Never doubt that a small group of thoughtful, committed people can change the world. Indeed it's the only thing that ever has. - Margaret Meade

THE COMMUNITY

The South Bronx is well known as the poorest urban congressional district in the United States.1 Its residents are primarily African Americans, Caribbean Americans and Latinos from Puerto Rico, the Dominican Republic, and Central America. Many recent immigrants have come from West Africa. Roughly 40% live below the federal poverty line, and more than half rely on some form of public assistance.2 Levels of educational attainment are also low. Health statistics are typical of a poor urban community, with high rates of asthma, HIV, diabetes, heart disease, and infant mortality.

Between 2003 and 2005, nearly one-third of the children in New York City (NYC) Head Start programs were obese; one-quarter of the children in public elementary schools were obese, and about 15% of public high school students were obese.3 These high rates of obesity in school children-known precursors of many of the health problems their parents already faced-were of grave concern to public health advocates in the community.

Just prior to the period that the campaign to eliminate whole milk and sweetened milk from schools began, the NYC school system had undergone a major reorganization combining community school districts into regions. The system, which enrolled over 1 million children in 32 geographic community school districts representing primary and middle schools, as well as borough and citywide high school districts, was divided into 10 geographic regions. Each region included 2 to 4 community school districts, contained approximately 120 schools, and had a learning support center led by a Regional Superintendent that provided operational and support services to schools.

Region 1, where the efforts to change school milk policy began, included the neighborhoods of Grand Concourse, Morrissania, Tremont, and Highbridge, as well as the communities of Wave Hill and Riverdale, in the south and west Bronx. In school year 2003 to 2004, Region 1 had 129 schools and more than 95,000 students.

THE PARTNERS

There were many partners involved in the "1% Or Less" campaign described below-each of whom played critical roles, working out front and behind the scenes, garnering both community support and the support of the agencies for which they worked. The Bronx Health REACH Coalition (BHR) had been working in the area since 1999, reaching out to residents in schools, churches, and community-based organizations. BHR's Coalition included more than 40 groups, and had several subcommittees, or workgroups. Its work focused in several areas: primary prevention designed to teach people about nutrition and exercise to promote healthier choices; environmental change designed to make healthier foods and places to exercise more available; education about health disparities and equal access to health and health care; and policy change to support the goals of the Coalition.4 BHR played a leading role in the campaign to eliminate whole milk, bringing the partners together through its Nutrition and Fitness Workgroup (known as "Nut/Fit"), which included both the Montefiore School Health Program and the Bronx District Public Health Office of the NYC Department of Health and Mental Hygiene (BxDPHO). BHR was also instrumental in educating its Coalition members about obesity and the benefits of reduced fat milk, thereby garnering both parent and community support for the campaign.

The Bronx Healthy Hearts (BHH) project grew out of the Nut/Fit Workgroup as a strategy to address nutrition and fitness education in the schools. Previously, the Nut/Fit workgroup had sponsored activities in local restaurants and small grocery stores, including a campaign to promote low fat milk in these settings, and was seeking a mechanism to link these efforts with activities that would involve school children and their parents. Funded in 2003, BHH's primary goal was to establish Wellness Councils at both the school and district levels to initiate local environmental and policy changes to ensure a healthy school population. The New York State Department of Health, which funded the Healthy Hearts project, recommended the implementation of the "1% or Less" low-fat milk campaign as a way to get started, on the basis of the success of a similar program in upstate New York.5 As most of the schools did not have cooking cafeterias, changing the menus would have been quite difficult. The milk policy provided the group with an opportunity to improve nutrition even in schools without cooking capacity.

Other key players included the Region 1 Office of School Health, and the Jacobi Weight Management Program. The Region 1 Office is responsible for ensuring that schools in the Bronx meet the health education and health services needs of the students, and provides services, support and technical assistance to individual schools to meet the state health mandates. The Region 1 Health Director often served as a bridge between the advocates and the Office of School Food and Nutrition. The Jacobi program provided health and nutrition education, including cooking demonstrations for students, parents and staff at Public School 54, and became an active participant in the advocacy efforts. (see Table 1)

Table 1. The Partners

SETTING THE STAGE

At the start of the 2004 to 2005 school year, Bronx Healthy Hearts recruited 6 schools to participate and be the first to establish Wellness Councils in their schools. Fortuitously, 1 of the schools, Public School 28, had a school-based health center run by School Health Program. The Region 1 Health Director worked closely with the school health program, and welcomed the Healthy Hearts program into the region. As a result, in October 2004, the 3 directors from Montefiore's School Health Program, Region 1's Office of School Health, and the Healthy Hearts Program met to discuss program goals, school recruitment, and strategies for program implementation.

PS 28, in the Mount Hope neighborhood, already had a Nutrition Committee, organized by the assistant principal, consisting of student representatives from the upper grades as well as a representative of the Office of School Food and Nutrition (OSFN). The PS 28 Nutrition Committee recommended the elimination of whole milk and sweetened vanilla and strawberry milks, and phasing out chocolate milk in their school with the understanding that both BHH and the Montefiore School Health Program would help educate parents and students about the benefits of the plan. However, according to several accounts, when the school decided to place the order for all low-fat milk, the OSFN staff objected, raising the question of whether a school had the right to decide foods could be served.

The PS 28 committee investigated whether an individual school had the right to make this decision, and requested assistance from the Region 1 office. The director responded by sharing information from the Chancellor's Regulations on Wellness Councils and practices of school food partnerships with the councils. She also discussed the matter with the OSFN administrators to obtain their support for the initiative proposed by the PS 28 committee. Given the 2004 federal School Wellness Policy mandating that educational institutions participating in the national school lunch program establish a wellness policy, the director decided there was both a strong rationale for, and interest in, establishing a regional committee to develop a milk policy. As a result, the Region 1 Fitness and Nutrition Committee was established. (see Table 2)

Table 2. Timeline

THE "MOOOVE" TO LOW-FAT MILK

The first Region 1 Fitness and Nutrition Committee meeting was convened in April 2005. Invitations to join the Committee were sent to members of the community that were involved in health and wellness, including hospitals, community health centers, community-based organizations, and the local office of the City's Department of Health and Mental Hygiene. The Committee included representatives from BHR, Bronx Healthy Hearts, Montefiore School Health, Weight Management Program, Local Instructional Specialists, principals, OSFN, WIC program representatives from 2 area health centers, and the Bronx District Public Health Office. A regional milk policy was at the top of its agenda, with the intent to also develop an educational plan, a fitness plan, and a plan to address vending machines, snacks and fundraisers.

In June 2005, the Region 1 Fitness and Nutrition Committee, with the support of the Regional Superintendent, adopted both a Regional Milk Policy-including plans for an elementary school pilot program-and a template for future wellness policies in the region, which served as the impetus for the Department of Education's citywide wellness policy. The pilot was to be rolled out in 53 of Region 1's elementary schools at the beginning of the 2005 to 2006 school year. The plan was to eliminate whole milk, limit the availability of flavored milk, and implement an educational component for grades K-5. The plan proposed that no whole milk would be offered, and flavored milk would be offered in 2 ways: in those schools that had health promotion programs in place, it would be available 1 day a week; and in the rest, it would be offered 3 days a week. In both cases, flavored milk would be available at lunchtime only, not in the breakfast or after-school programs. This was designed to appease those who feared that milk consumption might drop drastically and affect student health. Ironically, several principals slated to be in the "three times a week group" requested to be moved into the "one day a week" category, which was permitted.

The OSFN prepared the cafeteria staff to institute the pilot plan. OSFN managers were responsible for explaining the change to both principals and others in their school communities, as well as ensuring that kitchen personnel understood the rationale behind eliminating flavored milk. During the planning stages, the BxDPHO of the NYC Department of Health and Mental Hygiene proposed to evaluate the pilot by posting researchers who would actually measure milk consumption, by comparing milk purchases and gallons of discarded milk on days when flavored milk was served and when it was not made available. This laborious process was later abandoned because of lack of funds, and an alternative plan was utilized detailing monthly milk purchases according to each variety served and comparing it to the previous year's usage.

Staff from Montefiore's School Health Program, Healthy Hearts, and the Jacobi Weight Management program, as well as school-based health coordinators worked with teachers to encourage the students to try the milk, while the Committee developed a toolkit that included classroom lessons and letters to parents. The kit included lesson plans for grades K-3 about milk, recipes for school and home, fitness activities in the classroom, noncandy fundraising ideas, a healthy snack policy template, ideas for healthy vending machine items, and parent resources. Cafeteria posters encouraged students to "Mooove to 1% or Less-Yes!!!!" and "Muuuviendo a 1% o Menos- Si!!"

WINNING SUPPORT FROM THE OFFICE OF SCHOOL FOOD

The original plan was to pilot the program in Region 1 elementary schools only. But the Regional Director of OSFN advised the Committee that the decision to proceed had to be brought to the executive director of the citywide office of OSFN. The citywide office was tentative about proceeding with the pilot. The director was very concerned with students not consuming enough calcium, and the potential loss of student participation in the breakfast and lunch programs.

Meetings with the citywide office of OSFN did not always go smoothly. According to some, the director was protective; after all, he had more than 1,500 schools to consider. Later, the group learned that OSFN was indeed beginning to investigate changing menus, introducing whole grains, eliminating trans fat, and reformulating products, and may have been reluctant to approach the milk issue at this time. Others described him as oppositional-presenting his own plan to introduce sweetened vanilla milk as the new "plain," as well as highly sweetened chocolate and strawberry milk as the only milk options.

All agree, however, that the citywide director attended a Committee meeting in October 2005 and patiently asked every member of the group to state why she or he thought the policy was so essential. Members responded passionately describing both the high incidence of obesity in the community, and their belief that students would not "learn to like" low-fat milk as long as sweetened milks were available. The director then surprised the group by stating that he had decided to implement the Region 1 policy citywide. It was a bold move; one that he knew would involve serious renegotiation of the City's contract with the dairy industry, and could possibly jeopardize federal reimbursement.

The Committee soon learned, however, that the challenges it had faced with OSFN were inconsequential in comparison to the American Dairy Council assault.

THE DAIRY INDUSTRY RESPONDS

The American Dairy Council had been talking to the Office of School Food and Nutrition about the implementation of the policy. Not only did they fear a decline in business from their largest school district, they also feared the ripple effect this policy might have throughout the country.6

The group knew they were having an impact when the Dairy Council sent their representatives from Chicago to community meetings at Bronx elementary schools, and tried to scare parents with the threat of calcium deficiency in their children. They put ads on the local radio stations, focusing on stations with the greatest audience in minority communities, urging parents to sign on to a petition for greater choice. The petition was available at a Web site that purported to be from parents, http://www.MilkChoices.org. A search of domain registration data provider http://www.WhoIs.net performed at the time revealed that the Web site was owned by the International Dairy Foods Association, a dairy lobbyist that represents "a membership of 550 companies [and] a $110-billion a year industry," according to its Web site.7 The MilkChoices site, however, appeared to be grassroots and contained no contact or sponsorship information.

The Dairy Council, in what many described as a disingenuous attempt to appear as allies, asked if there was any way they could be involved in the plan and was offered the opportunity to fund the evaluation that the Bronx District Public Health Office had designed. Instead, in August 2005, the week before school started, the Council presented their own evaluation plan to the OSFN and members of the Region 1 Fitness and Nutrition Committee. The plan was not what the Committee had intended. The industry proposed a design that would offer whole and sweetened milk for the first 3 weeks of school in 20 schools. During the following weeks, whole milk would be eliminated and sweetened milk would be offered on a limited basis. The researcher, Beverage Marketing International, Inc., intended to compare milk consumption in the first 3 weeks to the following 8 weeks. The committee reeled: giving everyone sweetened milk every day and then taking it away would surely confirm what the Dairy Council wanted, not what the Committee wanted, which was to encourage children to choose healthier milks. The Region 1 Health Director had several internal discussions with OSFN to convince them to reject the Dairy Council plan and move ahead with the pilot. She proposed using existing OSFN food consumption data from the previous school year as baseline, and monitoring ongoing consumption to determine the effect of the plan.

Although the Region 1 Fitness and Nutrition Committee members, the BxDPHO, parents, multiple Bronx community-based organizations, and health advocates voiced concerns about the study design and involvement of the American Dairy Association/Dairy Council and Dairy Management Inc., the of School Foods did not immediately end the Dairy Council's involvement as evaluator. The Assistant Commissioner of the Bronx District Public Health Office developed formal recommendations on the subject of sweetened milk.8 She provided the Committee with an analysis demonstrating that small reductions in milk intake would not negatively impact calcium metabolism or bone development, and that the risks associated with obesity were far greater than the risk of calcium deficiency. The recommendations were sent to the Region 1 Fitness and Nutrition Committee with a pointed letter objecting to the Dairy Council's research. On September 6, 2005, in the midst of the debate, The Assistant Commissioner wrote, "...we are fairly confident that the schools that have sweetened milk offered 3 times a week will 'fail' to increase the percentage of low fat/unsweetened milk that is consumed by the students. There is also evidence to suggest that even in the schools where unsweetened milk is offered only once per week, that the consumption of low-fat/unsweetened milk may not go up and may in fact go down, and that participation rates might follow with these trends."

In spite of these concerns, some advocates believed that the OSFN agreed to reject the Dairy Council's evaluation proposal only after seeing that a determined and astute group of community advocates with strong parent support was poised to report the story to The New York Times.

POLITICAL CHALLENGES

The rejection had a significant impact on the Dairy Council's campaign tactics. Soon the advocates learned that the Ickes and Enright Group, a lobby firm with strong political ties now representing the International Dairy Foods Association, had asked a member of the NYC Council's Education Committee, to hold a hearing on the new policy. In fact, the council member sponsored a resolution requesting a formal reevaluation of the milk policy, which was applauded by International Dairy Foods Association.9 During the meeting, Council members criticized both the Department of Health and Mental Hygiene and the Department of Education for having implemented a policy with no community input. This erroneous statement was refuted by identifying the strong parent and community involvement in the School Wellness Councils, and the many letters of support for the policy written by members of the BHR Coalition, which had been actively engaged in educating its members about obesity and about the Dairy Council's role. OSFN also strongly defended its decision to eliminate multiple flavored milk products and whole milk from the breakfast and lunch programs.

A nutritionist representing a group called "Advocates for School Milk Choices-a coalition of local and regional nutritionists, physicians, researchers, and parents,"10 attended the meeting and supported the Dairy Council's position that the policy would place children at risk, implying that kids might get rickets if the policy were implemented. In 2009, this same nutritionist was identified on National Public Radio as having ties to the dairy industry.11

From the Dairy Council's point of view, the effort backfired. Researchers from the Albert Einstein College of Medicine wrote a memo to the Committee regarding concerns about decreased calcium intake that were being used to support the case for offering flavored milk on a daily basis. The primary objection raised was that weight gain caused by sweetened milk, estimated at 30 pounds over the course of a student's school career, was a far greater risk than the potential 10% reduction in calcium intake.

RESULTS

After months of wrangling, the dairy industry gave up the battle to overturn the new policy. The policy was implemented as planned later that Fall, and was rolled out in the different schools from October 2005 through February 2006. In 2009, the City's Department of Health and Mental Hygiene conducted an analysis of the impact of the implementation by comparing annual milk purchases from 2004 through 2009 that was recently published in a CDC Morbidity and Mortality Weekly Report.12 The City found that after 2004 to 2006 there was an 8% decline in milk purchases following the elimination of whole and sweetened milk, but by 2009, purchases had actually increased by 1.3%. The NYC Department of Health and Mental Hygiene calculated that per student per year, almost 5,960 calories and 619 g of fat were eliminated, or more than a pound of weight per child per year.12

Unfortunately, the Dairy Council and its allies have not given up the fight to promote sweetened milk to children, and have recently initiated an aggressive series of marketing measures-from more "kid friendly" packaging to new flavors. Their ads are attractive and ubiquitous, and carry endorsements from a broad range of health-related associations, including the American Academy of Pediatrics, the American Academy of Family Physicians, the American Dietetic Association and the School Nutrition Association, to name just a few.13

By employing scare tactics about the health consequences of a decreased calcium intake in childhood, the dairy industry and its supporters are promoting sweetened milk without considering the potential adverse consequences with respect to overall food preferences. USDA figures show that sales of plain white milk (whole, reduced-fat, and skim) have been dropping since 1945.14 Between 1977 and 2001, caloric intake from sweetened beverages increased 135% at the same time that it decreased 38% for milk.15 Not surprisingly, the flavored milk industry has grown from about $750 million in 1995 to $2 billion in 2004.16

The food and dairy industries know very well that children's preferences influence their parents spending choices, so they invest tremendous resources to conquer their palates. Schools, therefore, should offer only healthy food and beverages without concessions, thus promoting lifelong healthy habits, as interventions directed at children are a key component of a public health obesity prevention strategy.17

CONCLUSION

Subsequent discussions of lessons learned have focused primarily in two areas. First, what was it about this particular campaign that made it effective? And second, what are the ongoing concerns that advocates must remain alert to?

Success is attributed to a confluence of factors:

* Relationships: The members of the groups that participated in this effort have known one another for several years, worked together on a variety of projects and programs, and shared a high degree of trust.

* Mission: Participants shared the same goals, and were invested in success, not individual or even organizational credit.

* Strategy: There was a parallel focus on educating the community, including students, teachers, and parents, while simultaneously influencing policy makers.

* Collaboration: There was recognition that each group had an important role to play, and that sometimes one group could do things that others could not. For example, community advocates could take stands that representatives of city agencies could not, whereas representatives of city agencies like the Board of Education and the Department of Health had an inside track enabling them to influence agency leaders.

* Synergy: The confluence of federal and city policies validated the role of the Wellness Councils, at the same time that both the Department of Education and health advocates were increasingly concerned about child nutrition and the obesity epidemic.

On the contrary, the participants are well aware that the milk battle is just one step among many that must be taken to improve the diets of young people, and that changes in diet are just one step among many lifestyle decisions that must be made to promote health. NYC schools, for example, are so overcrowded that gymnasiums have been turned into class rooms, and physical education classes have no place to meet. And recess? Schoolyards are also filled with temporary structures holding classes.

Further, the participants are mindful of the enormous sums of money available to the American Dairy Council and other members of the food industry to promote their products, compared to the pitiful amounts available to promote public health. According to public records, a lobbying firm was paid roughly $200,000 for their role in the NYC milk campaign.18 The Federal Trade Commission reported that in 2006, 44 food companies spent approximately $1.6 billion to promote food and beverages to children and adolescents (aged 2 to 17 years) in the United States, whereas the overall expenditures for promotional activities directed to all audiences (adults and children) was $9.6 billion.19 Marketing in schools accounted for 11% of the youth marketing expenses, 90% of which was for beverages.

It is frustrating to compare these sums to the constrained budgets public health agencies have to promote wellness. In 2004, the federal campaign to increase consumption of fruits and vegetables to "5-A-Day" had a budget of $4.85 million, whereas California had an additional $4.7 million, bringing the national total to under $10 million, a mere fraction of what the food companies spent.20

But perhaps the most distressing observation is that the industry is co-opting the credibility of community groups by using "faux" grassroots organizations to promote their positions. The Dairy Council launched a Web site posing as concerned parents. Recently, the beverage industry representatives lobbying against the proposed NYC soda tax produced commercials featuring local grocers and bodega owners. How can the community know whom to trust when seeking reliable health information?

In spite of these concerns, the NYC milk policy was a stunning win-one that affects the lives of more than 1 million schoolchildren. It also raised awareness about health and well-being throughout the Department of Education, the community, and the NYC Council. And perhaps most importantly, it sets the stage for subsequent changes in other school districts throughout the country.

The successful implementation of the "1% or Less" campaign in the NYC schools demonstrates the importance of building broad-based networks of concerned individuals and groups. It highlights the fact that a community coalition, with strong, committed and inclusive leadership, like that provided by Bronx Health REACH, the Region 1 Office of School Health, the Montefiore School Health Program and other partners, can create a potent forum for collaboration. Parents, educators, public health professionals and advocates armed with information and expertise can have a powerful impact on policy and must work together to achieve sustainable change.

REFERENCES