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HEALTHY EATING ENVIRONMENTS, POLICES AND
PROGRAMS OF MICHIGAN PRIMARY AND
SECONDARY SCHOOLS:

THE HEALTHY SCHOOLS STUDY

presented by

Richard Anthony Miles

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5108 K lPrq/Acc8Pres/CIRC/Dale0ue Indd

HEALTHY EATING ENVIRONMENTS, POLICIES AND PROGRAMS OF
MICHIGAN PRIMARY AND SECONDARY SCHOOLS:
THE HEALTHY SCHOOLS STUDY
By

Richard Anthony Miles

A THESIS

Submitted to
Michigan State University
in partial fulfillment Of the requirements
for the degree of

MASTERS OF SCIENCE
Food Science and Human Nutrition

2008

ABSTRACT

HEALTHY EATING ENVIRONMENTS, POLICIES AND PROGRAMS OF
MICHIGAN PRIMARY AND SECONDARY SCHOOLS:
THE HEALTHY SCHOOLS STUDY
By

Richard Anthony Miles

Schools have been identified as key public health intervention Sites to promote healthy
eating. The Healthy School Action Tool (HSAT) was designed to assist schools in
moving towards school health through a 3-step health improvement process including
self-assessment, planning, and action. The Healthy Schools Study (HSS) was an
exploratory assessment of school healthy eating characteristics based on the self-
assessment of 332 Michigan schools that completed the HSAT from October 2004 to
February 2007. A majority of the schools that completed the HSAT had Coordinated
School Health Teams (CHST). The prevalences of healthy eating policies, practices and
environments varied, and this variation was associated with school characteristics
including demographics, CSHT characteristics and external resources. Several CSHT
characteristics were associated with desirable healthy eating outcomes. However, the
relationship between healthy offering policies and practices was inconsistent. Further
investigation is needed to describe the relationship between CSHT’S, policies and school

healthy eating outcomes.

Copyright by
RICHARD ANTHONY MILES

2008

Dedicated to God, my family and the children of America

ACKNOWLEDGEMENTS

This thesis was made possible by the collective effort of many individuals who
care deeply about the health of school-age children. Many of these individuals have
dedicated years of hard work to pursuing healthy solution for public health concerns and
share their findings with others. Now, I would personally like to thank them for
supporting me with their resources and expertise while collaborating on this project.

Undoubtedly, I must begin by expressing my gratitude to my advisor, supervisor
and friend, Dr. Katherine Alaimo. She not only provided excellent academic guidance,
training and employment, but a nurturing environment for my personal and professional
development as well. In addition to the intellectual tools she gave me, I truly value her
“people first” philosophy. Throughout my time at Michigan State University, she
demonstrated how a great leader can involve people of various skills sets and interests in
a common cause for the benefit of all. The key is listening to others before taking action
and valuing everyone’s contributions. Well, I would like to let her know I was listening
and I value her as a leading contributor to this project. This philosophy enabled me to
develop the Healthy Schools Study (HSS) with the support of a diverse coalition.

Key partners in this coalition included members of the Michigan Action for
Healthy Kids. The steering committee members, Nick Drzal, Shannon Carney, Diane
Golzynski and others, Obtained the primary data set from the Healthy School Action Tool
(HSAT), facilitated coalition meetings and assisted in key areas of the research process.
Without their participation, the HSS would not have been possible. So I would like to

convey my sincere appreciation for each one of them.

In addition, I would like to acknowledge the members of my guidance committee,
Drs. Stan Kaplowitz and Lorraine Weatherspoon, for their commitment to my graduate
studies and this paper. In particular, I am grateful for Dr. Kaplowitz’s statistical advice
and Dr. Weatherspoon’s guidance in the dietetic program. Additionally, they both
provided great feedback during the development and presentation of the HSS.

Next, I must express gratitude to my teammates in the laboratory. Jennifer,
Deanne, Deb and Caroline, each one Of you are special to me. Thank you all for being so
supportive in my times of need. I look forward to continuing to work with you on the
School Nutrition Advances Kids Study (SNAK).

The Department Of Food Science and Human Nutrition should be recognized for
affording me a quality educational experience. Individuals from the community nutrition
specialization were especially accommodating during my tenure at Michigan State
University. They are truly a great community of academics.

As for my family and God, I would not have survived without your
encouragement and aid. Since long before I made it to Michigan State University, you
gave me all that I needed to succeed. I thank you for you unconditional love. I hope to
make you proud.

Lastly, I would like to relay my appreciation to all those who completed the
HSAT and are striving for school health and beyond. Your hard work was the inspiration

for this study. I hope this study will assist you in your efforts.

vi

TABLE OF CONTENTS

 

 

 

 

 

 

 

 

 

 

 

LIST OF TABLES X
LIST OF FIGURES XII
CHAPTER 1: INTRODUCTION 1
Overview - - 1
Benefits of Healthy Eating for Children -- 2
Healthy Eating Recommendations and Trends 4
Healthy Eating Recommendations .............................................................. 4

Eating Trends .............................................................................................. 5

Healthy Eating Intervention: Schools - 7
Intervention Site .......................................................................................... 7

School Policy ............................................................................................ 10

School Programs ....................................................................................... 1 3

School Environments ................................................................................ 14

School Interventions - - -_ - 15
Measuring School Health Environments -- - 18
School Health Assessment Tools .............................................................. 19

Healthy School Action Tool ..................................................................... 21

Michigan School Health Environments .................................................... 24

Rationale and Study Aims 24
Research Questions and Hypotheses -- -- 26
Organization of Thesis ..... _ 30
CHAPTER 2: METHODS 32
Description of Data Sets - - - - 32
Definitions of Outcomes and Covariates -- 35
Outcomes .................................................................................................. 35

Healthy Eating Policies ......................................................................... 36

Eating Environment ............................................................................... 42

vii

Eating Venues: Healthy Food Availability ............................................ 44

 

 

 

 

 

 

Meal Offerings and Meal Period Structure ........................................... 46

Healthy Meal Preparation and Serving Practices ................................. 50

Covariates .................................................................................................. 52

«- School Type ............................................................................................ 52

Grade Level ............................................................................................ 52

Student Enrollment ................................................................................. 53

Location ................................................................................................. 54

Income .................................................................................................... 54

Independent Variables ............................................................................... 55

Team Nutrition ....................................................................................... 55

Coordinated School Health Team .......................................................... 55

Scales ........................................................................................................ 58

Development of Scales ........................................................................... 58

Software Used in Analysis 68

Description of Analyses by Research Question 68

CHAPTER 3: RESULTS 74

Characteristics of Schools that Completed the HSAT -- 74

Type Of School .......................................................................................... 74

School Grade Classification ...................................................................... 75

Student Enrollment ................................................................................... 76

Location .................................................................................................... 77

Income: F rec/Reduced Eligibility ............................................................. 79

Team Nutrition/Grant Funding ................................................................. 79

Who was involved In the HSAT process? - 81

Coordinated School Health Team Presence and Oversight ...................... 81

Coordinated School Health Team Meeting Frequency ............................. 81

Coordinated School Health Team Member Composition ......................... 81

Associations between CSHT and School Characteristics- 83
What are the prevalences of policies, environments and programs related to

healthy eating among schools that have completed the HSAT? 86

Healthy Eating Polices .............................................................................. 86

Healthy Food Offering Practices ............................................................... 88

Eating Environment Elements (Cafeteria/ Eating Area) ........................... 89

School Meals Programs ............................................................................ 90

Meal Period Characteristics ...................................................................... 90

Nutrition Information and Student Opinions ............................................ 90

viii

Healthy Meal Preparations and Serving Practices .................................... 92

 

Associations between School Characteristics and Healthy Eating Policy ..... 93
Associations between School Characteristics and Eating Environmental

Elements - -- -- 97
Associations between School Characteristics and Venue Offerings ............... 99

Associations between School Characteristics and Healthy Meal Preparation
and Serving Practices - 101

 

Associations between Healthy Eating Policies and Healthy Offering Practices

 

 

103

CHAPTER 4: SUMMARY AND DISCUSSION 105
Summary of Findings - 105
Characteristics of Schools that Completed the HSAT ............................ 105

Who Was Involved in the HSAT Process ............................................... 105

Prevalences of School Eating Policies, Programs and Environments 106
Association between School Characteristics and School Policies, Programs
and Environments ................................................................................... 107
Associations between School Healthy Eating Policies and Practices ..... 109

 

 

Discussion of Findings -- - - - 110
Utilization of School Health Enhancement Resources ........................... 110
CSHT Characteristics and the Coordination School Health Model ........ 111
Prevalences of Eating Policies, Programs and Environments ................. 114
Associations between school characteristics and policies, programs and
environments ........................................................................................... 1 1 8
Associations between Policies and Practices .......................................... 120

Strengths and Limitations -- - - - - - - 121

Conclusion and Recommendations for the Future - ............ - - - 122

 

APPENDIX A: MICHIGAN STATE BOARD OF EDUCATION HEALTHY

EATING POLICY 124
APPENDIX B: LOCATION OF HSAT SCHOOLS BY COUNTY 128
REFERENCES 131

LIST OF TABLES

Table 2.1: Grant Funding Sources in Michigan Requiring HSAT Completion from 2004-

2007 ................................................................................................................................... 34
Table 2.2: HSAT Question 1.2a ........................................................................................ 38
Table 2.3: HSAT Question 1.2b ........................................................................................ 39
Table 2.4: HSAT Question 1.2d ........................................................................................ 41
Table 2.5: HSAT Question 1.3b ........................................................................................ 43
Table 2.6: HSAT Question 1.3c ........................................................................................ 45
Table 2.7: HSAT Question 4.la ........................................................................................ 47
Table 2.8: HSAT Question 4.1b ........................................................................................ 48
Table 2.9: HSAT Question 4.1d ........................................................................................ 51
Table 2.10 HSAT Question 1.] (Coordinated School Health Team) ............................... 57
Table 2.11: Factor Loadings for Scale Items from an Exploratory Factor Analysis ........ 59
Table 2.12: Healthy Eating Policy Scale .......................................................................... 61
Table 2.13 Eating Environment Scale ............................................................................... 63
Table 2.14: Healthy Venue Offerings Scale ..................................................................... 65
Table 2.15: Healthy Preparation and Serving Practices Scale .......................................... 67
Table 3.1: Type of School ................................................................................ , ................ 75
Table 3.2: School Grade Classification ............................................................................. 76
Table 3.3: Average Student Enrollment per School ......................................................... 77
Table 3.5: Average Percentage of Free/Reduce Students per School ............................... 79
Table 3.6: Prevalences of Team Nutrition Schools and Grant Recipient Schools among

School that Completed the HSAT ..................................................................................... 80
Table 3.7: Coordinated School Health Team Presence and Oversight ............................. 81
Table 3.8: CSHT Meeting Frequency during the Last 12 Months .................................... 82

Table 3.9: Coordinated School Health Team Members .................................................... 82
Table 3.10: Number of Member Categories Represented on CSHT ................................ 83
Table 3.11: Associations between school characteristics and presence of a CSHT ......... 84

Table 3.12: Associations between School Characteristic and Presence of a CSHT that
oversees Healthy Eating .................................................................................................... 85

Table 3.13: Percentage of Schools with School-Wide Healthy Eating Policies ............... 87

Table 3.14: Percentage of Schools with Healthy Eating Policies for School Venues ...... 87

Table 3.15: Percentage Of Healthy Eating Venues among HSAT Schools ...................... 88
Table 3.16: Prevalences of Eating Environment Elements ............................................... 89
Table 3.17: Prevalences of USDA School Meals Program Participation ......................... 90
Table 3.18: Prevelances of School Meal Period Characteristics ...................................... 91

Table 3.19: Prevelances of Nutrition Information and Student Food Service Surveys 91
Table 3.20: Prevelances of Healthy Preparation and Serving Practices ........................... 92

Table 3.21: Average Scale Scores for Schools that Completed the HSAT ...................... 93

Table 3.22: Associations between School Characteristics Healthy Eating Policy Scale
based on a Multiple Regression Model ............................................................................. 95

Table 3.23: Associations between School Characteristics and Adoption of MSBE Healthy
Eating Policy based on a Logistic Regression Model ....................................................... 96

Table 3.24: Associations between School Characteristics and Eating Environment Scale
Scores Based on a Multiple Regression Model ................................................................ 98

Table 3.25: Associations between School Characteristics and Healthy Venue Scale
Scores Based on a Multiple Regression Model ............................................................... 100

Table 3.26: Associations between School Characteristics and Healthy Meal Preparation
Scale Scores based on a Multiple Regression Model ......................................... 102

Table 3.27: Associations between Healthy Eating Policies and Corresponding Healthy
Offering Practices based on Multiple Logistic Regression Models ................................ 104

Table 4.1 Comparison of Healthy Meal Preparation Techniques: HSAT vs SHPPS ..... 117

xi

LIST OF FIGURES
Figure 1.1: School Health — Three Legs of Support ......................................................... 10

Figure 3.4: School Location: Number of Schools that Completed the HSAT in Michigan
by County .......................................................................................................................... 78

xii

CHAPTER 1: INTRODUCTION

1.1 Overview

Poor diets can significantly increase the risk for young people Of serious health
problems.1 The United States Department Of Health and Human Services (HHS)
acknowledges healthy eating as a key to the prevention, treatment and amelioration Of
several chronic diseasesz’ 3 Among youth, healthy eating has been recognized to reduce
risk factors for chronic diseases such as cardiovascular disease (CVD). 4'6 In addition,
proper nutrition supports childhood growth, development and performance.7'9

In order to promote healthy eating, schools have been identified as key public
health intervention Sites.lo F ox et al, in a recent review of school intervention literature,
found that schools could promote healthy eating through establishing strong policies and
implementing creative interventions to control foods and beverages offered at school.ll
The authors fiIrther suggested that there is enough evidence to support wide-spread
implementation of school interventions to promote healthy eating among children.

In the state of Michigan, adoption of school health polices and implementation of
school health interventions are controlled at the school district or building level. '2
However, the state supports these actions by providing guidance and recommendations
for the creation, adoption and implementation of school health policies and interventions.
In order to assist schools and districts with these tasks, a special interactive toolkit, the
Healthy School Action Tool (HSAT) was created. The HSAT is a unique school health
measurement and motivational toolkit designed to support schools in moving toward

healthy environments, policies, and programs. Developed by members of Michigan

Action for Healthy Kids in 2004, the HSAT assists schools through a 3-step (1.

assessment, 2. planning, and 3. implementation) school health improvement process.
Prior to 2007, the HSAT consisted of eight separate modules: 1. School Health Policies
and Environment, 2. Health Education, 3. Physical Education and Other Physical Activity
Programs, 4. Nutrition Services, 5. Professional Development/Continuing Education, 6.
School Health Services, School Counseling, Psychological, and Social Services, 7.
Health Promotion for Staff, and 8. Family and Community Involvement; each module
corresponded to one of the components of the Centers for Disease Control and Prevention
Coordinated School Health Model.[3

The producers of the HSAT recommend that schools form a multi-disciplinary
Coordinated School Health Team (CSHT) including school administrators, faculty, staff,
students and community members to work through the HSAT process. 14’ '5 Collectively,
this team is encouraged to promote a healthy lifestyle through the creation and
implementation Of policies, programs and environmental elements. However, the
effectiveness of this prescribed CSHT model has not been extensively studied.16

The Healthy Schools Study (HSS) was an exploratory assessment of school
nutrition programs, policies and environments among schools that completed the HSAT
in the state of Michigan. This study aimed to describe the eating environments of sample
schools and the characteristics of their CSHT’s, and explore potential associations
between CSHT’S and school policies, programs and environments in order to provide a

foundation for school health recommendations and future studies.

1.2 Benefits of Healthy Eating for Children

Inadequate nutrition has become a national concern. The three leading causes Of

death in the United States are chronic diseases (heart disease, cancer and stroke) related

to lifestyle, including diet and physical activity.17 The United States Department of
Health and Human Services (HHS) acknowledges healthy eating as a key to the
prevention of cardiovascular disease, cancer, type 2 diabetes, and other chronic diseasesz’
3 Healthy eating plays a critical role in the health outcomes of Americans. Poor diet and
physical inactivity are leading causes of death in the United States; each year they
account for more than 300,000 deaths. '0

Similar to that of the general population, the youth of America are challenged
with a growing number of health disorders. A recent study of data from the National
Health and Nutrition Examination Survey (N HANES) 2003-2004 found that 19% of
children aged 6 to 11 were overweight and an additional 17% of adolescents were
considered at risk for overweight.18 Additionally, the percentage of children with high
blood pressure (from 1994-2002) has increased along with the prevalence of overweight.4
Childhood overweight and hypertension as well as other risk factors for chronic diseases,
such as cardiovascular disease, diabetes and cancer, can be the consequences of an
unhealthy lifestyle. Healthy eating has been recognized to reduce risk factors
(hypertension and dyslipidemia) for developing cardiovascular disease (CVD) among
youth.5’ 6 In addition to CVD, healthy eating plays a key role in the prevention of
osteoporosis and type 2 diabetes.” 20 The prevention of type 2 diabetes is particularly
critical at this time because of the rapid increase in incidence observed among young
children. 2" 22 Proper nutrition can assist in the regulation of blood glucose and other
metabolic processes, which may assist in the prevention and management of diabetes. 23

The benefits of proper nutrition extend beyond disease control and prevention.

Healthy eating supports childhood growth and development.7 When abnormal eating

patterns are developed, such as those seen in adolescents with anorexia, physical and
emotional development are Often harmed.24 Failure to consume an adequate diet can lead
to nutrient deficiencies, such as vitamin D deficiency, which prevents optimal
development by reducing. peak bone mass.25 In contrast, a healthy diet that provides
adequate nourishment has been shown to have positive effects on oral health and
academic performances’ 9 Specifically, adequate nutrition is associated with the
prevention and treatment of dental caries, periodontal disease and oral cancer; along with
better concentration, test scores, learning capacity and attendance in school. 8’ 9’ 26 Overall
children’s ability to function and perform, including in an academic environment, is

enhanced when they are well nourished.
1.3 Healthy Eating Recommendations and Trends

1.3.1 Healmv Eatingecommendations

In response to the growing body of literature supporting the benefits Of healthy
eating, the United States government has established recommendations to promote good
health. According to the 2005 Dietary Guidelines for Americans, it is recommended that
children and adolescents consume a variety of fruits and vegetables, most grains as whole
grains and low-fat dairy daily along with the recommended dietary allowances (RDA) or
adequate intake (AI) Of specific vitamins and minerals.27 With respect to specific
macronutrients, both the Institute of Medicine’s (IOM) and the American Dietetic
Association (ADA) promote acceptable macronutrient distribution ranges (AMDR) for
children. 28 According to the AMDR’S, children should receive 45 to 65 percent of total
daily calories from carbohydrates. This recommendation mimics that of the adult

recommendation. However, the recommendations for fat and protein are more age-

specific to address special developmental needs. It is recommended that young children
(1 to 3 years old) consume 30-40% and 5-20% of total daily calories from fat and protein
respectively, and older children consume 25-3 5% and 10-30% of these nutrients,
respectively. Saturated fat, trans fat and cholesterol should be minimized. In addition,
both ADA and IOM encourage a diet low in added-sugars. Although there is not a
specific dietary reference intake (DRI) for added sugar, some evidence suggests 310% of
calories could be beneficial. 29 Conversely, high fiber diets are recommended for the
prevention of chronic diseases. 28 Specifically, the National Academy of Sciences and
IOM recommend that children and adolescents consume 14 grams of fiber for every

1,000 kcal of food consumed. 30

1.3.2 Eating Trends

Over the last 25 years several notable dietary trends have been observed in the
American culture. Americans are consuming more fast food meals and meals away from
home, larger portion sizes, and less nutritious food and beverage choices at school.28‘ 3 '
Each of these trends may promote dietary habits which oppose the recommended
guidelines and could result in undesirable health consequences.

The routine consumption of fast food has been associated with poor dietary
habits. A recent study by Paeratakul et al of US. children and adults found that
consumers of fast food were more likely to have higher intakes of fried foods and
carbonated soft drinks, and lower intakes of fruits, vegetables and milk than non-fast food
consumers. 32 In addition, when this consumption pattern was assessed in terms of

specific nutrients, fast food consumers’ intake of total calories, fat, saturated fat and

sodium were found to be higher, and vitamins A and C were found to be lower than that

of non-fast food consumers.32 This consumption pattern could lead to several health
consequences. For example, excessive consumption of total calories and calories from fat
can cause energy imbalance and lead to being overweight and increase one’s risk for
chronic diseases including cardiovascular disease.31 33 Additionally, low vitamin A and C
intake can lead to vitamin deficiency conditions, such as scurvy and xenophthalmia,
along with other disorders (e. g. night blindness). Therefore, routine fast food
consumption could be harmful.

Likewise, the trend towards larger portion Sizes can affect consumer health
negatively. According to Young’s retrospective review of weight trends and portion
sizes, the average body weight of Americans has increased along with typical food and
beverage portion sizes. 34 This strong association between portion size and weight has
lead Young and others to consider the trend towards larger portions sizes as one potential
Contributor to the obesity epidemic. ”’36

The increasing availability of unhealthy foods at school venues is another trend
which can have a harmful impact on the nation’s children. Although the National School
Lunch Program and the National Breakfast Program regulate most meals served at
school, there is little national regulation for the competitive foods sold or distributed
outside of the school meals programs. 37 Competitive foods are often high in added
sugars, fat and calories, which may replace key nutrients required for grth and
learning. 31’ 37

Collectively these trends may significantly contribute to poor dietary patterns for

a wide-range Of consumers including children. On average, the country’s youth are not

consuming enough fruits and vegetables, and are consuming excessive amounts of (total)

calories and calories from fat and sugar.” 38 Continuing these trends could be detrimental
to the health of our population. Therefore, interventions may be necessary to prevent

serious health consequences.
1.4 Healthy Eating Intervention: Schools

1.4.1 Intervention Site

Schools have been identified as key public health intervention sites to improve
nutrition among American youth for several reasons: 1) a large number of children
attend schools, 2) children spend a large amount of time in schools, 3) schools are
platforms for learning, and 4) schools can provide many opportunities to engage in
eating.10 During the 2005-2006 school year, over 55 million children attended primary or
secondary schools in the United States. 39 Michigan alone had 1.6 million public primary
or secondary school attendees in the 2005-2006 school year.39 Hence, school-based
interventions implemented in every school could potentially have an impact on the
school-age population of the nation.

The extensive amount of time children spend in school also provides unique
intervention opportunities. Although the amount of time children spend in school may
vary based on school and student circumstances, minimum standards have been
established by the US. Department of Education and the Michigan Department of
Education to ensure the every child receives academic instruction. 4° 4' Annually
Michigan public schools are required to provide a minimum of 1,098 instructional hours
to students. 42 Schools generally make instruction available to students five days per week

and the typical school day contains instructional lessons in the morning and afiernoon.

The time children spend in school can provide Opportunities for short-tenn as well as
long-term interventions.

Schools are learning institutions and have many useful resources for educational
interventions. 43 Primary and secondary schools have skilled teachers and materials to
educate students on a series Of subject matters including math, science, English, social
studies, and others. The Michigan Department of Education requires that schools within
the state teach curriculum which meets specific standards in each subject area. 44‘ 45
Nutrition education and healthy lifestyle lessons and interventions may be incorporated
into this curriculum for students of various academic levels. 46

Finally, eating opportunities at school may allow for dietary interventions. Within
the traditional American school day, students have the opportunity to eat meals or snacks.
Congress acknowledged the importance of school meals with the creation of the National
School Lunch Program in 1946, which provides federally assisted meals to over 100,000
schools across the country. 47 Since its inception, school feeding programs have been
expanded to include breakfast, after school, and summer meals and snacks. In addition to
federally assisted feeding programs, students can often purchase or receive other foods
from vending machines, snack stations, school stores and others venues at a school. 37
Through each of these venues, schools have the Opportunity to influence the diets of the
students.

Schools can have an impact on the eating behavior Of students in several ways.
Schools may encourage or discourage eating behaviors through traditional classroom

education as well as school policies, programs and environments. Classroom courses

such as home economics and health education may provide children with healthy

knowledge on meal preparation and food selection. However, it is also important to note
that without careful consideration for nutrition and healthy eating behaviors, students
may learn unhealthy habits from these courses as well. For example, if the majority of the
cooking or food preparation lessons in a home economics course focused on baking pies,
cakes and cookies, which are typically high in fat and added-sugar, students may not
learn how to make a nutritionally-balanced meal. The state of Michigan has
acknowledged the importance of a well-constructed health and nutrition education
curriculum and designed the Michigan Model for Health, which includes comprehensive
nutrition education lessons for the classroom- 46

In addition to traditional classroom lessons, nutrition education can be effectively
incorporated into other activities including gardening and cafeteria food service. School
gardening classes have been shown to increase student knowledge and consumption of
fruits and vegetables, while cafeteria food point-of—purchase labeling along with special
events designed to educate and promote healthy foods were reported to influence food
purchases and consumption.‘""52 These non-traditional forms Of nutrition education may
play Significant roles in developing optimal dietary habits among students.

Beyond nutrition education, schools may influence eating behavior through
policies, programs and environments. These policies, program and environments can
discourage or promote healthy eating. For example, at many schools, students may
purchase foods high in fat, sodium and added sugars with low nutritional value, even

though it is well known that frequent consumption of these foods can have adverse health

consequences. 53 On the other hand, to promote adequate nutrition, many schools give

students a reserved period of time to consume lunch each day. During this time students
may eat a nourishing meal before completing the remainder of their school day.

The US. Surgeon General’s Office encourages schools to incorporate supportive
school-wide policies, programs and environments to consistently promote a healthy life-
style throughout the school. '0 These elements can form a supportive triad for school
health that includes healthy eating. (Figure 1.1) The Surgeon General’s Call tO Action to
Prevent and Decrease Overweight and Obesity recommends schools take actions

regarding each Of these elements and collaborate these efforts to support a healthy

lifestyle within the school. '0

Figure 1.1: School Health - Three Legs of Support

 

 

 

 

SCHOOL HEALTH

 

Policy

 

 

 

 

 

 

 

 

 

L

1.4.2 School Policy

School policy is one means to support school health. A school policy is a plan or
course of action intended to influence and determine decisions, actions, and other matters
in a school. Policy can be created by almost any governing body and the scope of the

policy could apply to a nation, state, district, school, department, classroom or other

10

divisions. Policies can be an instrument for supporting healthy lifestyles among youth.
School policies can be developed to promote certain behaviors by requiring or mandating
associated actions. 54

Research supporting the value of school policies relative to health led the federal
government to require every school in the country to have a School Wellness Policy by
2006 through the Child Nutrition and W1C Reauthorization Act (CNRA) of 2004.55 The
act requires school wellness policies contain 5 key components: 1) goals for nutrition
education, physical activity, and other school wellness elements, 2) nutrition guidelines
for foods offered in the school, 3) methods to assure that USDA guidelines for school
meals are being met, 4) a monitoring plan for school food policy, and 5) a process for
involving parents, students, the community, school food service and administration in the
development of the school wellness policy.” 57 Within these requirements, a variety of
policies can be developed. The act was designed to encourage schools to customize their
wellness policy for their particular school or district.

Model policies have been created to assist schools with adopting comprehensive
school healthy policies. For example, the Michigan State Board of Education (MSBE)
drafted a policy on offering healthy food and beverages in venues outside of the federally
regulated child nutrition programs. The policy states a school will offer: 58

1. Whole and enriched grain products that are high in fiber, low in

added fats and sugars, and served in appropriate portion sizes

consistent with the current United States Department of Agriculture

standards.

2. Fresh, frozen, canned or dried fruits and vegetables using healthy
food preparation techniques. Offer 100 percent fruit juice in 12-

ounce servings or less.

3. Nonfat, low-fat, plain and/or flavored milk and yogurt. Offer
nonfat and/or low-fat real cheese, rather than imitation cheese. Offer
the following serving sizes: yogurt in eight-ounce servings or less,
milk in l6-ounce servings or less, cheese in 1.5-ounce (two-ounce, if

processed cheese) servings or less.

4. Nuts, nut butters, seeds, trail mix, and/or soybean snacks in one-
ounce portions or less. Offer portions of three ounces or less of
cooked lean meat, poultry, or fish using healthy food preparation

techniques.

5. Sauces, dressings, and dips in one-ounce servings or less.

This policy along with other model policies may be adopted as is by schools or utilized as
a template to develop their own school policies to promote healthy eating.

However, the development of a policy does not ensure the implementation or
practice of its contents, especially when the policy is not created at the local-level or by
the unit responsible for implementation. 59 Implementation Of policy can be a complex

and challenging process. Therefore, the CNRA requires each school to produce a plan for

12

monitoring their wellness policy and assuring that guidelines established in the policy are
being met. 55

Implemented policies can have a positive affect on programs and the environment
including food offerings and promotional programming practices. For example, in the
Trying Alternative Cafeteria Options in Schools (TACOS) study, the sales of low-fat
foods among students was increased after the implementation of a policy to decrease the
availability of high-fat foods in the school along with low-fat food promotions. 60 In other
instances, policy has been associated with healthy practices and programming including
limiting the hours of Operation for vending machine with foods of low nutritional value
and eliminating programs that include the distribution of food coupons as rewards. 6'
These studies demonstrate the ability of healthy eating policies to support healthy

environments and programming.

1.4.3 School Programs

Programming is another tool available for addressing healthy eating in schools. A
program is a series Of events or other pertinent activities designed around a specific topic
or issue. Programs may be developed in response to a policy, support an existing practice,
or fulfill other related needs. One of the largest school-based healthy eating programs in
the country is the National School Lunch Program (N SLP). 62 The NSLP provides
lunches for students throughout the nation equivalent to at least one third of the nutrients
a school-age child needs each day. Students of low-income households are eligible to
receive free or reduced price lunches from the program.(’3 In 2006, the NSLP served 5
billion lunches to 30.1 million participants across the nation.64 Michigan schools alone

served 137 million lunches to 885,000 students.65 The nutritional requirements of the

13

NSLP are generally considered the standard for school lunch programs in the country.
The guidelines for the program were developed by the United States Department of
Agriculture (USDA) to correspond with the Dietary Guidelines for Americans. 66
In addition to national programs, other state and local programs, such as food
service personnel training programs and farm-to-school programs, are utilized to promote
nutrition in schools. For example, the Coordinated Approach to Child Health (CATCH)
Eat Smart Nutrition Program was utilized in Texas to provide specialized training for the
preparation of meals that met healthful guidelines. 67 The program contributed resources
including recipes and training in low-fat cooking techniques to school food service
departments so that they might be better equipped tO deliver healthy school meals. F arm-
to-school programs have also been utilized to deliver healthful school meals. 68 In the
state of Michigan several schools have developed relationships with local producers to

supply fresh fruits and vegetables which are served in school meals. Programs such as

these can play a key role in supporting school health.

1.4.4 School Environments

The environment is the third support element that may be utilized to promote a
healthy lifestyle in schools. In general terms, the environment is the surrounding
circumstances and conditions in which people Operate and interact. The environment is
commonly subdivided into two areas: 1) physical environment and 2) social environment.
The physical environment includes physical structures and features of the surroundings
such as the seating capacity of the cafeteria and the presence Of water fountains, while the
social environment refers to the behavior or interaction of people including staff

supervision and peer conversations.69

l4

School environments can include the school campus and the community in which
the school is located. Elements of the school’s environments, such as availability of
health food options, advertisements of unhealthy foods and peer support, can encourage
or discourage a healthy lifestyle.70 7' In order to consistently promote a healthy-lifestyle,

schools should consider environmental elements. 10

1.5 School Interventions

Several research studies have shown that the creation and implementation Of
nutrition policies, programs and environmental interventions can have positive effects on
student behavior.” 73 For example, students in the National School Lunch Program
(NSLP) consume more recommended healthful foods (milk, fruits and vegetables), and
fewer foods with little nutritional value (sweetened beverages and candy) than students
that purchase non-NSLP foods.74 However, not all interventions designed to promote a
healthy lifestyle are equally as effective. Thirty-two percent Of the interventions and
programs reviewed by Doak and colleagues were classified as ineffective in childhood
Obesity prevention because they failed to decrease the percentage of overweight
participants or had adverse consequences (e. g. increased the percentage underweight
participants). 75 Therefore, school administrators and staff may benefit from assistance in
designing and implementing programs, policies and environments to promote healthy
eating in their schools. Knowledge obtained from studies, reviews and evaluations of
school-based interventions could serve as a guide for designing, implementing or
improving health interventions at schools.

One desirable outcome of school health interventions is the adoption Of healthy

practices by students and staff. Accomplishing this goal may require the consideration of

multiple factors in the design and implementation process. 76 Experts have developed
several health behavior and health education models and theories to serve as guides in
addressing the complexity of this task. For example, the Social-Cognitive Theory (SCT)
has been utilized effectively to design interventions focused on improving eating and
physical activity behavior.77 This theory, like other behavior-change theories,
acknowledges the complexity of health behavior change by recognizing the roles of at
least seven different constructs and concepts in health behavior (environment, situation,
behaviorally capacity, expectations, self-control, observational learning, reinforcements,
self-efficacy, emotional coping responses, and reciprocal determinism) that could be
considered.69 The framework provided by this theory and others could assist schools and
others in developing effective interventions.

In addition to the general guidelines put forth by theoretical models, intervention
designers should bear in mind the target audience and other unique circumstances of the
intervention situation. A study of school children’s eating patterns in Maryland showed
notable differences in the number Of meals skipped by children attending school in rural
communities versus those in urban communities. 78 Hence, unique intervention may be
needed to meet the specific needs of each student population. Another research team from
Minnesota found that among youth populations, specifically adolescent students, health
behaviors tend to coexist.79 When various health behaviors of Minnesota high school
students were examined, consumption of unhealthy foods was found to be inversely
associated with seat-belt use and teeth brushing.79 This finding supports the notion that it
may be more beneficial to design interventions that address a series Of health behaviors

rather than only one. Neumark-Sztainer and colleagues’ review Of the literature led them

to recommend focusing on adolescent lifestyle and not individual health behaviors.79

These sample specific findings, suggest that an in-depth understanding of the target
population could assist intervention designers in producing effective interventions.

Another consideration when designing school healthy eating interventions is the
availability of food choices in various locations throughout the school. Currently many
schools across the state of Michigan offer more than just the traditional school meals. 80
They have a la carte stations, vending machines, school stores and other food sale venues.
Foods Offered at these venues may differ greatly, especially between schools. Hence,
each school and venue may require Special attention to ensure consistent health
promotion.

In terms of nutrition education, interventions may be required to ensure that all
students receive formal nutrition education in school. Although is it highly encouraged,
nutrition education curriculum is not required for Michigan high school students. 8'
According to the recently instated Michigan Merit Curriculum, the high school standards
in Michigan require one combined credit of physical and health education in which
nutrition education may or may not be included. 45 Still, the Michigan Department of
Education recommends the use of the Michigan Model for Health, a standardized health
education curriculum for health and physical education classes, which includes nutrition
education. However, since schools may choose not to use this curriculum or any other
standardized curriculum with nutrition education components, some Michigan students
may receive little or no nutrition education in high school. 46

Effectively addressing this complex mixture of school health challenges (e. g.

developing and implementing policies, designing effective programs, producing health

promoting environments and instating nutrition education curriculum) may call for the
cooperation of a diverse group of individuals representing different areas of the school
system and community, such as school administration, school food service, teaching
staff, parents, students and others (e. g. healthcare professionals). Researchers have found
that in certain cases more than staff and administrative involvement were needed to
effectively deliver desirable outcomes, and that schools could benefit from the support of
families, the community and other organizations. 60’ 82 Therefore, Michigan Action for
Healthy Kids and others (e. g. Centers for Disease Control and Prevention) encourage
schools to form a multi-disciplinary team (administrators, teachers, parents, students,
healthcare professionals, and community members) to address school health. 83’ 84 The
team is referred to as a Coordinated School Health Team (CSHT) or school health
council.

A CSHT could be an asset in school health promotion for several reasons. 85’
86One value of a multi-disciplinary collaboration is that persons of various disciplines
could promote a healthy lifestyle within the school in different ways based on their
expertise. For example, administrators likely have the ability to change policy, food
service staff could modify the foods available to the students, and physical education
instructors could teach children ways to stay or become physically active. When

coordinated together, these efforts by the team could offer a school-wide consistent

message to promote a healthy lifestyle including healthy eating.

1.6 Measuring School Health Environments

The self-assessment, planning and action model recommended by the Centers for

Disease Control and Prevention (CDC) and Michigan Action for Healthy Kids (MAFHK)

for a CSHT to undertake school health issues is a three-tier process. 87' 88 Although the
approach has various names around the world (e. g. comprehensive school health model
and health promoting schools model), the process follows the same general guidelines.89’
90 The process begins with the gathering of information about the current environment
(determining strengths and weaknesses), planning changes and implementing the plan.
Knowledge of current school health programs, policies and environments can
provide a firm foundation on which to begin building future interventions. Evaluation of
this knowledge is valuable to the process of making environmental improvements or
sustaining successes. 9' However, there has not been an extensive evaluation of school
health policies, programs and environment in the state of Michigan. '6 Therefore, studies
designed to assess these school health elements may provide beneficial information about

the health of Michigan schools.

1.6.] School Health Assessment Tools

Tools have been developed to assist schools and researchers in gathering
information about school health policies, programs and environments. The School Health
Index (SHI) is one of the most widely recognized self-assessment and planning guide in
the United States. The SHI was created by the Centers for Disease Control and
Prevention (CDC) in 2000 (and revised in 2004).92 This tool utilizes eight modules to
cover the wide spectrum Of school health elements.1 The eight modules are grouped
together and presented in two forms, one designed specifically for primary (elementary)

schools and the other for secondary (middle and high) schools. The School Health

 

1 Modules: 1) School health and safety policies and environment; 2) Health education; 3) Physical
education and other physical activity programs; 4) Nutrition services; 5) Health services; 6) School
counseling, psychological, and social services; 7) Health promotion for staff; 8) Family and community
involvement

19

Policies and Programs Study (SHPPS) is a national surveillance program which uses SHI
and interviews to measure the health environment and monitor the progress of schools
around the country.93 Data collected from this program is analyzed on the state, district,
school and classroom level. Results of the analyses are used to determine if schools are
meeting the national recommendations. Beyond measuring and monitoring school
environments, the SH1 is also designed to assist schools in: (1) identifying the strengths
and weaknesses Of their health-promotion policies and programs, (2) developing an
action plan for improving student health, and (3) involving teachers, parents, students,
and the community in improving school policies, programs, and services.92 The
utilization of the SHI has effectively led to school improvements by assisting schools in
healthful policy creation and implementation.94

In order to build upon the success of the SHI, the United States Department Of
Agriculture (USDA), the Food and Nutrition Service (FNS) and Team Nutrition (TN)
created “Changing the Scene: Improving the School Nutrition Environment” (Changing
the Scene).2 This toolkit follows the same basic principals as the SHI, but focuses
Specifically on nutrition and healthy eating. Changing the Scene is primarily a motivation
tool for encouraging change in the school nutrition environment and it provides a less
comprehensive assessment of the school health environment than the SHI.

Another tool developed that gathers information about school health
environments is the Elementary School Environment and Policy Survey (SEPS). The
SEPS was created by a team of colleagues at the Rocky Mountain Prevention Research

Center from the University Of Colorado to measure the environment Of local elementary

 

2 Changing the Scene: Improving the School Nutrition Environment website
http://www.i‘ns.usdagovhn/Healthv/changing.html

20

schools in response to the growth of obesity and other chronic diseases in the youth
population of the state.95 The SEPS has recently been adapted for middle schools in
collaboration with researchers from Michigan State University and representatives from
Michigan Action for Health Kids. The SEPS was developed to provide in—depth
assessment Of nutrition and physical activity elements in schools and has been utilized as

a surveillance tool, similar to the SHPPS.

1.6.2 Healthy School Action Tool

The Healthy School Action Tool (HSAT), like the SH1, Changing the Scene and
SEPS, may be utilized to assess elements of the school health environment. The HSAT is
a unique school health measurement and motivational tool that was designed specifically
for Michigan schools. The HSAT is the product of the Michigan Health Advisory Group
(MHAG) and Michigan Action for Healthy Kids (MAFHK). The MHAG was established
to provide guidance to schools and assist in the development of statewide
recommendations. Experts on youth health issues from around the state of Michigan were
invited to join the advisory group. The MHAG was comprised Of the Michigan
Department of Education, Michigan Department of Community Health, and the Michigan
Govemor’s Council on Physical Fitness, Health and Sports. This committee produced
“The Role of Michigan Schools in Promoting Healthy Weight”, an evidence-based
document designed specifically to address the health of Michigan schools, especially
obesity.13 The paper describes the built environment, social environment, status Of
nutrition and physical activity among Michigan students, and ways to improve school

health environments.

21

The advisory council determined that the implementation of state school health
recommendations would require a collective effort from districts, schools and
communities. Several key players were identified in the school intervention process
including school administrators, food service directors/managers, physical education
teachers, health and life management teachers, school nurses, parents, students, and
community members. The desire to connect the recommendations with key players in
districts, schools and communities led to the production of the HSAT.

The HSAT was adapted from the School Health Index for Physical Activity,
Healthy Eating, and a Tobacco-Free Lifestyle: A Self-Assessment and Planning Guide
from Centers for Disease Control and Prevention (SHI) and the Changing the Scene
Healthy School Nutrition Environment Improvement Checklist create by USDA, Food
and Nutrition Service, and Team Nutrition (Changing the Scene). Experts from key state
departments and related organizations customized the elements of the tool to fit the
profile of Michigan’s schools. The development of the HSAT was a collaborative effort
(Michigan Department Of Community Health, the Michigan Department of Education,
Michigan State University Extension, Michigan Team Nutrition, and United Dairy
Industry Of Michigan).

According to its developers, the functions of the HSAT online assessment were to
assist Coordinated School Health Teams (CSHT’S) in determining if their “school’s
environment gives Opportunities for students to make healthy choices and Offers
consistent messages about the importance of healthy eating, physical activity, sun safety
and a tobacco-free lifestyle, and to provide a forum for action planning.” 83 The HSAT,

prior to being revised in November of 2007, consisted of eight separate modules (1.

22

School Health Policies and Environment, 2. Health Education, 3. Physical Education and
Other Physical Activity Programs, 4. Nutrition Services, 5. Professional
Development/Continuing Education, 6. School Health Services, School Counseling,
Psychological, and Social Services, 7. Health Promotion for Staff, and 8. Family and
Community Involvement); each corresponded to one of the components of the CDC
Coordinated School Health Program, and all followed a similar format. ‘3 Every module
contained multiple-choice questions for a school’s CSHT to answer about the module
topic along with links to an electronic resource guide which schools could utilize tO
gather more information about the topic of interest. Responses to the items in each
module corresponded to points. The quantity of points given for each response was based
on evidence found in the Role of Michigan Schools and Promoting Health Weight and
other scientific literature. When all questions in the assessment were completed, a
scorecard was provided to the school, which enabled the school to compare itself to the
ideal score. The assessment revealed the school’s strengths and weaknesses, and provided
a resource guide with recommended actions to improve the school’s health environment.
Upon completion of the assessment, the school’s CSHT was prompted to develop an
action plan to improve the schools health environment. The action plan template provided
to the team took into consideration the feasibility of actions by considering factors such
as cost, time, support and importance. Upon completion of an action plan, CSHT’S were
encouraged to implement the action plan, monitor the school’s progress, and reassess

periodically and update their action plan accordingly.

23

1.6.3 Michigan School Health Environments

In the state of Michigan, schools are managed primarily by local entities or school
districts. Typically, these school districts determine the policies, programs and
environments in place within schools. The state of Michigan contains over 835 school
districts which vary in structure, management style and emphasis on school wellness. 96
These differences and others may significantly contribute to variations observed in school
health environments. The School Health Policies and Programs Study’s found wide
variation in the nutrition and physical activity policies, programs and environments
among Michigan school districts.93 Some of these variations, such as differences in
school nutrition policies, are related to measurable factors recorded by the Healthy
School Action Tool (HSAT). An analysis of this information collected by the HSAT may
assist in determining elements associated with variations in the school health

environments.

1.7 Rationale and Study Aims

The Healthy Schools Study (HSS) was a cross-sectional exploratory assessment
of school nutrition programs, policies and environments among schools that completed
the HSAT in the state of Michigan. This study utilized the HSAT data collected from
Coordinated School Health Teams (CSHT’s) and other school staff members, educators,
related professionals and community members from across the state between October
2004 and February 2007. This study was the first in Michigan to extensively evaluate the
school nutrition policy, program and environmental self-assessment data from the
Healthy School Action Tool (HSAT).

The HSS aims were specifically:

24

a. To provide a description of the school healthy eating environments among
those schools that completed the HSAT between October of 2004 and
February of 2007. A descriptive analysis of the school health environments was
conducted to determine strengths, weaknesses and areas where Michigan’s
schools could improve. Dissemination of the study’s findings could be used to
build awareness of the successes and gaps regarding healthy eating policies,
programs and environments in Michigan schools, and lend support in the
development of plans for healthy eating policy, program and environmental
improvements for Michigan’s schools.

b. To explore differences in school characteristics between schools with a
CSHT that oversees healthy eating, schools with a CSHT that does not
oversee healthy eating and schools without a CSHT. The presence and
oversight of C SHT’s are important parts of the state-recommended HSAT
process for school health. This study explored differences in school
characteristics among schools with and without a CSHT along with schools that
have a CSHT to oversee healthy eating. Differences between these schools may
add to the current understanding of the CSHT model in Michigan schools.

c. To explore the relationships between the CHST model and school nutrition
policy and environmental elements. The CSHT model is currently
recommended for the HSAT process and improving school health by the State of
Michigan. However, there is little evidence available to support the effectiveness
of using the CSHT model. 97' 98 This study investigated the differences in the

healthy eating policies and environments between schools using the CSHT model

25

without a focus on healthy eating, schools using the CSHT model with a focus on
healthy eating, and schools who did not use this model. In addition, the
associations between other CSHT characteristics (CSHT meeting frequency and
member composition) and healthy eating policies and environments were also
investigated.

(1. To investigate the relationships between healthy eating policies and
corresponding practices. One of the primary goals of the CSHT model and the
HSAT process is to create healthy school policies. In theory, these policies
should support healthful programs, practices and environments.99 However, the
relationship between policy and environment is not well understood. This study
investigated associations between food offering policies and food offering
practices.

e. To offer information about schools that completed the HSAT to Michigan
Action for Healthy Kids Coalition (MAFHK). Findings from this study will be
provided to MAFHK and partners. This was the first in-depth analysis Of the
HSAT healthy eating items, and the study’s findings may be useful to MAFHK

and its efforts to promote school health.

1.8 Research Questions and Hypotheses

The specific research questions of the study were:

26

Research Question 1: What are the characteristics of the schools that completed the

HSA T between October 2004 and February 200 7?

To answer this research question, a description of the study sample was created
based on school characteristics. Schools were characterized by their type (c. g. public),
grade level (e. g. elementary), student enrollment, location and income. The sample
schools were then compared to the Michigan school population. In addition, the
percentages of schools in the sample that were members of Michigan Team Nutrition

(TN) and HSAT-related grant recipients were determined.

Research Question 2: Who was in valved in the HSA T process?

The Healthy School Action Tool (HSAT) was designed tO be a team-orientated
process. Schools are encouraged to build a Coordinated School Health Team (CSHT) and
collectively complete the HSAT process. However, schools may complete the HSAT
without forming a CSHT. In addition, the composition of CSHT could vary greatly from
school to school. Therefore, the frequency and percentage of schools within the sample
that have a CSHT along with the types of members (e. g. administration, food service
department, student, etc.) represented on each team were determined. Additionally, an
exploratory assessment Of the relationship between CSHT characteristics (presence and
oversight) and school characteristics was conducted to determine if any associations

exist.

27

Research Question 3: What are the prevalences of policies, environments and

programs related to healthy eating among schools that have completed the HSA T?

School policies, environments and programs can have an impact on student eating
behavior. 100‘ '0' Thus, an assessment of the policies, programs and environments in place
at the sample schools based on HSAT self-assessment items was conducted. The
prevalence of each HSAT item pertaining to a nutrition policy, program or enviromnent
was calculated. In addition, scales were created by combining categorically similar
HSAT items to represent four separate areas of school healthy eating. Scales included a
healthy offerings policy scale, an eating environment scale, a healthy offerings at school

venues scale, and a healthy meal preparation and serving practice scale.

Research Question 4: What are the relationships between school characteristics,
healthy eating polices and healthy eating environments existing in a school at the time

the HSA T self-assessment was completed?

Four hypotheses were developed which described the likely relationships between
CSHT characteristics recorded by the HSAT assessment and the types of policies and
environments existing in a school. In addition, other factors were tested for associations
with school policies and environments, including: school demographics, Team Nutrition
membership, and grant funding. The existence of associations between these factors, and

the magnitude and the direction of the relationships are described.

Hypothesis 1: Schools that have a CSHT that oversees healthy eating are associated

with an increased number of: 1) healthy eating policies (written and enforced), and 2)

28

positive environmental factors (I. adequate, safe and encouraging cafeterias and serving
areas, and 11. healthy food preparation and offering practices) when compared to schools
that do not have a CSH T or have a CSHT that does not oversee healthy eating.

The creation and implementation of healthy eating policies and environments are
ways to promote healthy eating. Teams overseeing healthy eating would likely produce a
greater number Of policies and environmental changes to address healthy eating than

schools without a team in place or with a team that oversees other areas of school health.

Hypothesis 2: The number ofCSHT meetings held in the last year is positively
associated with the number of: 1) healthy eating policies (written and enforced), and 2)
positive environmental factors (I. adequate, safe and encouraging cafeterias and serving
areas, and 11. healthy food preparation and oflering practices)

Since the goal of a CSHT is to enhance school health, CSHT meetings are
generally held to facilitate the sharing of expertise and resources to address that goal. One
reason the number of CSHT meetings may be associated with the number of polices and
positive environmental elements in a school is that each CSHT meeting may be an
opportunity to collectively establish policies or positive environmental changes. Plus, the
number of CSHT meeting could reflect how active the team is in pursing its goals. Each
meeting demonstrates effort on the part of the CSHT to work towards healthful outcomes.
Therefore, a greater number of CSHT meetings could represent a greater effort towards

achieving outcomes.

29

Hypothesis 3: The number of representatives on a CSHT is positively associated with the
number of' 1) healthy eating policies (written and enforced), and 2) positive
environmental factors (I. adequate, safe and encouraging cafeterias and serving areas,
and 11. healthy food preparation and ofi’ering practices)

One potential advantage Of the CSHT model in creating and implementing
healthy policies, programs and environments is the collective effort of a team with
diverse expertise and resources. Increasing the number of representatives on the CSHT
could increase amount of expertise and resources available to the team. Healthy eating
policies and positive environmental factors may be created more effectively with these

additional resources.

Hypothesis 4: Schools' healthy offering policies are associated with healthy offering
practices in school food distribution venues.

The state and federally supported CSHT model encourages the creation of school
health policies. School health policies are intended to influence environments and
behaviors. Therefore, nutrition and healthy eating polices should be associated with
corresponding healthful eating environments and practices. A comparison of healthy
offering policy and healthy offering practice scales was conducted along with direct
comparisons of individual policies with corresponding individual practices to determine

if associations were present.

1.9 Organization of Thesis

This thesis is organized by the following sections: introduction (Chapter 1),

methods (Chapter 2), results (Chapter 3) and discussion (Chapter 4). References cited in

30

the text are displayed following Chapter 4. Tables and figures which are not found within

the text are included as appendices.

3l

CHAPTER 2: METHODS

The Healthy Schools Study (HSS) was conducted using a retrospective
collaborative research approach. This method entailed university researchers working in
collaboration with community organizations and state institutions to evaluate existing
data from the Healthy School Action Tool (HSAT). This research project was a
partnership between Michigan State University and members of the Michigan Action for
Healthy Kids Coalition (MAFHK) (Michigan Department of Community Health,
Michigan Department of Education, Michigan State University Extension, United Dairy
Industry of Michigan, National Kidney Foundation, American Cancer Society, Michigan
Team Nutrition, and Michigan Public Health Institute). The research questions and
analyses were developed with the assistance of several coalition members, and findings

from this study will be shared with MAFHK and other partners.

2.1 Description of Data Sets

The primary dataset used for the Healthy Schools Study (HSS) was responses to
the Healthy School Action Tool (HSAT) by Michigan primary and secondary schools
who completed the self-assessment portion of the tool online between October of 2004 to
the February of 2007. All Michigan schools with at least one grade level from
kindergarten through twelfth grade were eligible to complete the HSAT. Schools were
notified Of the HSAT’S availability by email, letters and posting promotions conducted by
MAFHK and its partners. In addition, the HSAT was publicized by the Michigan State
University Extension (MSUE) and Team Nutrition (TN) through website postings and

printed materials such as newsletters.

32

Completion of the HSAT was voluntary and there was no cost to the schools.
However, some state-based grant programs required completion of the HSAT to receive
grant funding. For example, school nutrition-related grants provided by Michigan Team
Nutrition, Michigan Department of Education and Michigan Department of Community
Health since the fall of 2004 required the completion of the HSAT for funding. However,
not all grants which required the completion of the HSAT for funding were nutrition-
related. A description of the grants distributed requiring completion of the HSAT during
the data collection period is shown in Table 2.1.

Some schools that were selected to receive these grants (12.8%) were not
included in the sample because they did not complete the HSAT online during the
monitoring period. Completion of the HSAT online may not have occurred during the
monitoring period for several reasons: 1) schools completed the HSAT after the end of
the monitoring period, 2) schools completed a paper-version of the HSAT and never
recorded their responses online, and 3) schools were granted permission to complete the
SHI as an alternative to the HSAT. From the time the HSAT was first introduced online
until February of 2007, 332 schools completed the online self-assessment portion of the
tool. These self-selected schools were the sample for the HSS study.

Data collected by the HSAT online assessment tool were downloaded from the
website and organized by modules into a series of Microsoft Excel databases. The
databases were then transferred into STATA 10.0 statistical software data files and
merged for statistical analysis. Information from Module 1 (School Health Policies and
Environment) and Module 4 (Nutrition Services) provided the primary basis for the HSS

analysis.

33

 

 

 

 

 

 

 

 

 

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In addition, complementary data was obtained from the records Of the Center for
Educational Performance and Information (CEPI). The CEPI collects information about
Michigan K-12 schools to determine compliance with state and federal laws. '02 This
information includes building-level data, individual personnel data and individual student
data. Building-level data from the CEPI database was used in the HSS to determine
school type, grade level, student enrollment, location, and the percentage of free/reduce
lunch eligible students for the HSAT sample and the Michigan school population. This
data was downloaded in the form of two subdatabases, the 2005-2006 Free and Reduced
Lunch Building Dataset and the School Code Master State Dataset. '03 '04 The
information from these databases were merged with the HSAT data in STATA 10.0

statistical software prior to analysis.
2.2 Definitions of Outcomes and Covariates

2.2.1 Outcomes

Outcome variables for this study included: school healthy eating policies, eating
environmental elements, food Offerings in eating venues, meal preparation practices, and
meal period structure. Each outcome variable was determined by schools’ responses to
HSAT items. The HSAT items for each outcome are described in this section. In addition
to the descriptions provide in this section, corresponding examples and definitions
pertaining to HSAT items were available to school when completing the HSAT through
weblinks. Some of these examples and definitions are presented in corresponding tables

(see Table 2.2 — 2.10) throughout this section.

35

2.2.1.1 Healthy Eating Policies

In order to assess healthy eating policies, responses from a series of related items
found in the first module (School Health Policies and Environment) of the HSAT were
analyzed. Each item pertained to a different type of policy a school could have adopted.
Three types of multiple choice questions were included in the item series.

The first group of policy question items allowed for three categorical responses
(“NO written policy”, “Written policy exists” or “Written policy exists and is enforced”)
(see Table 2.2). Schools selected one Of the Options for each policy in the section (HSAT
Question 1.2a). The policies in the section included: “Prohibits use of food as a reward”,
“Prohibits withholding food as a punishment” and “Offers predominately healthy
food/beverages for classroom celebrations/parties”. Foods and beverages were
considered healthy if they met the nutrition-based guidance established by the Michigan
Department of Education’s Policy on Offering Healthy Food and Beverages Outside of
the Federally Regulated Child Nutrition Programs (MSBE Healthy Eating Policy) (see
Appendix A).

The policies in the second group of items included: “Prohibits the use of the sale
of foods with low nutrient value in school fiindraising”, “Stipulates that predominantly
healthy foods and beverages are offered at school events”, “Stipulates that predominantly
healthy foods and beverages are offered in school stores”, “Stipulates that predominantly
healthy food and beverages are Offered as a la carte options” and “Regulates hours that
vending machines containing food or beverages with low nutrient value are accessible to
students”. In this section schools selected from four categorical responses: “No written

’9 66

policy , Written policy exists”, “Written policy exists and is enforced”, or “Not

36

Applicable” (see Table 2.3). Schools selected one of the options for each policy in the
section (HSAT Question 1.2b). The “Not Applicable” response category was intended for
schools which did not sell or distribute food or beverages in the venue. Foods of low
nutritional value were considered foods, beverages or candies which provided their
calories primarily from sugar and/or fat and contained few vitamins or minerals, such as
chips, soda pop and candy.

The third type of policy item allowed for only two responses: “Yes” or “No”.
There was only one policy item in this format. Schools selected whether or not they had
adopted the state recommended comprehensive policy (MSBE Healthy Eating Policy)
created by the Michigan State Board of Education as a guide for foods Offered outside of
the federally funded meal programs (see Table 2.4). The policy contains nutrient
requirements and portion sizes for foods sold or distributed in vending machines, a la
carte stations, school stores, concession stands, classroom parties and other venues

throughout the school.

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2.2.1.2 Eating Environment

The physical eating environment was included in this study because of its
importance to the “Healthy School Nutrition Environment.” '05 A clean, well-maintained
cafeteria with appropriate amenities can have several benefits such as the promotion of
food safety, limitation of allergens, and encourage children to eat school prepared foods.
106.107 The responses to the eating environment items from HSAT Question 1.3b were
assessed (see Table 2.5). Schools selected all of the environmental elements present in
their school from a list of ten potential items, including: “Tables/eating surfaces are

9,

cleaned between lunch periods , “The physical structure of the cafeteria/eating

environment does not need repair“, “The tables/eating surfaces and chairs are undamaged
AND the appropriate size for students”, “There are enough tables/eating surfaces and
chairs for all students to sit while eating”, “Adults properly supervise the cafeteria/eating
environment and role model healthy eating practices “, “Drinking fountains are available
for students to get water at meals and throughout the day”, “Positive and consistent
messages about healthy eating are provided throughout the school “, “Noise level in
eating areas is appropriate; students aren’t required to be silent“, “There is an opportunity

for students to wash hands before eating” and “The cafeteria/eating environment is

attractive, appealing and inviting”.

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43

2.2.1.3 Eating Venues: Healthy Food Availability

Assessment of healthy food offering outside of the school meals was based on
responses to seven related items in the first module of the HSAT (see Table 2.6). Schools
indicated in which venues healthy foods were available to students. The venues in
question included: vending machines, a la carte, school stores, concession, school events,
classroom parties/celebrations, and fundraisers. Healthy foods were defined by the
nutrition-based guidance established in the Michigan State Board of Education Policy on
Offering Healthy Food and Beverages Outside of the Federally Regulated Child Nutrition
Programs (MSBE Healthy Eating Policy) (see Appendix A). Based on the design of the
HSAT item, schools that offered no foods or beverages in a venue were placed in the

same category as schools that offered healthy options rather than unhealthy options.

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45

2. 2. 1.4 Meal Offerings and Meal Period Structure

The structure of the meal period and the food offered during the meal can affect
the eating behavior of consumers. '08 Two groups of items from the fourth HSAT module
(Nutrition Services) described elements of the schools’ meal offerings and meal period
structures including participation in feeding programs and recess (free time in which
physical activities can be done) coordinated with the meal period. Responses to these
items were assessed.

For the first group of “School Food Service Program” items, schools selected
whether or not their school offered each of the 5 items listed in HSAT Question 4.1a (see
Table 2.7). These items included: “The USDA School Breakfast Program”, “The USDA
National School Lunch Program”, “Low-fat (1/2 or 1%) or fat-free every day”, “At least
20 minutes to eat lunch after students obtain food”, “Meals are scheduled at appropriate
times and do not conflict with other activities”.

The second group of “School Food Service Program” items from HSAT Question
4.1b allowed for three categorical responses (“Not Offered”, “Offered” and “Not
Applicable”). The “Not Applicable” response was intended for schools which did not
offer school meals. The food service items in HSAT Question 4.1b included: “Meals that
are fully accessible to all students”, “Meals that include a variety of foods”, “Meals that
include appealing foods”, “Meals that include low-fat foods daily”, “Lower fat meats
every day”, “At least 10 minutes to eat breakfast afier students obtain food” and “Recess

before lunch rather than after” (see Table 2.8).

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2.2.1.5 Healthy Meal Preparation and Serving Practices

The ingredients used by and preparation techniques of school food services play a
critical role in the nutritional value of foods served. For example, choosing lower fat
ingredients and preparation methods could reduce the amount of total fat and calories in
the meal. Responses gathered from a group of items in the fourth module of the HSAT
described eight fat—reducing practices schools may have employed. This data was
analyzed in the HSS.

Schools selected the practices their school food service had done consistently in
the past 12 months. Three response options were available for this group of items: “No”,
“Yes” and “Not Applicable”. The “Not Applicable” response was intended for schools
that did not serve school meals. Practice items available in this section included: “Baking,
roasting or broiling meat more often than frying”, “Sauces, dressings or dips offered
included low-fat or non-fat options and portion size was limited to one-ounce servings”,
“Serving skinless poultry”, “Using low-fat or non-fat real cheese“, “Serving cooked
meats in portion sizes of three ounces or less “, “Preparing vegetables with minimal fat”,
“Thoroughly draining fat from ground meats“ and “Cooking with non-stick spray or pan

liners“ (see Table 2.9).

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2.2.2 Covariates

2.2.2.1 School Type

The type of schools within the sample and the Michigan school population were
determined by a classification system produced by Michigan Department of Education
and the Center for Educational Performance and Information. These data were gathered
from the 2005-2006 School Code Master Database. ‘04 Schools were classified into one
of the following categories: Public School (Local Education Agency), Charter School
(Public School Academy), Private School (Nonpublic School), and Other (Ancillary
Facility). Each school type classification represents a different institutional governing

structure.

2.2.2.2 Grade Level

Schools within the state of Michigan can contain many combinations of grade
levels, and the Michigan Department of Education has different educational standards for
these grade levels. ln order to account for these variations, each school within the sample
and the Michigan school population was categorized into one of six categories based on
grade levels taught within the building. This categorization scheme was developed by the
Center for Educational Performance and Information. The grade-level data were taken
from the 2005-2006 School Code Master Database. ‘04 Schools were considered
elementary schools if all the grades taught in the school were between kindergarten and
sixth grade. Schools were classified as middle schools if all the grades taught in the
school were between sixth grade and eighth grade. If a school had sixth grade students

only it was considered an elementary school. Schools were considered high schools if all

52

the grades taught in the school were between ninth and twelfth grade. Schools that
contained grades from a combination of elementary, middle and high school were
classified in the following manner --1) schools with grades between kindergarten and
eighth grade that were not previously classified as elementary or middle were considered
elementary-middle schools, 2) schools with grades between sixth grade and twelfth grade
that were not previously classified as middle or high schools were considered middle-
high schools, 3)schools with grades between kindergarten and twelfth grade that were not
previously classified were considered elementary-high schools, and 4) schools that taught
only pre-kindergarten, alternative education, special education, adult education or
career/technical education were excluded from the analysis.

During statistical analysis a modified categorical variable was created to represent
school grade-level variation. This variable had three categories: primary school
(elementary school), secondary school (middle school, high school, and middle-high
school) and combination school (elementary-middle school and elementary-high school).
This was done to reduce the number of grade level categories, thus increasing the

simplicity of the analyses and results.

2.2.2.3 Student Enrollment

The number of students in a school may not only have an impact on the size of the
school, but the resources a school receives from the state and federal government. State
and federal educational funding distributed to each school varies based on student
enrollment. '09 The number of students enrolled at a school building during the 2005-
2006 school year represented school enrollment in the HSS. This information for the

study sample and the Michigan school population was gathered from the 2005-2006

53

104

School Code Master Database. In order to correct for the skewed distribution, student

enrollment was logarithmically transformed for all regression analyses.

2.2.2.4 Location

The location of each school was classified by county. The state of Michigan has
83 counties spread across two peninsulas. Each county has a unique governing body
which may influence local schools. The county of each school in our sample and each
school in the state of Michigan was gathered from the 2005-2006 School Code Master

Database. '04

2.2.2.5 Income

The income of a school or school district may determine the resources the school
has available to promote school health. Although most Michigan schools receive revenue
from federal, state and local sources, local income contributes over 20% of the average
income per pupil. ‘09 These local revenues are typically generated primarily from
property taxes which are paid by families and businesses residing in the area.

Since the income of the students’ household determines their eligibility for
National School Lunch Program free or reduced price lunch and this information is
readily accessible. Students’ eligibility for free or reduced price lunch in the National
School Lunch Program was utilized as the income marker in the study. Percentage of free
and reduced lunch eligible students in a school was the variable used in the analyses. This
information was obtained from the Michigan Department of Education 2005-2006

Building Level Free Reduced Lunch Public Data. ‘03

54

2.2.3 Independent Variables

2.2.3.1 Team Nutrition

Team nutrition membership was also included in this study as an independent
predictor of school characteristics. Team Nutrition provides nutrition education materials,
problem solving support, examples of successful interventions and other helpful
resources for member schools. “0 Participation in Team Nutrition was determined

according to the Michigan Team Nutrition roster.

2.2.3.2 Coordinated School Health Team

The elements of the CSHT model recorded by the HSAT were the presence of a
CSHT, the topics the CSHT may be responsible for addressing (i.e. physical activity,
healthy eating and tobacco free-lifestyle), the number of CSHT meetings held, and
member disciplines (e.g. school administration, food service and physical education)
present on the CSHT. This information was determined based on schools’ responses to a
series of HSAT items in Module 1 (see Table 2.10).

The first CSHT item required schools to select “Yes” or “No” to the phrase, “Our
school has a CSHT that oversees school health policies and programs.” This question was
utilized to determine if a school had a CSHT at the time the HSAT was completed. Next,
schools selected the topic areas their CSHT was responsible for overseeing. Schools were
available to select each of the following topic areas: “Physical Activity”, “Healthy
Eating” and “A Tobacco Free-Lifestyle”. Once school selected the topical responsibilities
of their CHST, they recorded the number of meetings their CSHT had in the last 12

months, excluding their meeting to complete the HSAT, by selecting one of four

55

categorical responses: “None”, “1 time”, “2-3 times” or “4 or more times”. The final
element in the CSHT section determined the composition of the CSHT. Schools selected
the type of active representatives present on their CSHT from a list of 11 recommended
representative categories. These representative categories included: “School
Administration”, “Nutrition Services”, “Physical Education”, “Health Education”,
“Family Involvement”, “Health Services Provider or School Nurse”, “School Counselor,
Psychologist or Social Worker”, “Students”, “Classroom Teacher”, “Community

Involvement” and “Others”.

56

Table 2.10 HSAT Question 1.1 (Coordinated School Health Team)

1.1a Our school has a CSHT* that oversees school health policies and programs.
Note: If this is your first team meeting, you may check “yes”.

1:) Yes (1 pt; proceed to 1.1b) CI No (0 pts for 1.]; skip to 1.2)

1.1!) Our CSHT oversees policies and programs regarding: (Check all that apply.) 1 pt ea
C] Physical activity
[I] Healthy eating

C] A tobacco-free lifestyle

1.1c Not including today, how many times did the CSHT meet during the past 12
months:

[3 None (0 pts) [:1 1 time (1 pt) [3 2-3 times (2 pts) [:1 4 or more times (3 pts)

*For information about what a Coordinated School Health Team is and does, paragraph

at the top of this page the Resource Guide.

 

 

 

 

 

 

 

 

 

 

 

 

 

1.1e The CSHT includes and active representative from each of these groups:
(Check all that apply)
School Administration (Principal, Assistant Principal or
. E] (3 pts)
Supermtendent)
Nutrition Services (Food Service Director or Manager) [I] (2 pts)
Physical Education (PE Teacher) El (2 pts)
Health Education (Health Teacher/ Health Educator) [:1 (1 pt)
Family Involvement (Parent/Guardian) El (1 pt)
Health Services Provider or School Nurse [3 (1 pt)
School Counselor, Psychologist or Social Worker [:1 (1 pt)
Students (on the team for middle/high school; input from for
El (1 pt)
elementary schools) .
Classroom Teacher (other than PE or Health) [3 (1 pt)
Community Involvement (Examples: Health Dept. and MSU
. E] (1 pt)
Extensron)

 

 

 

57

2.2.3 Scales

2. 2.3.1 Development of Scales

Scales are meaningful ways to express the measure of a concept or topic
composed of multiple items. In the HSS, categorically similar items were combined to
form scales. Each scale corresponding to one of the hypothesized elements in Research
Question 4 (see 1.8 Research Questions and Hypotheses). There were four scales
developed: 1) Healthy Eating Policy, 2) Eating Environment, 3) Healthy Venue
Offerings, and 4) Healthy Meal Preparation and Serving Practices. Each represented a
different aspect of school health related to healthy eating promotion in the Healthy
School Action Tool (HSAT).

Content validity of scales was determined by expert review. University
researchers in collaboration with Michigan Action for Healthy Kids steering committee
members assessed the content of each scale for theoretical application and statistical
relevance. The statistical relevance was determined by an exploratory factor analysis and
statistical measures for goodness-of-fit and reliability. Specifically, the statistical analysis
included assessment of Eigenvalues, factor loadings, and Cronbach’s Alpha reliability
coefficients. Based on findings from the factor analysis, it was determined that the items
analyzed measured four different factors (see Table 2.11). Each of the factors was
considered a scale. All scales yielded a Cronbach’s Alpha reliability coefficient greater
than or equal to 0.6. Collectively, the statistical assessment and expert review justified the

utilization of the scales for the study’s analysis.

58

Table 2.11: Factor Loadings for Scale Items from an Exploratory Factor Analysis

 

Healthy Eating Policy Scale

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(“Our school has a written policy that”) Fact 1 Fact 2 Fact 3 Fact 4
Prohibits use of food as a reward 0.67 0.00 -0.03 0.06
Prohibits withholding food as a punishment 0.53 0.01 -0.01 0.04
Requires healthy foods for classroom parties 0.71 0.04 0.06 0.01
Prohibits innutritious foods in fundraising 0.80 0.08 0.07 -0.01
Requires healthy foods at school events 0.78 0.06 0.07 0.05
Requires healthy foods in school stores 0.64 0.08 0.04 0.02
Requires healthy foods as a la carte options 0.61 0.09 0.13 0.01
Regulates vending machines hours 0.59 0.11 -0.03 -0.01

Eating Environment Scale

(Our school’sz)

Tables are cleaned between lunch periods 0.05 -0.08 0.02 0.22
The cafeteria does not need repair 0.02 0.03 0.01 0.27
The tables/chairs are undamaged & appropriate 0.03 -0.04 0.00 0.21
There are enough tables/chairs for all students 0.04 -0.12 0.00 0.35
Adults supervise cafeteria/model healthy eating 0.09 0.03 0.12 0.44
Drinking fountains are available 0.07 -0.03 0.12 0.32
The noise level in eating areas is appropriate 0.09 -0.03 0.04 0.37
Students have chance to wash hands 0.16 0.05 0.00 0.37
The cafeteria is attractive and invitig 0.06 -0.04 0.09 0.43
Healthy Venue Offerings Scale
(Our school offers healthy food choices:)
In vending machines -0.11 0.17 0.47 0.25
As part of a la carte options -0.06 -0.03 0.41 0.21
As options sold in the school store -0.01 0.04 0.29 0.25
As part of concessions sold on campus -0.05 0.03 0.56 0.18
At school events 0.27 -0.01 0.49 0.01
As part of classroom parties or celebrations 0.29 -0.16 0.54 -0.08
For fundraising events 0.29 0.00 0.56 -0.1 1
Healthy Meal Preparation Scale
(Our school’s food service:)
Bakes, roasts or broils meat more than fries 0.07 0.65 0.00 -0.05
Offers sauces low-fat & limited to 5102 0.20 0.29 -0.04 0.07
Serves skinless poultry 0.18 0.45 -0.03 0.00
Uses low-fat or non-fat real cheese 0.1 1 0.34 -0.04 -0.07
Serves cooked meats in 5302 portions 0.12 0.46 0.04 0.27
Prepares vegetables with minimal fat 0.09 0.53 -0.03 0.06
Thoroughly drains fat from ground meats 0.11 0.66 0.00 -0.02
Cooks with non-stick spray or pan liners 0.04 0.63 0.01 -0.03

 

 

 

 

 

59

 

2.2.3.1.] Healthy Eating Policy Scale

The Healthy Eating Policy Scale was composed of 8 items from the first module
of the HSAT that referred to healthy eating policies (see Table 2.12). Categorical
responses to policy items resulted in corresponding points. Schools received 0 points on
the scale if they responded “No written policy”, 1 point if a “Written policy exists”, and 2
points if a “Written policy exists and is enforced”. If a school selected “Not applicable,”
it received 0 points for the policy item. Percentage scores for the scale were created by
dividing the total number of points earned from the scale by the total number of points
each school could receive (excluding “Not applicable” items). This was done to properly
account for schools that selected “Not applicable” for certain policy items. The factor
loading values for items in the scale were greater than 0.5 for in all cases. This indicated
a large percentage of variance in the items was explained by the scale. The Cronbach’s
Alpha reliability coefficient was 0.86, which was evidence of strong reliability. The items
of this scale collectively represented healthy eating policy in the HSS analysis. In order to
correct for the skewed distribution, the healthy eating policy scale was logarithmically

transformed for all regression analyses.

60

Table 2.12: Healthy Eating Policy Scale

 

 

 

 

 

 

 

 

 

 

Scale Items (N = 8) Factor
Our school has a written policy that: Loading_
Prohibits use of food as a reward 0.67
Prohibits withholding food as a punishment 0.53
Offers predominantly healthy food/beverages for 0.71
classroom celebrations/parties

Prohibits the use the sale of foods with low nutrient 0.80
value in school fundraising

Stipulates that predominantly healthy foods and 0.78
beverages are offered at school events

Stipulates that predominantly healthy foods and 0.64
beverages are offered in school stores

Stipulates that predominantly healthy food and 0.61
beverages are offered as a la carte options

Regulates hours that vending machines containing 0.59

food or beverages with low nutrient value are
accessible to students.

 

 

Point System

0 No written policy
(0 points)

0 Written policy
exist
(1 point)

0 Written policy
exists and is

enforced
(2 points)

mm!

Min: 0% (0 points)
Max: 100% (6 - 16
points)

Cronbach a = 0.86

 

61

 

2. 2. 3. I . 2 Eating Environment Scale

The Eating Environment Scale was composed of nine items from the first module
of the HSAT which referred to the “nutrition/healthy eating environment” (see Table
2.13). Categorical responses to environmental items resulted in corresponding points.
Schools received 1 point on the scale if they selected that the item applied to their school,
and 0 points if they did not select that an item applied to their school. Percentage scores
for the scale were created by dividing the total number of points earned from the scale by
the maximum number of possible points (9 points). Percentage scale scores were created
to maintain consistency in the reporting of scales throughout the HSS. The Cronbach’s
Alpha reliability coefficient was 0.56 which was evidence of moderate reliability. The
average factor loading value for items in the scale was 0.33, which indicates that
variation in these items was not well explained by one factor. However, the scale
produced was the best combination of available items that described the cafeteria eating
period and environment. The items of this scale collectively represent the eating

environment in the HSS analysis.

62

Table 2.13 Eating Environment Scale

 

 

 

 

 

 

 

 

 

 

 

Scale Items (N=9) Factor
Our school’s: Loading_
Tables/eating surfaces are cleaned between lunch 0.22
periods

The physical structure of the cafeteria/eating 0.27
environment does not need repair

The tables/eating surfaces and chairs are undamaged 0.21
AND the appropriate size for students

There are enough tables/eating surfaces and chairs 0.35
for all students to sit while eating

Adults properly supervise the cafeteria/eating 0.44
environment and role model healthy eating practices

Drinking fountains are available for students to get 0.32
water at meals and throughout the day

Noise level in eating areas is appropriate; students 0.37
aren’t required to be silent

There is an opportunity for students to wash hands 0.37
before eating

The cafeteria/eating environment is attractive, 0.43

appealing and inviting

 

 

Point System

> Characteristic
does m1 describe
school or current
school practices
(0 points)

> Characteristic
describes school
or current school
practices
(1 point)

Possible Points
Max: 9 points
Min: 0 points

Cronbach a = 0.56

 

63

 

2. 2. 3.1.3 Healthy Venue Offerings Scale

The Healthy Venue Offerings Scale was composed of 7 items from the first
module of the HSAT which referred to healthy food and beverage offerings outside of
traditional school meal programs (see Table 2.14). Categorical responses to offering
items resulted in corresponding points. Schools received 1 point on the scale if they
selected “Our school offers healthy food and beverage choices” in the venue or if they do
not have such a venue in the school, and 0 points if they did not that select healthy
offerings were available. Percentage scores for the scale were created by dividing the
total number of points earned from the scale by the maximum number of possible points
(6 points).

A percentage scale score was developed to maintain consistency in the reporting
of scales throughout the study. The Cronbach’s Alpha reliability coefficient was 0.66,
which was evidence of moderately-strong reliability. The factor loading values for items
in the scale were all greater than 0.4, except for the item regarding concessions. However,
this item was allowed to remain in the scale because it clearly related to the offering of
healthy foods in a venue outside of school meals like all of the other items in the scale.

The items of this scale collectively represented the venue offerings in the HSS analysis.

64

Table 2.14: Healthy Venue Offerings Scale

 

 

 

 

 

 

 

 

 

Scale Item (N=7) Factor
Our school offers healthy food choices: Loading_
In vending machines (check this box if you do not 0.47
have vending machines available for student use)

As part of a la carte options (check if you do not have 0.41
a la carte options for sale to students)

As options sold in the school store (check if you do not 0.29
sell food or beverages in your school store or don’t

have a school store)

As a part of concessions sold on the school campus 0.56
(check if you did not sell concessions at your school)

At school events (check if no food is offered at such 0.49
events)

As part of classroom parties or celebrations (check if 0.54
no food is offered at such events)

For fundraising events (check if no fundraising events 0.56

or if no food or beverages are sold)

 

 

Point System

> Venue does n_ot
offer healthy
food and
beverage choices
(0 points)

> Venue offers
healthy food and
beverage choices
(1 point)

Possible Points
Max: 6 points
Min: 0 points

Cronbach a = 0.66

 

65

 

2. 2. 3. I . 7 Healthy Meal Preparation and Serving Practices Scale

The Healthy Meal Preparation and Serving Practices Scale was composed of 8
items from the fourth module of the HSAT which referred to school food service
preparation and serving practices (see Table 2.15). Categorical responses to practice
items resulted in corresponding points. Schools received 1 point on the scale if they
selected that “Our school offers [or conducts]” the mentioned practice, and 0 points if
they selected “Not Offered”. If a school selected “Not applicable” it received 0 points for
the practice item. Percentage scores for the scale were created by dividing the total
number of points earned from the scale by the total number of points each school could
earn. This was done to properly account for schools that selected “Not applicable” for
certain practice items. The Cronbach’s Alpha reliability coefficient was 0.73, which was
evidence of moderately-strong reliability. The factor loading values in the scale were
greater than 0.4 for all items except two (items pertaining to sauces and cheese).
However, expert review determined that these items were valuable fat-lowering meal
preparation practices, and therefore allowed to remain in the scale. The items of this scale

collectively represent the healthy meal preparation practices in the HSS analysis.

66

Table 2.15: Healthy Preparation and Serving Practices Scale

 

 

 

 

 

 

 

 

 

 

Scale Items (N=8) Factor
School food service practices: Loading_
Baking, roasting or broiling meat more 0.65
often than frying

Sauces, dressings or dips offered included 0.29
low-fat or non-fat options and portion size

was limited to one-ounce servings

Serving skinless poultry 0.45
Using low-fat or non-fat real cheese 0.34
Serving cooked meats in portion sizes of 0.46
three ounces or less

Preparing vegetables with minimal fat 0.53
Thoroughly draining fat from ground meats 0.66
Cooking with non-stick spray or pan liners 0.63

 

 

Point System

> Characteristic does not
describe school meals
or current school
practices (0 points)

> Characteristic
describes school meals
or current school
practices (1 point)

Possible Points
Max: 11 points
Min: 0 points

Cronbach a = 0.73

 

67

 

2.3 Software Used in Analysis

Statistical analysis for the Healthy Schools Study was conducted using STATA

SE v.10.

2.4 Description of Analyses by Research Question

Research Question 1: What are the characteristics of the schools that completed the
HSA T?
The following factors were used to describe schools that completed the HSAT:

type of school, grade level, student enrollment, location, income and grant fimding. The
type of school was categorized as public, private or charter.‘ ” Specialized institutions
were dropped from the study sample due to inherent differences (e. g. students live at the
facility) between these institutions and the rest of the sample. These included two
juvenile detention centers and an ancillary facility. The prevalence and proportion of each
type of school within the HSAT sample were determined and compared to the proportion
of each type of school in the state of Michigan according to the Center for Educational
Performance and Information (CEPI) School Master Code. '04 The prevalence and
proportion of HSAT schools in each grade level classification were determined and
compared to the proportion of schools in each grade level classification in the state of
Michigan according to the CEPI database. '04 The mean, minimum and maximum
number of students enrolled in schools that completed the HSAT were determined by
descriptive statistics. The income of the schools was represented by the percentage of
students in the school that were eligible for free or reduced price National School Lunch
Program meals. This percentage was obtained for schools that completed the HSAT using

the CEPI database and compared to the state average.'03 The percentage of sample

68

schools in each Michigan county was determined by comparing the number of schools in
the county who have completed the HSAT to the total number of schools in the county.
The prevalence and percentage of schools that were members of Michigan Team
Nutrition and schools that have received state grant funding that required completion of

the HSAT in the sample were calculated as well.

Research Question 2: Who is involved in the HSA T process?

Involvement in the HSAT process was assessed by describing Coordination
School Health Team characteristics (presence of a team, responsibilities of the team, team
membership and meeting frequency). The frequency and percentage of schools that had
CSHT and the percentage of CSHT that oversaw healthy eating in the school were
determined for the sample along with the number of meetings held by CSHT in the past
year prior to completing the HSAT and percentage of each type of member (school
administrator, food service director, physical education teacher, health education teacher,
parent/guardian, school health service provider, school counselor/psychologist/ social
worker, student, classroom teacher, community organization and other) represented on a
CSHT. In addition, the average number of member types represented on a CSHT was
also calculated.

Association between the presence of a CSHT (and its oversight of healthy eating)
and the grade level, student enrollment, income, Team Nutrition membership, and grant
funding of sample schools were determined by logistic regression models. School type
was excluded from this analysis and all other regression models due to the grossly

disproportionate distribution of this characteristic among sample schools.

69

Research Question 3: What are the prevalences of policies, environments and

programs related to healthy eating among HSA T schools?

The prevalences and percentages of schools with various healthy eating policies,

programs and environments were calculated and compared.

Research Question 4: What are the relationships between school characteristics,
healthy eating polices and healthy eating environments existing in a school at the time

the HSA T self-assessment was completed?

Multiple regression and logistic regression models were designed to determine if
several hypothesized factors were associated with the types of policies, programs and
environments that exist in HSAT schools. These factors included school demographics,

CSHT characteristics, Team Nutrition membership and grant funding.

Hypothesis 1: Schools that have a CSH T that oversees healthy eating are associated
with an increased number of: 1) healthy eating policies (written and enforced), and 2)
positive environmental factors (I. adequate, safe and encouraging cafeterias and serving
areas, and 11. healthy food preparation and offering practices) when compared to schools
that either do not have a CSHT or have a CSHT that does not oversee healthy eating.

The scale score percentages of healthy eating policies, which are written and
enforced, were compared between three groups: 1) schools without a CSHT, 2) schools
with a CSHT that does not oversee healthy eating, and 3) schools with a CSHT that
oversees healthy eating. This comparison was conducted using multiple regression
models that controlled for demographics, Team Nutrition membership and grant funding.

A similar comparative analysis of sample schools was conducted with the healthy meal

70

preparation scale and the positive environmental factors scales (eating environment scale

and healthy venue offerings scale).

Hypothesis 2: The number of CSH T meetings held in the last year is positively
associated with the number of: 1) healthy eating policies (written and enforced), and 2)
positive environmental factors (I. adequate, safe and encouraging cafeterias and serving
areas, and 11. healthy food preparation and offering practices).

The healthy eating scale score percentages were compared between four groups:
1) schools that did not hold a CSHT meeting in the last 12 months, 2) schools that held
one meeting, 3) school that held 2-3 meetings and 4) schools that held more than 3
meetings. This comparison was conducted using a multiple regression model that
controlled for demographics, team nutrition membership and grant funding. Similar
comparative analyses of sample schools were conducted with the healthy meal
preparation scale and the positive environmental factors scales (eating environment scale

and healthy venue offerings scale).

Hypothesis 3: The number of representatives on a CSHT is positively associated with the
number of: 1) healthy eating policies (written and enforced), and 2) positive
environmental factors (I. adequate, safe and encouraging cafeterias and serving areas,
and 11. healthy food preparation and oflering practices)

The scale score percentage of healthy eating policies were compared between four
groups: 1) schools that had a CSHT with less than 5 representatives or no CSHT, 2)

schools with 5-6 representatives on a CSHT, 3) schools with 7-8 representatives on a

7]

CSHT, and 4) schools with more than 8 representatives on a CSHT. This comparison was
conducted using a multiple regression model that controlled for demographics, Team
Nutrition membership and grant funding. Similar comparative analyses of sample schools
were conducted with the healthy meal preparation and serving practices scale and the
positive environmental factors scales (eating environment scale and healthy venue

offerings scale).

Hypothesis 4: Schools' healthy offering policies are associated with healthy offering
practices in school food distribution venues.

For this hypothesis, the average healthy eating policy scale score percentage was
compared to the average healthy venue offering scale score percentage using multiple
regression analysis controlling for the number of CSHT meetings held, student
enrollment, income, school grade level, Team Nutrition membership and grant funding.
The number of CSHT meetings held was the only CSHT characteristic added to the
model because it was the only significantly associated CSHT characteristic with the scale
and the addition of all of the CSHT characteristics caused excessive collinearity in the
model.

Next, a comparison of the healthy venue offering scale and Michigan State Board
of Education Policy on Quality Food and Beverages Served Outside of the National
School Lunch Program (MSBE Healthy Eating Policy) was performed. The healthy
venue offering scale score percentages were compared between schools that have adopted

the MSBE Healthy Eating Policy and schools that have not adopted the policy using a

72

multiple regression model controlling for school demographics, Team Nutrition
membership and grant funding.

Finally, comparisons of individual venue offering policies to the corresponding
individual healthy offering practices were conducted. Six venues (classroom parties,
fundraisers, school events, a la carte stations, school stores and vending machines) were
analyzed to determine if specific healthy eating policies were associated with practices
among schools that completed the HSAT. Specifically, logistic regression was used to
compare of the proportion of schools with a particular policy (i.e. prohibits the sale of
foods with low nutrient value in school fimdraising) to the proportion of schools that
practiced the corresponding action (i.e. offers healthy foods and beverages in school

fundraisers).

73

CHAPTER 3: RESULTS

3.1 Characteristics of Schools that Completed the HSAT

The characteristics of schools that completed the HSAT along with comparisons
between these schools and Michigan schools are described in this section. From October
of 2004 until February of 2007, 332 Michigan schools completed the HSAT self-

assessment. This sample represents approximately 6.5% of Michigan schools.

3.1.1 Type of School

Table 3.1 describes the types of schools present in the sample and in the Michigan
school population along with the percentage of schools from each school type that
completed the HSAT. The majority of the sample schools were considered public schools
(92.5%), while 7.5% were private, charter or other (juvenile detention centers and an
ancillary facility) schools. This distribution reflects the general composition of the state
school population, however a larger percentage of public schools were represented in the
HSAT sample than in the Michigan school population (72.0%). Within the state
population, the percentage of public schools that completed the HSAT (9.6%) was larger
than the percentage of private, charter or other schools (2.0%). Schools that were
classified as “Other” were dropped from the rest of the study analysis due to the
differences (e. g. students live at the school) between these schools and the rest of the

sample.

74

Table 3.1: Type of School

 

 

 

 

 

 

 

HSAT Michigan HSAT/M10
Type N % (SE) N % (SE) % (SE)
Public 307 92.5 (1.5) 3187 72.0 (0.6) 9.6 (1.6)
Private 11 3.3 (1.0) 854 19.3 (0.6) 1.3 (1.1)
Charter 11 3.3 (1.0) 280 6.3 (0.4) 3.9 (1.0)
Other 3 0.9 (0.5) 105 2.4 (0.2) 2.9 (0.6)
Total 332 100 5130 100 6.5

 

 

 

 

 

 

 

 

0 Percentage of schools in the state of Michigan that completed the HSAT in each
school type category

3.1.2 School Grade Classification

The sample of schools included a diverse range of grade classifications. Table 3.2
describes the grade classification of schools present in the sample and the state
population along with the percentage of schools from each grade classification in the
state that completed the HSAT. Although many more elementary schools completed the
HSAT (N=142) than schools of any other grade classifications, middle schools (N=49),
high schools (N =57) and schools with a combination of these grade levels (N=84) were
also represented. Middle schools were the school group with the highest percentage of the
state population to complete the HSAT (10% HSAT/MI). Schools that did not provide
traditional primary or secondary education were excluded from the school population
description. These schools included ancillary, special education, alternative education,

career and technical education (CTE), and adult education facilities.

75

Table 3.2: School Grade Classification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HSAT Michigan HSAT/M10
Grade Classification N % (SE) N % (SE) % (SE)
Elementary (K-6) 142 43.2 (2.7) 1967 45.5 (0.8) 7.2 (2.8)
Middle (6-8) 49 14.9 (2.0) 492 11.4 (0.5) 10.0 (2.0)
High (9-12) 57 17.3 (2.1) 699 16.2 (0.6) 7.5 (2.2)
Ele-Mid (K-8) 30 9.1 (1.6) 701 16.2 (0.6) 4.3 (1.7)
Ele-High (K-12) 27 8.2 (1.5) 297 6.9 (0.4) 9.0 (1.6)
Mid-High (6-12) 24 7.3 (1.4) 167 3.9 (0.3) 13.8 (1.5)
Total 332 100.0 4426 100.0 7.5

 

0 Percentage of schools in the state of Michigan that completed the HSAT in each

school grade classification

3.1.3 Student Enrollment

The average number of students enrolled per building in the sample was similar to

that of the state average based on grade classification, in which middle schools enrolled

more students than elementary schools, and high schools enrolled more students that

middle schools (see Table 3.3). School enrollment ranged from 56 to 2,873 students. The

average number of students enrolled per school building in the sample was 531.

Collectively more than 176,000 students were enrolled in schools that completed the

HSAT.

76

 

Table 3.3: Average Student Enrollment per School

 

 

 

 

 

 

 

 

 

HSAT Michigan
School Classification Students SE Students SE
Elementary (K-6) 437 23.4 386 3.5
Middle (6-8) 535 32.8 606 11.2
High (9-12) 954 86.3 878 24.7
Ele-Mid (K-8) 482 51.7 478 13.7
Ele-High (K-12) 548 78.9 318 31.4
Mid-High (6-12) 525 86.2 447 29.3
Total 531 23.1 489 6.0

 

 

 

 

 

 

 

3.1.4 Location

Schools from counties across the state of Michigan completed the HSAT (see
Figure 3.4). At least one school from 63 of Michigan’s 83 counties completed the HSAT
during the data collection period. Wayne (32 schools), Ottawa (22 schools) and Macomb
(21 schools) had the most schools that completed the HSAT within a county. In five
counties (Alcona, Alger, Crawford, Lenawee and Luce) 50% or more of the schools

completed the HSAT (see Appendix B).

77

Figure 3.4: School Location: Number of Schools that Completed the HSAT in
Michigan by County

 

 

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78

3.1.5 Income: F ree/Reduced Eligibility

 

The average percentage of enrolled students eligible for the National School
Lunch Program’s free or reduced price lunches in the sample was nearly 41%; one
percent less than the Michigan average (Table 3.5). Middle schools had a higher average
percentage of students eligible for free or reduced-price lunch (33.3%) than high schools
(29.1%), and elementary schools had a higher percentage (44.5%) than middle schools.
The percentages in the state population, based on school classification, followed the same
pattern as the sample (i.e., high schools had a lower percentage than middle schools,

which had a lower percentage than elementary schools).

Table 3.5: Average Percentage of F rec/Reduce Students per School

 

 

 

 

 

 

 

 

 

School Classification HSAT Michigan
% SE % SE
Elementary (K-6) 44.5 2.2 40.9 0.6
Middle (6-8) 33.3 3.7 35.5 1.1
High (9-12) 29.1 2.6 32.0 0.9
Ele-Mid (K-8) 55.3 5.8 58.5 1.5
Ele-High (K-12) 40.4 3.9 53.5 2.5
Mid-High (6-12) 44.6 5.2 43.5 1.9
Total 40.6 1.4 41.8 0.4

 

 

 

 

 

 

 

3.1.6 Team Nutrition/Grant Funding

Table 3.6 describes the number of schools in the sample who were members of
Team Nutrition at the time they completed the HSAT and the number of schools that
received a grant that required completion of the HSAT for funding. The majority of

schools (60.8%) in the sample were members of Team Nutrition at the time they

79

completed the HSAT. These schools (from the sample) represented 21.6% of the Team
Nutrition schools in Michigan. Team Nutrition participation among schools of different
grade classifications ranged from 57.1% to 69.2%.

Less than half of the sample schools (41.0%) received a grant during the data
collection period that required them to complete the HSAT and implement a nutrition or
physical activity change in the school (see Table 3.6). Middle schools were nearly twice
as likely to be a grant recipient as elementary schools in the sample; 59.2% of middle
schools and 30.3% of elementary schools received grants. The percentage of Team
Nutrition member schools that received a grant was 46.8%, while only 32.0% of schools
that were not members of Team Nutrition were grant recipients. This difference was not
statistically significant.

Table 3.6: Prevalences of Team Nutrition Schools and Grant Recipient Schools
among School that Completed the HSAT

 

 

 

 

 

 

 

 

 

 

School Grade Level TN Member Grant Recipient
N °/o (SE) N % (SE)

Elementary (K-6) 89 62.7 (4.1) 43 30.3 (3.9)
Middle (6-8) 28 57.1 (7.1) 29 59.2 (7.1)
High (9-12) 34 59.6 (6.6) 26 45.6 (6.7)
Elementary-Middle (K-8) 18 60.0 (9.1) 12 40.0 (9.1)
Elementary-High (K-12) 14 51.9 (9.8) 12 44.4 (9.7)
Middle-High (6-12) 18 75.0 (9.0) 13 54.2 (10.4)
Total 202 60.8 135 41.0

 

 

 

 

 

80

 

3.2 Who was involved in the HSAT process?

3.2.1 Coordinated School Health Team Presence and Oversight

Among schools that completed the HSAT between October of 2004 and February
of 2007, 94% of them had a Coordinated School Health Team (CSHT) and the majority
(70.8%) of the schools reported that their C SHT oversaw healthy eating as at least one of

its functions (see Table 3.7).

Table 3.7: Coordinated School Health Team Presence and Oversight

 

 

 

 

 

HSAT Schools with: N % (SE)
No CSHT 20 6.1 (1.3)
CSHT does not oversee healthy eating 76 23.1 (2.3)
CSHT oversees healthy eating 233 70.8 (2.5)
Total 329 100.0

 

 

 

 

 

3.2.2 Coordinated School Health Team Meeting Frequency

Most schools (63.1%) in the sample with a CSHT had at least one CSHT meeting
in the last year prior to completing the HSAT (see Table 3.8). Twenty-three percent of
the schools held one meeting, 20% held two or three meetings, and 20% held four or
more meetings. However, 114 schools (36.9%) did not have a CSHT meeting in the last

year.

3.2.3 Coordinated School Health Team Member Composition

The composition of CSHT’s varied among schools (see Table 3.9). School
administration and physical education were the most common categories to be

represented on a CSHT (94.5% and 90.6% respectively). Student and community

81

representatives were the least common on CSHT’s (46.0% and 59.6% respectively). The
average number of member categories represented on a CSHT was 7.8 member types. A
few schools (14 schools) had less than 5 member categories represented on their team

(see Table 3.10). Most schools (59.8%) had 8 or more member categories represented on

their team.

Table 3.8: CSHT Meeting Frequency during the Last 12 Months

 

 

 

Number of CSHT None 1 Time 2-3 4 or More Total
meetings Times Times
N 114 71 63 61 309
% (SE)<> 36.9 (2.7) 23.0 (2.4) 20.4 (2.3) 19.7 (2.3) 100.0

 

 

 

 

 

 

 

 

0 Percentage of schools in each meeting frequency category

Table 3.9: Coordinated School Health Team Members

 

 

 

 

 

 

 

 

 

 

 

 

CSHT Member Type N % (SE) 0
School Administrator 292 94.5 (1.3)
Nutrition Services Representative 269 87.1 (1.9)
Physical Education Teacher 280 90.6 (1.6)
Health Teacher 226 73.1 (2.5)
Parent/Guardian 230 74.0 (2.5)
School Nurse/ Health Provider 207 67.0 (2.7)
School Counselor/ Psychologist/ Social Worker 195 63.1 (2.7)
Student 142 46.0 (2.8)
Teacher (other than PE or Health) 220 71.2 (2.6)
Community Representative 184 59.6 (2.8)
Other 185 59.9 (2.8)

 

 

 

 

 

0 Percentage of CSHT’s with representation from the category

82

Table 3.10: Number of Member Categories Represented on CSHT

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Number % (SE) 0
Member Categories of CSHT

1 representative 1 0.3 (0.3)

2 representatives 1 0.3 (0.3)

3 representatives 6 1.9 (0.8)

4 representatives 6 1.9 (0.8)

5 representatives 27 8.7 (1.6)

6 representatives 39 12.6 (1.9)
7 representatives 44 14.2 (2.0)
8 representatives 54 17.5 (2.2)
9 representatives 68 22.0 (2.4)
10 representatives 30 9.7 (1.7)
11 representatives 33 10.6 (1.8)
Total 309 100.00

 

 

 

 

 

0 Percentage of CSHT’s with each number of member categories

3.3 Associations between CSHT’s and School Characteristics

Associations between school characteristics and the presence of a CSHT based on
a logistic regression analysis are displayed in Table 3.11. The regression model included
school grade-level categories, Team Nutrition membership, and percentage of free or
reduced eligible students, student enrollment and grant funding as covariates. Team
nutrition membership was the only school characteristic in the model significantly

associated (P<0.01) with the presences of a CSHT in schools. Schools that were members

83

of Team Nutrition were more likely (odds ratio = 4.06) to have a CSHT than non-Team

Nutrition schools.

Table 3.11: Associations between school characteristics and presence of a CSHT

 

School Characteristic Odds Ratio Coefficient SE

 

School Grade Classification

Primary school (reference) 1.00 -- --

Secondary school 1.40 0.34 0.60

Combination school 3.47 1.24 1.08
Free/Reduced (%) 0.52 -0.65 1.07
Student Enrollment 0.61 -0.49 0.49

Team Nutrition Membership

Non-Team Nutrition member (reference) 1.00 -- --

Team Nutrition member“ 4.06 1.40 0.53
Grant Funding

Non-grant recipient (reference) 1.00 -- --

Grant recipient 1.13 0.13 0.55

 

 

 

Regression Model: R2 = 0.11, F -va1ue <0.01
*=P<0.05; **P<0.01
Among sample schools with CSHT’s, associations between CSHT’s that oversaw
healthy eating and school characteristics based on a multiple regression model are

displayed in Table 3.12. The regression model included grade-level categories, Team

84

Nutrition membership, and percentage of free or reduced eligible students, student
enrollment and grant funding as covariates. Grade-level was the only school
characteristic in the model significantly associated (P<0.05) with the presence of a CSHT
that oversees healthy eating in the school. Secondary schools were more likely (odds ratio
= 2.44) to have a CSHT that oversaw healthy eating than primary schools.

Table 3.12: Associations between School Characteristic and Presence of a CSHT
that oversees Healthy Eating

 

Variable Odds Ratio Coefficient SE

 

School Grade Classification

Primary school (reference) 1.00 -- --

Secondary school* 2.44 0.89 0.36

Combination school 1.95 0.67 0.45
F rec/Reduced (%) 0.79 -0.23 0.64
Student Enrollment 1.20 0.18 0.28

Team Nutrition Membership

Non-Team Nutrition member 1.00 -- --

Team Nutrition member 1.53 0.43 0.32
Grant Funding

Non-grant recipient 1.00 -- --

Grant recipient 0.60 -0.51 0.32

 

 

 

Regression Model: R2 = 0.18, F -value < 0.01
*=P<0.05; **=P<0.01

85

3.4 What are the prevalences of policies, environments and programs related to

healthy eating among schools that have completed the HSAT?

3.4.1 Healthy Eating Polices

The prevalences of written, and written and enforced school policies related to
healthy eating among schools that completed the HSAT were low. Less than 40% of the
schools reported having a written, or written and enforced policy on each of school-wide
and venue specific healthy eating policy items (see Table 3.13 and Table 3.14). However,
118 schools (35.8%) reported adopting the comprehensive Michigan State Board of
Education Policy on offering healthy foods and beverages in venues outside of school
meals (MSBE Healthy Eating Policy). The most likely policies to be written and enforced
were polices prohibiting withholding food as a punishment (20.4%) and regulating the
hours of vending machines with foods of low nutritional value (21.6%). The least likely
policies to be written and enforced were policies prohibiting the sales of foods with low
nutritional value in fundraisers (4.6%), requiring predominately healthy foods be sold at
school events (5.8%), and prohibiting the use of food as a reward (5.8%). The policies
that were most likely to be written but not enforced were policies requiring
predominately healthy foods be offered in classroom parties (17.0%), prohibiting the
sales of foods with low nutritional value in fundraisers (12.2%), and requiring

predominately healthy foods be offered at school events (11.5%).

86

Table 3.13: Percentage of Schools with School-Wide Healthy Eating Policies

 

 

Policy Description No Written Written Written &

Policy Policy Enforced
N=329 % (SE) % (SE) % (SE)
Prohibits food as a reward 84.5 (2.0) 9.7 (1 .6) 5.8 (1.3)
Prohibits food withholding 71.7 (2.5) 7.9 (1 .5) 20.4 (2.2)
punishment

 

 

 

Table 3.14: Percentage of Schools with Healthy Eating Policies for School Venues

 

Policy Description NA No Written Written Written &
Policy Policy Enforced
N=329 % (SE) % (SE) % (SE) % (SE)

 

Offer Predominately Healthy Foods and Beverages (in venue)

Classroom Parties NA<> 75.4 (2.4) 17.0 (2.1) 7.6 (1.5)
School Events 5.5 (1.3) 77.2 (2.3) 11.5 (1.8) 5.8 (1.3)
School Stores 47.1 (2.8) 39.5 (2.7) 6.1 (1.3) 7.3 (1.4)
Ala carte 21.3 (2.3) 51.7 (2.8) 9.4 (1.6) 17.6 (2.1)

Prohibits sale of low nutrition value foods
Fundraisers 1.8 (0.7) 81.5 (2.1) 12.2 (1.8) 4.6 (1.2)
Regulates hours that foods of low nutrition value are sold

VendingMachines 34.0(2.6) 36.8 (2.7) 7.6(1.5) 21.6(2.2)

 

 

 

0 NA = The HSAT item which assessed classroom parties did not have NA as a
response option (see 3.2.1.1 Healthy Eating Policies)

87

3.4.2 Healthy Food Offering Practices

Schools in the sample had a variety of healthy offering practices (see Table 3.15).
All schools in the sample had at least one healthy eating venue (offered healthy
food/beverage choices to students or offered no food/beverage choices to students)
outside of school meals (vending machines, a la carte, school stores, concessions, school
events, classroom parties or fundraisers). Twenty-one schools reported all 7 of the school
venues assessed were healthy eating venues. The most common healthy eating venues
were school stores (72.0%), a la carte (69.9%) and vending machines (67.5%), and least

common were fundraisers (17%), classroom parties (19.5%) and school events (26.4%).

Table 3.15: Percentage of Healthy Eating Venues among HSAT Schools

 

 

 

Schools offered healthy foods choices
No Yes

(or no food choices) in:

% (SE) % (SE)
N=329
Vending Machines 32.5 (2.5) 67.5 (2.5)
A la carte 30.1 (2.5) 69.9 (2.5)
School Stores 28.0 (2.5) 72.0 (2.5)
Concessions 46.2 (2.8) 53.8 (2.8)
School Events 73.5 (2.4) 26.4 (2.4)
Classroom Parties 80.5 (2.2) 19.5 (2.2)
Fundraisers 83.0 (2.1) 17.0 (2.1)

 

88

 

3.4.3 Eating Environment Elements (Cafeteria! Eating Area)

Results of the analysis of school eating environments indicated little variation
among schools that completed the HSAT (see Table 3.16). Greater than 80% of the
sample schools indicated that all of the eating environmental items listed on the HSAT
applied to their school. The most common eating environmental element to be reported
was providing appropriate eating surfaces for children (97.0%), and the least common

factor reported was providing an attractive cafeteria environment (84.2%).

Table 3.16: Prevalences of Eating Environment Elements

 

 

 

 

 

Eating Environmental Elements N % (SE)

Clean eating surfaces 314 95.4 (1.2)
Cafeteria structures do not need repair 315 95.7 (1.1)
Appropriate eating surfaces for children 319 97.0 (0.9)
Enough eating surfaces for all students 316 96.1 (1.1)

 

Proper adult supervision and role modeling in
283 86.0 (1 .9)

 

 

 

 

cafeteria

Drinking foundations available 315 95.7 (1.1)
Appropriate noise level in eating area; not silent 316 96.1 (1.1)
Opportunity for hand washing 294 89.4 (1.7)
Attractive cafeteria environment 277 84.2 (2.0)

 

 

 

 

 

89

3.4.4 School Meals Programs

Schools’ participation in the National School Lunch Program was nearly universal
(98.8%); however, fewer schools participated in the School Breakfast Program (85.7%)

(see Table 3.17).

Table 3.17: Prevalences of USDA School Meals Program Participation

 

School Meal N % (SE)

 

USDA School Breakfast 282 85.7 (1.9)

 

USDA School Lunch 325 98.8 (0.6)

 

 

 

 

 

3.4.5 Meal Period Characteristics

The structure of the meal period described by HSAT items was nearly constant
among schools in two areas: 1) meal time did not conflict with other activities (98.2%)
and 2) meals are fully accessible to all students (99.7%) (see Table 3.18). In addition,
most schools gave students at least 10 minutes to eat breakfast and 20 minutes to eat
lunch (77.5% and 71.4% respectively). However, only 15.5% of schools scheduled recess

or free time before lunch.

3.4.6 Nutrition Information and Student Opinions

More than half of the sample schools provided positive and consistent messages
about healthy eating throughout the school (59.6%) and displayed nutrition information
or had it readily available (51.7%), while fewer schools highlighted healthy items on

menus or other posted information (36.2%)(see Table 3.19). Additionally, 55.3% of

90

schools conducted surveys (verbal or written) with students to obtain opinions about the

foodservice program or food preferences for school meals.

Table 3.18: Prevalences of School Meal Period Characteristics

 

 

 

 

 

 

 

 

 

 

School Meal Characteristic N % (SE)

Meals are fully accessible to all students 328 99.7 (0.3)
Meals that include a variety of foods 283 86.0 (1 .9)
Meals that include appealing foods 313 95.1 (1.2)
Meals that include low-fat foods daily 271 82.4 (2.1)
Lower fat meats every day 192 58.4 (2.7)
210 mins to eat break after students obtain food 225 77.5 (2.3)
Recess before lunch rather than after 51 15.5 (2.0)
220 mins to eat lunch after students obtain food 235 71.4 (2.5)
Meal time doesn’t conflict with other activities 323 98.2 (0.7)

 

 

 

 

 

Table 3.19: Prevalences of Nutrition Information and Student Food Service Surveys

 

Scale Items N % (SE)

 

Displaying nutritional information for foods served or 170 51.7 (2.8)

having it readily available

 

Highlighting healthy items on menus or other posted 1 19 36.2 (2.7)

information

 

Conducting surveys with students to obtain opinions about 182 55.3 (2.7)

the foodservice program or food preferences

 

Positive and consistent messages about healthy eating are 196 59.6 (2.7)

 

 

 

 

provided throughout the school

 

91

3.4.7 Healthy Meal Preparations and Serving Practices

Healthy meal preparation and serving practices that could reduce the amount of
fat and calories in a dish were common among sample schools (see Table 3.20).
However, not all practices were equally as prevalent. The majority of the sample schools
baked, roasted or broiled meat more often than fiied (87.8%), served cooked meats in
portion sizes of three ounces or less (91.5%), prepared vegetables with minimal fat
(94.2%), thoroughly drained fat from ground meats (86.6%), and cooked with non-stick
spray or pan liners (91.2%). Fewer schools offered sauces, dressings or dips in low-fat or
non-fat options and had portion sizes limited to one-ounce servings (60.5%), served

skinless poultry (63.2%), and used low-fat or non-fat real cheese (58.1%).

Table 3.20: Prevalences of Healthy Preparation and Serving Practices

 

Scale Items N °/o (SE)

 

Baking, roasting or broiling meat more often than frying 289 87-8 (1.8)

 

Sauces, dressings or dips offered included low-fat or non-fat 199 60.5 (2.7)

options and portion size was limited to one-ounce servings

 

 

 

 

 

 

Serving skinless poultry 208 63.2 (2.7)
Using low-fat or non-fat real cheese 191 58.1 (2.7)
Serving cooked meats in portion sizes of three ounces or less 301 91 -5 (1 5)
Preparing vegetables with minimal fat 310 94.2 (1.3)
Thoroughly draining fat from ground meats 285 86.6 (1.9)
Cooking with non-stick spray or pan liners 300 91.2 (1 .6)

 

 

 

 

 

Scale score percentages (healthy eating policy scale, eating environment scale,
healthy venue scale and meal preparation scale) varied greatly by school (see Table 3.21).

The average scale score percentages ranged from 18.7% (Healthy Eating Policy) to

92

92.8% (Eating Environment). However, on each scale some schools achieved 100%, the
maximum score. In contrast, the minimum score (0%) was achieved on the healthy eating
policy scale by 159 schools. The mean percentage score was greater for the healthy
eating venue scale (45.4%) than the healthy eating policy scale (18.7%), and the mean
percentage score of the eating environment scale (92.8%) was greater than the healthy

meal preparation and serving practices scale (83.9%).

Table 3.21: Average Scale Scores for Schools that Completed the HSAT

 

 

 

 

 

Scale Mean (%) SE (%) Range (%)
Healthy Eating Policy 18.7 1.4 0.0 - 100.0
Eating Environment 92.8 0.6 33.3 — 100.0
Healthy Venue 46.6 1.4 0.0 — 100.0
Healthy Meal Preparation 79.1 1.2 0.0 — 100.0

 

 

 

 

 

 

3.5 Associations between School Characteristics and Healthy Eating Policy

The next analyses determined associations between school characteristics and
healthy eating policies in schools within the HSAT sample. The healthy eating policy
scale and whether or not the school had adopted the MSBE Healthy Eating Policy were
regressed separately with school characteristics.

Two school characteristics were associated with the healthy eating policy scale:
Team Nutrition membership and frequency of CSHT meetings in the last year (Table
3.22). Schools that were members of Team Nutrition had average policy scores higher
than non-member schools when controlling for presence of a CSHT overseeing healthy
eating, student enrollment, free/reduced lunch eligibility, school grade level and grant

funding. Schools that were members of Team Nutrition scored, on average, 0.5% higher

93

on the healthy eating policy scale than non-Team Nutrition schools. Furthermore, schools
with CSHT’s that met at least four times in the past year (prior to completing the HSAT)
had healthy eating policy scores 0.6% higher, on average, than schools that had no CSHT
meetings in the past year when controlling for the same set of school characteristics.

In addition, two school characteristics were significantly associated with adoption
of the Michigan State Board of Education Policy on Offering Healthy Food and
Beverages in Venues Outside of the Federally Regulated Child Nutrition Programs
(MSBE Healthy Eating Policy) (see Table 3.23). Schools that received a grant for healthy
eating or physical activity were less likely (odds ratio = 0.52) to have adopted the MSBE
Policy than non-grant recipients when controlling for presence of a CSHT overseeing
healthy eating, student enrollment, free/reduced lunch eligibility, school grade level and
grant funding. The second characteristic, frequency of CSHT meetings in the last year,
was positively associated with adoption of the policy. Schools with a CSHT that met 2-3
times in the last year prior to completing the HSAT and met four or more times in the last
year were more likely (odds ratio = 2.07 and 3.05, respectively) to have adopted the
MSBE Healthy Eating Policy than schools that did not have a CSHT meeting in the past

year.

94

based on a Multiple Regression Model

Table 3.22: Associations between School Characteristics Healthy Eating Policy Scale

 

Unstandardized

 

 

School Characteristics Coefficient SE
School Grade Classification
Primary school (reference) -- --
Secondary school 0.05 0.15
Combination School 0.21 0.20
Student Enrollment -0.03 0.12
Free/Reduced (%) -0.29 0.29
Team Nutrition Membership
Non-Team Nutrition member -- --
Team Nutrition member” 0.46 0.14
Grant Funding
Non-grant recipient (reference) -- --
Grant recipient -0.1 1 0.13
CSHT Presence & Oversight
No CSHT (reference) -- --
CSHT (w/o health eating oversight) -0.02 0.29
CSHT oversaw healthy eating 0.20 0.26
Number of representatives on CSHT
0-4 representatives (reference) -- --
5-6 representatives 0.22 0.27
7-8 representatives 0.25 0.25
>8 representatives 0.20 0.25
Number of CSHT meetings last year
No meetings (reference) -- --
i 1 meeting 0.18 0.17
2-3 meetings 0.20 0.16
>3 meetings" 0.63 0.17

 

Regression Model: R2 = 0.18, F-value = 0.02,

95

*= P<0.05, **== P<0.01

 

Table 3.23: Associations between School Characteristics and Adoption of MSBE
Healthy Eating Policy based on a Logistic Regression Model

School Characteristics Unstandardized SE Odds
Coefficient Ratio

 

 

School Grade Classification

 

 

Primary school (reference) -- -- 1.00

Secondary school 0.06 0.31 1.07

Combination School 0.05 0.40 1.05
Student Enrollment 0.11 0.24 1.12
Free/Reduced (%) 0.03 0.58 1.03
Team Nutrition Membership

Non-Team Nutrition member -- -- 1.00

Team Nutrition member 0.27 0.28 1.31
Grant Funding

Non-grant recipient (reference) -- -- 1.00

Grant recipient“ -0.66 0.28 0.52
CSHT Presence & Oversight

No CSHT (reference) -- -- 1.00

CSHT (w/o health eating oversight) -0.39 0.63 0.67

CSHT oversaw healthy eating 0.66 0.56 1.93
Number of representatives on CSHT

0-4 representatives (reference) -- -- 1.00

5-6 representatives 0.66 0.51 1.94

7-8 representatives 0.62 0.48 1.86

>8 representatives 0.80 0.47 2.23
Number of CSHT meetings last year

No meetings (reference) -- -- 1.00

1 meeting -0.50 0.38 0.61

2-3 meetings” 0.99 0.36 2.70

>3 meetings" 1.1 1 0.37 3.05

 

Regression Model: R2 = 0.10, F—value < 0.01, *= P<0.05, **= P<0.01

96

3.6 Associations between School Characteristics and Eating Environmental

Elements

According to the multiple regression model conducted assessing associations
between school characteristics and eating environment scale scores, two school
characteristics (student enrollment and income) were associated with the eating
environment (see Table 3.24). Student enrollment was inversely associated with the
eating environment scale scores when controlling for presence of a CSHT overseeing
healthy eating, student enrollment, free/reduced lunch eligibility, school grade level and
grant funding (P=0.03). In other words, greater student enrollment was associated with
less positive eating environmental factors. Further, the percentage of students eligible for
free/reduced price lunches was inversely associated with eating environment scale scores
in the same model (P<0.01). Hence, greater free/reduced price lunch eligibility was

associated with less positive eating environmental factors.

97

Table 3.24: Associations between School Characteristics and Eating Environment
Scale Scores Based on a Multiple Regression Model

School Characteristics Unstandardized SE
Coefficient

 

 

School Grade Classification

Primary school (reference) -- --

Secondary school -0.01 0.02

Combination School -0.01 0.02
Enrollment* -0.03 0.01
Free/Reduced" -0.1 1 0.03
Team Nutrition Membership

Non-Team Nutrition member -- --
Team Nutrition member 0.02 0.01
Grant Funding

Non-grant recipient (reference) -- --

Grant recipient -0.02 0.01
CSHT Presence & Oversight

No CSHT (reference) -- --

CSHT (w/o health eating oversight) -0.01 0.03

CSHT oversaw healthy eating 0.00 0.03

Number of representatives on CSHT

0-4 representatives (reference) -- -—

5-6 representatives -0.02 0.03
7-8 representatives -0.01 0.02
>8 representatives 0.00 0.02

Number of CSHT meetings last year

No meetings (reference) -- --

1 meeting -0.01 0.02
2-3 meetings 0.03 0.02
>3 meetings -0.02 0.02

 

 

 

Regression Model: R2 = 0.09, F-value = 0.02, *= P<0.05, **= P<0.01

98

3.7 Associations between School Characteristics and Venue Offerings

Based on a multiple regression analysis, only one school characteristic, school
grade-level, was significantly associated with the healthy venue scale (Table 3.25).
Secondary and combination schools, on average, had lower healthy venue scale scores
(P<0.05) than primary schools when controlling for CSHT characteristics, student
enrollment, free/reduced lunch eligibility, school grade level and grant funding. None of

the CSHT characteristics were significantly associated with the healthy venue scale.

99

Table 3.25: Associations between School Characteristics and Healthy Venue Scale
Scores Based on a Multiple Regression Model

School Characteristics Unstandardized SE
Coefficient

 

 

School Grade Classification

Primary school (reference) -- _-

Secondary school" -0.11 0.04
Combination School" -0.15 0.05
Student Enrollment -0.01 0.03
Free/Reduced (%) -0.11 0.07

Team Nutrition Membership
Non-Team Nutrition member -- --
Team Nutrition member 0.05 0.03
Grant Funding

Non-grant recipient (reference) -- -_

Grant recipient 0.05 0.03
CSHT Presence & Oversight

No CSHT (reference) -- --

CSHT (w/o health eating oversight) -0.05 0.07

CSHT oversaw healthy eating 0.00 0.06

Number of representatives on CSHT

0-4 representatives (reference) -- --

5-6 representatives -0.02 0.06
7-8 representatives -0.09 0.05
>8 representatives -0.03 0.06

Number of CSHT meetings last year

No meetings (reference) -- --

1 meeting -0.04 0.04
2-3 meetings 0.06 0.04
>3 meetings -0.03 0.04

 

 

 

Regression Model: R2 ~—— 0.11, F-value < 0.01, *-—— P<0.05, **= P<0.01

100

3.8 Associations between School Characteristics and Healthy Meal Preparation and

Serving Practices

Several school characteristics (school grade classification, Team Nutrition
membership and CSHT characteristics were associated with the healthy meal preparation
scale based on a multiple regression model (see Table 3.26). Secondary schools had 0.1%
higher average healthy meal preparation scale scores than primary schools, and schools
that were members of Team Nutrition had 0.1% higher healthy meal preparation scale
scores on average than non-member schools. In regards to CSHT characteristics, the
presence of a CSHT that oversaw healthy eating, the CSHT size and meeting frequency
were all positively associated with the meal preparation scale. Schools with a CSHT that
oversaw healthy eating had 0.1% higher meal preparation scores than schools without a
CSHT. Schools with a CSHT that had 5 or more member types had 0.1%-0.2% higher
healthy meal preparation scale scores than schools with 4 or fewer member types on a
CSHT. Schools that held 2 or 3 CSHT meetings in the last year had 0.1% higher meal

preparation scores than schools that did not hold a CSHT meeting.

101

Table 3.26: Associations between School Characteristics and Healthy Meal
Preparation Scale Scores based on a Multiple Regression Model

School Characteristics Unstandardized SE
Coefficient

 

 

School Grade Classification

Primary school (reference) -- --

Secondary school" 0.13 0.03

Combination School 0.08 0.04
Student Enrollment 0.00 0.02
F ree/Reduced (%) 0.00 0.06
Team Nutrition Membership

Non-Team Nutrition member -- --
Team Nutrition member* 0.06 0.03
Grant Funding

Non-grant recipient (reference) -- --

Grant recipient -0.03 0.03
CSHT Presence & Oversight

No CSHT (reference) -- --

CSHT (w/o health eating oversight) 0.07 0.06

CSHT oversaw healthy eating* 0.14 0.05

Number of representatives on CSHT

0-4 representatives (reference) -- --

5-6 representatives“ 0.11 0.05
7-8 representatives" 0.14 0.04
>8 representatives" 0.16 0.04

Number of CSHT meetings last year

No meetings (reference) -- _.

1 meeting -0.01 0.03
2-3 meetings* 0.08 0.04
>3 meetings 0.01 0.04

 

 

 

Regression Model: R2 = 0.18, F—value < 0.01, *= P<0.05, **= P<0.01

102

3.9 Associations between Healthy Eating Policies and Healthy Offering Practices

The final analyses determined associations between school healthy eating policies
and healthy food offering practices in the HSAT sample. The healthy eating policy scale
and whether or not the school had adopted the MSBE Healthy Eating Policy were
regressed separately with the healthy venue scale. This was followed by independent
regressions of venue specific healthy food offering policies with the corresponding venue
food offering practices (see Table 3.28).

According the regression analyses, the healthy eating policy scale was not
associated with the healthy venue scale. However, the MSBE Healthy Eating Policy was
associated (P=0.08) with the healthy venue scale. Schools that adopted the MSBE
Healthy Eating Policy, on average, had 0.1% higher healthy venue scale scores than
schools that did not adopt the policy when controlling for school demographics, Team
Nutrition membership, grant funding and CSHT characteristics.

In relation to venue specific associations, schools with a written and enforced
policy to offer predominately healthy foods in classroom parties were more likely (odds
ratio = 4.50) to report having healthy classroom parties than schools without a policy.
Furthermore, both schools with a written policy and schools with a written & enforced
policy were more likely (odds ratio = 2.46 and 8.09, respectively) to have healthy
fundraisers than schools without a policy. Similarly, schools with a written policy and
schools with a written & enforced policy were more likely (odds ratio = 2.46 and 8.09,
respectively) to have healthy school events than schools without a policy. Healthy a la
carte, vending machine, and school store policies were not significantly associated with

the corresponding offering practices. However, healthy school store written and enforced

103

policies showed a weak statistical (P=0.07) association with corresponding venue

offerings.

Table 3.27 : Associations between Healthy Eating Policies and Corresponding
Healthy Offering Practices based on Multiple Logistic Regression Models

 

 

 

 

 

 

 

School Food Venue Coefficient SE Odds
Ratio

Classroom Parties

No policy (reference) -- -- 1.00

Written policy 0.53 0.40 1.69

Written & enforced policy" 1.51 0.52 4.51
Fundraisers

No policy (reference) -- -- 1.00

Written Policy* 0.90 0.46 2.46

Written & Enforced" 2.09 0.64 8.09
School Events

No policy (reference) -- -- 1.00

Written“ 1.36 0.43 3.91

Written & Enforced* 1.40 0.60 4.05
School Stores

No policy (reference) -- -- 1.00

Written 0.26 0.58 1.30

Written & Enforced 1.10 0.61 3.00
A la carte

No policy (reference) -- -- 1.00

Written -0.1 1 0.49 0.89

Written & Enforced 0.69 0.46 1.98
Vending Machines

No policy (reference) -- -- 1.00

Written -0.36 0.54 0.70

Written & Enforced -0.23 0.36 0.79

 

 

Regression models controlled for school demographics, Team Nutrition

membership, grant funding and significant CSHT characteristics.

"‘ = P<0.05, ** = P<0.01

104

 

CHAPTER 4: SUMMARY AND DISCUSSION

4.1 Summary of Findings

4.1.1 Characteristics of Schools th_at Completed the HSAT

From October of 2004 to February of 2007, 332 Michigan schools completed the
online HSAT self-assessment. This self-selected sample was composed of a wide range
of school types (public, private, charter and others), grade levels (primary, secondary and
combinations), incomes (percentagepf students eligibility for free/reduced lunches
ranged from 5% to 98%), and locations (multiple counties).

The study sample shared some similarities with the state school population. In
both the HSAT sample and in Michigan, public schools were the most prevalent type of
school, elementary schools were the most prevent grade level, and high schools had the
greatest average student enrollment per building. Additionally, less than a 2% difference
in the average percentage of free and reduced lunch eligible students was found between
the sample and in Michigan.

Many schools in the sample had actively pursued resources to enhance the health
of their school. In addition to completing the HSAT, 61% were members of Team
Nutrition and 41% received at least one grant to enhance nutrition or physical activity at

their school.

4.1.2 Who Was Involved in the HSAT Process

Coordinated school health teams (CSHT’s) were prevalent among the sample
schools. Within the sample, 94% had a CSHT and 71% had a team that oversaw healthy

eating in the school. Schools that were members of Team Nutrition were more likely to

105

have a CSHT than non-Team Nutrition schools. Secondary schools were more likely to
have a CSHT that oversaw healthy eating when compared to primary schools. CSHT’s
meetings were held at least once in the past year (prior to completing the HSAT) by 63%
of the schools. CSHT’s included representation from school administration, faculty, staff,
the student body and the community. Schools had an average of 8 different member types

represented on their CSHT’s.

4.1.3 Prevalences of School Eating Policies, Programs aid Environments

The healthy eating policies assessed by the HSAT were not widely prevalent. For
each of the nine policy items assessed in the study, less than 40% of the schools had
written or adopted a corresponding policy. The average healthy eating policy scale score
percentage was only 19%. Policies most likely to be written and enforced among the
available items were prohibiting withholding food as a punishment (20%) and regulating
the hours of vending machines with foods of low nutritional value (22%). In contrast,
fundraising and school events were among the least likely venues to have a healthy
offerings policy (5% and 6% respectively). The comprehensive MSBE Healthy Eating
Policy was adopted by 36% of the schools. School policies were not reported if a school
did not have a particular food distribution venue. School stores and vending machines
(accessible to students) were absent in 47% and 31% of the schools respectively.

All schools in the sample had healthy offering practices in at least one venue
outside of school meals (vending machines, a la carte, school stores, concessions, school
events, classroom parties or fundraisers). Schools achieved an average of 47% on the
healthy venue offering scale. School fundraisers (17%), classroom parties (20%) and

events (26%) were the least likely venues to offer healthy food choices, and school stores

106

(72%), a la carte (70%) and vending machines (68%) were the most likely venues to offer
healthy foods.

Responses to school eating environment items indicated that more than 80% of
the schools in the sample applied all of the healthy environmental elements mentioned at
their school. The average eating environment scale percentage score was 93%. Sample
schools generally provided safe, adequate and encouraging eating environments based on
HSAT items. Schools’ participation in the National School Lunch Program was nearly
universal (99%); fewer schools participated in the School Breakfast Program (86%).
Schools indicated providing time and access to meals for all students including at least 10
minutes to eat breakfast (78%) and 20 minutes to eat lunch (71%).

Information was available to assist students in making healthy food choices in
64% of the schools in the form of nutrition information about foods served or
highlighting healthy items available. Student surveys were conducted about the school’s
food service in 55% of the schools and 60% of schools said they provided a consistent
positive message about healthy eating throughout the school. At least one healthy meal
preparation or serving practice to decrease fat was utilized by each school in the sample.
Preparing vegetables with minimal fat was the most common (94%) and using low-fat or
fat-free real cheese was the least common (58%). Sample schools scored an average of

82% on the healthy meal preparation scale.

4.1.4 Association between School Characteristics and School Policies, Programs and

Environments

School characteristics including characteristics of CSHT’s were associated with

healthy eating policies, the eating environment, healthy food offerings and healthy meal

107

preparation practices. One of the associated characteristics was grade level. School grade
level was associated with healthy venue offerings and healthy meal preparation practices.
Secondary and combination schools were associated with lower healthy venue scale
scores than primary schools, but higher healthy meal preparation scores than primary
schools. Other associated characteristics included student enrollment and income. Higher
student enrollment and percentages of free/reduced lunch eligible students were
associated with lower eating environmental scale scores, and higher percentages of
free/reduced lunch eligible students alone were associated lower healthy venue offering
scale scores. Collectively, school demographics were both positively and negatively
associated with different areas of the school healthy eating environment.

CSHT characteristics showed significant positive associations with several scales.
Schools with a CSHT that oversaw healthy eating had higher healthy meal preparation
scores that schools without a CSHT. CSHT meeting frequency was positively associated
with health eating policy scale scores and adoption of the MSBE Healthy Eating Policy.
Schools that held at least 3 CSHT meetings in the last year had higher healthy eating
policy scores and were more likely to adopt the MSBE Healthy Eating Policy than
schools that did not hold a CSHT meeting in the last year. In regards to CSHT
membership, schools with a CSHT comprised of more than 6 member categories had
higher healthy meal preparation scores than schools with fewer than 6 member categories
represented on their CSHT. Overall, CSHT characteristics including a CSHT overseeing
health eating, meeting at least 3 times per year and having representation from at least 7
different types of members were associated with some desirable policy and environment

outcomes.

108

External support from Team Nutrition and grant funding had conflicting
associations. Team nutrition membership was associated with higher healthy eating
policy scale scores and healthy meal preparation scale scores when compared to schools
that were not members of Team Nutrition. However, grant funding was negatively
associated with the adoption of the MSBE Healthy Eating Policy. Schools that received
grants were less likely to have adopted the MSBE Healthy Eating Policy than school that

did not receive a grant.

4.1.5 Associations between School Healthy Eating Policies and Practices

Associations between healthy offering policies and healthy offering practices
were detected in some, but not all of the venues, assessed. The collective analysis of
healthy offering policies and healthy offering practices in multiple venues did not yield a
significant association (the healthy eating policy scale was not associated with the healthy
venue scale). However, the comprehensive MSBE Healthy Eating Policy had a weak
positive association with the healthy venue scale. In a series of independent analysis of
individual policies with corresponding practices, a significant positive association was
seen in three venues and no association was observed in three others. School healthy
fundraising and healthy school event policies written or written and enforced were
positively associated with healthy offering practices in these venues. Also, written and
enforced healthy classroom parties policies were associated with healthy offering
practices in the venue. In contrast, no associations were detected between healthy
offering policies and practices in school stores, a la carte and vending machines; although

the school store comparison of policies and practices was nearly significant. Overall,

109

between healthy offering policies and healthy offering practices in various school venues

were inconsistent.
4.2 Discussion of Findings

4.2.1 Utilization of School Health Enhancement Resources

The Healthy School Study demonstrated the wide-spread use of the HSAT among
Michigan schools. A large diverse group of Michigan schools (332 schools) completed
the HSAT between October 2004 and February 2007. These schools utilized the self-
assessment tool to evaluate their school’s health environment in the eight areas of the
CDC Coordinated School Health Model including nutrition services and school health
environment. ”2

The sample of schools that completed the HSAT was generally representative of
the Michigan school population in terms of school type, grade classification and income.
Since completion of the HSAT was voluntary, the composition of the sample suggests
three things about the HSAT process. First, the HSAT appeals to the diverse collection of
schools that are found in Michigan. Second, a wide-variety of schools are aware of the
HSAT’s availability. Finally, schools have been actively pursuing resources to enhance
the health of their schools.

The prevalences of Team Nutrition membership and grant funding also indicate
that schools in Michigan are actively pursuing resources to improve their schools’ health.
During the 2005-2006 school year, 936 schools in Michigan were members of Team
Nutrition, 202 of which completed the HSAT during the data collection period (October
2004 to February 2007). 8' In regards to grant funding, at least 164 schools applied for

and received a grant for nutrition or physical activity-related resources. ”3 The

110

considerable participation in voluntary programs designed to provide resources to address
school health needs demonstrates schools’ desire to pursue school health and willingness
to utilize resources made available by outside organizations and institutions.

Schools that received a grant were required to complete a grant eligibility process
(see Table 3.6). Prior to receiving funding, schools were mandated to complete the HSAT
and develop a plan of action for utilizing grant funds once received. Schools that
completed the HSAT during this phase had not yet utilized grant resources to enhance
their school health environment. Therefore, it is likely that data collected from the HSAT
reflects the schools environments prior to grant-induced changes. Hence, the HSS’s
assessment of the grant recipient schools does not reflect the effectiveness of the grant

programs.

4.2.2 CSHT Characteristics and the Coordin_ation School Health Model

Nearly all of the schools (94%) in the sample formed a CSHT, which is a key
component of the state and federally recommended coordinated school health model. '4‘ '5
When compared to another study, the percentage of schools in the HSS with a CSHT was
considerable higher than the percentage of schools (65%) with a school health council or
team according to the 2006 Mississippi School Wellness Principals Survey (MSWPS
2006). ”4 One potential contributor to the variation in the findings is the differences in
the data collection tools. First, the MSWPS 2006 utilized a random sample of schools, as
compared to the HSS which utilized data collected from schools that voluntarily
completed the HSAT. Next, the HSAT, used in the HSS, instructs school to form a CSHT
before beginning the assessment, while the MSWPS 2006 does not request the formation

of a CSHT, rather it only inquires if a team is present. Finally, schools likely voluntarily

lll

completed the HSAT as part of the coordinated school health process to improve school,
which includes the formation of a CSHT, while the principals who completed the
MSWPS 2006 were likely not using the survey as a school health improvement tool.
Therefore, the interpretation of the findings from the two data collection tools should be
different. The HSS’s findings may describe the percentage of schools with a CSHT who
are actively participating in the coordinated school healthy process by assessing the
school’s health, whereas the MSWPS 2006 may describe the general school population of
the area surveyed. From this one can theorize that CSHT’s may be more common among
schools that are actively participating in the coordinated school health self-assessment
process (HSAT) than a generally surveyed school population (MSWPS 2006), but
additional evidence is needed to support this theory.

Within the HSS sample, the CSHT formed varied in oversight responsibility,
membership composition and meeting frequency. Most schools (71%) placed the
oversight of healthy eating as a responsibility of the CSHT. When compared to a national
sample from the third School Nutrition and Dietary Study (SNDS III), a greater
percentage of schools in the HSS had a CSHT to oversee healthy eating than the
percentage of schools with a nutrition/health advisory council to address healthy eating in
the SNDS III (22%). 54 Similar to differences observed in the comparison of the HSS to
the MSWPS 2006, the contrast in findings between the HSS and SNDS 111 may be related
to differences in the data collection tools. Like the MSWPS 2006, the SNDS III survey is
a surveillance tool and not a school healthy improvement tool. This may lead to the

following interpretation; schools that are actively participating in the coordinated school

112

health self-assessment process (HSAT) may be more likely to have a CSHT to oversee
healthy eating than a general school population (SNDS III).

The CSHT’s in the HSS sample were composed of representatives of several
different areas of the school body (e. g. school administration, food service, teaching staff,
parents and students); eight different representatives types on average were reported to be
active members on the CSHT’s. This finding is consisted with previous studies that found
a diverse group of stakeholders can be incorporated into a CSHT. “5’ ”6’ “7 Furthermore,
the formation of a school health council or CSHT can be used to involve key stakeholders
such as parents, teachers, healthcare professionals and others in the school health.

Finally, the findings regarding CSHT meeting frequency could be interpreted in
several ways. The large portion of schools (37%) with a CSHT that did not hold at least
one CSHT meeting in the last year may describe two different situations. In the first
situation, schools had newly formed their CSHT and may have begun using the
coordinated school health model when they completed the HSAT. On the other hand,
schools may have had a CSHT in place for a considerable amount of time and this team
was not actively meeting during the last year. The first theory represents a possible
positive trend. Schools that did not have a CSHT in the past are forming teams and
beginning to move through the school health improvement process. In contrast, the
second theory represents a negative trend. Schools with established CSHT are not
meeting regularly and may be inactive in overseeing school health. More information is
needed, including the date the CSHT were formed, to determine if either theory or a
combination of the theories accurately explains the findings. Despite the lack of CSHT

meetings held by some schools, many other schools had CSHT meetings (63%) and most

113

of these schools held multiple meetings in the last year (64%). This could be considered
evidence that the schools in the HSS sample are actively working to address school

health.

4.2.3 Prevalences of Eating Policies, Programs and Environments

The majority of the schools in the sample (52%) had at least one written healthy
eating policy. This demonstrates support for healthy eating within many of the schools.
On the other hand, 48% of schools had none of the assessed policies. In a study of
Minnesota high schools French et al found results comparable to the HSS findings; many
schools (68%) did not have of a policy about food and nutrition. ”8 One potential
contributor to the low prevalence of school nutrition policies in the Minnesota study was
that only 65% of principals surveyed felt that school nutrition policy was important.
Therefore, the perceived lack of importance of school nutrition policy could be one
barrier to adopting school nutrition policies.

Differences in the prevalences of policies between school venues may also
warrant consideration. Notable variation in the prevalences of healthy food offering
policies was found between school venues. For example, 13% of schools had a policy
regarding food offerings in school stores, while 29% had a policy regarding vending
machines. Similar significant variations in the prevalences of school nutrition policies by
venue have been detected in other studies as well. 54' ”8’ ”9

The prevalences of healthy offering practices, like that of policies, varied between
venues. Healthy food choices were most likely to be available in school stores, a la carte
food service and vending machines while healthy choices were less available in

fundraisers, classroom parties, and school events. These findings were similar to an

114

earlier study conducted in the state, regarding offering practices. In a review of Michigan
schools that completed the School Health Index conducted by Murphy, 17% of schools
offered healthy food choices in classroom parties as compared to the HSS which found
19% offered healthy classroom options. '20 However, additional findings from the
Murphy’s review recorded an increase of 22% in healthy food offerings among the same
schools after grant funding and assistance was distributed. Murphy’s findings led her to
suggest a combination of grant funding and technical assistance may lead to
improvements in offering practices.

The cafeteria eating environments and participation in national school meal
programs were similar among sample schools based on the HSAT assessment. A great
majority of schools (80%— 99%) gave positive responses to HSAT items regarding the
cafeteria eating environment and school meals programs. However, one exception was
noted. Only 15% of schools provided recess (or free time) before lunch. This finding is
consistent with a previous study of Michigan schools by Grost and colleagues. 121 Among
1999-2004 healthy school environment grant recipients, 11% of schools offered recess
before lunch. Since there is a growing body of literature that shows benefits to recess
before lunch (reduced plate waste and increased physical activity), efforts to support
schools in adopting this practice could be beneficial. 122’ '23

Healthy meal preparation techniques that could reduce fat and calories in school
meals were prevalent among sample schools. However, some differences existed between
the percentages of schools that utilized each technique. For example, 58% of schools
used low-fat or non-fat real cheese in cooking, while 91% cooked with non-stick spray or

pan liners. A similar pattern of prevalences was reported by O’Toole et a1. based on the

115

School Health Policies and Programs Study 2006 (SHPPS) (see Table 4.1). 53 In both the
HSS and the SHPPS, the percentage of schools that used low-fat or non-fat cheese was
considerably lower than the percentage of schools that used non-stick spray or pan liners.
The noted similarities in healthy meal preparation techniques may be due to common
factors in both samples, such as the utilization of USDA commodity foods. These foods
(e. g. chicken) are available to all schools that participate in the NSLP. '24 Therefore, an
investigation of common resources available to schools’ food services may provide

additional insight.

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4.2.4 Associations between School Characteristics and Policies. Programs and

Environments

The HSS findings revealed associations between school characteristics and
healthy eating policies, the eating environment, healthy food offerings and healthy meal
preparation practices. Characteristics associated with these policies and environments
could be classified in three ways: 1) demographics, 2) CSHT characteristics, and 3)
external resources. Demographic characteristics with significant associations to eating
policies or environments included school grade classification, student enrollment and
income. In order to demonstrate how variations in the healthy eating environment may
occur in relation to demographics in the HSS, this section further explores the
relationships between grade level classification and eating environments beginning with
healthy meal preparation items.

Based on the HSS analysis, secondary schools were associated with lower healthy
venue scale scores and higher healthy meal preparation scores than primary schools. Two
hypotheses could explain the differences between the healthy venue scale and meal
preparation scale scores of various grade levels. First, primary schools inherently have an
advantage in receiving points on the healthy venue scale. Points on the scale were
awarded not only for offering healthy foods in the venues, but also for not offering any
foods in the venues. In the study sample, 61% of primary schools reports not having
student accessible vending machines compared to only 7% of secondary schools.
Therefore, assessing primary and secondary schools separately, given a large enough

sample, may be beneficial.

H8

The second hypothesis, attempts to describe the differences between meal
preparation scale scores based on grade level classification. On the meal preparation
scale, schools are rewarded for offering healthfully prepared foods. The more healthy
meal preparation techniques used and healthy foods offered, which correspond to HSAT
items, the greater the school’s health meal preparation scale score. Since secondary
schools traditionally offer more meal options than primary schools, there is a greater
likelihood that they will offer the foods in question. This however, does not ensure that
healthier meals are being consumed in the schools with more choices. A better approach
could be to assess school meals based on a content analysis of the schools’ menus. The
associations between demographic factors and the HSS policies and environment scales
demonstrate the importance of controlling for these variables when assessing school
healthy eating environments.

The CSHT may be a valuable component of school health, in particular healthy
eating. As hypothesized, CSHT characteristics were associated with positive eating
environments and healthy offering policies. Specifically, the presence of a CSHT that
oversees healthy eating was positively associated with higher healthy meal preparation
scores. School meals are a central component of the school eating environment and
would likely be addressed by a CSHT that oversees healthy eating. In addition to the
presence of a team, other CSHT characteristics, CSHT composition and meeting
frequency, may be related to a healthier school. Larger CSHT’s with 7 or more
representatives had significantly higher healthy meal preparation scale scores schools
than schools with fewer than 5 members. In terms of meeting frequency, schools received

higher healthy eating policy scores when their CSHT met at least 3 times in the past year

119

(compared to schools that did not hold a meeting). Different CSHT characteristics may
play unique roles in the healthy eating promotion. Therefore, schools may benefit from
have not only having a CSHT, but holding multiple meetings annually and having
representatives from many areas of the school community. However, additional research
is needed to further investigate this theory.

External support may play a key role in the school health environment as well.
Both Team Nutrition membership and grant funding utilization may have positive
benefits for school health. Team nutrition membership was positively associated with
healthy eating policies and healthy meal preparations in the HSS, and utilization of grant
funding was related to improvements in the school healthy eating environment in the
review by Murphy. '2' The resources provided by groups outside of the school may assist
in establishing a healthy eating environment and continuing to explore this relationship

may be beneficial.

4.2.5 Associations between Policies and Practices

Evidence to support a relationship between healthy eating policies and healthy
offering practices was inconsistent. Three of the six individual venue policies and
practice analyses yielded significant positive associations (classroom parties, fundraisers
and school events), while the other three venues did not (school stores, a la carte and
vending machines). This inconsistency of associations was replicated when the healthy
venue scale was assessed with the healthy eating policy scale and the MSBE Healthy
Eating Policy. The healthy eating policy scale was not associated with healthy venue

scale, but was positively associated with the MSBE Healthy Eating Policy. These

120

inconsistent findings suggest that other factors not in the models, such as venue manager

or vendor, may play a significant role in the association of policy and practice.

4.3 Strengths and Limitations

There were strengths and limitations to the Healthy Schools Study. The study
sample, 329 schools, was sufficiently large to determine many significant differences.
However, in some ways this sample was less than ideal. The sample contained a diverse
group of schools that shared some similarities with the Michigan school population, but
the sample was not representative of the state because the schools were not randomly
selected. Schools that completed the HSAT voluntarily may have been more motivated to
address school health than schools that did not choose to complete the HSAT. In turn,
these motivated schools may have higher prevalences of healthy eating policies and
environments than the general population. Another limitation to the sample was the
disproportionately small number of schools without a CSHT. The sample contained only
20 schools that did not have a CSHT. Additional significant findings may have been
determined if a greater number of schools in this category were present in the sample.

If completed by a random sample of Michigan schools, the use of the HSAT self-
assessment as a surveillance tool has both strengths and limitations. Notable strengths of
the HSAT were: 1) its ability to provide information about multiple areas of the school
health environment including policy and practices, and 2) its assessment of multiple
elements in each area, which allowed for the creation of scales during analysis.
Limitations of the HSAT as a surveillance tool included self—reporting inaccuracies and
some subjective questioning. An example of subjective questioning from the HSAT is

found in item 4.1d:

121

“During the past 12 months, has school food service staff consistently

followed practices to reduce fat and calories in meals offered to students

such as: Preparing vegetables with minimal fat.”
Preparing vegetables with minimal fat could be interpreted in multiple ways. Since many
vegetables can be steamed without the addition of any fat, one may or may not, perceive
sautéing vegetables in vegetable oil as being prepared with minimal fat. By further
defining these terms, consistency of reporting may increase. However, overall, the data
collected from the sample through the HSAT provide enough specificity to gather

information about the school eating environment required for the HSS.

4.4 Conclusion and Recommendations for the Future

The HSS assessment of the HSAT revealed information about the tool as well as the
schools that utilized it. The study’s findings demonstrated that the HSAT can be
completed by a wide-variety of schools, which compliments the diversity of the Michigan
school system. Schools that voluntarily completed the HSAT displayed some desirable
(i.e. healthy meal preparation practices) and undesirable (i.e. lack of healthy eating
policy) characteristics. In summary, the prevalence of healthy eating policies, practices
and environments varied. Part of this variation in the sample was associated with
differences in school characteristics including demographics, CSHT characteristics and
external resources. Each of the three CSHT characteristics assessed (a CSHT that
oversaw healthy eating, CSHT member representation and meeting frequency) and Team
Nutrition membership was associated with a desirable healthy eating outcome. Although
this study was able to determine the existence of statistical associations between school

characteristics (e. g. CSHT characteristics and Team Nutrition membership) and school

122

health markers (e. g. healthy eating policies and offering practices), intricacies of these
relationships are still unknown. Future studies may consider investigating these
relationships with a longitudinal model to determine causality. Furthermore, inconsistent
findings between healthy offering policies and corresponding offering practices may also
warrant future investigations to understand these phenomena. Additionally, findings from
this study call for further exploration into the potential benefits of external resources and
formation of an active multi-disciplinary CSHT that oversees healthy eating for the

promotion of health eating within primary and secondary schools.

123

APPENDIX A: Michigan State Board of Education Healthy Eating Policy

Michigan State Board of Education

Policy on Offering Healthy Food and Beverages In Venues Outside
of the Federally Regulated Child Nutrition Programs

The Michigan State Board of Education recognizes and acknowledges, through its policy
on coordinated school health programs,1 that “schools cannot achieve their primary
mission of education if students and staff are not physically, mentally and socially
healthy.” Establishing healthy eating behaviors during the school-age years can make an
important contribution to short and long-term disease prevention and health promotion.2

The Board believes that schools should provide a campus-wide environment supporting
student adoption of healthy eating behaviors. Students should be given the opportunity to
learn and practice these behaviors by having access to healthy food and beverage choices.

The Board’s 1973 Food and Nutrition Policy Statement provided guidelines for
elementary school students only. Given the current health issues faced by school age
children in this state, the 2003 policy encourages all Michigan school buildings to adopt
the recommendations listed below, regardless of age/grade level.

This policy focuses on one component of a healthy school environment: to ensure that
healthful food choices are offered in venues that are within the school/district’s control but
outside federally regulated child nutrition programs. These venues include, but are not
limited to, vending machines, a-la-carte sales, food rewards, fiindraisers, school stores,
concessions, school parties, activities, and meetings. In addition, this policy is consistent
with recommended actions outlined in The Role of Michigan Schools in Promoting
Healthy Weight3 and goals of the Michigan Action for Healthy Kids coalition.4

The purpose of this policy is to ensure that students have access to food that meets their
nutrient requirements to promote health and foster learning. Food and beverages that
compete with this policy’s purpose should be discouraged. Healthy food and beverages
that comply with this policy’s purpose should predominate in all school venues.

The Board recommends that each school building offer and promote the following food
and beverages in all venues outside federally regulated child nutrition programs.
Appendix A provides background research supporting each recommendation.

1 Coordinated School Health Programs to Support Academic Achievement and Healthy Schools,
September 2003. 2 Healthy People 2010: Understanding and Improving Health, Stock Number:
017-001-00550-9. 3 The Role of Michigan Schools in Promoting Healthy Weight, A Consensus
Paper. Michigan Department of Education, Michigan Department of Community Health, and the
Govemor’s Council on Physical Fitness, Health and Sports, September 2001. 4 Action for
Healthy Kids Coalition. www.actionforhealthykids.org

124

. Offer whole and enriched grain products that are high in fiber, low in added fats
and sugars, and served in appropriate portion sizes consistent with the current
United States Department of Agriculture standards.

. Offer fresh, frozen, canned or dried fruits and vegetables using healthy food
preparation techniques. Offer 100 percent fruit juice in 12-ounce servings or less.

. Offer nonfat, low-fat, plain and/or flavored milk and yogurt. Offer nonfat and/or
low-fat real cheese, rather than imitation cheese. Offer the following serving
sizes: yogurt in eight-ounce servings or less, milk in 16-ounce servings or less,
cheese in 1.5-ounce (two-ounce, if processed cheese) servings or less.

. Offer nuts, nut butters, seeds, trail mix, and/or soybean snacks in one-ounce
portions or less. Offer portions of three ounces or less of cooked lean meat,

poultry, or fish using healthy food preparation techniques.

. If offered, serve accompaniments (sauces, dressings, and dips) in one-ounce
servings or less.

125

Because excess calories are stored as body fat, children who eat more calories than their
bodies require are at increased risk for becoming overweight in childhood and obese as adults.
Limiting the portion sizes of foods served can decrease calorie intake. Excess dietary fat may
provide excess calories and may also increase the risk for chronic diseases. Added sugars add
excess calories and contribute to weight gain or lower consumption of more nutritious foods.

1. Grain Food Research and Rationale: Offer whole and enriched grain products that are
high in fiber, low in added fats and sugars, and served in appropriate portion sizes that are
consistent with the current United States Department of Agriculture standards.

> Grains provide essential vitamins and minerals, and provide fiber if they are a whole
grain. Whole grains contain the entire grain kernel. Examples include whole-wheat
flour, bulgur, oatmeal, rye bread, whole cornmeal, and brown rice. Whole grains,
when eaten with other healthful foods, may help decrease the risk of many chronic
diseases. Moreover, whole grain foods containing fiber promote proper bowel function
and have been shown to trigger the feeling of fullness with fewer calories.

V4

Nutrients are lost when grains are milled, including B vitamins, iron, and dietary fiber.

"Enriched" grains are grains to which iron, folic acid and other B vitamins, including

niacin, thiamine and riboflavin are added back to the grain mixture after milling. Over
5

the years, enrichment has helped eliminate many nutrition-related diseases.

2. Fruits and Vegetables Research and Rationale: Offer fresh, frozen, canned, or dried
fruits and vegetables using healthy food preparation techniques. Offer 100 percent fruitjuice
in 12-ounce servings or less.

K

r The benefits of eating a minimum of five servings of fi'uits and vegetables each day cannot
be overstated. Not only 15 fruit and vegetable intake associated with decreased risk for

cardiovascular system diseases6 and cancers, but stronger bones as well. 8Unfortunately,
children and adolescents do not eat enough fi'uits and vegetables and, as a result, may be at
higher risk for developing chronic diseases later in life.9 Fruit juice offers no nutritional
advantage over whole fruit. Excessive juice consumption may result in an increase in
calorie intake and may contribute to the development of obesity.

5
“Get on the Grain Train.” United States Department of Agriculture Dietary Guidelines for

Americans. May 2002. (http: //www. usda. gov/cnpp/Pubs/Brochures/GrainTrainPamphlet. pdt)6
JAMA, 1999; 282: 1233-1239.; KJ Joshipura, FB Hu, et al. “The Effect of Fru1t and Vegetable

7
Intake on Risk for Coronary Heart Disease.” Annals of lntemal Medicine. 134:1]0611 14.2001.

J Natl Cancer Inst 2000 ,:92(1) 61 -.8 8Am J Clin Nutr 1999; 69: 727- 36. 91A Pesa and LW Turner
“Fruit and vegetables intake and weight control behaviors among U. S. youth.” Am .1 Health
Behavior. 25(1):3-9. 2001.

126

3. Dairy Food Research and Rationale: Offer nonfat, low-fat plain, and/or flavored milk
and yogurt. Offer nonfat and/or low-fat real cheese rather than imitation cheese. Offer the
following serving sizes: yogurt in eight-ounce servings or less, milk in 16-ounce servings or
less, cheese in 1.5-ounce (two-ounce, if processed cheese) servings or less.

3> Milk, cheese, and yogurt are excellent sources of many essential nutrients (such as
calcium), including those that are often lacking in the diets of children and teens. Nutrients
within dairy products may help reduce the risk of cavities and chronic diseases such as
osteoporosis, hypenension and some cancers. Many reputable health professional
organizations recommend that children and teens choose low-fat milk, cheese, and yogurt
to get the calcium (and other nutrients) they need for strong bones and overall health.

4. Meat, Beans, and Nut Food Research and Rationale: Offer nuts, nut butters, seeds, trail
mix, and/or soybean snacks in one-ounce portions or less. Offer portions of three ounces or
less of cooked lean meat, poultry, or fish using healthy food preparation techniques.

> Nuts, seeds, beans, meats, eggs, poultry and fish offer protein and other valuable nutrients
such as zinc, iron, and B vitamins. Protein supplies amino acids, which are building blocks
that build, repair, and maintain body tissues.

5. Accompaniments Rationale: lf offered, serve accompaniments (sauces, dressings, and
dips) in one-ounce servings or less.

> Limiting the portion sizes of accompaniments served with food can decrease calorie
intake. Excess dietary fat may provide excess calories and may also increase the risk for
chronic diseases. Added sugars may add excess calories and contribute to weight gain or
lower consumption of more nutritious foods.

10 Johnson, R.K., C. Panely, and M.Q. Wang. “The association between noon beverage consumption and
the diet quality of school-age children.” J. Child. Nutr. Manage. 22(2):95, 1998. 11 Institute of Medicine.
Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. “Dietary Reference Intakes
for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride.” Washington, D.C.: National Academy
Press, 1997. 12 US. Department of Agriculture, Agricultural Research Service. Data tables: Results from
USDA's 1994-96 Continuing Survey of Food Intakes by Individuals and 1994-96 Diet and Knowledge
Survey. Riverdale, MD: ARS, USDA. February 1999.
(http:/lwww.nhlbi.nih.gov/guidelines/obesity/prctgd_b.pdt) 13 Ballew, C. et al. “Beverage Choices Affect
Adequacy of Children’s Nutrient Intakes.” Arch. Pediatr. Adolesc. Med. 154:1148, 2000. 14 Bowman, S.
“Beverage Choices of Young Females: Changes and Impact on Nutrient Intakes.” J. Am. Diet. Assoc.
102:1234, 2002.

127

 

APPENDIX B: Location of HSAT Schools by County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County County HSAT Michigan HSAT/M10
Code Schools Percent Schools Percent Percent
01 Alcona 1 0.30 2 0.06 50.0%
02 Alger 3 0.90 5 0.15 60.0%
03 Allegan 5 1.51 40 1.17 12.5%
04 Alpena 1 0.30 12 0.35 8.3%
05 Antrim 5 1.51 12 0.35 41.7%
06 Arenac 0 0.00 6 0. 1 8 0.0%
07 Baraga 0 0.00 5 0.15 0.0%
08 Barry 1 0.30 15 0.44 6.7%
09 Bay 2 0.60 34 0.99 5.9%
10 Benzie 0 0.00 7 0.20 0.0%
11 Berrien 2 0.60 72 2.10 2.8%
12 Branch 0 0.00 15 0.44 0.0%
13 Calhoun 5 1.51 61 1.78 8.2%
14 Cass 2 0.60 20 0.58 10.0%
15 Carlevoix 0 0.00 13 0.38 0.0%
16 Cheboygan 0 0.00 1 l 0.32 0.0%
17 Chippewa 6 1.81 18 0.53 33.3%
18 Clare 1 0.30 13 0.38 7.7%
19 Clinton 11 3.31 29 0.85 37.9%
20 Crawford 2 0.60 4 0.12 50.0%
21 Delta 5 1.51 15 0.44 33.3%
22 Dickinson 3 0.90 10 0.29 30.0%
23 Eaton 8 2.41 42 1.23 19.0%
24 Emmet 0 0.00 12 0.35 0.0%
25 Genesee 8 2.41 148 4.32 5.4%
26 Gladwin 0 0.00 8 0.23 0.0%
27 Gogebic 3 0.90 8 0.23 37.5%
28 Grand Traverse 3 0.90 26 0.76 11.5%
29 Gratiot 2 0.60 22 0.64 9.1%
30 Hillsdale 1 0.30 22 0.64 4.5%
31 Houghton 4 1.20 17 0.50 23.5%
32 Huron 6 1 .81 15 0.44 40.0%
33 Ingham 15 4.52 99 2.89 15.2%
34 Ionia 5 1.51 27 0.79 18.5%
35 Iosco 0 0.00 15 0.44 0.0%
36 Iron 0 0.00 6 0.18 0.0%
37 Isabella 2 0.60 19 0.55 10.5%
38 Jackson 20 6.02 55 1.60 36.4%
39 Kalamazoo 6 1.81 76 2.22 7.9%

 

 

 

 

 

OPercentage of Michigan Schools to complete the HSAT in each county

128

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County County HSAT Michigan HSAT/M10
Code Schools Percent Schools Percent Percent

40 Kalkaska 0 0.00 9 0.26 0.0%
41 Kent 13 3.92 223 6.51 5.8%
42 Keweenaw 0 0.00 0 0.00 NA

43 Lake 0 0.00 4 0.12 0.0%
44 Lapeer 0 0.00 33 0.96 0.0%
45 Leelanau 1 0.30 6 0.18 16.7%
46 Lenawee 19 5.72 37 1.08 51.4%
47 Livingston 3 0.90 40 1.17 7.5%
48 Luce 1 0.30 2 0.06 50.0%
49 Mackinac 2 0.60 9 0.26 22.2%
50 Macomb 21 6.33 227 6.62 9.3%
51 Manistee l 0.30 13 0.38 7.7%
52 Marquette 6 1.81 26 0.76 23.1%
53 Mason 1 0.30 15 0.44 6.7%
54 Mecosta 0 0.00 19 0.55 0.0%
55 Menominee 1 0.30 14 0.41 7.1%
56 Midland 2 0.60 33 0.96 6.1%
57 Missaukee 1 0.30 3 0.09 33.3%
58 Monroe 12 3.61 46 1.34 26.1%
59 Montcalm 1 0.30 29 0.85 3.4%
60 Montmorency 0 0.00 4 0. 1 2 0.0%
61 Muskegon 5 1.51 72 2.10 6.9%
62 Newaygo 0 0.00 22 0.64 0.0%
63 Oakland 10 3.01 348 10.15 2.9%
64 Oceana 1 0.30 16 0.47 6.3%
65 Ogemaw 0 0.00 5 0.15 0.0%
66 Ontonagon 1 0.30 4 0. 12 25 .0%
67 Osceola 2 0.60 13 0.38 15.4%
68 Oscoda 1 0.30 2 0.06 50.0%
69 Otsego 0 0.00 1 1 0.32 0.0%
70 Ottawa 22 6.63 75 2.19 29.3%
71 Presque Isle 0 0.00 6 0.18 0.0%
72 Roscommon 2 0.60 l 1 0.32 18.2%
73 Saginaw 6 1.81 79 2.31 7.6%
74 St. Clair 4 1.20 57 1.66 7.0%
75 St. Joseph 0 0.00 30 0.88 0.0%
76 Sanilac 2 0.60 23 0.67 8.7%
77 Schoolcraft 1 0.30 4 0.12 25.0%

 

 

 

 

 

 

 

<>Percentage of Michigan Schools to complete the HSAT in each county

129

 

 

 

 

 

 

 

 

 

 

 

County County HSAT Michigan HSAT/M10
Code Schools Percent Schools Percent Percent

78 Shiawassee 2 0.60 33 0.96 6.1%
79 Tuscola 2 0.60 28 0.82 7.1%
80 Van Buren 6 1.81 38 1.11 15.8%
81 Washtenaw 9 2.71 87 2.54 10.3%
82 Wayne 32 9.64 624 18.21 5.1%
83 Wexford l 0.30 11 0.32 9.1%

Total 332 100 342 7 I00

 

 

 

 

 

 

 

<>Percentage of Michigan Schools to complete the HSAT in each county

130

 

10.

11.

12.

13.

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