 403 samples, 56% corresponded to samples of Enteral Nutrition and 44% to samples of Infant Formulas. The data indicate that from 227 samples of Enteral Nutrition, 6.2% were in disagreement with the legislation, while from 176 samples of Infant Formulas, 4.6% were also in disagreement with the legislation. CONCLUSION: The ineffective implementation of the sanitary and hygienic requirements during the preparation results in a microbiologically unsafe product to patients in debilitated health state, and the count of mesophilic microorganisms can be a good indicator of microbiological safety.

Introducción y objetivo: La contaminación microbiológica de dietas enterales y fórmulas infantiles puede conducir a una situación de riesgo de agravación del cuadro clínico de pacientes, ya debilitados y susceptibles a los agentes patógenos. El objetivo fue evaluar aspectos de la gestión de calidad de condiciones sanitarias de dietas enterales y fórmulas infantiles en los hospitales, centrándose en estructura, proceso y resultado. Métodos: Fue hecho un estudio observacional, descriptivo, prospectivo, con variables cuantitativas y cualitativas. La encuesta fue por 12 meses y se recogieron 227 muestras de dietas enterales y 176 de fórmulas infantiles en los Servicios de Nutrición y Dietética de la Secretaría de Estado de Salud del Distrito Federal. Los datos fueron analizados a partir de la Tríada de Donabedian para la evaluación de los servicios de salud por medio de un cuestionario. Resultados: Los resultados obtenidos muestran que en Bloque Almacenamiento cumple con los requisitos legales. Por otro lado, el Bloque Vestuario es un factor de riesgo de contaminación. De las 403 muestras, 56% eran muestras de Nutrición Enteral y 44%, muestras de Fórmulas Infantiles. Los datos indican que de 227 muestras de Nutrición Enteral, un 6,2% estaban en desacuerdo con la ley, mientras que de las 176 muestras de las Fórmulas Infantiles, 4,6% también estaban en desacuerdo con la legislación. Conclusión: La falta de aplicación efectiva de requisitos higiénicos sanitários durante la preparación resulta en producto microbiológicamente inseguro para pacientes debilitados, y el recuento de mesófilos totales puede ser un buen indicador de la seguridad microbiológica.

Phenolic compounds content and antioxidant capacity of meals provided to elementary public schools in Chile during 2011.

The Chilean National School Feeding Program (NSFP) delivers breakfast and lunch meals that supply 250 and 450 kcal, respectively, along the country. In the last decades, a significant increase of obesity has been observed in primary education children, and it involves risk factors of non-communicable diseases. The dietary intake of foods containing phenolic compounds (PC) exerts favorable effects on health by reducing risk factors of prevalent diseases. The aim of the study was to measure the PC content and antioxidant capacity (AC) [ORAC and DPPH] of meals provided by the NSFP in Quillota, Chile, in 2011. The PC supply of the whole meals served ranged from 362.7 to 1,730 mg GAE. The best breakfast foods include whole grain cookie (2.59 ± 0.3 mg GAE/g), bread with avocado, quince jelly or strawberry jam (1.61 ± 0.13 to 2.05 ± 0.3 mg GAE/g); while the best lunch salads include beetroot, lettuce, and cabbage/fish (1.66 ± 0.3 to 2.35 ± 0.1 mg GAE/g), and main courses contain legumes, or mixed vegetables. The lowest PC contents were observed in pasta and rice preparations (p < 0.05). Among desserts, the best source of PC is fruit (1.81 ± 0.04 to 6.91 ± 0.31 mg GAE/g). The correlation between PC and AC varied according to the type of meal. PC content and AC are additional criteria for selecting the best quality meals, in addition to the nutrients and energy content. The results support the recommendation to increase the supply of fruits and vegetable/legumes preparations and fruits instead of starchy foods to scholars.

Análisis de la norma técnica de salud de la Unidad Productora de Servicios de Salud de Nutrición y Dietética / Analysis of technical standards in health Services Producer Unit of Nutrition and Dietetics

El proceso administrativo involucra 4 pilares fundamentales que no han cambiado de manera significativa a lo largo de la historia. Lo que si ha cambiado es la forma en que estos principios se aplican en el trabajo diario. Sin embargo, y a pesar de la gran evolución del proceso administrativo, la aplicación de estos conceptos a la Gestión en Salud, no tiene más de 20 años. La aprobación de la NTS N°103-MINSA/DGSP-V.01 Norma Técnica de Salud de la Unidad Productora de Servicios de Salud de Nutrición y Dietética pone fin a un proceso de algo más de 3 años en los que se ha buscado dotar a los Nutricionistas de herramientas técnicas y de recursos humanos que les permitan desarrollar al máximo su potencial profesional.

The administrative process involves 4 pillars that have not significantly changed throughout history. The way these principles are applied in daily work is what changed. However, despite the great evolution of the administrative process, the application of these concepts to the Health Management, has no more than 20 years. The approval f the NTS No. 103-MINSA/DGSP-V. 01 "Technical Standards in Health of the HealthServices Producer Unit of Nutrition and Dietetics" ends a process of just over 3 years in which it is have been sought to provide Nutritionists of the technical tools and human resources to order to maximize their professional performance.

Evaluating the Wellness School Assessment Tool for use in public health practice to improve school nutrition and physical education policies in New York.

BACKGROUND: Addressing the limitations of existing Local Wellness Policies (LWPs) and promoting their implementation remain priorities for health and education agencies. One gap has been the absence of a standard assessment to support LWP revision. During planning for an initiative to improve school nutrition and physical education policy, the Wellness School Assessment Tool (WellSAT) was evaluated. METHODS: Five public health practitioners used WellSAT to assess 50 LWPs. A randomized, counterbalanced design ensured each LWP was coded twice by separate raters. Models evaluated the extent to which WellSAT ratings reflected differences in the LWPs and order, familiarity and rater effects. During field testing, 18 public health practitioners used WellSAT as part of a statewide public health initiative. RESULTS: In pilot testing the majority of the variability in WellSAT scores (median = 88%; range = 76% to 100%) was attributable to differences between policies. Correlations between independent raters' strength and comprehensiveness scores were strong, r = .88 and r = .77, respectively. During field testing, WellSAT was well accepted by public health practitioners and members of the school community. CONCLUSIONS: WellSAT represents a reliable and feasible tool for health and education agencies to use in improving LWPs and aligning them with recognized standards.

Evaluating documentation of dietetic care in Swedish medical records.

An adequate documentation in medical records is essential for patient safety and high quality care. The aim of this study was to evaluate documentation by dietitians in Swedish medical records. A retrospective audit of147 dietetic notes in electronic medical records was performed. The audit focused at documentation of essential parts of the dietetic care, as well as other quality aspects such as lingual clarity and structure of the documentation. The nutrition intervention showed to be the most documented part of dietetic care. However, the audit showed that several important parts of nutrition care were poorly documented, for instance nearly half of the audited records had no clear nutrition problem documented, and in most of the records, the goal of nutrition intervention was missing. The study shows that Swedish dietitians need to improve documentation in medical records, as a suggestion by implementing a more structured documentation model.

Go Slow Whoa meal patterns: cafeteria staff and teacher perceptions of effectiveness in winning with wellness schools.

BACKGROUND: School-based interventions hold promise for child obesity prevention. Implemented as a part of the Winning With Wellness obesity prevention project, the "Go Slow Whoa" meal pattern (GSW) was designed to promote healthier foods in school cafeterias. This investigation determined perceived program effectiveness and impact on student's food purchases. METHODS: A mixed method design was used, including focus groups with cafeteria staff (CS), quantitative analysis of CS and teacher surveys, and pre-post analysis of cafeteria sales. A total of 37 CS and 131 teachers from 7 schools in northeast Tennessee participated. RESULTS: CS recognized the important role of school nutrition services in influencing student choices, yet perceived lack of administrative support for cafeteria-based interventions and minimal interaction with teachers were barriers. CS also believed that students choose less nutritious options due to family influence. Cafeteria sales indicated that changes were made in menu planning and production, yet students' choices improved minimally. Teachers expressed moderate levels of confidence in GSW as influential in children's dietary habits. CONCLUSIONS: Successful implementation of school-based nutrition programs requires supportive policies, administrators, and teachers. CS should be included in program implementation efforts and the role of school nutrition services should be maximized.