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    Start Strong: Move Your Feet and Eat Before School

    An Analysis of the Walk to School and

    School Breakfast Program

    Prepared by:

    The Students in Nutrition 531

    University of Washington

    Nutritional Sciences

    School of Public Health and Community Medicine

    March 2007

Table of Contents

    Abstract………………………………………………………………………………. 3

    Background……………………………………………………………………........... 4

    Methods……………………………………………………………………………. 18

    Results………………………………………………………………………………... 20

    Discussion……………………………………………………………………….…… 31

    Conclusion.……………….……………………………………………………..….… 36

    References…………………………………………………………………………. 38

Appendices

     Appendix A: Interview Questions for School Staff…………………………... 42

     Appendix B: Interview Questions for Parents……………………………..…. 47

     Appendix C: Student Breakfast and Transportation Survey……………….. 53

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ABSTRACT

    Objective: The purpose of this study was to evaluate the effectiveness of the Start Strong program in increasing participation in school breakfast and walking school bus programs. Methods: The Start Strong program was implemented in four Seattle public elementary schools: Dearborn Park, Emerson, Maple, and Wing Luke. Each school served breakfast daily and the walking school bus program was available at least once a month. To evaluate the effectiveness of the program, Dearborn Park and Emerson Elementary were compared against Beacon Hill, the control school. A hands-up survey was conducted to compare student transportation to school as well as their participation in school breakfast. Quantitative and qualitative interviews were also conducted with parents and school staff to determine their perspectives of the Start Strong program.

    Results: The number of children participating in school breakfast remains low at all schools, however, there was a significant increase in the number of students participating in the intervention schools. Improvements in the number of students walking to school were less consistent. Interviews indicated that both parents and teachers were familiar with the program, however, the program has been unsuccessful in improving communication between the school and parents. Parents indicated that breakfast was important for their children. This did not necessarily translate into participation in school breakfast. The primary barrier of the walking school bus program was the distance between home and school.

    Recommendations: Parents are a critical asset to the success of the Start Strong program and need to be more heavily targeted. To encourage student participation in the walk to school program, it should be conducted at least weekly and involve an incentive program.

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BACKGROUND

The Importance of Nutrition and Physical Activity Programs in Elementary Schools

    Food insecurity and hunger are serious problems affecting millions of children in the U.S. According to the Department of Agriculture (1), approximately 10% of all American children experience food deprivation. A large number of studies have been conducted to elucidate the accessibility of adequate nutrition in elementary school children. Major emerging themes include: academic performance, psychosocial functioning, self-image, body weight, lifelong eating habits, and long term health outcomes. These important considerations deserve increased attention and further research.

     Academic performance is one aspect impacted when children are food insecure. A recent review article examined the relationship between school performance and food insecurity (2). Of the 10 articles discussed, seven were conducted outside the U.S. and reported changes in cognitive ability and school achievement. These studies also emphasized that severe food shortages altered the children‘s height-weight ratios. Of the three studies in the U.S., two

    reported associations between food insufficiency and significantly lower cognitive function, increased absenteeism, or reduced academic achievement. For example, although reported by the parent or child, children were two times more likely to have impaired functioning if they were hungry or at risk for hunger. In the second study, food insecure children 6-11 years-old had a significant decrease in arithmetic scores and higher likelihood of repeating a grade than those with adequate food. Failure to improve food security can have lasting impact on children‘s

    academic performance, but also on their psychosocial functioning.

     It is difficult to separate academic performance from psychosocial difficulties in hungry and food insecure children. In a 1998 study, 328 families with at least one child less than 12 years-old participated in the Community Childhood Hunger Identification Project (CCHIP) (3). As part of the study, the parents completed a Pediatric Symptom Checklist (PSC) assessing the child‘s emotional and behavioral symptoms. The authors showed that hungry children scored

    over twice as high (18 points) on the PSC as the not hungry controls (8.4 points). Hungry children were more likely to be classified as dysfunctional than their not hungry peers (21% vs. 3%, respectively). Hunger was strongly associated with diminished psychosocial functioning. These hungry children were more likely to receive special education services, have a history of

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    mental health counseling, and were more likely to repeat a grade. Furthermore, hunger was positively associated with anxiety, depression, attention deficit, antisocial and aggressive behavior, and stealing (3). Greater self-esteem is negatively correlated with antisocial behaviors, depression, anxiety, aggression, and substance use (3,4). Moreover, in a review article by Taras, ―teachers reported higher levels of hyperactivity, absenteeism, and tardiness‖ for U.S. children that were either hungry or at-risk for hunger versus non-hungry children (2). It is quite clear that the behavioral, emotional and learning disorders in elementary school children can amount to violence, underachievement, and substance abuse five to 10 years later (3).

     Of course, not all problems associated with poor nutrition or disordered eating are immediately obvious. Poor nutrition in young children is associated with adult obesity and a myriad of other chronic diseases. Providing elementary school children with regular meals throughout the day presents an excellent opportunity to shape their tastes and eating habits to some degree and educate children about healthy lifestyles and better food choices. It is not enough to give children lectures on good eating habits, if the information is not reinforced by example. In fact, one study found that children who ate their free meals at school did not experience increases in body mass index (BMI), relative to controls who received nutritional education alone (5). Adequate nourishment might also protect children from binging behaviors when food is finally presented, which could lead to obesity and eating disorders.

     The growing obesity epidemic is clearly evidenced by the reduction of physical activity among children. Indeed, U.S. children walking or biking to school has declined by over 40% since 1977 (6). Direct observation studies report only 5% of the elementary school children actively commute to school (7). Considering children spend a major portion of their days in school, it seems very appropriate for them to get exercise in the school setting. In a 2005 study, walking or biking to school was associated with an average of 24 minutes increase in daily exercise in school children (8). Studies found that students walking or biking to school are likely to have lower BMI than their car-riding peers, which could be protective against obesity, type 2 diabetes mellitus, cardiovascular disease, hypertension, and other associated diseases (9). Other research has illustrated an association between active commuting to school and increased physical activity at other times (10).

    Conversely, decreased physical activity is associated with failing to achieve health guidelines in young age, making children more vulnerable to colds and infections, and also

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    setting the stage for later development of chronic diseases (11). Moreover, Erickson et al reported an association between increased BMI in pre-adolescent girls and depressive symptoms (4). Additionally, physical activity decreases the time spent in front of a television or a computer, which are associated with high consumption of energy dense snacks and have a very pronounced influence on body weight (12). Furthermore, children might find greater intellectual stimulation from exploring the world around them, which in turn can enhance their academic performance. Physical activity and breakfast are important components to promote overall good health and positive life-long behaviors.

The Importance of School Breakfast Programs

     There is much consensus and evidence to support the importance of regular, nutritious meals for school children, which is reflected by the implementation of a National School Breakfast Program. School Breakfast Programs (SBP) provide a unique opportunity to influence the healthy habits of children by modeling the correct way to begin the day each morning: eating a nutritious breakfast. About one quarter of all students fail to eat breakfast altogether (13), and breakfast skipping is associated with adolescent overweight (14). Relative to the cost of individual family nutritional counseling or pediatric interventions, serving school breakfast is a low-cost health intervention that allows for a population-based approach to impacting the health of many children (15). Benefits to students of breakfast intervention at the school level include: short term and long-term health improvement, increased cognitive development and learning, and the development of life-long healthy habits, including good nutrition choices.

     Health is a consideration in planning school breakfasts that offer nutrients to students who may not be eating nutritious foods outside of school or at home. Children attending SBP schools are more likely to eat breakfast and more likely to meet nutritional standards for a number of micronutrients (e.g., vitamin C, calcium); fiber intake; and fruit and vegetable servings (16). Students attending a SBP consume less added sugar and total fat while limiting daytime snacking (16). According to the United States Department of Agriculture (USDA), school breakfasts must provide no more than 30 percent of an individual‘s calories from fat and less than 10 percent from saturated fat. Breakfasts must also provide one-fourth of the Recommended Dietary Allowance for protein, calcium, iron, vitamin A, vitamin C, and calories

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    (17). To help meet these nutritional standards, the USDA provides schools with training and assistance so food service staffs prepare healthy meals (17).

    Specifically, breakfast consumption is shown to influence overall energy intake. A diurnal distribution of food also indicates an association between an increased risk of being overweight and the percent of food intake at dinner (16). Therefore, moving energy consumption to breakfast (even with no overall energy change) might reduce the risk of obesity. In addition, children who skip breakfast also tend to have less adequate nutrient intakes than breakfast-eaters (18). For example, children who ate breakfast had significantly better healthy eating index component (HEI) scores for grains, fruits, milk products, and variety than those who did not eat breakfast. More importantly school breakfast eaters had a better overall diet (even higher fruit, milk, and variety scores) (19). Finally, there is a decreased risk of overweight among food insecure girls participating in SBP (16). This indicates the need to encourage breakfast eating and promotion of a secure food environment in controlling the obesity epidemic in children. Thus, nutritionally, it is efficient to intervene with nutritious breakfasts at the level of the school.

Positive Impact of School Breakfast Programs

     School breakfast programs suggest impacting the classroom environment. Improvements in nutrient intake were associated with significant improvements in student academic performance (math and reading scores, speed and memory), psychosocial functioning, and decreases in hunger (20). Data also suggests that children who participate in the SBP have fewer nurse visits, fewer disciplinary problems, reduced tardiness or absenteeism, and generally improved learning environments (21,22). In a study conducted in Ontario, teachers saw positive study habits, better listening, and improved concentration when children ate breakfast (2). Studies also reinforce the importance of eating breakfast to influence test outcomes. Eating closer to class time and prior to a test resulted in higher scores (23). Breakfast not only may impact the school environment, but can also affect the home situation.

     Eating school breakfast can positively influence a child‘s eating behavior at home as well. Enforcing nutrition at school can indisputably affect family eating behaviors and these strategies aimed at younger children have better long-term results. Thus, the effects of the SBP are age-dependent (24). Encouraging breakfast and healthy eating also promotes ideas of healthy body

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    image (e.g., less eating disorder development, binging, or skipping of meals) (23). The School Breakfast Program has significant beneficial aspects, yet it is not perfect.

Barriers to the School Breakfast Programs

     The School Breakfast Program (SBP) faces barriers to successful implementation and overall effectiveness. Most SBP users receive reduced or free meals, thus meal pricing may be a barrier to children paying for breakfast (20). Low funding decreases the ability to serve nutritious foods (25). Currently, total and saturated fat contents of meals provided by most schools exceed limits required by the National School Breakfast Programs (24). This indicates the necessity for healthier foods and enforcement of adequate meal-planning. In addition, school administrators are required to monitor the breakfast period, which can be difficult logistically (26). Time limitations affect many families, who, regardless of income, are too busy to sit down for breakfast. SBP in the past have been perceived by some as a threat to the family link (26). Other reasons for missing school breakfast include long commute times (23) and late bus arrivals or late arrivals at school (26). Additionally, students frequently are not hungry in morning (23). For some, there is a perceived stigma associating SBP with poverty that interferes with SBP participation (23). Unappetizing cafeteria food not including the students‘ ethnic or other food preferences can also decrease the desire to eat at school (23). Preparing specially-designed school breakfasts is difficult due to small onsite kitchens (cooking occurs in a huge commercial off-site kitchen). Consequently, the variety of foods served is not controllable (23). Numerous methods are available to help overcome the barriers within the SBP.

Complimentary Factors to School Breakfast Programs

     Despite barriers to the program, there also exist many enhancers to improve its effectiveness. Scheduling the bus arrivals twenty minutes earlier may prevent late bus arrivals and provide the children with enough time to eat breakfast at school. An earlier school start time would also allow for a required breakfast window for all students. In addition, faculty or parent volunteers can serve as role models for breakfast and positively influence the breakfast environment. Ensuring that the school breakfasts consist of healthy foods allows for nutrient and energy needs to be met and enhance the benefits of breakfast. To improve freshness and appeal to the students, cooking more meals ―on-site‖ is yet another option to improve the SBP

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    effectiveness (23). Implementation of taste-testing sessions may better align the breakfasts with the desired tastes of the students (23). Delivery of classroom breakfast or bag breakfasts also can increase student breakfast participation (23). Increasing levels of student participation help to fund further improvements in the SBP system and provide for healthier foods and fresher produce (23). Finally, implementation of universal SBP can greatly increase the participation of students eating breakfast. It does so by alleviating cost, the single largest determinant of school breakfast participation. It can also remove the negative stigma surrounding free breakfast programs (21). Alternately, creating the concept of school meal ―accounts‖ would allow students of all household income levels to pay by using a PIN rather than cash (23). Demographics also impact the effectiveness of the SBP.

Demographics of School Breakfast Programs

     Demographic differences influence whether schools offer and students participate in school breakfast. Schools serving low-income neighborhoods and rural settings are more likely to serve school breakfast than schools in higher-income neighborhoods or inner city settings (19). Thus, the location of a school can dictate the implementation of the SBP. For example, children from low-income families are more likely to start school without breakfast each morning. In the 2005-2006 school-year, 81% of SBP breakfasts consumed were free or reduced price breakfasts (20). A 1994-1996 survey from the USDA determined 19% of low-income children and only 2% of higher income children consumed breakfast at school (19). Among children in low-income households, those who ate a school breakfast had a statistically significant higher HEI score than children who ate breakfast at home or elsewhere and children who did not eat breakfast (19). Thus, it is important to serve this population with healthy school breakfasts otherwise unlikely attainable. Other characteristics associated with the potential participation in school breakfast are as follows: breakfast skipping varies depending on race (e.g., Black and Hispanic adolescents are most likely to skip breakfast), age (e.g., older age groups are more likely to skip) and gender (e.g., girls are more likely than boys to skip) (16). In addition, food stamp participation influences eligibility for SBP, targeting children from low-income families to participate. Also eligible for free meals are the homeless, runaway, and migrant children (20). Reaching those in need is vital to improving the child‘s life, education, and health.

    The Importance of Walking- to-School Programs

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     Making the SBP a part of every child‘s morning can greatly improve overall quality of life, educational, and health outcome possibilities otherwise unattainable. In addition, school breakfasts can affect other areas of healthy living. Eating breakfast creates a cumulative positive effect on health, as it has been associated with greater total physical activity (23). Thus, the SBP is a natural counterpart to the implementation of emerging programs that support walking to school as a means of active transportation and physical activity for elementary school children. The greatest proponent of such programs are those concerned with many health related trends seen in today‘s youth. Such programs involve children and often parents alike to incorporate physical activity as a means of transport to and from school. One of these progressive programs is the walking school bus which involves a parent or another adult as a leader that begins a route and picks up children along the way to school (27). Another is the Safe Routes to School initiative that develops safe walking routes for children to follow and petitions for improvements in sidewalks and traffic signals (28). In addition to a healthy breakfast, regular physical activity is crucial for children.

     The incorporation of regular physical activity into children‘s daily schedule is important for numerous reasons. Most importantly, the elevation of metabolism provides improved fitness and corresponding health related benefits. Secondly, regularly scheduled activity further elevates overall activity levels including participation in a wider range and higher frequency of activity. Therefore, this suggests that these programs indeed provide a framework to support activity as a component of a healthy lifestyle (29). Along with major contributions to the health and fitness of the children, these programs also improve the health of the community by reducing excessive traffic congestion and noise pollution. This in turn provides an environment that is more pedestrian friendly allowing for expansion of such programs. Additionally, the implementation of walking programs decreases dependency on the school districts financial resources to provide other more expensive modes of transportation. Walking programs are important, but barriers often prevent their implementation.

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