Childhood obesity in the testing era: what teachers and schools can do!

In this era of increasing accountability and high-stakes testing in schools, a serious paradox has surfaced. Children are becoming overweight at an alarming rate, and mounting evidence points to a relationship between obesity and poor school performance. Ironically, pressure to improve children's academic achievement has led many schools to adopt certain policies, such as eliminating recess or reducing the number of physical education (PE) classes, that put children at greater risk of obesity (Cook, 2005). Critics have characterized schools as "obesogenic" environments that promote obesity through sedentary academic work, limited physical activity, and cafeteria fare of low nutritional value (Davidson, 2007). Furthermore, obesity is thought to be particularly of concern for children of minorities and those in poverty, who are already at high risk for underachievement (Centers for Disease Control and Prevention [CDC], 2008b; Mirza et al., 2004).

Teachers and schools can provide powerful leadership to help reverse the worldwide epidemic of childhood obesity while they endeavor to improve children's academic success. This article describes five strategies to guide teachers and schools in the fight against childhood obesity.

Strategy 1: Get in the Know! Stay Informed

Scope of the Problem. Childhood obesity is epidemic in the United States and represents an increasing public health problem worldwide (CDC, 2008b). According to the U.S. National Health and Nutrition Examination Survey (NHANES), obesity rates for U.S. children have risen sharply in a single generation, with rates doubling for preschoolers and quadrupling for school-age children! Although rates have plateaued, one third of children in the United States are currently overweight or obese--health experts caution that these numbers are dangerously high (CDC, 2008b; Ogden, Carroll, & Flegal, 2008).

Multiple influences lead to childhood obesity, including genetic, cultural, and environmental factors. Associated conditions, such as cardiovascular disease, insulin resistance and Type 2 diabetes, orthopedic problems, sleep apnea, psychosocial dysfunction, and other serious problems, can result and threaten a child's health for a lifetime (CDC, 2008a).

Obesity Threatens To Widen the Achievement Gap. Increasing obesity rates threaten to widen the achievement gap that already exists among children. Those who are at highest risk of school failure, children in poverty and minorities, are also at the highest risk of obesity. The rate of increase in obesity for black, Native American, and Hispanic children is double that for white children (Crawford, Story, Wang, Ritchie, & Sabry, 2001; Mirza et al., 2004). Racial disparities in child and maternal health account for nearly one quarter of the school readiness gap between black and white preschoolers, and poor nutrition contributes to this persistent gap. In the United States, poor children become obese from eating too much food that is deficient in iron, B vitamins, and other critical nutrients essential for neural and cognitive development (Currie, 2005).

When schools know the scope of childhood obesity in their area, school leadership is likely to make informed decisions, improve policies, and implement more effective programs to address this crisis. While few states require schools to collect body mass index and fitness data, local health agencies may have statistics that will reveal the extent of the problem. With local data, schools can inform parents and mobilize community obesity prevention efforts.

All school personnel need information and training about this issue. When children are overweight and performing poorly in school, teachers who are well-informed can serve as a resource for children and parents. Providing all teachers with high-quality training on health, nutrition, and physical activity can improve children's chances to beat the odds. One way teachers can stay informed is by reading professional journals and visiting credible websites, regularly.

Strategy 2: Design a School Action Plan

Teachers and schools can create an action plan by:

* Starting early with prevention

* Providing extra support in the early grades

* Self-evaluating and examining school policies and practices

* Collaborating with parents

* Building a school-community partnership.

The Role of Schools. The obesity epidemic is extremely serious and experts worldwide have issued calls to action (Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity, 2007; World Health Organization, 2004). Schools have a unique opportunity to lead the fight on obesity. As hubs in the community, schools have tremendous potential to reach large numbers of children and families. Schools already influence children's eating patterns by providing one or more meals, daily. Physical education opportunities provided at school influence children's patterns of physical activity. School personnel, such as teachers and nurses, can deliver programs designed to improve children's health-related" knowledge and behaviors (Cole, Waldrop, D'Auria, & Garner, 2006; Davis, Davis, Northington, Moll, & Kolar, 2002).

The CDC has developed an instrument called the School Health Index (SHI), which is designed to aid schools in conducting a comprehensive self-assessment. The SHI can be found at http://apps.nccd.cdc. gov/shi/default.aspx and will help teachers, administrators, and advisory committees create an action plan for their schools. The self-assessment helps schools become aware of strengths and weaknesses in their policies and programs related to students' health.

Start Early--With Prevention. We cannot afford to wait--increasingly, obesity is striking younger children. NHANES data reveal that 9.5% of children under the age of 2 are already overweight (National Center for Health Statistics, 2007). Research underscores the need for prevention-focused programs that are implemented early in a child's life (Parsons, Power, Logan, & Summerbell, 1999; Rolland-Cachera, Deheeger, Maillot, & Bellisle, 2006). Prevention strategies can complement existing school readiness programs, such as Head Start and community child care centers. With the trend toward serving younger children in elementary schools and with child care programs being located more commonly on high school campuses, these settings can also be targeted for early prevention programs involving families.

An analysis of the Early Childhood Longitudinal Study (ECLS-K) revealed that children who become overweight between kindergarten and 3rd grade have poorer school outcomes than those who did not become overweight during the early grades. Girls suffered greater consequences than boys, with girls scoring lower on math and reading achievement tests. Teachers reported that overweight girls had less self-control and more social and behavioral problems (Datar & Sturm, 2006). Teachers who notice a weight gain pattern in girls during the early grades can seek collaboration with school health personnel and, together, involve parents. School nurses can give priority to screening young children in the early grades, checking motor development, and paying special attention to the weight status of girls.

Build a School-Community Partnership. When schools can involve not only parents but also agencies and stakeholders in the community, a strong partnership can evolve. As part of the Healthy Youth for a Healthy Future program, the U.S. Department of Health and Human Services has published checklists of steps for parents, caregivers, schools, teachers, and the community to use to prevent obesity in children. These checklists, located at www.surgeongeneral.gov/ obesityprevention/pledges/index.html, are useful in drawing all key stakeholders into the school planning process. Besides offering tangible goals, the program asks parents and teachers to make a firm commitment toward improving their own health, thus becoming good role models for children.

School-community partnerships can be the best use of limited community resources, and they offer a wealth of opportunities for teachers and schools to reach children early. Such partnerships mobilize a variety of health agencies to make services more accessible to families. The concept of a "community school" implies a partnership between the school and the community's health agencies and social services (Blank, Berg, & Melaville, 2006). The American Council for Fitness and Nutrition (ACFN) studied successful grassroots community programs, identifying characteristics of effective obesity prevention programs. ACFN found that programs were most successful when healthful eating and activity topics were taught together in culturally sensitive ways, using positive approaches that emphasized fun and enjoyment. Programs were goal-oriented and used role models who were supportive and never punitive (ACFN, 2006).

Strategy 3: Promote Positive Psychosocial Development of Children

Teachers and schools can promote children's psychosocial development by:

* Fostering a positive and supportive school context

* Helping children develop self-regulation

* Using an authoritative interaction style

* Providing good modeling and social learning opportunities.

Psychosocial Health and School Success. Children who are overweight have lower self-esteem, feel less athletically competent, and are more concerned about their appearance and body image (Franklin, Denyer, Steinbeck, Caterson, & Hill, 2006). They are at higher risk for developing psychological problems, such as depression and eating disorders (Allen, Byrne, Blair, & Davis, 2006). Combining overweight and socioeconomic factors, such as low income, appears to increase the risk of mental health problems in young children (Sawyer et al., 2006). Girls who are overweight appear at greater risk of psychosocial problems, including poor self-control, more conduct problems, and difficulty with social acceptance (Datar & Sturm, 2006; Judge & Jahns, 2007).

The relationship between overweight and low achievement is fairly consistent from early childhood through high school. Psychosocial problems associated with childhood obesity add to the complexity of this relationship. Evidence suggests that school culture--the values and norms of students and teachers--also may influence childhood obesity and its psychosocial effects (Crosnoe & Muller, 2004). Fostering a positive and supportive school context can help children avoid psychosocial problems associated with overweight. Support at school is especially important for overweight girls, who are at high risk of psychosocial problems.

Use an Authoritative Interaction Style. Research has identified four interaction styles of parents and teachers: authoritarian, authoritative, indulgent, and uninvolved. Each style varies on two dimensions: sensitivity toward the child and demands for child self-control. Authoritarian teachers are insensitive and coercive, indulgent or permissive teachers make few demands to help children learn acceptable behavior, and uninvolved teachers provide no support or structure for children. The ideal interaction style is authoritative.

Authoritative teachers respond to children and place developmentally appropriate demands on their behavior (Baumrind, 1991). Authoritative interaction helps children develop self-regulation and thereby builds their competence and self-esteem. Authoritative teachers seldom reward children with food and instead offer choices, which may involve more time for physical activities. Children's eating environments are critical social contexts for the development of eating behaviors. When teachers use an authoritative interaction style during supervision of meals and snacks, they encourage children to try new foods or establish good eating patterns through facilitation. In contrast, authoritarian teachers use coercion, such as the admonition to "Clean your plates!," which interferes with children's self-control and responses to their own natural cues (Patrick, Nicklas, Hughes, & Morales, 2005; Rhee, Lumeng, Appugliese, Kaciroti, & Bradley, 2006).

Provide Good Modeling and Social Learning Opportunities. Social Cognitive Theory (SCT) demonstrates that children can learn by observing and modeling the behaviors of others. Teachers can be powerful role models who promote healthful eating and physical activity. When teachers eat only healthful meal and snack options in view of children, they provide strong modeling that may influence children to choose more healthful snacks. School settings provide many opportunities for social learning. For example, teachers can apply SCT techniques to increase children's physical activity by encouraging non-competitive physical activities, such as dancing, that emphasize participation and social interaction with peers. SCT techniques are highly effective and commonly used in schools. Teachers, in collaboration with school nurses, dieticians, and health personnel, can help use these techniques to promote children's health (Cole et al., 2006).

Strategy 4: Promote Healthy Diet and Nutrition Teachers and schools can promote better nutrition by:

* Helping promote healthful eating habits and good nutrition

* Creating a positive eating environment

* Increasing food security of families in poverty

* Respecting cultural preferences of families.

Diet Quality and School Performance. Fast food has become a dominant dietary staple of many U.S. children, and fast food consumption results in lower quality diets. Americans have become a fast food culture, with consumption of fat-dense, sugary meals and snacks accepted as the norm in all socioeconomic strata (Bowman, Gortmaker, Ebbeling, Pereira, & Ludwig, 2004; Nestle, 2002; Schlosser, 2001). Among American children who are poor and at high risk of becoming obese, insufficient food is not typically the problem. Rather, poor children in the United States are likely to consume more calories than they need, but the foods they consume are high in fat and sugar and low in nutritional quality. Ironically, food-insecure children who miss meals due to their family's lack of resources are more likely to be obese (Currie, 2005). When a school serves children who have food insecurity, it is important to ensure that families have access to community resources that will improve the diet quality of their children.

The link between diet quality and school performance is consistent and has been reported to hold true across all socioeconomic levels. Children who consume a poor diet that fails to meet recommended guidelines for key nutrients experience difficulty in school. Conversely, children who regularly eat a variety of nutritious foods are more likely to experience success in school (Florence, Asbridge, & Veugelers, 2008; Taras & Potts-Datema, 2005). Teaching children about nutrition and good dietary choices is an important responsibility shared by parents and schools.

Help Children Acquire Healthful Eating and Lifestyle Habits. Children acquire their preferences for foods very early in life, and changing these preferences becomes progressively more difficult (Nicklas & Fisher, 2003). The mother's food preferences may limit the variety of foods offered to children (Skinner, Carruth, Wendy, & Ziegler, 2002). Family patterns of feeding children and the kinds of foods that parents offer are influenced by cultural heritage (Briefel, Ziegler, Novak, & Ponza, 2006; Kaiser et al., 2003). Unfortunately, children from minority groups are at higher risk for diets that fail to meet recommended guidelines (Mier et al., 2007). Teachers can successfully deliver curricular lessons aimed at helping children to develop healthful lifestyle habits, such as eating more fruits and vegetables, increasing physical activity, and watching less television (Cole et al., 2006). By preschool, some children have already adopted eating patterns with inadequate nutritional intake of key nutrients, such as iron, zinc, and Vitamin D. It is critical for teachers and parents to encourage children to eat nutrient-rich foods essential for optimal growth and development (Zive, Taras, Broyles, Frank-Spohrer, & Nader, 1995).

Strategy 5: Encourage Physical Activity

Teachers and schools can increase physical activity by:

* Scheduling recommended amounts of physical activity

* Integrating physical activity into a balanced "whole child" curriculum

* Reducing sedentary behavior with enriched school environments.

Increase Physical Activity in the School Day. During this era of emphasis on high-stakes testing and academic accountability, many schools have adopted policies that reduce or eliminate opportunities for PE in favor of increased time for academic subjects. However, no credible evidence exists to support the belief that increasing time in PE during school will have a negative effect on children's academic achievement. To the contrary, evidence shows that increasing time for physical education results in cognitive benefits that may improve children's academic performance (Carlson et al., 2008; Coe, Pivarnik, Womack, Reeves, & Malina, 2006). There appears to be no legitimate justification for reducing physical activity and PE programs in schools. In fact, increasing time for physical activity during the school day is associated with increased academic advantages, especially for girls (Carlson et al., 2008; Datar & Sturm, 2004).

Experts recommend 60 minutes of moderate to vigorous physical activity daily to prevent obesity in children. Elementary schools should provide at least 150 minutes of physical education a week and daily unstructured recess breaks of at least 20 minutes (Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity, June 8, 2007; National Association for Sport and Physical Education, 2008). For younger children, providing many options for fun, gross motor activities within well-equipped free play environments is essential (Bower et al., 2008; Council on Sports Medicine and Fitness and Council on Health, 2006; Timmons, Naylor, & Pfeiffer, 2007). Environment appears to make a difference in the activity levels of young children. Access to well-equipped playgrounds with diverse features and occasional bouts of more structured activity result in increased physical activity, improved confidence, and better motor skills for young children (Bower et al., 2008; Reilly et al., 2006; Reilly & McDowell, 2003).

Reduce Children's Sedentary Behavior Through Enriched School Environments. Children's engagement in such sedentary activities as watching television, playing video games, and using computers increases throughout childhood while the time they spend in physical activity drops. It has been reported that by the age of 23 months, 48% of toddlers are viewing two hours of television per day, and the amount of television viewing rises with age (Certain & Kahn, 2002). Not surprisingly, engagement in sedentary options predicts the amount of time spent engaged in physical activity (Timmons et al., 2007). Consequently, it is critical for teachers to use active instruction integrated into a "whole child" balanced curriculum. Music and movement integrated into academic lessons are attention-grabbing and add extra minutes of physical activity to a child's day. A "move to learn" curriculum approach can significantly increase physical activity of children (Connor-Kuntz & Drummer, 1996; Silence, 2006; Trost, Fees, & Dzewaltowski, 2008).

Conclusion

The sad irony of the testing era is that our zeal to improve children's academic performance has led to a decline in children's health, and childhood obesity rates have risen to dangerously high rates. Paradoxically, some of the school policies adopted to help improve test scores may reduce children's chances of performing well by contributing to their ill health. Clearly, children in poverty, racial and ethnic minorities, and girls in general, have an increased risk of obesity, which might negatively affect their academic achievement. The intent of this article is to raise the consciousness of teachers about this risk and to equip them with strategies for examining school policies and changing practices toward promoting more healthful schools, homes, and community contexts for children. With schools and teachers as key leaders, communities can begin to reverse obesity trends and improve the chances for all children to be successful in school. While much remains to be discovered, mounting research strongly suggests that attention to children's health is critical to improving the school performance and academic outcomes for all children.

Important Websites To Check Often!

U.S. Department of Agriculture

www.usda.gov

American Dietetic Association

www.eatright.org

Centers for Disease Control and Prevention

www.cdc.gov

Robert Wood Johnson Foundation

www.rwjf.org

Kids Health

www.kidshealth.org

American Medical Association

www.ama-assn.org

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Suzanne M. Winter is Associate Professor of Early Childhood and Elementary Education, Child and Adolescent Policy Research Institute, The University of Texas at San Antonio.