By Dayle Hayes, MS, RD 2013-06-11 22:21:44
For decades, numerous K-12-based health initiatives have been launched by public and private entities in an effort to create lasting societal change in our dietary, activity and overall wellness decisions. Are they actually starting to make a difference? IT’S NOT UNREASONABLE TO CONCLUDE that nearly every school in America today currently has some type of health initiative in place. Your school (or district) may be involved in one of the major national initiatives like Fuel Up to Play 60 (FUTP 60), Alliance for a Healthier Generation’s (AHG) Healthy Schools Program, Action for Healthy Kids’ (AFHK) Game On! The Ultimate Wellness Challenge, the Presidential Youth Fitness Program or another campaign. Or your school may have received a U.S. Department of Agriculture (USDA) HealthierUS School Challenge (HUSSC) Award or a Fresh Fruit and Vegetable Program (FFVP) grant. Or perhaps your school is participating in a statewide initiative, like Mississippi’s John D. Bower, M.D. School Health Network, or something significantly more local, like the Chef Initiative launched by the Boston Public Health Commission. While some programs have been in schools for years—HUSSC, for example, began in 2004—many newer ones piggybacked on the attention driven by First Lady Michelle Obama’s 2010 launch of the Let’s Move! campaign to raise a healthier generation of children. In fact, several grew directly out of Let’s Move!, including Chefs Move to Schools and Let’s Move Salad Bars 2 Schools. And dozens of other state and local school health initiatives—too numerous to list here— have sprung up in response to the First Lady’s campaign. While most of these programs combine nutrition and physical activity, their format, frequency and funding vary widely. This means that it can be challenging to accurately ascertain if they are accomplishing their stated goals; it’s even more difficult to assess their true impact on children’s health. Consider, for example, the Chefs Move to Schools campaign: Chefs and schools may have been inspired by the program to form partnerships, but they are not required to register with the official initiative, making it impossible to know how many chefs are working in schools—and impossible to determine what kind of impact those collaborations have on student health. The Road to Research and Results High participation or popularity does not necessarily mean that programs are truly effective in the short or long term. That’s why impartial, outside evaluations often are the most accurate way to assess program success. But evaluation research is always challenging. Comprehensive evaluations require significant resources—time, trained personnel and funding—that are not typically available in “real world” school settings. And sometimes, even once research has begun, additional studies and evaluations are needed to more fully draw conclusions about an initiative’s effectiveness. For example, an evaluation of Boston’s Chef Initiative published in The Journal of the Academy of Nutrition and Dietetics shared the results of a carefully designed, two-year study by Harvard School of Public Health researchers. They concluded that, at the Chef Initiative middle schools, 51% more students chose whole grains and students consumed 0.36 more vegetable servings per day than students at those middle schools that were not participating in the Chef Initiative. Beyond these findings, they could only say that more research is needed “to corroborate these findings, assess the fiscal implications of the menu changes and evaluate the impact of similar dietary changes on health outcomes. Additional research is needed to evaluate if the consumption of healthier school meals impacts food choices outside of school.” Sigh. Another example of a health initiative that is in need of more nationwide data to examine its efficacy is Let’s Move! As part of the celebration for the campaign’s third anniversary earlier this year, Mrs. Obama traveled to Mississippi, which ranked at the top of the list for obesity rates when Let’s Move! was launched. Since then, the state has recorded a 13% reduction in obesity, which the First Lady attributed at least partially to the efforts of local school nutrition operators. “Your schools did hard work. They replaced their fryers with steamers—hallelujah—and started serving more fruits and vegetables and whole grains… . That means that tens of thousands of children here in Mississippi are getting the healthy start to their lives that they need,” said Mrs. Obama. Nonetheless, there is not quantifiable data that definitively links the promotional efforts of Let’s Move! and the healthy changes in school environments to the reduction in obesity levels across the state. Start From a Place of Strength Despite all the limitations of evaluation research, it’s important to understand and acknowledge what we do know about the impact of school-based health initiatives and the early demonstrations of a successful track record. First is an awareness and confidence that school nutrition professionals are in a unique position to put such initiatives in place—and follow through on them. After all, you work every day to serve the next generation of kids and do so in collaboration with members throughout the whole school environment, as well as local community advocates, in order to make a positive difference in student health. If you are trying to get your school involved in participating in a health-based initiative, it’s critical to be able to present the potential benefits to your coworkers, first and foremost. This means your team in the school cafeteria, as well as colleagues in the school administration, teachers, parents and other stakeholders. Be conversant about the value of the effort and the intent. Set your own goals (facts, figures, observations, participation rates, point-of-service data, plate waste) to ensure that everyone is on the same page when it comes to identifying and interpreting some type of measurable impact. This is especially important if you have encountered parents or other community members who dismiss school meals and are skeptical that anything can be done within the school environment that will lead to healthier kids. You want to be able to present them with evidence that school-based health initiatives can and do make a discernible difference. To help you articulate the success of some of these school-based initiatives—and to prepare you to conduct your own evaluations—let’s explore some signs of success from recent evaluations of several national health initiatives. On the National Stage Fresh Fruit and Vegetable Program (FFVP) Federal nutrition programs often benefit from comprehensive evaluations for a simple reason: The evaluation component is mandated and funded by the legislation authorizing the program. This was the case with the recently released Evaluation of the Fresh Fruit and Vegetable (FFVP) Program: Final Evaluation Report, published by USDA’s Food and Nutrition Service, Office of Research and Analysis. The research document contains more than 390 pages of data and conclusions, with dozens of detailed charts and almost 120 pages of the evaluation surveys used with various participant groups. (A much more user-friendly summary document is two pages of bottom-line talking points.) The evaluation was carefully designed by researchers at Abt Associates and involved hundreds of schools, thousands of students across the country and trained personnel to administer surveys and conduct interviews. All of this means that the results of this evaluation can be shared with the confidence that they truly represent the actual impact of the FFVP in U.S. schools. The bottom line of the FFVP evaluation is quite positive, confirming the results of several smaller-scale studies that examined the program in a single state. (The results of any one evaluation are more compelling when they are confirmed by other studies with a similar design.) From the summary, here are some key findings from the 2013 Final Evaluation Report. • FFVP students consumed more fruits and vegetables than non-participating students. On the days that a FFVP snack was served, students consumed about one-third cup more of produce, mostly in the form of fruit, rather than vegetables. • FFVP students consumed more carbohydrates, beta-carotene, fiber and vitamins A and C than non-participating students, but they did not consume significantly more calories. • FFVP schools offered nutrition education more frequently than non-participating schools. Significantly more FFVP schools offered a variety of nutrition education materials and messaging to students and staff. • A majority of FFVP students took, tried and consumed the fruit or vegetable snack when it was offered. Overall, fruit snacks were found to be more popular with students than vegetable snacks. • Everyone surveyed—from students to principals— had very positive opinions about the FFVP in their schools. More than 85% of the participating directors, principals, school nutrition staff, teachers, students and parents reported a positive opinion of FFVP. Nearly all participating students (97%) wanted FFVP to continue in their schools. Since so many districts now have the FFVP in at least some of their schools, following are some ideas that you can add from your own experience, if you choose to perform your own evaluation: • Pounds of produce served and/or procured from local farms • Favorite produce items served to students in your school • Strategies you are using to specifically increase vegetable popularity • Specific nutrition education lessons provided in your program • Photos and brief stories about student enjoyment of FFVP snacks HealthierUS School Challenge While the HealthierUS School Challenge also is a federal program administered by USDA, its establishment did not come with the same mandate for evaluation as the Fresh Fruit and Vegetable Program, nor any funding to support such research. Information about the impact of HUSSC awards is positive but limited. It comes from two sources, both of which looked at a small sample of schools that won awards (under the old criteria in place prior to the implementation of the new meal patterns for school lunch and breakfast). The first source of impact data was a sub-study of the comprehensive School Nutrition Dietary Assessment Study-IV (SNDA-IV), conducted by Mathematica Policy Research in SY 2009-10 and published by USDA’s Food and Nutrition Service, Office of Research and Analysis in 2012. Since the overall number of award winners was small at that time, SNDA-IV looked only at a random sample of HUSSC-designated elementary schools and compared them to elementary schools nationwide. Two findings stand out in this evaluation. • Compared with elementary schools nationwide, larger proportions of HUSSC schools met most of USDA’s School Meals Initiative for Healthy Children (SMI) standards for both NSLP lunches offered and served. • HUSSC elementary schools also offered raw vegetables (63% vs. 57%) and fresh fruit (82% vs. 56%) more frequently on lunch menus compared with non-HUSSC elementary schools. A smaller 2012 study published by researchers at Texas Woman’s University also found positive results among HUSSC award winners. They analyzed surveys from a national sample of 76 schools (out of 149 winners as of January 2011). Among the findings of this research: • The three most frequent challenges reported were limited availability of whole-grain items, increased food costs and student acceptance of healthier items. • Compared to the period prior to the award, average lunch participation had increased slightly, while current nutrition education minutes per week, food costs and labor costs had increased significantly. Since, HUSSC participation has increased dramatically at all grade levels, and this would be an opportune time to evaluate the program under both the old and new criteria. With 5,524 schools certified under the old criteria as of March 8, 2013, it would be possible to have much larger sample sizes and, perhaps, to compare the impact of the different criteria used for awards. (Note: If your school is an HUSSC award winner, please make time to respond to any surveys or requests for interviews about your program! Evaluation is always better with higher response rates.) Healthy Schools Program The Alliance for a Healthier Generation (AHG) was founded in 2005 as a partnership between the American Heart Association and the Clinton Foundation. AHG’s Healthy Schools Program (HSP), started in 2006 with financial support from the Robert Wood Johnson (RWJ) Foundation, has a strong commitment to research and evaluation. In 2012, AHG and RWJ researchers published two articles from an in-depth analysis of the first four years of the Healthy Schools Program, with participation by more than 1,300 schools with high rates of childhood obesity and predominantly low-income, African American or Hispanic students. These schools participated in intensive training sessions and had access to AHG’s online resources, as well as to ongoing technical assistance and grant opportunities. From this thorough evaluation, conducted prior to the release of even the proposed changes to the school lunch meal pattern, here’s what we know about the first four years of the HSP: • An impressive 80% of HSP schools made progress in creating healthier environments by implementing policies and programs that improved the nutritional value of foods, health education, physical education and access to physical activity. • An estimated 56% of HSP schools improved the nutritional value of the foods served as a part of school lunch and breakfast. Schools made an average of seven to eight specific changes, including increasing whole grains, serving more lowfat or fat-free milk and offering more fruits and vegetables. • In addition to healthful changes made to school meals, other changes were documented in HSP schools. Specifically, 58% established an employee wellness program to help staff to model healthy eating and physical activity behaviors for students; 44% enhanced their physical education programs; and 41% found new ways to help students increase their rates of physical activity. While acknowledging that some schools might be able to implement these and similar changes relying predominantly on the online AHG/HSP resources (as well as tools from similar programs), the 2012 evaluation did suggest that technical assistance and intensive staff training increased the likelihood for success with the changes promoted in this school-based health initiative. The study also directly assessed some childhood health parameters in a smaller, random sample of 21 HSP schools, where researchers identified some promising indicators of health improvements among students. These included reduced consumption of sugar-sweetened beverages, increased time in physical education and decreases in average BMI (body mass index levels). Even with the limitations of this evaluation acknowledged by the researchers (notably, lack of validation for school meal changes and the absence of a control group), this study confirms that schools can create healthier environments that do make a difference in student health. It also underscores the critical need for training and technical assistance in making—and sustaining—healthy changes. Action for Healthy Kids Action for Healthy Kids (AFHK), founded in 2002 with Surgeon General David Satcher, MD, takes a different approach both to its programming and to evaluating the impact of the initiative’s efforts. With funding from several different foundations and agencies, AFHK supports a wide variety of nutrition and physical activity grant opportunities for schools, including efforts targeting youth (Students Taking Charge), families (Parents CATCH On To Wellness) and overall school environments (Game On! The Ultimate Wellness Challenge). While AFHK does provide evaluations of these programs separately, its major assessment comes from key indicators of its overall reach; these are based on the goals of its 2009-12 strategic plan. In the most recently published year-end report for 2011 (2012 data are currently being analyzed, and a complete report is expected to be available soon), AFHK shows impressive growth toward goals in all categories, including: • 8.5 million students reached with its various programs • 20,500 schools reached • 34,000 volunteers and constituents engaged • 397 trainings and events • $10 million in-kind volunteer contributions Fuel Up To Play 60 Fuel Up to Play 60 (FUTP 60), a partnership of the National Dairy Council (NDC) and the National Football League (NFL) in collaboration with USDA and supported by SNA, was launched in 2009. FUTP 60, a student-centric, flexible school wellness program, is, on paper, the furthest-reaching school-based health initiative in the United States. According to a 2012 FUTP 60 Fact Sheet, the program has enrolled nearly 73,000 schools, involving more than 11 million students and 26,000 adult program advisors. Recent evaluations have shown that FUTP 60 contributes to positive changes in the school environment and in healthy student eating and physical activity behaviors. FUTP 60 was first evaluated at the conclusion of a pilot program conducted in 72 middle schools nationwide during SY 2009-10. The pilot results confirmed that a variety of schools, under various conditions, were able to implement FUTP 60 and improve their schools’ nutrition and physical activity environment. • FUTP 60 pilot schools made changes in many school wellness practices. On average, schools improved in five nutrition areas and three areas of support for physical activity. • Results from pre/post student surveys (involving more than 30,000 students) found a small but significant increase in the number of students eating breakfast, dairy, vegetables, fruits and whole grains. • More students also had opportunities for 60 minutes of physical activity six days a week after implementing FUTP 60. Annual FUTP 60 Utilization Surveys (conducted in Spring 2011 and 2012) also confirmed the positive impacts of the program. The surveys are conducted with adults in more than 10,000 enrolled schools, and the data are statistically weighted to correct for non-response bias. Here are some of the key findings from the last two FUTP 60 Utilization Surveys: • Students participate at many levels, such as taking the lead to plan nutrition and physical activity opportunities, conducting in-school promotions and participating in school-wide wellness events and ongoing initiatives. • Schools receiving FUTP 60 grants report higher levels of student involvement; nearly one-quarter of schools receiving funding claim that 100% of the student body is involved with FUTP 60 activities. • There is a positive correlation between greater student participation and greater health improvements in the school environment and among students. More school adults in 2012 than 2011 felt that FUTP 60 helped increase the presence and visibility of healthy foods on campus (56%); helped increase physical activity opportunities for students (66%); helped students make healthier food choices (70%); and helped increase the amount of time students are physically active (62%). A Culture of Wellness While the research findings highlighted in this article represent an important start in the ongoing evaluation and anticipated success of K-12 health initiatives, the need to dig into the data to determine detailed, quantifiable—and applicable—results remains. In the meantime, school-based initiatives themselves continue to be more vital than ever. According to The Wellness Impact: Enhancing Academic Success Through Healthy School Environments, a report published earlier this year by the GENYOUth Foundation, National Dairy Council, American College of Sports Medicine and American School Health Association, “The rise in poor nutrition, inactivity and unhealthy weight among children and youth not only adversely affects academic achievement, but also comes with devastating monetary, individual and societal costs.” Some of these costs include higher healthcare rates for employees, additional instructional costs to support underperforming students and higher medical costs for businesses, as well as disability and unemployment benefits related to obesity, the findings state. To do your part in helping to develop a generation of healthy, productive Americans, you can continue your participation in various school-based initiatives— both those coordinated by the school nutrition department and those spearheaded elsewhere in the school community. Stay on the lookout for new ways to get involved in similar campaigns. Remember, national and state initiatives such as the ones featured in this article can help school nutrition professionals to create a culture of wellness at school and throughout local communities alike. Dayle Hayes is a nutrition consultant and speaker based in Billings, Mont. She also maintains the School Meals That Rock Facebook page (www.facebook.com/SchoolMealsThatRock). You can reach her at EatWellatSchool@gmail.com. Photography by Stuart Monk, Josh Rinehults, Ljupco, esolla and Chris Fertnig/ iStockphoto.com. SNAPSHOT • High participation or popularity does not necessarily mean that programs are truly effective. • Many factors make it difficult to assess the long-term impact of school-based health initiatives. • To win over naysayers, learn to articulate the success of such initiatives—and support national results with local data. Look Who’s Talking… …about peer influence Eating is, and will always be, a social activity. The lunchroom culture is one that is complex, stacked with emotions and thoroughly intertwined relationships involving food, friendships and fitting in. Peer pressure is most often assumed to be negative, and it often is, since for many kids, food has an undeniably social connotation—going out for ice cream, getting a pizza to share with friends and so on. Kids are bred to associate celebration and fun with the fatty, less-healthy foods that should be considered as a treat. But peer pressure also can be a great tool, when used correctly. All it takes is one kid to try something new, one kid to have a new idea, for the effects to ripple. The reason that peer pressure is so electric and contagious is that it comes from within. Kids fear the unknown, dislike what is unfamiliar—but all it takes is one kid to get the ball rolling. Adults have a crucial role in this, as well. Not only do kids often take cues from adults subconsciously, they naturally follow by example. Parents, as well as teachers, can do a lot to set in motion good habits and encourage positive peer pressure, especially by exhibiting the behaviors that they’d like the kids to pick up on. However, as much as adults can encourage types of behavior, it is incredibly powerful to see a peer trying something new. Chloe Rosen, 17, Noble and Greenough School, Concord, Massachusetts School Nutrition thanks our youth authors, representatives of the Alliance for a Healthier Generation’s Youth Advisory Board, for sharing their insights and enthusiasm with readers. Look Who’s Talking… …about changing the world Our future is not bright. Obesity is one of the rapidly growing health concerns we face today; both obesity and malnutrition act as facilitators, making way for even more healthcare issues, such as diabetes, high blood pressure, high cholesterol and cancer. As the old saying goes, “Knowledge is power,” and it’s exactly what is needed to end this epidemic. As a community, as a country, as the future, we must work together. Information and resources are needed to help others maintain a healthy lifestyle. Communities must band together. Youth especially have the power to inspire all generations. Advertising and forums and health fairs are building blocks for educating the community. When I organized my first health fair, the time and effort I put into it was enormous, but so was my satisfaction when I realized that people actually learned about living healthy. Working to advocate for [solutions to] childhood obesity has opened my eyes to the fact that youth have the power to reach all generations. It is important to involve youth in order to make the enormity of the childhood obesity epidemic real. Health reigns as an important factor in all three factions of life: physical, emotional and mental; we must maintain a balance and have good health in all three areas. Knowledge is a powerful and necessary tool, and it is imperative that we find a way to educate our communities, equipping them with tools to create a brighter future. After education, motivation is the key to driving home the importance of knowledge. Ideally, I would like to ensure that every community has affordable healthy foods and a safe space [where people] can remain active. I would cover the bill, if that was needed, at stores in order for them to sell healthy foods [at an affordable cost]. I would advocate the importance of requiring physical education within schools and create non-profit organizations that build elaborate areas for staying active. Unfortunately, I am not currently able to make that happen [on my own], but I will work toward [these goals]. In order to succeed and live a healthier lifestyle, we all must commit to helping one another and encouraging everyone to be the best we can be throughout our journeys. Then our future will shine bright. Ashlyn Pinkins, 17, Thomas Jefferson Senior High School, Gretna, Louisiana School Nutrition thanks our youth authors, representatives of the Alliance for a Healthier Generation’s Youth Advisory Board, for sharing their insights and enthusiasm with readers. Look Who’s Talking… …about changing the world We’ve all heard it before—our generation is more precariously perched than any other from times past. With new problems emerging each day, from oil spills to new diseases developing, one cannot help but agree with this sentiment. Our future is in jeopardy, but for once, there seems to be a beacon of hope; it’s us, it’s the youth of the next generation. Living in Connecticut, I have seen a lot of the tragedies that have affected our nation within the last year. Over 99% of my town lost power during Hurricane Sandy; I live a mere 20 minutes from where the Sandy Hook shooting occurred; and relatives and friends of community members were injured in the recent Boston Marathon bombings. I will steadfastly argue that global warming is indeed occurring and damaging our planet. I will staunchly advocate for gun control, having seen the effects so close to home. But then there are the issues and problems threatening our world that do not directly affect me, yet I can understand why we need change. Poverty is not a major issue in my community, yet its effects are far-reaching. Poverty is like the trunk of a tree, with other problems branching off that can prove to be serious, as well. For example, infectious diseases are bred in impoverished conditions. They spread rapidly through areas with limited resources, poor sanitation and a generally uneducated population. All of these byproducts of poverty can affect my community, too—sanitation problems cause new diseases that spread before anyone has time to create a cure; limited resources give rise to future inadequacies in public policy and funding; and an uneducated populace leads to the proliferation of poverty. But my generation has a secret weapon: We know the consequences of inaction. I’m here to put my foot down, refusing to become a member of the generation known to have created a forsaken planet, destroyed humanity, spurring our own self-destruction. I will not conform to this idea that we are good-for-nothing teenagers who are unable to effect change. Rather, I am striving to be one who makes the difference. We have the power to educate in a way the world has never seen. Yes, social media can seem all-consuming, but it is also a link between individuals, a way of coordinating global projects to ensure that our generation goes down in history as the one that has made good, lasting changes in this world. People will look back at this generation and not think that we’ve doomed all future civilization, but instead set a brilliant example. We are willing to get dirty and work hard to provide for the betterment of the community. We are willing to do the tough jobs that no one else has the mental strength to do. We are willing to take one for the team, to motivate the masses and to point out how, together and not divided, we can make a difference. But it must start at the local level, [so that we can show] what change looks like. We can inspire others to take those courageous first steps with us, beginning a long haul to reach every person in this country and on this planet. Daniel Muller, 18, Weston High School, Weston, Connecticut School Nutrition thanks our youth authors, representatives of the Alliance for a Healthier Generation’s Youth Advisory Board, for sharing their insights and enthusiasm with readers. Resources at the Ready Be ready and willing to demonstrate measurable indicators of the success of your efforts by setting benchmarks and other goals that can be tracked. Support what you can through research findings collected beyond your program. Check out articles published twice yearly in SNA’s onlineexclusive The Journal of Child Nutrition & Management (www. schoolnutrition.org/jcnm); visit the Child Nutrition Showcase of research posters at the Annual National Conference in July; and stay abreast of other published reports by reading School Nutrition’s “NewsBites” column and subscribing to the SNA Smart Briefs and CN Direct e-newsletters (www.schoolnutrition.org). Following are additional resources for tracking the success of the specific initiatives highlighted in this article. Chef Initiative/Boston Public Health Commission “Long-Term Impact of a Chef on School Lunch Consumption: Findings from a 2-Year Pilot Study in Boston Middle Schools,” June 2012, Journal of the Academy of Nutrition and Dietetics, http://tinyurl.com/andchefboston Fresh Fruit and Vegetable Program • Evaluation of the Fresh Fruit and Vegetable Program: Final Evaluation Report, http://tinyurl.com/ffvpfinal report • Evaluation of the Fresh Fruit and Vegetable Program— Summary, http://tinyurl.com/ffvpsummary HealthierUS School Challenge • Assessment of Changes in School Nutrition Programs and the School Environment as a Result of Following the HealthierUS School Challenge Program, www.school nutrition.org/Content.aspx?id=17278 • School Nutrition Dietary Assessment Study-IV: Summary of Findings, http://tinyurl.com/sndasummary Healthy Schools Program • Healthy Schools Program: Resources and Tools, https:// schools.healthiergeneration.org • Evaluation of the Healthy Schools Program: Part I. Interim Progress, http://tinyurl.com/healthyschools1 • Evaluation of the Healthy Schools Program: Part II. The Role of Technical Assistance, http://tinyurl.com/healthyschools2 Action for Healthy Kids • Action for Healthy Kids: Accomplishments and Annual Reports, www.actionforhealthykids.org/about-us Fuel Up to Play 60 • www.fueluptoplay60.com GENYOUth Foundation, National Dairy Council, American College of Sports Medicine and American School Health Association • The Wellness Impact: Enhancing Academic Success Through Healthy School Environments, http://tinyurl.com/ndcwellnessimpact
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