7
Schools

Childhood obesity prevention efforts have primarily focused on the school environment because nearly all children, ages 5 years and older, spend a large part of their days in school for 9 to 10 months out of the year. Schools are an important setting to enhance students’ dietary intake and physical activity opportunities and to provide relevant education and behavioral change programs. Policies and programs have the potential to influence the behaviors of all the students in a classroom, school, or school district. However, because the nation’s estimated 66,000 public elementary schools, 12,000 middle schools, and 14,000 high schools are often governed at the local school board, town, or district level, it is difficult to systematically evaluate prevention strategies or to disseminate promising strategies, policies, and programs (NCES, 2005). Further, more attention needs to be paid to the provision of low-calorie and high-nutrient foods and beverages that contribute to a healthful diet and opportunities for physical activity in the child-care, after-school, and preschool environments regarding the.

The Health in the Balance report provided a range of recommendations for schools (Box 7-1) with the goals of creating and maintaining a consistent environment that supports healthful eating behaviors and regular physical activity. The report also emphasized the need to help students understand the benefits of healthy lifestyles and the relationship between calorie intake and energy expenditure to achieve energy balance at a healthy weight (IOM, 2005).



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Progress in Preventing Childhood Obesity: How Do We Measure Up? 7 Schools Childhood obesity prevention efforts have primarily focused on the school environment because nearly all children, ages 5 years and older, spend a large part of their days in school for 9 to 10 months out of the year. Schools are an important setting to enhance students’ dietary intake and physical activity opportunities and to provide relevant education and behavioral change programs. Policies and programs have the potential to influence the behaviors of all the students in a classroom, school, or school district. However, because the nation’s estimated 66,000 public elementary schools, 12,000 middle schools, and 14,000 high schools are often governed at the local school board, town, or district level, it is difficult to systematically evaluate prevention strategies or to disseminate promising strategies, policies, and programs (NCES, 2005). Further, more attention needs to be paid to the provision of low-calorie and high-nutrient foods and beverages that contribute to a healthful diet and opportunities for physical activity in the child-care, after-school, and preschool environments regarding the. The Health in the Balance report provided a range of recommendations for schools (Box 7-1) with the goals of creating and maintaining a consistent environment that supports healthful eating behaviors and regular physical activity. The report also emphasized the need to help students understand the benefits of healthy lifestyles and the relationship between calorie intake and energy expenditure to achieve energy balance at a healthy weight (IOM, 2005).

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Progress in Preventing Childhood Obesity: How Do We Measure Up? BOX 7-1 Recommendations for Schools from the 2005 IOM report Preventing Childhood Obesity: Health in the Balance 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. 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. SOURCE: IOM (2005). In June 2005, the committee sponsored the symposium Progress in Preventing Childhood Obesity: Focus on Schools in collaboration with the Kansas Health Foundation and sponsored by the Robert Wood Johnson Foundation (Appendix F). The symposium was held in Wichita, Kansas and provided the committee with the opportunity to interact with a range of

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Progress in Preventing Childhood Obesity: How Do We Measure Up? stakeholders—teachers, students, principals, health educators, dietitians, after-school personnel, food service providers, industry representatives, state government and community leaders, and researchers—and learn about innovative interventions, challenges in implementing and evaluating school-based and after-school programs, and opportunities for evaluating policies and initiatives. In addition to the symposium, the committee draws from reports, scientific literature, and the media to provide examples of obesity prevention activities in schools for this chapter. The obesity prevention effort in schools is an active area for change, and the committee recognizes that it can capture only a small proportion of the obesity prevention-, physical activity-, and nutrition-related policies and programs being implemented. This chapter focuses on assessing progress and ensuring that evaluations are conducted so that the most promising approaches can be identified and disseminated. As noted in the Health in the Balance report (IOM, 2005), there is a relative paucity of scientific data on obesity prevention efforts in schools. Teachers, schools, school districts, states, and the nation are in the midst of many exploratory efforts and new interventions, which provide opportunities to build the evidence base in order for promising efforts to be replicated and scaled up. Additionally, it is important that efforts found to be ineffective are either revised or discontinued, so they do not use resources that can be more effectively used for other efforts. The multitude of actions revolving around nutrition and physical education in schools is a positive step forward. However, as detailed in a recent report examining state and regional obesity prevention-related policies, much remains to be done to provide a consistent healthy school environment that promotes energy balance for children and youth (TFAH, 2005). Although many states are addressing nutrition-related issues, these efforts are not being implemented in all states, and limited attention is focused on concurrently increasing physical activity levels and reducing sedentary behaviors. Highlights from the 2005 Trust for America’s Health (TFAH) report indicate that, as of the time of publication of the report: Six states (Arkansas, Kentucky, South Carolina, South Dakota, Tennessee, and Texas) have mandated nutritional standards for school meals and snacks that are stricter than current USDA requirements. Eleven states (Arizona, California, Hawaii, Kentucky, Maryland, New Mexico, Oklahoma, South Carolina, Tennessee, Texas, and West Virginia) have established nutritional standards for competitive foods sold in schools. Many of these changes had occurred recently with six states setting requirements for competitive foods since 2004. All states except South Dakota have physical education require-

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Progress in Preventing Childhood Obesity: How Do We Measure Up? ments for students; however Illinois is the only state that requires physical education for every grade in schools on a daily basis. Four states (Arkansas, Illinois, Tennessee, and West Virginia) have passed legislation that allows schools to measure students’ body mass index (BMI) levels as part of health examinations or physical education activities. OPPORTUNITIES AND CHALLENGES One of the greatest challenges for school-based obesity prevention efforts may also be an opportunity to rapidly advance progress. As noted above, because schools are primarily controlled and administered at the local level, there are challenges in disseminating effective prevention interventions and for schools to learn about what has been effective or ineffective in other schools or school districts. However, this same lack of coordination between educational institutions may also provide the opportunity for a broad array of highly innovative approaches to emerge or for similar approaches to be implemented within many different settings. If evaluation efforts can be applied to these various approaches, there is an opportunity to rapidly expand the evidence base. In the absence of evaluation, this multiplication of efforts and approaches has less opportunity to support effective policies, programs, and initiatives or ensure the efficient use of resources. Time and financial resources were two key barriers to the implementation of obesity prevention interventions identified by teachers and school administrators at the committee’s regional symposium (Appendix F). The school year and school day are finite, and teachers report competing demands on their time. In particular, the school day is filled with nationally and state-mandated academic subjects, and there has been an increased emphasis in recent years on teaching to meet academic testing requirements. Teachers and school officials also reported that the effort to comply with the academic requirements set forth in the No Child Left Behind Act that was signed into law in 2002 (DoEd, 2006a) and similar state or local mandates often results in a de-emphasis on physical education and nutrition education programs. Financial resources are also limited and are spread across many different competing priorities. Unless an individual school or school district has established health promotion as a high priority, financial resources will be insufficient to hire and train highly qualified physical education teachers, after-school program personnel, health educators, and school health professionals (e.g., school nutritionists and school nurses) and equip them with the space, equipment and supplies, and curricula that they require for creating a healthy school environment. Even when health promotion and obesity

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Progress in Preventing Childhood Obesity: How Do We Measure Up? prevention have been identified as high priorities, school funding may still be insufficient to effectively implement and evaluate relevant policies, programs, and initiatives. As with other sectors that affect the health and wellness of children and youth, schools are only one setting where young people spend part of their day and their year. Therefore, an important challenge is to promote and achieve collaborations between many stakeholders that provide healthful messages and opportunities. These collaboration should involve parents; after-school and child-care programs; media; sports organizations; nonprofit organizations that sponsor after-school, evening, and summer activities (e.g., Girl Scouts, Boy Scouts, and Boys and Girls Clubs); and industry. Nevertheless, although schools are attractive partners and settings for collaborative initiatives, they are also asked to address many other health and social issues (e.g., violence prevention, sexual health education, and substance abuse prevention). Extra demands may create more competition for the time that children and adolescents spend in school and the human and financial resources needed to implement nutrition and physical activity programs. Assessing progress in childhood obesity prevention in the school setting is assisted by many surveillance systems, surveys, and self-assessment tools—some of which have been actively used for 10 to 15 years. The discussions in this chapter frequently refer to the major surveillance systems or tools that are being used to assess progress in obesity prevention in the school setting (Table 7-1; Chapter 4; Appendixes C and D). However, as noted later in the chapter, most surveys do not comprehensively cover all school grades and local-level data are limited. EXAMPLES OF PROGRESS IN PREVENTING CHILDHOOD OBESITY With the myriad of obesity prevention initiatives occurring across the nation, the committee can provide only selected examples of innovative practices. This section examines the progress toward meeting the recommendations presented in the Health in the Balance report (IOM, 2005), provides examples of relevant efforts to fulfill the recommendations, and, where available, discusses the tools and strategies being used to evaluate and assess that progress. Creating an Environment Conducive to Healthy Lifestyles School wellness plans and councils are the focus of current efforts to address the comprehensive issues of creating and sustaining schools throughout the nation that promote healthy lifestyles. The Child Nutrition and

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Progress in Preventing Childhood Obesity: How Do We Measure Up? TABLE 7-1 Overview of Surveillance and Monitoring Systems Surveillance System Description School Health Policies and Programs Study (SHPPS) SHPPS has been conducted every six years by the Centers for Disease Control and Prevention (CDC) since 1994. SHPPS provides state, school district, school, and classroom information that is aggregated at the national and state levels. Of greatest relevance to childhood obesity prevention are the sets of questions about health education, physical education and activity, food service, and school policy and the school environment. School Health Profiles (SHP) SHP is a biennial survey, which CDC has conducted since 1994, of a representative sample of middle and senior high schools in a state or school district. Principals and health education teachers are asked to respond to surveys that encompass a range of school health issues. Youth Risk Behavior Surveillance System (YRBSS) YRBSS collects self-reported data on the risk behaviors primarily of 9th- to 12th-grade students, and has been conducted every two years since 1991. CDC provides technical assistance to states and municipalities that conduct the Youth Risk Behavior Survey (YRBS) at state or local levels concurrent to CDC conducting the YRBS at the national level. In 2005, weighted results (requiring a 60 percent or higher response rate) were collected for 40 states and 21 school districts (Eaton et al., 2006). School Nutrition Dietary Assessment Study (SNDA) SNDA has been conducted by the U.S. Department of Agriculture (USDA) in the 1991–1992 and 1998–1999 school years and data for SNDAS III were collected in the 2005 school year. The study examines calorie content, fat content, pricing, student participation, and other elements of school food sales for a nationally representative sample of elementary, middle, and high schools. School Health Index (SHI) The School Health Index (SHI), developed and promoted by CDC, is an eight-module assessment tool aimed at assisting individual schools examine and evaluate their comprehensive school health and safety policies. Two sets of SHI modules—one for elementary schools and the other for middle and high schools—have been developed. WIC Reauthorization Act (Public Law 108-265) was initiated and passed by Congress in 2004 and requires school districts participating in the National School Lunch Program (NSLP) or School Breakfast Program (SBP) to establish local school wellness policies by the beginning of the 2006–2007 school year (CNWICRA, 2004). Local school wellness policies address a

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Progress in Preventing Childhood Obesity: How Do We Measure Up? range of health-related issues, including nutrition and physical activity. The Act includes a plan for assessing the implementation of local school wellness policies supported by $4 million in appropriated funds (Chapter 4). A number of organizations have developed model wellness policies and components of those policies. For example, the National Alliance for Nutrition and Activity has developed model nutrition and physical education policies that states and school districts can use and customize to local situations (NANA, 2006). The National Association of State Boards of Education in collaboration with the National School Boards Association has developed the resource Fit, Healthy, and Ready to Learn, which provides sample policies that reflect promising practices (NASBE, 2006). USDA has assembled reference materials in its online Team Nutrition: Local Wellness Policy database (USDA, 2006b). Action for Healthy Kids, in partnership with the Centers for Disease Control and Prevention (CDC) has developed the Wellness Policy Tool, which complements the Team Nutrition website and which assists school districts in identifying appropriate policy options (Action for Healthy Kids, 2006). Both websites also include evaluation resources. Additional resources include the wellness policy evaluation checklists developed by state agencies in Pennsylvania and Texas (Pennsylvania School Boards Association, 2006; Texas Department of Agriculture, 2006). Most evaluations conducted to date have focused on outcome measures related to developing and implementing policy changes at the school or school district level (e.g., structural, institutional, and systemic outcomes). Future evaluations should examine the effect of these changes on students’ cognitive, dietary, and physical activity behaviors, as well as health outcomes. It is unclear at this point whether most schools will have the resources required to conduct further evaluations that focus on behavioral and health outcomes. A presentation at the committee’s symposium in Wichita, Kansas highlighted the joint efforts of the Kansas Department of Education and the Kansas Department of Health and Environment. The two departments are collaborating to develop model wellness policies for school districts throughout the state (Appendix F). Additionally, tools are being developed that individual school districts can use to evaluate the implementation of their wellness policy and a state-level database will be used to track the implementation of these policies in each district. Technical assistance will be provided to the school districts, and efforts are under way to sustain local changes through school health advisory councils. In the next few years, as school wellness policies are adopted and promoted, it will be important to systematically evaluate the implementation of the wellness policies and to focus on sustainability issues. The development and implementation of coordinated school health

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Progress in Preventing Childhood Obesity: How Do We Measure Up? programs are the emphases of the funding and technical assistance available through CDC’s Division of Adolescent and School Health (Kolbe et al., 2004). Currently 23 states receive funding focused on the coordinated school health program model, which has eight components, including nutrition, physical education, creating a healthy school environment, and health promotion for staff. Many states and cities are currently enacting legislation that focuses on multiple aspects of enhancing a healthy school environment. For example, in June 2005 South Carolina’s legislature and governor approved legislation that focused on school nutrition, physical activity, and health education particularly in elementary schools (Box 7-2). Arkansas took an early lead in this effort with a focus on assessing BMI levels, implementing changes in school foods, and promoting physical activity (Ryan et al., 2006). Additionally, a number of organizations, foundations, government agencies, corporations, and others are partnering with schools on efforts that affect multiple aspects of the school environment. Examples of these BOX 7-2 South Carolina’s Students’ Health and Fitness Act of 2005 Beginning in the 2006–2007 school year: Students in kindergarten through fifth grade must be provided 150 minutes a week of physical education and physical activity. A minimum of 60 minutes per week must be for physical education, with plans to increase it to 90 minutes per week. The fitness status of individual students, as determined during fifth and eighth grades and during high school physical education classes, must be reported to the student’s parent(s) or guardian. All schools must administer the South Carolina Physical Education Assessment. The assessment of students in the second, fifth, eighth grade, and in high school are used to evaluate the effectiveness of the school’s physical education program and its adherence to the South Carolina Education Curriculum Standards. Effectiveness scores will be developed and reported through the school district and school report cards. The State Board of Education will establish requirements for elementary school food service meals and competitive foods. The State Department of Education will make available to each school district a coordinated school health model. An assessment of district and school health education programs will be conducted. Each school district will establish a coordinated school health advisory council. SOURCE: South Carolina General Assembly (2006).

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Progress in Preventing Childhood Obesity: How Do We Measure Up? broad-based initiatives include Action for Healthy Kids (a public-private partnership with state-based coalitions) and the Healthy Schools Program sponsored by the Alliance for a Healthier Generation (a joint effort of the American Heart Association and the William J. Clinton Foundation with support from the Robert Wood Johnson Foundation) (Chapters 2 and 5). Improving School Food and Beverage Nutrition The food and beverages sold or available in schools through the federal meal programs, as competitive (à la carte) items in the school cafeteria, in vending machines, in school stores, or in the classroom have been the focus of obesity prevention efforts in many localities (CSPI, 2006; Story et al., 2006). Policies related to the types of foods and beverages available in elementary, middle, and high schools generally differ, with more restrictive policies implemented for the lower grades. Many states are developing and implementing state nutrition standards for the foods and beverages served and sold in schools (see for example, Andersen et al., 2004; Connecticut State Department of Education, 2006). Certain cities and localities, such as Chicago and Philadelphia (Box 7-3) are enacting requirements stricter than those mandated by state law. In 2004, the School Health Profiles (SHP) survey found that carbonated soft drinks, sports drinks, or fruit drinks were offered for sale in vending machines in 95.4 percent of the schools in the 27 states for which weighted data were available. Similarly, bottled water was offered by 94.3 BOX 7-3 Overview of Nutrition Standards of the School District of Philadelphia Soft drinks will not be sold or served in school. Juice beverages must contain at least 25 percent real fruit juice. The total fat content of snack foods must be less than or equal to 7 grams per serving. The saturated fat content of snack foods must be less than or equal to 2 grams per serving. The sodium content of snack foods must be less than or equal to 360 milligrams per serving. The sugar content of snack foods must be less than or equal to 15 grams per serving. Candy will not be served or sold during the school day. SOURCE: Philadelphia Comprehensive School Nutrition Policy Task Force (2002).

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Progress in Preventing Childhood Obesity: How Do We Measure Up? percent of the schools (Kann et al., 2005). In future SHP surveys, it will be important to track trends in the type of foods and beverages available for purchase by students. Despite all the attention being paid to improving the nutritional quality of the foods and beverages provided in schools, however, the committee heard at the Wichita symposium that food service managers face ongoing challenges in improving school nutrition. These include insufficient funding, the use of sole-source contracts, open campuses where students can choose to leave schools to eat, a lack of nutrition education, short meal periods, and competition with vending machine options (Appendix F). Other barriers that food service managers face include preferences for fast foods, carbonated soft drinks, and salty snacks; the mixed messages sent by school personnel; and school food preparation and serving space limitations (Gross and Cinelli, 2004). At the more local level, individual schools and school districts have made innovative changes to their menus, food sales, and beverage choices (Box 7-4) (Kojima et al., 2002). One of the challenges, however, has been in disseminating that information. The Produce for Better Health Foundation, in conjunction with 5 a Day and Fresh from Florida, has compiled promo- BOX 7-4 Key Considerations in Improving School Foods and Beverages from the Minneapolis Public Schools Food Service Presentation at the IOM Symposium on Schools Ensure that Minneapolis Public School students have access to nutritious meals and ensure that nutritional and cultural needs of the diverse community are met. Meet or exceed USDA standards for nutrition requirements, food safety, and food security (offering more fresh fruits and vegetables, more whole grains). For example, a free “fixin’s bar” that provides fresh vegetables and salsa can be added outside the serving area so students can help themselves. Broaden community involvement by establishing and maintaining Nutrition Advisory Councils, conducting student and parent annual surveys, and providing school meal and nutrition information on the school’s website. Establish nutrition standards for à la carte items, considering portion size, and sugar and fat content. Form partnerships with local universities and technical colleges, local extension agencies, and state and county health departments. Evaluations can include tracking what students are selecting and consuming; conducting annual student/parents/staff surveys; and using input from partnerships. SOURCE: Dederichs (2005).

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Progress in Preventing Childhood Obesity: How Do We Measure Up? tional ideas and implementation models to help food service managers increase students’ fruit and vegetable consumption (PBH, 2005a,b). A recent CDC and USDA publication, Making It Happen: School Nutrition Success Stories, documents some of those changes. Examples include efforts made in Ennis, Montana, where students were involved from the initial planning in 2002–2003 in restocking vending machines and removing brand logos from vending machine signage. The vending services for the Oceanside, California school district were placed under the auspices of the food services program; and the results included healthier options and increased revenue from vending sales for the high school. In McComb, Mississippi, school policies were changed so that fundraising through the sale of candy or other less nutritious food items is not permitted in kindergarten through the eighth grade (USDA, DHHS, and DoE, 2005). Federal, state, and community programs are increasingly focused on improving the nutritional quality of school foods and beverages—those offered as part of the NSLP and SBP, as well as those sold competitively. As discussed in Chapter 4, USDA’s Team Nutrition program provides technical assistance to school food service personnel and child-care professionals, including Fruit and Vegetables Galore, a tool to assist schools in promoting fruit and vegetable consumption (USDA, 2006c). Additionally, innovative approaches to increase fruit and vegetable availability and consumption are being implemented by students, teachers, food service personnel, and the community through farm-to-school programs and school gardens (Graham and Zidenberg-Cherr, 2005; USDA, 2005). The U.S. Department of Defense (DoD), in partnership with USDA, conducts the DoD Fresh program, which in the 2005–2006 school year distributed produce to school foodservice programs in 46 states and more than 100 American Indian reservations (Chapter 4) (David Leggett, USDA, personal communication, July 13, 2006; USDA, 2006a). Fresh fruits, dried fruits, and fresh vegetables are also being made available to students outside the regular school meal periods through USDA’s Fresh Fruit and Vegetable Program (FFVP). Established as a pilot program in the 2002–2003 school year, the program aims to increase student consumption of fruits and vegetables by increasing the availability of these foods in the school environment (Chapter 4). In 2004, the Child Nutrition and WIC Reauthorization Act (Public Law 108-265) established FFVP as a permanent program and expanded the program from four to eight states and added additional American Indian reservations (UFFVA, 2006); subsequent appropriations legislation in 2006 expanded the program to 14 states, and additional funding for a nationwide program is being sought. FFVP has undergone a preliminary evaluation, and further evaluation efforts are under way (Buzby et al., 2003) (Appendix D). For example, an evaluation of 25 schools in Mississippi that participated in the

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Progress in Preventing Childhood Obesity: How Do We Measure Up? mechanisms, such as through presentations at professional meetings and the publication of findings in professional journals. They also, however, need to be disseminated through innovative mechanisms that can provide teachers, principals, school administrators, and food service personnel with examples of specific interventions that can be implemented. Sharing the innovative changes through publications with concrete examples and details, such as the recent compilation by CDC and USDA of innovations in school food and beverages, Making It Happen: School Nutrition Success Stories, should be continued. Such publications should provide as much detail on the intervention and on the results of its evaluation as possible. Mechanisms to incentivize evaluation and disseminate promising practices include the provision of awards or recognition for schools or school districts that implement and evaluate relevant programs and policies and that are able to demonstrate positive changes on the path to obesity prevention. For example, the Keystone Healthy Zone Schools program in Pennsylvania provides schools with technical assistance in improving the school wellness environment and offers competitive minigrant funding to make improvements. The program also assists schools with collecting benchmark measures of progress and actively disseminates school success stories through its website (Keystone Healthy Zone, 2006). Another example is the Utah Gold Medal Schools program, which was begun just before the 2002 Olympic Games. With the support of the Utah Department of Health, Intermountain Healthcare and other organizations, the program offers incentives for schools that implement policies and programs focused on increasing physical activity, improving nutrition, and reducing tobacco use (Utah Department of Health, 2006). In addition to bronze, silver, and gold awards, schools can work toward the platinum award, which in addition to other nutrition- and physical activity-related stipulations, requires the involvement of families and the community in health-related efforts; a policy of selling only food and beverage choices that contribute to healthful diets at school events, in vending machines, and at school stores; policies that ensure that meal periods are of the appropriate length or policies that schedule recess before lunch; and the implementation of a faculty wellness program (Utah Department of Health, 2006). SUMMARY AND RECOMMENDATIONS Current childhood obesity prevention efforts are largely focused on changes in the school environment, with much of the attention on improving the nutritional quality and the portion sizes of the foods and beverages made available in schools. Momentum related to promoting increased opportunities for physical activity seems to be growing; however, the limited

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Progress in Preventing Childhood Obesity: How Do We Measure Up? time available in the school day and the many competing demands on school time are presenting obstacles to these efforts. Similar to community obesity prevention efforts, wide variations in the extent of resources and the amount of effort devoted to increasing physical activity and making changes in the school nutrition environment are seen across states, school districts, and individual schools. Wide variations in other areas, such as improving the school curriculum on energy balance, discouraging branded marketing in schools, and assessing and communicating student BMI and fitness levels, as well as the collaborative efforts between schools and communities to use schools as community centers, are also found. Less attention appears to be being paid to improving nutrition and increasing the levels of physical activity in the preschool, child-care, and after-school environments, although again, some locations are quite focused on this issue, whereas others are not yet engaged. Throughout the nation there appears to be only limited efforts to evaluate the many policies and programs being implemented in states, local school districts, individual schools, and classrooms. Each of the report’s four recommendations (Chapter 2) is directly relevant to promoting leadership and collaboration and improving the evaluation of school-based childhood obesity prevention efforts. The following provides the report’s recommendations and summarizes the specific implementation actions (detailed in the preceding sections) that are needed to improve childhood obesity prevention efforts in schools. Recommendation 1: Government, industry, communities, schools, and families should demonstrate leadership and commitment by mobilizing the resources required to identify, implement, evaluate, and disseminate effective policies and interventions that support childhood obesity prevention goals. Implementation Actions for Schools School boards, administrators, and staff should elevate the priority that is placed on creating and sustaining a healthy school environment and advance school policies and programs that support this priority. To accomplish this: Relevant federal and state agencies and departments, local school districts, individual schools and preschools, and child-care and after-school programs should prioritize opportunities for physical activity and expand the availability and access in schools to fruits, vegetables, and other low-calorie and high nutrient foods and beverages that contribute to healthful diets.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Increased resources are needed to develop, implement, and evaluate policies and programs. State and local school-based nutrition and physical activity standards need to be implemented, and the relevant educational entities should be held accountable for promoting and adhering to these standards. Recommendation 2: Policy makers, program planners, program implementers, and other interested stakeholders—within and across relevant sectors—should evaluate all childhood obesity prevention efforts, strengthen the evaluation capacity, and develop quality interventions that take into account diverse perspectives, that use culturally relevant approaches, and that meet the needs of diverse populations and contexts. Implementation Actions for Schools Schools and school districts should strengthen evaluation efforts by partnering with state and federal agencies, foundations, and academic institutions to develop, implement, and support evaluations of all relevant school-based programs. To accomplish this: Federal agencies (e.g., CDC, USDA, Department of Education), state departments of education and health, foundations, academic institutions, school districts, and local schools should Increase the resources devoted to technical assistance for evaluating school-based childhood obesity prevention policies, programs, and interventions and Develop partnerships to fund, develop, and implement childhood obesity prevention evaluations. Recommendation 3: Government, industry, communities, and schools should expand or develop relevant surveillance and monitoring systems and, as applicable, should engage in research to examine the impact of childhood obesity prevention policies, interventions, and actions on relevant outcomes, paying particular attention to the unique needs of diverse groups and high-risk populations. Additionally, parents and caregivers should monitor changes in their family’s food, beverage, and physical activity choices and their progress toward healthier lifestyles. Implementation Actions for Schools Schools and school districts should conduct self-assessments to enhance and sustain a healthy school environment, and mechanisms

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Progress in Preventing Childhood Obesity: How Do We Measure Up? for examining links between changes in the school environment and behavioral and health outcomes should be explored. To accomplish this: Relevant federal agencies (e.g., CDC, NIH, USDA, and the Department of Education), state education departments, school districts, and local schools should Expand and fully use current surveillance systems related to children’s dietary and physical activities, obesity-related health indicators, and relevant school policies and programs; Implement a national survey focused on the physical activity behaviors of all children and youth; Support research on means to improve the monitoring of diet and physical activity; Establish mechanisms to link health, educational, economic, and sociological data sources across a variety of areas related to childhood obesity prevention; and Expand and adapt self-assessment tools for schools, preschools, child-care, and after-school programs and evaluate their validity for predicting changes in children’s levels of physical activity, dietary intakes, and weight. Recommendation 4: Government, industry, communities, schools, and families should foster information-sharing activities and disseminate evaluation and research findings through diverse communication channels and media to actively promote the use and scaling up of effective childhood obesity prevention policies and interventions. Implementation Actions for Schools Schools should partner with government, professional associations, academic institutions, parent-teacher organizations, foundations, communities, and the media to publish and widely disseminate the evaluation results of school-based childhood obesity prevention efforts and related materials and methods. To accomplish this: Schools, preschools, child-care and after-school programs, and relevant stakeholders should broadly disseminate the evaluation results using diverse communication channels and media and develop incentives to encourage the use of promising practices.

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