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School Nutrition Success Cries For Research

Our piece entitled Getting Kids To Choose Healthy Snacks detailed the interaction of two generations of the Hunt family (as in Grant Hunt of the Grant J. Hunt Company and his parents Jim and Elizabeth Hunt), with issues surrounding getting children to eat fresh produce. It brought a note from a longtime industry leader:

Your May 17, 2007 Pundit was great. The insights in all the articles are excellent, but I’m really responding to your piece about getting kids to choose healthy snacks.

At the Produce for Better Health meeting in San Francisco in March, I sat next to Robin Abodeely at the awards luncheon. Robin received an award for her work at Dr. Crisp elementary school in Nashua, NH (she’s the school nurse), where the kids now are happily making healthy food choices. Robin went to her principal and suggested a strategy for steering kids toward healthy snacks that focused more on education about healthy foods than on prohibition of unhealthy ones.

I know Robin would be willing to tell you her story, and you’ll thoroughly enjoy hearing her tell about what she (and the kids!) have accomplished at Dr. Crisp.

Thanks for your excellent work,

— Dave Parker
Fruit Patch Sales, LLC
Dinuba, California

Well a recommendation from Dave Parker is good enough for this Pundit. We asked Pundit Investigator and Special Projects Editor Mira Slott to give Robin Abodeely a call so we could catch up on this program:

Robin Abodeely
School Nurse
Dr. Norman W. Crisp Elementary School
Nashua, New Hampshire

Q: Congratulations on winning the Produce for Better Health Foundation’s National Excellence Award. Tell us the story of how you became the advocate to transform the school’s food programs.

A: I’ve been a registered nurse for 26 years. I made the transition to being a school nurse about 10 years ago when I joined Dr. Crisp Elementary. When my own two school age children were younger, I found the hours of working at the hospital challenging, missing bonding time with them and having to work on Christmas. Being a school nurse put me on the same hours my own kids were at school.

I remember that first day of school at my new job. It was the craziest, busiest day I ever had, but I went back for more. With so many things to do, it was not on my radar to think what the kids were eating. Then as time went on, kids would come into the nurse’s office not feeling well, and I would ask them what they ate.

Over and over I would hear that they were eating ring dings, honey buns, greasy chips and all kinds of unhealthy food choices. I started to witness a startling correlation between eating habits and health. Usually, when kids didn’t eat well, there was a connection with them not feeling well.

Then, information about childhood obesity, diabetes and other health risks facing our children started to emerge, and the frightening prediction that this could be the first generation to have a shorter lifespan than their parents.

Q: When did you start to take action within the school?

A: In November of 2003, I met with other City of Nashua school nurses where we shared our concerns and learned about a USDA Food & Nutrition Service program called Changing the Scene, which was sponsored by multiple agencies including CDC.

Using the Changing the Scene assessment tool, delivered through the University of New Hampshire Cooperative Extension, we conducted a survey to assess the school eating environment; from the basic question of whether the cafeteria was a pleasant place to eat, to what food was being served, to how health and nutrition were incorporated into the school culture.

A few key areas really stuck out as needing improvement; the food being offered in the cafeteria throughout the day, and food being brought in by the kids and parents for holidays and celebrations, and for snacks. But it wasn’t until April 2004 that we had our first wellness team meeting.

Q: Did the school administration back your efforts or did you face resistance?

A: Chronologically, I talked to the principal about attending a conference on childhood obesity. When I went back to the principal to share my knowledge and ideas for implementing a wellness program at the school, she not only supported me to go ahead, she ended up hiring a personal trainer, and losing weight herself. Our current principal is equally supportive of the program, but much has transpired from where we started to how we got to where we are today.

Q: How did you get the program off the ground?

A: Initially, we sent out a flyer encouraging people to join in a meeting to learn more about our mission to become a healthy school, and response was terrific. At least a dozen teachers came to our first meeting along with the principal, school administrators, the guidance counselor, the kitchen manager, and a group of parents to get broader input and to determine the legitimacy of implementing such a program.

We learned a lot. Teachers said kids were bringing in junk food at snack time. Parents didn’t always know what their kids were eating in school. And there was a lot of misinformation about what kinds of foods were healthy and nutritious. We wanted to promote health education and nutritious eating in a positive manner. We wanted to send messages in school to children and send information home to parents.

We decided to kick off the 2004/2005 school year by declaring ourselves a Healthy School. From now on snacks, lunches and celebrations at school would be nutritious rather than sugary, salty, and fattening.

Q: Did you have a particular event to jumpstart the program?

A: We launched the Healthy School concept at open house, which is a big deal here, with all the children and their parents, grandparents, and extended families attending. When we made the announcement that we would now be a Healthy School, the whole room went quiet for an instant. People were surprised by the idea and caught off guard. It was an intense moment, and then the atmosphere switched to a positive energy and people started clapping.

We set up a non-profit farmers’ market that night where we sold fresh, locally grown produce and talked to parents about healthy options. We didn’t ban any foods like cupcakes or cookies, but we encouraged them to join us in making healthy choices for their families. We also sent letters home with recipes for fruit kebabs, veggies and dips.

Our affiliation with the University of New Hampshire Cooperative Extension helped us connect with a local farmer. The guidance counselor went to the market that day and picked up the fresh produce for us to sell at wholesale prices.

We sent the message out loud and clear that night.

Q: How did the program evolve from there, and what funding have you garnered to back the initiatives?

A: Around the same time, we sought a nutrition grant. A federal teen nutrition program offered a $5,000 grant to schools promoting healthy nutrition and fitness. We applied and were successful. The money supported three major initiatives.

The first was creating a cookbook called “Cooking the Crisp Way.” We use that line like a brand. When new students register, we say we’re a healthy school, and let them know what our cafeteria looks like and the many choices of fresh produce. Branding our school this way has served us well. The word is out there now. We have a reputation to a fault. We are a small community. When we are out at the grocery store and my kids want ice cream, all the kids are looking to see if I give it to them.

Nutrition analysis was done on the recipes. Parents and staff members gave us their favorite recipes. We screened them, and if there was too much sugar or fat, the recipe didn’t make it or we adjusted the ingredients. Children did the artwork for the cookbook, and some kids brought in recipes too. A third grader created an English muffin pizza, but she had put pepperoni and sausage on it! Kids want to learn and do right.

In addition to the cookbook, we took part in a state-supported program called KidPower, where we purchased pedometers for all the kids through a grant funded for that. The kids loved the gadgets; some called them thermometers! They each had journals keeping track of how many steps they took. Because we wanted to include all students K through 5, for the younger kids we had a picture chart, where the kids could circle pictures of their activities, such as raking leaves, jumping rope, vacuuming, riding bikes, and chart their progress. We encouraged any activity where they were up and moving as opposed to watching T.V. or videos.

We did an Excel data sheet on the participation rate, and we considered ourselves successful. At the end of four weeks, we received information that 200 students, or more than half of the total school population, fully participated in it.

Q: Four weeks sounds relatively brief when looking at the monumental task of changing eating habits and physical activity in children. How does this fit in with the last initiative in this trio, and in the larger picture of your healthy school development?

A: For the third part, we targeted fourth-graders. A nutrition educator came in to teach the children. She demonstrated how much sugar is in a cup of soda, how much fat the kids are eating when they order French fries, and better alternatives. Then she served samples of healthy food choices like celery, carrots and raisins.

We’ve been very successful doing things to promote health without money. Teachers send out the message to children regularly, each in his or her own way. At break time, teachers ask the kids to talk about the snacks they brought in, and it becomes a mini nutrition lesson; some days and some teachers more than others. A fourth grade teacher has a ritual each day where anyone that knows they have a healthy snack can go get it and start eating, then those that think they have a healthy snack go next. Instead of negative peer pressure, we have this positive peer influence.

I walk into the classrooms on snack patrol with a pocket of stickers, pencils, and other little prizes passing them out to kids that have healthy snacks like apples and sunflower seeds. The kids think it’s cool and it gives them incentives to try new things.

We also try to put out information to parents in our monthly newsletter. We receive countless thank yous, and helpful feedback from parents. One parent was grateful because her child used to be in the minority bringing in carrot sticks and was embarrassed and upset because the other kids had ring dings and honey buns.

Q: What happens at the cafeteria? Do all the kids buy lunch?

A: We’re an inner city school and part of the federal lunch program. Some 70 percent of our families qualify for free or reduced cost lunch. It gives us some control because we’re responsible for serving breakfast and lunch to these children. In addition to regular lunch in the cafeteria, all classes have snack time.

Q: How have you influenced the selection of cafeteria food? Wouldn’t the federally funded lunch program set some guidelines for healthy selections?

A: In the last few years much has changed in our cafeteria. Before we started this program, if you go back to the winter of 2003 or even 2004, we had a food cart salad bar set up, but it was covered in a corner and wasn’t being used. When I asked why, I was told it was because of staffing concerns; that the salad bar concept was too labor-intensive for them to do.

It took a phone call from the principal to the kitchen director for the staff to get the salad bar operation up to par. It takes time to do the prep work and to cut up fresh fruit and vegetables and rotate them, ideally not only for the salad bar. Kids have issues with eating whole apples when they have braces.

To some degree for federal programs food is determined in advance, but we can have major influence on what ends up on the menus. If the kitchen director is interested in promoting nutrition and gives me a heads up about a month in advance, I can talk to her about setting up the menus to be sure healthy choices are available.

What happened in our school has been a domino effect. By requesting the salad bar cart to be put out every day, more kids became aware there were choices, and started to look for fresh produce. It was a learning curve. People throughout the school were promoting healthy choices, and the message was being carried over in the classrooms.

It made sense to the kids to eat produce and try new items like kiwis. Kiwi has become popular. It’s a versatile fruit, cores well and doesn’t go bad quickly. Kids thought it was neat and in turn told their parents to buy it for them at home.

Q: Have you been able to track and quantify progress?

A: I have some interesting numbers for you in terms of increased produce sales over the last few years.

In the 2004/2005 school year, we had 461 students and just under $5,000 of produce purchased. It is difficult to do a direct comparison in the 2005/2006 school year. We had 417 students because the sixth graders moved to the middle school and had produce sales of $4,300.

What is telling, however, is how this school year is shaping up. Produce sales are up to $5,880 as of early May, which is a 17 percent increase from 2004/2005 to 2006/2007. And from 2005/2006 to where we are now in 2006/2007, we’re looking at a 34.8 percent increase in produce sales with the same age kids and the same number of kids, and the difference will be even greater by the end of the school year.

Beyond that, though, snack time here doesn’t look like snack time at other schools. When staff members leave this school and see what is going on elsewhere, they say they are shocked. The greatest changes occur at the younger grade levels. We’ve seen fourth and fifth graders who are more independent in packing their own lunches and snacks and may not make as many healthy choices.

Q: Any other grants in the works?

A: We received two more grants both for this school year. With the one from the Healthy New Hampshire Foundation, we have been able to get recess equipment like kick balls, and hula hoops. The other was a renewed Changing the Scene grant through the University of New Hampshire coop extension.

Q: Does your state and the New England area in general have lower rates of childhood obesity than in other parts of the United States like the Midwest?

A: Maine was the only New England state with an incidence of obesity greater than national average. However, being an inner city school, and having somewhat of a transient population, we’re not always serving the same families so we face challenges that some other schools may not.

Q: Have you carried on some of the original concepts, like the farmers’ market from the open house when you launched the healthy school brand?

A: Yes. We’ve done the same concept, but a newer and improved farmers’ market. The first year the farmers’ market was a big hit. We did another farm stand the next year, but I felt uncomfortable about selling the food, even at wholesale, not-for-profit prices.

Some of the produce is still expensive for many of our families to purchase. I talked to the produce supplier for our school district, Saunders Produce, and they donated 10 cases of fresh produce. We told them we were working on a healthy nutrition program and wanted to do a farmers market, but hated selling produce to families just trying to get by.

We put the fruit in paper bags with circular nutrition stickers on them that said, ‘Eat Better, Eat Together’ with a picture of a family of four sitting around the table eating. The bags contained bananas, apples, kiwis, cucumbers, peppers and carrots. We gave these bags away till they were gone. We had 10 cases of fruit and an assembly line of staff members putting hundreds of bags together.

We started out giving one bag per family at the open house and it was great seeing people walking around eating the produce. The industry should realize that giving away the free produce comes back in dividends. Kids are asking for more produce and families are purchasing more produce at retailers.

Q: Do you integrate your program with retail stores, perhaps taking the kids on a produce department tour with the local supermarket produce manager?

A: We have a third-grade group arranging an educational field trip to Shaw’s supermarket. And they will receive a tour. In this case, the store is close enough to make it a walking field trip.

Q: What other resources have you used to augment your healthy school program?

A: Some of our giveaways have been connected to the Five a Day program. One of the other ways we’ve been able to get supplies has been through a Changing the Scene arrangement. They have a program where for every 30 hours you spend promoting and emphasizing healthy nutrition and fitness, you get $100 worth of free nutrition educational supplies.

We keep reaching out and growing our program. One resource I use is the Dole 5-a-Day catalogue. That’s where I saw the application for the PBH National Excellence Award.

We try to do new and different things each day. Kids are going home and telling parents they made fruit and yogurt parfaits at school. We just had an international dinner on May 10, through the Changing the Scene grant. It was a way to celebrate cultural diversity in our school environment and connect it with healthy nutrition. We made it a pot luck event and asked families to bring in healthy food dishes based on their cultural background. We focused on main meals and salads and side dishes. We didn’t ask for desserts and didn’t get any. Kids got involved in what to cook and bring.

We tied in the grant money to purchase food from local restaurants such as Japanese and Middle Eastern, and we made sure that it was healthy. It turned out to be a fun evening, and the cafeteria was beautiful with colored flags the kids made that reflected their cultural backgrounds.

Leading up to the event, we purchased books and posters on cultural foods and had an international cookbook with sample recipes in the school newspaper for inspiration.

Q: What advice would you give to people who want to get involved in a healthy school program?

A: The options are so far reaching. The key is keeping a positive consistent message. We are careful in the language we use, complimenting children who are eating nutritiously, and are involved in healthy activities. The program has a momentum all its own. It used to be me encouraging the change, but now things are happening without my input at all.

Our Title 1 Program helps coordinate assemblies and shows. The first assembly this year was a fun show called Read the Label with Wayne from Maine. It taught kids the importance of looking at the label. They could see the sugar-infused cereal box had 58 ingredients, versus natural rolled oats with one.

That was a big way to start the school year. And we turned that into a one ingredient snack challenge. For one week, children were rewarded with raffle tickets each time they brought in one-ingredient snacks, and at the end of the week they traded their tickets in for all kinds of little incentive items. Kids ended up bringing in a total of 17 different varieties of produce.

Q: What do you have on tap for the future?

A: Another statewide pilot we’ve gotten involved in through the Foundation for Healthy Communities is called 5-2-1-0. The five stands for promoting consumption of five fruits and vegetables a day; the two is for cutting kids’ video game time to two hours or less; the 1 means kids are supposed to add in an hour of athletic activity; while the zero tells kids to reduce sugar-sweetened sports drinks and soda.

We don’t have vending machines in our school as of now, but our school district has vending programs in place with no soda and healthy snack requirements.

We are now starting a steering committee to get other school districts on the same page with consistent guidelines.

Q: What do your own kids think of all you have done?

A: When I first started working on this program, my now high school age kids came to me and said, “Mom, are you responsible for there being no more bacon on my sandwich in the school cafeteria?” They weren’t pleased with me back then!

All joking aside, it has been so rewarding for me to be involved in this program and I have received such positive feedback.

It is wonderful to have people so filled with such enthusiasm as Robin Abodeely. How wonderful all these things are and how incredible that she managed to pull together resources from so many different programs to make so much happen.

Robin deserves nothing but praise for trying to help her local community, and her local community deserves nothing but praise for trying to help the children in the community.

Yet we would like to see PBH add a criteria to its award program. We would like to see a requirement for a research component.

For the truth is that as wonderful and appealing as this program at Dr. Norman W. Crisp Elementary School seems to all of us in the industry, we have no idea whether it is helping the health of the children or will do so in the future.

Did all these efforts result in children being less obese than in other schools where the program wasn’t done? We don’t know; no control group was set up for study purposes.

After the children leave this elementary school and the influence of this program, will they be less obese in five years than children who went to elementary schools without the program? We don’t know; no plan for continuing monitoring is included in the program.

Nobody, least of all this Pundit, wants to be critical of what Nurse Abodeely did here. She is a miracle worker and used her exceptional commitment and enthusiasm to try and help her community. The Mayor should give her a medal.

The produce industry at large, though, has a problem. The Produce for Better Health Foundation, our industry’s premier effort to both increase produce consumption and improve public health, simply does not have the resources necessary to run major national campaigns to improve public health. We can’t compete with individual companies such as McDonald’s or Coca-Cola on media expenditure, much less transform the whole health and fitness culture of a country.

This shortage of funds is not due to any lack of generosity on the part of produce companies. It is unrealistic to expect the produce industry, a mostly commodity industry with thin margins, to fund such a program.

Besides, the primary beneficiary of a switch in public eating and exercise habits is not the produce industry — this is an issue of the general welfare.

We need to be looking for funding among foundations, insurance companies and the government. In fairness, Elizabeth Pivonka and her staff at PBH have been pursuing this for years.

What we don’t actually have, though, is a specific, tested plan that we need funded. In other words, we need to be able to go to the federal government and say, “You are going to spend two trillion dollars on diabetes in the Medicare and Medicaid programs but if we implement plan X, that cost will be only one trillion. So it is well worth it for you to fund a national rollout of plan X for a hundred billion dollars.”

Right now we can’t say that. So when we learn about a great program such as the one Nurse Abodeely has created, we can only wonder if this program rolled across the country might be the answer. And we weep a bit that we don’t have any data to support us in an effort to roll it out.

When PMA began an initiative with Scholastic to encourage produce consumption in children, we pleaded for a research component to judge the effectiveness of the effort.

As the 5 a Day campaign gave way to the Fruits & Veggies — More Matters, we thought it would be churlish to say anything other than best wishes to an effort so many in the industry worked so hard on — yet, what we really wanted was to see a study based on a rollout of More Matters in a test market against 5 a Day in another market and against doing nothing in a third market — only then would we get the kind of hard data that would give the industry the tools it needs to attract substantial outside funding.

When we praised the Food Dudes program both here and here, it was primarily because it was a program that had at least attempted to submit itself to some real research metrics to evaluate its effectiveness. In the end, it was the result of that research that led the Irish government to fund a rollout across the country.

We know that everyone from Nurse Abodeely to the PBH Board of Directors is working-hard and trying to increase healthy eating and increase public health. Our focus, though, needs to shift so the industry is not thought of as the party to pay for this national public health initiative.

We need to think of our roll as the one to handle pilot testing various programs. Incumbent in this roll is that we need to be thinking about how we are going to sell these programs to other parties. In almost every case, this means we will want to have good research proving the results of our pilot programs.

Only then is it even possible to imagine we will get the scale of support we need to roll out these programs and actually begin having large scale impact on both produce consumption and public health.

It is a fine line to walk — and we must be careful not to take away anything from the individuals and organizations trying to do good things right now. We must also, though, start doing the kinds of programs, under the kinds of research conditions that actually might give us a shot of getting the funding that will allow us to obtain our goals.

Many thanks to Nurse Abodeely and the school district and community that have supported her for all their efforts to boost produce consumption and increase public health. Also thanks to Dave Parker for bringing us this intriguing story and this opportunity to think about broader issues.

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