AMERICAN CHILDREN, toddlers to adolescents, are getting fatter, faster than ever before. The causes are, as the experts say, “multifactoral.” And so are the solutions. Schools are one place where several factors promote obesity—or could prevent its rapid rise. In an ideal world, family meals provide the opportunity for parents to serve nutritious food in appropriate portion sizes, to pass on healthy eating habits, and to strengthen family bonds through mealtime conversations. Increasingly, however, children eat away from home. The eating-away-from-home trend, which is driven in no small part by the popularity of fast food, fuels the continuing rapid rise in childhood obesity. High calorie, high fat food with few, if any, vegetable and fruit choices are practically universal in the 2 main places children spend their days—in school and in the nearby neighborhood. Ever-available soft drinks, laden with sugar and corn syrup, supply plenty of additional calories—at home and at school.
Snacking is the standard accompaniment to activities throughout the day for most young people. There remain few off-limit locations for eating. Twenty years ago, schools forbade chewing gum; students now bring doughnuts, soda, and candy to class. Many school libraries allow children to eat and read. At most youth sports games, treats—generally candy, chips, and soda—are served at halftime and after the game. Children come with extra soda and chips to fill in the down time. This trend of eating-anywhere-anytime and eating-on-the-go is a big factor in increased obesity. 1
Schools provide both opportunity and food availability to support this growing trend. Vendors on campuses and right outside school gates dispense soda, pizza, fries, burgers, and baked goods to students who rarely sit down to eat a balanced meal from the cafeteria or a nutritious brown-bag lunch from home. One might hope that schools would provide a healthy oasis in an otherwise fattening environment, but quite the opposite is true in many schools. Schools not only allow, but provide many of the high calorie snacks and meals consumed by youth. 2 Some of the challenges, proposed prevention and intervention strategies, and responses to them are presented here.
THE RUNAWAY INCREASE IN CHILDHOOD OBESITY
One out of 3 children and adolescents aged 6 to 19 is overweight or at risk of becoming overweight. Their body-mass index (BMI) places them in the 85th percentile or above on the 2000 BMI growth charts. Over half of these children were at or above the 95th percentile in 2000 and this prevalence rate has doubled since 1980. The number of 3-year-old to 5-year-old children at risk of overweight and those who are overweight is an astonishing 21%—1 out of 5. 3–5 With the majority of these children in school or in preschool for a large part of the day, these institutions are an obvious place to begin reshaping the factors that contribute to this growing health problem among children.
SCHOOL FOOD PROGRAMS AND PROBLEMS
Concerns about the increase in the number of overweight children in the United States has an effect on the $7.9 billion school foods programs that provide more than 6 billion lunches, breakfasts, and after-school snacks to over 27 million children. 6 Almost all public schools participate in the National School Lunch Program, authorized in 1946 “to safeguard the health and well-being of the nation's children,” and administered by the United States Department of Agriculture (USDA). 7 School food programs are key players in both the cause and remedy of childhood obesity, since they are available to so many children. Federal guidelines assure that these lunches are relatively healthy. But the problem is that many students do not eat them because kids say the lunches do not taste very good, and because the students fill up on food from other sources. Or they choose high calorie a la carte combinations that far exceed their energy needs. Many report that they skip lunch and save their money for after school snacks. 8 Snacks are often high calorie fast food—with “fries.”
Nationwide data show that about 10% of school food sold is from the cafeteria USDA reimbursable lunch available to all and specifically to those eligible for free and reduced price meals. Over 70% of school foods is sold a la carte items from the cafeteria “Trend” menu, which offers daily choice of burgers, fries, pizza, ice cream, cookies and other snack type foods, and from school stores; over 20% came from vending machines in the schools. 9 Almost half of the student population reported daily shopping at student stores for lunch or snacks in a survey of 24 public middle schools in Southern California. 10 About 30% of high schools have student stores; most are open throughout the school day and 47% during lunch. The stores are meant to provide students experience in planning and organization as well as a means to support special activities, speech debates, band trips, and the like. Yet the foods they sell—such as king-sized candy bars, chips, cakes, cookies, and soft drinks are generally high in fat, sugar, and calories. Most are low in nutrient density.
School lunch programs “have taken a variety of innovative steps to overcome barriers,” according to a 2003 report, Efforts Needed to Improve Nutrition and Encourage Healthy Eating. These steps are driven by obesity concerns. The average percent of fat in reimbursable lunches in 1999 was 34% compared to 38% in 1993. Fruit and vegetable choices increased. Yet, the report noted that school officials say they are taking a risk that students will buy fewer school lunches when they offer fruit and vegetables or modify popular recipes such as pizza. A second 2003 report, School Meal Programs: Revenue and Expense Information from Selected States reported that just half of the revenue now comes from reimbursable lunches; the other half from the less healthy a la carte food sales. 11,12
Some schools have opted out of the USDA program altogether in order to take advantage of commercial cash and other incentives from food contracts. Besides contracts to sell soft drinks and snack foods in vending machines, chain restaurants have taken over many school cafeterias. It is worth noting that vegetables and fruits required by USDA school food guidelines are not likely to be available when schools opt out of government programs. But, unfortunately, they are unlikely to be missed. A study of fourth-graders found that half the children served vegetables did not eat them. 13 Children are less likely to eat their vegetables when they come from a can and are overcooked, but for many schools, serving fresh produce is difficult.
Again, money is an issue. “I've been in school kitchens where they haven't the simplest tools like knives or equipment to store fresh fruits and vegetables, much less processors for shredding and chopping or containers and utensils for salad bars,” Thomas Forster, of the nonprofit Community Food Security Coalition, told the New York Times. 14
Cafeteria managers agree. In analysis of nationwide government survey data, 65% said that a major reason for plate waste is that children do not like the food; 50% said children do not like the way food looks or tastes. Socializing and not having enough time to eat were also named as reasons for not eating their meals. 6
In some schools, the problem is not the lack of equipment or even serving only easy prepackaged foods. Many food service managers are eager to serve attractive food, the cooks would be pleased to cook rather than open packages and reheat foods, the students would enjoy freshly prepared salads and vegetables. Yet, centralized buying contracts with corporate food companies and low-cost USDA food commodities divert funds from local and fresh food sources. Difficulties with food service unions pose another barrier to on-site food preparation. 15
The debate on serving high-fat fast food and selling high calorie, low nutrient snacks in schools is making headlines, but nutrition advocates warn that it will do very little to improve the unhealthy foods served and sold in our schools every weekday if parents, school boards, and state education standards do not move healthy food higher on the list of priorities for school children. “If Johnny can't read by first grade, parents are going to be up in arms,” says Connie Holt, a dietitian. “But if he gains 5 pounds in first grade and doesn't eat well, nobody's going to say anything.” 16 There are also similar problems with disappearing recess and physical education—both have low priority in school schedules.
PHYSICAL ACTIVITY PROGRAMS FACE CHALLENGES
Today's students are less fit than ever before, 17–20 in large part because physical activity is no longer built into their school days. Ironically, educators' and administrators' well-meaning efforts to boost academic standards is partly to blame for the reduction in physical fitness, because students who are burdened with homework and busy with computer assignments have less time and energy to run around at recess, take a gym class, or join after-school sport activities.
Recess has all but disappeared from the daily school schedule. Principals complain that they have little money to hire aids to supervise children in playgrounds; besides, more supervision than in the past is needed because parents demand increased safety standards. Another reason is that kids are simply more sedentary and less fit and are not able to participate in vigorous, or even moderate physical activity. In 1991, 46% of high school students and 57% of middle school students took a daily physical education class. By 1999, those figures had dropped to 29% of high school students and 35% of middle school students. Of those participating, only 38% were physically active in the class for more than 20 minutes. 17 Further, 2000 statistics show that only 40% of high school students enroll in physical education; by twelth grade, enrollment is only 37%. 18 Girls have lower rates of physical activity than boys; starting in early adolescence, girls' physical activity declines at least 7% per year; boys' activity decreases 3% per year. 19
More startling than the drop in physical education participation is the worsening of physical fitness among children of all ages, regardless of BMI. Only 3% of children surveyed by the Center for Disease Control in 2001 met the standard for 30 minutes of continuous vigorous physical activity (aerobic capacity measured by heart rate). 20
Even as the rate of physical activity falls and obesity rises, both parents and children state that physical education (PE) is important at school. Over 80% of adults and 70% of teens believe that daily PE should be mandatory in schools. 21 One way to get attention and respect for physical activity is to revamp the old “PE for athletes” into “PE for fitness.” This new PE philosophy encourages gym teachers to focus as much or more on coaching poorly conditioned kids as they do on the student athletes. “Proponents of the New PE say their goal is to get “mouse potatoes” moving again. 22 Momentum seems to be building among educators and legislators to salvage PE and make it a priority.
Improving school food is also rising in the list of concerns for our children's health. There are reports, too, that schools around the country are taking on the challenge of providing healthier food: initiating farm to school produce programs, remodeling school cafeterias as attractive “dining destinations,” promoting “schools that cook” programs, and leveraging buying power to buy healthier food.
WHAT SCHOOLS AND HEALTH PROFESSIONALS CAN DO
Even if schools want to become part of the solution and make obesity prevention a high priority, they face significant hurdles. School administrators were surveyed and asked to name the barriers to making changes on campus that would help prevent and treat obesity: 49% named lack of trained personnel; 43% said lack of materials; 40% lack of classroom time; 40% lack of funds; and 34% lack of staff time, especially in low social and economic school districts. 23
The main problem is money, lack of money to support the healthy food and physical activity needs of kids, and to meet the expectations of parents and teachers for academic achievement. Here are actions that schools can take—with the support of health professionals, parents, the community, and state and local funding.
Offer healthier alternative food and beverage choices
Two dozen states introduced legislation in 2002–2003 to regulate school vending machines or set new nutrition standards such as bans on candy and soda, according to the National Conference of State legislatures. 24 For example, California school boards did not renew lunch contracts with Pizza Hut and sought healthful juice and water alternatives for school vending machines. In 2003, New York City enforced regulations that ban the sale of soda, chewing gum, and hard candies in schools and began offering free breakfast to all children.
School stores that sell foods of “minimal nutritional value” are also being overhauled in some school districts. The snack bar at Aptos Middle School in San Francisco used to sell items such as extra-large cheeseburgers, Slim Jims, and Hostess cupcakes. “I'd see kids coming in with $2 and buying a 20-ounce caffeinated soda and a giant bag of chips every day,” the principal told the San Francisco Chronicle. But then the snack bar revolutionized its food offerings after the school district passed a resolution calling on schools to phase out unhealthy food offerings. Now the snack bar menu offers items such as chicken vegetable soup and fruit, while the vending machines dispense bottled water. “We have not seen kids bringing in their own junk food or quarts of soda. It has worked really well,” one parent reported. 25
Overhaul the school lunch program to make it more appetizing, nutritional, and popular
Over 135,000 high school students around the country participated in student-led dialogues in nearly 250 high schools to identify their top 10 concerns about schools, communities, and the world in which they live. Most concerns were with school; school lunch policies were number one. Students were concerned with cost and quality of lunch and advocated longer lunches and improved nutritional value. 26
Nancy Rice, nutrition services director in Griffin, Ga, tried some of the student recommendations from a survey by the National Foodservice Management Institute and was successful in raising lunch participation. These recommendations include sandwiches and a fresh fruit bowl served everyday and express carts that help speed up the serving lines with only 1 choice per line. Ready to go salads packed in “see-thru” containers have been a sold out success in many schools. And, a scheduled lunch of at least 20 minutes from “sit down” time improves the lunch experience. 8
An inspiring model is Opelika, Ala, where parents and school officials in this rural community decided that nutritious school lunches were nonnegotiable and increased financing to buy fresh fruits and vegetables from local farms, and prepared them in the school kitchens. Kids there eat and like fresh sweet potatoes, butter cream peas, and black-eyed peas. 14
Just as inspiring, the 54,000 student, urban school food revolution example in Oakland, Calif took nearly 2 years of planning and team building to serve nutritious lunches. 27 Oakland Unified School District formed a nutrition task force that negotiated improvements, including buying nutritious prepared food from local merchants that kids like and is sold by students from easy access carts. The goals they implemented were as follows:
- Identify foods that are nutritious and liked by students, eg, vegetable wraps, tasty grilled chicken, soy burgers, salads, and fruit juice.
- Serve enjoyable and culturally familiar foods; expose students to new foods, eg, “yam sticks.”
- Improve the quality of food service workers by working with their unions in training them and developing career ladders.
- Proactively work with parents and the school board to fund the purchase and preparation of fresh foods and to reduce the expectation that the school food program should not only pay for itself, but make money for other activities. This goal was the most difficult to implement in Oakland and many schools.
- Seek cooperation from teachers and school officials to buy into the idea that learning about food and health is important in the curriculum.
Implementing these goals required a widespread grassroots strategy and work that involves the school board, the budget, the school officials, the teachers, and students. The Surgeon General's Call to Action To Prevent and Decrease Overweight and Obesity triggered many ideas and actions to help overweight children and adolescents around the country. One excellent resource group initiated by the Surgeon General is Action for Healthy Kids (www.actionforhealthykids.org). Their “virtual folder” on Health-Promoting Foods in Our Schools provides fact sheets, data, research reports, tools, and programs that work. The Web site provides a slide presentation for “making the case” to school officials.
Reinstate daily recess and physical education, and promote physical activity throughout the day
The “New PE,” is structured to meet the needs of individual kids with the aim of fitness for life. The Web site www.PE4Life.org offers ideas on how to make “PE For Life” work for schools. Implementing this new approach to physical education and reclaiming recess are vital to a child's development and major tools for preventing obesity.
“Take 10!” in the classroom is a program that includes physical movement in short spurts to increase study efficiency. This program is guided by teachers and provides an opportunity to help meet the 60 minutes of daily activity recommended for children. See www.ilsi.org/activities.
Encourage walking to school
Of trips to and from school that are 1 mile or less, only 31% are made by walking; of those within 2 miles, just 2% of school trips are made by bicycling. Parents and schools can support the nationwide Kidswalk-to-School initiative, a coalition of several government agencies and volunteer organizations spearheaded by the Centers for Disease Control.
Kidswalk-to-School is a program to promote safe routes for walking to school. One aspect involves organizing “walking trains” with volunteer leaders to ensure safe passage by foot. Another aims to reduce bus stop pickups by having children walk in groups accompanied by adults to one central bus stop in a neighborhood. The program offers a step-by-step plan to involve kids, parents, school officials, police officers, and community members. A “Walkability Checklist” is helpful in getting a program started (www.walkinginfo.org).
Use interdisciplinary intervention to reduce youth obesity
Parents and school boards must identify nutrition and health as priorities and, in turn, support teacher training to highlight learning healthy food and fitness behaviors as part of the daily curriculum. One place to start is with the Cookshop Program, a nutrition education curriculum for school children grade K-6. The program is designed to encourage children and their families to eat more vegetables, fruits, and whole grains. It links foods served in the School Lunch Program with children's experience in preparing, cooking, and learning about these foods in the classroom and at home. 28
If the value and need for improved food and physical activity is recognized as a priority, several programs are available for adapted use in the curriculum and in after-school programs. A program tried and tested for 2 years in public schools in 4 Massachusetts communities, “Eat Well and Keep Moving,” has been used in 14 city schools in Baltimore for 4 years and others across the country. Its development and evaluation was supported with grants from the National Institutes of Child Health and Human Development, the Centers for Disease Control and Prevention, Harvard School of Public Health, and sister institutions. First called Planet Health, the program is a multifaceted program that encompasses all aspects of the learning environment—classroom, cafeteria, gymnasium, school hallways, home, and community centers. Among girls in the 2-year study phase, the rate of obesity decreased compared to girls in schools without the program. Both girls and boys reduced television hours and increased fruit and vegetable consumption as compared to the children in schools who did not have the program. 29
Keep schools open longer on a daily and annual basis for after-school activity
Quality, supervised, after-school physical activities in school facilities for all children who need them require as many, although different, resources as the regular school program. A tested and ready-to-go active recreation program is SPARK—Sports, Play, and Active Recreation for Kids aged 5 to 14. Developed and tested at San Diego State University, this program includes training youth leaders, teachers, after school staff and parents in strategies that motivate participants. The program focus is on fun, inclusive activities: cooperative and aerobic games, multicultural dances for all ages, modified sports to incorporate all skill levels and both sexes, challenging competitions without elimination, and nutrition awareness (www.foundation.sdsu.edu/projects/spark).
As health professionals, parents, and caretakers of the future generation, there is much to be done about the rising rate of obesity among children. Working with schools is an excellent way to restore the health of our children by providing attractive and nourishing food choices, a variety of physical activities for children of all sizes and abilities, and opportunities to learn about food and health in the classroom.
1. Binkley JK, Eales J, Jekanowski M. The relation between dietary change and rising US obesity. Int J Obes Relat Metab Disord
2. Goodnough A. Schools cut down on fat and sweets in menus. New York Times
. June 25, 2003:B1,B4.
3. Ogden CL, Flegal KM, Carrol MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999–2000. JAMA
4. Ogden CL, Troiano RP, Breifel RR, Kuczmarski RJ, Flegal KM, Johnson CL. Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics
5. Dalton S, Watts SO. Defining childhood obesity: revised 2000 growth charts, body mass index, and public perceptions. Top Clin Nutr
6. Ralson K, Buzby J, Guthrie J. A healthy school meal environment. Food and Nutrition Research Report, FANRR 34-5. Available at: www.ers.usda.gov/publications/fanrr34-5
. Accessed July 26, 2003.
7. Child nutrition programs: school meal initiatives for healthy children; final rule. 7CFR, Parts 210, 220. Fed Regist
. June 13, 1995:1–20.
8. Trissler RJ. Food for thought: new directions for school foodservice. J Am diet Assoc
9. Kennedy E. Healthy meals, healthy food choices, healthy children: USDA's Team Nutrition. Prev Med
10. Wildey D. Food sold in school stores. J Am Diet Assoc
11. US General Accounting Office. Efforts needed to improve nutrition and encourage healthy eating, GAO-03-568. Available at: www.gao.gov
. Accessed October 2, 2003.
12. US General Accounting Office. School meal programs: revenue and expense information from selected states, GAO-03-569. Available at: www.gao.gov
. Accessed October 2, 2003.
13. Baxter SD, Thompson WO. Fourth-grade children's consumption of fruit and vegetable items available as part of school lunches is closely related to preferences. J Nutr Educ Behav
14. Becker E, Burros M. Eat you vegetables? Only at a few schools. New York Times
. January 13, 2003:A1, A14.
15. Arnow P. Obesity and the schools. Gotham Gazette
. November 11, 2003:24.
16. Yeoman B. Unhappy Meals. Mother Jones
. January/February, 2003:81.
17. CDC, President's Council on Physical Fitness and Sports. Healthy people 2010. 2000. Available at: www.health.gov/healthypeople/document/HTML/Volume2/22Physical.htm
. Accessed September 13, 2001.
18. Centers for Disease Control and Prevention. Youth Behavior Surveillance System: U.S. Summary Results 2001
. Atlanta, Ga: CDC; 2001.
19. Sallis JF. Epidemiology of physical activity and fitness and adolescents. Crit Rev Food Sci Nutr
20. Pate RR. Physical activity and fitness of children and adolescents. Ann Epidemiol
21. National Association for Sport and Physical Education. Public attitudes toward physical education. February 2000. Available at: www.aahperd.org/naspe/whatsnew-survey
. Accessed July 10, 2003.
22. Tyre P. Getting physical: a new fitness philosophy puts gym teachers on the front lines in the battle against childhood obesity. Newsweek
. February 3, 2003:46–47.
23. Story M. School-based approaches for preventing and treating obesity. Int J Obes
. 1999;23(suppl 2):S49–S54.
24. Center for Science in the Public Interest. State Degislation and statutes health promotion. Available at: www.cspinet.org/policy
. Accessed August 8, 2003.
25. Severson KLA. Schools to stop soda sales: district takes cue from Oakland Ban. San Francisco Chronicle
. August 28, 2002:A1.
26. Pew Charitable Trusts. Project 540: students turn for a change, high school students nationwide speak out on issues that matter most to them. News release
. April 28, 2003. Available at: www.project540.org
27. Lau E. Childhood obesity prevention in the schools. Presented at: Childhood Obesity Conference on Making an Impact Now: Environmental, Family and Clinical Approaches; January 6–8, 2003; San Diego, Calif.
28. Castle J. The CookShop Program
. New York: Community Food Resource Center, 39 Bdwy, New York, NY 10006.
29. Gortmaker SL, Peterson K, Wiecha J. Reducing obesity via a school-based interdisciplinary intervention among youth. Arch Pediatr Adolesc Med