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2018

The Role of Programs and Policies in Shaping the Observed School Nutrition Environment and Rural Childhood Obesity Shadai Martin South Dakota State University

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Recommended Citation Martin, Shadai, "The Role of Programs and Policies in Shaping the Observed School Nutrition Environment and Rural Childhood Obesity " (2018). Electronic Theses and Dissertations. 2464. https://openprairie.sdstate.edu/etd/2464

THE ROLE OF PROGRAMS AND POLICIES IN SHAPING THE OBSERVED

SCHOOL NUTRITION ENVIRONMENT AND RURAL CHILDHOOD OBESITY

BY

SHADAI S. MARTIN

A dissertation submitted in partial fulfillment of the requirements for the

Doctor of Philosophy

Major in Nutrition and Exercise Science

South Dakota State University

2018

iii

This dissertation is dedicated to my parents. Thank you for the many years of

support, encouragement and guidance. Thank you for loving me more than I loved myself

some days and helping me to realize that my life is worth it, and I do deserve good things

in life. There were many days where all I could think about was packing up and going

home but you would always know the right words to say to keep me going. Although it

has been 1 year and 4 months since I have last seen you all, thank you for calling me

every single day, sometimes a few times in a day to make sure I was still going and

letting me know I was one day closer. Mom, I value your wisdom and I hope to be half

the woman you are one day. I love you with all my heart; thank you for never giving up

on me and loving me unconditionally. Our best is yet to come!

iv

ACKNOWLEDGEMENTS

I would like to thank the members of my committee for the time they have

spent ensuring my academic success; I appreciate your flexibility, time and support. I

would like to thank my advisor, Dr. Lacey McCormack, for your role as my supervisor

and mentor and for accepting me as a student half way through the program. I am grateful

to have had the opportunity to work with you. I have grown personally and professionally

being under your tutelage; I still have quite a bit of growing and maturing to do but I have

come along way. Thank you for everything!

v

TABLE OF CONTENT

ABBREVIATIONS …………………………………………………………… vii

LIST OF FIGURES …………………………………………………………… viii

LIST OF TABLES ……………………………………………………………. ix

ABSTRACT……………………………………………………………………. x

CHAPTER 1: Introduction………………………………………………………1

Importance of the Nutrition Environment……………………………………… 2

Importance of School Meals…………………………………………………….4

Importance of School Wellness Policies ……………………………………….7

Importance of Researching Rural vs. Non-Rural ………………………………8

Specific Aims…………………………………………………………………...9

References ……………………………………………………………………...11

CHAPTER 2: The Association Between Free & Reduced School Lunch

Participation and Rural Obesity ………………………………………………. 17

Abstract ………………………………………………………………………. 18

Introduction…………………………………………………………………….20

Methods ………………………………………………………………………. 23

Results …………………………………………………………………………24

Discussion ……………………………………………………………………. 24

References ……………………………………………………………………. 28

CHAPTER 3: The Association Between Strength and Comprehensive Wellness Policy

Scores and the Nutrition Environment ………………………………………...37

vi

Abstract ………………………………………………………………………. 38

Introduction…………………………………………………………………… 39

Methods ………………………………………………………………………. 41

Results …………………………………………………………………………43

Discussion ……………………………………………………………………. 44

References……………………………………………………………………...48

CHAPTER 4: Association between More Comprehensive and Stronger School Nutrition

Wellness Policy Scores and Nutrition Policy Implementation…………………56

Abstract ………………………………………………………………………...57

Introduction……………………………………………………………………..58

Methods ………………………………………………………………………...59

Results ………………………………………………………………………….62

Discussion ……………………………………………………………………...62

References……………………………………………………………………... 67

Chapter 5………………………………………………………………………..74

vii

ABBREVIATIONS

BMI-body mass index

HHFKA – Healthy Hungry- Free Kids Act

LEA – Local Education Agencies

NSLP- national school lunch program

RUC codes- Rural-Urban Continuum Codes

SPAN-ET – School Physical Activity and Nutrition Environment

SWP- school wellness policy

USDA- United States Department of Agriculture

Well SAT – Wellness School Assessment Tool

viii

LIST OF TABLES

Table 2.1 BMI definitions ……………………………………………… 34

Table 2.2 RUC code definitions...………………………………………. 35

Table 2.3 RUC code groups …………….……………………………… 37

Table 3.1 Well SAT and SPAN-ET (physical)…………………………. 53

Table 3.2 Well SAT and SPAN-ET (situational)………………………. 54

Table 3.3 Well SAT and SPAN-ET (policy)……………………………. 55

Table 3.4 Total SPAN-ET and Well SAT………………………………. 56

Table 4.1 SPAN-ET Criteria…….………………………………………. 72

Table 4.2 SPAN-ET and Well SAT correlations………………………… 74

ix

ABSTRACT

THE ROLE OF PROGRAMS AND POLICIES IN SHAPING THE OBSERVED

SCHOOL NUTRITION ENVIRONMENT AND RURAL CHILDHOOD OBESITY

SHADAI MARTIN

2018

Childhood obesity is an ongoing public health concern that impacts many children

in the United States. Research has shown that the prevalence of childhood obesity is

higher in rural populations compared to non-rural populations. This may be attributable

to differences in the school nutrition environment, particularly school meals and school

wellness policy implementation. In order to design effective intervention targeted at

weight management and obesity reduction, information regarding the school nutrition

environment must be known. Therefore, the purpose of this research was to examine the

school nutrition environment, particularly school lunch participation and weight

outcomes between metro, non-metro and rural counties. Additionally, strength and

comprehensiveness of nutrition wellness policies and its association with the nutrition

environment along with nutrition policy implementation were examined. Rural

populations are understudied and differ from their metro and non-metro counterparts in

terms of sociodemographic factors and access to food.

The following analyses utilize school meals participation data from the Annie E. Carsey

Foundation, SPAN-ET tool from the Oregon State University extension services and

WellSAT tool from UCONN Rudd Center. School lunch participation by county

ruralness was examined to determine if meal participation was associated with weight

outcomes. Strength and comprehensiveness of school nutrition wellness policies and the

x

observed physical, situational and policy nutrition environment were examined and

finally SPAN-ET and WellSAT scores were examined to assess whether more

comprehensive and stronger policies equate to better nutrition policy implementation and

a better nutrition environment. The findings in this dissertation can be used not only to

understand how the school nutrition environment can play a role in weight management,

particularly in rural neighborhoods but also for determining how to move forward for

designing appropriate interventions targeted at reducing obesity in these populations.

1

Introduction

Today, approximately 1 in 5 school aged children (ages 6-19) are classified as

obese.1 Multiple factors such as environmental factors, eating and physical activity

behaviors, metabolism and genetics contribute to childhood obesity.2 Childhood obesity

has immediate and long-term impact on physical, social and emotional health.3 It has

been shown that obese children tend to miss more school days compared to their

counterparts of normal weight due to factors such as isolation, bullying and illness. Rural

areas experience higher rates of obesity and overweight; rural areas are 25% more likely

to be overweight or obese than their peers in metropolitan areas and are also at increased

risk for poverty as they face lower access to health care, lower levels of physical activity,

poorer-quality food and limited options for transportation.4 There are multiple reasons as

to why children become obese, but genetics, lack of physical activity, unhealthy eating

patterns or a combination of these patterns seem to be the main cause.1 A child’s overall

diet and physical activity levels play an important role in determining their weight and

many children in today’s society spend quite a bit of time being sedentary.2 Childhood

obesity has immediate and long term impacts on physical, social and emotional health. 3

Children who are obese are more than likely to become obese adults which usually is also

linked to the individual developing heart disease, type 2 diabetes and risk factors for heart

disease. There is also a social stigma attached to being obese that can be just as

detrimental as physical limitations. Low self-esteem, lack of self-confidence and bullying

may all be issues that may lead to poor academic performance at school. Depression,

discrimination and even emotional eating may be an issue for some children who are

overweight/obese.3

2

Obesity is defined as having excess body fat, with a BMI above the 95th percentile

for children and teens of the same age and sex whereas overweight is defined as a BMI at

or above the 85th percentile and below the 95th percentile for children and teens of the

same age and sex.1 BMI is generally used to assess an individual’s body weight as

calculations only require height and weight and is generally inexpensive and easy for

clinicians’ and the general public.1 Children dwelling in rural areas are 25% more likely

to be overweight/obese than their counterparts in urban communities.4 Challenges such as

geographical distances between their home and opportunities for physical activity can be

a hindrance. Lower access to healthcare, poorer quality foods and limited options for

transport all impact obesity rates of those dwelling in rural areas. Families in rural areas

have a higher risk of food insecurity compared to their urban peers; rural food desserts

are associated with both higher rates of poverty and higher rates of childhood obesity. 6

Importance of the Nutrition Environment

School food environments can have a large impact on children’s dietary intake.

Students consume meals and snacks daily at school and designing school policies on the

federal and local levels that support healthy eating via incorporating evidence based

nutrition standards and limiting competitive foods can have an impact on childhood

obesity.5 Changes in the environment where children spend their time, which includes

school, home and community settings can play a significant role in assisting children

maintaining a healthy weight by incorporate daily physical activity and making nutritious

foods easily accessible and fewer foods and beverages high in solid fat and sugar not

3

easily accessible.2 Nutrition policy can also impact food availability and food choices.

Federal and state policies regarding the nutritional value of foods (breakfast, lunch and

snacks) served at public schools should be designed to improve health. A comprehensive

school-based approach which supports school nutrition and physical activity environment

along with incorporating parents, care givers and community members is effective at

preventing obesity.

There has been increased public awareness regarding the impact that food choices

and dietary practices have on health. Schools can play a critical role in childhood obesity

as children spend a large percentage of their day at school. Most US children attend

school for 6 hours a day and consume as much as half their daily calories at school.7

Developing and implementing school-based programs that promote physical activity and

healthy eating can make a big impact on childhood obesity. School-based obesity

interventions hold promise, but to make a difference, schools need accurate data.7 It’s

important to have not only height & weight data but data regarding health-related

behavior, school health programs & policies to be able to make the right choices about

how to allocate resources to address childhood obesity based on what creates the biggest

impact. Data collection surveys can be a valuable asset to combatting childhood obesity

as these surveys produce an abundance of data on measures such as physical activity,

fruit and vegetable consumption, content of school vending machines, and school’s

physical education requirements. The data collected can be used to make meaningful

changes regarding physical activity & nutrition policies along with environmental

4

changes in an effort to help children and the schools make better choices or improve

certain policies that impact the children in an effort to reduce obesity.

Nutrition policies such as how to reward students for good behavior or good work

and class parties can potentially have an impact on obesity and is in important part of the

nutrition environment. Often, using food as a reward or as a punishment can undermine

healthy eating habits. Giving sweets, chips, soda as a reward can often lead to children

overeating foods that are high in sugar, fat and empty calories and may also interfere with

children’s natural ability to regulate their eating.8 It also encourages children to eat when

they are not hungry to reward themselves. Using food as a special treat or giving “off-

limit” foods to reward good behavior may send mixed messages and may even cause

children to start associating “unhealthy” foods with certain moods, such as reaching for a

sweet treat when feeling accomplished/happy. Cavities and weight gain through offering

rewards with little/no nutritional content but high in sugar and the enabling of emotional

eating at a young age can be detrimental as a child grows. Many times, best intentions

can be sabotaged when rewarding children with food; some children may become less

interested in eating their vegetables and behavior can turn from good to bad as deception

may be used to get a reward.

Importance of School Meals

5

The majority of children who attend school consume at least one meal at school.

The National School Lunch Program & The National School Breakfast Program is

another way in which children’s fruit and vegetable consumption can be impacted along

with lowering the rate of childhood obesity. The National School Lunch program (NSLP)

is a federally assisted program operating in over 100,000 public and non-profit private

schools and residential child care institutions.9 Any child at a participating school may

purchase a meal through the NSLP, however, children from families with incomes below

or at 130 percent of the poverty level are eligible for free or reduced meals. Those with

incomes between 130 and 185 percent of the poverty level are eligible for reduced-price

meals.11 Children from families with incomes over 185 percent of poverty pay a full

price, though their meals are still subsidized to some extent. Local school food authorities

set their own prices for full‐price (paid) meals, but must operate their meal services as

non‐profit programs. 10

School lunches must meet meal pattern and nutrition standards based on the latest

Dietary Guideline for Americans. The current meal pattern increases the availability of

fruits, vegetables and whole grains on the school menu. Following the implementation of

the new guidelines, fruit selection increased by 23%; average fruit consumption was

unchanged, but because more students selected fruit, overall more fruit was consumed

post-implementation. Consumption of vegetables per student increased by 16.2%. Entrée

selection per student remained unchanged. The meal pattern’s dietary specifications set

specific calorie limits to ensure age-appropriate meals for grades K-5, 6-8, and 9-12;

other meal enhancements include gradual reductions in the sodium content of the meals.10

6

While school lunches must meet federal meal requirements, decisions about what specific

foods to serve and how they are prepared are made by local school food authorities.

Similar to the National School Lunch program, the U.S. Department of Agriculture

reimburses schools for each breakfast they serve, with higher reimbursements for reduced

and free meals. Participating schools must offer free or reduced-price breakfast to eligible

students and meals must meet federal nutrition guidelines.11 According to the Economic

Research Service of the USDA children from low income households or with parents

leaving for work in the morning used the program the most. Children with access to

school breakfast were more likely to consume breakfast in the morning. Previous studies

have shown that children who eat breakfast have improved standardized test scores,

attendance and punctuality and decreased hyperactivity, depression & anxiety. School

breakfast has the same eligibility criteria as school lunch, but fewer than half of the lunch

participants eat breakfast. 12,13,14,15

Within recent years, subsidized school meals have generally tilted towards processed,

high in fat, sugar and sodium.13 In response the to these trends, congress passed the

Healthy, Hunger-Free Kids Act of 2010 which required the USDA to update its standards

to align with the Dietary Guidelines for America Presentation and marketing of these

foods is also important and can have significant benefits. Strong school breakfast and

lunch policies can make a positive difference in children’s diet and is important in the

effort to reduce childhood obesity.13,16

7

Importance of School Wellness Policies

The Local School Wellness Policy requirement was established by the Child

Nutrition and WIC Reauthorization Act of 2004 and further expounded upon by the

Healthy, Hunger-Free Kids Act of 2010. It requires each local education agency

participating in the School Meals Program to develop a local school wellness policy that

promotes the health of students and addresses the growing problem of childhood

obesity.17 The responsibility for developing a local school wellness policy is placed at the

local level so that the unique needs of each school under the jurisdiction of the LEA can

be addressed.17,18 The School Wellness Policies (SWP) is a written document that guides

local education agencies (LEA) or district’s offices to establish a school environment that

promotes students’ health and well-being and ability to learn. In 2014, USDA Food and

Nutrition Services (FNS) proposed regulations to create a framework and guidelines for

written polices established by LEA’s.17,18

SWP’s should include specific goals such as: nutrition promotion, nutrition

education, physical activity and other school-based activities that promote student

wellness. SWP’s should also include nutrition guidelines for all foods and beverages,

policies for other foods and beverages and policies for food and beverage marketing.

Annual progress reports, three-year assessments, updates to the wellness policy, public

updates, monitoring/oversight are the proposed rules for local school implementation

under the Hungry-Free Kids Act of 2010.17,18,19

8

SWP’s, particularly nutrition policies can impact how food is purchased and

consumed. Nutrition is important for student success; children who are healthy and well-

nourished are more likely to attend school and are more prepared and motivated to

learn.20,21 The school nutrition environment should encourage all students to make

healthy eating choices and be physically active throughout the school day.21,22 The school

environment is one where students can learn the knowledge and skills needed to make

healthy decisions; school leaders can create an environment that supports clear

expectations for healthy behavior by faculty, staff and students.20-24

Importance of Researching Rural vs Non-Rural

There are differences between rural and non-rural populations which include

sociodemographic factors such as education, income, access and availability of food and

physical activity resources.25,26 The majority of research regarding school meals and

school wellness policies and the nutrition environment has occurred in metropolitan

areas. Rural areas experience higher rates of obesity and overweight than the nation as a

whole, but many rural areas do not have the resources to address this health concern.4,24

Rural healthcare facilities are less likely to have dietitians or individuals with expertise in

weight management; schools can play a role in encouraging healthy weight and address

challenges children in rural schools may face.4,24

Conclusion

It is important to examine the relationship between school meals and weight

outcomes in rural counties in an effort to assess why children in rural neighborhoods

9

experience higher rates of overweight/obesity than their counterparts in rural

neighborhoods. School wellness policies have the potential to promote student’s

wellness, prevent and reduce childhood obesity and assure the school meal nutrition

guidelines meet the minimum federal school meal standards but they must be

implemented for them have an impact on the school nutrition environment. This

information would be valuable in creating a school nutrition environment that fosters

weigh management/ weight loss, particularly in rural counties and creating an

environment that fosters student wellness. Additional studies that incorporate school meal

participation in schools in rural studies are needed to close the gap on rural/urban

disparity in obesity-related research. Additional studies regarding school wellness policy

implementation and its association with the nutrition environment are needed to

understand whether wellness policies are effective in creating a healthy school

environment and understanding facilitators and barriers that can possibly have an effect

implementation.

Specific Aims

The following chapters enhance the limited body of literature surrounding school

meal participation, particularly school lunch in rural counties and school wellness

policies and the nutrition environment. Specifically, school lunch participation by county

ruralness was examined to determine if meal participation was associated with weight

outcomes. Additionally, the association between comprehensiveness and strength of

written nutrition wellness policies and the observed nutrition environment (physical,

situational and policy) in schools was examined. Finally, written nutrition wellness

10

policies and specific nutrition areas of interest observed within the school environment

were examined to determine if stronger and more comprehensive written school wellness

nutrition policy scores correlated to better scores for implementing a healthful nutrition

environment within the school.

11

References

1 Fryar CD CM, Ogden CL. Prevalence of overweight and obesity among children and

adolescents: United States, 1963-1965 through 2011-2012. Atlanta, GA. National Center

for Health Statistics. 2014.

2 Drewnowski A, Aggarwal A, Tang W, et al. Obesity, diet quality, physical activity, and

the built environment: the need for behavioral pathways. BMC Public Health. 2016 Nov

10;16(1):1153.

3 Hamburger WW. Emotional aspects of obesity. Med Clin North Am. 1951

Mar;35(2):483-99.

4 Davis AM, Bennett KJ, Befort C, Nollen N. Obesity and related health behaviors

among urban and rural children in the United States: data from the National Health And

Nutrition Examination Survey 2003-2004 and 2005-2006. J Pediatr Psychol. 2011

Jul;36(6):669-76.

5 Ohri-Vachaspati P TL, Chaloupka F. Alliance for a Healthier Generation's Competitive

Beverage and Food Guidelines: Do Elementary School Administrators Know About

Them and Do They Report Implementing Them? Journal Of School Health.

2012;82(10):469-77.

12

6 Ling J KK, Speck B, Kim S, Wu D. Preliminary Assessment of a School-Based

Healthy Lifestyle Intervention Among Rural Elementary School Children. Journal Of

School Health. 2014;84(4):247-55.

7 Millimet D TR, Husain M School Nutrition Programs and the Incidence of Childhood

Obesity. Journal Of Human Resources. 2010;45(3):640-54.

8 A F. How Food as a Reward Is Detrimental to Children's Health, Learning, and

Behavior. Journal Of School Health. 2015;85(9):648-58.

9 D S. Do School Lunches Contribute to Childhood Obesity? Journal Of Human

Resources. 2009;44(3):684-709.

10 Arteaga I HC. Participation in the National School Lunch Program and food security:

An analysis of transitions into kindergarten. Children & Youth Services Review.

2014;47:224-30.

11 Blondin S CS, Goldberg J, Griffin T, Economos C. Nutritional, Economic, and

Environmental Costs of Milk Waste in a Classroom School Breakfast Program. American

Journal Of Public Health. 2017;107(4):590 - 2.

12 JM M. “Breakfast and Learning: An Updated Review.”. Journal of Current Nutrition

and Food Science 2007;3(1):3-36.

13

13. Vaudrin N, Lloyd K, Yedidia M, Todd M, Ohri-Vachaspati P. Impact of the 2010 US

Healthy, Hunger-Free Kids Act on School Breakfast and Lunch Participation Rates

Between 2008 and 2015. American Journal Of Public Health. 2018;108(1):84-86

14. Peckham J KJ, Mroz T, Haley-ziylin V, Granberge E, Hawthorne N. . Socieconomic

and demographic determinants of the nutritional content of national school lunch

program entrée selections. American Journal Of Agricultural Economics. 2017;99(1):1-

17

15. Li J HN. Childhood Obesity and Schools: Evidence From the National Survey of

Children's Health. Journal Of School Health. 2010;80(2):96-103.

16. Guinn C BS, Royer J, Hitchcock D. Explaining the Positive Relationship Between

Fourth-Grade Children's Body Mass Index and Energy Intake at School-Provided Meals

(Breakfast and Lunch). Journal Of School Health. 2013;83(5):328-34.

17. United States Department of Agriculture Food and Nutrition Services. Local School

Wellness Policy. https://www.fns.usda.gov/tn/local-school-wellness-policy. November

2017. Accessed February 2nd 2018.

18. US Centers for Disease Control and Prevention, Bridging the Gap Research Program.

Local school wellness policies: where do they stand and what can you do? 2014.

14

Available at: http://www.cdc.gov/healthyyouth/npao/ pdf/LWP_Overview_Brief.pdf.

Accessed July 6, 2017.

19.Snelling A, Belson S, Katz N, et al. Measuring the Implementation of a School

Wellness Policy. Journal Of School Health. 2017;87(10):760-768 5.

20.Mâsse L, Frosh M, Mâsse L, et al. Development of a School Nutrition–Environment

State Policy Classification System (SNESPCS). American Journal Of Preventive

Medicine. 2007;33(4):S277-S291

21.Lucarelli J, Alaimo K, Liu H, et al. Little Association Between Wellness Policies and

School-Reported Nutrition Practices. Health Promotion Practice. 2015;16(2):193-201.

22.Cox M, Ennett S, Ringwalt C, Hanley S, Bowling J. Strength and Comprehensiveness

of School Wellness Policies in Southeastern US School Districts. Journal Of School

Health. 2016;86(9):631-637.

23. Turner L, Chaloupka F. Perceived reactions of elementary school students to changes

in school lunches after implementation of the united states department of agriculture’s

new meals standards: minimal backlash, but rural and socioeconomic disparities exist.

Childhood Obesity. 2014: 10(4);349-356.

24. Allen J MJ. Urban-rural differences in childhood and adolescent obesity in the united

states:a systematic review and analysis Childhood Obesity 2015;11(3):233-241.Health

TfAs. Childhood obesity in rural america 2017;

http://healthyamericans.org/pages/?id=248.

15

25. Lenardson JD HA, Hartley D. Rural and remote food environments and obesity Curr

Obes Rep. 2015;1:46-53.

16

Chapter 2

17

Title

The Association Between Free & Reduced School Lunch Participation Rates and Rural

Obesity

18

Abstract

Purpose: The aim was to examine school lunch participation by county ruralness and to

determine if meal participation was associated with weight outcomes.

Methods: De-identified data from a Midwest state were obtained in electronic format

from the State Department of Health. Height, weight, sex and age were used to calculate

body mass index z-scores, which were then categorized into overweight/obese vs not

overweight/obese. Free and reduced-price school lunch program participation from 2013-

2014 by county was obtained from the Annie. E Casey foundation and further classified

by Rural-Urban Continuum Codes (RUC) codes. ANOVA and multiple

regression were used to compare differences in mean BMI categories among RUC codes.

Results: Overall, rural counties had significantly higher rates of participation in the free

and reduced-price school lunch program (group 3 = 53%) compared to non-metro

neighborhoods (group 2 = 36%) and metro neighborhoods (non-metro = 34%), all (p <

0.001). Rural counties had significantly greater odds of overweight and obesity compared

to their non-metro and metro counterparts (p <0.001); free and reduced school lunch

participation was a significant predictor of overweight/obesity (p<0.001). When both

free and reduced lunch participation and RUC code group were included together in the

model, both remained significant (p<0.001)

Conclusion: Higher free and reduced participation and overweight/obesity in rural

counties may be attributable to higher rates of poverty and food insecurity in rural areas

along with the challenge rural children face in locating affordable food due to food

19

desserts. School lunch, should be a part of the systematic

approach in combatting childhood obesity, particularly in rural neighborhoods.

20

Introduction

Most children who attend public and non-profit private schools (K-5, 6-8, and 9-

12) consume at least one meal at school.1 The NSLP is a federally-assisted program

operating in over 100,000 public and non-profit private schools and residential child care

institutions.1 Any child at a participating school may purchase a meal through the NSLP,

however, children from families with incomes ≤130% of the poverty level are eligible for

free meals. Families with incomes between 130 and 185% of the poverty level are

eligible for reduced-price meals.1 Approximately 68% of all lunches served are free or

reduced-price.2 Local school food authorities set their own prices for full‐price (paid)

meals, but must operate their meal services as non‐profit programs; participating school

districts and independent schools receive cash subsidies and United States Department of

Agriculture (USDA) foods for each reimbursable meal they serve.1 School lunches must

meet meal pattern and nutrition standards based on the latest Dietary Guideline for

Americans.

Although not implemented until 2012, in 2010, Congress passed the Healthy,

Hunger-Free Kids Act (HHFKA) which required the USDA to align its standards for

school meals to the Dietary Guidelines for Americans in response to subsidized school

meals shifting towards higher fat, sugar and sodium content.3 In 2007-2010, 67% of

children did not consume sufficient fruit to meet the daily recommendations and 93% of

children did not consume enough vegetables. In 2013, the Center for Disease Control

(CDC) reported that the amount of whole fruit children aged 2-18 consumed each day

increased by 67% from 2003-2010 but consumption is still low. Although there has been

improvement in fruit consumption, recommended intake for fruit and vegetables are not

21

being met. The current meal pattern increases the availability of fruits, vegetables and

whole grains on the school menu.3 Following the implementation of the new guidelines

which encourages the use of a salad bar that offers fruits and vegetables in alignment

with the dietary guidelines , fruit selection increased by 23%, but average fruit

consumption was unchanged and consumption of vegetables per student increased by

16.2%.1,2 Rural schools however fared worse than urban and suburban school’s with

regards to fruit and vegetable consumption in the NSLP, and also with perceived student

complaints about the new meals and purchasing of meals and consumption of meals.4

Schools in small towns and rural neighborhoods also had fewer policies to support

healthy school meals and environments particularly with regards to fruit and vegetable

availability than do urban and suburban schools.5

There has been an increase in the number of students qualifying for free and

reduced-price lunch.8,9 With regards to percent of households participating in the

National School Lunch program the Casey Institute found that 22.4% of rural households

participated in this program compared to 12% participation in suburban neighborhoods

and 22.7% participation in the central city.10 Children living in rural areas experience

higher rates of obesity and overweight than their peers residing in metropolitan areas.6

16.5% of rural children are obese compared to 14.4% of urban children, and 35.5% of

children in large rural neighborhoods and 38.2 % of children in small rural

neighborhoods aged 10-17 are overweight or obese compared to 30.1% of urban

children.7

22

In general, little is known about school lunch participation in rural counties and

even less regarding factors related to school lunch participation and weight outcomes in

rural counties.11 School lunch makes up one-third to on-half of a child’s nutritional intake

for an entire day and is essential for helping children succeed in school and develop

successfully and healthfully.1 It has been noted that under the old school guidelines

students who eat school lunches are more likely to be overweight than their classmates

with bag lunches; students just eligible for free and reduced-price lunch enter

kindergarten with the same BMI as those who were not eligible but at the end of first

grade they are significantly heavier.11,12 Under the old guidelines that students receiving

free or reduced-price lunches are more likely to select entrees with more fat or less

protein than students who purchase full-price lunches.13 However, there have been no

research studies published regarding school meal participation in rural neighborhoods,

particularly school lunch and weight outcomes.

The school food environment can assist with shaping children food preferences,

food acceptance patterns and food choices. School lunch can provide nutritious food and

assist children, particularly in rural neighborhoods, with meeting their daily nutritional

needs.3,9,14 In this study, a mid-west’s state 2013-2014 school lunch participation rates by

county were matched to RUC codes and BMI percentiles to analyze participation rates in

metro, non-metro and rural counties and also overweigh/obesity. The aim was to

examine school lunch participation by county ruralness and to determine if meal

participation was associated with weight outcomes.

23

Methods

2013-2014 de-identified data from a Midwest state were obtained in electronic

format from the State Department of Health. Height and weight were used to calculate

body mass index (BMI) and further classify subjects into BMI categories. (Table 2.1).

The county variable was used to assign a Rural Urban Continuum (RUC) code to each

individual. RUC codes (rural-urban continuum codes) form a classification scheme that

distinguishes metropolitan (metro) counties by their population size of their metro area

and nonmetropolitan (nonmetro) counties by degree of urbanization and adjacency to a

metro area or areas.15 For this study, RUC codes 8 and 9 were considered rural (RUC

code group 3), Counties within RUC codes 5, 6 and 7 were considered non-metro (RUC

code group 2) and counties within RUC code 3 were considered metro (RUC code group

1) (Table 2.2). RUC code 4 was not represented in this study as no county fit the

definition of this code. Grouping by RUC codes in this study allowed for county data to

be broken into finer residential groups beyond metro and non-metro.15

Free and reduced-price school lunch program participation data by county from

2013-2014 were obtained from the Annie. E Casey foundation.16 Each county’s school

lunch percent participation was attached to their respective RUC codes. Counties with

missing percent participation rates in the lunch program during 2013-2014 were

eliminated (one county); counties with no RUC code assigned were also eliminated (one

county). Ultimately, 46,356 students were included in analyses.

Statistical Analyses

24

Data were analyzed in Stata Statistical Software: Release 15.17 One-way

ANOVA with a Bonferroni post-hoc test was used to determine if free- and reduced-price

lunch participation differed across RUC code groups. Chi-square analyses were used to

examine differences in proportion of BMI categories (overweight/obese vs not) across

RUC code groups. Logistic regression was used to examine the relationship between

free- and reduced-price lunch participation, RUC code group and overweight/obesity

(outcome) whilst controlling for race, age and gender.

Results

Rural counties (RUC code group 3) had significantly higher rates of participation

in the free and reduced lunch program (53%) compared to non-metro counties (RUC

code group 2, 36%) and metro counties (RUC code group 1, 34%), (p < 0.001), (Figure

2,1).

Group 2 had higher odds of obesity compared to group 1 (p<0.001) and group 3

had higher odds of obesity compared to group 1 (p<0.001)

When controlling for race, age and gender, RUC code group (i.e. rurality) was

significantly associated with child overweight/obesity (p <0.001). Likewise, free and

reduced lunch participation was significantly associated with child overweight/obesity

(p<0.001). When both free and reduced lunch participation and RUC code group were

included together in the model, both remained significant (p<0.001).(Table 2.1)

Discussion

25

There has been an increase in the number of students qualifying for free and

reduced-price lunch.8,9 Within the school meals program, rural schools however fared

worse than urban and suburban schools with regards to fruit and vegetable consumption

in the NSLP. At the same time, children living in rural areas experience higher rates of

overweight and obesity than their peers residing in metropolitan areas. In general, little is

known about school lunch participation in rural counties and even less regarding factors

related to school lunch participation and weight outcomes in rural counties. In this study,

we assessed whether rural counties had higher rates of participation in the free or reduced

lunch program compared to their metro and non-metro counterparts and if free- and

reduced-price school lunch participation was associated with overweight/obesity. Free

and reduced lunch participation and overweight and obesity were higher in rural counties.

Free and reduced lunch participation and RUC code groups were both significant

contributors to child overweight/obesity.

Although previous work has not specifically examined free and reduced lunch

participation in rural areas, rural areas typically have a lower population density and

lower student enrollment rates compared to their metro and non-metro counterparts

which could potentially play a role in higher percent participation in the free and reduced

lunch program seen in rural counties in this study. Of the 46,356 students in this study,

4% (2067 students) were classified as rural, compared to 53% (24387 students) metro, 36

% (16,834 students) non-metro. Schools where there are few nonsubsidized students

participating in the NSLP meal program, participation itself may be an easily

recognizable marker of income status and may deter those who qualify or may need free

and reduced lunch from utilizing the school lunch program keeping the percent

26

participation low, which could potentially be the cause of lower free and reduced lunch

participation percent in metro neighborhoods.18 Higher free and reduced lunch

participation in rural counties may also be attributable to higher rates of poverty and food

insecurity in rural areas along with the challenge of locating affordable food due to food

desserts.9 Food deserts typically exist in rural areas for economic reasons such as low -

income populations and insufficient population base to support a grocery store that stocks

a variety of healthy and affordable foods, which may also be the reason why rural

counties in this study had higher overweight and obesity.7,19,20 Other factors that may

play a role in free and reduced-price lunch participation include school level and

neighborhood circumstantial factors.21 Lower levels of stigma were found to be

associated with increased likelihood of individual-level NSLP participation, whilst

controlling for the local area poverty rate.21 Enrollment, outreach and practices that

identify low-income students who have received subsidized meals under the NSLP, also

have the potential to inhibit participation by stigmatizing program participants in some

counties, although it is officially prohibited.22

School lunch has the potential to impact childhood rural obesity; prioritizing fruits

and vegetables, increasing funding for the farm to school grant program, smart snacks,

and nutrition education can all have a positive impact on the school food environment

and can help to shape lifelong healthy eating behaviors. 21,22 Schools have the potential to

assist students with making choices that are healthy via even subtle methods such

as marketing fruits, vegetables and water via posters whether in the cafeteria or on

vending machines that stock preferably foods and beverages that meet smart snack

regulations, textbooks or even school scoreboards. 23,24,25,26

27

This study is not without limitations. RUC code 4 was not represented in this

study as no county fit the definition of this code. Majority of schools visited in this study

were located in rural counties. Having equal parts rural, metro and non-metro schools and

being able to observe the scores would make this study more generalizable. These rural

schools also had small school population sizes which may not be the case in more

populated states with multiple inner-city schools. Despite these limitations this study is

the first to assess school lunch participation by county ruralness and to determine if meal

participation was associated with weight outcomes.

Conclusion

Many factors play a role in free and reduced-price lunch participation such as

school level and neighborhood circumstantial factors. Higher free and reduced

participation and overweight/obesity in rural counties may be attributable to higher rates

of poverty and food insecurity in rural areas along with the challenge rural children face

in locating affordable food due to food desserts. Rural children face unique challenges in

locating affordable and healthy food; school lunch, should be a part of the systematic

approach in combatting childhood obesity, particularly in rural neighborhoods.

28

References

1. United States Department of Agriculture. National School Lunch Program 2017;

https://www.fns.usda.gov/nslp/national-school-lunch-program-nslp. Accessed 29

Sept., 2017.

2. Food Policy Research Center. School Meal Regulations and Child Nutrition:

Environmental Approaches to Improve Intake.2014;

https://www.foodpolicy.umn.edu/policy-summaries-and-analyses/school-meal-

regulations-and-child-nutrition-environmental-approaches

3. Mansfield J SD. Effect of school wellness policies and the healthy, hunger-free

kids act on food -consumption behaviors of students, 2006-2016: a systematic

review. . Nutrition Reviews. 2017;75(7):533-552.

4. Askelson N, Golembiewski E, Ghattas A, Williams S, Delger P, Scheidel C.

Exploring the Parents' Attitudes and Perceptions About School Breakfast to

Understand Why Participation Is Low in a Rural Midwest State. Journal Of

Nutrition Education & Behavior. 2017;49(2):107-116.e1.

5. Turner L, Chaloupka F. Perceived reactions of elementary school students to

changes in school lunches after implementation of the united states department of

agriculture’s new meals standards: minimal backlash, but rural and

socioeconomic disparities exist. Childhood Obesity. 2014: 10(4);349-356.

6. Allen J MJ. Urban-rural differences in childhood and adolescent obesity in the

united states:a systematic review and analysis Childhood Obesity 2015;11(3):233-

241.

29

Health TfAs. Childhood obesity in rural america 2017;

http://healthyamericans.org/pages/?id=248.

7. Millimet D TR, Husain M. . School nutrition programs and the incidence of

childhood obesity. Journal of Human Resources. 2010;45(3):640-654.

8. Lenardson JD HA, Hartley D. . Rural and remote food environments and obesity

Curr Obes Rep. 2015;1:46-53.

9. Carsey Institute. Federal Child Nutrition Programs are Important to Rural

Households.

2010.https://scholars.unh.edu/cgi/viewcontent.cgi?referer=https://www.google.co

m/&httpsredir=1&article=1093&context=carsey

10. Schanzenbach D. Do School Lunches Contribute to Childhood Obesity?. Journal

Of Human Resources. 2009;44(3):684-709.

11. Mirtcheva D, Powell L. National School Lunch Program Participation and Child

Body Weight. Eastern Economic Journal. 2013;39(3):328-345

12. Peckham J KJ, Mroz T, Haley-zitlin V, Granberg E, Hawthorne N. .

Socioeconomic and demographic determinants of the nutritional content of

national school lunch program entree selections. American Journal of

Agricultural Economics. 2017;99(1):1-17.

13. Turner L, Chaloupka F. Perceived reactions of elementary school students to

changes in school lunches after implementation of the united states department of

30

agriculture’s new meals standards: minimal backlash, but rural and

socioeconomic disparities exist. Childhood Obesity. 2014: 10(4);349-356.

14. Canto A BL, Deller S. Rural poverty, food access and public health outcomes.

Agricultural & Applied Economics Association. 2014;29(2).

15 NIH Surveillance E, and End Results Program Rurual- Urban Continuum Codes

2014; https://seer.cancer.gov/seerstat/variables/countyattribs/ruralurban.html.

Accessed 3 Oct, 2017.

16. Kids Count Center. A project of the Annie. E Casey Foundation.

http://datacenter.kidscount.org/data/tables/6185-free-or-reduced-price-school-

lunch-participation#detailed/2/any/false/1600,1536,1460,1249,1120/any/12903.

Accessed July 2017.

17. StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX:

StataCorp LLC

18. Bhatia R, Jones P, Reicker Z. Competetive foods, discrimination and participation

in the national school lunch program. Am J Public Health 2011;101(8):1380-1386

19. Huang J BE. Low-income children's participation in the national school lunch

program and household food insufficiency. Social Science & Medicine.

2016;150:8-14.

20. JR. S. Measuring potential access to food stores and food-service places in rural

areas in the U.S. AM J Prev Med. 2009;4:151-155.

31

21. Mirtcheva D, Powell L. Participation in the National School Lunch Program:

Importance of School-Level and Neighborhood Contextual Factors. Journal Of

School Health. 2009;79(10):485-494.

22. Yang B, Welk G. School and County Correlates Associated with Youth Body

Mass Index. Medicine & Science In Sports & Exercise. 2017;49(9):1842-1850

23. Daly C FS, Wadsworth D. Physical activity, sedentary behavior, fruit and

vegetable consumption and access: what influences obesity in rural children?

Journal Of Community Health. 2017;42(5):968-973.

24. A R. Nutrition education and promotion in primary schools. Aust J Hol Nurs.

2001;8(2):39-44.

25. Eliassen E WM, Mary W. Selecting appropriate elementary school nutrition

education resources American Journal of Health Studies 2007;22(4):224-227.

26. Peralta L DD, Cotton W. . Teaching healthy eating to elementary school students:

a scoping review of nutrition education resources. . Journal of School Health

2016;86(5):334-345.

32

Table 2.1- BMI Definitions 27

BMI categories Definition

Category 1 Underweight, less than the 5th percentile

Category 2 Healthy weight, 5th percentile up to the

85th percentile

Category 3 Overweight, 85th to less than the 95th

percentile

Category 4 Obese, equal to or greater than the 95th

percentile

33

Table 2.2. Rural-Urban Continuum Codes Definitions15

Rural-Urban Continuum Codes

(RUC codes)

Code Definitions Number of

counites in

each RUC

code

Metro (RUC code group 1)

RUC code 3 Counties in metro areas of fewer than

250,000 population

N= 7

Non-Metro (RUC code group 2)

RUC code 5 Urban population of 20,000 or more, not

adjacent to a metro area

N=3

RUC code 6 Urban population of 2,500 to 19,999,

adjacent to a metro area

N=5

RUC code 7 Urban population of 2,500 to 19,999, not

adjacent to a metro area

N=9

Rural (RUC code group 3)

RUC code 8 Completely rural or less than 2,500 urban

population, adjacent to a metro area

N=8

RUC code 9 Completely rural or less than 2,500 urban

population, not adjacent to a metro area

N=37

34

Figure 2.1: Summary of Free & Reduced Lunch Participation by RUC code group

*Similar superscripts indicate a significant different between groups at p<.001

34%ab

36%ac

53%bc

0%

10%

20%

30%

40%

50%

60%

3 (metro) 5,6,7 (non-metro) 8 & 9 (rural)

F &

R L

u n

ch P

e rc

e n

t P

a rt

ic ip

a ti

o n

RUCcodes

Free & Reduced Lunch Participation

35

Table 2.3: Estimated associations between RUC code groups and overweight/obesity

while controlling for race, age and sex.

Odds Ratio Std. Error P>|z| 95% CI

Free- and Reduced

Lunch Participation

1.57 .18 0.000 (1.25, 1.97)

RUC code group (1)

2 1.14 .03 0.000 (1.10, 1.20)

3 1.29 .05 0.000 (1.19, 1.39)

36

Chapter 3

37

Title: The Association between Strength and Comprehensiveness of Written School

Nutrition Wellness Policies and the Observed Nutrition Environment

38

Abstract

Purpose: To determine if written school wellness policies exist and examine whether

there is an association between Strength and Comprehensiveness of written school

nutrition wellness policies and the observed physical, situational and policy nutrition

environment within elementary schools.

Methods: Twenty-six elementary schools were visited during the 2017-2018 academic

year. At each school, the School Physical Activity and Nutrition Environment Tool

(SPAN-ET) was used to assess the physical, situational and policy environment within

the school. Two trained researchers scored independently; discrepancies in scores were

discussed and the best possible answer chosen. School Wellness Policies (SWP) were

scored by two trained researchers, using the WellSAT 2.0 tool prior to the onsite school

visit.

Results: Every school assessed had a wellness policy. There were no statistically

significant associations between the strength and comprehensiveness of written nutrition

wellness policies and the observed physical, situational or policy nutrition environment

within schools.

Conclusion: There is a disconnect between written wellness policies and the

healthfulness of the school nutrition environment. Care must be taken to ensure that

written wellness policies align with the observed nutrition environment which is

important for ensuring strong and comprehensive policies in place that support evidence-

based healthy nutrition environment.

39

Introduction

According to the Center for Public Education, children spend approximately 175

to 180 days at school and/or between 900 and 1,000 hours of instructional time per year

depending on the grade level.1 Adequate nutrition and physical activity are important for

children’s development and wellbeing and the school environment is a good place for

students to learn and practice healthy habits.2 The school environment can make it either

easier or more difficult for children to choose nutritious food and acquire physical

activity.2,3 Children can learn about nutrition through the curriculum, but school provides

multiple opportunities to practice and reinforce healthy eating behaviors and acquire

physical activity.4

An organization without policy is one void of control; formal documented

policies allow for guidance on how to make decisions and an absence of policy leads to

inconsistency with decision making.5 School wellness policies are important as they

assist schools with establishing rules and procedures and create a standard of quality as

well as accountability and expectations, but they must be implemented for them to be

effective.5,6 Healthy policies have played a key role in school settings for quite a while;

school wellness policies generally include a number of provisions designed to address

childhood obesity and often include nutrition standards, nutrition education, physical

education and health promotion programs.5,6 There are many additional benefits to

having a well written school wellness policy which includes: efficient staff decisions,

reduction in bias of decision-making and instructions on how to execute a task. School

wellness policies also guide the food and beverages offered and sold at schools along

with the amount of physical activity children should receive daily.5,6

40

During the 2006-2007 school year, all districts were required to establish a local

school wellness policy. In 2010, Congress passed the Healthy, Hunger-Free Kids Act of

2010 and added new provisions for local school wellness policies related to

implementation, evaluation and publicly reporting on progress of local school wellness

policies.6 Local education agencies were required to begin developing a revised school

wellness policy during the 2016-2017 school year, with full compliance with all the

requirements being adhered to by June of 2017.6 Local education agencies are supposed

to evaluate their wellness policy once every three years which should be made available

to the public.7 In addition to district wellness policies, some individual schools have

developed their own guidelines around wellness.3 Studies have demonstrated that school

wellness policies exist but the language of policies is vague with a wide variation in

strength of the language used to address mandated components.8,9,10,11 Whilst

comprehensiveness and strength of SWP’s have been increased in the years following the

2006-2007 mandate by Congress, they remain highly inconsistent and weak. Prior to the

federal mandate, fewer than half of all U.S school districts adopted policies to promote

healthy eating and physical activity but after the mandate nearly all had adopted a policy

of some sort, however, relatively little has been written about policy implementation and

evaluation.12

The school nutrition environment can help shape lifelong healthy eating behaviors

by providing students with nutritious appealing foods and beverages, consistent and

accurate messages about good nutrition. Schools can implement policies and practices to

create a nutrition environment that supports students in making healthy choices. School

wellness policies are an important tool for parents, local educational agencies (LEAs) and

41

school districts in promoting student wellness, preventing and reducing childhood

obesity, and providing assurance that school meal nutrition guidelines are met, but they

must be implemented to be effective.5,6 Therefore, the aim of this proposed study is to

determine if written school wellness policies exist and examine whether there is an

association between Strength and Comprehensiveness of School Nutrition Wellness

Policies and the Observed Physical, Situational and Policy Nutrition Environment.

Methods

School Recruitment

A list of school districts within a Midwest state was obtained from the department

of education website. Every elementary school principal was contacted by the

Department of Education via a recruitment e-mail. If interested, schools were encouraged

to complete a recruitment questionnaire. As part of this electronic questionnaire,

principals attached their current school wellness policy (SWP) and staff contact

information. Twenty-six schools were visited during the fall of 2017 and spring of 2018.

Assessments

The School Physical Activity and Nutrition Environment Tool (SPAN-ET) was

used to quantify the school’s physical, situational and policy environment as it relates to

nutrition and physical activity.14 Completing the SPAN-ET involved several methods of

data collection including face-to-face and/or telephone interviews with key informants,

on-site direct observations, and content review of various forms of documentation,

including written and/or published district and school wellness policies, nutrition and

42

school meal policies and guidelines, school meals menus, playground rules and

regulations. Two trained data collectors conducted SPAN-ET independently and

simultaneously.

Upon completion of SPAN-ET, scores were calculated separately by 2

individuals, discrepancies were discussed, and the best possible answer chosen. Scores

were grouped into poor (<25%), fair (26% <50%), good (51% <75%) and best (76%

<100%) based on guidance from the scoring document. A report was generated targeting

areas and strategies for improving the nutrition and/or physical activity environments to

promote healthy habits and enhance student learning outcomes.

For this study, only nutrition environment sections of the SPAN-ET were

examined. The physical nutrition environment included cafeteria/meal service area and

garden features scores, while the situational nutrition environment included school meals,

food and beverage habits, food and beverage practices, drinking water, cafeteria

atmosphere and before/after school extracurricular programs and nutrition and wellness

policy. Additionally, nutrition and wellness committee and health and nutrition education

scores from the policy environment were used. The physical, situational and policy

environment sections were also summed for a total nutrition environment score.

To quantify the strength and comprehensiveness of written SWP, each was

separately evaluated by two researchers, using the WellSAT 2.0 tool prior to the onsite

visit.13 Sections from the WellSAT used to examine written nutrition-focused policies

included nutrition education (NE) (section 1), standards for USDA child nutrition

programs, and school meals (SM) (section 2) and nutrition standards for competitive and

other foods and beverages (NS) (section 3). Written wellness policy strength refers to

43

describes how strongly the content is stated while comprehensiveness scores reflect the

extent to which the recommended content areas are covered in the policy.

Statistical Analysis

Data were analyzed using Stata Statistical Software: Release 15.15 Schools with any

missing criteria were eliminated (one school), results from 25 schools were used in this

analysis. Pairwise correlations were used to examine associations between WellSAT and

SPAN-ET sections. One-way ANOVA was used to determine if mean scores for

WellSAT sections differed across categorical scores of SPAN-ET sections. When

significant differences were found, post-hoc examinations using Bonferroni tests were

used to determine which groups differed from each other.

Results

Every school attended had a wellness policy that minimally met district standards.

Mean WellSAT nutrition section strength and comprehensiveness scores across

categorical scoring of the physical, situational and policy environments are presented in

Tables 3.1, 3.2 and 3.3, respectively. Overall mean WellSAT strength and

comprehensiveness scores across categorical scoring of overall nutrition environment is

presented in Table 3.4. There were no statistically significant associations between

nutrition sections or overall scores within the written SWPs and the observed nutrition

environment.

44

Discussion

Whilst comprehensiveness and strength of SWP’s have been increased in the

years following the 2006-2007 mandate by Congress, they remain highly inconsistent and

weak, however relatively little has been written about school wellness policy

implementation and evaluation. In this study we assessed whether stronger and more

comprehensive written school wellness policy nutrition section scores were correlated

with higher nutrition physical, situational and policy environment section scores, and

ultimately, an observed healthier school nutrition environment.

Overall, no associations were seen between the written wellness policy sections

and the physical, situational and policy nutrition environment sections examined. There

was also no association between total SWP scores and the total nutrition environment. In

the physical nutrition environment, no school scored within poor category, but quite a

few schools scored within the best category (80% mean score). The current USDA school

meals guidelines may potentially have a role to play with the schools having good score

in the physical nutrition environment. School meals are required to meet specific

nutrition standards to operate the school meals program which must align with the latest

nutrition guidelines for Americans.3

The best situational environment had the lowest strength score for SWP nutrition

standard for competitive foods. Assessment of the situational environment within schools

incorporated school stores, school carts and vending machine content. High scores in this

area indicates that schools had no school stores, carts or competitive foods with vending

machine content meeting smart snack regulation; many schools had no written policies

specifically addressing nutrition competitive foods in the situational environment. Many

45

of the schools had no before/after school summer extracurricular programs and hence

nothing in the wellness policy to address it. Food and beverage practices, specifically

vending machines, classroom parties/treats and food rewards, in this section could also be

improved in the physical and situational environment. Overall strength of the wellness

policies was also quite low across the situational environment which indicates minimal

policies regarding the situational environment.

In the policy environment, no school scored within the best category as written

wellness policies generally contained ambiguous policies and addressed few practices

which lead to low comprehensiveness and strength scores. In the policy environment, the

nutrition wellness committee, particularly having a committee with broad representation

such as students, teachers, parents, various school administrators and a well-defined

implementation and evaluation plan of the policies along with a well written and concise

policy could also be improved. Some schools had not reviewed their policies within the

last 3 years and had no formal wellness committee or agenda for the committee. Written

wellness policies in this study often did not reflect school-reported nutrition policies and

practices but all schools visited had a wellness policy that minimally met district

standards. It was noted that accountability was a big factor as to why wellness policies

were not adhered to and also a key barrier to policy implementation in these studies as

key informant’s data showed ubiquitous shortfall with who was responsible for executing

and reinforcing school health and wellness policies even though it had already been

adopted by the district.7 ,9,17,18

46

Funding and time constraints represent important obstacles to the successful

adoption, implementation, and evaluation of school wellness policies that will require

systemic change in order to address.19 Gaining the support of key stakeholders and

having adequate tools to support those responsible for implementation and evaluation

might be overcome through programmatic strategies and social marketing

initiatives.20,21,22 Evaluating the development and implementation of a policy is critical in

understanding its effectiveness and provides important information about the barriers to

and facilitators of implementation and its intended effect on the observed nutrition

environment.

This study has certain limitations that should be noted. Majority of schools visited

in this study were located in rural counties. Having equal parts rural, metro and non-

metro schools and being able to observe the scores would make this study more

generalizable. These rural schools also had small school population sizes which may not

be the case in more populated states with multiple inner-city schools. Schools were only

observed for one full school day, observing for multiple days would allow for assessing

whether policies were followed consistently. Despite these limitations, there are very few

studies that address comprehensiveness and strength of SWP’s and its association with

the nutrition environment and this study serves to fill that gap.

It is essential to evaluate, and review implemented policies regularly as a policy

review seeks and identifies relevant policies and practices that are shaping the current

health status of the school community. 20,21 Policies may be implemented through various

actions, instruments, protocols or procedures but once implemented they should be

47

analyzed/ evaluated in an effort to observe its consequences whether they are intentional

or unintentional.20 Only then can appropriate moderations to implemented policies be

made, if necessary, to formulate alternatives or policy modifications that work more

efficiently for that particular school environment. Improving policies and policy

implementation can increase operational efficiency and impact learning.20,21,22

Conclusions

Every school visited had a wellness policy that minimally met district standards.

There is a disconnect between written wellness policies and the healthfulness of the

school nutrition environment. Care must be taken to ensure that written wellness policies

align with the observed nutrition environment so that there are strong and comprehensive

policies in place that support evidence-based healthy nutrition environment. Evaluating

the development and implementation of the policies is important for understanding its

effectiveness and provides important information about the barriers to and facilitators of

implementation.

48

References

1.The Center for Public Education. Time in school: How does the US compare?

http://www.centerforpubliceducation.org/research/time-school-how-does-us-compare.

December 2011. Accessed February 3rd 2018.

2.Mâsse L, Frosh M, Mâsse L, et al. Development of a School Nutrition–Environment

State Policy Classification System (SNESPCS). American Journal Of Preventive

Medicine. 2007;33(4):S277-S291

3.United States Department of Agriculture Food and Nutrition Services. Local School

Wellness Policy. https://www.fns.usda.gov/tn/local-school-wellness-policy. November

2017. Accessed February 2nd 2018.

4.McKenna M. Nutrition policies for schools. Nutrition Bulletin. 2000;25(3):201-207.

5.Shearer J, Abelson J, Kouyaté B, Lavis J, Walt G. Why do policies change?

Institutions, interests, ideas and networks in three cases of policy reform. Health Policy &

Planning. 2016;31(9):1200-1211

6. US Centers for Disease Control and Prevention, Bridging the Gap Research Program.

Local school wellness policies: where do they stand and what can you do? 2014.

Available at: http://www.cdc.gov/healthyyouth/npao/ pdf/LWP_Overview_Brief.pdf.

Accessed July 6, 2017.

7.Snelling A, Belson S, Katz N, et al. Measuring the Implementation of a School

Wellness Policy. Journal Of School Health. 2017;87(10):760-768 5.

49

8.Hoxie-Setterstrom G, Hoglund B. School wellness policies: opportunities for change. J

Sch Nurs. 2011;27(5):330-339.

9.Cox M, Ennett S, Ringwalt C, Hanley S, Bowling J. Strength and Comprehensiveness

of School Wellness Policies in Southeastern US School Districts. Journal Of School

Health. 2016;86(9):631-637

10.Lucarelli J, Alaimo K, Liu H, et al. Little Association Between Wellness Policies and

School-Reported Nutrition Practices. Health Promotion Practice. 2015;16(2):193-201.

11.Meendering J, Kranz E, Shafrath T, McCormack LA. Bigger ≠ Better: The

comprehensiveness and strength of school wellness policies varies by school district size.

J Sch Health. 2016;86:653-659.

12.Belansky ES, Cutforth N, Delong E, et al. Early effects of the federally mandated

local wellness policy on school nutrition environments appear modest in Colorado’s

rural, low-income elementary schools. J Am Diet Assoc. 2010;110(11): 1712-1717. 12.

13.UCONN Rudd Center Food For Policy & Obesity. Wellness School Assessment

Tool.2018 http://uconnruddcenter.org/

14.Oregon State University. School Physical Activity & Nutrition Environment

Tool.2018 http://extension.oregonstate.edu/growhkc/tools/span-et

15.StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX:

StataCorp LLC

50

16. Guthrie J, Newman C, Ralston K et al. Nutrition Standards for Competitive Foods in

Schools Implications for Foodservice Revenues. Economic Research Service. 2013:114

17.Sánchez V, Hale R, Halasan C, et al. School Wellness Policy Implementation: Insights

and Recommendations From Two Rural School Districts. Health Promotion Practice.

2014;15(3):340-348.

18.Agron P, Berends V, Ellis K, Gonzalez M. School Wellness Policies: Perceptions,

Barriers, and Needs Among School Leaders and Wellness Advocates. Journal Of School

Health. 2010;80(11):527-535

19.Harriger D, Lu W, McKyer E, Pruitt B, Goodson P. Assessment of School Wellness

Policies Implementation by Benchmarking Against Diffusion of Innovation

Framework. Journal Of School Health. 2014;84(4):275-283.

20.Cox M, Ennett S, Ringwalt C, Hanley S, Bowling J. Strength and Comprehensiveness

of School Wellness Policies in Southeastern US School Districts. Journal Of School

Health. 2016;86(9):631-637.

21.Juby C, Meyer E. Child nutrition policies and recommendations. Journal Of Social

Work. 2011;11(4):375-386.

22.Lucarelli J, Alaimo K, Liu H, et al. Little Association Between Wellness Policies and

School-Reported Nutrition Practices. Health Promotion Practice.2015;16(2):193-201

51

Table 3.1. Mean (±SE) WellSAT nutrition section scores across SPAN-ET nutrition

physical environment section scores.

Poor Fair Good Best p-value

NS Strength - 0 20.7±5.5 82 .61

NS Comp - 18 40.6±7.5 91 .55

SM Strength - 14 26.2±5.0 36 .96

SM Comp - 21 40±5.4 43 .98

NE Strength - 0 37.1±7.5 43 .28

NE Comp - 57 81±5.9 100 .22

Overall Strength - 2 24.4 48 .55

Overall

Comprehensiveness

- 23 45.9±5.1 80 .46

p-value determined using one-way ANOVA (Bonferroni post-hoc); within WellSAT

variables, similar superscripts indicate significant different (p≤0.05)

NS – nutrition standards for competitive foods and beverages

SM- school meals

NE – nutrition education

52

Table 3.2. Mean WellSAT nutrition section scores across SPAN-ET nutrition situational

environment section scores.

Poor Fair Good Best p-value

NS Strength - - 31.2±7.6 13.9±3.4 .07

NS Comp - - 48.8±9.0 33.9±6.3 .22

SM Strength - - 23.6±5.7 30.1±4.7 .39

SM Comp - - 37.9±6.4 44.8±5.8 .44

NE Strength 34.3±9.8 38.5±8.3 .75

NE Comp 75.8±8.3 80.2±8.3 .71

Overall Strength 18.9±4.1 31±6.0 .13

Overall

Comprehensiveness

39.8±4.3 52.4±6.8 .16

p-value determined using one-way ANOVA; within WellSAT variables, similar

superscripts indicate significant different (p≤0.05)

NS – nutrition standards for competitive foods and beverages

SM- school meals

NE – nutrition education

53

Table 3.3. Mean WellSAT nutrition section scores across SPAN-ET nutrition policy

environment section scores.

Poor Fair Good Best p-value

NS Strength 36.0 27.8±8.0 16.4±3.7 - .48

NS Comp 45.0 45.6±9.4 37.2±6.9 - .80

SM Strength 29 28.4±5.5 25.4±5.4 - .93

SM Comp 43 43.6±6.4 39.6±6.0 - .88

NE Strength 43 36.2±8.9 36.6±9.9 - .98

NE Comp 86 80.2±8.8 74.7±8.2 - .88

Overall Strength 24 28.5±6.4 21.9±4.3 - .74

Overall

Comprehensiveness

42 49.9±7.2 43.1±4.5 .76

p-value determined using one-way ANOVA; within WellSAT variables, similar

superscripts indicate significant different (p≤0.05)

NS – nutrition standards for competitive foods and beverages

SM- school meals

NE – nutrition education

54

Table 3.4. Mean WellSAT nutrition section scores across all SPAN-ET nutrition

environment section scores.

Poor Fair Good Best p-value

NS Strength - - 24.8±5.5 16.3±3.8 .57

NS Comp - - 42.8±6.7 39.0±11.0 .83

SM Strength - - 28.5±4.1 19±6.4 .40

SM Comp - - 42.0±4.9 40±6.7 .92

NE Strength - - 37.1±7.1 33.7±4.7 .86

NE Comp - - 81.0±12.7 77.9±6.5 .86

Overall Strength - - 27.0±4.5 17.3±1.7 .43

Overall

Comprehensiveness

- - 47.8±5.0 41±3.5 .62

p-value determined using one-way ANOVA; within WellSAT variables, similar

superscripts indicate significant different (p≤0.05)

NS – nutrition standards for competitive foods and beverages

SM- school meals

NE – nutrition education

55

Chapter 4

56

Title: Association between written school nutrition wellness policies and observed

nutrition areas of interest within the elementary school environment

57

Abstract

Purpose: The aim of this study is to assess whether strength and comprehensiveness of

policies equate to a better nutrition environment.

Methods: Twenty-six elementary schools were visited during the 2017-2018 academic

year. At each school, the School Physical Activity and Nutrition Environment Tool

(SPAN-ET) was used to assess the physical, situational and policy environment within

the school. Two trained researchers scored independently; discrepancies in scores were

discussed and the best possible answer chosen. School Wellness Policies (SWP) were

scored by two trained researchers, using the WellSAT 2.0 tool prior to the onsite school

visit.

Results: There was a statistically significant correlation between strength of SWP

written nutrition standards for competitive foods and beverages section and garden

features area of interest (p=.01) and a significant negative correlation between

comprehensiveness of written SWP nutrition education section in the wellness policy and

school meals area of interest (p=0.05). No other significant correlations were seen.

Conclusion: Assessing whether strength and comprehensiveness of school wellness

policy is associated with better nutrition environment provides information that has the

potential to shape policy development, implementation and in turn, the school nutrition

environment. Understanding how schools are creating and implementing

school wellness policies is important in determining where additional resources or

support is needed to support school-wide adoption of wellness policies and also improve

the school nutrition environment.

58

Introduction

During the 2006-2007 school year, all districts were required to establish a local

school wellness policy. In 2010, Congress passed the Healthy, Hunger-Free Kids Act of

2010 and added new provisions for local school wellness policies related to

implementation, evaluation and publicly reporting on progress of local school wellness

policies.1 Local education agencies were required to begin developing a revised school

wellness policy during the 2016-2017 school year, with full compliance with all the

requirements being adhered to by June of 2017.1 Local education agencies are supposed

to evaluate their wellness policy once every three years which should be made available

to the public.1 Although local education agencies are required to create school wellness

policies and meet the school meal nutrition requirements in order to receive federally

subsidized reimbursements, little evaluation of the effect of these policies on students and

student health has been conducted.2,3 Currently, there are existing evaluation tools that

allow researchers, schools and school districts to analyze the strengths and

comprehensiveness of school wellness policies but in general there has not been much

research regarding measuring the implementation of policies at the school level.3,4 Some

studies have assessed the relative strength of written school wellness policies, examining

the extent to which the policies contained enforcement mechanisms, funding

mechanisms, provision for evaluation, or guidelines for addressing the federal mandate

but little has been documented about policy implementation and evaluation after adopting

the wellness policy.4,5

School wellness policies are important as they assist with reinforcing and

elucidating expected standards and should define what is expected or unexpected in the

59

nutrition and physical activity environment.6 7 The policies adopted should be tailored to

each specific school’s need and not just generic.8 Policies should be concise and

measurable to be able to determine if it is effective. School policies should be realistic,

and the school should have the time, resources and personnel to implement the policies;

policies should be made available to the entire school staff.

There is a link between poor nutrition, obesity and chronic disease in youth.9

There has been increasing attention geared towards the school being an ideal setting for

promoting nutrition eating practices, but nutritious foods need to be available and having

nutrition education as a key component of the curriculum should be a key component of

the physical environment.10,11 The school nutrition environment can provide students the

opportunity to learn about and practice healthy eating through available foods and

beverages, nutrition education and messages about food in the cafeteria and throughout

the school campus. A healthy school nutrition environment can make it easier for

students to make healthy choices; assessing the school nutrition environment identifies

opportunities for improvement and begin a planning process for making schools even

healthier. Policies should support creating a healthy nutrition environment but it is

unknown if they do. The aim of this study is to examine whether strength and

comprehensiveness of school wellness nutrition policy scores correlate to a better

nutrition environment in Midwestern elementary schools.

Methods

School Recruitment

60

A list of school districts within a Midwest state was obtained from the department

of education website. Every elementary school principal was contacted by the

Department of Education via a recruitment e-mail. If interested, schools were encouraged

to complete a recruitment questionnaire. As part of this electronic questionnaire,

principals attached their current school wellness policy (SWP) and staff contact

information. Twenty-six schools were visited during the fall of 2017 and spring of 2018.

Assessment

Twenty-six schools were visited during the Fall of 2017 and Spring of 2018. At

each school, The School Physical Activity and Nutrition Environment Tool (SPAN-ET)

was used to assess the school nutrition and physical activity environment.13 Completing

SPAN-ET involved several methods of data collection including face-to-face and/or

telephone interviews with key informants, on-site direct observations, and content review

of various forms of documentation, including written and/or published district and school

wellness policies, nutrition and school meal policies and guidelines, school meals menus,

playground rules and regulations. Two auditors conducted SPAN-ET independently. The

nutrition physical, situational and policy environments were assessed; discrepancies were

discussed, and the best possible answer chosen. With the completion of SPAN-ET, a

report was generated targeting areas and strategies for improving the nutrition and/or

physical activity environments to promote healthy habits and enhance student learning

outcomes and sent to every school that participated.

61

This study focuses on the specific areas of interest under the physical, situation

and policy environment. In this study, cafeteria/meal service area and garden features

scores from the physical environment were used; school meals, food and beverage habits,

food and beverage practices, drinking water, cafeteria atmosphere and before/after school

extracurricular program from the situation environment scores from the situation

environment were used and nutrition and wellness policy, nutrition and wellness

committee and health and nutrition education scores from the policy environment was

used. Scores were grouped into 4 categories; poor (<25%), fair (26% < 50%), good

(51%<75%) and best (76% <100%).

Each SWP was separately evaluated by two researchers, using the WellSAT 2.0

tool prior to the onsite visit.12 For Well SAT, only nutrition education (NE) (section 1),

standards for USDA child nutrition programs, and school meals (SM) (section 2) and

nutrition standards for competitive and other foods and beverages (NS) (section 3) were

used.

Statistical Analysis

Data were analyzed using Stata Statistical Software: Release 15.14 Schools

missing SPAN-ET data were excluded from analyses (n=1), and a total of 25 schools

were used in this study. Mean scores for each area of interest within the SPAN-ET were

calculated by taking the number of criteria met divided by the total number of criteria

within the area of interest and multiplying by 100. This scaled scores between 0-100, the

same range used for WellSAT scores. Pairwise correlations were used to determine if

areas of interest within the observed nutrition environment sections of the SPAN-ET

62

were significantly associated with scores from the nutrition sections of the written

wellness policy.

Results

Mean scores for each SPAN-ET area of interest are presented in Table 4.1 along

with frequency of categorical scoring. Correlations between each SPAN-ET area of

interest and each nutrition section of the written wellness policy are presented in Table

4.2. There was a significant, positive correlation between strength of SWP nutrition

standards for competitive foods and beverages section and the garden features area of

interest (p=.01). Additionally, there was a significant, negative correlation between

comprehensiveness of written nutrition education section in the wellness policy and the

school meals area of interest (p=.05). No other significant correlations between the

observed nutrition environment and wellness policy scores were seen.

Discussion

In this study we assessed whether strength and comprehensiveness of written

wellness policies are correlated with a better observed nutrition environment in

elementary schools. School wellness policy strength and comprehensive scores were

examined against eleven separate areas of interest in the observed nutrition environment.

Two significant correlations were found in this study; there was a significant positive

correlation between strength of written nutrition standards for competitive foods and

beverages and garden features of interest. There was a significant negative correlation

between comprehensive SWP nutrition education and the school meals area of interest.

63

No other significant correlations were observed between strength and comprehensiveness

of the school wellness policies and the observed nutrition environment.

With regards to physical, situational and policy environment, schools are doing

well in the cafeteria/meal service (96% scored within the best category), school meals

(83% scored within the best category) and drinking water availability (100% scored

within the best category), but there is room for improvement with gardens/garden

features (96% scored within the poor category) , nutrition wellness committees (60%

scored within the poor category) and nutrition education (20 % scored within the poor

category and 40% scored within the fair category).

For school meals, majority of the scores fell within best category (96%) but had

low wellness policy strength and comprehensive scores (correlation= -.16). The current

school meals program could possibly have a role to play to play in these results. In the

observed nutrition environment school meal scores included standards for reimbursable

meals, which the USDA provides to all schools participating in the school meals

program. Currently, school meals must meet the Dietary Guidelines for Americans with

their fruit, vegetables, whole-grains and protein although the decisions about what

specific foods to serve and how to prepare meals are made by the local school food

authorities.15

Assessment of food and beverage habits and food and beverage practice criteria

incorporated school stores or carts, vending machines, fundraisers, birthday parties,

classroom reward parties and classroom treats/rewards. Higher scores in this area

indicates that schools did not use food as a reward for good behavior or good grades and

the contents of the vending machines met smart snack regulations. Majority of schools,

64

all but one school scored within the poor category for garden features; only one school

visited had a garden; there is room for improvement with school garden implementation.

School gardens with edible fruits and vegetables have the potential to teach students

about their true source of food and teach them valuable gardening and agriculture

concepts and skills that can be integrated into subjects such as health education, science

and art and also improve the school nutrition environment.16

In the health and nutrition education criteria, nutrition education policies, health

educator hired by the school district and minutes of annual health education were

assessed. Poor scores indicated that schools did not meet the recommended 400 minutes

of annual nutrition education time and had no health educator. Due to lack of funds and

resources many schools had no nutrition educator hired by the school district. Physical

education teachers often incorporated nutrition education into their classes or the school

nurse or counsellor provided weekly or monthly nutrition topics or education. This

finding is similar to that of Snelling et al. who noted that schools have been successful in

incorporating nutrition topics or lessons, but more resources are needed for schools to

achieve the needed minutes of health and physical education.4

Implemented written wellness policies in this study, often did not reflect school-

reported nutrition policies and practices, this is evident by there being no significant

relationship between overall strength and comprehensiveness of school wellness policies

and SPAN-Et nutrition and wellness policy area of interest. This finding was similar to

Budd et al. who found that: the quality of wellness policy implementation varies among

schools in the United States, with challenges to implementation including lack of time or

65

coordination of the policy team, lack of monetary resources, lack of student acceptance,

no consequences for non-compliance, lack of training, unsure about how to proceed, lack

of leadership and insufficient food and beverage choices available from vendors and

suppliers.18 Understanding how schools are complying with school wellness policies is

important in determining where additional resources or support is needed in order to

support school-wide adoption of wellness policies and ensuring best practices for a

healthy nutrition environment. 19 Facilitating factors such as grants and barriers such as

lack of clarity about responsibility for policy enforcement are important factors that

determine whether policy implementation will be successful.20 Funding and time

constraints represent important obstacles to the successful adoption, implementation, and

evaluation of school wellness policies that will require systemic change in order to

address.21 Gaining the support of key stakeholders is also critical for successful policy

implementation.21

This study is not without limitations. Majority of schools visited in this study

were located in rural counties. Having equal parts rural, metro and non-metro schools and

being able to observe the scores would make this study more generalizable. These rural

schools also had small school population sizes which may not be the case in more

populated states with multiple inner-city schools. Schools were observed for one full

school day, observing for multiple days would allow for assessing whether policies were

followed consistently and reflected the physical, situational and policy nutrition

environment. Despite these limitations, there are very few studies that address

comprehensiveness and strength of policy implementation and its association with the

66

nutrition environment; this study serves to fill the gap of whether strength and

comprehensive nutrition policies have an impact on nutrition environment.

Conclusion

Assessing whether strength and comprehensiveness of school wellness policy is

associated with better nutrition environment provides information that has the potential to

shape policy development and the school nutrition environment. Lack of funds, resources

and time constraint could potentially play a role in policy development and

implementation and in turn the nutrition environment. Understanding how schools are

creating and implementing school wellness policies is important in determining where

additional resources or support is needed in order to support school-wide adoption of

wellness policies and also improve the school nutrition environment, along with ensuring

policies align with what we know about healthy eating nutrition environment within

schools.

67

References

1. United States Department of Agriculture Food and Nutrition Services. Local

School Wellness Policy. https://www.fns.usda.gov/tn/local-school-wellness-

policy. November 2017. Accessed February 2nd 2018.

2. Methos J, Nanney MS. The strength of school wellness policies: one state’s

experience. J Sch Health. 2007;77(7):367-372.

3. Phillips MM, Raczynski JM, Goodell M, Perez AG. Creating and using index

scores in the analysis of school policy implementation and impact. J Sch Health.

2012;82(6):253-261.

4. Snelling A, Belson S, Katz N, et al. Measuring the Implementation of a School

Wellness Policy. Journal Of School Health. 2017;87(10):760-768

5. Cox M, Ennett S, Ringwalt C, Hanley S, Bowling J. Strength and

Comprehensiveness of School Wellness Policies in Southeastern US School

Districts. Journal Of School Health. 2016;86(9):631-637

6. Craven T, Young T, Markenson D, Gibson C. School Wellness Policy

Development. Journal Of The Academy Of Nutrition & Dietetics. 2017;117:A48.

7. Chan E, Ross V. Narrative understandings of a school policy: intersecting student,

teacher, parent and administrator perspectives. Journal Of Curriculum Studies.

2014;46(5):656-675.

8. Holland J, Green J, Alexander L, Phillips M. School Health Policies: Evidenced-

based Programs for Policy Implementation. Journal Of Policy

Practice.2016;15(4):314-332.

68

9. Kelsey M, Zaepfel A, Bjornstad P, Nadeau K. Age-Related Consequences of

Childhood Obesity. Gerontology. 2014;60(3):222-228.

10. Price C, Cohen D, Pribis P, Cerami J. Nutrition Education and Body Mass Index

in Grades K-12: A Systematic Review. Journal Of School Health.

2017;87(9):715-720

11. Rubio D, Lane H, Lopes M, et al. School wellness team best practices to promote

wellness policy implementation. Preventive Medicine.2017;101:34-37

12. UCONN Rudd Center Food For Policy & Obesity. Wellness School Assessment

Tool.2018 http://uconnruddcenter.org/

13. Oregon State University. School Physical Activity & Nutrition Environment

Tool.2018 http://extension.oregonstate.edu/growhkc/tools/span-et

14. StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX:

StataCorp LLC

15. Vaudrin N, Lloyd K, Yedidia M, Todd M, Ohri-Vachaspati P. Impact of the 2010

US Healthy, Hunger-Free Kids Act on School Breakfast and Lunch Participation

Rates Between 2008 and 2015. American Journal Of Public

Health.2018;108(1):84-86

16. Cairns K. Connecting to food: cultivating children in the school

garden. Children's Geographies. 2017;15(3):304-318.

17. Sánchez V, Hale R, Halasan C, et al. School Wellness Policy Implementation:

Insights and Recommendations From Two Rural School Districts. Health

Promotion Practice. 2014;15(3):340-348.

69

18. Budd E, Schwarz C, Yount B et al. Factors Influencing the Implementation of

School Wellness Policies in the United States, 2009. Prev Chronic Dis.

2012;9(118): 1-9.

19. Agron P, Berends V, Ellis K, Gonzalez M. School Wellness Policies: Perceptions,

Barriers, and Needs Among School Leaders and Wellness Advocates. Journal Of

School Health. 2010;80(11):527-535.

20. Harriger D, Lu W, McKyer E, Pruitt B, Goodson P. Assessment of School

Wellness Policies Implementation by Benchmarking Against Diffusion of

Innovation Framework. Journal Of School Health. 2014;84(4):275-283

21. Lucarelli J, Alaimo K, Liu H, et al. Little Association Between Wellness Policies

and School-Reported Nutrition Practices. Health Promotion Practice.

2015;16(2):193-201

70

Table 4.1. Mean criteria met for each area of interest and frequency of categorical

scoring among all schools within the Physical, Situational and Policy Environment

sections of SPAN-ET (n=25).

Area of Interest (total criteria) Mean (range) Poor Fair Good Best

Cafeteria/Meal Service (5) 93.9

(60-100)

- - 4% 96%

Garden Features (2) 2

(0-50)

96% 4% - -

School Meals (9) 82.1

(66.7-100)

- - 17% 83%

Food and Beverage Habits (7) 47

(28.6-71.4)

4% 60% 36% -

Food and Beverage Practice (5) 53.6

(20-100)

16% 32% 28% 24%

Drinking Water (8) 98

(87.5-100)

- 100%

Cafeteria Atmosphere (10) 90

(70-100)

- - 4% 96%

Before/After School Extracurricular Programs (7) 53.7

(0-85.7)

20% 24% 36% 20%

Nutrition and Wellness Policy (15) 55.5

(40-73.3)

- 32% 68% -

Nutrition and Wellness Committee (5) 36.5

(0-100)

60% 4% 16% 20%

Health and Nutrition Education (8) 52

(12.5-100)

20% 40% 24% 16%

71

Table 4.2. Correlation between SPAN-ET nutrition area of interest and WellSAT section

score.

Area of Interest

(total criteria)

NS Strength NS Comp SM

Strength

SM Comp NE Strength NE Comp Overall

Strength

Overall

Comp

Cafeteria/Meal

Service (5)

.11 .13 -.01 .01 .23 .27 .13 .16

Garden Features (2) .55** .38 .11 .01 .05 .17 .26 .34

School Meals (9) -.35 -.27 -.15 -.21 -.34 -.53* -.38 -.38

Food and Beverage

Habits (7)

-.15 -.16 -.12 -.07 -.34 -.17 -.29 -.22

Food and Beverage

Practice (5)

.05 .02 -.11 .09 .14 .11 .003 .07

Drinking Water (8) .03 -.12 -.13 -.27 -.10 -.003 -.11 -.11

Cafeteria

Atmosphere (10)

.09 .07 -.01 .13 .13 .11 .05 .14

Before/After School

Extracurricular

Programs (7)

-.32 -.12 -.18 -.20 -.21 -.25 -.30 -.27

Nutrition and

Wellness Policy

(15)

-.22 -.28 -.23 -.32 .16 .09 -.16 -.14

Nutrition and

Wellness

Committee (5)

.05 -.02 .05 .12 -.13 -.13 .04 .07

Health and

Nutrition Education

(8)

-.30 -.24 -.15 -.03 -.25 -.08 -.26 -.19

*P<0.05, ** P<0.01, ***P<0.001

72

Chapter 5- Discussion and Overall Conclusions

The purpose of this research was to examine school lunch participation by

county ruralness and weight outcomes, along with the association between

comprehensiveness and strength of wellness policies and the observed nutrition

environment were examined and school wellness policy nutrition scores and nutrition

policy implementation. It is known that childhood obesity is a prominent public health

issue and previous research indicates that children in rural neighborhoods have higher

prevalence of obesity compared to non-rural populations. This disparity may be driven by

the school nutrition environment, however little research exists that investigate factors

that have an effect on obesity, particularly in rural populations. General recommendations

have been developed regarding guidelines on school meals components and school

wellness policies development and implementation but not specific to the challenges rural

populations may face. This dissertation adds to our understanding of school meal

participation in rural neighborhoods and weight outcomes and how school wellness

policies association with the observed nutrition environment. This information has the

potential to be used for appropriate weight management intervention planning in the

school nutrition environment.

The second chapter of this dissertation is the first study regarding school meals,

particularly school lunch and weight outcomes in rural neighborhoods. There are a few

studies that assess school meal participation in metropolitan areas regarding school lunch

standards and the importance of school meals, and school meals and weight outcomes,

however no other studies have assessed school meals and weight outcomes in rural

73

counties. The findings in this study provide important information on areas where school

meals intervention aimed at weight loss can be successful in rural neighborhoods.

The third chapter of this dissertation builds upon previous cross-sectional research

regarding whether school wellness policies exist and whether the nutrition environment,

particularly the physical, situational and policy environment reflect school wellness

policies. The findings in this study provide important information on barriers and

facilitators regarding school wellness policy implementation. School wellness policies are

an important tool for parents, local educational agencies (LEAs) and school districts in

promoting student wellness, preventing and reducing childhood obesity, and providing

assurance that school meal nutrition guidelines meet the minimum federal school meal

but they must be implemented to be effective.

The fourth chapter of this dissertation builds upon previous research regarding

school wellness policies and the observed nutrition environment. Very few research

studies exist regarding strength and comprehensiveness of school wellness policy and the

observed nutrition environment. This study provides important insight regarding whether

strength and comprehensive policies correlate to a better observed nutrition environment.

The findings in this study assist with determining where additional resources or support is

needed to support school-wide implementation of wellness policies and also improve the

school nutrition environment.

In conclusion this dissertation advances the knowledge of school meals, nutrition

wellness policies and the observed nutrition environment. The first study was unique in

that it was the first to assess school meals and weight outcomes in rural counties but at

the same time incorporated counties from metro and non-metro areas. Study two and

74

three were unique in that they provide valuable information regarding barriers and

facilitators to creating comprehensive and strong school wellness policies and whether

school wellness policies have an effect on the nutrition environment. All of the data

presented can not only be used for understanding factors that contribute to a healthy

school nutrition environment but also for determining how to move forward with

designing appropriate interventions targeting a health school nutrition environment and

overall reducing childhood obesity.