7

Upgrading Food and Physical Activity Options Before, During, and After School in Low-Income Neighborhoods

Important Points Made by Speakers

•     Disparities in society contribute to disparities in obesity, and these disparities are mirrored in schools. (Thompson)

•     Food service departments can be central to efforts in schools to improve the nutrition of students. (Taylor)

•     Out-of-school time programs before, during, and after the school day can complement and augment the efforts of schools to encourage physical activity and healthy eating. (Hinkle)

The fifth goal of Accelerating Progress in Obesity Prevention (IOM, 2012a) focuses on schools as a critical mediator of obesity prevention (see Box 7-1). As the report notes, schools are uniquely positioned to support physical activity and healthy eating. Children and adolescents can consume the majority of their calories in schools and out-of-school time programs, which means these institutions have a unique opportunity to improve the quality of their diets. Given that young people can spend up to half their waking hours in schools and out-of-school time programs, these institutions also can reverse the trends that have made a physically active lifestyle more difficult (IOM, 2012a).

Three speakers considered schools and out-of-school programs in the context of health disparities. Joe Thompson, surgeon general for the State of Arkansas; director, Arkansas Center for Health Improvement; and professor in the Colleges of Public Health and Medicine at the University of Arkansas for Medical Sciences, reviewed the strategies in this area



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7 Upgrading Food and Physical Activity Options Before, During, and After School in Low-Income Neighborhoods Important Points Made by Speakers  Disparities in society contribute to disparities in obesity, and these disparities are mirrored in schools. (Thompson)  Food service departments can be central to efforts in schools to improve the nutrition of students. (Taylor)  Out-of-school time programs before, during, and after the school day can complement and augment the efforts of schools to encourage physical activity and healthy eating. (Hinkle) The fifth goal of Accelerating Progress in Obesity Prevention (IOM, 2012a) focuses on schools as a critical mediator of obesity prevention (see Box 7-1). As the report notes, schools are uniquely positioned to support physical activity and healthy eating. Children and adolescents can consume the majority of their calories in schools and out-of-school time programs, which means these institutions have a unique opportunity to improve the quality of their diets. Given that young people can spend up to half their waking hours in schools and out-of-school time programs, these institutions also can reverse the trends that have made a physically active lifestyle more difficult (IOM, 2012a). Three speakers considered schools and out-of-school programs in the context of health disparities. Joe Thompson, surgeon general for the State of Arkansas; director, Arkansas Center for Health Improvement; and professor in the Colleges of Public Health and Medicine at the University of Arkansas for Medical Sciences, reviewed the strategies in this area 71

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72 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT BOX 7-1 Goal 5 from Accelerating Progress in Obesity Prevention Goal: Make schools a national focal point for obesity prevention. Recommendation: Federal, state, and local government and education authorities, with support from parents, teachers, and the business community and the private sector, should make schools a focal point for obesity prevention. laid out in Accelerating Progress in Obesity Prevention and the influence of broader social inequities on schools. Rodney Taylor, director of nutrition services for the Riverside Unified School District in Riverside, California, described the food service program he has created in the Riverside schools, which could be a model for comparable programs across the country. Finally, Arnell Hinkle, founding executive director of Communities, Adolescents, Nutrition, and Fitness (CANFIT), a nonprofit organization supporting efforts of after-school providers and community- based organizations to enhance nutrition, physical activity opportunities, and policy developments, discussed out-of-school time programs and their potential to complement and augment the health-promoting activities of schools. STRATEGIES FOR MAKING SCHOOLS A FOCAL POINT FOR OBESITY PREVENTION Summary of Remarks by Joe Thompson Outside the home, schools and out-of-school time programs are at the center of the lives of children and adolescents; schools also can be central institutions in a community. In thinking about interventions to change environments and behaviors, Thompson said, schools are therefore an obvious focus. The first strategy directed at schools in Accelerating Progress in Obesity Prevention is to require quality physical education and opportunities for physical activity in schools. This strategy has been undercut in recent years by the emphasis of the federal No Child Left Behind legislation on mathematics and reading, said Thompson, which has led some schools to devote less time to physical activities, arts, and

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UPGRADING FOOD AND PHYSICAL ACTIVITY OPTIONS 73 music. In one survey, up to 40 percent of school administrators reported that they had eliminated or reduced recess and physical activity in elementary schools to focus on measured outcomes for education (RWJF, 2010). According to Thompson, a new bill proposed in the Senate1 could bring more balance into the school day, but its prospects are uncertain. Other government programs have changed the environments around schools to make them more conducive to physical activity. For example, the Safe Routes to School program has encouraged students to walk or ride bicycles to schools or bus stops, although the program has had to deal with concerns about competing transportation programs and gentrification (Safe Routes to School National Partnership, 2010, 2013). In Arkansas, more than a hundred new joint-use agreements2 that together cost relatively little brought city and school officials together to consider how they could use limited assets in the most productive ways. As Thompson observed, a school gym can be a community gym after school and a gym for faith-based organizations on the weekend. The second strategy for schools in Accelerating Progress in Obesity Prevention is to ensure strong nutrition standards for all foods and beverages sold or provided through schools, while the third is to ensure food literacy, including skill development, in schools. In these areas, too, said Thompson, progress has been made, although it often has been slow—the result of two steps forward and one step back. He noted that some of the best evidence for what does and does not work in preventing obesity comes from schools because of their relatively controlled environment (Beam et al., 2012a,b). However, schools are not the only solution, because children spend considerable time in other settings as well. Longitudinal data drawn from both within and outside schools could demonstrate factors that make a difference in obesity prevention, Thompson suggested, which in turn could support policy approaches to making changes in various environments. Thompson reiterated the central theme of the workshop—that broad disparities in society contribute to disparities in obesity and health in general. Racism still exists in society, he pointed out, as do environmental 1 S. 1094: Strengthening America’s Schools Act of 2013, 113th Cong., intro- duced June 4, 2013. 2 See http://www.arkansascsh.org/apply-it-in-your-school/584c0b1fb838fc7e23da42 ce07caf9b3.php and http://www.healthy.arkansas.gov/programsServices/health Statistics/Brfss/Documents/publications/Other/JumpStartJointUse.pdf.

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74 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT inequalities, urban blight, and cultural differences. The median household income in Mississippi is approximately $39,000 per year, while that in Maryland is approximately $72,000 per year (Census Bureau, 2013b). Under such circumstances, similar outcomes cannot be expected, Thompson suggested. These inequities are mirrored in schools. Many schools are funded partly by property taxes, which means that schools have different financial starting points (Education Commission of the States, 2013a,b). Schools also have different community and parental resources, which likewise has an impact on students’ educational outcomes. At the same time, a divergent set of issues that must be addressed to safeguard children’s health converge in schools, and a focus on inequities among children can mobilize resources in ways that a similar approach focused on adults could not. Identifying ways to make people feel they have a personal stake in the issue is important, Thompson said, so they will use the available evidence to take action. “Over the last decade, [we have] started to have conversations that never happened before, and conversations that have started to build an evidence base that are going to guide us to where we need to go in the future.” —Joseph W. Thompson CASE STUDY: FOOD SERVICES IN THE RIVERSIDE UNIFIED SCHOOL DISTRICT Summary of Remarks by Rodney Taylor The Riverside Unified School District is the fifteenth largest school district in California, with 47 schools serving 43,000 students, 68 percent of whom are eligible for free or reduced-price meals (California Department of Education, 2013a,b). When Taylor arrived at the school district as director of nutrition services in 2002, the Nutrition Service Department owed $3.1 million to the general fund. The department had built a central kitchen for $28 million and could not make the payments on the facility. When Taylor was asked how he was going to deal with the department’s problems, he said he was going to put salad bars in the schools. The response was laughter, he said.

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UPGRADING FOOD AND PHYSICAL ACTIVITY OPTIONS 75 Today, Taylor noted, the Nutrition Service Department has erased the $3.1 million debt and has a $5.8 million reserve. It has a nationally known nutrition program, for which Taylor credits his 328 employees. His contribution, he said, was to remind his employees that the students they were serving were their children—whether literally or figuratively— and that those children were at risk. The salad bar is called the Farmers’ Market Salad Bar because it buys produce from the local farmers’ market, with much of the food being less than 2 days from the fields. The salad bar provides a stand- alone meal along with access to fruits and vegetables that children may not be getting at home. It appeals to all five senses because, as Taylor was taught in the restaurant industry, people buy food with their eyes. The salad bar also is kid-friendly, with foods like oranges being peeled and ready to eat. Despite fears that the salad bar would spread disease, Taylor said, it has safely served 6 million meals to children in his schools. Salad bars are now in all 31 elementary schools in the Riverside district. Children encounter the salad bar first and then are offered the hot lunch entrée or an alternate protein with grain. All reimbursable meals must include a fruit or a vegetable. When children have loaded their plates with fruits and vegetables of different colors, they get a sticker that says they have a rainbow in their tummy. The salad bar is introducing children to foods that they then request from their parents, and was so successful in the elementary schools that when students entered middle school, they demanded to have salad bars there as well. Taylor said he is in the nutrition business. For example, he has converted an employee cafeteria into a restaurant that now feeds members of the public, and the district does catering and prepares food for 15 entities outside the school district, such as Meals on Wheels. A chef works on creating healthier meals that are still popular, so that when chicken nuggets came off the school menu, they were replaced by foods that still appeal to students. Students participate in taste tests of foods pre- pared by the chef and respond to surveys. When children asked why French fries and chips were no longer available at the school, they were told that the school had a responsibility to ensure that they lived long and healthy lives and that part of the school’s role was to teach them life-long healthy eating habits. The program also has a marketing supervisor and engages in a wide range of marketing activities directed at parents and students. For example, it has staff who promote the food service program during the first week of the school year.

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76 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT Changing a food service program requires changing a culture, said Taylor. Most food service employees are accustomed to heating and serving food, whereas Taylor was asking his employees to prepare fresh foods. But changing the food makes it possible to change marketing and outreach, even if the obstacles to change are sometimes substantial. High schools pose special challenges, which Taylor likened to the challenges of appealing to college students. He sought to change the ambiance of food service in the Riverside district. For example, he removed the railings that kept students in line and treated them like grownups. The food was fresh, not previously frozen and heated, and it was culturally appropriate for the students in the school. When Taylor came to the school district, only 40 percent of the students attending schools were eating there. Now 70 percent are, and the Food Service Fund, a separate fund within the school district, is self- sufficient. Taylor said the budget has risen from $8 million in 2002 to $19 million today. The school system is continuing to experiment with and expand its nutrition programs. For example, the chef for the district developed five different rubs that could be applied to the government commodity chicken—rotisserie, barbeque, lemon herb, grilled ranch, and sesame. The result was an economical, popular meal that provided students with less processed and more fresh food. The district also has an adult eating program whereby teachers who text, e-mail, or call before 9 AM can have a lunch delivered to any 1 of 51 locations by 11:30 AM. The district also has a summer feeding program since, as Taylor put it, hunger does not take a vacation. The program offers barbecues at 24 parks, and Taylor expected to serve half a million meals through the program in 2013, up from 32,000 meals in 2008. Finally, the district is offering three breakfast programs: 1. Classroom Breakfast—Students eat breakfast in their classroom at the beginning of the academic day. 2. Grab-and-Go Breakfast—All the components of school breakfast are conveniently packaged so students can grab a breakfast and go. 3. Second Chance Breakfast—Breakfasts are available between first and second periods in the cafeteria and from grab-and-go carts placed in high-traffic areas. These programs are producing healthier and better-behaved students without taking time away from instruction, Taylor said. Sometimes he

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UPGRADING FOOD AND PHYSICAL ACTIVITY OPTIONS 77 gets calls from principals saying he needs to feed students well during a week of testing, but students need to be fed well year-round, he replies. What he has done in Riverside could be done in any district, Taylor added. The percentage of students eating food prepared at school is a good indicator of success, he pointed out, although more affluent schools tend to have lower numbers. Taylor emphasized that increasing this percentage requires engaging with the customer. “When we get serious about education, we will get serious about ensuring that every child is fed in the morning, prepared, and ready to go to school. You can’t focus and you can’t learn when you are hungry.” —Rodney Taylor OUT-OF-SCHOOL TIME Summary of Remarks by Arnell Hinkle In addition to their time in school, youth spend considerable time in out-of-school programs—after-school programs, summer camps, church activities, community-based programs, and so on. Many low-income youth also are in alternative schools, the juvenile justice system, or the foster care system, and in Hinkle’s experience, these programs often are overlooked in obesity prevention. Nationwide, more than 8 million school-age children are in out-of-school time programs (Afterschool Alliance, 2009). Young people get information in different ways than did previous generations, Hinkle said. More than 90 percent of them use the Internet, with 57 percent posting their own content (Jones and Fox, 2009; Lenhart and Madden, 2005). Youth also remain surprisingly segregated. California, for example, is one of the nation’s three most segregated states for Latino students and one of the five most segregated for African American students (Torlakson, 2011). CANFIT was started in 1993 to work with communities and policy makers to develop culturally resonant policies and practices that improve food and physical activity environments for adolescents in low-income communities and communities of color. Its organizing framework is that culture determines values, values shape behavior, and behavior is the explicit language of culture. The organization provides training, technical

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78 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT assistance, and consultation to youth-serving organizations; develops effective and culturally appropriate educational materials on nutrition and physical activity; and advocates for nutrition and physical activity policies at the local, state, and national levels. Among CANFIT’s current priorities are implementing snack, meal, and physical activity policies; using peer-led social media to encourage healthy behaviors; and examining the quality of meals being imple- mented through child nutrition programs. The organization promotes the concept of being healthy at every size rather than emphasizing obesity prevention or weight reduction. It also is working on improving food systems and the built environment in communities of color and on developing youth engagement strategies. As an example of such strategies, Hinkle mentioned the E-Advocates project, in which youth create YouTube videos, tweets, and Facebook entries about health activities in their communities.3 Another example is the Oakland Unified School District’s After School Learning Community,4 in which staff from after-school sites are encouraged to think of them- selves as community advocates for physical activity. CANFIT also serves on state and local policy groups and provides technical assistance for several foundation initiatives. CANFIT’s website (www.canfit.org) offers a variety of resources, including “99 Ways to Make Your After-School Program Healthier,” physical activity toolkits, a cultural needs assessment guide, a healthy snack and meal guide, and policy briefs. Progress and Challenges Hinkle cited several indicators of progress in reducing disparities in food and physical activity environments outside of school:  The importance of out-of-school time healthy eating is widely recognized.  Several state and national organizations are creating nutrition and physical activity standards specifically for out-of-school time programs.  More after-school meals are being served as part of the Healthy, Hunger-Free Kids Act. 3 More information is available at http://canfit.org/our_work/programs/eadvocates. 4 See http://canfit.org/our_work/programs/PALearningCommunity.

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UPGRADING FOOD AND PHYSICAL ACTIVITY OPTIONS 79  Communities are making greater use of school grounds and fields.  More research on out-of-school time is being conducted.  Technology is being adapted to encourage youth in out-of-school time settings to eat well, be active, and inventory the resources available in their communities.  Out-of-school nutrition education programs, such as gardens and activity options, have increased.  Racial equity is receiving more attention in out-of-school time. However, much room for improvement remains, Hinkle said. A typical after-school meal, even after passage of the Healthy, Hunger-Free Kids Act, might consist of a bag of Doritos, a bagel sandwich, a pineapple spear, a juice box, and a milk box. The implementation of policies is inconsistent, often depending on the resources of the school, program, or community, Hinkle stated. In higher-income districts, stellar programs are being established, while in low-income districts, much less is being done. Nutrition education often is not correlated with access or with health, Hinkle stated. For example, well-intended people may teach students with no access to a blender how to make smoothies. Physical activity often consists only of games of tag. Staff training is a major issue because of low wages, frequent turnover, or difficult working conditions. The effects of budget sequestration had just begun at the time of the workshop but threatened to intensify, and could lead to programs or even schools being closed, according to Hinkle. Even in Berkeley, the center of the farm-to-school movement, school gardens and school nutrition are being cut. The monitoring and evaluation of government and industry standards have been lacking, Hinkle pointed out. Because food and beverage companies are being shut out of schools, they are marketing heavily in after-school settings. To illustrate, Hinkle cited instances of soft drink companies donating millions of dollars to charitable organizations that serve children (Boys & Girls Clubs of America, 2013; PepsiCo, Inc., 2012; Public Health Law & Policy, 2011). Also, Hinkle said, many after- school program providers tend to overemphasize weight status and reduction, stoking a fear of fat rather than a passion for health in youth. CANFIT emphasizes healthy behaviors at every weight so that even if weight does not change, behaviors do.

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80 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT Policy Recommendations Hinkle had several policy recommendations:  Include after-school programs in school wellness and farm-to- school policies.  Revise the Child and Adult Care Food Program standards to be consistent with school lunch and competitive food standards.  Establish programs that channel college students (especially female athletes) into community after-school programs as coaches and volunteers.  Educate out-of-school programs about joint-use agreements.  Promote physical activity programming that provides lifelong skills (such as swimming, walking, yoga, Tai Chi, martial arts, dance, and community walks and races).  Support regular staff training and professional development in nutrition and physical activity.  Investigate the interrelationship between mental health issues and obesity.  Extend food and activity guidelines to alternative schools and juvenile justice agencies.  Emphasize youth engagement and health at every size. An important aspect of making changes, Hinkle said during the discussion period, is building leadership among young people. Students can take the reins in such areas as the development of community gardens or physical activities other than organized sports. If students who were involved in these programs were tracked over time, their leadership potential could be recognized and nurtured. Taylor agreed, adding that a sense of purpose, not money, is the motivating force behind the actions of most young people. “It is harder to find someone who knows how to work with young people than it is to teach them about healthy eating and fitness. We always strive to find the groups of people who have that connection with young people and then work with them to give them the skills about eating and fitness.” —Arnell Hinkle