June 2017 Issue

Team Nutrition
By Christen Cupples Cooper, EdD, RDN
Today's Dietitian
Vol. 19, No. 6, P. 26

Plans are underway to improve this federal program to promote healthful eating and boost physical activity in our nation's schools.

Childhood overweight and obesity are among the most menacing health issues of our time. Schools and child care centers have access to more than 95% of the nation's young people through the National School Breakfast and Lunch Programs, the Child and Adult Care Food Program (CACFP), and the Summer Meal programs. All together, they feed more than 45 million children at a cost of over $20 billion per year, according to the Congressional Budget Office. Many children receive one-half or more of their daily calories and nutrition through some type of school or day care facility, making these environments nutritional homes away from home for many of these children.

Since the mid-1990s, advocates have sought improvements in the quality of food served in the federal child nutrition programs. During those years, the USDA's Food and Nutrition Service created the School Meals Initiative for Healthy Children, which aimed to boost the nutritional value of school meals. School foodservice staff required training, resources, nutrition education, and technical assistance to implement the changes. As a way to help school districts, parents, teachers, and other community stakeholders understand the importance of the new nutrition standards, the USDA's Food and Nutrition Service created Team Nutrition, a multifactorial approach to nutrition and physical activity promotion.

Over the years, Team Nutrition, which receives discretionary funding from Congress and has continued to grow in scope over the years, provides educational materials free of charge to any school or program that requests them. Schools also can sign up as "Team Nutrition Schools," which puts them on a list of schools that have committed to providing good nutrition and implementing healthful levels of physical activity.

Team Nutrition also offers Team Nutrition Training Grants for states to implement and evaluate nutrition education, training, and technical assistance activities that support application of USDA nutrition standards for meals and snacks offered through the Child Nutrition Programs (eg, National School Lunch Program, School Breakfast Program, and CACFP). States must apply Team Nutrition's following three behavior-focused strategies in their proposals:

1. Provide training and technical assistance to pediatric nutrition professionals to enable them to prepare and serve nutritious meals that appeal to children.

2. Increase nutrition education through multiple communication channels to help children develop the knowledge, skills, and motivation to make healthful food and physical activity choices as part of a healthful lifestyle.

3. Build support for healthy school and child care environments that encourage nutritious food choices and physically active lifestyles.

(More detailed information can be found on the Team Nutrition website at www.fns.usda.gov/fy-2017-team-nutrition-training-grants.)

Team Nutrition uses a variety of channels to deliver its messages. These include the following:

Foodservice initiatives. The cafeteria environment can reinforce nutrition messages and provide opportunities for students to put healthful choices into practice. Foodservice directors and workers can receive technical training or professional development to help them prepare and serve healthful foods and promote healthful foods among students by offering fruit and vegetable tastings and placing signage around a school to promote messages such as "Eat the Rainbow," to promote the value of eating a variety of fruits and vegetables.

Classroom activities. These enable students to exercise nutrition skills using hands-on activities, songs, lessons, stories, cooking, or gardening.

Schoolwide events. These bring together students, teachers, school administration, parents, and others, uniting whole communities behind positive food and physical activity messages. For example, a grant may fund a family fitness night in which students, parents, and school staff come together to move and eat healthful snacks.

Home activities. When students bring home what they learn in the form of literature, books, or games, they can discuss it with parents, and thus entire families can learn about and get on board with making healthful choices.

Community engagement. Local farmers, chefs, nutrition experts, cooperative extension agents, and others can help children learn about food and how it's grown.

Media events and coverage. Press releases, articles, and other announcements, as well as the use of social media outlets such as Twitter, help disseminate Team Nutrition's messages to a wider audience.

Alicia White, MS, RD, chief of the Nutrition Education and Promotion Branch of the USDA's Food and Nutrition Service, says that the ideal grant application for Team Nutrition funding combines several communication channels, since the more channels used to deliver nutrition and physical activity messages, the more likely schools will be able to achieve real behavior changes. She states that Team Nutrition's key behavior change strategies include technical assistance and training for foodservice staff, nutrition education for students and caregivers, and creation of a school environment that supports healthful behaviors.

School-Based Nutrition Programs
There's considerable evidence that school-based nutrition programs can influence children's dietary practices, according to a study by Kubik and colleagues in the October 2002 Journal of School Health. However, in the 1990s, experts began to realize that getting children to eat healthfully takes more than just putting good food in front of them. Studies began to highlight the importance of multicomponent interventions that integrated education in the classroom, the availability of healthful foods in the cafeteria and on campus, family involvement, and community health resources. More recent research suggests that these would be the most efficacious for effecting positive behavior change.1,2

As stated in the Position of the American Dietetic Association, Society for Nutrition Education, and American School Food Service Association concerning comprehensive school health programs published in April 2003 in the Journal of the American Dietetic Association, a healthful school environment is one that "provides youth the skills and support they need to adopt healthy eating behaviors, obtain a positive nutritional status, and achieve improved academic success."

Thus, adding components that reach others in the school environment can enhance interventions that target school food quality or children's behaviors in isolation. Teachers in particular play significant roles in positively influencing children's dietary behaviors, but often lack appropriate knowledge, motivation, materials, or support from school administrators to teach or model what good nutrition looks like. Hoelscher and colleagues reported in the Journal of the American Dietetic Association in March 2002 that these factors are effective for enhancing teachers' confidence to teach these topics. It's also useful for teachers to understand cultural food practices among their students, according to Koplan and colleagues in the January 2005 issue of the Journal of the American Dietetic Association. This knowledge can help teachers focus on consumer skills that students need so they can make healthful choices. Team Nutrition provides its materials on all of these topics and in several languages, as well as valuable staff development that emphasizes teaching methods and offers lessons for teachers to use in their classrooms.

Other key stakeholders in the realm of school wellness are parents. White emphasizes the importance of having parents on board with practicing healthful habits. "We want to engage parents in nutrition education activities because the lessons taught at school can only be fully beneficial if the same messages are reinforced at home," White says. "Team Nutrition's Serving Up MyPlate, Discover MyPlate, and garden-based resources all include ways to engage parents, such as parent newsletters, family event ideas, and cooking activities.

Healthful School Environment and Wellness Policies
In the spirit of building healthful school environments, Congress passed the Child Nutrition and WIC Reauthorization Act of 2004, which included a provision that made it mandatory for schools participating in the National School Lunch Program to implement local school wellness policies by the 2006–2007 school year. The purpose of the policies was to require schools to have their students, teachers, administrators, and community stakeholders sit down and evaluate the healthfulness of their school food, their physical activity opportunities, and the general school health environment. Wellness policies shifted the emphasis from food quality to a broader spectrum of factors that help promote healthful behaviors. Wellness policies were to include the following:2

• goals for nutrition education, physical activity, and other activities to promote student wellness;
• nutrition guidelines for school meals and for all foods available on school campuses during the school day;
• assurance that nutrition guidelines for school meals wouldn't be less restrictive than the federal guidelines;
• a plan for measuring implementation of the local wellness policies, including designation of a person or persons with operational responsibility for ensuring requirements were met; and
• involvement of parents, students, school boards, school administrations, and public representatives in the development of the policies.

In the June 2012 issue of the Journal of the Academy of Nutrition and Dietetics, Ohri-Vachaspati and colleagues found that while some school health environment practices have improved since school wellness policies became mandatory, some practices haven't improved as much, such as the prevalence of school gardens, participation in farm-to-school programs, and the inclusion of whole grain products and lower-fat milks in lunches. However, overall, the authors conclude that the changes have been minimal and that much still needs to change in order to produce a significantly more health-minded generation. Team Nutrition has an opportunity to help schools to develop wellness policies and form wellness committees.

Healthy, Hunger-Free Kids Act of 2010
Team Nutrition became even more relevant on the school food scene in 2010 when former President Obama signed the Healthy, Hunger-Free Kids Act. This law brought the foods served in federal child nutrition programs in line with the Dietary Guidelines for Americans. After the law passed, schools were required to serve a greater quantity and variety of fruits and vegetables, increase the percentage of whole grains vs refined grains, serve lower-fat milks, and, in some cases, abide by meal calorie limits.

Team Nutrition may have valuable tools to assist schools in encouraging the new, upgraded meals. Some states are putting Team Nutrition grants into practice to tackle new meal standards and include all stakeholders in a movement towards a more healthful school environment.

Outstanding States

Tessa Adcock, MS, RD, of Kansas Team Nutrition, says that she and her colleagues work to implement a wide variety of projects across her state. Adcock, who was trained as a chef at the Culinary Institute of America in Hyde Park, New York, and later became a dietitian, believes that she brings a unique skill set to Team Nutrition. With her broad background, she creates menus, conducts nutrition analyses, teaches nutrition education, develops and tests recipes, implements statewide programs, and problem-solves along the way. "The most exciting part about being an RD working with Team Nutrition is that no two weeks ever look exactly the same," Adcock says. "Kansas Team Nutrition has been fortunate to receive grants for a number of years, and I believe the continued success stems from the variety of projects accomplished through the grant. Any particular project written into a Team Nutrition grant comes from a place of feedback and reflection on how best to reach Kansas students, teachers, foodservice, and schools with the nutrition opportunities."

Some examples of projects Adcock has worked on include "Smarter Lunchroom Makeovers," in which Team Nutrition assists schools in placing healthful foods in the most visible places in cafeterias, among other tactics to encourage healthful choices. Team Nutrition Kansas also helps run "Regional Wellness Workshops" with district stakeholders to get communities involved in upgrading the healthfulness of school food environments.

A recent project that Adcock found especially notable was a "Middle School Wellness Summit," which gathered middle school students from across the state to allow for developing ideas and planning ways to improve their school wellness environments. At the summit, Adcock conducted a breakout session called "BAZINGA! Are your taste buds bored?" The goal of the session was to allow students to create seasoning blends, explore the world of herbs and spices, and have the experience of creating their own recipes to liven up healthful foods. Adcock believes that RDs' characteristic attention to detail and their understanding of how small adjustments in diet can lead to important health gains over time make RDs key to Team Nutrition's success.

The Colorado Department of Public Health and Environment, Child and Adult Care Food Program is working to develop and implement a farm-to-child care initiative designed to increase children's consumption of fresh, seasonal, and local fruits and vegetables. The program, built on a three-level intervention, will involve culinary training, gardening activities, and nutrition education using Team Nutrition's "Grow It, Try It, Like It" curriculum geared for preschool-age children.

The program's effectiveness will be assessed by comparing the following three interventions:

1. a one-day group culinary training of 100 CACFP providers and 25 partners;
2. a one-day group culinary training and garden-based nutrition education event in 25 day care centers and day care homes; and
3. a one-day group culinary training, garden-based nutrition education, and culinary coaching event in 16 child care centers and day care homes.

Outcomes of Team Nutrition
Since school wellness policies are still relatively new in many school districts, programs such as Team Nutrition, which aim to improve school food environments, are still untapped by potential grantees.

"Bridging the Gap," a research project of the Robert Wood Johnson Foundation, reported in 2011 that over the four-year period from 2006 to 2010, elementary school participation in Team Nutrition didn't change significantly with 39.2% and 42.8%, and 37.6% and 35.9% of schools participating during each year, respectively.

Research on Team Nutrition interventions is limited. Only a handful of the projects that have received grants have been studied. In one study, school participation in Team Nutrition didn't appear to make a significant difference in the availability of whole grains or offerings of low-fat milk in school lunches. However, all schools—Team Nutrition participants and nonparticipants—improved on these items. Team Nutrition participation did appear to increase the likelihood that schools would offer several healthful items. Team Nutrition participants had a 40% greater likelihood of offering fresh fruit, an 85% greater likelihood of offering whole grains, a 30% greater likelihood of offering salads, and a 70% to 80% lesser likelihood of offering salty snacks or baked goods at lunch from the period of 2009 to 2010.3 It's likely that, since the mandate to implement wellness policies is relatively recent, changes will happen gradually. Furthermore, these are only a few of the types of outcomes that can be studied. There are many opportunities to conduct research on Team Nutrition projects to evaluate outcomes across many types of interventions and across many different states with diverse demographics.

Team Nutrition Materials
Last year, Team Nutrition released its Local School Wellness Policy Outreach Toolkit to help schools engage parents and staff in school wellness activities. School wellness committees, which are a key element of school wellness policies, should include students, parents, school administrators, and community stakeholders, according to the Team Nutrition website. The toolkit includes customizable presentations, newsletter articles, and social media posts about school wellness policies.

Team Nutrition offers several educational lessons that are aligned with educational standards for health, English language arts, science, and math classes. Serving Up MyPlate, which includes lessons for grades 1 through 6, was downloaded more than 63,000 times during fiscal year 2016. New digital resources are being developed for middle schools and will include short videos that deliver age-appropriate messages about food choices, interactives such as video games, and standards-aligned briefs that encapsulate messages in short, easy-to-understand language.

White says Team Nutrition is developing new materials that target key populations. Given that the CACFP is the most recent child nutrition program to undergo upgrades in meal pattern standards, with regulations going into effect in October, Team Nutrition will be rolling out new tools for child care centers and family day care homes, including training worksheets and posters for child care staff and an updated Feeding Infants Guide.

Dayle Hayes, MS, RD, a school nutrition advocate and founder of School Meals that Rock, says RDs should be aware of the many culturally and age-appropriate Team Nutrition materials at their disposal. They also should be aware of the grants available for improving food, physical activity, and overall school health environments. She believes Team Nutrition provides tools for RDs and others working with child nutrition programs to avoid "reinventing the wheel" while working towards meaningful changes in the health and wellness of children, parents, and even whole school communities.

According to Adcock, Team Nutrition is a "perfect fit" for RDs with an interest in food, nutrition, and helping children to make healthful choices at a critical stage in the lifespan.

— Christen Cupples Cooper, EdD, RDN, is founding director of nutrition programs at Pace University in Pleasantville, New York.

1. Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health. 2008;29:253-272.

2. Briggs M, Fleischhacker S, Mueller CG; American Dietetic Association; School Nutrition Association; Society for Nutrition Education. Position of the American Dietetic Association, School Nutrition Association, and Society for Nutrition Education: comprehensive school nutrition services. J Nutr Educ Behav. 2010;42(6):360-371.

3. Robert Wood Johnson Foundation, Bridging the Gap. Improving school foods through the Team Nutrition program: new findings from U.S. elementary schools. http://www.bridgingthegapresearch.org/_asset/z9cm9b/btg_team_nutrition_111711.pdf. Published November 2011.