Challenging Dogma - Fall 2007

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

Sunday, December 9, 2007

Public Schools: A Public Health Failure Due To Inadequate Nutrition Curriculum and Ignorance of Social Determinants – Daniel Lau

From the age of five children are separated from their parents, sent to government institutions of learning known as schools. They will remain there for the rest of their childhood years, listening to what the government has mandated appropriate for them to learn in order to become active, contributing citizens to this society. There is an unspoken contract of trust between schools and parents; that children sent to school will be cared for and educated with the basic skills for survival in this world. They will come home with the knowledge of how to read, write, do simple calculations, and some basic facts of how this country was founded. Yet, there are some glaring omissions in the education principles of public schools. Children come home with little to no education about nutrition, food, and healthy eating habits. Children come home malnourished or over-nourished. Children come home with indigestion and stomachaches because of federally subsidized foods that are required to be served at lunch (1).

Public schools, as government institutions of public health, fail to provide children with quality nutrition education and well-balanced meals. Ignorant nutrition curriculum based on the Health Belief Model coupled with the lack of creative nutrition activities fail to prepare youth to lead healthy lifestyles. In addition, federal school lunch programs serve nutrient-deficient, institutionally racist foods that serve as initial catalysts for the creation of health disparities along racial and socio-economic lines.

Nutrition Education
Education and knowledge are powerful tools for empowering children to make healthy decisions and lead healthy lifestyles. Yet elementary school teachers provide inadequate nutrition education to their students. Delving deeper into the issue of nutrition education, a March 2000 study analyzed what activities are actually taking place in the classroom. On average, the amount of time spent on nutrition curriculum was 13 hours per school year, well below the 50 hour minimum thought to be necessary to impact behavior change (2). In addition, only 29 and 27 percent of teachers utilized hands-on activities and collaborative work, respectively, in their nutrition education coursework. A majority of 52 percent of teachers reported facing barriers to teaching nutrition, which include lack of instructional time, uncertainty of what nutrition activities are possible, and lack of collaboration with meals staff (3).

Focusing on the education that is taking place in classrooms, it is obvious the curriculum framework is designed off of the Health Belief Model. The HBM weighs the perceived susceptibility and severity of a condition against the perceived costs of adopting a new behavior to avoid that condition. If the benefits outweigh the costs, the HBM assumes people will change their intention, thus resulting in a behavior change (4). From the research studies mentioned above, it is clear that the majority of nutrition education is conducted through talking: lectures, information sharing and classroom discussion. These efforts are aimed at shaping intention, which according to the HBM, directly define and control behavior. Public schools teach children about the dangers of obesity and other chronic illnesses as well as the nutritious behaviors they can incorporate into their lifestyles to prevent these illnesses. Therefore, public schools prescribe if children have the education to intend to eat nutritiously and exercise daily, they will do so in their everyday lives. However, schools are incognizant to the social determinants that surround children in schools everyday. When a child is presented with the choice of French fries and an apple for a snack, the food pyramid they learned in class is not the only thing factoring into their decision. The HBM ignores the role of social influences in public school environments. For example, awareness of what foods children see their teachers, faculty, and peers eating can shape behavior. This idea of modeling behavior is explained through Social Learning Theory, which focuses on learning occurring within a social context. SLT advocates that people can learn by observing one another perform different behaviors and witness the outcomes of those behaviors. These observations can have an increasingly cognitive effect through individual interpretation and spark a behavior change (5). Ultimately, what a child sees their teacher eating during lunch may have a larger impact than what the teacher talks about in class, a notion that the HBM fails to acknowledge and address.

An excellent example of the power of quality nutrition education in conjunction with creative hands-on activities and healthier food options can be inferred from the Agatston Research Foundation. Published in August of 2006, the Healthier Options for Public Schoolchildren (HOPS) Study took on the challenging task of changing child behavior through a three-pronged approach: a fruit and vegetable garden, engaging curricula in the classroom, and low-fat, high-fiber foods in the cafeteria. The elementary schools in Florida set aside space for fruit and vegetable gardens, allowing the children to plant, water, cultivate and harvest crops. They then took what they grew and through an innovative cooking activity, prepared meals for themselves and their classmates. In-class activities also incorporated families, emphasizing food as well as physical activity and healthy lifestyle management in and out of school. Finally, HOPS investigators negotiated with the school district to remove nutrient-deficient foods and add low-fat, low in sugar, nutrient dense foods into the cafeteria. This innovative, holistic approach resulted in the acceptance of healthier food options for breakfast, lunch and snacks by 4,000 elementary school children. The children were more engaged and invested into their nutrition and saw the direct results of their hard work (6). The connection between agriculture, nutrition and health were made clear and the students gained experience that will empower them for the rest of their lives. This deeper level of nutrition and lifestyle education exposes the flaws of surface-level nutrition education designed on the HBM.

National School Lunch Program
The availability of unhealthy and harmful foods also contributes to the failure of schools as promoters of public health. The federal government launched a program in 1946 called the National School Lunch Act to ensure every child could receive a nutritious lunch every school day. The act was initially introduced in response to a large number of healthy young men rejected in the World War II draft. An investigation showed a direct correlation between physical deficiencies and malnutrition during childhood, leading to rejection in the draft. Currently, children of families that fall below certain income levels are eligible to receive free or reduced lunches at school (7). Therefore every child does receive lunch, but the “nutritious” portion of the legislation can be argued.

Every year the Physicians Committee for Responsible Medicine (PCRM) conducts a school lunch report card to evaluate the nutritional value of meals served in school. In the 2007 report, 22 of the nation’s largest elementary school districts were evaluated and given a grade on their report card. The criteria for receiving grades were divided into three areas: obesity and chronic disease prevention, health promotion and nutrition adequacy, and nutrition initiatives. A school could earn points in obesity and chronic disease prevention by offering foods low in fat, low in cholesterol and vegetarian/vegan options. In health promotion and nutrition adequacy, points were assigned on servings of vegetables, fruits and non-dairy beverages. Preparation methods were also taken into consideration; to receive full points fruits had to be served fresh and vegetables had to be served fresh, steamed or cooked in low-fat oil. The nutrition initiative category examined the labeling of vegetarian/vegan options, the incorporation of innovative nutrition activities (ex: fruit and vegetable garden), and the quality of nutrition curricula. The breakdown of the elementary school districts was as follows: 4 schools received A’s, 6 schools received B’s, 4 received C’s, and the remaining 8 received failing grades. The report card cites poor grades resulting from high-fat, high-cholesterol foods such as pizza, tater tots and French fries. Processed and canned fruits and vegetables received no points and resulted in the downfall of many of the school districts (8).

The wide range of scores schools received is disturbing. Some of these school districts are performing extremely well; yet, others are performing very poorly. Because these are the foods served in free and reduced lunches, some children are forced to choose between eating unhealthily and not eating at all. A study conducted by the National Institute for Environmental Health Sciences followed a public high school student in Florida through his daily activities. In addition to receiving inadequate physical education, the student had the option of pizza, tacos and burritos, fried chicken fingers, or a cheeseburger for lunch (9). In a completely ironic fashion, the legislation that was developed to feed children a nutritious meal is now feeding them into obesity and chronic illness. Decreased opportunities for physical exercise at school and the unavailability of fruits, vegetables, and other nutritious foods are two of the fundamental causes of childhood obesity. With the definition of obesity as a BMI score of 30 or higher, the prevalence of obesity in children aged 6-11 has tripled over the past three decades. Currently, 9 million children over the age of 6 are classified as obese, and under the current nutritional and educational conditions, the number is only projected to grow (10).

Even more outrageous is the federal requirement to serve milk. This institutionally racist beverage is forced upon schools to serve at lunch if they wish to be reimbursed for their expenditures (11). Lactose intolerance overwhelming affects people of color, with 70 percent of African Americans, 95 percent of Native Americans, 60 percent of Hispanic Americans and 90 percent of Asian Americans unable to break down milk. Consequences of lactose intolerance include nausea, intestinal gas, bloating, and diarrhea (12). By disregarding racial and ethnic health data, school lunches are disproportionately affecting children of color and damaging their health. Progress is being made in some school districts, which are offering lactose-free milk or alternative beverages like soymilk and fruit juice. However, many schools continue to offer milk as the sole subsidized beverage or only have alternatives available for purchase.

Healthy Lifestyle
A broader dependence on the HBM and ignorance of social determinants outside of school leads to the exacerbation of public health education shortcomings. Reliance on the notion that intention directly leads to behavior simply does not account for social environment and influences. Due to the eligibility criteria of federal school lunch programs, it can be inferred the children receiving free and reduced lunches come from low-income families. Low-income families generally live in urban housing units, reflecting poorer neighborhoods within cities and where segregation and neglect are common (13). Citing the first seminar in Boston University School of Public Health course Social and Behavioral Sciences 721: Challenging Dogma, together the class deconstructed different neighborhoods in Boston to see what food markets were available and where they could be found. A field trip around campus in Roxbury and the South End proved that little was within walking distance. The only groceries to be found were at 7-11 and smaller food stores like the Don Quixote market. Health-conscious, organic markets like Trader Joe’s and Whole Foods were found centralized in higher-income neighborhoods, in communities like Newton and Chestnut Hill (14). This income stratification shows disparities in environmental food justice exist, impacting accessibility and affordability to fresh, nutritious foods for low-income families. The children of low-income families have a justified greater dependence on schools to feed them well-balanced meals, as they may not be getting them at home.

Another perspective is to look at what foods are available in low-income neighborhoods. A study conducted by Tulane University investigated the intersectionality of fast food, race/ethnicity, and income. In black and low-income neighborhoods, there were 2.4 fast food restaurants per square mile while in white neighborhoods there were 1.5 fast food restaurants per square mile (15). This increased prevalence predisposes low-income families to eat at cheap, fast food restaurants when other food is not available. When money is limited, fast food that tastes good and will keep children full suddenly makes more sense. Fresh fruits and vegetables that have to be bought, washed and cooked seem cumbersome. In the United States a paradox exists among low-income populations; the poorest people in this country will become the fattest and most obese (16).

The federal government, public schools and current nutrition education fail to acknowledge the social backgrounds children come from. Schools ignore social science information regarding urban housing, race/ethnicity and socio-economic status that define the reality some children are living. Schools do not realize that some parents see school as a blessing, an institution that will provide education and nutrition where the parents are not able. Schools do not understand that education may be the only opportunity for underserved children to rise out of their situation and make a difference.

The current state of nutrition education and federal lunch programs fail in the promotion of lifelong healthy lifestyle habits. Nutrition education aimed at controlling intention, unhealthy and racist meals that do not support the education, and ignorance of social factors in and out of school environments place school children in jeopardy of chronic illness and disease. A multidisciplinary, socially conscious approach is needed to provide an inclusive lifestyle education curriculum that will positively impact all children.

1. Green, Che. Not Milk: The USDA, Monsanto, and the U.S. Dairy Industry. Vegan Health.
2. Lytle, Leslie A. "Nutrition Education for School-aged Children." Journal of Nutrition Education, 27(6) (November-December 1995):306.
3. National Center for Education Statistics. Nutrition Education in Public Elementary School Classrooms, K-5. Institute of Education Sciences, United States Department of Education. March 2000.
4. Green, Lawrence W. Health Belief Model. Encyclopedia of Public Health.
5. Ormrod, J.E. Human learning (3rd ed.). Upper Saddle River, NJ: Prentice-Hall 1999.
6. Study Finds, When Combined With Nutrition Education, Healthier Foods Are Accepted by Elementary School Children in Florida. Medical News Today. August 2006.
7. National School Lunch Program. Washington, DC: Food Research and Action Center.
8. Healthy School Lunches. 2007 School Lunch Report Card. Physicians Committee for Responsible Medicine. August 2007.
9. Foulk, D. and Imwold, C. The School as a Contributing Factor to Adolescent Obesity. National Institute for Environmental Health Sciences. Spring 2004.
10. Childhood Obesity in the United States: Facts and Figures. Preventing Childhood Obesity Health in the Balance. Institute of Medicine of the National Academies. September 2004.
11. Rangwani, Shanti. White Poison: The Horrors of Milk. ColorLines. December 2001.
12. Robbins, John. Racism, Food, and Health. Healthy at 100: The Scientifically Proven Secrets of the World’s Healthiest and Longest-Lived Peoples.
13. Cloutier, Norman R. Urban Residential Segregation and Black Income. The Review of Economics and Statistics, Vol. 64, No. 2 (May, 1982), pp. 282-288.
14. Siegel, Michael and Social and Behavioral Sciences 721 Class. Seminar 1. September 13, 2007.
15. Block JP, et al. Tulane University School of Medicine. Fast Food, Race/Ethnicity, and Income: A Geographic Analysis. American Journal of Preventive Medicine, October 2004; 3:211-217.
16. Cannon, Goffrey. Out of the Box. Public Health Nutrition. 8(7), pg. 808-811, 2005.

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  • At December 10, 2007 at 7:06 PM , Anonymous MelanieN said...

    Thank you for this well-researched and thorough review of the public school nutrition issue.

    These are the same issues we face in our work, and are trying to improve the situation through innovative means of communicating nutrition education messages.

    Keep up the great work!

    Melanie Nelson


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