Addressing Childhood Obesity: Nutrition Education and Policies in Schools

Background

The Centers for Disease Control and Prevention (CDC) has declared an epidemic of child and adolescent overweight in the United States (3). In the United States, 15.3% of children ages 6-11 and 15.5% of teens ages 12-19 are overweight. Childhood overweight is defined as having a body mass index (the ratio of weight in kilograms to the square of height in meters) above the 95^th percentile (1).
 
Poor nutrition and physical inactivity are responsible for 28% of preventable deaths in the U.S., second only to tobacco and more than violence, AIDS, drugs, alcohol, and car crashes combined (3). Many conditions generally associated with adults are increasingly common among the nation's children, including:

• Type II diabetes;
• High blood pressure;
• Various forms of cancer (5,9,10).

In addition, overweight children are at increased risk for orthopedic, respiratory, and skin disorders as well as asthma and bronchial hyperactivity (8). Children who remain overweight beyond the age of six run a 50% chance of chronic, lifelong overweight (8). The consequences of overweight are not limited to physical ailments. A correlation has been found between childhood weight problems and depression, lowered self-esteem, social withdrawal, and discrimination (6,11,12).
 
Overweight is the result of increased caloric consumption and decreased physical activity, but the underlying causes are multifaceted (3). Shifts in eating habits in the U.S. are one source of overweight. CDC cites increases in fast food consumption, portion size, and soft drink consumption as possible causes. Increased snacking and meal skipping have coincided with increased overweight rates (3). Poverty, lack of health insurance, national advertising, and social norms are also problems that contribute to the overweight epidemic (2).
 
Schools are in the unique position to influence and improve child nutrition, since most children spend a substantial portion of their time in school (12). Over 50% of youth in the U.S. eat one of three major meals in school, and one in ten children and adolescents eat two of three main meals in school (4). Schools influence students' eating patterns by what is or is not taught in the classroom and by what is or is not sold and promoted on campus (2).
 

Polices

1. School districts can enact a policy that mandates age-appropriate nutritional instruction for students in grades K-12.
 
School is a critical part of the social environment that shapes a young person's eating behaviors (4). Making nutrition a required component of school curricula can help students develop lifelong healthy eating habits.
 
According to the School Health Policies and Programs Study (SHPPS), 85% of elementary schools, 81% of middle schools, and 87% of high schools require instruction on nutrition and dietary behavior (5). However, according to the same study, the average number of hours spent in a school year on nutrition education was five for elementary schools, four for middle schools, and five for high schools (5). This is far below the recommended minimum of 50 hours to impact behavior (8).
 
Policies to include nutrition as a component of core curricula and to provide comprehensive training for nutrition teachers would help encourage healthy eating habits among American youth. CDC recommends that nutrition education be a part of a comprehensive health education curriculum that focuses on understanding the relationship between personal behavior and health. CDC also recommends that lessons be sequential and age-appropriate from preschool to secondary school, and that teachers allocate sufficient time to teach the lessons, in order to ensure an impact on behavior. Finally, curricula should strive to promote healthy eating behaviors, as several programs using this behavioral approach have achieved a significant, positive change in students' eating behaviors (4).
 
2. School districts can establish a coordinated school nutrition policy that promotes healthy eating through a comprehensive school health program.
 
The school environment is a powerful influence on students' attitudes, preferences, and behaviors, and classroom lessons alone might not be enough to effect lasting changes in students' eating behaviors. Students also need access to healthy food and the support of persons around them. The influence of school goes beyond the classroom and includes normative messages from peers and adults regarding food and eating patterns (4).
 
Students are more likely to receive a strong, consistent message when healthy eating is promoted through a comprehensive school health program (4). According to CDC, such a program should:

• Provide adequate time for nutrition education taught in a sequential series as a part of a comprehensive school health education program;
• Make available healthy and appealing foods and discourage the sale of foods high in fat, sodium and added sugars;
• Develop food outlines for teachers, discouraging them from using foods for reward or punishment;
• Create an environment of support for healthy eating, by illustrating examples of healthy meals in the classroom, educating parents on healthy eating, and giving children adequate time to eat meals;
• Establish links with nutrition service providers who can give additional information on health promotion services available in the community (6).

 

Effectiveness Data

A society that is "health literate" can act positively to promote its good health. Nutrition education in schools has shown promising results.  Several programs using a behavioral approach have achieved significant positive changes in students' eating behaviors. Compared with students in control schools, students in some behaviorally based health and nutrition education programs had significant favorable changes in serum cholesterol levels, blood pressure levels, and body mass index (4). For example, the Know Your Body program was a sequential nutrition curriculum from kindergarten through grade 7 designed to reduce disease risk. In one study of the effectiveness of the program, in New York City, teachers taught the curriculum for 30 minutes each week throughout the school year, and the school meal program provided healthier lunches. A longitudinal study of the program over 5 years showed significant improvements in nutrition knowledge, in intake of total fat and complex carbohydrates, and in total cholesterol (7). In 1989, after extensive evaluation, the Know Your Body program became only the second school health curriculum to receive approval from the U.S. Department of Education's Program Effectiveness Panel (9).
 
The Santa Monica - Malibu School District has chosen to take a comprehensive, total environment approach to nutrition and education. In 1997, the district launched the Farmers' Market Fresh Fruit and Salad Bar at McKinley Elementary School in Santa Monica. The school district purchases produce for the salad bar directly from local farmers to give students the freshest produce possible. In addition, the program also provides farm tours, farmers' market tours, a "chef in the classroom" component, cooking cart demonstrations connected to the curriculum, nutrition education materials, and gardening and composting lessons. The school children, through this process, become enmeshed in the whole food system, from farm to cafeteria, which allows students to learn where food comes from, how it is grown, the importance of agriculture, and to understand that selecting health food choices can improve their quality of life. The school district also encourages parents to become involved in the nutrition education of their children, as parents can act as volunteers to set up the salad bar and to coordinate the program. After the implementation of this program, use of the school salad bar increased by up to seven times. The district has expanded the pilot program to fourteen other school sites, where participation in the salad bar program has increased by up to 1700% in some schools (10).
 

Resources

Centers for Disease Control and Prevention - School Health Index and Self-Assessment
http://www.cdc.gov/nccdphp/dash/SHI/index.htm
The CDC's School Health Index for Physical Activity and Healthy Eating: A Self Assessment & Planning Guide, helps schools identify strengths and weaknesses within their physical activity and nutrition policies and programs; develop an action plan for improving student health; and involve teachers, parents, students, and the community in improving school services.


California Center for Public Health Advocacy
http://www.publichealthadvocacy.org
Among other activities to raise awareness and mobilize communities regarding public health issues, the Center established a consensus panel of state and national experts to develop recommendations for nutrient standards for competitive foods sold in California schools.
 
Changing the Scene, Improving the School Nutrition Environment: A Guide to Local Action
http://www.fns.usda.gov/tn/Resources/changing.html
The site introduces a tool kit designed to help local citizens take action to improve their school's nutrition environment. 
 
Fit, Healthy, and Ready to Learn: A School Health Policy Guide
http://www.nasbe.org/HealthySchools/fithealthy.mgi
Developed by the National Association of State Boards of Education in partnership with the Centers for Disease Control and Prevention, this policy guide provides direction on establishing overall policy framework for school health programs and specific information on various topics.
 

References

1. American Academy of Pediatrics. (203, August). Prevention of Pediatric Overweight and Obesity. Pediatrics, 112(2):424-430.

 

2. California Center for Public Health Advocacy. (2002, January 18). California working families policy summit recommendations to promote nutrition and physical activity for children and adolescents. Davis, CA: Author.

 

3. California Center for Public Health Advocacy. (2002, March). National Consensus Panel on School Nutrition: Recommendations for competitive food standards in California schools. Davis, CA: Author.

 

4. Centers for Disease Control and Prevention. (1996). Guidelines for school health programs to promote lifelong healthy eating.  Morbidity and Mortality Weekly Report, 45(RR-9). Retrieved May 31, 2002, from http://www.cdc.gov/nccdphp/dash/guidelines/nutraag.htm

 

5. Centers for Disease Control and Prevention. (2000) School Health Policies and Programs Study: Fact Sheet, Nutrition Services. Retrieved July 14, 2003 from: http://www.cdc.gov/nccdphp/dash/shpps/factsheets/fs00_ns.htm

 

6. Cohen, J. (2000). Overweight kids: Why should we care? Sacramento, CA: California Research Bureau, California State Library.

 

7. Contento, I. (1995 December). The Effectiveness of Nutrition Education and Implications for Nutrition Education Policy, Programs, and Research: A Review of Research. Journal of Nutrition Education, 27(6).

 

8. National Center for Education Statistics. (2000, February) Nutrition Education in Public Elementary School Classrooms, K-5. Retrieved July 1, 2003 from http://nces.ed.gov/pubs2000/2000040.pdf

 

9. Promising Practices Network. (2000, May) Proven and Promising Programs: Know Your Body. Retrieved September 24, 2003 from: http://www.promisingpractices.net/program.asp?programid=109&benchmarkid=4

 

10. Santa Monica/Malibu Unified School District, Food and Nutrition Services. (n.d.) Farmer's Market. Retrieved July 3, 2003 from: http://www.smmusd.org/depts/food/

 

11. U.S. Department of Health and Human Services. (2001). The Surgeon General's call to action to prevent and decrease overweight and overweight. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General.

 

12. U.S. Preventive Services Task Force. (1996). Guide to Clinical Preventive Services (2nd ed.). Alexandria, VA: International Medical Publishing.

 

Acknowledgements

Harold Goldstein, PhD, Executive Director, California Center for Public Health Advocacy, Davis, CAH
 
Mary McKenna, PhD, Health Scientist, Centers for Disease Control and Prevention, Division of Adolescent and School Health, Atlanta, GA
 
Tracie Thomas, Director, Food and Nutrition Services, Santa Monica-Malibu Unified School District, Santa Monica, CA.