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Schools

Key Points Highlighted by Individual Speakers

  • Evidence on what works in school-based obesity prevention efforts has grown dramatically over the past decade. The result has been guidelines, recommendations, and programs that have improved students’ health, with some school-based strategies also yielding cost savings. (Lee)
  • Continued attention to translation, dissemination, and diffusion could increase the uptake and sustainability of evidence-based tools, resources, and professional development for diverse school communities. (Lee)
  • Designating physical education as a core subject in schools and making better use of grassroots innovation and champions could help bend the obesity curve. (Economos)
  • Technical assistance and training, school–community collaborations, and adequate resources could help ensure that every food sold to a child in school is healthy. (Donze Black)

Three speakers addressed obesity prevention in the school setting. Sarah Lee, health scientist at the Centers for Disease Control and Prevention (CDC), considered how increasing evidence on what works in obesity prevention could be applied to make further progress on fighting the obesity epidemic. Christina Economos, director of ChildObesity180 and associate



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4 Schools Key Points Highlighted by Individual Speakers • Evidence on what works in school-based obesity prevention efforts has grown dramatically over the past decade. The result has been guidelines, recommendations, and programs that have improved students’ health, with some school-based strategies also yielding cost savings. (Lee) • Continued attention to translation, dissemination, and diffu- sion could increase the uptake and sustainability of evidence- based tools, resources, and professional development for diverse school communities. (Lee) • Designating physical education as a core subject in schools and making better use of grassroots innovation and champions could help bend the obesity curve. (Economos) • Technical assistance and training, school–community collabo- rations, and adequate resources could help ensure that every food sold to a child in school is healthy. (Donze Black) Three speakers addressed obesity prevention in the school setting. Sarah Lee, health scientist at the Centers for Disease Control and Preven- tion (CDC), considered how increasing evidence on what works in obesity prevention could be applied to make further progress on fighting the obesity epidemic. Christina Economos, director of ChildObesity180 and associate 23

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24 CURRENT STATE OF OBESITY SOLUTIONS professor at Tufts University, and Jessica Donze Black, director of the Kids’ Safe & Healthful Foods project at the Pew Charitable Trusts, spoke about promoting physical activity and nutrition, respectively, in schools. PUTTING THE EVIDENCE TO WORK The evidence on what works in school-based childhood obesity pre- vention has grown dramatically over the past decade, said Lee. Examples include CDC’s School Health Guidelines to Promote Healthy Eating and Physical Activity,1 a Cochrane Review on obesity prevention in children (Waters et al., 2011), and articles by Flynn and colleagues (2006) and Folz and colleagues (2012) on population-level interventions. Other publications have complemented comprehensive evidence-based reviews; they include reports from the Institute of Medicine (IOM) on school meals (2009b), competitive foods in schools (2007a), and physical activity (2013a). Based on this evidence, a multitude of guidelines and recommendations have been developed in which the following strategies are common: • establishing an environment that promotes healthy eating and physical activity; • incorporating healthy eating, physical activity, and body image topics across the school curriculum; • adding more time for physical activity both during the school day and throughout the school week; • improving the nutritional quality of school foods; and • providing training for teachers and other school staff on the imple- mentation of such evidence-based health-promoting strategies. Lee noted further that certain school-based strategies identified in reviews have been shown to yield cost savings. These strategies include providing classroom-based lessons about reducing time spent watching television and reducing the consumption of sugar-sweetened beverages, as well as multifaceted programs that encompass both improved nutrition and physi- cal activity. A growing number of evidence-based programs have been launched in recent years. Examples at the federal level include Let’s Move! Active Schools,2 Let’s Move Salad Bars to Schools,3 and the Presidential Youth 1  Available at http://www.cdc.gov/mmwr/pdf/rr/rr6005.pdf (accessed April 29, 2014). 2  For more information, see http://www.letsmove.gov/active-schools (accessed April 29, 2014). 3  For more information, see http://saladbars2schools.org (accessed April 29, 2014).

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SCHOOLS 25 Fitness Program.4 The U.S. Department of Agriculture (USDA), through its Team Nutrition, has used the HealthierUS School Challenge5 to recognize schools that are making important evidence-based changes. In addition, nonprofit organizations and other national groups have developed pro- grams such as Action for Healthy Kids, Alliance for a Healthier Genera- tion, and ChildObesity180, which collectively have reached thousands of schools to change nutrition and physical activity policies, systems, and environments. Potential Future Directions Lee divided her proposed next steps into four areas: research; transla- tion, dissemination, and diffusion; communication; and policy. In the area of research, many important questions remain unanswered: • What is the impact of parent engagement on both child and family health behaviors? • What is the role of school health services in helping students who are already obese or overweight? • What are the effects of increasing access to safe, free drinking water in schools? • What is the impact of a comprehensive physical activity program on the overall activity level of students? • What is the impact of food marketing in schools? • What policies, practices, and programs can reduce health dispari- ties? For example, how can interventions be culturally tailored to be relevant and feasible for the populations that are most affected? In this last area of health disparities, Lee noted that the topic cuts across all four of the areas she discussed. For example, the link between disparities in health and education is well established, but interventions typically target one or the other, not the link between the two. In the area of translation, dissemination, and diffusion, much more needs to be known about how to translate findings for underserved and dis- parate populations. In addition, the uptake and sustainability of evidence- based tools, resources, and professional development need to be examined for diverse school communities. With respect to communication, the evidence regarding effective pro- grams, policies, and practices needs to be communicated more effectively, 4  For more information, see http://www.pyfp.org (accessed April 29, 2014). 5For more information, see http://www.fns.usda.gov/hussc/healthierus-school-challenge (ac- cessed April 29, 2014). 

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26 CURRENT STATE OF OBESITY SOLUTIONS Lee said. The benefits to different stakeholders could be identified to foster and sustain change. For example, stronger communications and messaging for a variety of stakeholders could help promote greater implementation of the National Physical Activity Plan6 within the education community. Another subject that needs better communication is the evidence link- ing healthy eating, physical activity, and academic achievement. This is “speaking the language of those in the education sector,” said Lee. Evidence on the link between health and educational attainment needs to be com- municated to school boards in ways that resonate with them, using the lan- guage of education rather than health. Evidence regarding the link between disparities in health and education also could be disseminated to create a stronger message and greater impact. At the same time, negative messages need to be countered, said Lee. For example, new school meal patterns are still being criticized, and these messages can influence the general public, parents, and students. Communicating the positive benefits of nutritious school meals could counter these messages. Much also remains to be learned about policy development and imple- mentation, from both the top down and the bottom up. Large-scale poli- cies can be critically important, but school-level practices and programs can capture the attention of decision makers and lead to more widespread change. As an example of how greater understanding of policy could help, Lee cited the establishment and revision of local wellness policies. Deeper examination of the implementation of such policies would provide informa- tion that could be used to help school districts move forward. Lee noted that few interventions have implemented and evaluated a multistrategy approach, focusing instead on a single component, such as physical activity or nutrition. Also, little is known about what kinds of policies and systems are needed to implement evidence-based curricula and programs in a scalable and sustainable way. There has been minimal implementation and evaluation of interventions that reach large numbers of K-12 schools and entire school districts. A Potential Breakthrough Action As a breakthrough action, Lee cited the need for federal, state, and local physical education and physical activity policies and practices that could dramatically change the landscape of physical activity in schools. Continued support for the U.S. Department of Education’s Carol M. White Physical Education Program7 will be important, as will continuing to allow 6  For more information, see www.physicalactivityplan.org (accessed April 29, 2014). 7  For more information, see http://www2.ed.gov/programs/whitephysed/index.html (accessed April 29, 2014).

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SCHOOLS 27 local districts and schools to tailor their physical education and physical activity programs to local needs. Under a new CDC cooperative agreement, all 50 states are funded to develop multicomponent physical education and recess policies that can achieve both high quantity and high quality. Thirty-two states are receiving additional funds to implement comprehen- sive physical activity programs in high-need school districts. At the local and district level, education systems must be able to adopt, implement, and monitor evidence-based wellness policies, said Lee. Many of the nation’s wellness policies have strong physical activity components, but many do not. Finally, Lee pointed to the relationship between health and educa- tion agencies as key to making change sustainable. “Without this type of relationship, it will be very difficult to achieve and sustain this level of a breakthrough action,” she suggested. PROMOTING PHYSICAL ACTIVITY The United States is dedicated to increasing educational attainment and closing achievement gaps, yet policy makers often disregard emerging research showing that simple strategies such as physical activity breaks during the school day can improve academic focus and behavior in the classroom, observed Economos. “We tweak our educational curricula based on test scores,” she said. “But we have yet to make a commitment to use physical activity and fitness data systematically to inform programmatic efforts.” Children need 60 minutes of moderate to vigorous activity daily to promote health, said Economos. Because they spend a significant portion of their days in school, schools need to become hubs for quality physical activity, providing at least half of that requirement. Economos proposed two breakthrough actions. The first would be to designate physical education as a core subject in schools, delivering high- quality school-wide moderate to vigorous physical activity as recommended by the IOM (2013a). Economos suggested that schools need to help gener- ate the data that will reverse the decline of physical education programs seen in recent years. A group of forward-thinking schools, districts, or states could take on this challenge and produce the evidence for return on investment and cost-effectiveness needed to spark national change. The second breakthrough action Economos identified would be to foster and make better use of grassroots innovation and local champions. Educators and parents across America recognize the need to get children up and moving and are not waiting for someone else to make it happen. ChildObesity180, a collaborative effort of academic researchers and leaders from government, business, and nonprofit organizations, has been working

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28 CURRENT STATE OF OBESITY SOLUTIONS to identify innovative and integrated solutions with the potential to work on a national scale. It has identified scalable physical activity programs from a national competition that drew more than 500 applicants and is currently attempting to replicate the most promising programs. Programs that work well in school environments are low-barrier, low-cost, flexible, efficient, and equitable and provide an opportunity to work toward a common goal, said Economos. Examples include in-classroom physical activity breaks; all-school workouts; and walking, running, and wheeling clubs. “The most rewarding visual I have ever seen is an entire school of 5- to 12-year-olds on the blacktop outside exercising simultaneously with the entire school staff,” said Economos. “That can be done at every school across America.” Implementing such innovative physical activity programs at the local level requires identifying and supporting local school-based champions, noted Economos, including teachers, physical activity educators, admin- istrators, parents, nurses, and cafeteria workers. These champions create momentum as early adopters, can serve as role models, and inspire peer- to-peer networks. Together, the above two actions could help bend the obesity curve by changing the physical activity levels of America’s children, Economos concluded. PROMOTING NUTRITION Many children consume as much as half their calories in schools, and while changes in schools over the past decade have been “extraordinarily successful” in improving children’s health, more can be done, suggested Donze Black. First, she proposed that every food sold to a child in every school in America should be a healthy food. Districts, states, and the federal government all have issued policies aimed at achieving this objective, and experience has demonstrated that these policies can be implemented and succeed. Second, comprehensive strategies could ensure that both the nutri- tion and nutrition education that students receive are of high quality and impactful. In addition to changes in what is sold in vending machines, students need to be taught the value of the difference and how such change can be leveraged in the community. For example, the Let’s Move Salad Bars to Schools program has gotten multiple community players to work with schools to improve the quality of school meals, snacks, and foods available in the a la carte environment. As a result, students have increased access to fruits and vegetables while also learning to enjoy those foods. Such initiatives require ensuring that schools have the equipment, the technical assistance and training, and the resources needed to serve healthy

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SCHOOLS 29 meals. In this regard, collaboration can be critical. For example, a school may need updated facilities while a community needs a community kitchen, creating a win-win opportunity. Superintendents, principals, teachers, and others who have seen positive outcomes in practice can act as advocates to move the culture forward and bring more schools into the conversation. Action cannot wait for the best possible evidence, Donze Black said. Logic, intuition, and the available evidence all indicate that improving the school health environment will make a difference. Ensuring that everything sold to students is healthy and leveraging community, state, and federal resources to maximize the quality of students’ educational experience could ensure that they receive both the nutrition and the nutrition education they need to have a healthy eating lifestyle for the rest of their lives.

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