School Policies That Promote Healthy Eating: A Survey of Foodservice Directors in North Carolina Public Schools
R. Denise Barratt, MS, RD; Nanna A. Cross, PhD, RD; Mildred K. Mattfeldt-Beman, PhD, RD; and Barry M. Katz, PhD

The purposes and objectives of this paper were to 1) determine the extent to which North Carolina school districts had coordinated nutrition policies consistent with the Centers for Disease Control and Prevention’s (CDC) Guidelines for School Health Programs to Promote Lifelong Healthy Eating (CDC, 1996); 2) discover ways in which existing nutrition policies could be improved; and 3) explore barriers to designing and implementing policies in the schools without such a coordinated nutrition policy.

Foodservice directors in all 117 public school districts in North Carolina received a questionnaire survey and 92% completed the survey. Descriptive statistics were used to analyze the responses and chi-squared analysis was applied to determine 1) the association between school districts having coordinated nutrition policies and individual nutrition policies; and 2) the size of the school district and presence of such policies.

Only 24.5% of districts reported having coordinated nutrition policies. None of these districts had policies that fulfilled all six CDC guidelines. Districts with coordinated nutrition policies were more likely to have individual policies for fundraising (P<0.05), vending machines operated outside of foodservice (P<0.01), use of food given as a reward (P<0.05), and evaluating the effectiveness of the school health program to promote healthy eating (P<0.05). Having a nutrition policy was not related to the size of the school district. Policies regarding the minimum amount of time for eating school lunches were reported by 18% of the districts, while 28% reported policies concerning referrals of at-risk children to a registered dietitian. Foodservice directors listed the lack of support, financially and from school administrators and teachers, as barriers to setting nutrition policies.

School nutrition policies are needed to provide guidelines for school districts to plan, develop, maintain, and administer comprehensive school health programs (American Dietetic Association, 2003). Nutrition services are one of eight components of a comprehensive school health program recommended by the CDC (CDC, 1996). Schools can influence eating habits by creating a healthy school nutrition environment (Crocket & Sims, 1995). Influencing factors in the school nutrition environment include food choices offered through the USDA’s school meal programs and access to foods through other school activities. Often, foods and beverages available outside the school meal programs are not consistent with USDA nutrition standards and guidelines. These include foods available in vending machines, at parties, sporting events, fundraising activities, school stores, and snack bars, or used as a reward in the classroom (Contendo, Balch, & Bronner, 1995; Olds & Eddy, 1986; American Dietetic Association, 1995).

Frequently school foodservice departments sell a la carte foods in addition to the school meal programs as a means to generate income. These foods are often high in fat, sodium, and sugar and may put children at nutritional risk (American School Food Service Association, 1991; American Dietetic Association, 2000; USDA, 2001). Students who eat these foods have lower intakes of key nutrients than those who eat meals from the National School Lunch Program (NSLP) (Burghart & Devaney, 1993).

Competitive foods are any foods sold to children in foodservice areas during lunch periods that are not associated with the NSLP (Federal Register, 1980). Foods of Minimal Nutritional Value (FMNV), which provide less than 5% of reference daily intakes for eight specified nutrients per 100 calories per serving (Federal Register, 1980), are prohibited from being sold in foodservice areas during meal periods. They may, however, be sold in other areas of the school (USDA, 2001). North Carolina regulations prohibit FMNV foods to be included in a la carte menu items, but allow competitive food sales in the lunchroom if the profits go to school foodservice and are used solely for the school meal programs (North Carolina Statute, 1991).

In an effort to improve the quality of meals served to schools under the NSLP and the School Breakfast Program, the USDA launched the School Meals Initiative for Healthy Children (SMI) in 1995 (USDA, 2001). According to SMI, meals served to students must be consistent with the Dietary Guidelines for Americans. These dietary guidelines limit calories from total fat to 30% or less and saturated fat to 10% or less of total calories, and call for reduced sodium and added sugars (USDA, 2003). The USDA’s Team Nutrition Program was designed to implement SMI by providing training and technical assistance to school foodservice workers and nutrition education to students (USDA, 1998).

The CDC’s Guidelines for School Health Programs to Promote Lifelong Healthy Eating (CDC, 1996) established seven recommendations for a coordinated school nutrition policy that promotes healthy eating. A coordinated nutrition policy integrates a school foodservice nutrition curriculum with all related activities consistent with the guidelines for school programs. Individual policies relate to foods available during school activities, in addition to USDA-supported school meal programs. Schools may have individual policies for foods sold in vending machines, school stores, and snack bars; foods sold at sporting events or as part of fundraising activities; and foods served in the classroom or used for reward or punishment. Only one study has compared nutrition and food policies in secondary schools that adhere to the CDC’s Guidelines for School Health Programs to Promote Lifelong Healthy Eating (French, Story, & Fulkerson, 2002).

The objectives of this research were to answer the following questions:

• Do school districts in North Carolina have coordinated nutrition policies consistent with the CDC’s Guidelines for School Health Programs to Promote Lifelong Healthy Eating (CDC, 1996)?
• How can existing nutrition policies be improved in school districts that have a coordinated nutrition policy?
• What are the barriers to designing and implementing a coordinated nutrition policy in school districts that do not have such a policy?

A statewide survey was conducted of all foodservice directors within the public

school districts of North Carolina (N=117). The North Carolina Department of Public Instruction provided a list of foodservice directors. Subjects were recruited at the state’s annual conference for Child Nutrition Program Directors in 1997. Those who were unable to attend were mailed a survey with a self-addressed, postage-paid envelope. An incentive for completing the questionnaire was a copy of The American Dietetic Association's Complete Food and Nutrition Guide (Duyff, 1996).

Development of the survey questionnaire
The survey questionnaire included 58 questions, with space at the end of the questionnaire for written comments. The questionnaire was designed to evaluate the extent to which school districts had policies consistent with the CDC’s recommendations for school health programs to promote healthy eating (Table 1). Questions were asked to determine if school districts had 1) a coordinated school nutrition policy that promoted healthy eating through classroom lessons and a supportive school environment; 2) no coordinated school nutrition policy; and 3) individual policies related to:

• Foods served in the classroom; sold a la carte; available from vending machines, snack bars, and school stores; or offered at athletic and fundraising events
• Time allowed for the lunch period
• The referral of high-risk students to a registered dietitian
• Training for school staff in nutrition education
• Family and community involvement to support nutrition education
• The existence of an evaluation program designed to assess the effectiveness of the school health program in promoting healthy eating

In addition, questions were asked to identify barriers to designing and implementing new nutrition policies and to highlight ways in which current guidelines could be improved.

A preliminary pilot study was conducted from a randomly selected group of 10% of the foodservice directors. State and district experts in school nutrition helped determine content validity and survey methods. Reliability was measured using a retest of the pilot group four months after the first response and 82% of the responses were identical. The second set of questionnaires from the pilot study was included in the final sample.

Data analysis
Statistical analysis included descriptive statistics of the nominal data using the SPSS statistical software package for Windows 95, version 8.0. Frequencies for each response were calculated. Chi-square analysis was done for all 58 questions to determine the association between a coordinated policy and individual nutrition policies and between the size of the school district and a coordinated school policy.

All school district foodservice directors in North Carolina public schools were eligible to participate in the study (N=117). The response rate was 92%; 106 directors completed the survey. Table 2 lists characteristics of the directors. The average age was 46 years old (± 7.67 SD), the majority was female and had a college degree, and 8% were registered dietitians. Most school districts had either less than 5,000 (44%) or 5,000-20,000 (42%) students, and had 5-20 schools (57%) per district.

Only 24.5% (n=26) of the districts had a coordinated school nutrition policy, none of which were consistent with all of the CDC guidelines. Districts with a coordinated school nutrition policy were more likely to have individual policies for fundraising (x2=6.5, P<0.05), food as a reward (x2=6.38, P<0.05), vending machines not operated by foodservice (x2=8.325, P<0.01), and an evaluation program to assess the effectiveness of the school health program in promoting healthy eating (x2=16.502, P<0.01). The size of the school district was not related to the presence or absence of nutrition policies.

These findings are consistent with research in other states. Pateman et al., (1995) found that few schools had nutrition policies. Story, Hayes, and Kalina (1996) surveyed 55 secondary schools in the St. Paul-Minneapolis metropolitan area and found that none had a coordinated nutrition policy. French, Story, and Fulkerson (2002) reported that 32% of secondary schools in Minnesota had nutrition policies.

Strategies that foodservice directors identified to improve existing coordinated nutrition policies were greater financial support (38%) and support from teachers (58%), school administrators (54%), and parents (46%). Those surveyed pointed most frequently to an increase in the training of classroom teachers (53%) and the integration of nutrition into other subjects (29%) as ways in which to improve nutrition curriculum policy. Table 3 lists methods to improve existing individual policies. Changing the type of food and times of operation were tactics given for improving policies for vending machines not operated by foodservice staff.

Districts with a coordinated nutrition policy were more likely to have a policy regarding use of food for reward or punishment than districts without a coordinated policy. The American School Health Association (1997) recommends using verbal praise or token gifts instead of food to reinforce healthy eating among students. Giving food as a reward may reinforce a preference for low nutrient-dense foods and encourage children to eat when not hungry. Teachers may need new ideas for rewarding students in ways that do not involve food.

More school districts had policies regarding school foodservice a la carte and vending machine food items (56%; n=60) than the 25.5% reported by Pateman et al., (1995). North Carolina state law limits the type of foods sold a la carte and in vending machines operated by child nutrition programs, but not other vending machines (North Carolina Statute, 1986). Intervention through legislation may be needed to achieve the CDC’s goals of promoting a healthy nutrition environment in schools.

A policy requiring a minimum amount of time for the school lunch period was reported by 18% of the districts; at least 20 but less than 30 minutes was allowed. Sanchez, Hoover, Cater, Sanchez, and Miller (1998) reported that children typically spend only 10 minutes eating. These researchers recommended 20 to 30 minutes for eating a meal and social interaction; this does not include time for travel and waiting in line for service. Keys to Excellence provides tools that school foodservice directors can use to compare their operation to established standards (American School Food Service Association, 1995).

Barriers reported for establishing a coordinated nutrition policy were lack of financial support (28%) and a lack of support from school administrators (39%) and teachers (31%). Table 4 lists barriers to implementing individual policies in school districts that don’t have policies. However, 25% of the responding foodservice directors did not answer questions regarding barriers to having nutrition policies. Those who did respond to these questions identified several barriers. Lack of support from school administrators was listed as a hindrance for individual polices for the snack bar, school parties, fundraising, athletic events, and using food as a reward or punishment. School board members were perceived as an impediment to having policies related to school parties, fund raising activities, and food sold at athletic events. Lack of support from both administrators and teachers was identified as barriers for having a policy concerning vending machines operated outside foodservice, as well as for using food as a reward or punishment. The obstacles cited to establishing an integrated nutrition curriculum included little to no support from school administrators and teachers and deficient teacher training. A lack of financial backing was listed most often as an obstacle to having policies for fundraising and athletic events. The difficulties identified in this survey – including a lack of time and money and commitment from school administrators, parents, and community members – are similar to those reported by Meyer et al. (2001).

Support from teachers was listed frequently as a barrier to implementing nutrition policies and as a way current policies could improve. Four districts reported that teachers participated in designing a coordinated nutrition policy and seven districts had teachers involved in implementing policies. A lack of time also was listed as a barrier to improving policies that promote adequate nutrition training for teachers. Incorporating nutrition into subject areas already taught has allowed some teachers to make time for nutrition in a crowded curriculum (Probart, McDonnell, Achterberg, & Anger, 1997). Students need ongoing, long-term contact with teachers trained in nutrition education for behavior change to occur (Auld, Romaniello, Heimendinger, & Hambidge, 1999).

On the questionnaire section requesting written comments, foodservice directors expressed concerns about the types of foods sold during fundraisers. One director commented on the need to educate Parent and Teacher Association members about the importance of using healthy foods for fundraising activities. Meyer et al. (2001) concluded that school organizations send mixed messages with regard to using food as a reward and the foods available in vending machines, as snacks/a la carte, and at fundraisers. Children may consider all food purchased at school as part of the school lunch program (Moag-Stahlberg, Miles & Marcello, 2003). Non-food items, such as movie tickets or craft sales, may be more appropriate for fundraising events (Hinkle, 1982; Olds & Eddy, 1986).

On the questionnaire’s section for written comments, some foodservice directors commented that there was no one to initiate a coordinated school nutrition policy. Only one district in this survey had a registered dietitian who was trained to implement a nutrition curriculum in the schools and who was involved in planning a coordinated nutrition policy. Registered dietitians have the opportunity to initiate and implement a coordinated nutrition policy in schools as advocates, consultants, researchers, and practitioners (American Dietetic Association, 1995 & 2000).

In regard to nutrition policies concerning at-risk children, federal law requires referral of at-risk students for screening and nutrition counseling (USDA, 1995; Taylor, 1997). North Carolina Child Nutrition Services and the State Development and Evaluation Center are working with school districts, health departments, and health care professionals to identify at-risk students with chronic diseases or disabilities that may impair nutritional status (R. Addesso, personal communication, April 14, 1998). At the time of this study, 26% of all the responding North Carolina districts had a program for the referral of at-risk children to a registered dietician. Nutrition services are an essential part of comprehensive care for special needs children (American Dietetic Association, 1995). School-based nutrition services can positively impact the physical growth of children with developmental disabilities (Cross-McClintic, Oakland, Brotherson, Secrist-Mertx, & Linder, 1994).

School board members and administrators need to be made aware of the importance of having a coordinated school nutrition policy, and how the policy relates to the improvement of academic performance and student behavior. The Division of Adolescent and School Health of the CDC asked the National Association of State Boards of Education to provide assistance to states, districts, and schools in developing policies to promote a healthy school environment (NASBE, 2002). Symons, Cinelli, James, and Groffet (1997) concluded that even if school administrators saw a link between health programs and positive academic performance and student behavior, additional incentives were needed for administrators to design and implement health programs in their schools.

This statewide survey of foodservice directors evaluated nutrition policies in North Carolina public school districts and compared existing policies with the CDC’s Guidelines for School Health Programs to Promote Lifelong Healthy Eating. The survey was designed to evaluate perceived barriers to implementing nutrition policies and how existing nutrition policies could be improved. The strengths of this study were that it was conducted statewide and had a high response rate (92%). Limitations of this research included the fact that only foodservice directors participated in the study and that 25% of the responding directors did not respond to the survey question regarding barriers to implementing nutrition policies.

In this study, barriers to implementing or improving existing nutrition policies were a lack of financial support and a lack of support from school administrators, school board members, teachers, students, and parents. These findings are consistent with that of other research surveying school administrators, teachers, and foodservice directors from across the U.S. participating in focus groups (Meyer et al., 2001).

School foodservice directors are encouraged to use available resources to promote a healthy school environment. Resources may be available from the American Dietetic Association, National Food Service Management Institute, American School Food Service Association, American School Health Association, USDA’s Team Nutrition, National Association of School Boards of Education, and registered dietitians at the state level who are responsible for school nutrition and/or child nutrition programs. School foodservice directors should work with school board members, administrators, teachers, school foodservice personnel, parents, and students to develop a nutrition advisory council (NAC). A NAC can be a way for school administrators, board members, nurses, students, teachers, parents, and school foodservice personnel to work together to develop and implement nutrition policies (American School Food Service Association, 1994; Kubrick, Lytle, & Story, 2001). School foodservice is only one part of the school environment; all areas should promote healthy eating. Parents and students can influence policy through communication with school board members and administrators. However, Kubrick, Lytle, and Story (2001) concluded that establishing a policy at the local school level is complex and time intensive and school administrators are not familiar with establishing and implementing nutrition policies.

Creative ideas are needed for generating the funds required to promote a healthy school environment for children. More state funding may be necessary for individual school districts to accomplish this goal. Money spent to ensure a healthy school environment could be viewed as long-term savings of future health care costs and concerns, including those related to obesity and subsequent chronic diseases in children.

Since this survey was conducted, concerned public health and nutrition advocates and state agencies in North Carolina have been working with individual schools, school districts, the state school board, and state legislators to improve the nutrition environment in schools. A follow-up study of administrators, teachers, parents, and students, in addition to foodservice directors, is needed to evaluate the effectiveness of recent efforts in North Carolina to improve the school nutrition environment.

This research was part of the requirement for a master of Science in Medical Dietetics at Saint Louis University. The authors would like to acknowledge the following people for their contribution to this research: Hani Zayed, Rebecca Addesso, John Murphy, and Kathy Andersen with the North Carolina Education and Training Program for providing Roberta Duyff’s book The American Dietetic Association’s Complete Food and Nutrition Guide to the school foodservice directors who completed this study. Thank you to all those directors who completed the questionnaire.

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Barratt is a research nutritionist with the Women's Health Initiative at the University North Carolina, Chapel Hill. Cross is a nutrition consultant. Mattfeldt-Beman and Katz are, respectively, chairperson and professor for the Department of Nutrition and Dietetics and professor of research methodology at Saint Louis University.