Throughout the USA, parents and school personnel are concerned about the alarming rise in childhood obesity. Kids that are overweight may be susceptible to health problems both immediately and in the future, and the federal and state governments are looking at food reform in our school cafeterias:

September 25, 2005
What? No Fries and Pepsi?
By DEBRA NUSSBAUM, NY TIMES

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FRENCH fries and mozzarella sticks washed down with a can of Coke. Skittles and a cool, slushy, fruit-flavored drink.

Throughout the state's 600 public school districts, this will soon be history. In many of them, it already is. Alarmed by the rise in student obesity, New Jersey is putting school cafeterias on a diet.

Although a new set of regulations adopted by the state in June - the most aggressive in the nation - will not take effect until September 2007, about 20 percent of the districts are already offering a lighter menu to students who buy lunch at school. Disappearing from the cafeteria lines from prekindergarten to high school will be soda, salad dressings with high fat content, fried foods and any item listing sugar as the first or principal ingredient.

"It has been a growing call to arms," said Carolina Lobo, a vice president for the Aramark Corporation, which provides meals for 26 of the state's school districts. "It's been a wonderful change in this industry."

And with good reason.

About 15 percent of the nation's youths from ages 6 to 19 are overweight and another 15 percent are obese, according to the American Obesity Association. A report issued by the New Jersey Department of Health and Social Services covering the 2003-4 school year showed that 2,393 of the state's sixth graders, or 60 percent, were of normal weight, 20 percent were obese and another 18 percent were overweight - resulting in an increase in Type 2 diabetes, elevated blood pressure and orthopedic complications.

Even before New Jersey addressed the issue, the federal government began focusing on nutrition in schools and childhood obesity. President Bush signed the Child Nutrition Reauthorization Act in 2004 requiring all districts that participate in the federal school-meals program (which is almost every one in the nation) to address obesity and come up with wellness policies by 2006. But New Jersey developed more detailed requirements.

While other states, including Arkansas, California, Texas and New York, are slimming down lunch offerings and pressing for legislation to remove junk foods from school cafeterias, Kathy Kuser, director of the division of food and nutrition for the State Department of Agriculture, said New Jersey had "the most comprehensive policy to date."

"A lot of states don't touch high schools because it is too controversial," Ms. Kuser added.

Or at best, many states pick their battles carefully. For example, Arkansas has banned vending machines in elementary schools, and California has banned carbonated beverage sales in vending machines at elementary, middle and junior-high schools. But New Jersey schools, regardless of grade, will not be able to sell anything during the normal day that lists sugar in any form as the first ingredient of the product, or any candy.

Moreover, districts have been told that whenever possible, physical education or recess should be scheduled before lunch.

Some experts warn that schools risk making the forbidden sweets more appealing to students.

Dr. Peter Bordi, a professor at the Penn State School of Hospitality Management, who researches healthier snacks and menu alternatives, suggested that schools sell smaller portions and look for snack products in which manufacturers have lowered fats and sugars. "A Snickers bar isn't going to kill these kids," he said.

Nonetheless, according to the guidelines, introduced by Acting Gov. Richard J. Codey, no item with more than eight grams of fat per serving will be sold in school cafeterias. With the exception of water and low-fat milk, no beverage can be larger than 12 ounces.

Only milk, water and 100 percent fruit and vegetable juices will be permissible in elementary schools. In middle and high schools, 60 percent of the beverages - other than water and milk - will have to be 100 percent fruit and vegetable juice.

For now, some schools in the state still have soda machines, although since 1989 they have been prohibited from selling sodas during lunch periods. But under the new guidelines, schools that participate in the National School Lunch Program, which includes most of them, will not be permitted to sell sodas during any part of the school day.

Getting a Head Start

School districts like Cherry Hill, West Windsor-Plainsboro, Brick Township, Washington Township in Gloucester County, South Orange-Maplewood and Bernards Township are already trying to offer more fruits and vegetables.

Schools in the West Windsor-Plainsboro district are serving only low-fat mayonnaise and salad dressings, steaming vegetables and serving them without butter, and providing only hot dogs with a turkey base and potato chips that are baked rather than fried. French fries can be purchased à la carte, but they are not offered as part of a meal. In addition, two kinds of fresh fruit are offered each day.

In Washington Township in Gloucester County, the mozzarella sticks are gone. Pretzels and baked chips are served instead of fried chips, and low-fat meats and salad dressings are being offered. In addition, there are no 20-ounce drinks; fruit and sports drinks are being sold only in 12-ounce containers. And cookies - with less fat - have been made smaller in the last few years.

Ginny Bowden, the director of food service for the Washington Township district, said that food service workers taste-tested several brands of hot dogs during the summer before finding a good turkey and beef wiener with a lower fat content.

"All these things were done gradually," Ms. Bowden said, "so we didn't have upheaval."

Nor have those been the only changes. Indeed, some of the most comprehensive changes have been introduced in the South Orange-Maplewood district, where Mr. Codey went in June to announce the new regulations. The district began changing its menus two years ago, partly because of criticism from parents about French fries and other fatty foods.

For starters, Pat Johnson, the food services director in South Orange-Maplewood, eliminated high-sugar foods and drinks as well as fried foods.

"I thought, why are we frying and not baking?" Ms. Johnson said. "Why are we putting this oil in children's bodies? We took small steps, it wasn't overnight."

Last year she began introducing new fruits and vegetables every week, and jazzed up the menus with offerings like "fish in a boat" - peanut butter on celery with a few goldfish crackers stuck on top. "If you give them the right things, they don't miss the French fries," Ms. Johnson said.

In Cherry Hill, where Aramark is the food provider, salads now appear on the menu every day, and easy-to-eat foods like cut-up fruit and cheese with crackers are being offered.

Skittles and Starbursts are gone from the cafeterias, along with slushy juice drinks. Romaine lettuce has replaced iceberg lettuce. And peanut butter and jelly sandwiches are made with whole wheat bread.

The Millburn school district has formed a 10-member nutrition committee of parents and educators to devise a plan for promoting healthier eating, said the superintendent, Dr. Richard Brodow.

"We have tried to introduce more nutritious foods," Dr. Brodow said. "We have an obligation to work with our teachers and parents to promote healthy eating. We are trying to work together. We aren't going to be the food police. Everything needs to be done in moderation."

Winning Over the Kids

Not that students have to embrace the changes all at once.

When South Orange-Maplewood decided to stop offering cookies and French fries with globs of cheese, Etta Denk of Maplewood said, her 12-year-old son, Alex, was not too happy.

"His initial reaction was, 'They got rid of the good stuff,' " Ms. Denk said.

But now, she said, Alex is buying salads and eating foods more in line with what he finds in his own kitchen, where soda, cookies and potato chips are not on the menu, but fat-free ice cream and low-carbohydrate bread are.

Ms. Denk said that Alex, who is in the seventh grade at South Orange Middle School, initially found the new offerings at school "pretty weird," but that he had gotten with the program.

"The food is pretty good," he said. "The spaghetti is good and vegetables are nice and fresh."

The objectives of all these districts, administrators say, is simple: better health.

Ms. Kuser, the director of the division of food and nutrition for the State Department of Agriculture, said that the hope was to tie in the changing of cafeteria menus with physical fitness.

For their part, health teachers say they like linking what they are teaching with what the schools are serving. "Our curriculum is being supported in the cafeteria," said Judy LoBianco, who runs physical education programs for the South Orange-Maplewood district.

To further this statewide effort, about 150 New Jersey schools last year participated in Shape It Up, a program that was developed at Rutgers University with the help of elementary school teachers around the state. This year, the program hopes to reach the same number of students.

The free program uses demonstrations like putting lumps of shortening in a tube and trying to pour red liquid through it to show how the flow of blood is impeded when moving through arteries clogged with cholesterol.

The program also addresses the difference between a healthy serving and super-size food in some restaurants, and how to make good choices - even when being hurried along in the fast-food line, said Dr. Saira Jan, the director of Shape It Up and an associate clinical professor at the Ernest Mario School of Pharmacy at Rutgers.

"It's a big, big step," Dr. Jan said. "Kids choose from what they are offered. They are hungry. They will eat. You can offer baby carrots or you can offer French fries. We have a big health-care problem. We can't just talk about it."

Teaching Good Habits Early

Educators say that the way to really change how children eat is to begin talking about the food groups at an early age. To that end, the Nutritional Sciences Preschool in New Brunswick, which is run by Rutgers University, accepts about 40 3- and 4-year-olds a year.

At the preschool - which claims to be the only one in the country whose curriculum is designed around teaching principles of eating healthy foods - college students studying nutrition cook with the children as well as help them make menus and recipes. As in any preschool, the day includes art, music, reading activities and free play, but it also includes talk about food and healthy snacks, said Harriet Worobey, the school's director.

"If we start at the beginning with small children, we can make a difference," Ms. Worobey said.

Snacks there include peas, potatoes, baby carrots with dip and fruits like mangoes and kiwi - and nobody is forced to eat anything. "We make it available and we model it," Ms. Worobey said.

A study of 42 children done at a Head Start center in New Brunswick in 2001 and 2002 showed that even young children were at risk for obesity. The study found that 60 percent of the 4- and 5-year-olds were at risk for being overweight, and that a quarter of them already were.

But how much difference does what children eat in school make in the total picture of their health?

"I wish I could say 100 percent," said Ms. Worobey, who added that the same study also showed that students in breakfast and lunch programs consumed 60 percent of their daily recommended calories at school.

But once they returned home, they often went right back to eating foods with a high fat and sugar content.

"It's a national problem," she said. "If it were an easy problem, it would already be solved."

Healthy School Lunches

Helping School boards Enact Policies that Support Healthy Eating

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The primary responsibility of schools is to foster academic achievement. Schools can do this by providing a high-quality instructional program, but also by paying attention to student health. There is substantial research that shows a clear connection between nutrition, physical activity and learning. Healthy, well-nourished children are more prepared to learn, more likely to attend school and class, and able to take advantage of educational opportunities. Inadequate nutrition during childhood can have a detrimental effect on children's cognitive development and productivity in adulthood. (1)

Research also shows a direct relationship between breakfast and educational achievement. Studies have repeatedly demonstrated that breakfast at school not only enhances learning, but also reduces tardiness and improves daily attendance.(2)

Physical activity can also have a positive impact on student achievement. Schools that offer intense physical activity programs see positive effects on academic achievement, including increased concentration, improved mathematics, reading and writing test scores, and reduced disruptive behavior, even when time for physical education classes reduces the time for academics. (3) In California, higher achievement was associated with higher levels of fitness for fifth-, seventh- and ninth graders. (4)

One of the ways to prevent chronic diseases is to establish policies and programs that encourage children and adolescents to develop and sustain healthy eating and physical activity habits that they can maintain throughout their lives.

Poor diet and inadequate physical activity are the second leading cause of death in the United States and together account for at least 300,000 deaths annually; only tobacco use contributes to more deaths. (5) The general health of our students is at risk, in part, due to poor nutrition.

Continuing increases in the number of overweight children and adolescents is of public concern. Among children and teens ages 6-19, 15 percent (almost 9 million) are overweight according to the 1999-2000 data, triple what the proportion was in 1980.(6) An increase in Type 2 diabetes among children has paralleled the rising rates of obesity. (7). A recent study showed that consumption of sugar-sweetened beverages, such as soda and fruit-flavored drinks, is associated with obesity in children.(8)

Schools should provide education and an environment that gives students the skills, opportunities and encouragement they need to adopt healthy lifestyles. This requires more than educating youth on the importance of eating healthy foods and being physically active. Students cannot practice what they learn if they are offered mostly foods and beverages high in fat and sugar, and little opportunity to be physically active.

School-based programs such as the California Project LEAN (Leaders Encouraging Activity and Nutrition) Food on the Run program and CATCH (A Coordinated Approach to Child Health) have shown positive behavior change in students despite the prevalence of high fat and sugary foods offered outside of school.

Schools cannot meet all of the nutrition-related needs of student alone. However, because the relationship between health, nutrition, physical activity and learning is so strong, and because young people spend so much of their time at school or at school-related activities, schools can be a vital part of the solution.

A comprehensive school nutrition and physical activity program can help students attain full academic potential and optimal health by providing the skills, social support and environmental reinforcement necessary to adopt lifelong, healthy eating and physical activity behaviors. By adopting policies, school board members ensure that the health of students is a top priority.

To provide a comprehensive nutrition and physical activity program, districts should consider the following steps. These recommendations have been adapted from the Surgeon General's Prescription for Change, Centers for Disease Control and Prevention, and the United States Department of Agriculture's Changing the Scene.

1. Emphasize proper nutrition and physical activity as a priority.

Establish a vision and goals for the district's child nutrition and physical education programs.
Adopt policies that ensure all foods and beverages available on campuses and at school events contribute toward eating patterns that are consistent with the school food standards in state and federal law. In California, school food standards have been developed and incorporated in SB 19 (Escutia, Chapter 913, Statutes of 2001). Extend the more rigorous nutrient standards that are typical at the elementary schools so that they apply to middle and high schools.
Retain well-trained food service professionals who reinforce student's adoption of healthy eating habits.
Ensure that nutrition and physical education policies are implemented and evaluated annually.

2. Ensure quality school meals.

Involve students in the selection, tasting and marketing of healthy foods and beverages that appeal to students.
Provide more options, such as fruits, vegetables, whole grains and dairy foods, that are low in fat and added sugars.
Offer a variety of healthy choices that appeal to students, including cultural and ethnic favorites.
Commit all schools to participate in available child nutrition programs, including breakfast, lunch, after school snacks, child care and summer food service.

3. Monitor competitive food sales.

Restrict student access to unhealthy foods in vending machines, school stores, and other venues that compete with healthy school meals in all grades, pre-kindergarten through grade 12.
Ensure that healthy snacks and beverages are provided in vending machines, school stores and other venues within the district's control. These options should be available at the same cost or less than unhealthy alternatives.

4. Provide an environment conducive to good health.

Allow an adequate amount of time and space for students to eat school meals, and schedule lunch periods at reasonable hours around midday. Make sure that lunch lines are not too long and students have plenty of time to eat their food and socialize in a safe, comfortable and inviting place.
Encourage safe access to physical activity facilities during and after school.
Ensure that drinking fountains are operable, clean and convenient for students to access throughout the school day.

5. Support nutrition education and physical education.

Offer nutrition education and daily physical activity in all grades, pre-kindergarten through grade 12. Enforce mandated physical education requirements.
Focus on skill development so students are able to learn and adopt healthy eating and physical activity behaviors.
Offer nutrition education in the school dining area and in the classroom with coordination between food service staff and teachers
.
6. Promote healthy eating and physical activity.

Discourage the use of unhealthy foods (e.g. soda, candy or high-fat foods) as an incentive or reward in the classroom, and instead encourage non-food alternatives (e.g. inexpensive stickers, pencils, erasers).
Serve healthy foods such as smoothies or salads for class parties.
Use a variety of strategies to actively promote healthy eating and physical activity to students, parents, teachers, administrators and the community.
Conduct promotional campaigns in the cafeteria and on campus that encourage healthy eating and do not promote less nutritious food choices.
Discourage the promotion and advertising of unhealthy foods and beverages.
Explore revenue-generating alternatives.
Continually seek other sources of revenue for schools so food service programs, booster clubs, student clubs and parent-teacher associations do not have to support their activities through the sale of unhealthy foods in vending machines, snack bars, student stores and other food outlets.
Explore how some districts are able to be less reliant on the sale of unhealthy foods and beverages.
Assess the district's nutrition and physical activity program.
Visit your school cafeteria for breakfast and lunch and spend time with students and staff to learn what students are eating and drinking.
Involve students, parents, school staff, administrators, nutritionists and community leaders in assessing the school's eating and physical activity environment. Develop a shared vision and an action plan to achieve it.
Review successful school-based models.
Identify other resources to develop sound policies for physical education and physical activity, and other components of comprehensive school health program.

Many school districts are meeting the challenge. They are offering healthy foods that students like while remaining financially sound. For example, Vista Unified School District strived to become the first "junk food free" district in the San Diego, California area. Vista's Child Nutrition Services (CNS) program took over responsibility for managing vending machine contracts and introduced new, healthier products, such as fresh fruit, nuts, dried fruit, lower fat ice cream bars, and fruit bars. Sodas are still offered, but only in limited quantities. The program has met with unqualified success. The students are eating better and during the first year, the school generated $200,000 more in sales than in the previous year  which translated into nearly $15,000 in commissions for the school versus $9,000 the previous year.

Other California districts are taking similar steps to improve the nutritional quality of food sold to students. Capistrano Unified School District passed a resolution banning soda from vending machines during the entire school day, and also improved the quality of vended snacks. Los Angeles Unified School District has banned the sale of all soda and sugary drinks from all campuses before, during and until one-half hour after the end of the school day. Oakland Unified School District adopted one of the strictest policies on soft drinks and junk food in the nation. Unlike some school regulations that allow sales of unhealthy foods and beverages after school, Oakland has completely banned caffeinated drinks and some high-sugar sports drinks, candy, and all similar products. The policy expands nutritional standards to apply to all foods served on campus and extends the policy to middle and high schools, and important change since more rigorous nutritional standards typically exist at the elementary level.

Folsom Cordova Unified School district has revamped its entire food service operation. As a result, healthier school meals are available, point of sale locations have been increased to reduce the amount of time students must stand in line to receive food, and the district has eliminated the practice of requiring students who are eligible for free or reduced-prices lunches from standing in separate lines by allowing all students to punch ID numbers into a computerized keypad to pay for their lunch. The district is serving a substantially greater number of meals to students, and even more importantly, a district that was losing $200,000 annually on its food service program now has a $400,000 reserve and an annual budget that has gone from $1.75 million in 1995 to $3.5 million in 2002 due to increased revenues.

These districts all had to overcome a variety of challenges in the quest to improve nutritional standards for their students. These obstacles included concern from school officials that the changes would lose money for the schools, opposition from students who fought to keep sodas on campus, and the sheer effort that can be required to adopt and enact procedures necessary to comply with initiatives that support healthy eating.

In Capistrano, those pushing the ban on sodas and junk food found more support than they originally expected, and they also speculate that a closed campus made the switch easier to enforce. In Los Angeles, proponents of the ban made a concerted effort to stress that the central issue was health, not economics, and they worked with health advocates and district students to amass data and statistics supporting the ban. In Oakland, a small but vocal group of parents, community leaders, and health advocates raised concerns, and their outcry led to the creation of an official task force, the Nutrition Advisory Board (NAB). NAB is charged with implementing the ban on soft drinks and junk food, with the input of the community and staff. In Folsom Cordova, it took the concerted effort of a new food service director determined to do what it takes to steer nutrition programs through the changes in philosophy necessary to radically overhaul food delivery mechanisms to maintain nutritional integrity and fiscal viability. These examples all prove one thing: the ingredient required for success is the recognition of the vital importance of good nutrition for students, and a vocal determination to change practices and procedures to achieve it.

Information in this article has been adapted from The Healthy Food Policy Resource Guide developed by the California School Boards Association and California Project LEAN (Leaders Encouraging Activity and Nutrition). Copies are available for $20 each. To order a copy, contact CSBA at (866) 266-3382 or send an email to policy@csba.org. Visit www.csba.org and www.Californiaprojectlean.org for more information on children's health and nutrition-related policy development.

(1) Tufts University, Center on Hunger, Poverty, and Nutrition Policy, Statement on the Link Between Nutrition and Cognitive Development in Children, Tufts University, Medford, MA, 1994.

(2) Meyers, A.F., et al., "School breakfast program and school performance, "American Journal of Diseases of Children, 1989, 143:1234-1239.

(3) Symons, C.W., Cinelli B., James, T.C., and Groff, P., "Bridging student health risks and academic achievement through comprehensive school health programs," Journal of School Health 1997, 67(6):220-227. See also Kolbe, L.J., Green, L., Foreyt, J., et al, "Appropriate functions of health education in schools: improving health and cognitive performance," In: Krairweer, N., Arasteli, J., Cataldo, M., eds. Child Health Behavior: A Behavioral Pediatrics Perspective, New York, NY John Wiley, 1986.

(4) California Department of Education, The Relationship Between Physical Fitness and Academic Achievement, 2001, PFT/SAT-9 Study, Sacramento, CA, 2002.

(5) McGinnis, J.M., and Foege, W.H., "Actual causes of death in the United States," JAMA, 1993, 270:2207-2212.

(6) Centers for Disease Control and Prevention (CDC), National Health and Nutrition Examination Survey (NHANES). Obesity Still on the Rise, Press Release, October 8, 2002.

(7) Rosenbaum, A.L., Joe, J.R., and Winter, W.R., "Emerging epidemic of type 2 diabetes in youth," Diabetes Care, 1999; 2292:345-54. and American Diabetic Association, "Type 2 Diabetes in Children and Adolescents," Diabetes, March 2000, 23(3):381-389.

(8) Ludwig, D.S., Peterson, K.E., Gortmaker, S., "Relationship between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis," Lancet, 2001, 357:505-508.

Victoria Berends is Marketing Manager of California Project LEAN, a program to promote healthy eating and physical activity among adolescents as a way to improve chronic disease. She can be reached at Vberends@dhs.ca.gov.

Martin Gonzalez is the Assistant Executive Director for Policy Services at the California School Boards Association. He can be reached at mgonzalez@csba.org

For Additional Information:

Action for Healthy Kids

More information on this topic can be found through Action for Healthy Kids (AFHK), a nationwide initiative dedicated to improving the health and educational performance of children through better nutrition and physical activity in schools. This effort represents a response to our nation's epidemic of overweight, sedentary, and undernourished children and adolescents. Healthy schools produce healthy students -- and healthy students are better able to learn and achieve their true potential. An outgrowth of the 2002 Healthy Schools Summit, AFHK is composed of 51 State Teams and a national coordinating and resource group. AFHK fosters sharing and collaboration among diverse stakeholders to encourage and facilitate meaningful change in schools. Guidance and direction is provided by more than 30 national organizations and government agencies representing education, health, physical activity and nutrition.

Childhood Obesity

Obesity in Children and Adolescents

Athealth:Childhood and Adolescent Obesity and Eating Disorders

Childhood Obesity From the Mayo Clinic: What Parents Can Do

Preventing Childhood Obesity

ERIC: Childhood Obesity

About Childhood Obesity and Overweight Kids

To obtain more specific information regarding physical education and healthy eating policies contact NSBA's School Health Programs Department at schoolhealth@nsba.org or 703-838-6722.

California Project Lean Resource Library

California Project Lean Bright Ideas

The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity

Action For Healthy Kids

Tool Kit on Trends and Policy Solutions for Adult Obesity

RECHARGE!

Child Development Basics

US Department of Health and Human Services Health Research and Services Administration Information Center

Teen Health Connection

Teen Growth

Teen Health

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