Appendix: Guidelines for School Health Programs to Promote Lifelong Healthy Eating

APPENDIX A: NUTRITION EDUCATION RESOURCE LIST

Nutrition education curricula and print, audiovisual, and computer-based materials are available from government agencies, voluntary organizations, corporations, and commodity organizations. State Nutrition Education and Training Program coordinators can help schools identify the most appropriate nutrition education curricula and materials. National clearinghouses that can help schools identify a wide range of nutrition education and school food service resources are sponsored by the U.S. Department of Agriculture's Food and Nutrition Information Center and the National Food Service Management Institute; the former also serves as a lending library.

Food and Nutrition Information Center National Agricultural Library U.S. Department of Agriculture 10301 Baltimore Blvd., Room 304 Beltsville, MD 20705 301-504-5719 National Food Service Management Institute P.O. Box 188 University of Mississippi University, MS 38677 800-321-3054

At the local and state levels, educational materials or curricula may be available from affiliates of voluntary health promotion organizations (e.g., the American Cancer Society or the American Heart Association), commodity organizations or national boards for specific food industries, county cooperative extension services, local and state health departments, school districts, state education agencies, and universities. At the national level, nutrition education materials can also be obtained from the following voluntary organizations and federal government agencies:

American Cancer Society 1599 Clifton Road, NE Atlanta, GA 30328 800-ACS-2345 (800-227-2345) American Dietetic Association National Center for Nutrition and Dietetics 216 W. Jackson Blvd., Suite 800 Chicago, IL 60606-6995 800-745-0775 ext. 5000 American Heart Association 7272 Greenville Ave. Dallas, TX 75231-4596 800-AHA-USA1 (800-242-8721) American School Food Service Association 1600 Duke St., 7th Floor Alexandria, VA 22314 800-877-8822 ext. 116 Consumer Information Center Pueblo, CO 81009 719-948-4000 (call for catalog) International Food Information Council 1100 Connecticut Ave., NW, Suite 430 Washington, DC 20036 202-296-6540

National Cancer Institute Office of Cancer Communications Building 31, Room 10A16 31 Center Drive MSC-2580 Bethesda, MD 20892-2580 800-4-CANCER (800-422-6237) National Heart, Lung, and Blood Institute Information Center P.O. Box 30105 Bethesda, MD 20824-0105 301-251-1222 Team Nutrition U.S. Department of Agriculture 3101 Park Center Drive, Room 802 Alexandria, VA 22302 703-305-1624

APPENDIX B: YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM AND SCHOOL HEALTH POLICIES AND PROGRAMS STUDY

In 1990, CDC established the Youth Risk Behavior Surveillance System to help monitor progress in attaining national health and education objectives by periodically measuring the prevalence of behaviors in six health risk categories. These behaviors, which are usually established during youth, contribute to the leading causes of death and disease in the United States. Dietary behaviors are one of the six health risk categories. CDC conducts the Youth Risk Behavior Survey (YRBS) biennially in a national probability sample of high school students and enables interested state and local education agencies to conduct the survey in comparable probability samples in states and cities (127). The specific dietary behaviors and attitudes monitored by the YRBS include consumption of fruits and vegetables, consumption of foods high in fat, perceptions of body weight, and attempted weight loss and weight-loss techniques used. The YRBS also obtains information about specific physical activity behaviors.

In 1994, CDC conducted the School Health Policies and Programs Study (SHPPS), which is a national study of school policies and programs at the school, district, and state levels that support comprehensive school health programs. The study also provides baseline data on national health and education objectives that can be attained through school health and physical education, school food service, and school health services and policies (229).

SHPPS included a mail survey of local and state education agencies' policies related to school health in grades kindergarten through 12. The survey was conducted in all states and in a nationally representative sample of districts. The study also included on-site, structured interviews with school principals, health education teachers, physical education teachers, school food service directors, school nurses, counselors, and other personnel in a nationally representative sample of middle schools and high schools. The questionnaire included the following: school nutrition education requirements for students; the content of nutrition education curricula; training and joint activities of food service staff and teachers responsible for nutrition education; school policies related to foods sold in vending machines and for fundraising; food service practices related to purchasing and preparing food; involvement of parents, staff, and students in planning food service meals; and involvement of fast-food or food service management companies in school meals.

Single copies of YRBS and SHPPS reports are available from CDC's Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K-33, 4770 Buford Highway, NE, Atlanta, GA 30341-3724; telephone: (770) 488-5330.

APPENDIX C: SELECTED SCHOOL-BASED STRATEGIES TO PROMOTE HEALTHY EATING

Different, developmentally appropriate activities are listed for lower elementary school, upper elementary school, and middle and high school students (194). This list is not intended to be comprehensive. However, it does include many of the concepts critical to improving the diet and health of young persons in this country. Schools should review these educational activities in relation to their students' needs and abilities to determine which activities are appropriate at each grade level.

Interventions that promote healthy changes in eating behaviors need to target three interacting spheres of influence: (a) the environment, which influences the likelihood that healthy eating behaviors will be adopted through social norms, influential role models, cues to action, reinforcements, and opportunities for action; (b) personal characteristics (e.g., knowledge, attitudes, beliefs, values, confidence in one's ability to change eating behaviors, and expectations about the consequences of making those changes); and (c) behavioral skills and experience, which are related to selecting or preparing specific foods, dietary self-assessment, and decision-making (186, 194,203,204).

The strategies listed here require the involvement of teachers, administrators, food service personnel, other school staff, and parents (194). Classroom teachers play the lead role in most of these activities, but many activities would be most effective if they were reinforced by other persons; all adults in the school community can help by serving as role models. Each school or district should determine the policies it needs to guide its nutrition-related activities and who is responsible for the tasks.

For lower elementary students

Strategies to make the food environment more health-enhancing

• Make healthy foods (e.g., fruits, vegetables, and whole grains) widely available at school, and discourage the availability of foods high in fat, sodium, and added sugars.

• Involve parents in nutrition education through homework.

• Provide role models (e.g., teachers, parents, other adults, older children, and celebrities or fictional characters) for healthy eating.

• Provide cues, through posters and marketing-style incentives, that encourage students to make healthy choices about eating and physical activity.

• Use incentives, such as verbal praise or token gifts, to reinforce healthy eating and physical activity. Do not use food for reward or punishment of any behavior.

Strategies to enhance personal characteristics that will support healthy eating

• Make basic connections between food and health (e.g., "You need food to feel good and to grow").

• Teach the importance of balancing food intake and physical activity.

• Identify healthy snacks (e.g., fruits, vegetables, and low-fat milk).

• Increase students' confidence in their ability to make healthy eating choices by gradually building up their food selection and preparation skills and giving them practice.

Strategies to enhance behavioral capabilities that will support healthy eating

• Provide many healthy foods for students to taste in an enjoyable social context.

• Let students prepare simple snacks.

• Have students try unfamiliar and culturally diverse foods that are low in fat, sodium, and added sugars.

For upper elementary students

Strategies to make the food environment more health-enhancing

• Make healthy foods (e.g., fruits, vegetables, and whole grains) widely available at school, and discourage the availability of foods high in fat, sodium, and added sugars.

• Involve parents in nutrition education through homework.

• Provide role models (e.g., teachers, parents, other adults, adolescents, and celebrities or fictional characters) for healthy eating.

• Through class discussions and small-group exercises, provide social support for making healthy changes in eating and physical activity.

• Provide cues, through posters and marketing-style incentives that students design, that encourage students to make healthy choices about eating and physical activity.

• Use incentives, such as verbal praise or token gifts, to reinforce healthy eating and physical activity. Do not use food as a reward or punishment of any behavior.

Strategies to enhance personal characteristics that will support healthy eating

• Explain the effects that diet and physical activity have on future health as well as on immediate concerns (e.g., current health, physical appearance, obesity, sense of well-being, and capacity for physical activity).

• Teach the principles of the Dietary Guidelines for Americans and the Food Guide Pyramid. Instill pride in choosing to eat meals and snacks that comply with these principles.

• Help students identify foods high and low in fat, saturated fat, cholesterol, sodium, added sugars, and fiber.

• Teach the importance of balancing food intake and physical activity.

• Teach the importance of eating adequate amounts of fruits, vegetables, and whole grains.

• Help students increase the value they place on health and their sense of control over food selection and preparation.

• Increase students' confidence in their ability to make healthy eating choices by gradually building up their food selection and preparation skills and giving them practice.

• Have students analyze food preferences and factors that trigger eating behaviors.

Strategies to enhance behavioral capabilities that will support healthy eating

• Provide opportunities for students to taste many healthy foods in an enjoyable social context.

• Let students prepare healthy snacks or simple meals.

• Encourage students to try unfamiliar and culturally diverse foods that are low in fat, sodium, and added sugars and that are high in fiber.

• Have students select healthy foods from a fast-food restaurant menu.

• Teach students how to recognize the fat, sodium, and fiber contents of foods by reading nutrition labels.

• Help students record and assess their food intake.

• Teach students how to use the Food Guide Pyramid to assess their diet for variety, moderation, and proportionality.

• Have students set simple goals for changes in eating and physical activity, and devise strategies for implementing these changes and monitoring progress in reaching their goals.

• When appropriate, let students practice (through role plays) encouraging parents to make healthy choices about eating and physical activity at home.

• Have students examine media and social influences on eating and physical activity; teach students how to respond to these pressures.

For middle and high school students

Strategies to make the food environment more health-enhancing

• Make healthy foods (e.g., fruits, vegetables, and whole grains) widely available at school, and discourage the availability of foods high in fat, sodium, and added sugars.

• Provide role models (e.g., teachers, parents, other adults, and celebrities) for healthy eating.

• Use peers as role models, and use peer-led nutrition education activities.

• Through class discussions and small-group exercises, provide social support for making healthy changes in eating and physical activity.

• Provide cues, through posters and marketing-style incentives that students design, that encourage students to make healthy choices about eating and physical activity.

Strategies to enhance personal characteristics that will support healthy eating

• Explain the effects that diet and physical activity have on future health as well as on immediate concerns (e.g., current health, physical appearance, obesity, eating disorders, sense of well-being, and capacity for physical activity).

• Have students identify reasons to adopt healthy eating and physical activity patterns.

• Teach the principles of the Dietary Guidelines for Americans. Instill in the students pride in choosing to eat meals and snacks that comply with these principles.

• Teach students how to identify foods high and low in fat, saturated fat, cholesterol, sodium, and added sugars.

• Teach students how to identify foods that are excellent sources of fiber, complex carbohydrates, calcium, iron, vitamin A, vitamin C, and folate.

• Teach the importance of balancing food intake and physical activity.

• Teach the effects of unsafe weight-loss methods and the characteristics of a safe weight-loss program.

• Help students increase the value they place on health and their sense of control over food selection and preparation.

• Increase students' confidence in their ability to eat healthily by gradually building up their skills and giving them practice.

• Help students examine what motivates persons to adopt particular eating habits. Have students keep a food diary noting what cues their own eating behavior (e.g., mood, hunger, stress, or other persons).

Strategies to enhance behavioral capabilities that will support healthy eating

• Let students plan and prepare healthy meals.

• Have students select healthy foods from restaurant and cafeteria menus.

• Teach students how to use nutrition labels to make healthy food choices.

• Teach students ways to modify recipes and prepare foods to reduce fat and sodium content and to increase fiber content.

• Help students identify incentives and reinforcements for their current eating and physical activity behaviors.

• Have students examine media and social inducements to adopt unhealthy eating and physical activity patterns, teach them how to respond to these pressures, and let them use their new knowledge to identify their own resistance strategies.

• Have students analyze environmental barriers to healthy eating and physical activity; explore strategies for overcoming these barriers.

• When appropriate, give students practice in encouraging parents to make healthy choices about eating and physical activity at home.

• Teach students to record their food intake, then have them assess and compare their diets with the standards set forth in the Dietary Guidelines for Americans and the Food Guide Pyramid. Have them assess and compare their intake of key nutrients (e.g., calcium and iron) with the intake recommended by the Public Health Service.

• Have students set goals for healthy changes in eating and physical activity, identify barriers and incentives, and assess alternative strategies for reaching their goals and decide which to follow. Show students how to monitor their progress, revise their goals if necessary, and reward themselves for successfully attaining their goals.

• Teach students how to evaluate nutrition claims from advertisements and nutrition-related news stories.

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