Volume 8: No. 5, September 2011
The Ethical Basis for
Promoting Nutritional Health in Public Schools in the United States
Patricia B. Crawford, DrPH, RD; Wendi Gosliner, MPH, RD; Harvey Kayman,
Suggested citation for this article:
Crawford PB, Gosliner W, Kayman H. The ethical basis for promoting
nutritional health in public schools in the United States. Prev Chronic Dis
2011;8(5):A95. Accessed [date].
Schools may have an ethical obligation to act in response to the
precipitous increase in the incidence of obesity among children. Using a
bioethics framework, we present a rationale for school programs to improve
the nutritional quality of students’ diets. Because children are required to
spend half their waking hours in school and because they consume a
substantial portion of their daily food there, school is a logical focus for
efforts to encourage healthy dietary behaviors to prevent obesity and its
consequent individual and collective costs. We suggest that beyond strategic
considerations, the concept of the common good justifies actions that may
appear to conflict with freedom of choice of children, parents, and school
staff, or with the interests of food and beverage companies.
Back to top
Public schools have an obligation to question and refute policies that do not
benefit their students and their communities and a corresponding responsibility
to protect students, for whom school attendance is mandated, from harm. However,
implementation of change in school procedures and policies presents challenges
and requires an ethical justification for the change and feasible methods for
The mission of schools is broader than simply teaching academic skills.
Schools have long accepted responsibility for supporting the health of their
students, for example, by requiring immunizations, providing health screenings,
and by offering meal programs that support their students’ nutritional health.
Nutritional health is associated with academic performance (1), and
well-nourished students are better able to learn and less likely to miss school
for health reasons (2). Research shows that children from low-income families
who participate in school breakfast programs score higher on standardized tests
and have better school attendance than similar students who do not participate
(3). Breakfast programs also improve classroom behavior and attentiveness (4).
In 1904, Robert Hunter wrote, “It is utter folly, from the point of view of
learning, to have a compulsory school law which compels children, in that weak
physical and mental state . . . to sit at their desks, day in and day out for
several years, learning little or nothing . . . because hungry stomachs and
languid bodies and thin blood are not able to feed the brain” (5).
Focusing on nutritional health promotion in schools can support the common
good by reducing the impact, including substantial financial costs, of future
diet-related disease associated with the childhood obesity epidemic.
Furthermore, optimizing nutrition in childhood is critical to learning and
future productivity. We must consider whether schools have an ethical obligation
to serve the common good in this area, even if the actions they take appear to
conflict with the autonomy or freedom of choice of children, parents, and school
staff, or the interests of food and beverage companies.
The purpose of this article is to present a bioethics framework for
justifying stricter regulation of school food, specifically, to determine
whether this type of health promotion in schools is ethically justified (6). To
determine whether current school environments meet an ethical threshold or
whether these environments fall short and should be altered, we will apply
Beauchamp and Childress’s 4 foundational principles for a discourse on the
ethics of a biomedical intervention: autonomy (addressing conflict around
individualism), beneficence (addressing the social benefit), nonmaleficence
(addressing the issue of doing no harm), and justice (addressing equity in
burdens and benefits) (7). We describe the underlying problem of rapidly
increasing incidence rates of childhood obesity and the potential role of
schools in altering the trend.
Back to top
Schools’ Roles in Addressing Childhood Obesity
The National School Lunch Program was established in 1946 to “safeguard the
health and well-being of the Nation’s children” as a “measure of national
security” by preventing the widespread malnutrition that disqualified many
military recruits during World War II (8). Early program participants were
served balanced meals to ensure consumption of vegetables, protein, starches,
and dairy products according to the best nutrition standards of the time (5).
Participation in the program, which was expanded during the 1960s and 1970s, was
demonstrated to improve children’s diets (9).
Back to top
The obesity epidemic
With the tripling in obesity rates among children (10), schools face new
challenges. Approximately 1 in 3 children born in 2000 will develop diabetes in his
or her lifetime (11), and in a large study of children aged
5 to 17 years, 39% of those who were obese had 2 or more risk factors for cardiovascular disease (12). Poppendieck, in advising policy makers on the benefits of putting money into
healthy school foods today to reduce future health care expenditures, calls her
recommendations “Pay now or pay later” (13).
Children’s inadequate nutrition
Although children today are consuming sufficient or even excessive food
calories, they are not meeting the nutritional requirements described in the
federal government’s Dietary Guidelines for Americans (14). Children's intake
of fruits, vegetables, and whole grains does not come even close to current
recommendations. Furthermore, children aged 5 to 18 years consume approximately
720 to 950 empty discretionary calories per day (15). Calories from added fats
and sugars are displacing those from the nutrient-rich foods needed for growth
Schools’ provision of food to students
Children spend up to half their waking hours in school, where they may
consume as much as one-third to one-half of their daily calories. Therefore, the
school food environment is a logical focus for efforts to encourage healthy
dietary behaviors. Today, school food service includes 2 competing arms — the
federally regulated reimbursable National School Lunch and School Breakfast
programs (8,16) and the competitive foods marketplace, which has expanded
substantially during recent decades. Competitive foods and beverages are those
foods sold throughout schools in vending machines, school stores, snack bars,
and at fund-raisers. These are typically foods of low nutritional quality,
including sweetened beverages, chips and other salty snacks, and sweets such as
cookies and pastries (17,18).
During a typical day in the first 5 years of the 21st century, 55% of high
school students and 44% of middle school students consumed competitive foods at
school, frequently instead of school meals (19). Although states and school
districts can voluntarily impose restrictions on competitive foods, these
agencies are often unaware of the impact of the school food environment on
student health. This lack of awareness, coupled with the funding that
competitive foods provide to schools, has led to prolonged inaction. However,
data now indicate that reductions in competitive food offerings can actually
increase meal program participation rates, thereby increasing food service
department revenues rather than reducing them as is often feared by school
administrators (20). Efforts to promote and increase access to the meal program
can be key to school-based efforts to reduce obesity, benefiting both children
Recent trends in school food regulation
California in 2005 became the first state to legislate statewide nutrition
standards to regulate sale of competitive foods and beverages in grades
kindergarten through 12 (21). Evaluation studies of California’s implementation
of the legislation reveal that schools were successful at eliminating or
severely reducing offerings of noncompliant (less nutritious) competitive foods
and beverages in schools (20,22). The food and beverage industry replaced or
adapted snack foods to meet the new guidelines mandated by the legislation. For
example, sports drinks replaced sodas, baked chips replaced original varieties
of chips, and reduced-fat crackers replaced original crackers. Although the new
offerings met the letter of the legislation’s requirements to limit fat, sugar,
and calories, they did not substantially increase the availability of such
health-promoting foods as fruits, vegetables, whole grains, and low-fat dairy
During the past decade, other states and municipal governments have
implemented new obesity-prevention policies in schools with respect to
competitive food sales. These policies vary considerably by state and locality.
Although competitive foods continued to be available in most schools in the
latter half of this decade (19), more than half of all states and several local
authorities adopted policies regarding such foods that were more restrictive
than those mandated by US Department of Agriculture (USDA) regulations (15).
In recent years, perhaps in response to the variability of state and local
requirements, Congress and USDA have been pressured to revisit the issue of
school food quality. Furthermore, 2 Institute of Medicine (IOM) reports (15,23)
recommended improvements to both competitive and school meal food offerings on
the basis of the strongest scientific evidence available. In December 2010, the
Healthy, Hunger-Free Kids Act of 2010 was signed into law (24). The act requires
the Secretary of Agriculture to establish science-based nutrition standards
within a year of enactment. The standards apply to all foods and beverages
served outside school breakfast or lunch programs anywhere on school campuses.
The extent to which these standards will fully meet the Institute of Medicine
recommendations is not clear.
Furthermore, the Healthy, Hunger-Free Kids Act mandates significant
improvements to the National School Lunch and School Breakfast programs whereby
school meals will be aligned with dietary recommendations for children as
outlined in federal Dietary Guidelines for Americans. As the new standards are
implemented, school meals will provide increased offerings of nutritious items (eg,
fruits, vegetables, whole grains, 1% or nonfat milk) and decreased offerings of
foods high in fat, sugar, and sodium. Meal reimbursement rates will be increased
slightly to support the purchase of the nutritious offerings. If these policies
are implemented as recommended by IOM, significant improvements in nutrition
will be realized. However, the political challenge of effectively limiting the
sale of less nutritious foods and the economic challenge of paying for more
healthful options could result in more limited improvements than are needed to
enable schools to promote children’s optimal nutritional health.
Back to top
Application of a Bioethics Framework for Change in
Opponents of school food regulation argue that people have the right to
choose the foods they eat. However, we structure and regulate many student
activities in the school setting and do not consider doing so an abridgement of
children’s rights. The argument that a child has the right to choose foods of
poor nutritional quality at school conflicts with the societal value of child
protection. A child’s right to freedom from obesity is among the 54 binding
standards and obligations of the 1989 United Nations Convention on the Rights of
the Child (25).
Beauchamp and Childress’s (4) 4 foundational principles of biomedical ethics —
autonomy, beneficence, nonmaleficence, and justice — can help address the
question of whether a mandate to provide nutritious foods to children at school
meets bioethics standards that justify regulatory action.
- Autonomy. The conflict between school nutrition interventions and
individual rights can be summarized as follows: who is responsible for
ensuring that a child eats healthful foods — the parent, the child, or the
school? Children are not autonomous agents at home or at school. Because
children do not have the knowledge and experience needed to choose foods on
the basis of nutritional quality, responsible parents provide foods in the
home from which the child can reasonably select. For example, parents would
rarely serve candy alongside vegetables on the dinner table and expect their children to choose
the vegetables instead of the candy. Similarly, school authorities are
responsible for offering foods from which the child can select but limiting
choices to those that provide nutritional benefit rather than harm.
- Beneficence. Core to the mission of the National School Lunch and
School Breakfast programs is provision of foods that meet the recommended
dietary guidelines for optimal nutrition for children. However, efforts to
encourage children to eat nutritionally sound school meals are undermined by
provision of snacks and beverages that compete with healthier meals. Even
partially regulated snack foods compete with healthier meals. Offering
nutritious, appealing foods at school meals without competition from less
healthy snack foods optimizes students’ opportunity to consume a
health-promoting diet. Furthermore, the provision of a healthful school meal
can serve as a model for educating children and parents alike. From its
origins, the National School Lunch Program has asserted: “The educational
features of a properly chosen diet served at school should not be
under-emphasized. Not only is the child taught what a good diet consists of,
but his parents and family likewise are indirectly instructed” (8).
- Nonmaleficence. The principle of nonmaleficence is based on the
premise that an intervention should not inflict harm. Providing nutritional
foods does not cause harm. However, providing easy access to foods of poor
nutritional quality should be construed as causing harm. The ongoing
situation in which schools and their suppliers profit from sales of
unhealthy foods may be purposely disguised by efforts to teach children not
to choose the less healthy food that is offered. Observers might argue that
children will not eat foods that are held to a higher nutritional standard;
however, children will not go hungry. Students at schools providing
nutritious food offerings will still have access to a variety of food
choices along with the option of bringing foods from home. Furthermore,
students have reported a preference for healthy, fresh food choices over
other snack foods (26).
- Justice. The principle of social justice demands that humans be
treated fairly, with an equitable distribution of benefits and burdens.
Distributive justice takes differences into account and recommends that
social and economic inequities are acceptable if they are consistent with
just principles and lead to the greatest benefit for the least advantaged
(27). Schools provide an opportunity to address social inequities so that
children from disadvantaged families have an equal opportunity to become
productive citizens. Marketing of foods and beverages on school grounds (eg,
in classroom materials, on sporting equipment, by signage) is a school
fund-raising technique. Frequent exposure to this marketing in schools in
low-income areas where children are at greater nutritional risk is at odds
with fairness and social justice. Children from low-income families often
experience more psychosocial stresses; having access to healthful foods may
modify the effects of these stresses on children’s growth and development.
Although access to healthful food in schools will be of the greatest benefit
to those with the fewest resources, all children benefit from improved
nutrition. Doing harm, especially to the most vulnerable children, can never
be justified. Selling foods of poor nutritional quality for profit, even if
for support of desirable sports or music programs, is an example of such
Back to top
The Ethical Basis for Future Action
Providing foods of poor nutritional quality to finance school programs and
profit commercial entities fails to meet society’s ethical obligation to
minimize harm, provide benefit, and protect vulnerable children who are a
captive audience. Children are suffering as a consequence of such practices, and
children from low-income families, who are most vulnerable to food insecurity,
are at greatest risk for damage from consuming empty calories at school.
Fostering optimal nutrition not only protects against obesity but is also
essential for maximizing cognitive function and academic performance (2).
Although new school policies related to health education, school food offerings,
and physical education often have been well-received, they rarely have been of
sufficient strength to produce demonstrated changes in child obesity rates.
Using a bioethics framework, we can begin to formulate a rationale for
interventions that support the crucial role schools play in providing
nutritious, appealing meals that help children meet their dietary requirements.
Schools can and should model an environment that promotes learning and health.
In that context, interventions should limit competitive foods to only those
foods that contribute to meeting the Dietary Guidelines for Americans and do not
contribute empty calories. Only foods that support children’s nutritional health
should be offered at public schools, and available competitive foods should be
equally healthy supplements to the school meal, not less healthy alternatives.
These interventions are in children's best interests.
The precautionary principle (28) states, “When an activity raises threats of
harm to human health or the environment, precautionary measures should be taken
even if some cause and effect relationships are not fully established
scientifically.” The principle implies that society has a responsibility to
intervene and protect the public from exposure to harm where scientific
investigation identifies a plausible risk. The risk that malnutrition poses to
children’s ability to learn is well-documented (1,2). Recent studies link
provision of improved nutrition and physical activity at school to improved
academic performance for students, especially among low-income minority students
(29,30). Providing a healthy diet would help minimize disparities in learning, and children whose families are least able to provide consistent access
to adequate food would benefit most substantively. The risk that poor nutrition
and obesity pose to children’s future health (eg, osteoporosis, heart disease,
diabetes) is also well-documented. There is no justification for the promotion
of diets that increase those risks. Societal will is needed to provide the
required resources to help children achieve nutritional health and
simultaneously develop healthy lifetime eating habits. The best interests of
children and society demand no less.
Back to top
This article highlights ideas generated and conclusions reached at the
Symposium on Ethical Issues in Interventions for Childhood Obesity, sponsored by
the Robert Wood Johnson Foundation (RWJ) and Data for Solutions, Inc. We gratefully acknowledge
RWJ’s support of
this work and thank Sheila Stern and Lauren Goldstein for their editorial
Back to top
Corresponding Author: Patricia B. Crawford, DrPH, RD, School of Public
Health, University of California, Berkeley, CA 94720-3104. Telephone:
Author Affiliations: Wendi Gosliner, University of California, Berkeley,
California; Harvey Kayman, School of Public Health, University of California,
Back to top
- Taras H. Nutrition
and student performance at school. J School Health 2005;75(6):199-213.
- Center on Hunger, Poverty, and Nutrition Policy. Statement on the link
between nutrition and cognitive development in children. Medford (MA): Tufts
University School of Nutrition; 1995.
- Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD.
nutritional status, body weight, and academic performance in children and
adolescents. J Am Diet Assoc 2005;105(5):743-60.
- Kleinman RE, Murphy JM, Little M, Pagano M, Wehler CA, Regal K, et al.
Hunger in children in
the United States: potential behavioral and emotional correlates.
- Roberts SR. School food: does the future call for new food policy or can
the old still hold true? National Agricultural Law Center, Arkansas School
of Law; 2002.
Accessed October 30, 2010.
- Sindall C. Does
health promotion need a code of ethics? Health Promot Int
- Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th edition.
New York (NY): Oxford University Press; 2001.
- Pub L No. 396, 60 Stat 231.
- Gordon AR, Devaney BL, Burghardt JA.
Dietary effects of the
National School Lunch Program and the School Breakfast Program. Am J
Clin Nutr 1995;61(1 Suppl):221S-31S.
- Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM.
Prevalence of high
body mass index in US children and adolescents, 2007-2008. JAMA
- Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF.
Lifetime risk for
diabetes mellitus in the United States. JAMA 2003;290(14):1884-90.
- Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH.
factors and excess adiposity among overweight children and adolescents: the
Bogalusa Heart Study. J Pediatr 2007;150:12-17 e2.
- Poppendieck J. Free for all: fixing school food in America. California
Studies for Food and Culture. Berkeley (CA): University of California Press;
- Krebs-Smith SM, Guenther PM, Subar AF, Kirkpatrick SI, Dodd KW.
Americans do not meet
federal dietary recommendations. J Nutr 2010;140(10):1832-8.
- Institute of Medicine. Nutrition standards for foods in schools: leading
the way toward healthier youth. Stallings VA, Yaktine AL, editors.
Washington (DC): National Academies Press; 2007.
- US Department of Agriculture Food and Nutrition Service. School Breakfast
Accessed May 12, 2011.
- US General Accounting Office. Report to the Committee on Agriculture,
Nutrition, and Forestry, US Senate. Nutrition education: USDA provides
services through multiple programs, but stronger linkages among efforts are
needed. Washington (DC): Government Accountability Office; 2004.
http://www.gao.gov/new.items/d04528.pdf. Accessed October 30, 2010.
- Wechsler H, Brener ND, Kuester S, Miller C.
Food service and foods
and beverages available at school: results from the School Health Policies
and Programs Study 2000. J Sch Health 2001;71(7):313-24.
- Fox MF, Gordon A, Nogales R, Wilson A.
consumption of competitive foods in US public schools. J Am Diet Assoc
- Woodward-Lopez G, Gosliner W, Samuels SE, Craypo L, Kao J, Crawford PB.
Lessons learned from
evaluations of California's statewide school nutrition standards. Am J
Public Health 2010;100(11):2137-45.
- Cal EC § 49431 and 49431.5.
- Samuels SE, Craypo L, Boyle M, Crawford PB, Yancey A, Flores G. The
Healthy Eating, Active Communities program: a midpoint review. Am J
Public Health 2010;100(11): 2114-23.
- Institute of Medicine. School meals:building blocks for healthier
children. Stallings VA, Suitor CW, Taylor CL, editors. Washington (DC):
National Academies Press; 2010.
- Pub L No. 111-296, 124 Stat 3183.
- UNICEF. Convention on the rights of the child. New York (NY): United
Nations; 2008. http://www.unicef.org/crc/. Accessed October 30, 2010.
- Gosliner W, Madsen KA, Woodward-Lopez G, Crawford PB.
Would students prefer
to eat healthier foods at school? J Sch Health 2011;81(3):146-51.
- Rawls J. A theory of justice. Cambridge (MA): Harvard University Press;
- Science and Environmental Health Network. Wingspread Conference on the
Precautionary Principle, January 26, 1998. http://www.sehn.org/wing.html.
Accessed October 25, 2010.
- Hollar D, Messiah SE, Lopez-Mitnik G, Hollar TL, Almon M, Agatston AS.
Effect of a two-year
obesity prevention intervention on percentile changes in body mass index and
academic performance in low-income elementary school children. Am J
Public Health 2010;100:646-53.
- Hollar D, Lombardo M, Lopez-Mitnik G, Hollar TL, Almon M, Agatston AS,
Messiah SE. Effective
multi-level, multi-sector, school-based obesity prevention programming
improves weight, blood pressure, and academic performance, especially among
low-income, minority children. J Health Care Poor Underserved 2010;21(suppl
Back to top