7
Schools

Schools are one of the primary locations for reaching the nation’s children and youth. In 2000, 53.2 million students were enrolled in public and private elementary and secondary schools in the United States (U.S. Department of Education, 2002). Many of these schools are also locations for preschool, child-care, and after-school programs in which large numbers of children participate.

The school environment has the potential to affect national obesity prevention efforts both because of the population reach and the amount of time that students spend at school each day. Children obtain about one-third1 of their total daily energy requirement from school lunch (USDA, 2004a), and should expend about 50 percent of their daily energy expenditure while at school, depending on the length of their school day. Given that schools offer numerous and diverse opportunities for young people to learn about energy balance and to make decisions about food and physical activity behaviors, it is critically important that the school environment be structured to promote healthful eating and physical activity behaviors. Further-

1

These estimates are for a school day and do not take into account weekends, holidays, or school vacations. Students who eat breakfast at school could consume approximately 58 percent of their total daily energy requirement at school. This estimate is based on the federal School Breakfast Program’s goal of providing one-fourth of the Recommended Dietary Allowances (RDAs) of certain nutrients through school breakfast and the National School Lunch Program’s goal of providing one-third of the RDAs through school lunches (7CFR210.10; 7CFR220.8; USDA, 2004a).



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Preventing Childhood Obesity: Health in the Balance 7 Schools Schools are one of the primary locations for reaching the nation’s children and youth. In 2000, 53.2 million students were enrolled in public and private elementary and secondary schools in the United States (U.S. Department of Education, 2002). Many of these schools are also locations for preschool, child-care, and after-school programs in which large numbers of children participate. The school environment has the potential to affect national obesity prevention efforts both because of the population reach and the amount of time that students spend at school each day. Children obtain about one-third1 of their total daily energy requirement from school lunch (USDA, 2004a), and should expend about 50 percent of their daily energy expenditure while at school, depending on the length of their school day. Given that schools offer numerous and diverse opportunities for young people to learn about energy balance and to make decisions about food and physical activity behaviors, it is critically important that the school environment be structured to promote healthful eating and physical activity behaviors. Further- 1 These estimates are for a school day and do not take into account weekends, holidays, or school vacations. Students who eat breakfast at school could consume approximately 58 percent of their total daily energy requirement at school. This estimate is based on the federal School Breakfast Program’s goal of providing one-fourth of the Recommended Dietary Allowances (RDAs) of certain nutrients through school breakfast and the National School Lunch Program’s goal of providing one-third of the RDAs through school lunches (7CFR210.10; 7CFR220.8; USDA, 2004a).

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Preventing Childhood Obesity: Health in the Balance more, consistency of the messages and opportunities across the school environment is vital—from the cafeteria, to the playground, to the classroom, to the gymnasium. Increasingly, schools and school districts across the country are implementing innovative programs focused on improving student nutrition and increasing their physical activity levels. Parents, students, teachers, school administrators, and others play important roles in initiating these changes, and it is important to evaluate these efforts to determine whether they should be expanded, refined, or replaced and whether they should be further disseminated. It is acknowledged that the school environment is complex, and schools face many economic and time constraints on their ability to address a broad array of student needs. Further, many food- and physical activity-related policies and practices are linked at multiple levels. A change in one practice may impact other areas of the school environment, either related directly to food or physical activity or indirectly to other areas (such as academic, extracurricular, financial, or administrative). The recommended actions, described below, therefore, were developed with the goal of being implemented concurrently and not as stand-alone strategies. Moreover, these actions should reinforce and support each other not only in the schools but in other settings, including the community and home environments (Chapters 6 and 8). Recommendations regarding schools also must acknowledge the diverse ways in which public schools are governed and funded throughout the United States. Although public school governance is primarily local (school boards that oversee school districts), there is variability in the additional role that states play (NRC, 1999). The recommended actions in this chapter are intended to apply, as relevant, to all the settings where children and youth spend a majority of their organized time outside the home. For most children and youth over the age of 5 years, this will be a school setting (i.e., elementary school, middle school, or high school). For children below the age of 5 years, this may be kindergarten, formal preschool, early childhood education program, child development center, child-care center, or family or other informal child-care setting. FOOD AND BEVERAGES IN SCHOOLS The school food environment has undergone a rapid transition from a fairly simple to a highly complex environment, particularly in high schools. Traditionally, school cafeterias offered only the U.S. Department of Agriculture (USDA) federally subsidized school meal, which is required to meet defined nutritional standards. Recently there have been increases, however, in the amount of “à la carte” foods and beverages—items offered individu-

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Preventing Childhood Obesity: Health in the Balance ally and not as part of a school meal—sold in or near the school cafeteria in tandem with the federally reimbursed school meal. Individual foods and beverages are also sold or served in vending machines, at school stores, or at school fundraisers. Foods and Beverages Sold in Schools Federal School Meal Programs The National School Lunch Program (NSLP) was established in 1946 to “safeguard the health and well-being of the Nation’s children and to encourage the domestic consumption of nutritious agricultural commodities and other food” (7CFR210.1). Each school day approximately 28 million school-aged children participate in the NSLP and some 8 million participate in the School Breakfast Program (SBP) (USDA, 2003). Nutrition guidelines for the school meal programs have been revised periodically to maintain consistency with changes in nutritional recommendations. Current regulations for the programs require that the meals be consistent with the Dietary Guidelines for Americans and adhere to the RDAs for energy, protein, calcium, iron, vitamin A, and vitamin C. These guidelines are described in Box 7-1. Several food-based menu-planning approaches are used in the NSLP to ensure that lunches and breakfasts are nutritionally balanced. The majority of schools use the “traditional” food-based menu-planning system, which BOX 7-1 USDA Requirements for School Meal Programs Meet the applicable recommendations of the Dietary Guidelines for Americans, which recommend that no more than 30 percent of an individual’s calories come from fat, and that less than 10 percent from saturated fat. Provide one-third of the RDAs of protein, vitamin A, vitamin C, iron, and calcium through school lunches and provide one-fourth of the RDA requirements through school breakfasts. “Foods of minimal nutritional value” (FMNV) as defined by federal regulations, cannot be sold in food service areas during the school meal periods. The four categories of foods defined as FMNV are soda water, water ices, chewing gum, and certain candies (including hard candy, jellies and gums, marshmallow candies, fondant, licorice, and spun candy). SOURCES: 7CFR210.10; 7CFR220.8; 7CFR Appendix B to Part 210.

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Preventing Childhood Obesity: Health in the Balance requires school lunches to offer five food items selected from four food types: fluid milk; meat or meat alternative; at least one serving of bread or grain products; and two or more servings of fruit, vegetables, or both. A second approach is the “nutrient-based” menu-planning approach used by about one-fourth of schools (USDA, 2004c). School food authorities prepare a nutrient analysis of meals for a one-week period to determine whether these meals meet the nutritional requirements outlined by the dietary guidelines (USDA, 2004b). Schools that use this approach must serve milk and offer at least one entrée and one side dish per meal. Requirements for fruit and vegetable servings are not specified under the current guidelines (USDA, 2004b), and it should be noted that high-calorie, energy-dense items (e.g., cookies, cake, and batter-fried foods) can be served to students as part of their school meals. The target goals for the NSLP and SBP are that no more than 30 percent of calories should come from fat and less than 10 percent of calories from saturated fat (USDA, 2004b). Because milk with high saturated fat content has been a particular concern regarding the students’ dietary intake, schools were required to offer both whole and low-fat milk (currently defined as having 1 percent fat content or less) beginning in 1994 (USDA, 2004b). In response to research in the early 1990s indicating that school meals were generally not meeting key nutritional goals, USDA launched the School Meals Initiative for Healthy Children in 1995, which provides schools with educational and technical resources for meal planning and preparation (USDA, 2001b). According to data from the second School Nutrition Dietary Assessment Study (SNDAS-II), a nationally representative study of the NSLP and SBP conducted in the 1998-1999 school year, lunches in elementary schools provided an average of 33 percent of calories from fat (target goal is 30 percent or less) and 12 percent of calories from saturated fat (target goal is less than 10 percent). The average lunch in secondary schools provided about 35 percent of calories from fat and 12 percent of calories from saturated fat, also failing to meet the targets (USDA, 2001b). However, compared with the first SNDAS survey in the 1991-1992 school year, there were significant increases in the percentages of schools that served meals consistent with the Dietary Guidelines regarding fat and saturated fat content. In the second survey, approximately two-thirds of NSLP menus offered two fruit and vegetable choices, and more than 25 percent included five or more fruit and vegetable choices (USDA, 2001b). All students are eligible to take advantage of the NSLP and SBP. The 1998-1999 SNDAS-II survey found that approximately 60 percent of students at participating schools did so, either through full-price or reducedcost purchase or by being eligible to receive free meals. Participation was highest in elementary schools (67 percent) and lowest in high schools (39

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Preventing Childhood Obesity: Health in the Balance percent) (USDA, 2001b). Participation was highest among students approved to receive free meals (80 percent) as compared with students receiving reduced-price meals (69 percent) or students paying full price (48 percent). Only a few studies have compared dietary quality of NSLP participants and nonparticipants. Cullen and colleagues (2000) found that fifth-grade students who selected only the NSLP meal reported consuming up to twice as many servings of fruit, juice, and vegetables than students who ate from the snack bar or brought their lunch from home. In a two-year follow-up study, diets of students as fourth-graders (when they had access to NSLP lunches only) were compared with their diets during the subsequent year, when as fifth-graders they had access to the snack bar in middle school (Cullen and Zakeri, 2004). During that second year the students consumed fewer fruits, fewer nonfried vegetables, less milk, and more sweetened beverages. Competitive Foods The term “competitive foods” is used to describe all foods and beverages served or sold in schools that are not part of the federal school meal programs. This includes “à la carte” foods and beverages offered by the school food service; items sold from vending machines located inside or outside the school cafeteria; foods and beverages sold anywhere in the school as part of fundraising efforts by student, faculty, or parent groups; items served in the classroom for snacks and rewards; and foods and beverages made available during after-school activities. As discussed below, competitive foods from these various sources are typically lower in nutritional quality than those offered as part of the school meal programs. Current federal nutritional guidelines for competitive foods are limited. Foods of “minimal nutritional value”—narrowly defined primarily as soft drinks and certain types of candy (Box 7-1) (7 CFR Appendix B to Part 210)—are prohibited from sale in the school cafeteria while meals are being served. However, no other national standards currently exist to screen competitive foods for nutritional quality within the school setting. Thus items of low nutrient density or high energy density, including cookies, candy bars, potato chips, and other salty or high-fat snack foods, are often allowed for sale in direct competition with the school meals. Furthermore, federal guidelines do not prohibit foods of minimal nutritional value from being sold in vending machines near the cafeteria or at other school locations. States and school districts, however, may implement their own more-restrictive policies regarding competitive foods, and many states have passed legislation that limits the types of foods allowed for sale in the schools and

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Preventing Childhood Obesity: Health in the Balance the hours during which they are available. A recent report by the General Accounting Office (GAO) found that 21 states had policies that restrict competitive foods beyond USDA regulations (GAO, 2004). For example, California has mandated guidelines for foods and beverages offered in schools. This 2001 legislation includes a provision for funding pilot programs that would, among other things, require fruits and vegetables to be offered for sale in any school location where food or beverages are sold. Additionally, the board of the Los Angeles Unified School District in 2001 voted to implement standards for beverages, which led to a ban on the sale of carbonated beverages on all school campuses (Los Angeles Unified School District, 2004). West Virginia prohibits schools from serving or selling candy bars, foods, or drinks consisting of 40 percent or more added sugar or other sweeteners; juice or juice products containing less than 20 percent real juice; and foods with more than 8 grams of fat per 1-ounce serving. In addition, all soft drinks are prohibited in West Virginia elementary and middle schools (Stuhldreher et al., 1998; Wechsler et al., 2000). Local schools and school districts are also implementing their own restrictions on competitive foods (GAO, 2004). The issues surrounding competitive foods are currently being discussed in many other states and school districts. Specific policies and nutritional standards are still needed, however, in most school districts. Data from the 2000 School Health Policies and Programs Study (SHPPS) found that only about 40 percent of school districts, but almost no state governments, required schools to offer a choice of two or more fruits or two or more vegetables at lunch time (Wechsler et al., 2001). With the exception of California, the 2000 SHPPS found that no states require schools to offer fruits and vegetables in school stores, snack bars, or vending machines. At the district level, 3.7 percent of school districts require fruits and vegetables to be available in school stores and snack bars, and 1.7 percent require fruits and vegetables to be available in vending machines (Wechsler et al., 2001). A recent statewide survey of Minnesota secondary school principals found that only 32 percent of their schools had policies of any kind about nutrition and food and that 18 percent had policies regarding items sold from school vending machines (French et al., 2002). Seventy-seven percent of these school principals reported having vending machine contracts with soft drink companies. Competitive foods represent a significant share of the foods that students purchase and consume at school, particularly in high schools (Wechsler et al., 2001). National survey data from the 2000 SHPPS show that competitive foods are widely available in many elementary schools, most middle schools, and almost all secondary schools (Wechsler et al., 2001). In 2000, food and beverage items were sold to students from vending machines, school stores, or snack bars in 98 percent of secondary schools, 74 percent of middle schools, and 43 percent of elementary schools.

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Preventing Childhood Obesity: Health in the Balance Data from a recent study of 20 high schools in Minnesota found a median of 11 vending machines in each school—typically four soft drink machines, five machines dispensing other beverages (e.g., fruit juice, sports drinks, or water), and two snack machines (French et al., 2003). Available data show that competitive foods are often high in energy density (often high fat or high sugar) and low in nutrient density (Story et al., 1996; Harnack et al., 2000; Wechsler et al., 2001; Zive et al., 2002; French et al., 2003). National data from the SHPPS survey show that 80 percent of the à la carte areas in high schools sell high-fat cookies and baked goods, and 24 percent sell chocolate candy (Wechsler et al., 2001). Although fruits and vegetables are generally available—they are sold in the à la carte areas of 68 percent of elementary schools, 74 percent of middle schools, and 90 percent of secondary schools—energy-dense foods tend to comprise the majority of competitive foods offered for sale. For example, at the 20 Minnesota high schools noted above, chips, cookies, pastry, candy, and ice cream accounted for 51.1 percent of all à la carte foods offered, while fruits and vegetables were at 4.5 percent, and salads 0.2 percent (French et al., 2003). Because students’ food choices are influenced by the total food environment, the simple availability of healthful foods such as fruits and vegetables may not be sufficient to prompt the choice of these targeted items when other food items of high palatability (often high-fat or high-sugar items) are easily accessible, especially those that are heavily marketed to children and youth. Data from two recent studies conducted in middle schools provide empirical evidence for this hypothesis (Cullen et al., 2000; Kubik et al., 2003). Fruit and vegetable intake was lower among students at schools where à la carte foods were available, in comparison with schools where à la carte foods were not available. Not surprisingly, when given the choice many students select the higher fat and higher sugar items. However, data from a recent randomized trial involving 20 high schools indicate that offering a wider range of healthful foods can be an effective way to promote better food choices among high school students (French et al., 2004). In combination with student-led schoolwide promotions, increases in the availability of healthier à la carte foods led to significant increases in sales of the targeted foods to students over a 2-year period. Taken together, such findings suggest that restricting the availability of high-calorie, energy-dense foods in schools while increasing the availability of healthful foods might be an effective strategy for promoting more healthful food choices among students in schools. The present reality, however, falls short of this situation. The rapid growth in the availability and marketing of à la carte foods and beverages, of soft drinks and other high-sugar beverages in school vending machines, and of other sources of competitive foods throughout the school environ-

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Preventing Childhood Obesity: Health in the Balance ment has become an important issue. Bearing significantly as it does on student nutrition and obesity prevention efforts, this issue urgently needs attention from leaders at national, state, and local levels. New policies are needed, both to ensure that the foods available at schools are consistent with current nutritional guidelines and to support the goal of preventing excess energy intake among students and helping students achieve energy balance at a healthy weight. School-Based Dietary Intervention Studies School-based interventions to improve food choices and dietary quality among students have been designed primarily as multifaceted interventions that include one or more of the following components: Changes in food service and the food environment (e.g., food availability, preparation methods, price) Promotional activities (cafeteria-based or schoolwide) Classroom curricula on nutrition education and behavioral skills Parental involvement (e.g., informational newsletters or parentchild home activities). Most often these interventions have targeted total fat, saturated fat, or fruit and vegetable intake. In addition, they may have addressed other weight-related behaviors such as physical activity or television viewing (reviewed later in this chapter). This section focuses on the large-scale controlled intervention studies that have examined weight status or body mass index (BMI) changes as an outcome measure. A much larger literature exists on school-based interventions to change the dietary behaviors of students, including the 5-A-Day and Know Your Body studies (Walter et al., 1985; Hearn et al., 1998). Evaluation of the literature on such interventions is complicated because of their variety and the multicomponent nature of their designs, making comparisons of results difficult. In addition, differences exist across studies in the number and types of food-related behaviors and age groups targeted. Studies based in elementary, middle, and high schools differ not only in the developmental stage of the students, but in the corresponding physical and social environments, which contrast dramatically, for example, in the availability of à la carte foods, fast foods, snack bars, and vending machines. High school students are also more likely than elementary or middle school students to leave campus during the lunch period. These variables may moderate the effects of interventions designed to influence food choices in the school setting.

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Preventing Childhood Obesity: Health in the Balance The Child and Adolescent Trial for Cardiovascular Health (CATCH), the largest and most comprehensive school-based intervention yet undertaken, targeted diet and physical activity behaviors as secondary outcome variables (Box 7-2). This randomized trial involving 96 elementary schools did not result in significant changes in body weight; however, significant changes did occur in the school food environment and in reported dietary intakes by students (Luepker et al., 1996). Compared to control schools, the fat content of meals at the intervention school meals was substantially lowered, and intervention students’ reported dietary fat intake was significantly reduced relative to that of control students. Also, as noted below in the discussion on physical activity, the percentage of physical education classroom time with moderate to vigorous physical activity increased in the intervention schools. The researchers speculated that the reasons for the lack of changes in physiologic risk factors may be related to the growth and development stage of the students or to the relatively low magnitude of the changes in food intake and physical activity levels (Luepker et al., 1996). Pathways, a large, multicomponent school-based intervention designed as an obesity prevention study, was conducted among third- to fifth-grade American-Indian children in reservation schools over a 3-year period (Caballero et al., 1998). Pathways did not significantly affect body-weight change, but significant intervention-related changes were observed for some dietary and physical activity behaviors, including lower fat intake and higher self-reported physical activity levels in the students in the intervention schools (Caballero et al., 2003). The goal of the food service intervention—to reduce the fat content of the school meals—was achieved. Both the CATCH and Pathways interventions show the feasibility of making positive changes in the school food environment, but also the challenges still to be faced in designing primary obesity prevention interventions in schools. As pointed out by the researchers in the Pathways study, restriction of energy intake is not an option in schools because there are students who are below the fifth BMI percentile, additionally, the school meals programs have to meet minimum mandatory levels for calorie content (Caballero et al., 2003). Several other school-based intervention studies have shown significant effects on body-weight outcomes; these studies tested multicomponent interventions not limited only to targeting dietary change. Planet Health reported reductions in the prevalence of obesity among girls only (Gortmaker et al., 1999), and the Stanford Adolescent Heart Health Program observed reductions in BMI, triceps skinfold thickness, and subscapular skinfold thickness among boys and girls (Killen et al., 1988). Overall, school-based interventions, both multicomponent and single component, have produced healthful food choices among students. Envi-

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Preventing Childhood Obesity: Health in the Balance BOX 7-2 Selected School-Based Interventions Child and Adolescent Trial for Cardiovascular Health (CATCH)—Designed as a health behavior intervention for the primary prevention of cardiovascular disease, CATCH was evaluated in a randomized field trial in 96 elementary schools in California, Louisiana, Minnesota, and Texas (Luepker et al., 1996).CATCH schools received school food service modifications and food service personnel training, physical education (PE) interventions and teacher training, and classroom curricula that addressed eating behaviors, physical activity, and smoking (Luepker et al., 1996). The primary individual outcome examined was change in serum cholesterol concentration; school-based outcomes were also examined. Pathways—Designed to reduce obesity in American-Indian children in grades three through five, a randomized trial was conducted in 41 schools serving American-Indian communities in Arizona, New Mexico, and South Dakota (Caballero et al., 1998; Davis et al., 1999). This multicomponent program involved incorporation of high-energy activities in PE classes and recess; food service training and nutritional educational materials; classroom curricula enhancements; and family efforts including family fun nights, take-home action- and snack-packs, and family advisory councils. The primary outcome measure was the mean difference between intervention and control schools in percentage of body fat at the end of the fifth grade. Planet Health—A curriculum-based health intervention, Planet Health lessons were integrated into the math, language arts, social studies, science, and PE curricula of grades six through eight. The lessons focus on teaching better dietary ronmental interventions, which target reduced consumption of high-fat foods and greater intake of fruits and vegetables through variations in availability, pricing, and promotion in the school environment (Whitaker et al., 1993, 1994; Luepker et al., 1996; Caballero et al., 1998; Perry et al., 1998, 2004; Reynolds et al., 2000; French et al., 2001, 2004; French and Stables, 2003) may have a particularly significant independent effect on food choices (French et al., 2001; French and Stables, 2003). But their impacts are perhaps smaller in magnitude than when deployed as part of a multicomponent intervention program (Perry et al., 1998, 2004; French et al., 2001; French and Stables, 2003). Because classroom education/behavioral skills curricula, for example, have typically been embedded in a multicomponent program, the effectiveness of this intervention component is difficult to evaluate as an isolated strategy. Furthermore, caution is needed in interpreting studies of self-reports of dietary intakes, which may be subject to reporting errors and bias.

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Preventing Childhood Obesity: Health in the Balance habits, promoting physical activity, and reducing television viewing (Gortmaker et al., 1999). Evaluation of the intervention involved comparing obesity prevalence and behavioral changes among students in five intervention and five control schools in the Boston area. Sports, Play and Active Recreation for Kids (SPARK)—A school-based intervention designed to improve the quantity and quality of physical education, the evaluation involved seven elementary schools in southern California in a 3-year study (McKenzie et al., 1997). The SPARK program involves enhancements to the PE curriculum, implementation of a self-management curriculum, and teacher inservice training programs. Outcomes assessed included changes in student BMI and physical activity levels. Stanford Adolescent Heart Health Program—Designed to reduce cardiovascular disease risk factors in high school students, the intervention consisted of 20 50-minute classroom sessions on physical activity, nutrition, smoking, and stress (Killen et al., 1988). The evaluation of the intervention compared the results of 10th-grade students in four high schools in northern California on behavioral changes and physiological variables including BMI. Stanford S.M.A.R.T. (Student Media Awareness to Reduce Television)—Designed to motivate children to reduce their television watching and video game usage, the intervention was evaluated in two elementary schools in California (Robinson, 1999). Students in the intervention third- and fourth-grade classrooms participated in an 18-lesson, six-month curriculum and families could use an electronic television time manager. The primary outcome measure was BMI; other physiologic variables and behavioral changes were also assessed. Recent and Ongoing Pilot Program Several pilot programs have been developed at the school, district, state, and federal levels to explore strategies to increase fruit and vegetable consumption among students in school. The committee is not aware of any published outcome evaluation of these studies but the programs are described here to illustrate current approaches that may warrant continued funding and more systematic analysis. The most recent and perhaps largest effort to increase the availability and consumption of fresh fruits and vegetables was implemented by USDA during the 2002-2003 school year (Buzby et al., 2003). One hundred schools in four states (Indiana, Iowa, Michigan, and Ohio) and seven schools in New Mexico’s Zuni Indian Tribal Organization participated in the pilot program, which distributed fruit and vegetables free to participating schools. Schools could choose when and how to distribute the produce to students. The program requested, however, that the fruits and vegetables be made available to students outside the regular school meal periods. Due to limited funding, no

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Preventing Childhood Obesity: Health in the Balance opportunity to design these schools with facilities that can best accommodate after-school or community center programs. As these programs are pursued, it is critical that the effects of changes in after-school programs and other after-school uses of school facilities (e.g., in the form of community centers) be evaluated. Innovations to encourage children and youth to participate in physical activities and learn about nutrition are particularly encouraged, because they have the potential to help prevent childhood overweight and obesity. Pilot results for after-school obesity prevention programs in low-income African-American communities are already showing promise in this regard (Beech et al., 2003; Robinson et al., 2003), though further research and evaluation is needed. EVALUATION OF SCHOOL PROGRAMS AND POLICIES In most if not all states, schools are mandated to perform periodic academic testing to compare student performance against established standards. The committee recommends extending these assessments to include parameters related to healthful eating, physical activity, and other factors related to the risk for obesity. Recognizing that the school environment is one of the many influences on a child’s dietary intake or energy expenditure, it is important to develop effective school-based programs. Thus, schools, school districts, state boards of education, and regional and national institutions have already begun to promote and implement innovative approaches for addressing the rising rates of obesity in children and youth and for promoting their health and fitness. Although these programs can be costly in terms of finances, personnel, and other resources, they have the potential to enhance the educational process. Without systematic and widespread assessments of obesity-related behaviors and physical activity measures, however, there will be no way to identify which of the many possible strategies are potentially effective, much less the most cost-effective. Specific cause-and-effect inferences will not always be possible, but the availability of pertinent local data will enable schools, parents, school districts, states, policy makers, and researchers to identify some of the more promising approaches for further testing and development. Many schools now use the School Health Index developed by CDC as a school self-assessment tool (CDC, 2004a). This measure incorporates physical and nutritional education components into evaluations as well as assesses other areas, particularly school health, counseling, health policies, health promotion, and family and community involvement. The committee encourages schools to use the School Health Index or similar school-specific

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Preventing Childhood Obesity: Health in the Balance assessments to identify areas to improve the school’s health and safety promotion policies and practices. In addition, some schools may want to assess more direct measures (such as students’ gender- and age-specific BMI percentile, physical fitness, and dietary intake) to help determine whether or not the school’s policy and programming changes are reducing the levels of overweight and obesity. Commitment to performing these evaluations will require legislators and other policy makers to allocate sufficient funding, employ professional staffing, and develop statewide mechanisms for reporting these assessments’ results to the public. State and local education authorities should perform periodic assessments of each school’s policies and practices related to nutrition and physical activity. These assessments should address curriculum, instructional methods, school environment, extracurricular programming, and relationships with the community. Other components that could be considered based on the needs of the schools are assessments of physical activity, physical fitness, dietary intake, and BMI percentile distribution of a representative sample of students. Results of school evaluations should be reported periodically to the public. If data are collected on a representative sample of students, the results should be publicly reported only in the aggregate. Research is needed to determine optimum ways to assess the impacts of school programs, policies, and environments on obesity prevention. Research is also needed to explore program adaptations that may be needed to accommodate schools with high levels of cultural diversity. Potential hurdles in implementing these actions will need to be addressed. In particular, if schools and school districts are to develop valid and easy-to-use assessment measures and protocols, provide sufficient staff training to ensure reliable data collection, and then implement and report the results of these assessments, they will need sufficient funding. If schools were to meet the School Health Index standards under current economic conditions, there would likely be increased financial burden on most school systems. The committee acknowledges that there is limited published information on schools that have implemented this type of schoolwide evaluation. However, based on the public attention paid to standardized academic testing by parents, teachers, administrators, and policy makers, it is the belief of the committee that assessment and public reporting of health-related outcomes will prove to be an incentive for schools to innovate and adopt more effective health promotion curricula, improved food-service options, and other health and fitness programming (e.g., after-school activities, family-oriented physical activities).

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Preventing Childhood Obesity: Health in the Balance RECOMMENDATION Schools offer the opportunity for reaching large numbers of young people, during a significant part of their day, and throughout much of the year. Furthermore, schools present opportunities, both in and out of the classroom, for the concepts of energy balance to be taught and put into practice. As discussed throughout the chapter, several large-scale, well-designed school-based intervention studies have shown that multicomponent changes in the school environment can improve the food and beverage selections by students, the nutritional quality of foods offered, and the duration and extent of students’ physical activity while at school. Schools should not only provide educational messages about nutrition, physical activity, and reducing sedentary behaviors, but should reinforce and support these concepts throughout the school environment. Changes that can make the school environment more supportive of healthful eating and physical activity behaviors begin with the development of nutritional standards for all food and beverage items sold in the schools and improvements in the federal school meal programs. Furthermore, opportunities for physical activity need to be expanded through ensuring daily PE, as well as increasing the options for both competitive and noncompetitive sports and activities, enhancement of after-school programs, and the opening of school facilities for use during other nonschool hours. It is also important to develop and implement curricula that will encourage students to move beyond an awareness of energy balance to the routine incorporation of good nutrition and physical activity into their daily lives. There are numerous innovative programs and changes relevant to obesity prevention that are being implemented in schools throughout the country, and it is important to adequately evaluate these efforts to determine whether they should be continued, expanded, or refined. Furthermore, preschools and child-care centers should be included in these efforts. The goal is for schools to implement evidence-based programs and approaches that promote healthful physical activity and nutrition behaviors for all components of school interventions, including health education, physical education, after-school programs, and walk-/bike-to-school programs. Adequate training and support for teachers, food-service personnel, and other leaders will be needed, along with adequate supplies and equipment. Federal and state agencies need to provide the resources for research and evaluation of school programs and interventions and work to disseminate those that are found to be effective in improving physical activity and nutrition behaviors. Next steps for making progress on this issue will involve discussions of the relevant stakeholders in schools, communities, regions, and states so

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Preventing Childhood Obesity: Health in the Balance that action plans can be tailored to best address the issues and high-risk populations in the area. Recommendation 9: Schools Schools should provide a consistent environment that is conducive to healthful eating behaviors and regular physical activity. To implement this recommendation: USDA, state, and local authorities, and schools should: Develop and implement nutritional standards for all competitive foods and beverages sold or served in schools Ensure that all school meals meet the Dietary Guidelines for Americans Develop, implement, and evaluate pilot programs to extend school meal funding in schools with a large percentage of children at high risk of obesity State and local education authorities and schools should: Ensure that all children and youth participate in a minimum of 30 minutes of moderate to vigorous physical activity during the school day Expand opportunities for physical activity through physical education classes; intramural and interscholastic sports programs and other physical activity clubs, programs, and lessons; after-school use of school facilities; use of schools as community centers; and walking- and biking-to-school programs Enhance health curricula to devote adequate attention to nutrition, physical activity, reducing sedentary behaviors, and energy balance, and to include a behavioral skills focus Develop, implement, and enforce school policies to create schools that are advertising-free to the greatest possible extent Involve school health services in obesity prevention efforts Conduct annual assessments of each student’s weight, height, and gender- and age-specific BMI percentile and make this information available to parents Perform periodic assessments of each school’s policies and practices related to nutrition, physical activity, and obesity prevention

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Preventing Childhood Obesity: Health in the Balance Federal and state departments of education and health and professional organizations should: Develop, implement, and evaluate pilot programs to explore innovative approaches to both staffing and teaching about wellness, healthful choices, nutrition, physical activity, and reducing sedentary behaviors. Innovative approaches to recruiting and training appropriate teachers are also needed REFERENCES AAP (American Academy of Pediatrics), Committee on Sports Medicine and Fitness and Committee on School Health. 2000. Physical fitness and activity in schools. Pediatrics 105(5):1156-1157. ACHI (Arkansas Center for Health Improvement). 2004. BMI Initiative. [Online]. Available: http://www.achi.net/BMI_Stuff/bmi.asp [accessed June 10, 2004]. Bachen CM. 1998. Channel One and the education of American youths. Ann Am Acad Pol Soc Sci 557:132-147. Bandura A. 1986. Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice-Hall Series in Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall. Beech BM, Klesges RC, Kumanyika SK, Murray DM, Klesges L, McClanahan B, Slawson D, Nunnally C, Rochon J, McLain-Allen B, Pree-Cary J. 2003. Child- and parent-targeted interventions: The Memphis GEMS pilot study. Ethn Dis 13(1):S40-S53. Bhandari S, Gifford E. 2003. Children with Health Insurance: 2001. Current Population Reports P60-224. Washington, DC: U.S. Census Bureau. Biddle S, Sallis JF, Cavill N. 1998. Young and Active? Young People and Health Enhancing Physical Activity. Evidence and Implication. London: Health Education Authority. Brener ND, Burstein GR, DuShaw ML, Vernon ME, Wheeler L, Robinson J. 2001. Health services: Results from the School Health Policies and Programs Study 2000. J Sch Health 71(1):294-304. Burgeson CR, Wechsler H, Brener ND, Young JC, Spain CG. 2001. Physical education and activity: Results from the School Health Policies and Programs Study 2000. J Sch Health 71(7):279-293. Buzby J, Guthrie JF, Kantor LS. 2003. Evaluation of the USDA’s Fruit and Vegetable Pilot Program: Report to Congress. Washington, DC: USDA. [Online]. Available: http://www.ers.usda.gov/publications/efan03006/ [accessed March 15, 2004]. Caballero B, Davis S, Davis CE, Ethelbah B, Evans M, Lohman T, Stephenson L, Story M, White J. 1998. Pathways: A school-based program for the primary prevention of obesity in American Indian children. J Nutr Biochem 9(9):535-543. Caballero B, Clay T, Davis SM, Ethelbah B, Rock BH, Lohman T, Norman J, Story M, Stone EJ, Stephenson L, Stevens J, Pathways Study Research Group. 2003. Pathways: A school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. Am J Clin Nutr 78(5):1030-1038. Cavill N, Biddle S, Sallis JF. 2001. Health enhancing physical activity for young people: Statement of the United Kingdom Expert Consensus Conference. Pediatr Exer Sci 13:12-25. CDC (Centers for Disease Control and Prevention). 1997. Guidelines for school and community programs to promote lifelong physical activity among young people. MMWR Recomm Rep 46(RR-6):1-36.

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