School wellness policies: perceptions, barriers, and needs among school leaders and wellness advocates

BACKGROUND: School wellness policies are a key component to the prevention of adolescent obesity. This national research study sought to understand the wellness environment in school districts across the country and to identify challenges districts face and needs they have in order to effectively implement, monitor, and evaluate school wellness policies. The study determined (1) perceptions, barriers, and opportunities regarding the development, implementation, and monitoring/evaluation of school wellness policies among school board members, state school boards association leaders, state public health nutrition directors, and school wellness advocates; (2) the readiness and capacity of survey groups to address nutrition and physical activity policies; (3) the extent to which survey groups collaborate; and (4) the acceptability of wellness tools. METHODS: In 2006, over 2900 individuals participated in online surveys, focus groups, and key informant interviews. School board members represented 1296 school districts across the nation. RESULTS: School board members expressed the highest level of confidence among all survey groups that their district has the capacity to develop, implement, and monitor/ evaluate the wellness policy. The disparities among groups are most notable with regard to perceptions of district capacity to monitor/evaluate the policy. School board members are interested in school wellness policy tools and trainings. CONCLUSIONS: There is an opportunity for state school boards associations, state public health nutrition directors, and school wellness advocates to build their own capacity to provide training and resources to districts on wellness issues, particularly physical education/activity, school-based wellness initiatives, and strategies for implementing and monitoring/evaluating wellness policies.     

Results of evaluability assessments of local wellness policies in 6 US school districts

BACKGROUND: A US federal mandate that school districts devise and implement local wellness policies (LWPs) has potential widespread impact on the nutritional content of foods and beverages available in schools and on the amount of physical activity that students engage in; however, evidence concerning the mandate's effectiveness is limited. This study describes the content of LWPs of 6 US school districts and steps taken toward their implementation and evaluation. METHODS: During visits to 6 school districts, we interviewed 88 school and community representatives about the content of their district's LWPs and how the LWPs were being implemented and evaluated. RESULTS: The 6 LWPs were consistent with the federal mandate, although they varied in content and degree of specificity, and none had been fully implemented. All 6 districts were pursuing strategies to ensure that foods and beverages available at school met nutrition standards but did not offer nutrition education to all K‐12 students. All 6 districts offered students only limited opportunities for physical activity, and all 6 collected data to monitor process and outcomes of their LWPs. CONCLUSIONS: Partial implementation of LWPs in the districts we visited resulted in significant improvement in the nutritional quality of foods available at district schools, but only slight improvement in students' opportunities for school‐based physical activity. We provide recommendations for school districts on implementation and evaluation. Future research is needed to determine the impact of these LWPs on students' health.     

Association and diffusion of nutrition and physical activity policies on the state and district level

BACKGROUND: School district wellness policies designed to reduce obesity and promote student health and well‐being often lack specific requirements or any mandate that schools comply with the policy. Researchers, educators, and policymakers have called for states to take an active role in shaping district policies. The objective of this study was to determine if states with strong school‐based nutrition and physical activity (PA)‐related policies have stronger district wellness policies, and explore the direction of policy diffusion between states and districts. METHODS: State policies and nationally representative samples of district policies for the 2006–2007 and 2008–2009 school years were obtained across 5 domains—competitive foods, school meals, nutrition education, physical education (PE), and PA—and were classified as “strong” or “weak,” based on policy language, in each grade level (elementary, middle, high). Linear models estimated the cross‐sectional and longitudinal associations between state and district policies. RESULTS: In 2006–2007 and 2008–2009, district elementary school competitive food policies were stronger in states with strong policies. For policies governing competitive foods in high schools and school meals at all grade levels, mean district policy strength increased from 2006–2007 to 2008–2009 in states with strong 2006–2007 policies. States that strengthened their PE policies from 2006–2007 to 2008–2009 saw an increase in mean district PE policy strength. Across all domains, states that had weak 2006–2007 policies and made no changes saw little increase in district policy strength. CONCLUSION: District competitive food, school meal, and PE policies are stronger in states that have developed strong policies in these domains.     

Evaluation of Alabama public school wellness policies and state school mandate implementation

BACKGROUND: This study evaluated wellness policies created by Alabama public school districts and progress made in the implementation of Alabama State Department of Education (ALSDE) school food and nutrition mandates. METHODS: Wellness policies from Alabama public school districts were compared to minimum requirements under the Child Nutrition and Women, Infants, and Children (WIC) Reauthorization Act of 2004. Additionally, data were analyzed from a survey of school district superintendents regarding compliance with ALSDE mandates. Districts were graded based on the percentage of 7 components addressed in wellness policies, and on the percentage of ALSDE mandates implemented. RESULTS: The majority of school districts (71%) were in compliance with all federal wellness policy requirements. An average 6.4 components were addressed, for a mean score of 92%. Mean implementation of ALSDE mandates was 79%; only 7% of districts indicated implementing all of the mandates. No significant differences were found in federal wellness policy or ALSDE mandate compliance scores based on district type, enrollment, percentage of students eligible for free and reduced‐price meals, use of an environmental assessment survey, and use of wellness committee and a nutrition professional during policy development. CONCLUSIONS: The majority of Alabama school districts created school wellness policies with appropriate content. This does not, however, guarantee effective policies. School districts have not done as well implementing ALSDE mandates, demonstrating delay between policy creation and implementation. Future research is needed regarding progress the school districts make in the implementation of school health policy and on factors influencing that progress.     

A national snapshot of local school wellness policies

Background: The federal mandate for local wellness policies (LWP) provides an unprecedented opportunity to improve schools’ practices that support student health, which, in turn, supports academic achievement. With a full agenda and budget challenges, districts need resources and support to turn policies into sustainable practices. The purpose of this study was to assess district policy goals and compare them to the federal mandate and benchmarks of best practices. It is hoped that this information will lead to development of specific assistance in the areas of policy implementation, evaluation, and revision. Methods: Action for Healthy Kids (AFHK) collected a convenience sample of 256 approved LWP. The sample included districts with small, medium, and large student enrollment from every state (except Hawaii). Policies were compared to federal requirements and the AFHK Wellness Policy Fundamentals, a tool which documents best practices for nutrition and physical activity in schools. Results: Sixty‐eight percent of policies sampled were consistent with the mandates set forth in the law. Thirty‐two percent did not address 1 or more goal areas set by the federal mandate with 15% not addressing goals for evaluation and monitoring. None of the policies addressed all components of AFHK’s Fundamentals. Less than 1% addressed all 4 of the evaluation components. Teacher requirements and training for nutrition and physical education were addressed by 43% and 45% of policies, respectively. Conclusions: This study’s findings indicate schools will need assistance to meet each of the mandates provided by the federal mandate. Areas lacking attention in policies, yet essential for sustaining wellness practices, include assurances of qualified staff, opportunities for staff development, and implementation, evaluation, and revision of the policy.     

The strength of school wellness policies: one state's experience

BACKGROUND: This study examines the results of federal legislation on the content and quality of policies written in 2005-2006 by Utah school districts (n = 30). METHODS: Policies were gathered by phone call requests to school districts or obtained on district Web pages. Content was compared to requirements outlined in the Child Nutrition Reauthorization Act (CNRA) of 2004 and recommendations made by a state coalition of health and education agencies. The strength of the language was assessed (mandate vs recommendation), and characteristics of school districts that adopted strong policies were identified. RESULTS: The majority of Utah school districts (78%) complied with the federal guidelines, and a variety of state recommended nutrition and physical activity policy statements were included. The strength of the language used in the policies revealed that districts were more likely to mandate items already required by other entities or well established in the district. School districts with high participation in free- and reduced-price programs had significantly more mandatory policies (mean = 9.2) versus low (mean = 7.1) and medium enrollment (mean = 4.7). Urban school districts were more likely to indicate mandatory competitive food policies than rural and suburban (mean = 2.3 vs 0.93, 0.83). There were no differences in policy language between school districts based on race or size. CONCLUSIONS: Compliance with the CNRA may be a positive step toward improving the school nutrition and physical activity environment, but it does not ensure a comprehensive or powerful policy. Schools and community partners must continue to work together to strengthen wellness policies and programs.     

Transparency and oversight in local wellness policies

BACKGROUND: Advocates have called for increased wellness policy transparency and oversight through the use of health advisory councils. This study examines (1) wellness policy transparency, (2) advisory council requirements, (3) factors associated with each, and (4) whether transparency or advisory council requirements are indicative of a stronger policy addressing nutrition and physical activity. METHODS: Policies for school year 2007–2008 were obtained from a nationally representative sample of 641 districts and analyzed for their applicability to elementary, middle, and high school levels. Main outcome measures included (1) policy transparency (online availability), (2) advisory council requirements, and (3) overall policy strength. T‐tests assessed variability in policy strength by transparency and advisory council requirements. Multivariate logistic and linear regression analyses controlled for district size, socioeconomic status, race/ethnicity, region, and locale; models of advisory council/policy strength relationships also controlled for state advisory council requirements. RESULTS: More than 41% of districts posted wellness policies online and more than 43% required advisory councils. Transparency was less likely in small‐/medium‐sized and non‐southern districts; and, for elementary school policies, most common in majority Hispanic districts. Advisory council requirements were less likely in small‐/medium‐sized districts for middle/high school policies and more likely in majority Hispanic districts for elementary school policies. After adjusting for all covariates, transparency was not associated with policy strength, but advisory council requirements significantly predicted policy strength. CONCLUSIONS: Transparency may facilitate awareness, but it does not mean that wellness policies will be stronger; however, advisory council requirements may be a marker for stronger policies.     

Creating and using index scores in the analysis of school policy implementation and impact

BACKGROUND: Epidemic increases in childhood obesity and associated health risks are resulting in efforts to implement school policies related to nutrition and physical activity (NPA). With multicomponent policy efforts, challenges exist in characterizing the extent of policy change across the breadth of NPA policies. METHODS: Aggregated policy indices were created to characterize NPA policy implementation in Arkansas public schools from 2004 through 2009. Index scores are presented by year, domain, and school level. RESULTS: Both mean and median index scores increased over time, with greater changes seen in nutrition than in physical activity policy scores. The composite index score was heavily dependent on the nutrition index score and, thus, is relatively less useful for the purposes of our evaluation. Policy index scores varied by school level, rurality, enrollment size, and percentage of students eligible for federal meal programs. CONCLUSIONS: The policy index approach facilitates the consideration of the effect of school policy change in a holistic, aggregated way. School characteristics influence policy adoption, and thus, should be taken into consideration in the promotion of policy change.     

Changing nutrition standards in schools: the emerging impact on school revenue

BACKGROUND: Although great focus has been placed on nutritional and other consequences of changes in food-related policies within schools, few reports exist describing the impact of such changes on school revenue. This review provides an overview of the few revenue-related studies published recently, as well as information from a sampling of state reports on the subject. METHODS: A systematic review of the literature was conducted. Four peer-reviewed papers and 3 state-based reports were identified that assessed the impact on revenues of either targeted policy changes or overarching, district-wide changes in food-related policies. RESULTS: Thus far, few data exist to substantiate the concern that changes in nutrition standards in schools lead to a loss in total revenue. An interesting phenomenon of increased participation in the National School Lunch Program was noted in a number of reports and might play a role in buffering financial losses. CONCLUSIONS: A renewed focus on school policies related to health provides the opportunity for researchers to investigate how nutrition-related policy change can affect, if at all, food service and overall school revenues.     

Lessons learned while implementing a legislated school policy: body mass index assessments among Arkansas's public school students

BACKGROUND: To comprehensively address the childhood and adolescent obesity epidemic, Arkansas enacted Act 1220 of 2003. Among a series of community- and school-based interventions, the Act requires each public school student to have his/her body mass index (BMI) assessed and reported annually to parents. The process of implementing this policy on a statewide level and lessons learned are described in this article. METHODS: A confidential, standardized protocol to measure student BMIs and report results to parents was developed. Affordable, reliable, and durable equipment was selected and school personnel who conducted BMI assessments were trained to ensure standardization. To enhance the efficiency and ease of the measurement and reporting process and promote long-term and locally based sustainability, during the first 3 years of implementation, a transition from a paper-based system to a Web-based system was made. Confidential, individualized Child Health Reports have provided students' parents with information about the health of their children. RESULTS: Participation by schools and students has been high as a result of collaboration between the health and education communities and the students and their families. Childhood obesity has not increased since Act 1220 was passed into law. CONCLUSIONS: Parents, schools, school districts, and the state are able to better understand the obesity epidemic and track progress using detailed annual data. Providing a standardized measurement protocol, equipment, and efficient data entry and report generation options has enabled Arkansas to institutionalize the BMI assessment process in public schools.     

Factors affecting sugar-sweetened beverage availability in competitive venues of US secondary schools

BACKGROUND: This study explores sugar‐sweetened beverage (SSB) availability in US secondary school competitive venues during the first 3 years following the school wellness policy requirement (2007‐2009). Furthermore, analyses examine associations with school policy and SSB availability. METHODS: Analyses use questionnaire data from 757 middle and 762 high schools in the nationally representative Youth, Education, and Society study to examine soda and non‐soda SSB availability associations with school policy including (1) beverage bottling contracts and related incentives, (2) individuals/organizations responsible for decisions regarding beverages available in vending machines, and (3) school wellness policies and nutrition guidelines. RESULTS: Non‐soda SSBs made up the majority of SSBs in both middle and high schools. Soda was especially likely to be found in vending machines; non‐soda SSBs were widely available across competitive venues. Access to soda decreased significantly over time; however, non‐soda SSB access did not show a similar decrease. School policy allowing beverage supplier contractual involvement (bottling contract incentives and beverage supplier “say” in vending machine beverage choices) was related to increased SSB access. However, the existence of developed nutritional guidelines was associated with lower SSB availability. CONCLUSIONS: Students had high access to SSBs across competitive school venues, with non‐soda SSBs making up the majority of SSB beverage options. Efforts to reduce access to SSBs in US secondary schools should include a focus on reducing both soda and non‐soda SSBs, reducing beverage supplier involvement in school beverage choices, and encouraging the development of targeted nutritional guidelines for all competitive venues.     

Changes in School Competitive Food Environments after a Health Promotion Campaign

BACKGROUND

Schools can reduce student access to competitive foods and influence healthy food choices by improving the school nutrition environment. This study describes changes in competitive nutrition environments in 100 K‐8 schools participating in the Philadelphia Campaign for Healthier Schools.

METHODS

Interviews with school staff were used to elicit information about policies, practices, and guidelines to restrict/limit competitive foods in schools, before and 1 year into the campaign. To increase the validity of responses, respondents provided documentation for reported policies and guidelines. Baseline interviews were conducted between April and June 2011 and follow‐up interviews were conducted between April and June 2012.

RESULTS

At follow‐up, significantly more schools reported having policies and/or guidelines in place to regulate food as a reward in the classroom, food served at parties and celebrations, outside foods allowed in school, and the availability of sodas and sugar‐sweetened beverages. There were no measurable effects on food available in school stores, fundraisers, or afterschool programs. Availability of concrete documentation of policies was limited, but when provided, it corroborated the interview responses.

CONCLUSIONS

In the context of a comprehensive school wellness policy, school wellness councils were associated with increases in school‐level policies and practices that improved the competitive nutrition environment.

     

Diet modelling: How it can inform the development of dietary recommendations and public health policy

With the global population expected to increase to 9 billion by 2050 coupled with concerns about food security in relation to climate change and increasing prosperity in many parts of the world causing desire for a less monotonous diet, efficient use of resources such as food becomes ever more important. While the prevalence of obesity is a cause for concern in many parts of the world, many people still go to bed hungry, and in many communities, obesity co‐exists with poor diet quality. The result is a series of complex and challenging nutrition problems, such as the access to nutritionally adequate and affordable diets and the development of dietary recommendations. Diet modelling is a useful tool to help identify solutions to such complex questions and this paper summarises a session on this topic at the International Congress of Nutrition that took place in September 2013.     

The future of public health nutrition: a critical policy analysis of Eat Well Australia

Objective: To better understand how public health nutrition has been represented during the past decade in Australia this paper critically analyses Eat Well Australia: An Agenda for Action for Public Health Nutrition 2000 – 2010 and its accompanying National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan. Method: The paper uses an interpretive approach, drawing on Bacchi's method of problem representation, to examine the strategies being offered within the policy. It uses this framework to uncover how public health nutrition has been represented and examines if the representation provided considers all aspects of the issue. The paper also considers how contextual factors affected policy development through examination of publicly available documents. Results: The problem is represented as being both an individual one and one due to social, structural and economic circumstances. There is a large focus on collaboration, research and capacity building. The context of the policy's development has affected the solutions contained within. Conclusion: The policy's proposed actions reflect the policy‐making environment in which it was conceived. A manifestation of this was unclear division of roles and responsibilities, lack of dedicated resources and inadequate focus on the social determinants of health. Implications: As the policy's timeframe is drawing to its end, critical reflection on how the problem of nutrition has been represented over the previous decade provides greater insight and awareness to direct future public health nutrition work.     

Promoting social responsibility for health: health impact assessment and healthy public policy at the community level

The 1997 Jakarta Declaration on Health Promotion into the 21st Century called for new responses to address the emerging threats to health. The declaration placed a high priority on promoting social responsibility for health, and it identified equity-focused health impact assessment as a high priority for action. This theme was among the foci at the 2000 Fifth Global Conference on Health Promotion held in Mexico. This paper, which is an abbreviation of a technical report prepared for the Mexico conference, advances arguments for focusing on health impact assessment at the local level. Health impact assessment identifies negative health impacts that call for policy responses, and identifies and encourages practices and policies that promote health. Health impact assessment may be highly technical and require sophisticated technology and expertise. But it can also be a simple, highly practical process, accessible to ordinary people, and one that helps a community come to grips with local circumstances that need changing for better health. To illustrate the possibilities, this paper presents a case study, the People Assessing Their Health (PATH) project from Eastern Nova Scotia, Canada. It places ordinary citizens, rather than community elites, at the very heart of local decision-making. Evidence from PATH demonstrates that low technology health impact assessment, done by and for local people, can shift thinking beyond the illness problems of individuals. It can bring into consideration, instead, how programmes and policies support or weaken community health, and illuminate a community's capacity to improve local circumstances for better health. This stands in contrast to evidence that highly technological approaches to community-level health impact assessment can be self-defeating. Further development of simple, people-centred, low technology approaches to health impact assessment at the local level is called for.     

Use of the youth risk behavior survey to monitor trends for nutrition and physical activity in a Midwest city school district

BACKGROUND: The Youth Risk Behavior Survey (YRBS) was used by a city school district (approximately 11,000 students) in the upper Midwest to monitor trends for nutrition and physical activity (PA) behaviors both within and between years and to compare with national 2003 data. METHODS: Independent random samples were obtained in 1999 (387 middle school [MS] and 931 high school [HS]), in 2001 (322 MS and 367 HS), and in 2003 (658 MS and 1026 HS). A two-sample test of proportions was used. RESULTS: Within each survey year, a higher proportion of MS compared to HS reported positive behaviors with some exceptions: (1) an increased proportion of HS having daily physical education (PE) and (2) a reduced proportion of HS reporting media time. Within 2003, a lower proportion of district females compared to males (MS and HS) reported participation in many measured behaviors. District trends overtime indicated a reduced proportion: (1) drinking milk (MS and HS), (2) eating breakfast (HS), and (3) watching television (MS). Trends overtime indicated an increased proportion: (1) using computers for fun (MS and HS), (2) participating in moderate PA (MS), and (3) daily PE (HS). District HS compared to national (2003) indicated a higher proportion: (1) drinking milk, (2) getting moderate PA, and (3) taking daily PE. District HS compared to national indicated a lower proportion: (1) at risk of overweight, (2) overweight, and (3) watching television. CONCLUSIONS: Analysis of district YRBS trends provides both a database for informed decisions by the school district and an assessment model for other districts.