2

The Current Opportunity

Important Points Made by Individual Speakers

  • Poor eating and physical inactivity increase the likelihood of poor educational outcomes, which will have a direct impact on the future state of society.
  • Issues of healthy eating and wellness are attracting more attention today than they have in the past.
  • The knowledge and resources exist today to change eating patterns and food environments.
  • Innovations in nutrition education could occur on a state-by-state basis and then expand.
  • Hunger and obesity are societal problems, not the fault of any particular institution, which means that everyone can contribute to solutions.

In the first two sessions of the workshop, three speakers explained why the time is right for national nutrition education curriculum standards. The severity of the hunger and obesity problems has intensified an ongoing conversation to the point where action is possible. The knowledge and resources to teach students about healthy eating either already exist or could be developed. Education standards could capture and embody the collective responsibility of society to counter obesity and poor health outcomes. For these reasons and more, the workshop presented an opportunity to advance understanding of nutrition education.



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2 The Current Opportunity Important Points Made by Individual Speakers • Poor eating and physical inactivity increase the likelihood of poor educational outcomes, which will have a direct impact on the future state of society. • Issues of healthy eating and wellness are attracting more atten- tion today than they have in the past. • The knowledge and resources exist today to change eating pat- terns and food environments. • Innovations in nutrition education could occur on a state-by- state basis and then expand. • Hunger and obesity are societal problems, not the fault of any particular institution, which means that everyone can contrib- ute to solutions. In the first two sessions of the workshop, three speakers explained why the time is right for national nutrition education curriculum standards. The severity of the hunger and obesity problems has intensified an ongoing conversation to the point where action is possible. The knowledge and re- sources to teach students about healthy eating either already exist or could be developed. Education standards could capture and embody the collective responsibility of society to counter obesity and poor health outcomes. For these reasons and more, the workshop presented an opportunity to advance understanding of nutrition education. 7

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8 NUTRITION EDUCATION IN THE K-12 CURRICULUM COMBINING HEALTHY FOODS WITH NUTRITION EDUCATION Healthy eating in America poses a dual challenge, said Janey Thornton, Deputy Under Secretary of Food, Nutrition, and Consumer Services at the U.S. Department of Agriculture (USDA). Hunger remains a “real issue,” de- spite the widespread belief that everyone in America either has enough food to eat or is personally to blame for lacking sufficient food. At the same time, obesity is a serious problem across income levels and demographic groups. Poor eating and physical inactivity in turn contribute to key educa- tional risks, including behavioral problems, short-term thinking, lack of motivation, disengagement from learning, and absenteeism. Before coming to Washington, Thornton was a home economics teacher and school nutri- tion director in Kentucky, and “I saw all of these things,” she said. These educational risks increase the likelihood of poor educational outcomes, including poor grades, low standardized test scores, grade level retention, and dropping out. These outcomes will have a direct impact on the future state of society, she said. “When people are saying, ‘We have to get people off welfare rolls,’ . . . it comes back to education.” The Obama administration is committed to improving healthy eating and physical activity, and this commitment has already helped produce pos- itive changes in schools and surrounding communities, Thornton observed. Schools serve about 32 million student lunches daily during the school year, and 12 million children participate in school breakfast programs. Yet, only about 60 percent of the students in schools eligible for the school lunch pro- gram participate, and only about 28 percent of students take advantage of breakfast programs. “Kids aren’t taking advantage of the food that’s there.” Thornton particularly called attention to the problems posed by schools with open campuses, where students can go elsewhere for lunch. “If I’m a poor kid and I’m sitting there and all the cool kids go to the nearest fast food restaurant to eat, do you think I want to be caught dead in the caf- eteria? I would rather be hungry than be viewed as a nerd.” This problem cannot be solved overnight, in part because of the limited capacity of many school cafeterias, but if communities recognized the importance of good nutrition, they could augment school cafeterias and gradually require more students to stay on campus for lunch. The Healthy, Hunger-Free Kids Act of 2010 (P.L. 111-296) calls for local wellness policies that include goals for nutrition education, physical activity, and other school-based activities that promote student wellness, in addition to school-based nutrition guidelines to promote student health and reduce childhood obesity. The act also requires that local wellness policies include goals for nutrition promotion. (Box 2-1 summarizes the act’s well-

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THE CURRENT OPPORTUNITY 9 BOX 2-1 Requirements of the Healthy, Hunger-Free Kids Act The 2010 Healthy, Hunger-Free Kids Act (P.L. 111-296, Sec. 204) “requires each local educational agency participating in the National School Lunch Program or other federal Child Nutrition programs to establish a local school wellness policy for all schools under its jurisdiction. Each local education agency must designate one or more local education agency officials or school officials to ensure that each school complies with the local wellness policy.” At a minimum, a local school wellness policy must •  nclude goals for nutrition promotion and education, physical activity, and I other school-based activities that promote student wellness. • nclude nutrition guidelines to promote student health and reduce childhood I obesity for all foods available in each school district. •  ermit parents, students, representatives of the school food authority, P teachers of physical education, school health professionals, the school board, school administrators, and the general public to participate in the development, implementation, and review and update of the local wellness policy. •  nform and update the public (including parents, students, and others in I the community) about the content and implementation of local wellness policies. •  e measured periodically on the extent to which schools are in compli- B ance with the local wellness policy, the extent to which the local education agency’s local wellness policy compares to model local school wellness policies, and the progress made in attaining the goals of the local wellness policy, and make this assessment available to the public. SOURCE: USDA-FNS, 2013a. ness provisions.1) The educational component of the act raises several key questions, according to Thornton. What is the best way to promote food literacy and nutrition knowledge and educate students on how to make healthy eating choices? How can parents learn to say no when their chil- dren ask for unhealthy foods? How can teachers be trained and convinced not to use unhealthy treats as a reward for achievement in schools? Many states used to require that future teachers take a basic course in nutrition education, but such courses generally are no longer required for teacher certification. “Yet, we expect nutrition education to be implemented and integrated in our classrooms today,” Thornton said. 1 See http://www.fns.usda.gov/tn/healthy/wellnesspolicy.html.

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10 NUTRITION EDUCATION IN THE K-12 CURRICULUM A wealth of resources and information is available.2 But putting these resources to use requires changes in schools. When Thornton was a school nutrition director, she tried to do some kind of nutrition education activity in 12 classrooms per year. But she oversaw 24 schools and spent less than an hour in each of those classrooms each year. “That’s not even a speck of sand on the beach,” she said. Similarly, school nutritionists from land-grant colleges do “great work,” but their impact is dwarfed by the job that needs to be done. Teachers feel overwhelmed and underappreciated, Thornton noted. They need to be empowered to help them understand how good nutrition and healthy eating can improve their classrooms. Teacher educators in colleges and universities need to teach future teachers how to implement nutrition education into their instruction. Teachers need to understand the importance of nutritional balance and proper portion sizes. Nutrition education needs to be incorporated not just into mathematics or science instruction but across the curriculum, with some form of accountability for nutrition instruction. Such changes could occur on a state-by-state basis and then expand, Thornton noted. Schools are highly competitive, and recognition for one school can spur others to make changes. The media can be a catalyst for such changes by celebrating successes where changes in schools increase learning. Thornton described some of the “phenomenal” school visits she has made, from seeing students eating baked kale in Arizona to visiting schools in Idaho where seniors join younger students for lunch and encourage them to eat healthy foods. Many current students have never seen or tasted kiwis, asparagus, Brussels sprouts, or broccoli. “Kids don’t have it at home, and they don’t know what it is.” Nutrition education and physical activity can ease the pressure on school budgets, help students make healthy choices that become lifelong habits, and improve the nation’s health, Thornton concluded. But progress will require acknowledging the issues, continued dialogue, goals focused on the big picture, and recognition of the roles that everyone can play. The realization has been growing that obesity and hunger are societal problems, not the fault of any particular institution. The consequence is that every- one can contribute to the solution. “It’s going to take everybody working together.” 2 See http://www.teamnutrition.usda.gov.

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THE CURRENT OPPORTUNITY 11 A TIPPING POINT FOR NUTRITION EDUCATION The nation has reached a tipping point on issues involving healthy eating and wellness, according to Norris Dickard, who directs the Healthy Students Group at the U.S. Department of Education. Shortly before the workshop, First Lady Michelle Obama announced the Let’s Move Active Schools initiative to create active environments for students before, during, and after school.3 A new report issued by the Healthy Schools Campaign and Trust for America’s Health, entitled Health in Mind, has compiled the scientific studies related to good nutrition, physical activity, learning, and mental health, providing what Dickard called “a good summary of the connection between healthy mind, wellness, and academic achievement” (Carr et al., 2012). Emerging science has informed the nutrition standards embodied in the MyPlate guidelines.4 Secretary of Education Arne Duncan has spoken often about the connection between wellness and academic suc- cess, and a key component of wellness is nutrition. Nutrition education needs to be infused throughout the curriculum to capture the hearts and minds of students, Dickard said. Students need enough time to eat in a healthy manner during school meals. They need to be educated about the benefits of eating healthy foods so that, as Dickard recalled of his daughter’s experiences at school, untouched apples do not end up in trash cans. The Education Department is prohibited by statute from exercising “any direction, supervision, or control over the curriculum, program of instruction, administration, or personnel of any educational institution, school or schools system, or over the selection of library resources, text- books, or other printed or published instructional materials” (20 U.S.C., Sec. 1232a). But it can provide program models that teachers and admin- istrators can use and adapt. Dickard cited the example of the Carol M. White Physical Education Program at the Department of Education, which emphasizes nutrition as well as physical activity. The grants made to schools and community-based organizations under this program foster innovation and emphasize getting parents and the community involved. Those seeking to develop nutrition education standards can learn from similar efforts in other fields. Various groups have developed standards in the arts, social sciences, mathematics, science, and other areas of the cur- riculum, and states have moved individually or as collaborative groups to implement these standards. But in developing curriculum standards it is important to be mindful that teachers feel squeezed by everything that they are asked to do, Dickard 3 See http://www.letsmove.gov/active-schools. 4 See http://www.choosemyplate.gov.

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12 NUTRITION EDUCATION IN THE K-12 CURRICULUM said, echoing Thornton’s comments. When he was a middle school science teacher, Dickard also was asked to teach the drug abuse prevention unit, the sex education unit, and other topics. The many demands made of teachers and schools require educators to make trade-offs if they are asked to teach new material. Adding to the curriculum may require subjects to be deleted from the curriculum elsewhere. Nevertheless, Dickard was optimistic. “The time is right. You have the most important and right questions before you. You have a broad group of people with the diverse expertise required to discuss the matter. . . . We’re at a crest of the issue of making a connection to student wellness and aca- demic achievement.” NUTRITION IN HEALTH AND LEARNING To support the need for nutrition education, Virginia Stallings, pro- fessor of pediatrics at the University of Pennsylvania Perelman School of Medicine and director of the Nutrition Center at the Children’s Hospital of Philadelphia, provided an overview of evidence on the effects of nutrition on children’s health and learning. At a broad level, health affects learning when children miss school or are late for school. More specifically, going to school without a good breakfast has a consistent impact on readiness to learn. In addition, food security has a major impact on learning. A student who is hungry multiple times during a week or during a month cannot help but be affected physi- ologically and emotionally. Children can be hungry and skinny or hungry and obese, and we in the educational setting need to particularly strive to understand that hunger and obesity often go together. Nutrition is mostly about food, not about specific micronutrients, with the exception of iron. Over time, the emphasis in nutrition programs has moved from micronutrients to the amount and variety of food, which is also easier to teach, Stallings observed. However, evidence about how to promote wellness and sustain health through healthy eating can be harder to generate than evidence about preventing illnesses caused by deficiencies of specific nutrients. Obesity rates among children have risen continually for more than 30 years, though the most recent evidence suggests that the rates may be plateauing. Nevertheless, obesity now affects large numbers of children in school, not just a few, as was the case in the past. As a result, more poor health outcomes are being seen in children. “Adult-onset” type 2 diabetes is now commonly seen in the pediatric endocrine clinic where Stallings practices, which marks a “fundamental shift,” she said. Children also are exhibiting cardiovascular disease and hypertension at an earlier age, have more orthopedic problems, and are more likely to suffer from asthma and

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THE CURRENT OPPORTUNITY 13 sleep apnea. Anemia is less common than it used to be but has not been eradicated, and poor nutrition continues to have an effect on bone health. Nutrition also has an effect on dental health, which in turn can affect eat- ing, speaking, and attending to learning. Anorexia and bulimia are being seen in younger and younger children and in boys as well as girls. Night eating syndrome also is proving to be common in adults who eat large amounts of calories at night, and expose their children to this behavior. According to surveys, many children in middle schools and even some in elementary schools say they are dieting, though the effects on their eating are largely unknown. Nevertheless, “the concept is already in their vocabulary and in how [they] think about food and life,” said Stallings. Children who are obese continue to suffer from discrimination from adults and peers, as well as bullying, despite the fact that obesity is fairly common in school-aged children. They also are more likely to feel a sense of isolation and to experience depression. Nutrition education has a “huge opportunity” to change these poor health outcomes, according to Stallings. The public has a greater awareness of the need for healthy foods and good nutrition, which may be contribut- ing to the stabilization of obesity rates. First, the food environment in schools is slowly changing. In the past, students have had many options for food during the school day, including à la carte items, vending machines, food from fundraisers, school stores, and competitive foods bought outside schools. These alternatives are culturally and often financially embedded in schools. At the same time, 99 percent of public schools and 83 percent of private schools participate in the school lunch program, and with that opportunity comes a responsibility to con- trol the food environment, said Stallings. The Institute of Medicine (IOM) report School Meals: Building Blocks for Healthy Children offered a set of practical and economical recommendations for standards that reflect cur- rent nutritional science, increase the availability of key food groups, and allow the National School Lunch Program and School Breakfast Program to better meet the nutritional needs of children, foster healthy eating habits, and safeguard children’s health (IOM, 2009). As a result of this and other initiatives, students have been eating more fruits and vegetables at lunch and fewer starchy foods and refined grains, Stallings reported. The school lunch and school breakfast programs are, in effect, the larg- est restaurant chain in the country, Stallings noted. A student who has lunch at school every day would consume one-sixth of his or her meals each year in that setting, and a student who has lunch and breakfast each day would consume one-third. “There’s almost nothing else in our interaction with the public where we could influence student health across such a big platform.”

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14 NUTRITION EDUCATION IN THE K-12 CURRICULUM If all the foods in schools could be healthy choices, healthful eating would be considerably advanced. Children make frequent food decisions related to calories, fats, sugar, salt, vegetables, snacks, portion sizes, and food choices. To make healthy choices, they have to be as interested in the carrot sticks and healthy sand- wich as in the less healthful snacks available to them. Most students—along with most teachers—get most of their information about foods from the media, their parents, and their peers. Some of this information is accurate and some is not, and nutrition science remains a work in progress and is sometimes contradictory. Teachers themselves need training to learn the basics after being barraged by a stream of accurate or inaccurate or confus- ing information. The IOM report Nutrition Standards for Foods in Schools identified foods to encourage and foods to avoid (IOM, 2007). It recognized the need for flexibility at the state and local levels and for traditions such as parties, holidays, and fundraisers. But it also proposed minimum standards and reasonable limitations on when and where specific foods would be avail- able. For example, it identified standards for foods and beverages related to such criteria as calories in a serving, calories from fat, the kinds of fats in food, and sugar and sodium content. Proposed rules from USDA to establish nutrition standards for all foods sold in schools, beyond the fed- erally supported school meals programs, have incorporated most of these recommendations, though at the time of the workshop the regulations had not yet been finalized. Fragmented efforts could be unified, said Stallings. The Special Sup- plemental Nutrition Program for Women, Infants, and Children (WIC) program, Head Start, day care, school meals, competitive foods, and the Supplemental Nutrition Assistance Program (SNAP) all affect eating and nutrition. The Dietary Guidelines for Americans were revised in 2010 and are in the process of being revised for 2015. USDA regulations and congressional legislation also provide overarching guidelines. The move to the MyPlate system constitutes a dramatic change in nutrition education guidance. Furthermore, new research, such as the School Nutrition Dietary Assessment study series, provides solid data on which to evaluate future changes. More political will exists today than at any time in the past, and stake- holder groups have been coming together to discuss how best to make progress. “There is no question that the health of children can be improved by what we serve in schools,” Stallings concluded. “Our next challenge is education and behavior so that students will choose the right things, and then that will blend into the rest of their lives.”