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An Evaluation of Elementary School Nutrition Practices and Policies in a Southern Illinois CountyJennifer S. Sherry, RDH, MSEd, is an assistant professor in the Dental Hygiene Program, School of Allied Health, Southern Illinois University Carbondale
The purpose of this study is to assess elementary school nutrition programs in a rural county in southern Illinois. The researcher interviewed the food service managers of eight schools and completed the School Health Index (SHI) based on their responses. Eighty-seven percent of the schools did not have venues such as vending machines outside the cafeteria. Three food service managers stated that from 75% to 80% of the students in the district ate lunch in the cafeteria. The SHI corresponds to the eight components of a coordinated school health program; nutrition services are just one of the eight components. The SHI is a tool that can be used to identify strengths and weaknesses in the nutrition program. It covers items from healthy, low-fat choices to food preparation and cafeteria practices. School nurses can work with teachers and food service personnel to create nutrition programs and a curriculum related to healthy nutrition practices.
Key Words: School Health Index • food service managers • nutrition services • elementary schools • cafeteria • vending machines There is a growing concern about the prevalence of obesity among today’s youth. Being overweight during childhood and adolescence has been associated with increased adult mortality, specifically heart disease, high blood pressure, and stroke (Centers for Disease Control and Prevention [CDC], 2006b). The United States Department of Agriculture (USDA) found that "85% of American schools failed their own standards for saturated fat, a leading contributor to coronary heart disease" (Yeoman, 2003, p. 31). Diet is a risk factor for the nation’s three leading causes of death—coronary heart disease, cancer, and stroke, as well as other health problems, such as diabetes, high blood pressure, obesity, and osteoporosis (Wechsler, Brenar, Kuester, & Miller, 2001). Poor dietary choices of children affect their immediate health as well as their health status in the future. Generally, children have unhealthy eating habits. More than 84% of children exceed national recommendations for total fat intake (Marx, Wooley, & Northrop, 1998). Schools alone cannot be held accountable for children’s nutrition behaviors. However, the school system, including teachers, dietary personnel, and school nurses can work in a collaborative manner to encourage healthy eating practices and to offer better food choices. Even though the majority of schools have a National School Lunch Program, about 40% of students made other choices with no nutritional standards (Marx et al., 1998). Peer pressure and approval enters into decision making because students see their classmates either choose unhealthy foods or skip meals altogether (U.S. Department of Health and Human Services [USDHHS], 1996). It is very important for school lunches to be nutritious and appealing to the students they serve. The purpose of this study is to assess elementary school nutrition programs in a rural county in southern Illinois. This study uses the School Health Index (SHI; CDC, 2006a) to evaluate nutrition services at the elementary school level: choices in school vending machines, nutrition practices in the cafeteria, credentials of the school food service managers, and their ability to collaborate with the teachers concerning good school nutrition.
On June 4, 1946, President Harry S. Truman signed the National School Lunch Act, which was renamed the Richard B. Russell National School Act in 1999. School food services were present prior to 1946, but this act authorized the National School Lunch Program (American School Food Service Association [ASFSA], 2007, p. 1). The National School Lunch Program is a federally assisted meal program that serves more than 101,000 public and nonprofit private schools and residential child care institutions (USDA, 2007). The number of children participating in the National School Lunch Program increased from 7.1 million in 1946 to 30.1 million in 2006 (USDA, 2007). President Lyndon B. Johnson signed the Child Nutrition Act of 1966 on October 11, 1966, that established the School Breakfast Program. At the signing of this act, President Johnson stated, "Good nutrition is essential to good learning" (ASFSA, 2007, p. 2). The School Breakfast Program offers nutritionally sound breakfast programs to children in public and nonprofit private institutions as well as child care centers. The Healthy Meals for Healthy Americans Act of 1994 "required that federally subsidized meal programs conform their meal requirements to the Dietary Guidelines for Americans, made the nutrition education and training (NET) program an entitlement, and made other changes to the WIC [Women, Infant, and Children] program, and expanded program outreach and coordination" (U.S. House Committee on Agriculture, 1994; online 2008, p. 2). The USDA and the USDHHS published the Dietary Guidelines for Americans in 1980. In 1995, the USDA devised a program that set the stage for healthy nutrition for children, called School Meals Initiative for Healthy Children (Dietary Guidelines Advisory Committee, 2000). The program established goals for nutrition in school breakfast and lunch programs. It also suggested that breakfast and lunch programs meet the recommendations of the Dietary Guidelines for Americans that incorporate healthy eating with daily activity and exercise (Dietary Guidelines Advisory Committee, 2000). In 1994, the first School Health Policies and Programs Study (SHPPS) examined food service policies and practices for kindergarten through 12th grade at the state and district levels. Six years later, SHPPS 2000 showed that 87.8% of schools participated in the USDA National School Lunch Program, and 63.8% participated in the USDA School Breakfast Program (CDC, 2001). The majority of milk ordered in a typical week remained whole or 2% milk. Some schools (19.5%) had committees that include students who provide suggestions to food service staff (CDC, 2001). SHPPS 2006 updated and expanded the 2000 study to measure policies and programs in grades kindergarten through 12 at the state, district, and school levels. SHPPS 2006 shows a steady improvement in low-fat à la carte choices and healthy food preparation practices in comparison to the SHPPS 2000 study. For example, in 2000, 31.4% of schools had reduced sodium in their recipes; by 2006, the number was 45.8% (CDC, 2006b). The Food Guide Pyramid provides a framework for a diet to meet the needs of most healthy Americans older than two years (Saltos, 1999). The principal idea is to divide foods into food groups that are easy to recognize. The Food Guide Pyramid created a way to organize foods and to illustrate the recommended number of servings. In 2005, the USDHHS and the USDA devised the "new" Food Guide Pyramid that changed the focus from nutrition to incorporating diet and exercise into a healthy lifestyle for Americans. The Food Guide Pyramid also has lifestyle suggestions for vegetarians and expectant mothers (USDA, 2008). The USDA is the governing body for the National School Lunch and School Breakfast Programs. In Illinois, the Illinois State Board of Education mandates that individual school districts follow the USDA guidelines (Illinois State Board of Education, 2008). According to the USDA Food and Nutrition Service, in November 2007, there were 1,167,883 participants in the National School Lunch Program and 284,657 participants in the School Breakfast Program (USDA, Food and Nutrition Service, 2008). Some states and districts prohibit the sale of "junk food," defined as food with low nutritional value and high sugar/fat content, in the cafeteria or as part of the à la carte sales during breakfast and lunch. According to SHPPS 2006, school districts prohibited "junk food" in school settings in vending machines, concession stands, school stores, and à la carte venues. The biggest change was in vending machines. In 2000, 4.1% of the districts prohibited "junk food" sales in vending machines and in 2006, the percentage jumped drastically to 29.8% (CDC, 2006b). The school beverage trend is shifting toward lower-calorie choices, such as water and 100% fruit juices, and away from full-calorie sodas. There was a 28% drop in high-calorie beverage sales and a 23% increase in water shipments (American Beverage Association, 2006). The Illinois State Board of Education neither requires nor recommends that schools prohibit junk food in vending machines, but it does recommend that schools prohibit junk foods in afterschool programs and during breakfast and lunch periods (CDC, 2006b).
This research took place in September of 2003 in a rural county in southern Illinois. Eight of the 14 public elementary school districts in the county participated in this study. According to the U.S. Census Bureau data, in 2000 this county had a population of 59,612. School districts were similar in population size. The enrollment at elementary schools in the county ranged from 254 to 2,330 students (Illinois State Board of Education, 2008). The Human Subjects Committee at Southern Illinois University gave approval for this study. Principals and superintendents were contacted via letter to request permission for the researcher to interview the food service managers at their elementary schools. Once the administrators gave permission, the researcher contacted the food service managers via phone and scheduled an interview. The researcher met with the food service manager for one-hour interviews in each public elementary school. Some of the food service managers were in charge of more than one cafeteria in their districts. There was one food service manager for three elementary schools in one district, one food manager for four schools in one district, and one food service manager for the last school district that participated in the study. This study used a portion of the SHI questionnaire, devised by the CDC. Module 4 of the SHI: Nutrition Services was used to collect information on strengths and weaknesses in the nutrition program; it covers items from healthy, low-fat choices to food preparation and cafeteria practices (CDC, 2006a). This study used descriptive measures to report data, as well as quantitative and qualitative reporting. A pilot study was conducted to determine the reliability and validity of the survey instrument. A school district in an adjoining area with approximately the same average enrollment size and demographics was selected for the pilot study. Module 4 of the SHI questionnaire was given to the food service manager on two separate occasions. First, the food service manager was interviewed; second, the food service manager completed a written questionnaire within a week of the interview. The questionnaires (one personal interview and one manually completed by the food service manager) were used to calculate a test–retest method to determine reliability. There was a difference of 7.3% between the interview and the second completion of the scorecard by the food service manager. The interview showed a score of 74.3% (29/39 on scorecard). One question on the questionnaire was not applicable because the school does not provide à la carte choices at breakfast or lunch. The scorecard completed by the food service manager resulted in a score of 67% (26/39 on scorecard). There were two questions scored differently on the interview versus the completion of the questionnaire by the food service manager. The SHI Module 4: Nutrition Services questionnaire has 14 discussion questions. Each question is scored on a Likert-type scale (3 = fully in place, 2 = partially in place, 1 = under development, 0 = not in place). Three open-ended planning questions are also included. Question 1 asks about strengths and weaknesses of the school’s nutrition program; question 2 asks about recommended actions for the staff to implement to address weaknesses identified; and question 3 asks respondents to rank these actions on (a) importance, (b) cost, (c) time, (d) commitment, and (e) feasibility, based on a five-point scale. The subtotals were totaled to calculate a score. The highest possible score on the questionnaire was 42 points. A percentage was calculated at the end of the questionnaire so that food service personnel would know how they scored (Table 1).
All eight food service managers reported their schools offered breakfast and lunch to all students. Four of the eight reported their schools had a nutrition program that was fully in place with decreased fat and sodium content. The other four stated that lowering both sodium and fat content in school meals was partially in place in their schools. None of the school managers reported à la carte items available to students in the elementary schools. Seven (87.5%) did not have any venues (school stores, vending machines) outside the cafeteria in operation. One (12.5%) manager reported having venues outside the cafeteria that offered low-fat choices; however, the vending machines were in operation only after school and did offer soda. Four of eight schools did not promote healthy cafeteria practices. The criteria for this were whether cafeterias promote and advertise healthy choices by means such as bulletin boards, promotional materials, or highlighting healthy cafeteria selections. The other four schools used at least three or more advertisement methods (school-wide video or audio announcements, menus highlighting choices, taste-testing opportunities) to promote and market healthy nutritional practices. Some of the promotional practices were posters and information from the Dairy Council or other governmental agencies, as well as posting the Food Guide Pyramid. All eight schools had newer or remodeled cafeteria facilities with up-to-date equipment. Four schools met all nine criteria for a safe, clean, and pleasant environment. The other four had all criteria in place except "age-appropriate decorations" in the cafeteria, such as posters, and Food Guide Pyramids that were age appropriate. Four of the eight schools that participated in this study had emergency training in how to deal with food allergies. The school nurses also provided updated lists of students who had food allergies or food-related difficulties. Four of the eight schools were prepared in all three types of emergencies listed on the questionnaire—choking, natural disasters, or medical emergencies. Half of the participating schools provided training as part of their district’s effort to ensure proper emergency training and readiness. Five food service managers stated all staff should be more prepared and trained in handling food emergencies. Four schools had one or two methods to reinforce nutrition education lessons taught in the classroom, although these food service managers stated there should be more done to bridge the gap between cafeteria and classroom. The other four food managers believed they had collaboration through three or more avenues. Some examples of collaborative methods were providing teachers with learning materials, giving ideas for nutrition education lessons, and providing food samples to the students. Five of the eight schools (62.5%) had food service managers who were credentialed by the state of Illinois or the ASFSA but did not have a college degree in food and nutrition. Three of the eight schools (37.5%) had food service managers who had a master’s degree in home economics and nutrition as well as credentials. Of the food service managers who were interviewed, only three (37.5%) felt a college degree in nutrition was important for a successful program. All the food managers participated in food service continuing education courses. The planning items on the SHI helped the school food service managers use results of the scorecard to identify strengths and weaknesses in their nutrition programs. This assessment was completed after the interview. Table 2 lists the recommendations by the food service managers and the total points given on the open-ended questions. The higher the score, the more their food service staff needed to work toward the goal of instituting a change. This higher score also meant the food service managers were interested in addressing the identified weaknesses of the nutrition program.
"The planning items on the School Health Index helped the school food service managers use results of the scorecard to identify strengths and weaknesses in their nutrition programs."
According to the USDA, the School Breakfast Program breakfasts served to U.S. elementary students in the school year 1998–1999 satisfied most program standards. The standard amounts of sodium were fewer than 600 milligrams, and the elementary schools had a mean amount of 574 milligrams of sodium present in their breakfast programs (USDA, 2001). The mean sodium content in elementary schools was 1,259 milligrams of sodium, and the standard was fewer than 800 milligrams (USDA, 2001). The elementary schools that participated in this study did not allow salt on the tables, which potentially lowers the amount of sodium in the meals. In the SHPPS 2006 study, 11.7% of elementary schools offered brand-name fast foods from companies such as Pizza Hut, Taco Bell, or Subway (CDC, 2006b). In 32.7% of elementary schools, there was either a vending machine or a school store, canteen, or snack bar where students could purchase food or beverages (CDC, 2006b). In this study, none of the schools had venues outside the cafeteria such as school stores or snack bars. Also presented in the SHPPS 2006 study was a statistic regarding food service managers. Among food service managers, 4.1% had not completed high school and 49.3% had no more than a high school diploma or GED. About 22.1% of school districts did not require a newly hired school food service manager to have a minimum level of education. But 74.1% of school districts did require a high school diploma or GED (CDC, 2006b). Although the grade levels were not discussed in this study, 62.5% of the food service managers did not have a college degree in food and nutrition. Many food service managers did not think this was a weakness, but they did feel very strongly about the importance of continuing education in the food service field.
Limitations
Implications for School Nursing Practice Another way the school nurse could get involved is to advocate for changes in the practices and policies related to nutrition and physical activity in the school environment. Many schools are calculating Body Mass Index on students. With this data, school nurses can track weight trends in obesity and provide helpful information to parents. School nurses can collaborate with school and community organizations in planning healthy activities for students. By working with organizations such as the Parent–Teacher Organization, Girl Scouts, and Boy Scouts, the school nurse can encourage activities that center around physical activities and healthy snacks. School nurses can also promote partnerships and a positive link from the cafeteria to the classroom. Food service managers and school nurses need to be involved in the nutrition curriculum and participate in classroom activities concerning nutrition. Some schools have initiated a healthy kids group that is involved with organizing community events such as walking for fitness, blood pressure screening, and blood screening for diabetes and cholesterol. This is another way to involve schools and the community to promote healthy lifestyles.
Conclusion
American Beverage Association. (2006). School beverage guidelines. Retrieved March 11, 2008, from http://www.ameribev.org/industry-issues/school-beverage-guidelines/index.aspx.American School Food Service Association. (2007). Your child nutrition resource: Program history and data. Retrieved February 20, 2008, from http://www.schoolnutrition.org/Index.aspx?id=71.Centers for Disease Control and Prevention. (2001). SHPPS 2000: School health policies and programs study: Fact sheet. Retrieved March 11, 2008, from http://www.cdc.gov/HealthyYouth/shpps/2000/factsheets/pdf/nutrition.pdf.Centers for Disease Control and Prevention. (2006a). School Health Index for physical activity and healthy eating: A self-assessment and planning guide: Elementary school version. Retrieved February 21, 2008, from http://apps.nccd.cdc.gov/SHI/PaperFormat/Questions.aspx?GradeID=1&HealthTopicID=2&ModuleID=4.Centers for Disease Control and Prevention. (2006b). SHPPS 2006: School health policies and programs study: Fact sheet. Retrieved February 20, 2008, from http://www.cdc.gov/Healthy-Youth/shpps/2006/factsheets/pdf/FS_Nutrition_SHPPS2006.pdf.Dietary Guidelines Advisory Committee. (2000). Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2000. Washington, DC: U.S. Department of Agriculture, Agriculture Research ServiceIllinois State Board of Education. (2008). Illinois district report cards. Retrieved February 21, 2008, from http://webprod.isbe.net/ereportcard/publicsite/getProfileSearchCriteria.aspx.Marx, E, Wooley, SF, & Northrop, D. (1998). Health is academic: A guide to coordinated school health programs. New York: Teachers College PressSaltos, E. (1999). Adapting the Food Guide Pyramid for children: Defining the target audience. Family Economics and Nutrition Review, 12(3–4), 3-17U.S. Department of Agriculture. (2001). Food buying guide for child nutrition programs. Washington, DC: Author. Publication No. PA-1331.U.S. Department of Agriculture. (2007). National School Lunch Program: Fact sheet. Retrieved February 22, 2008, from http://www.fns.usda.gov/cnd/lunch/aboutlunch/NSLPFactSheet.pdf.U.S. Department of Agriculture. (2008). Inside the Pyramid. Retrieved June 1, 2008, from http://www.mypyramid.gov/pyramid/index.html.U.S. Department of Agriculture, Food and Nutrition Service. (2008). School breakfast program: Children participating. Retrieved February 20, 2008, from http://www.fns.usda.gov/pd/31sblatest.htm.U.S. Department of Health and Human Services. (1996). Guidelines for school health programs to promote lifelong healthy eating. Morbidity and Mortality Weekly Report, 45(No. RR-9), 1-33U.S. House Committee on Agriculture. (1994). Healthy Meals for Healthy Americans Act of 1994. Retrieved February 22, 2008, from http://agriculture.house.gov/info/glossary/hi.htm.Wechsler, H, Brenar, ND, Kuester, S, & Miller, C. (2001). Food service and foods and beverages available at school: Results from the School Health Policies and Programs Study 2000. Journal of School Health, 71(7), 313-325[Medline] [Order article via Infotrieve]Yeoman, B. (2003). Is the U.S. government making children fat? Nieman Reports 30-32
The Journal of School Nursing, Vol. 24, No. 4,
222-228 (2008)
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Abstract
LITERATURE REVIEW