Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 23, 2008

National School Lunch Program Doesn’t Make the Grade: Why America’s Children are Obese- Jayme Lerner

Over the past decade, childhood obesity has increased significantly. Degree of obesity is commonly assessed through body mass index (BMI), a ratio of weight to height (1). A BMI of 25-29.9 is classified as overweight, 30 as obese with greater then 40 indicative of morbid obesity (1). According to the National Health and Nutrition Examination Survey (NHANES), in the 2003-2004 year, 17.1% of United States children and adolescents were overweight and 32.3% of adults were obese (2). Between 1999-2000 and 2003-2004, an increase in overweight children and adolescents rose from 13.8% to 16.0% in females and 14.0% to 18.2% in males (2). The more prevalent overweight and obesity occurs is in childhood and adolescent years, the higher risk of being overweight and obese is in adulthood.
In the past, health related complications of obesity were common only in adults, but now has been found in staggering numbers in children. Obesity is a multisystem disease, affecting psychological, neurological, pulmonary, cardiovascular, gastrointestinal, renal, musculoskeletal and endocrine systems (3, 4). The most prevalent complications include depression, sleep apnea, asthma, exercise intolerance, hypertension, atherosclerosis, dislipidemia, chronic inflammation, and type 2 diabetes mellitus (4). Each condition may have been avoided through weight loss, exercise and healthy eating (1).
The National School Lunch Program (NSLP) began in 1946 as part of the National School Lunch Act to ensure the health of children in the United States (5, 6). NSLP is a federally assisted meal program with the aim of providing nutritionally balanced, low-cost or free lunches to children in public, non-profit private schools and residential child care institutions. Individual school boards must apply to their state education agency to establish the program. Each district receives a cash subsidy and donated commodities from the United States Department of Agriculture for each meal served (5). In 1998, NSLP was expanded to include reimbursement for snacks served during after school educational programs (6). The number of participating children has grown from 7.1 million in 1946 to upwards of 30.1 million (5).
To combat the widespread epidemic of childhood obesity, Healthy People 2010 aims to decrease the proportion of youth who are overweight and obese (3). A specific objective is to increase the proportion of children and adolescents aged 6-19, whose intake of meals and snacks at school contributes proportionally to good overall dietary quality (7). The National School Lunch Program’s approach to resolving childhood malnutrition and obesity ignores pertinent aspects involved in combating this widespread epidemic. These faults are centered around includes low participation rates, competition, poor regulations, and deficient nutrition and physical education.
Low Participation Rates
The National School Lunch Program (NSLP) is available in all 50 states as well as the District of Columbia, Guam, Mariana Islands, Puerto Rico and Samoa (8).Even though the NSLP is available to all students, not all school districts partake in this program. Only 14,000 of 99,500 districts participated in 2006 (9, 10). Delaware, with a total of 34 school districts has only 19 participating. Nevada is one of the only states that have all 17 districts participating (9, 10). Participation is the highest in elementary schools at 67%, and lowest in high schools, 39% (12). Due to these low participation rates, the number of children and families taking advantage of the National School Lunch Program is extremely limited.
While a total of 30.1 million children participate in the National School Lunch Program, according to 2005-2006 school year data, there are strict eligibility requirements. Eligibility is contingent upon on household income levels and federal poverty lines (6). If a family currently receives Food Stamps, Temporary Assistance for Needy Families (TANF), participates in the Food Distribution Program on Indian Reservations (FDPIR) or if a child is homeless, runaway or migrant, they are automatically entitled to free meals (6). In these instances, the school works directly with the State to ensure families are aware that their children can receive free meals (6). A child whose family income falls below 130% of federal poverty level, $26,845 for a family of four, is eligible for free meals. In these situations, the school does not work in conjunction with the State to offer the program (11). Incomes higher then 185%, $38,203 for a family of four, must pay full price for meals (5, 6). Incomes falling between 130 and 185 % receive reduced fare lunches (5, 6). For those receiving free meals, participation reaches 80% while reduced priced meals and full price meals have lower rates of 69 and 48% respectively (12). Even though there are a high number of students receiving free lunches, there are low participation rates for the other meals. Coupled with the lack of participation throughout the United States, many students are no receiving the entitled meals, thus not improving the overall health status of children. In addition, some families feel that income and financial status is something that should be kept confidential, and because of this do not ask for help even though it is needed. The majority of families are left alone to determine their eligibility for NSLP. Since many may not be aware that such programs exist, or know how to start their children in the program, participation for reduced and full price meals is low.
There are potential additional reasons why children and adolescents who are eligible to receive meals are not participating in the program. According to public health theories, social norms and social networking theory have significant implications for people. Social norms are expected codes of behaviors set forth by and experienced by a group or culture (17). These codes are guidelines for how to behave, including the unspoken standards about what are “normal” and acceptable behaviors (17). Similarly, social networking theory assumes that depending on the social network someone belongs to, behaviors are influenced to conform to the group (17). If eating school provided meals is not something that is socially acceptable, NSLP participation rates will be low. Those who must pay the full price or reduced fares have the lowest participation rates compared to those receiving free meals. Students who can afford other foods may find it more socially acceptable to purchase foods from other sources. This may be the reason for why on a typical day only 17.7 million students are taking advantage even though 30.1 million are eligible (6).
Competitive Forces & the Lack of Regulation
The National School Lunch Program has narrow regulations on what foods can and cannot be served as lunches. The United States Department of Agriculture (USDA) sets the standards for nutrition guidelines found in school lunches. The target goal is for lunches to meet the recommendations of the Dietary Guidelines for Americas, with no more then 30% of calories from fat, and less than 10% from saturated fat. It is also suggested that lunches provide one third of the Recommended Dietary Allowances (RDA) for protein, vitamin A, vitamin C, iron, calcium, and total calories (5). In the 2004-2005 school years, around 15% of schools served lunches that did not meet the RDA standards, and 2/3 of schools served lunches that did not meet the standards for total fat and saturated fat (14). On average, lunches contained 34% of calories from fat and 11% of calories from saturated fat, missing the target goals (14). When evaluating elementary students’ nutrient intake composition, there was no difference between those who participate and those who do not, proving the ineffectiveness of the program (14). Even though each school must meet these requirements, they are at liberty to select the foods and preparation methods for each (5).
Although schools can select preparation methods, the USDA has some guidelines. It is required that schools follow one of two procedures. They must either offer five food items selected from four food types: fluid milk, meat or meat alternatives, at least one serving of grain, and two or more servings of fruit, vegetables or both, or determine foods based on weekly nutrient composition of meals (12). Requirements for fruits and vegetables are not specified. Similarly, there is no restriction for high calorie energy dense items such as cookies and cakes that are served with lunches (12). With these lax regulations, there is a wide variety of food types that can be served.
The National School Lunch Program has narrow restrictions on competitive foods found in and around schools. Competitive foods include a la carte foods and beverages, foods sold as fundraising efforts, vending machines, snacks in classrooms and those made available during after-school activities (12). Foods of low nutrient density that are high in calories are sold in competition to school meals through vending machines, school stores and off campus locations when students are allowed to leave school property (12). Fundraisers focused on food and beverage sales in 37% of elementary schools and 50 to 60% of middle and high schools included foods of minimal nutritional value (14). Although vending machines are sometimes located away from cafeterias, they are still are available in 17% of elementary schools, 82% of middle schools and 97% of high schools (14). In a study of 20 Minnesota schools, on average there were 11 vending machines in each school (12). Since there are no strict guidelines for hours of operation of competitive foods they are readily available.
With the high prevalence of competition, some states have enacted their own set of guidelines in addition to those set forth by the USDA. In Florida, competitive foods are not allowed in elementary schools, and are not available until one hour following the last lunch period in secondary schools. The sale of carbonated beverages is allowed at all times in high schools permitting there are 100% fruit juices available at each location (8). In Virginia, coffee and tea can not be sold to students regardless of the time of day (8). Even with these additional recommendations, foods of low quality are allowed for consumption and compete with school served lunches.
Additionally, the National School Lunch Program has no guidelines regarding portion sizes that are served to students. When there are no standards for portion control, even if a food is deemed to be “healthy”, in large quantities it may not be. Over the past 20 years, portion sizes for the majority of foods have increased significantly (15). This growing trend is one of the main reasons for the rise in obesity, since energy intake is exceeding energy expenditure (15). It would be virtually impossible to monitor each child’s eating behavior, but not having standard portions exacerbates the problem of obesity in children and adolescents.
Lack of Nutrition and Physical Education
While the National School Lunch Program aims to increase the proportion of healthy foods served at lunch to increase child and adolescent health, there is no simultaneous discussion of nutrition education. Food choices are influenced by the total environment, not just the availability of foods. Nutrition education is not something that is mandatory for each state. 69% of states require health education curricula to include nutrition and dietary behaviors (13). In a 2000 survey, 75% of health courses included lessons on nutritional and dietary behavior (12). On average, a total of 5 hours per academic year is spent on topics of nutrition and diet (12). In comparison to time spent on traditional subjects, these 5 hours are not enough to educate students on making the necessary changes. Additionally, many school districts do not require all grades to have health education classes. Some schools offer health education every other year. With the extreme lack of nutrition education, children are not learning about the c0responding health benefits of making these choices. The availability of healthy foods such as fruits and vegetables is not enough to prompt children to choose them especially when competition is available (12). For dietary changes to take place, it is essential to educate children and adolescents about the benefits of making dietary changes, and how to do so properly.
It is also vital that children participate in physical activity. Physical education (PE) is required by law, but there are no requirements on the nature and duration of classes (12). Physical education is mandated in 36 states for elementary school students, 33 states and 42 states for middle school and high school respectively (13). A 2000 School Health Policy and Programs Study (SHPPS) found that typical PE classes, lasted on average 45 minutes. Students spent an average of 15.3 minutes participating in games, sports or dance and 9.6 minutes on skill drills (13). In a typical 30 minute elementary school PE class, the average child was vigorously active for only two to three minutes of class time (13). In 2006, SHPPS found that 69% of elementary schools, 84% of middle schools, and 95% of high school required physical education. Students were exempt from gym if they participate in community service activities, community sport activities, band or chorus (16). At the same time, only 62% of states require physical activity and fitness education in health curriculums (13). In 2000, 69% of health courses addressed physical activity and fitness, averaging a total of 4 hours per year (12). With the lack of physical education students are not getting the activity necessary for optimal health.
The National School Lunch Program (NSLP) focuses only on what children consume for lunch in schools as a means of promoting good health. Since this program only focuses on school lunches, there is a large divide between what children and adolescents consume at school versus elsewhere. Parents and caregivers are often unaware their children are obese or at risk for obesity (13). When families are not aware of the risks of being overweight, the benefits of consuming nutritionally balanced meals and performing physical activity there are barriers to combating the obesity epidemic. If parents become aware of the consequences of poor health on their children, some may make the effort to increase healthful behaviors at home.
Associated with the lack of family education, NSLP lacks family involvement and encouragement which are vital components of children being healthy. Parents are the ones doing the food shopping, preparation or purchasing of meals, for the majority of children. It has been found that teens who eat meals with their families more frequently, or who assist in preparation of meals report higher intakes of fruits, vegetables, grains and essential nutrients (13). There are also lower intakes of sweetened soft drinks and dietary fat and are at lower risk for developing eating disorders (13). Even though 30% of meals are consumed outside the home, what children see and experience on a daily basis influences choices, as evident in these findings (1). Social learning theory explains the idea that people acquire behaviors through observation or vicarious learning (17). While people are not necessarily cognizant of this, the behaviors modeled are subconsciously acquired and put into practice. Parents and peers are two of the most prominent people modeled after. Children are picking up behaviors of their parents and caregivers. If a child is not exposed to healthy behaviors at a young age, when the majority of their time is spent with parents and caregivers, it is less likely that they will practice healthy behaviors on their own. This process occurs throughout life for both positive and negative behaviors, but it is up to parents to start the positive behaviors early, and to reinforce those acquired throughout their children’s lives.
Implications & Conclusion
A multifaceted program that involves healthy eating, physical activity and support systems is the optimal method to ensure overall health for children and adolescents 13). Due to the lack of these attributes, the National School Lunch Program fails in its mission to increase the overall health and nutritional status of students. Not all schools participate and those that do have relatively low participation. With low participation rates many of the eligible students are not receiving their entitled lunches. Additionally, the lack of regulatory action against competitive foods and portion sizes further complicates the issue of obesity. Targets for nutritional composition are not being reached. There is lack of support and encouragement from family members and potentially other students as seen through public health theories that are being overlooked. In order for this program to fulfill its mission of bettering the health status of students it is necessary to alter the approaches taken. Increasing participation rates, creating strict regulations, increasing health and physical education, and generating family education programs to increase involvement are necessary to make the National School Lunch Program efficient in promoting good overall health for students and decreasing the high rates of childhood obesity.
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6. Food Research and Action Center. National School Lunch Program. Food and Research Action Center, 2008
7. United States Department of Agriculture. National School Lunch Program/School Breakfast Program: Foods of Minimal Nutritional Value. 2001.
8. American Dietetic Association. Competitive Food Policies by State- A Report to Congress. Washington, D.C: American Dietetic Association.
9. LaFaive, M.D. A School Privatization Primer. Michigan: Mackinac Center, 2006
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11. American Dietetic Association. Income Eligibility Requirements. Washington, D.C; American Dietetic Association.
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13. Progress in Preventing Childhood Obesity: How Do We Measure Up?
Authors- Committee on Progress in Preventing Childhood Obesity
14. Food and Nutrition Service. School Nutrition Dietary Assessment Study- III, Summary of Findings. Washington, D.C; United States Department of Agriculture
15. Smicikilas-Wright, H et al. Foods Commonly Eaten in the United States. 1989-1991 and 1994-1996: Are Portion Sizes Changing? Journal of the American Dietetic Association. 2003, 103:41-47
16. Centers for Disease Control. School Health Policies and Program Studies. Washington, DC Centers for Disease Control:
17. Edberg, M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2007

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