Society for Nutrition Education

Slide 1:Society for Nutrition EducationAnnual MeetingCultural Shift?Implementing and Evaluating School Nutrition Policy

Mary McKenna, PhD, RD Professor, UNB, Canada Society for Nutrition Education Atlanta, GA July 21, 2008

Slide 2: The NEW Pause that Refreshes

Slide 3:Alliance for a Healthier Generation School Beverage Policy (2006)

Phase out full calorie carbonated soft drinks (FCCSD) by 2009-2010 No bonuses for signing contracts Increased access to information Amend existing contracts 2006-07 versus 2004 FCCSD shipments down 45% Water shipments up 23%

Slide 4:Overview

Background Policy options and implementation Stakeholder roles Evaluation Conclusion

Slide 5:School Nutrition Policy

Framework to guide school planning, implementation, and evaluation pertaining to student nutrition and health Promote norms Reflect national dietary guidance Consider cultural and dietary practices

Slide 6:Background Paper for the WHO Global Strategy on Diet, Physical Activity and Health

School policies and programmes should support the adoption of healthy diets and physical activity. Adopt policies that support healthy diets at school and limit the availability of products high in salt, sugar and fats Support contracts for locally grown foods WHO Global Strategy on Diet, Physical Activity and Health, 2004 http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf

Slide 7:Health Promoting Schools Comprehensive Nutrition Policy

Food available Healthy school environment Health education Health services, counselling, social support Community and family involvement and outreach

Slide 8:Food and Nutrition Policy for Nova Scotia Schools

Food and beverages Portion sizes Drinking water Fundraising Special functions Promotion & advertising Food as a reinforcer Vulnerable students Food safety Nutrition education http://www.ednet.ns.ca/healthy_eating/ Time to eat Local produce and products Environmental considerations Role models School partnerships and commitment

Slide 9:Policy Characteristics Influence Implementation

Comprehensive versus targeted Assessment, staff training, nutrition education, nutrition standards, social marketing, family outreach (Foster et al, 2008) Level of specificity Stringency Implementation requirements

Slide 10:Stakeholders

Government roles School personnel Students Parents Health professionals Non-governmental organizations Agricultural sector Industry and media Academic community

Slide 11:Overcoming Challenges

Low priority Resources, training, and support (including evaluation) Revenue concerns Idiosyncratic support Lack of clarity re desired foods Product procurement/preparation Coordination and communication among stakeholder groups Accountability

Slide 12: Process and Output Indicatorshttp://www.actionforhealthykids.org/wellnesstool/Presentations/pres-out652.php

% of schools with a comprehensive policy offering school food consistent with nutrition standards using local foods that meet nutrition standards with a person designated to coordinate food availability that involve families in advocating for healthy eating

Slide 13:Competitive Foods in Vending Machines (M�sse, et al, 2007)

6: State prohibits the sale or service of non-reimbursable food and beverages in vending machines (or student access to vending machines selling such items), with exceptions only for the sale or service of water, low-fat / non-fat milk, beverages with at least 100% fruit/vegetable juice with no added caloric sweeteners, and non-fried fruit and vegetables. 2: State requirement for food and beverages sold/served in vending machines outside the school meal program is undefined (e.g., �healthy� foods and beverages must be available); or state requires the development of nutrition standards applicable to vending machines sales/service.

Slide 14:Outcome Indicators

Food, nutrient, energy intake, and meal patterns in and out of school Adiposity Health outcomes (e.g., blood pressure, blood glucose, blood cholesterol) Unintended consequences Academic/school outcomes Cost/benefit analysis

Slide 15:Family Involvement

Slide 16:Goals

What is a realistic outcome for school-based policy? Level rates of obesity in children? Lower rates of increase in overweight children? Informed children who enjoy the taste of healthy food and have a healthy appreciation for the act of eating?

Slide 17:Reaching Goals

Consistent reinforcement from Government Industry (food and agriculture), advertising, media, public education Local communities Home Workplaces

Slide 18:Making Connections

Shared concerns (e.g., obesity and health costs) Opportunities for synergy (e.g., agriculture and environment re local foods) Extending reach (e.g., communities, workplaces, post-secondary institutions)

Slide 19:Conclusions

Increased policy understanding Increased evidence ________ political will The children of the world are waiting

Slide 20:Cultural Shift?Implementing and Evaluating School Nutrition Policy

Terry O�Toole, PhD Health Scientist Division of Adolescent and School Health July 21, 2008

Slide 21:Overview of Presentation

A glimpse of a National view of nutrition policy and practice in schools Consider implications for implementing nutrition policy through an example: IOM Nutrition Standards Print out IOM report brief Print out IOM report brief

Slide 22:SHPPS 2006

SHPPS is our national survey periodically conducted to assess school health policies and practices at the state, district, school, and classroom levels across multiple components that are supportive of school health programs. By culture, we might say the attitudes and behavior that are characteristic of a particular social group or organization � in this case, schools. By taking a look at the policies and practices of schools, we can get an idea of their culture, and in particular, changes across time. SHPPS is our national survey periodically conducted to assess school health policies and practices at the state, district, school, and classroom levels across multiple components that are supportive of school health programs. By culture, we might say the attitudes and behavior that are characteristic of a particular social group or organization � in this case, schools. By taking a look at the policies and practices of schools, we can get an idea of their culture, and in particular, changes across time.

Slide 23:Recommendations for Competitive Foods

Make healthy choices (e.g., fruits, vegetables, whole grains, low-fat/nonfat dairy) available whenever food and beverages are offered or sold. Prohibit or limit access to foods and beverages high in fat, sodium, or added sugars during the school day. Considering time constraints, let�s take what might be a piece of a school nutrition policy, competitive foods, and see what kind of cultural shift may already be occurring in U.S. schools. Let�s say our school nutrition policy goals for competitive foods are as follows: Considering time constraints, let�s take what might be a piece of a school nutrition policy, competitive foods, and see what kind of cultural shift may already be occurring in U.S. schools. Let�s say our school nutrition policy goals for competitive foods are as follows:

Slide 24:Food Choices in Schools

Schools with vending machines or a school store 33% of elementary schools 71% of middle schools 89% of high schools CAN STUDENTS PURCHASE CAN STUDENTS PURCHASE

Slide 25:Percentage of Schools in Which Students Could Purchase Foods and Beverages in Vending Machines, or in a School Store, Canteen, or Snack Bar

Slide 26:Percentage of States and Districts with Selected Policies to Offer Healthful Options

Only 7% of districts required that schools make fruits or vegetables available to students whenever food was offered or sold (eg, at school parties or school stores). 17.0% of districts required that schools make healthful beverages such as bottled water or low-fat milk available to students whenever beverages were offered or sold. Only 7% of districts required that schools make fruits or vegetables available to students whenever food was offered or sold (eg, at school parties or school stores). 17.0% of districts required that schools make healthful beverages such as bottled water or low-fat milk available to students whenever beverages were offered or sold.

Slide 27:Percentage of Schools in Which Students Can Purchase Items in Vending Machines or at School Stores, Canteens, or Snack Bars, 2000 and 2006

0 20 40 60 Percent 2000 2006 Here we see an INCREASE in the percentage of schools that sold bottled water in vending machines or in school stores, canteens, or snack bars; and a DECREASE in the percentage that sold high-fat baked goods, high-fat ice cream or frozen yogurt, high-fat salty snacks, and whole milk in these venues.Here we see an INCREASE in the percentage of schools that sold bottled water in vending machines or in school stores, canteens, or snack bars; and a DECREASE in the percentage that sold high-fat baked goods, high-fat ice cream or frozen yogurt, high-fat salty snacks, and whole milk in these venues.

Slide 28:CDC�s Healthy Eating Guidelines

Policy Nutrition education curriculum Nutrition education instruction School food service integration Training for staff Family & community Program evaluation When seeking to change the way people think or act regarding school nutrition policy, it helps to identify scientific evidence for school nutrition policyWhen seeking to change the way people think or act regarding school nutrition policy, it helps to identify scientific evidence for school nutrition policy

Slide 29:CDC Guidelines, Wellness Policies& IOM Nutrition Standards

Connection to CDC Guidelines Recommendation 1: Use a coordinated approach to develop and implement healthy eating and physical activity policies and programs. Form a council Adopt a process (development, implement, evaluate) Recommendation 5: Provide high quality school meals and other foods and beverages throughout the school campus. a strong CSHP can increase the priority of school health and assist schools with addressing childhood obesity, promoting healthy eating, and providing consistent nutrition messages and supportive environments. Strong actions have been taken by states that implement coordinated school health programs to promote the LWP mandate a strong CSHP can increase the priority of school health and assist schools with addressing childhood obesity, promoting healthy eating, and providing consistent nutrition messages and supportive environments. Strong actions have been taken by states that implement coordinated school health programs to promote the LWP mandate

Slide 30:IOM Nutrition Standards for Foods in Schools

Standards promote consumption of: Fruits Vegetables Whole grains Non- or low-fat dairy products Standards limit the amount of: saturated fat, salt, added sugars, caffeine, and total calories. At the time the LWP provision was enacted, there were no federal nutrition standards to assist jurisdictions with the component calling on LEAs to establish nutrition guidelines for foods and beverages. In an effort to augment local, state and federal initiatives, Congress called upon CDC to undertake a study, with the IOM, to make national recommendations about nutrition standards for foods offered in competition with the federally reimbursable meals and snacks. The IOM Nutrition Standards for Foods in School Report provides science-based recommendations about nutrition standards for competitive foods. At the time the LWP provision was enacted, there were no federal nutrition standards to assist jurisdictions with the component calling on LEAs to establish nutrition guidelines for foods and beverages. In an effort to augment local, state and federal initiatives, Congress called upon CDC to undertake a study, with the IOM, to make national recommendations about nutrition standards for foods offered in competition with the federally reimbursable meals and snacks. The IOM Nutrition Standards for Foods in School Report provides science-based recommendations about nutrition standards for competitive foods.

Slide 31:Types of Implementation Strategies

Mandate by law or regulation Incentive grant program Recognition/award program Resolution encouraging local policy action Policy development resources model policies guidance manuals assessment tools checklists These are some of the types of implementation strategies we�ve seen employed by states and districts� Tracy will provide more detail on these�These are some of the types of implementation strategies we�ve seen employed by states and districts� Tracy will provide more detail on these�

Slide 32:Implementation Implications: Bridging the Gap

School districts will need guidance & support Become familiar with the IOM Nutrition Standards for Foods in Schools Identify food and drink products that meet the Standards Determine policy revisions to reflect the Standards Assess nutrition education curricula Encourage environmental changes Engage school staff, families, and communities The SHPPS data tells us that states, school districts and schools across the country still need support with implementing strong nutrition policies in their schools�The SHPPS data tells us that states, school districts and schools across the country still need support with implementing strong nutrition policies in their schools�

Slide 33:IOM Nutrition Standards for Foods in SchoolImplementation Guide

Action Steps Plan for Change Communicate and Raise Awareness Implement Change Monitor and Evaluate Change Q & A section Tools and Resources The existence of nutrition standards alone is insufficient to achieve improvement; the adoption and implementation of strong standards�like those developed by the IOM School Foods Committee�will only be accomplished by the coordination and collaboration of stakeholders at the federal, state, and local levels. The IOM School Foods Committee identified action steps to facilitate implementation of the IOM Nutrition Standards for Foods in Schools by various groups. The action steps identified by the Committee are broad and provide a good starting point for communicating the key elements for success in driving change. CDC is currently developing a tool, an Implementation Guide to encourage use and operationalization of the IOM standards. The information included in the IOM Nutrition Standards for Foods in Schools Report are expanded upon in the Implementation Guide to provide audiences with specific action steps, tools and resources. The existence of nutrition standards alone is insufficient to achieve improvement; the adoption and implementation of strong standards�like those developed by the IOM School Foods Committee�will only be accomplished by the coordination and collaboration of stakeholders at the federal, state, and local levels. The IOM School Foods Committee identified action steps to facilitate implementation of the IOM Nutrition Standards for Foods in Schools by various groups. The action steps identified by the Committee are broad and provide a good starting point for communicating the key elements for success in driving change. CDC is currently developing a tool, an Implementation Guide to encourage use and operationalization of the IOM standards. The information included in the IOM Nutrition Standards for Foods in Schools Report are expanded upon in the Implementation Guide to provide audiences with specific action steps, tools and resources.

Slide 34:Society for Nutrition EducationAnnual MeetingCultural Shift? Implementing and Evaluating School Nutrition Policy

Atlanta, GA July 21, 2008 Tracy A. Fox, MPH, RD President, Food, Nutrition & Policy Consultants, LLC www.foodnutritionpolicy.com

Slide 35:Overview

Policies at local level State issues impacting policies Observations Challenges Data collection/evaluation What was accomplished Top 10 keys to success Next steps

Slide 36:Local Policies Vary

AL (Hoover): emphasis on each school; responsibility on each principal GA (Atlanta): policies developed at school level MD (MoCo), MD: broad policy; implementing regs slightly more specific TX (Aldine): �strive toward�; �consistent with healthy eating�; no specifics; scorecard for schools to evaluate

Slide 37:Local Policies Vary(cont�d)

AZ (Prescott): Healthier US challenge; follow AZ standards for all schools soon (comp foods) WY (Sweetwater): contact at school level; Healthier US Challenge; concessions recs modified based on backlash from community

Slide 38:State Role

USDA clarified that states need to check that districts have a policy But no mention of any state role in: ensuring that all policy requirements are met assessing policy quality assisting districts with policy development or implementation monitoring policy implementation

Slide 39:NASBE State Strategies To Support Local Wellness Policies(CDC-DASH funded project)

48 states are actively providing guidance, assistance, and support in one or more of the following ways: Additional accountability requirements Additional policy content requirements Policy compliance checking Resolutions encouraging local policy action Policy guidance materials State-level advisory councils Other state initiatives

Slide 40:State Strategies To Support Local Wellness Policies (cont�d)

19 state legislatures, state BOE, state agencies have gone beyond the federal guidance and adopted requirements to strengthen policy evaluation and accountability. At least 11 states have passed laws or adopted regulations that establish wellness policy content requirements regarding nutrition, physical activity, or both and that go beyond the general requirements of the federal government. At least 4 states have established state-level workgroups specifically tasked with providing guidance on implementing Section 204 local wellness policies. NASBE Document � Oct. 2007NASBE Document � Oct. 2007

Slide 41:Strong State Policies = Strong District Policies

AZ: AZ DOE developed nutrient stds for comp. foods in ES, MS and school-sponsored events; no FMNV during the normal school day; no sodas; fund raising is exempt. TN: milk, water, 100% juice, low cal only; snacks: 35/10/35 w/ sodium limits; portion limits. CA: 35/10/35; milk, water, 50% juice; more lenient for MS/HS CT: milk, water, juice only; limits on nutrients; v. detailed; stds for entrees & snax � 35/10/35; 10� per lunch

Slide 42:Observations

Vending: strongest Food Services: also seeing improvement (food costs a challenge) Fundraising: difficult to tackle-more �recommend� Nutrition ed: inconsistent and not well implemented Physical activity: considerable challenge Other school-based activities: mainly staff wellness

Slide 43:Challenges

Inconsistencies � especially across a state Other priorities take over No mechanism to revise/update Collecting dust Key decision makers don�t see importance Teams disbanded Burden often on school food services Inconsistent enforcement � keep health/nutrition/fitness front and center - continued interest � don�t let policy sit on shelf � keep intact spread the wealth/work � make sure schools understand policy and communicate consistently with students/parents 2 articles in the Examiner � about inconsistent application of policies an dhighlighted some cases in Howard, Carroll, ann arundal � talk about inconsistency of enforcement. Issues were about bringing food form home and parties� keep health/nutrition/fitness front and center - continued interest � don�t let policy sit on shelf � keep intact spread the wealth/work � make sure schools understand policy and communicate consistently with students/parents 2 articles in the Examiner � about inconsistent application of policies an dhighlighted some cases in Howard, Carroll, ann arundal � talk about inconsistency of enforcement. Issues were about bringing food form home and parties

Slide 44:Data Collection/Evaluation

Not consistent, non-existent; districts and schools aren�t used to this Common data sources (Youth Risk Behavior Surveillance Survey, student fitness, meal participation rates, nutritional content information, competitive food sales, body mass index, and training participation rates) are collected sporadically but not analyzed nor are results fed back to inform policy changes

Slide 45:What did they accomplish?

Supported/strengthened initiatives already underway Provided incentive to initiate policies/programs under development Raised awareness about CH obesity among a broader audience Brought together stakeholders in and out of school Stronger in elem schools

Slide 46:Top 10 Keys to Success

Transparent process Advisory committee with names, positions, backgrounds well-communicated Clear delineation of stakeholder roles (implementation and evaluation) Integrate with Coordinated School Health Program Policy is well written and understood by constituencies

Slide 47:Top 10 Keys to Success(cont�d)

Clear communication plan District level coordination and leadership Dedicated school-based component Dedicated budget/resources Strong monitoring, data collection, evaluation component that loops back to policy revisions

Slide 48:Mary McKennammckenna@unb.ca1-506-451-6872 Terry O�Tooletotoole1@cdc.gov770-488-5937Tracy Foxtracyfox@comcast.net301-564-0737