Childhood obesity is a serious public health problem in the US that is associated with significant health complications, including elevated cardiovascular risk, pediatric hypertension, and diabetes. Since children spend most of their daytime at school, school food programs are touted as effective interventions for reversing this epidemic. In this section, recent scholarly studies published within the last five years on school-based obesity interventions and perceptions of children and parents will be reviewed. The aim is to determine the efficacy of interventions that cut sugar and fat in school lunches and the behaviors and perceptions that define the success of such programs.
School Cafeteria Environment
The consumption of unhealthy food is the leading cause of childhood obesity. Some implemented programs aim at changing the school cafeteria environment by promoting healthier dietary behaviors. The rationale is that supporting the child to select healthier food leads to good dietary practices, even at home (Madden et al., 2013). Parental/peer support in healthier food selection and role modeling by the teachers have been shown to limit the intake of sugar-rich snacks and beverages (Madden et al., 2013). Strict school policies can also lead to healthier food practices in the school food environment.
In this regard, promoting healthy food choice requires changing the way food is consumed by controlling its availability and quality in the school food environment. The availability of sugar/fat-rich food/beverages is associated with increased consumption of unhealthy food by children, resulting in elevated obesity/overweight risk (Struempler, Parmer, Mastropietro, Arsiwalla, & Bubb, 2014)).
In contrast, providing healthier food options with restricted sugary/fatty food availability can improve fruit and vegetable consumption among schoolchildren (Struempler et al., 2014). Therefore, school policies/guidelines that control the availability of unhealthy food in school settings can curb childhood obesity. Other interventions within the school cafeteria environment that promote healthy food choice include placing healthier food first in a buffet, providing multiple healthier options, establishing a salad bar, attractive labeling of fruits/vegetables, and permitting pre-ordering of meals (Struempler et al., 2014).
The food sold through the school vending machines is also unhealthy. According to Madden et al. (2013), up to 75% of the beverages/soda and 85% of snacks contained in these machines are rich in sugar and fats, which increases obesity risk. Further, among fourteen-year-olds, more than three servings of sweetened beverages are consumed by 52% of boys and 32% of girls (Madden et al., 2013). The increased utilization of vending machines is attributed to limited lunchtime and congestion in the cafeterias.
Therefore, controlling the dietary content of food sold through vending machines can help curb the problem of childhood obesity. Another strategy includes using credit cards to track the child’s food choices from vending machines. Promoting vegetarian diets in schools can help prevent childhood obesity. According to Struempler et al. (2014), vegetarian children tend to have a normal BMI because plant-based meals are “low in energy density and rich in complex carbohydrates” that enhance satiety and metabolism (p. 288). Further, vegetarian diets contain lower levels of cholesterol and unhealthy fats.
Other studies have focused on the provision of nutrition education as a way of promoting healthy dietary practices extending into adulthood. Amini, Djazayery, Majdzadeh, Taghdisi, and Jazayeri (2015) note that teachers and peers collaborating with local media outlets can help promote healthy food choices by children. The important areas that should be addressed through such collaborations include the socio-cultural dimensions of food, preparation, preservation/storage, and healthier food choices. Nutrition education should focus more on fruit/vegetable diets as healthier alternatives to snacks and sweetened drinks.
School Lunch Programs
Research on school lunches has focused on caloric intake obtained from programs like the National School Lunch Program (NSLP). The NSLP is part of the USDA’s meal program for schoolchildren. Eligible children from poor households receive free school meals. The NSLP program has been blamed for the obesity epidemic because of the inadequate nutritional content in the meals (Amini et al., 2015). As a result, the dietary guidelines for this program have been modified to improve the nutritional status of the children.
Hopkins and Gunther (2015) found a significant association between NSLP meals and overweight (high BMI) prior to the changes to the national dietary guidelines in 2012. The meals were found to be high in “calories, fat, saturated fat, and sodium”, but low in fiber (Hopkins & Gunther, 2015, p. 10152). To improve child health outcomes and prevent obesity, school lunch programs should contain appropriate nutritional content. The modifications to the NSLP includes providing fruits and vegetables separately in a meal, daily inclusion of vegetables in the meal, reducing starch, serving fat-free or low-fat dairy products, and lowering sodium intake.
Healthy lunch initiatives provide a plausible approach to childhood obesity prevention. Evidence shows that initiatives that involve nutritional training of the staff involved in the preparation of school lunches and nutrition education to support healthy food choice achieve significant reductions in childhood obesity rates (Amini et al., 2015). Other useful school-based interventions include physical education and availability of healthier food options in the cafeteria environment. Other studies have compared the caloric content of school lunches and bagged lunches.
Evidence shows that children participating in school lunch programs have up to 2% more risk of developing obesity compared to those who bring bagged lunches (Amini et al., 2015). This indicates that school meals are rich in calories that predispose children to obesity. For bagged lunches, the mother’s occupational status influences the nutritional adequacy of the meals. In addition, the child’s level of physical activity, particularly at home, is a significant factor in the development of obesity.
Besides nutrition, school-based interventions focus on physical activity of the children. Physical education aimed at promoting fitness and health is linked to a reduction in obesity-related indicators, including lower BMI and adiposity (Hopkins & Gunther, 2015). Persistent extracurricular activities reduce the obesity risk by alleviating the impact of sedentary lifestyles in school-age children. They may involve sports or physical education programs.
Parental/Child Perceptions
Parents influence the development healthy dietary habits in their children as the primary caregivers. Therefore, the child’s diet quality is dependent on parental attitudes and perceptions. Clarke et al. (2015) argue that parental beliefs and awareness of dietary standards affect the nutritional status and health of their children. Their role modeling behavior shapes the child’s dietary practices in school and other environments. They differ in how they perceive their influence over the eating practices of their children (Clarke et al., 2015). However, evidence shows that parents control up to 72% of what their children consume (Clarke et al., 2015). Their perception that the children are young and therefore unable to make healthy dietary choices is the reason why they select what the child should eat in school lunches.
Parental perceptions of children’s diet quality in schools are critical in promoting quality nutrition for obesity prevention. However, due to the limited knowledge on nutritional standards, the parental perceptions of a healthy diet may be incorrect. Maternal education, BMI, and occupational status have been shown to predict perceptions of dietary quality of the children (Adamo & Brett, 2013).
The mother’s nutritional knowledge determines her perceptions of what she considers a healthy meal for the child. Parents often perceive homemade meals, e.g., packed lunch, as healthier than school lunches, even though this may not be the case. Most parents consider fruit/vegetable diet at the dinner table as a healthier alternative for children than soft drinks (Adamo & Brett, 2013). Therefore, involvement of parents through nutrition education can complement school-based interventions for childhood obesity prevention.
Parental socioeconomic status is an important predictor of a child’s nutritional status or dietary intake. Homelessness and dependency on food stamps is linked to poor nutritional status (Clarke et al., 2015). Therefore, while low-income parents may perceive the child’s diet as ‘good’, the food may actually be poor in nutritional quality. Parental attitudes also influence the child’s eating behaviors. Their food preferences, including what they consider healthy food choices, shape the children’s eating habits.
A positive correlation exists between the dietary practices of the parents and the children’s “fat, fruit, and vegetable intake”, which influence obesity development in children (Clarke et al., 2015, p. 6). Therefore, a child is more likely to eat food items he/she sees her parents eat or like. Parents can dissuade young children from consuming an unfamiliar food or developing binge habits while in school. The children can develop healthy eating habits through parental support – homemade lunches – as opposed to permitting the consumption of snacks, which increase the childhood obesity risk.
Conclusion
This review has revealed that the efficacy of school-based interventions in childhood obesity prevention lies in restricting the availability of sugar/fat-rich food/beverages in vending machines, offering healthy food options, nutrition education for children, and serving healthier school lunches – vegetables and fruits. Further, positive parental perceptions, role-modeling behavior, and beliefs influence healthy eating behavior in children. Therefore, school-based interventions aimed at preventing childhood obesity should involve parents who are the gatekeepers of healthy eating at home.
References
Adamo, K. B., & Brett, K. E. (2013). Parental perceptions and childhood dietary quality. Maternal and Child Health Journal, 18(4), 1-19. doi:10.1007/s10995-013-1326-6
Amini, M., Djazayery, A., Majdzadeh, R., Taghdisi, M., & Jazayeri, S. (2015). Effect of school-based interventions to control childhood obesity: A review of reviews. International Journal of Preventive Medicine, 6(68), 1-16. doi:10.4103/2008-7802.162059
Clarke, J. L., Griffin, T. L., Lancashire, E. R., Adab, P., Parry, J. M., Pallan, M. J. (2015).
Parent and child perceptions of school-based obesity prevention in England: A qualitative study. BMC Public Health, 15(1224), 1-9. doi:10.1186/s12889-015-2567-7
Hopkins, L. C., & Gunther, C. (2015). A historical review of changes in nutrition standards of USDA child meal programs relative to research findings on the nutritional adequacy of program meals and the diet and nutritional health of participants: Implications for future research and the summer food service program. Nutrients, 7, 10145–10167. doi:10.3390/nu7125523
Madden, A. M., Harrex, R., Radalowicz, J., Boaden, D. C., Lim, J., & Ash, R. (2013). A kitchen-based intervention to improve nutritional intake from school lunches in children aged 12-16 years. Journal of Human Nutrition and Dietetics: The Official Journal of the British Dietetic Association, 26(3), 1-15. doi:10.1111/jhn.12037
Struempler, B. J., Parmer, S. M., Mastropietro, L. M., Arsiwalla, D., & Bubb, R. R. (2014). Changes in fruit and vegetable consumption of third-grade students in body quest: Food of the warrior, a 17-class childhood obesity prevention program. Journal of Nutrition Education and Behavior, 46(4), 286-292. doi:10.1016/j.jneb.2014.03.001