Guidelines for School Health Programs to Promote Lifelong Healthy Eating (2024)

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Summary

Healthy eating patterns in childhood and adolescence promoteoptimal childhood health, growth, and intellectual development;prevent immediate health problems, such as iron deficiency anemia,obesity, eating disorders, and dental caries; and may preventlong-term health problems, such as coronary heart disease, cancer,and stroke. School health programs can help children andadolescents attain full educational potential and good health byproviding them with the skills, social support, and environmentalreinforcement they need to adopt long-term, healthy eatingbehaviors.

This report summarizes strategies most likely to be effectivein promoting healthy eating among school-age youths and providesnutrition education guidelines for a comprehensive school healthprogram. These guidelines are based on a review of research,theory, and current practice, and they were developed by CDC incollaboration with experts from universities and from national,federal, and voluntary agencies.

The guidelines include recommendations on seven aspects of aschool-based program to promote healthy eating: school policy onnutrition, a sequential, coordinated curriculum, appropriateinstruction for students, integration of school food service andnutrition education, staff training, family and communityinvolvement, and program evaluation.

INTRODUCTION

School-based programs can play an important role in promotinglifelong healthy eating. Because dietary factors "contributesubstantially to the burden of preventable illness and prematuredeath in the United States," the national health promotion anddisease prevention objectives encourage schools to providenutrition education from preschool through 12th grade (1). The U.S.Department of Agriculture's (USDA) Nutrition Education and Training(NET) Program urges "nutrition education {to} be a majoreducational component of all child nutrition programs and offeredin all schools, child care facilities, and summer sites" by theyear 2000 (2). Because diet influences the potential for learningas well as health, an objective of the first national educationgoal is that children "receive the nutrition and health care neededto arrive at school with healthy minds and bodies" (3).

The recommendations in this report are intended to helppersonnel and policymakers at the school, district, state, andnational levels meet the national health objectives and educationgoals by implementing school-based nutrition education policies andprograms. This report may also be useful to students, to parents,and to personnel in local and state health departments,community-based health and nutrition programs, pediatric clinics,and training institutions for teachers and public healthprofessionals. These recommendations complement CDC guidelines forschool health programs to prevent the spread of acquiredimmunodeficiency syndrome (AIDS) (4), to prevent tobacco use andaddiction (5), and to promote physical activity (6).

In this report, nutrition education refers to a broad range ofactivities that promote healthy eating behaviors. The nutritioneducation guidelines focus largely on classroom instruction, butthey are relevant to all components of a comprehensive schoolhealth program -- health education; a healthy environment; healthservices; counseling, psychological, and social services;integrated school and community efforts; physical education;nutrition services; and school-based health promotion for facultyand staff (7). Although the meals served by school food serviceprograms are an important part of a school health program, thisreport does not provide specific recommendations related topurchasing and preparing food for school meals. Detailedinformation on this topic is available from many other publications(8-19) and information sources (see Appendix A). These guidelinesalso do not address the specific nutrition education and counselingneeds of pregnant adolescents (20,21) or young persons with specialneeds (22-28).

These guidelines are based on a synthesis of research, theory,and current practice and are consistent with the principles of thenational health education standards (29), the opportunity-to-learnstandards for health education (29), the position papers of leadingvoluntary organizations involved in child nutrition (30), and thenational action plan to improve the American diet (31). To developthese guidelines, CDC convened meetings of experts in nutritioneducation, reviewed published research, considered therecommendations of national policy documents (1,32-35), andconsulted with experts from national, federal, and voluntaryorganizations.

EFFECTS OF DIET ON THE HEALTH, GROWTH, AND INTELLECTUAL DEVELOPMENTOF YOUNG PERSONS

School-based nutrition education can improve dietary practicesthat affect young persons' health, growth, and intellectualdevelopment. Immediate effects of unhealthy eating patterns includeundernutrition, iron deficiency anemia, and overweight and obesity.

Undernutrition

Even moderate undernutrition can have lasting effects onchildren's cognitive development and school performance (36).Chronically undernourished children attain lower scores onstandardized achievement tests, especially tests of languageability (37). When children are hungry or undernourished, they havedifficulty resisting infection and therefore are more likely thanother children to become sick, to miss school, and to fall behindin class (36,37); they are irritable and have difficultyconcentrating, which can interfere with learning (38); and theyhave low energy, which can limit their physical activity (38). Somereports have estimated that millions of children in the UnitedStates experience hunger over the course of a year (39), but noscientific consensus currently exists on how to define or measurehunger (1).

Skipping breakfast can adversely affect children's performancein problem-solving tasks (40-42). A study of low-income elementaryschool students indicated that those who participated in the SchoolBreakfast Program had greater improvements in standardized testscores and reduced rates of absence and tardiness than did childrenwho qualified for the program but did not participate (43). Twelvepercent of students reported skipping breakfast the day before onenational survey was taken (44); 40% of 8th- and 10th-grade studentsin another study reported having eaten breakfast on less than orequal to 2 days the week before the survey (45). Strategies toencourage adequate nutrition among young persons include thefollowing:

Promote participation in USDA food assistance programs (e.g., the School Breakfast Program and School Lunch Program, the Summer Food Service Program, and the Child and Adult Care Food Program).
Advise parents and guardians about community-based food supplementation programs (e.g., food stamps; local food pantries; and the Special Supplemental Nutrition Program for Women, Infants, and Children {WIC}).
Educate students and their families about the importance of eating breakfast.

Iron Deficiency Anemia

Iron deficiency anemia is the most common cause of anemia inthe United States (33). Iron deficiency hampers the body's abilityto produce hemoglobin, which is needed to carry oxygen in theblood. This deficiency can increase fatigue, shorten attentionspan, decrease work capacity, reduce resistance to infection, andimpair intellectual performance (33,46). Among school-age youths,female adolescents are at greatest risk for iron deficiency.Approximately 1% of elementary school-age children and 2%-4% ofadolescent girls ages 12-19 years show evidence of iron deficiencyanemia (47). To prevent iron deficiency, children and adolescentsshould eat adequate amounts of foods high in iron and in vitamin C,which helps the body absorb iron efficiently (33).

Overweight and Obesity *

Overweight and obesity are increasing among children andadolescents in the United States (48-52). The prevalence ofoverweight among youths ages 6-17 years in the United States hasmore than doubled in the past 30 years; most of the increase hasoccurred since the late 1970s (52). Approximately 4.7 million, or11%, of youths ages 6-17 years are seriously overweight (52).Obesity in young persons is related to elevated blood cholesterollevels (53-56) and high blood pressure (57-59), and some very obeseyouths suffer from immediate health problems (e.g., respiratorydisorders, orthopedic conditions, and hyperinsulinemia) (60). Beingoverweight during childhood and adolescence has been associatedwith increased adult mortality (61,62). Furthermore, obese childrenand adolescents are often excluded from peer groups anddiscriminated against by adults, experience psychological stress,and have a poor body image and low self-esteem (63,64). Increasedphysical activity and appropriate caloric intake are recommendedfor preventing and reducing obesity (35). CDC's guidelines forschool and community health programs to promote physical activityamong youths address strategies for increasing physical activityamong young persons (6).

Unsafe Weight-Loss Methods

Many young persons in the United States practice unsafeweight-loss methods. Deliberately restricting food intake over longperiods can lead to poor growth and delayed sexual development(65). Data from one study indicated that the rate of smokinginitiation is higher for adolescent girls who diet or who areconcerned about their weight than for nondieters or girls havingfew weight concerns (66), and another study indicated that manywhite female high school students who smoke report using smoking tocontrol their appetite and weight (67). Harmful weight losspractices have been reported among girls as young as 9 years old(68,69). Young persons involved in certain competitive sports anddancing are particularly at risk for unsafe weight controlpractices (70). A national survey of 8th- and 10th-grade studentsfound that 32% skipped meals, 22% fasted, 7% used diet pills, 5%induced vomiting after meals, and 3% used laxatives to lose weight(45). Children and adolescents should learn about the dangers ofunsafe weight-loss methods and about safe ways to maintain ahealthy weight. The emphasis of society in the United States onthinness should be challenged, and young persons need to develop ahealthy body image (71).

Eating Disorders

Eating disorders (e.g., anorexia nervosa and bulimia nervosa)are psychological disorders characterized by severe disturbances ineating behavior. Anorexia nervosa is characterized by a refusal tomaintain a minimally normal body weight, and bulimia nervosa ischaracterized by repeated episodes of binge eating followed bycompensatory behaviors such as self-induced vomiting (72). Eatingdisorders often start in adolescence, and greater than 90% of casesoccur among females (72). Anorexia nervosa and bulimia nervosaaffect as many as 3% of adolescent and young adult females, and theincidence of anorexia nervosa appears to have increased in recentdecades (72). Compared with adolescents who have normal eatingpatterns, adolescents who have eating disorders tend to have lowerself-esteem; a negative body image; and feelings of inadequacy,anxiety, social dysfunction, depression, and moodiness (73). Eatingdisorders can cause many severe complications, and mortality ratesfor these disorders are among the highest for any psychiatricdisorder (74). Persons who have eating disorders should receiveimmediate medical and psychological treatment.

Dental Caries

Dental caries is perhaps the most prevalent of all diseases(1). It affects 50.1% of youths ages 5-17 years and 84.4% of youthsage 17 years (75). More than 50 million hours of school time arelost annually because of dental problems or dental visits (76).Dental caries is a progressive disease, which, if left untreated,can result in acute infections, pain, costly treatment, and toothloss. A strong link exists between sugar consumption and dentalcaries (33). To prevent dental caries, children and adolescentsshould drink fluoridated water, use fluoridated toothpaste, brushand floss their teeth regularly, have dental sealants applied tothe pits and fissures of their teeth, and consume sugars inmoderation (1).

EFFECTS OF CHILDHOOD EATING PATTERNS ON CHRONIC DISEASE RISKS OFADULTS

Nutrition education also should focus on preventing childrenand adolescents from developing chronic diseases during adulthood.Some of the physiological processes that lead to diet-relatedchronic disease begin in childhood. For example, autopsy studieshave demonstrated that early indicators of atherosclerosis (thehardening of the arteries that is the most common cause of coronaryheart disease {CHD}) begin in youth (77-83) and are related toblood cholesterol levels in young persons (79,81-83). Unhealthyeating practices that contribute to chronic disease are establishedearly in life; young persons having unhealthy eating habits tend tomaintain these habits as they age (84). Thus, it is efficacious toteach persons healthy eating patterns when they are young;high-risk eating behaviors and physiological risk factors aredifficult to change once they are established during youth.

Diet-related risk factors for cardiovascular disease (e.g.,high blood cholesterol level, high blood pressure, and overweight)are common in youths in the United States (34,52,85-90). Comparedwith their peers, children and adolescents who have high bloodcholesterol (34,91-96), have high blood pressure (97,98), or areobese (91,99-103) are more likely to have these risk factors duringadulthood. Poor diet and inadequate physical activity togetheraccount for at least 300,000 deaths in the United States annuallyand are second only to tobacco use as the most prominentidentifiable contributor to premature death (104). Interventionsthat promote healthy eating and physical activity behaviors duringchildhood and adolescence may not only prevent some of the leadingcauses of illness and death but also decrease direct health-carecosts and improve quality of life.

Diet is a known risk factor for the development of thenation's three leading causes of death: CHD, cancer, and stroke(33). Other health problems of adulthood associated with diet arediabetes, high blood pressure, overweight, and osteoporosis.

Coronary Heart Disease

CHD kills more persons in the United States than any otherdisease does (1). Diet-related risk factors for CHD include highblood cholesterol, high blood pressure, and obesity. These riskfactors can be reduced by consuming less fat (particularlysaturated fat) and cholesterol and by increasing physical activity(105).

Cancer

One out of every five deaths in the United States isattributable to cancer (106). Dietary factors have been associatedwith several types of cancer, including colon, breast, and prostate(33). All cancer deaths in the United States might be reduced asmuch as 35% through dietary changes (107,108). The risk for sometypes of cancer may be reduced by maintaining a healthy weight;limiting consumption of fat, alcohol, and salt-cured, salt-pickled,or smoked foods; and eating more foods that protect the bodyagainst cancer (fruits, vegetables, whole grain cereals, and otherhigh-fiber foods) (109). The National Cancer Institute adviseseating at least five servings of fruits and vegetables each day(110).

Stroke

Cerebrovascular disease, or stroke, is the third leading causeof death in the United States and a major cause of illness anddisability (111). The most important risk factor for stroke is highblood pressure, which often can be controlled or prevented byadopting a healthy diet and maintaining a healthy weight (112). Therisk for stroke can be reduced by consuming less sodium, increasingphysical activity, and maintaining a healthy body weight.

Diabetes

Diabetes is the seventh leading cause of death in the UnitedStates (104). CHD is two to four times more common and stroke istwo to six times more common in persons who have diabetes than inpersons who do not have diabetes (113). Diabetes can lead toblindness, kidney disease, and nerve damage (113).Non-insulin-dependent diabetes mellitus, which affectsapproximately 90% of persons who have diabetes, is often associatedwith obesity (114). Maintaining a desirable body weight throughphysical activity and modest caloric restriction is important inpreventing diabetes and controlling its complications (114).

High Blood Pressure

High blood pressure is a major cause of CHD, stroke, andkidney failure. About one in four adults in the United States hashigh blood pressure (115). Persons who have high blood pressurehave three to four times the risk of developing CHD and as much asseven times the risk of stroke as do those who have normal bloodpressure (116). Persons can reduce their risk for high bloodpressure by consuming less sodium, increasing physical activity,and maintaining a healthy body weight. A diet high in potassium mayhelp reduce the risk of high blood pressure (117).

Overweight

In the United States, about one in three adults is overweight(118), and these persons are at increased risk for CHD, some typesof cancer, stroke, diabetes mellitus, high blood pressure, andgallbladder disease (33). Overall risk for premature death isincreased by excess weight; the risk increases as severity ofoverweight increases (33). The best way to lose weight is toincrease physical activity and control caloric intake, preferablyby adopting a diet that is low in fat and high in vegetables,fruits, and grains (35).

Osteoporosis

Osteoporosis is a decrease in the amount of bone so severethat the bone fractures easily. About 1.3 million bone fractures,including many fatal hip fractures, occur per year in personsgreater than or equal to 45 years of age (33). Low dietary calcium,a mineral essential for bone growth, may be associated with anincreased risk for osteoporosis (33). For females especially,eating enough calcium is particularly important during childhood,adolescence, and young adulthood -- when bones approach their maximumdensity -- to reduce the risk for osteoporosis later in life (1,119-122). Regular weight-bearing exercises also can help preventosteoporosis (33).

GUIDELINES FOR HEALTHY EATING

To prevent certain diseases and to promote good health,persons greater than 2 years of age should follow the sevenrecommendations that constitute the Dietary Guidelines forAmericans (35). These guidelines are developed by the USDA andUSDHHS and are published every 5 years. They are based on extensivereviews of hundreds of studies conducted over many years andrepresent the best current advice that nutrition scientists cangive. The guidelines are consistent with dietary recommendationsmade by major health promotion organizations, including theNational Research Council (32), the National Cholesterol EducationProgram of the National Institutes of Health (34,105), the NationalCancer Institute (109), the American Cancer Society (123), and theAmerican Heart Association (124).

The principles contained in the Dietary Guidelines forAmericans should be the primary focus of school-based nutritioneducation. By enabling young persons to adopt practices consistentwith the guidelines, schools can help the nation meet its healthobjectives (1), which were designed to guide health promotion anddisease prevention policy and programs at the federal, state, andlocal level throughout the 1990s. Objective 2.19 is to "increase toat least 75 percent the proportion of the Nation's schools thatprovide nutrition education from preschool through 12th grade,preferably as part of quality school health education" (1). The sixrelevant dietary guidelines are (a) eat a variety of foods; (b)balance the food you eat with physical activity -- maintain orimprove your weight; (c) choose a diet with plenty of grainproducts, vegetables, and fruits; (d) choose a diet low in fat,saturated fat, and cholesterol; (e) choose a diet moderate insugars; and (f) choose a diet moderate in salt and sodium. (Theseventh recommendation concerns adults and alcoholic beverages.)Enabling children and adolescents to follow these guidelines canhelp the nation achieve these national health objectives for theyear 2000 (1):2.3 Reduce overweight to a prevalence of less than or equal to 20%

among people aged 20 and older and less than or equal to 15% amongadolescents aged 12 through 19.2.5 Reduce average dietary fat intake to less than or equal to 30%

of calories and average saturated fat intake to less than or equalto 10% of calories among people aged two and older.2.6 Increase complex carbohydrates and fiber-containing foods in

the diets of adults to five or more daily servings for vegetables(including legumes) and fruits and to six or more daily servingsfor grain products.2.7 Increase to greater than or equal to 50% the proportion of

overweight people aged 12 and older who have adopted sound dietarypractices combined with regular physical activity to attain anappropriate body weight.2.8 Increase calcium intake so greater than or equal to 50% of

youth aged 12 through 24 and greater than or equal to 50% ofpregnant and lactating women consume three or more servings dailyof foods rich in calcium, and greater than or equal to 50% ofpeople aged greater than or equal to 25 consume two or moreservings daily.2.9 Decrease salt and sodium intake so that greater than or equal

to 65% of home meal preparers prepare foods without adding salt,greater than or equal to 80% of people avoid using salt at thetable, and greater than or equal to 40% of adults regularlypurchase foods modified or lower in sodium.

The Food Guide Pyramid (Figure_1) was designed by the USDA andUSDHHS to help persons follow the Dietary Guidelines for Americans.Schools can use the pyramid to illustrate the concepts of variety(eat different foods from among and within the food groups),moderation (limit the consumption of foods high in fat and addedsugars), and proportionality (eat relatively greater amounts offoods from the groups that are lower in the pyramid: grains,vegetables, and fruits) (125). Other educational materialssupplement the pyramid by listing low-fat choices within each foodgroup (35).

EATING BEHAVIORS OF CHILDREN AND ADOLESCENTS IN THE UNITED STATES

Many young persons in the United States do not follow therecommendations of the Dietary Guidelines for Americans or the FoodGuide Pyramid. On average, children and adolescents consume toomuch fat, saturated fat, and sodium and not enough fruits,vegetables, or calcium (44,126-129; CDC, unpublished data).Children and adolescents obtain 33%-35% of their calories from fatand 12%-13% from saturated fat (above the recommended levels of 30%and 10%, respectively) (44,128,129). Only 16% of children ages 6-11years and 15% of adolescents ages 12-19 years meet therecommendation for total fat intake; only 9% of children and 7% ofadolescents meet the recommendation for saturated fat intake (130).Almost one-half of 8th- and 10th-grade students eat three or moresnacks a day, and most of these snacks are high in fat, sugar, orsodium (45).

Unpublished data from CDC's 1993 Youth Risk Behavior Surveyindicated that, on the day before the survey, 41% of high schoolstudents in the United States ate no vegetables and 42% ate nofruits (127) (Appendix B). An analysis of a nationallyrepresentative sample of youths ages 2-18 years indicated that,over a 3-day period, the youths ate only 3.6 servings of fruits andvegetables daily and that fried potatoes accounted for a largeproportion of the vegetables consumed, 20.4% of the youths ate therecommended five or more servings of fruits and vegetables daily,50.8% ate fewer than one serving of fruit per day, and 29.3% atefewer than one serving per day of vegetables that were not fried(131). Adolescent females eat considerably less calcium and ironthan recommended by the Food and Nutrition Board of the NationalResearch Council (126,129).

Children and adolescents appear to be familiar with thegeneral relationship between nutrition and health but are lessaware of the relationship between specific foods and health. Forexample, young persons understand the importance of limiting fat,cholesterol, and sodium in one's diet, but they do not know whichfoods are high in fat, cholesterol, sodium, or fiber (45,132,133).One study indicated that adolescents were well-informed about goodnutrition and health but did not use their knowledge to makehealthy food choices (134).

THE NEED FOR SCHOOL-BASED NUTRITION EDUCATION

Young persons need nutrition education to help them developlifelong eating patterns consistent with the Dietary Guidelines forAmericans and the Food Guide Pyramid. Schools are ideal settingsfor nutrition education for several reasons:

Schools can reach almost all children and adolescents.
Schools provide opportunities to practice healthy eating. More than one-half of youths in the United States eat one of their three major meals in school, and 1 in 10 children and adolescents eats two of three main meals in school (135).
Schools can teach students how to resist social pressures. Eating is a socially learned behavior that is influenced by social pressures. School-based programs can directly address peer pressure that discourages healthy eating and harness the power of peer pressure to reinforce healthy eating habits.
Skilled personnel are available. After appropriate training, teachers can use their instructional skills and food service personnel can contribute their expertise to nutrition education programs.
Evaluations suggest that school-based nutrition education can improve the eating behaviors of young persons (136-138).

School-based nutrition education is particularly importantbecause today's children and adolescents frequently decide what toeat with little adult supervision (139). The increase in one-parentfamilies or families having two working parents and theavailability of convenience foods and fast-food restaurants inhibitparents' monitoring of their children's eating habits.

Young persons' food choices are influenced by televisionadvertisem*nts for low-nutritive foods. Young persons see about onefood advertisem*nt for every 5 minutes of Saturday morningchildren's shows (140). Most of the foods advertised duringchildren's programming are high in fat, sugar, or sodium;practically no advertisem*nts are for healthy foods such as fruitsand vegetables (140-142). Studies have indicated that, comparedwith those who watch little television, children and adolescentswho watch more television are more likely to have unhealthy eatinghabits and unhealthy conceptions about food (143), ask theirparents to buy foods advertised on television (144), and eat morefat (145). Some studies of young persons have found that televisionwatching is directly associated with obesity (146-149). Becauseyouths in the United States spend, on average, more than 20 hoursa week watching television (150) -- more time over the course of theyear than they are in school (141) -- school-based programs shouldhelp counter the effect of television on young persons' eatinghabits.

Schools are a critical part of the social environment thatshapes young persons' eating behaviors and can therefore play alarge role in helping improve their diet. However, schools cannotachieve this goal on their own when the cultural milieu has a largeinfluence on food-related beliefs, values, and practices (30,138).Families, food stores, restaurants, the food industry, religiousinstitutions, community centers, government programs, and the massmedia must also support the principles of the Dietary Guidelinesfor Americans. The USDA's Team Nutrition (see Appendix A) seeks togain the support of many sectors of society for improving the dietof young persons by creating innovative public and privatepartnerships that promote healthy food choices through the media,schools, families, and community (151).

PROMOTING HEALTHY EATING THROUGH A COMPREHENSIVE SCHOOL HEALTHPROGRAM

In the school environment, classroom lessons alone might notbe enough to effect lasting changes in students' eating behaviors(30); students also need access to healthy food and the support ofpersons around them (137). The influence of school goes beyond theclassroom and includes normative messages from peers and adultsregarding foods and eating patterns. Students are more likely toreceive a strong, consistent message when healthy eating ispromoted through a comprehensive school health program.

A comprehensive school health program empowers students withnot only the knowledge, attitudes, and skills required to makepositive health decisions but also the environment, motivation,services, and support necessary to develop and maintain healthybehaviors (152). A comprehensive school health program includeshealth education; a healthy environment; health services;counseling, psychological, and social services; integrated schooland community efforts; physical education; nutrition services; anda school-based health program for faculty and staff (7). Eachcomponent can contribute to integrated efforts that promote healthyeating. For example, classroom lessons on nutrition can besupported by

schools providing appealing, low-fat, low-sodium foods in vending machines and at school meetings and events;
school counselors and nurses providing guidance on health and, if necessary, referrals for nutritional problems;
community organizations providing counseling or nutrition education campaigns;
physical education instructors helping students understand the relationship between nutrition and physical activity;
school food service personnel serving healthy, well-balanced meals in the cafeteria; and
school personnel acting as role models for healthy eating (153). The USDA is promoting health-enhancing changes in the food service component of the school health program by requiring schools to serve meals that comply with the Dietary Guidelines for Americans (154) and by providing technical support to schools through Team Nutrition (151).

RECOMMENDATIONS FOR SCHOOL HEALTH PROGRAMS PROMOTING HEALTHY EATING

Based on the available scientific literature, nationalnutrition policy documents, and current practice, these guidelinesprovide seven recommendations for ensuring a quality nutritionprogram within a comprehensive school health program. Theserecommendations address school policy on nutrition, a sequential,coordinated curriculum, appropriate and fun instruction forstudents, integration of school food service and nutritioneducation, staff training, family and community involvement, andprogram evaluation. Strategies that schools can use to achievethese recommendations are available (Appendix C). However, localschool systems need to assess the nutrition needs and issuesparticular to their communities, and they need to work with keyschool- and community-based constituents, including students, todevelop the most effective and relevant nutrition education plansfor their communities. Vigorous, coordinated, and sustained supportfrom communities, local and state education and health agencies,institutions of higher education, and national organizations alsois necessary to ensure success (29).

Policy: Adopt a coordinated school nutrition policy that promotes healthy eating through classroom lessons and a supportive school environment.
Curriculum for nutrition education: Implement nutrition education from preschool through secondary school as part of a sequential, comprehensive school health education curriculum designed to help students adopt healthy eating behaviors.
Instruction for students: Provide nutrition education through developmentally appropriate, culturally relevant, fun, participatory activities that involve social learning strategies.
Integration of school food service and nutrition education: Coordinate school food service with nutrition education and with other components of the comprehensive school health program to reinforce messages on healthy eating.
Training for school staff: Provide staff involved in nutrition education with adequate preservice and ongoing in-service training that focuses on teaching strategies for behavioral change.
Family and community involvement: Involve family members and the community in supporting and reinforcing nutrition education.
Program evaluation: Regularly evaluate the effectiveness of the school health program in promoting healthy eating, and change the program as appropriate to increase its effectiveness.

Recommendation 1. Policy: Adopt a coordinated school nutritionpolicy that promotes healthy eating through classroom lessons anda supportive school environment.

Rationale for the Policy

A coordinated school nutrition policy, particularly as part ofan overall school health policy, provides the framework forimplementing the other six recommendations and ensures thatstudents receive nutrition education messages that are reinforcedthroughout the school environment. For example, such a policy wouldaddress nutrition education classes; school lunch and breakfast;classroom snacks and parties; use of food to reward or discipline;and food sold in vending machines, at school stores, snack bars,sporting events, and special activities, and as part of fundraisingactivities. The school environment can powerfully influencestudents' attitudes, preferences, and behaviors related to food(137). Without a coordinated nutrition policy, schools risknegating the health lessons delivered in the classroom andcafeteria by allowing actions that discourage healthy eatingbehaviors.

Developing the Policy

A school nutrition policy should be a brief document thatincorporates input from all relevant constituents of the schoolcommunity: students, teachers, coaches, staff, administrators, foodservice personnel, nurses, counselors, public health professionals,and parents. The policy should meet local needs and be adapted tothe health concerns, food preferences, and dietary practices ofdifferent ethnic and socioeconomic groups. Technical assistance forassessing nutrition education needs is available through the stateNET Program (155). Schools might consider using one or more of thefollowing techniques to assess their particular needs:

Interview nutrition professionals to learn more about local eating habits and to identify materials and services available for youths and adults. Schools might interview representatives from the school food service program; the state NET Program; the nutrition unit within the State Department of Health; the district or state school health coordinator; the local WIC program and Cooperative Extension nutrition education program; the state or local chapters of the American Cancer Society, American Dietetic Association, and the American Heart Association; nutrition councils or coalitions; university research programs; organizations with special insights into the particular nutrition education needs of cultural and ethnic minorities; or businesses that offer nutrition-related services or food products.
Interview food service staff about students' eating practices in the school cafeteria.
Observe the school cafeteria, the teachers' lunchroom, and other areas in the school where food is available.
Review nutrition curricula used by teachers.
Survey teachers to determine how nutrition is taught, whether teachers use food for reward or punishment, and the level of interest of teachers in nutrition or wellness programs for themselves.
Survey students to determine their dietary preferences and what types of healthy changes in school food they most want.

The policy plan should include means of obtaining follow-upinput from all parties and means of revising the plan as needed.Student involvement is critical to the success of a nutritionpolicy. A nutrition advisory committee or a nutrition subcommitteeof the school health advisory council having student members candevelop and promulgate a coordinated school nutrition policy.Technical assistance in forming a school nutrition advisorycommittee is available from the American School Food ServiceAssociation (Appendix A). Successful implementation of a nutritionpolicy also requires the active support of school and districteducational leadership.

Content of the Policy

The written policy should describe the importance of thenutrition component within the comprehensive school health program.This section can briefly describe the role of good nutrition inpromoting childhood growth, health, and learning; discuss the roleof child and adolescent nutrition in reducing the risk for chronicdiseases of adulthood; identify the importance of establishing aschool environment that supports healthy eating choices by youngpersons; and generate support for the policy by identifying howimprovements in student nutrition can satisfy the needs ofdifferent constituents of the school community (e.g., students,teachers, and food service personnel). An optimal policy onnutrition should publicly commit the school to providing adequatetime for a curriculum on nutrition, serving healthy and appealingfoods at school, developing food-use guidelines for teachers,supporting healthy school meals, and establishing links withnutrition service providers.

Curriculum. Adequate time should be allocated for nutritioneducation throughout the preschool, primary, and secondary schoolyears as part of a sequential, comprehensive school healtheducation program. In addition, teachers should be adequatelytrained to teach nutrition and be provided with ongoing in-servicetraining.

Healthy ** and appealing foods. Healthy and appealing foods shouldbe available in meals, a la carte items in the cafeteria, snackbars, and vending machines (Exhibit 1) (Table_1); as classroomsnacks; and at special events, athletic competitions, staffmeetings, and parents' association meetings. In addition, schoolsshould discourage the sale of foods high in fat, sodium, and addedsugars (e.g., candy, fried chips, and soda) on school grounds andas part of fundraising activities. Although selling low-nutritivefoods may provide revenue for school programs, such sales tellstudents that it is acceptable to compromise health for financialreasons (158). The school thereby risks contradicting the messageson healthy eating given in class. If schools contract with foodservice management companies to supply meals, the contractorsshould be required to serve appealing, low-fat, low-sodium mealsthat comply with the standards of the Dietary Guidelines forAmericans.

Food use guidelines for teachers. Schools should discourageteachers from using food for disciplining or rewarding students.Some teachers give students low-nutritive foods, such as candy, asa reward for good behavior, and punish misbehaving students bydenying a low-nutritive treat (159). These practices reinforcestudents' preferences for low-nutritive foods and contradict whatis taught during nutrition education. Schools should recommend thatboth teachers and parents serve healthy party snacks and treats(160).

Support for healthy school meals. Starting with the 1996-1997school year, schools will be required to serve meals that complywith the standards of the Dietary Guidelines for Americans (154).To encourage students to participate in school meal programs and tomake healthy choices in cafeterias, schools can use marketing-styleincentives and promotions (13,14,135,161); use healthy school mealsas examples in class; educate parents about the value of healthyschool meals; involve students and parents in planning meals; andhave teachers, administrators, and parents eat in the cafeteria andspeak favorably about the healthy meals available there. Studentsshould also be given adequate time and space to eat meals in apleasant and safe environment (162).

Links with nutrition service providers. Schools should establishlinks with qualified public health and nutrition professionals whocan provide screening, referral, and counseling for nutritionalproblems (30,163); inform families about supplemental nutritionservices available in the community, such as WIC (164), foodstamps, local food pantries, the Summer Food Service Program, andthe Child and Adult Care Food Program; and implement nutritioneducation and health promotion activities for school faculty, otherstaff, school board members, and parents. These links can helpprevent and resolve nutritional problems that can impair astudent's capacity to learn, demonstrate the value placed on goodnutrition for the entire school community, and help adults serve asrole models for school-age youths.

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* Obesity refers to an excess of total body fat. Body fat content is usually estimated by one of two techniques, measuring skinfold thickness or computing the ratio of body weight to height. Researchers who use weight-to-height ratios tend to use the term "overweight" instead of "obesity." Although weight-to-height ratios correlate highly with body fat, they do not distinguish between body fat and lean body tissue: excess fat tissue is generally assumed to account for the additional weight, but excess weight can also include lean body mass or a large body frame (33).

** As defined by the U.S. Food and Drug Administration (156,157) in its food label regulations, a "healthy" food must be low in fat (less than or equal to 3 g per serving), be low in saturated fat (less than or equal to 1 g per serving), contain limited amounts of cholesterol (less than or equal to 60 mg per serving for a single-item food), and contain limited amounts of salt (less than or equal to 480 mg per serving until 1998, when the criterion for a single-item food will decrease to less than or equal to 360 mg per serving). In addition, single-item foods that are not raw fruits or vegetables must provide greater than or equal to 10% of the daily value of one or more of the following nutrients: vitamin A, vitamin C, iron, calcium, protein, and fiber. Criteria for products that include more than one type of food (e.g., macaroni and cheese) vary depending on the food.

*** When serving food, teachers must use hygienic food handling practices and consider possible food allergies and religious prohibitions; the food service director can help in this area.

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EXHIBIT 1: Sample List of Vending Machine Foods Low in Saturated Fat (34)==================================================================================Canned fruitFresh fruit (e.g., apples and oranges) *Fresh vegetables (e.g., carrots)Fruit juice and vegetable juiceLow-fat crackers and cookies, such as fig bars and gingersnapsPretzelsBread products (e.g., bread sticks, rolls, bagels, and pita bread)Ready-to-eat, low-sugar cerealsGranola bars made with unsaturated fatLow-fat (1%) or skim milk *Low-fat or nonfat yogurt *Snack mixes of cereal and dried fruit with a small amount of nuts and seeds **Raisins and other dried fruit **Peanut butter and low-fat crackers ***----------------------------------------------------------------------------------* These foods are appropriate if the vending machine is refrigerated.** Some schools might not want to offer these items because these foods can contribute to dental caries.*** Some schools might not want to offer peanut butter; although it is low in saturated fatty acids, peanut butter is high in total fat.==================================================================================

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EXHIBIT 2: National Health Education Standards (29)======================================================================1. Students will comprehend concepts related to health promotion and disease prevention.2. Students will be able to access valid health information and health-promoting products and services.3. Students will be able to practice health-enhancing behaviors and reduce health risks.4. Students will analyze the influence of culture, media, technology, and other factors on health.5. Students will be able to use interpersonal communication skills to enhance health.6. Students will be able to use goal-setting and decision-making skills to enhance health.7. Students will be able to advocate for personal, family, and community health.======================================================================

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Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

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FAQs

Guidelines for School Health Programs to Promote Lifelong Healthy Eating? ›

The guidelines include recommendations on seven aspects of a school-based program to promote healthy eating: school policy on nutrition, a sequential, co- ordinated curriculum, appropriate instruction for students, integration of school food service and nutrition education, staff training, family and community in- ...

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What are the 8 guidelines you should follow when eating healthy food? ›

8 tips for healthy eating

Base your meals on higher fibre starchy carbohydrates. ...
Eat lots of fruit and veg. ...
Eat more fish, including a portion of oily fish. ...
Cut down on saturated fat and sugar. ...
Eat less salt: no more than 6g a day for adults. ...
Get active and be a healthy weight. ...
Do not get thirsty. ...
Do not skip breakfast.

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How can we promote healthy eating habits at school? ›

Schools and teachers can model healthy eating and being active at school by:

Packing a healthy lunch and taking the time to eat it.
Providing healthy snacks at school and staff functions (staff meetings, parent-teacher interviews, etc.)
Using non-food rewards (pencils, skipping ropes) instead of lollies and sweets.

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Which guidelines are recommended for all people to promote healthy eating? ›

Maintain healthy weight. Choose a diet low in fat, saturated fat, and cholesterol. Choose a diet with plenty of vegetables, fruits, and grain products. Use sugars only in moderation.

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How many guidelines are there for healthful eating? ›

There are 4 overarching Guidelines in the 2020-2025 edition: Follow a healthy dietary pattern at every life stage. Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations.

What are 5 healthy eating guidelines? ›

Healthy Eating Guidelines

Eat more vegetables, salad and fruit - Up to seven servings a day.
Limit intake of high fat, sugar, salt (HFSS) food and drinks.
Size matters: Use the food pyramid as a guide for serving sizes.
Increase your physical activity levels.
Small changes can make a big difference. Start TODAY!

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What are the 10 healthy lifestyle guidelines? ›

Measure and Watch Your Weight. ...
Limit Unhealthy Foods and Eat Healthy Meals. ...
Take Multivitamin Supplements. ...
Drink Water and Stay Hydrated, and Limit Sugared Beverages. ...
Exercise Regularly and Be Physically Active. ...
Reduce Sitting and Screen Time. ...
Get Enough Good Sleep. ...
Go Easy on Alcohol and Stay Sober.

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What is the role of the school in promoting healthy habits? ›

Schools play an important role in promoting the health and safety of children and adolescents by helping them to establish lifelong health patterns. Healthy students are better learners, and academic achievement bears a lifetime of benefits for health.

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Why should schools provide healthy lunches? ›

School lunch is critical to student health and well-being, especially for low-income students—and ensures that students have nutrition they need throughout the day to learn. Research shows that receiving free or reduced-price school lunches reduces food insecurity, obesity rates, and poor health.

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Why is a balanced diet important for school students? ›

Food plays a vital role in preparing children and students to learn and making sure they are healthy enough to attend school each day. Nutrition impacts brain development, memory and cognitive function, energy, attention and focus, which are all critical to the ability to absorb and retain information.

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What do the guidelines for healthy eating mean? ›

Choose fish, poultry, beans, and nuts; limit red meat and cheese; avoid bacon, cold cuts, and other processed meats. Eat a variety of whole grains (like whole-wheat bread, whole-grain pasta, and brown rice). Limit refined grains (like white rice and white bread).

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What are the three key principles of healthy eating? ›

When deciding what to eat or drink, follow these three key dietary principles.

Meet nutritional needs primarily from nutrient-dense foods and beverages.
Choose a variety of options from each food group: vegetables, fruits, grains, dairy, and protein foods.
Pay attention to portion size.

Why is it important to follow the healthy eating guidelines? ›

People with healthy eating patterns live longer and are at lower risk for serious health problems such as heart disease, type 2 diabetes, and obesity.

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What are the guidelines for healthy eating habits and lifestyle? ›

Eat plenty of vegetables and fruit: They are important sources of vitamins, minerals, dietary fibre, plant protein and antioxidants. People with diets rich in vegetables and fruit have a significantly lower risk of obesity, heart disease, stroke, diabetes and certain types of cancer.

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What is food guidelines? ›

Food-based dietary guidelines (also known as dietary guidelines) are intended to establish a basis for public food and nutrition, health and agricultural policies and nutrition education programmes to foster healthy eating habits and lifestyles.

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What are 8 ways to stay healthy? ›

Once you've got those down, move on to the others.

Maintain A Healthy Weight. ...
Exercise Regularly. ...
Don't Smoke Or Use Smokeless Tobacco. ...
Eat a Healthy Diet. ...
Limit Alcohol – Zero Is Best. ...
Protect Yourself from the Sun And Avoid Tanning Beds. ...
Protect Yourself From Sexually Transmitted Infections. ...
Get Screening Tests.

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What is 16 8 diet guidelines? ›

It involves consuming foods during an 8-hour window and avoiding food, or fasting, for the remaining 16 hours each day. Some people believe that this method works by supporting the body's circadian rhythm, which is its internal clock.

What is the 8 20 rule for eating? ›

The 80/20 rule is a guide for your everyday diet—eat nutritious foods 80 percent of the time and have a serving of your favorite treat with the other 20 percent. For the “80 percent” part of the plan, focus on drinking lots of water and eating nutritious foods that include: Whole grains.