Introduction
In 2001, The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity1 identified schools as a key setting for addressing the problems of poor nutrition and inadequate physical activity — the two root causes of the current obesity epidemic among our nation’s children. Since the Call to Action was released, officials have taken steps on several fronts to create healthier school environments in these areas. As of April 2005, 28 states have made efforts to restrict the sale of “competitive foods” — items that are sold in competition with the National School Lunch Program. Many large school districts have enacted policies that restrict the sale of specific items (such as soft drinks), or have limited the hours during which certain items can be sold.2
While these steps represent progress, schools still need to take a more comprehensive approach if they want to help students develop lifelong behaviors of good nutrition and physical activity. The Child Nutrition and WIC Reauthorization Act of 2004 requires every school district to develop and implement a local wellness policy by the beginning of the 2006–07 school year. The wellness policy must include, at a minimum:
• Goals for nutrition education, physical activity, and other school-based activities designed to promote student wellness in a manner that the local educational agency determines appropriate.
• Nutrition guidelines for all foods available on the school campus during the school day.
• Guidelines for school meals that, at the very least, are as restrictive as federal standards.
• A plan for measuring how local wellness policies are implemented.
• The involvement of parents, students, representatives of the school food authority, the school board, school administrators, and the public in the development of the policies.
This mandate provides an extraordinary opportunity to change school practices regarding nutrition and physical activity in a way that can greatly benefit children’s health and learning. However, the move to institutionalize wellness practices in schools faces a number of challenges. The legislation mandating wellness policies provides no additional funding to develop, implement, or monitor such policies. School districts face ever-growing budgetary challenges, and teachers and administrators face increasing pressures to devote scarce resources against performance goals. This means there is a very real risk that this opportunity will not be realized to its fullest potential. To comply with the legislative mandate, schools will need additional resources and a variety of easily adopted programs for implementing wellness practices.
Recently, a dozen Illinois schools participated in a project to test various approaches to improving school-based nutrition. Several organizations and businesses, including Action for Healthy Kids3 , were part of a working group established to help provide technical support and expertise to schools that were willing to implement strategies to improve students’ food choices. Schools participating in the project varied in size, location, demographics, grade level, and type of food service management. Each school faced the familiar challenges of budget and staffing constraints, crowded schedules, and numerous competing priorities.
With financial support from the Robert Wood Johnson Foundation, Action for Healthy Kids developed a technical assistance model that provided dedicated assistance and leadership, including plans for sustaining changes by developing School Health Advisory Councils and an approach for assessing the schools’ projects.
The use of volunteer experts was beneficial in helping schools implement changes. However, given the enormous challenges schools face, such an advisory resource — in and of itself — is not enough to bring about improvement. Without additional resources and help, schools were not able to fully implement projects, evaluate their efforts, or sustain the changes that were made.
Experience from this project serves to help identify what will be necessary in many districts and schools to successfully implement wellness policies. The purpose of this paper is to share these lessons and inform decision-makers about how they can best help schools improve students’ food choices and sustain health-promotion efforts.
Strategies for Improving Student Food Choices
Nine of the twelve participating schools/districts were able to complete projects that fell into the following categories (More detailed information on each intervention is available in the appendix.):
• Introducing healthier choices for entrées, snacks, and beverages: Two schools significantly revamped their food offerings for entrées, snacks, and beverages, requiring that these new offerings meet specific nutritional standards. These schools also began to remove less healthy snack options from vending machines.
• Repackaging to make healthy options more attractive: One high school introduced plastic bottles of flavored milk during a one-week promotion in an attempt to increase milk consumption among students. Research has shown that students more readily consumed milk when it was flavored and packaged in attractive plastic bottles.4
• Adding salad bars to the lunchroom: Two schools introduced a salad bar that offered a variety of healthy fruits, vegetables, and protein choices to meet meal standards of the National School Lunch Program.
• Promoting and introducing new fruits and vegetables: Two schools launched the “Eat Your Colors” program that introduced students to a new fruit or vegetable each day for a defined period of time (e.g., a week or a month).
• Increasing participation in breakfast: Three schools began offering and promoting a healthy breakfast. One implemented a breakfast bar, the second launched “Friday Family Breakfasts” at which both parents and students could eat a healthy meal, and the third implemented “Breakfast and a Movie,” wherein a segment from a popular movie is played during breakfast.
• Accommodating healthier snack foods: One school installed a cold vending machine offering healthy beverages and snacks. One school renamed its school store and revamped its offerings to emphasize healthier food options.
Each new initiative was promoted to students and/or parents — some much more heavily than others. Schools used a variety of media for communicating the launch of the programs, including posters, stickers, “grand opening” parties, teacher education, formal nutrition education classes, and letters to parents. Some schools also used giveaways (e.g., movie tickets) and contests with prizes to entice participation. In some cases, price discounts were offered on the new, healthier products.
General Results
• Most of the interventions appeared to succeed in making students aware of the new, more nutritious food offerings. However, success in getting students to switch to those offerings, it appears, did not come as easily. Not surprisingly, this transition occurs much more quickly when the new choices replace less nutritious foods, as opposed to the two being offered side by side.
• Salad bars appeared to be very popular, with a sizeable percentage of students (25 percent in one case, 30–35 percent in another) choosing items from those — including many who made it their full entrée.
• Offering healthy breakfasts also appeared to be popular, particularly when combined with some “perk” (e.g., a movie or the opportunity to eat with parents). • Getting students to try a healthy food for a period of time appeared to be the most important breakthrough strategy. Once they did this, their habits tended to change even after the perk was gone. The “Breakfast and a Movie” promotion, for example, increased daily breakfast attendance at one school from 250 to 343; once the promotion ended, average attendance dipped only slightly (to 320 students).
• Getting students to try a healthy food for a period of time appeared to be the most important breakthrough strategy. Once they did this, their habits tended to change even after the perk was gone. The “Breakfast and a Movie” promotion, for example, increased daily breakfast attendance at one school from 250 to 343; once the promotion ended, average attendance dipped only slightly (to 320 students).
Sustaining Changes: School Health Advisory Councils
School Health Advisory Councils have been a successful tool in bringing together key stakeholders to address the health and wellness needs of the school. To help schools sustain their nutrition demonstration projects, Action for Healthy Kids provided training, micro-grants, and assistance to those schools willing to form School Health Advisory Councils.
Most of the schools took the initial steps necessary to develop a School Health Advisory Council (SHAC). The composition of the councils varied by school, but typically included school principals and/or assistant principals, health educators, counselors, physical education teachers, nurses or nurse supervisors, parents and PTA representatives, food service personnel, and/or student representatives. By the end of the pilot in June 2005, four schools had held their first council meeting (meetings are typically held every six weeks), while several others had plans to hold their first meeting over the summer or at the beginning of the next school year. Four schools, however, made little or no progress toward developing School Health Advisory Councils.
Common Challenges to Implementing Good Nutrition Practices
Several challenges were encountered during the course of the demonstration project that, while common, were quite daunting. In some cases, these challenges impeded progress altogether. They are discussed below.
Resource Limitations
Schools’ limited resources and tight operating budgets made it difficult, if not impossible, to take on new projects or purchase new equipment or products. School staff was already stretched considerably, and much of the work that had to be done by school foodservice professionals was done on personal time.
Even with highly committed individuals, some strategies simply could not be implemented without additional resources. Some healthier food offerings, such as salad and breakfast bars and cold vending machines, took more time to prepare and/or maintain than did traditional offerings. This put a strain on existing foodservice personnel and/or created a need to hire additional staff (at additional cost). At the same time, some healthier food items, such as fresh fruits and vegetables or specially packaged milk, tend to be more expensive. While schools may feel the need to charge higher prices for such items, doing so may discourage students from buying them, as price is clearly a consideration for most students.
Product and Equipment Availability
For students to make healthier food choices, schools must have great-tasting options that can compete against less nutritious foods and beverages. Some schools participating in the demonstration project had difficulties obtaining or preparing these types of products.
Several schools participating in the demonstration project wanted to engage in a promotion to encourage students to drink more milk by offering a variety of flavored low-fat milk in plastic bottles. However, only one school was able to hold the promotion. That school could hold it for only one week, because products were more expensive and difficult to obtain. The school foodservice professionals at several schools tried to form a cooperative buying structure to help lower the cost of the low-fat flavored milk in plastic. However, they were unable to accomplish this within the time frame of the demonstration project.
One of the participating schools wanted to introduce healthy options for vending machines, but found that the slots in their existing machines would not accommodate many of the healthier options. As a result, they had to drop that part of the project. The school found that it could not immediately purchase or trade its existing machines for newer cold vending machines that can hold yogurt, veggies and dip, bagels and cream cheese, sandwiches, or cheese sticks and fruit. They also found that there was an additional cost for maintaining the machines and keeping fresh products. These circumstances could make more nutritious vending prohibitive for many schools.
Two schools added a salad bar, and found it required special equipment to accommodate the smaller size of their young students. For some schools, the cost and space required for the equipment could make this option impossible.
Some schools reported a loss in revenue because they did not have adequate product substitutes for some of the best-selling snack items that they quit offering. All schools participating in the project wanted to sell more healthful options in school stores, in vending machines and a la carte in the cafeteria, but found that options are still limited. Many found their distributors did not stock some of the newer products that students think taste great while also having fewer calories, less fat, and less sugar.
Support and Acceptance
Support and acceptance of nutrition policy changes among stakeholders (administrators, school foodservice, teachers, parents, students) is essential for these practices to be successfully adopted. Key stakeholders must be involved in developing and implementing new programs and practices, while involvement by the students who are ultimately affected by the new programs and practices is especially important.
A dedicated school foodservice professional took charge of implementing changes at each of the demonstration project schools. Once the project was underway, attempts were made to recruit others at the school to participate in the implementation and maintenance of the school initiatives. Several challenges were encountered in this area:
• It was difficult to engage teachers and administrators. Their busy schedules made it very hard for them to devote time to projects or committees such as School Health Advisory Councils.
• Students tended to resist changes they viewed as being “imposed” on them by school administrators. Students want to feel as if they are a part of the decision-making process with respect to food choices.
• Students can be picky eaters. They were highly receptive to some food offerings and not at all receptive to others. Thus, if the students are not consulted beforehand on the proposed changes, it can be difficult for schools to anticipate how students will react to specific food offerings.
• Because parents were not involved with its development, schools offering breakfast programs found it difficult to get students to school early enough to participate.
Lessons Learned
This project led to some important lessons on how to maximize the impact of any schoolbased initiative to improve students’ food choices.
• Involve Students: Gather information from students about their insights, perceptions, and opinions of new food choices. Whenever possible, involve students throughout the planning, implementation, and evaluation process of programs. Several schools found that students provide valuable guidance. For example, students at Evanston Township High School suggested offering a makeyour-own-sandwich station and a fruit and salad bar. And the students themselves have called for the elimination of candy as an available option to students. A national survey found that one in five schools has a committee that includes students who provide suggestions for the school foodservice program.5
• Tastings and Promotions Get Attention: To identify popular options and familiarize students with new products, schools should promote new programs as widely as possible. Printed educational materials (e.g., posters, pamphlets) for parents and students were used in the demonstration project, as well as out-of-classroom nutrition education and promotional tools. Such tools included videos and/or audio announcements at school, cafeteria taste-tests, games, contests, giveaways, and “grand openings”. Widespread, sustained promotion is more likely to encourage students to try new food offerings. If students try and like healthier offerings, they are likely to continue their healthy eating habits.
• Information is Powerful: Give students information on the nutrition and caloric content of available foods. Nationally, many schools are already taking this step. A survey conducted in 2000 found that more than nine in ten schools give menus to students, at least half collect student suggestions for the foodservice program, and more than one-third conduct taste tests with students.6
• Support and Collaboration: Gather support from a group of individuals inside and outside of the school. These individuals can work together and share ideas, thoughts, and responsibilities.
• Packaging Counts: Where possible, supply healthy options in appealing, fun packaging. The goal is to make healthy options more acceptable and perhaps even more fashionable. For example, Evanston Township High School sponsored the “Hug-aChug” program, which found a 20 percent increase in student milk purchases when milk was flavored and sold in a plastic “Milk Chug” bottle.
• Price Advantage for Healthy Options: Where possible, offer healthy options at a lower price (at least initially). Several studies have documented that price is a key factor to students, and that lowering prices of healthy options encourages trial and purchase. The discounted price during the “Hug-a-Chug” milk promotion, for example, helped contribute to the increase in sales during the weeklong dairy promotion at the high school.
• Be Consistent and Comprehensive: Provide a consistent, healthy environment throughout the school by replacing all items of low nutritional value that are sold through vending machines, school stores, and cafeterias. Students with the option of both healthy and non-healthy items will often choose the latter. For example, students at Quincy High School admitted that because unhealthy items tend to be less expensive and taste good, they would continue to purchase them if available. Unfortunately, only a small number of schools nationally have taken this step to date. For example, only 12.4 percent of schools prohibit the sale of “junk foods” outside the cafeteria (e.g., vending machines, student parties, after-school programs, concession stands), while only 20.8 percent of schools require that fruits or vegetables be sold in these settings.7
• It’s O.K. to Imitate: Do not try to reinvent the wheel. Implement a project or nutritional education curriculum that has already been developed and tested by another school. Action for Healthy Kids’ website (www.actionforhealthykids.org) serves as a clearinghouse of resources for improving school nutrition and physical activity. More than 200 programs and practices in the “What’s Working Database” are scored by experts using “best practice” criteria.
Recommendations
Action for Healthy Kids’ work with the schools in this project has demonstrated specific tactical approaches that are likely to make school nutrition programs and practices successful. The project also has demonstrated the need for schools and school districts to have assistance in putting wellness practices in place, as well as a systematic approach for sustaining changes and revisiting school health practices on a regular basis. The Child Nutrition Reauthorization Act’s mandate for wellness policies is precisely the sort of incentive needed to help school districts institutionalize an improved approach to nutrition.
Schools are under multiple constraints (budgetary, social, achievement, etc.) that prevent them from successfully approaching nutrition comprehensively throughout the school environment. A concerted, multidisciplinary approach is needed to bring widespread and much-needed change. Forming a committee to write the necessary comprehensive, relevant wellness policy under the assumption that it will get implemented properly, monitored, and evaluated will not bring lasting change.
This project illustrated the need for a systematic approach to developing, implementing, and monitoring wellness policies that are rooted in proven models, and that have “champions” for change inside and outside of the school. As this project has begun to show:
• Approaches for improving nutrition must come with resources and must be costeffective for successful implementation.
• Wellness practices and programs need to complement the larger school context, by fitting within the school schedule and aligning with a coordinated school health model.
• Approaches for improving nutrition practices must be sustainable — one-time events without additional programs and practices to improve student food choices will not have lasting impact.
• Schools need to develop School Health Advisory Councils. This ongoing, “institutionalized” body can be charged with identifying problems that affect children’s health and with recommending changes to alleviate the problems.
• Wide support from critical audiences is necessary — this includes administrators, parents, teachers, students, and other community leaders.
Schools can be invaluable in helping students practice nutrition skills in an environment supported by nutrition education and positive role modeling by adults. This project, like others, has shown that kids will make positive choices when healthful options are tasty, convenient, and competitively priced. Although its duration was brief, this demonstration project provided insight into the strategies, tactics, and actions necessary to help students make better food choices.
The advent of this nation’s wellness policy mandate is an exceptional opportunity to catalyze action. Schools must engage a variety of stakeholders — parents, students, community groups, and philanthropic and corporate organizations — to help make sure that planning is relevant, resources are available, and wellness policies are successfully implemented and sustained.
REFERENCES
1 United States Department of Health and Human Services (USDHHS). The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. USDHHS 2001.
2 United States Government Accounting Office Report to Congressional Requesters. School Meal Programs, Competitive Foods Are Widely Available and Generate Substantial Revenues for Schools. August, 2005.
3 Action for Healthy Kids is a national nonprofit organization dedicated to improving nutrition and increasing physical activity in schools in order to improve children’s health and their readiness to learn. Website: www.ActionforHealthyKids.org.
4 Promar International (2002). School Milk Pilot Test: Estimating the Effects of National Implementation, November 2002, American School Food Service Association and National Dairy Council, Unpublished.
5 Centers for Disease Control and Prevention. Fact Sheet Nutrition Services, from CDC’s SHPPS 2000.
6 Centers for Disease Control and Prevention. Fact Sheet Nutrition Services, from CDC’s SHPPS 2000.
7 Centers for Disease Control and Prevention. Fact Sheet Nutrition Services, from CDC’s SHPPS 2000.
PHOTO CREDITS
The photo on page 11 was provided courtesy of the National Dairy Council. All other photos were provided by the U.S. Department of Agriculture’s Photography Center.
APPENDIX
Descriptions of School Projects
Jones College Prep High School – Chicago
DEMOGRAPHICS
716 students; 18.9% White, 34.5% Black, 34.4% Hispanic, 11.6% Asian/Pacific Islander, and 0.7% Native American; 65% eligible for free/reduced price school breakfast and lunch.
PROJECT DESCRIPTION AND ELEMENTS
• Focused on improving main entrées in the school cafeteria, a la carte items, and nutrition education. Each daily entrée had a healthier profile than the National School Lunch Program (NSLP) nutrient guidelines; a la carte snacks and beverages met similar nutritional standards.
• Less healthy choices were removed from vending machines.
• Twenty students participated in Club Balance, a pilot nutrition education class that met for two hours monthly over a three-month period. Club Balance students taste-tested prospective foods, tracked their eating habits, learned how to use the USDA Food Guide Pyramid, and interpreted food labels.
• Developed and implemented by Chartwells Thompson Hospitality.
METHODS OF PROMOTING HEALTHY FOODS
• Students taste-tested entrees, healthier a la carte items, and beverage alternatives to soft drinks.
• A bulletin board in the lunchroom displayed a large scale to represent making “balanced choices”.
• One healthier drink item was initially offered at a reduced price.
IMPACT OF PROGRAM ON STUDENT FOOD CHOICES
• A la carte sales during the project time frame had a modest decline; however, sales were better once high-calorie, low-nutrient items were removed from vending machines. • A focus group of 26 students found that 88% had noticed the healthier a la carte snacks and beverages, and that on average they purchased them twice a week.
• A focus group of 26 students found that 88% had noticed the healthier a la carte snacks and beverages, and that on average they purchased them twice a week.
Kennedy High School – Chicago
DEMOGRAPHICS
1,525 students; 40.5% White, 15.3% Black, 42.4% Hispanic, 1.6% Asian/Pacific Islander, and 0.2% Native American; 82% eligible for free/reduced price school breakfast and lunch.
PROJECT DESCRIPTION AND ELEMENTS
• Focused on improving main entrées in the school cafeteria, a la carte items, and nutrition education. Each daily “Balanced Choice” entrée had a healthier profile than the National School Lunch Program (NSLP) nutrient guidelines; a la carte snacks and beverages met similar nutritional standards.
• Less healthy choices were removed from vending machines. • A nutrition lecture was delivered to 340 students in the senior class.
• Developed and implemented by Chartwells Thompson Hospitality.
METHODS OF PROMOTING HEALTHY FOODS
• Lunchroom posters, table tents on lunchroom tables, and stickers highlighted the “Balanced Choice” options.
• All seniors (340 out of 1,525 students) attended a nutrition education session in the school auditorium.
IMPACT OF PROGRAM ON STUDENT FOOD CHOICES
• A la carte sales for the project time frame saw an initial one-month drop, then an increase that exceeded sales for the same period of the previous year.
• Focus groups suggested that students noticed some changes in vending machine offerings and some in a la carte offerings, but had no real awareness of entrée changes.
Kennedy High School – Chicago
DEMOGRAPHICS
1,525 students; 40.5% White, 15.3% Black, 42.4% Hispanic, 1.6% Asian/Pacific Islander, and 0.2% Native American; 82% eligible for free/reduced price school breakfast and lunch.
PROJECT DESCRIPTION AND ELEMENTS
• Focused on improving main entrées in the school cafeteria, a la carte items, and nutrition education. Each daily “Balanced Choice” entrée had a healthier profile than the National School Lunch Program (NSLP) nutrient guidelines; a la carte snacks and beverages met similar nutritional standards.
• Less healthy choices were removed from vending machines.
• A nutrition lecture was delivered to 340 students in the senior class.
• Developed and implemented by Chartwells Thompson Hospitality.
METHODS OF PROMOTING HEALTHY FOODS • Lunchroom posters, table tents on lunchroom tables, and stickers highlighted the “Balanced Choice” options. • All seniors (340 out of 1,525 students) attended a nutrition education session in the school auditorium.
• Lunchroom posters, table tents on lunchroom tables, and stickers highlighted the “Balanced Choice” options.
• All seniors (340 out of 1,525 students) attended a nutrition education session in the school auditorium.
IMPACT OF PROGRAM ON STUDENT FOOD CHOICES
• A la carte sales for the project time frame saw an initial one-month drop, then an increase that exceeded sales for the same period of the previous year.
• Focus groups suggested that students noticed some changes in vending machine offerings and some in a la carte offerings, but had no real awareness of entrée changes.
