Research Article

An Assessment of Nutrition Education in Selected Counties

in New York State Elementary Schools (Kindergarten
through Fifth Grade)
~ ero, PhD2; Mark M. Alter, PhD2;
Sheldon O. Watts, PhD, MPH1,y; Domingo J. Pin
Kristie J. Lancaster, PhD, RD2

ABSTRACT
Objective: To assess the extent to which nutrition education is implemented in selected counties in New
York State elementary schools (kindergarten through fifth grade) and explore how nutrition knowledge is
presented in the classroom and what factors support it.
Design: Cross-sectional, self-administered survey.
Setting: New York State elementary schools in selected counties.
Participants: New York State elementary school teachers (n ¼ 137).
Main Outcome Measures: Hours spent teaching nutrition; nutrition topics, methods of teaching,
education resources, and aspects of the school environment that may influence nutrition education.
Analysis: Crosstabs with a chi-square statistic and ANOVA.
Results: Eighty-three percent of teachers taught some nutrition (9.0  10.5 hours) during the academic
year. Teachers taught lessons about finding and choosing healthy food (61%), relationship between diet
and health (54%), and MyPyramid (52%) most often. Suburban teachers (12.4  12.5 hours) taught
significantly (P ¼ .006) more hours of nutrition than rural teachers (4.2  3.9 hours). Teachers at schools
with fewer than 80% nonwhite students taught significantly (P ¼ .02) more (10.4  11.4 hours) compared
to schools with greater than 80% nonwhite students (5.6  6.4 hours).
Conclusions and Implications: Teachers reported that nutrition education is important and that they
are willing to teach nutrition. Efforts should be made that support integrated nutrition topics, methods
of instruction, and availability of resources.
Key Words: nutrition education, assessment, child, teachers, rural, overweight (J Nutr Educ Behav.
2012;44:474-480.)

INTRODUCTION 95th percentile), and 17% are over- diseases typically observed in the
weight ($ 95th percentile).2 Some adult population are affecting chil-
Obesity, a primary risk factor for research has suggested that if the cur- dren and adolescents at increasing
many other chronic diseases, may rent trend of excess weight continues, rates. The increased prevalence of
soon replace smoking as the leading by 2015, 75% of adults will be consid- type 2 diabetes, hypertension, and hy-
cause of preventable death in the ered overweight, and of those, 41% percholesterolemia among children
United States (US).1 Results from the will be obese; 24% of children and in the US has been concomitant
National Health and Nutrition Exami- adolescents are predicted to be over- with the rise in overweight.7-13 The
nation Survey indicate an increasing weight or obese.3 overweight/obesity epidemic was
prevalence of overweight among chil- In childhood, the most common a focus area of Healthy People 2010.
dren since 1963. An estimated 34% of and immediate consequences of over- One specific objective was to reduce
all children and adolescents aged 2-19 weight are psychosocial.4-6 However, by 50% or more the proportion of
years are at risk for overweight (85th- a number of obesity-related chronic children and adolescents who are
overweight or obese.14 This national
health objective underscores the seri-
1
Department of Public Health, Temple University, Philadelphia, PA ousness of the childhood overweight
2
Department of Nutrition, Food Studies, and Public Health, New York University, New epidemic in the US.
York, NY An effective way to reduce the risk
†
Dr. Sheldon O. Watts was affiliated with the Department of Nutrition, Food Studies, and for childhood overweight and its con-
Public Health, New York University at the time this study was completed. sequences is to promote and establish
Address for correspondence: Sheldon O. Watts, PhD, MPH, Temple University, Depart- healthy eating behaviors early in
ment of Public Health, 1301 Cecil B. Moore Avenue Ritter Annex, 9th Floor, Philadelphia, life.15-17 The family environment is
PA 19122; Phone: (215) 204-7535; Fax: (215) 204-1854; E-mail: sheldon.watts@temple.edu the main influential factor in the
Ó2012 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR development of a child's eating
http://dx.doi.org/10.1016/j.jneb.2012.01.010 behavior.18-21 If healthy attitudes

474 Journal of Nutrition Education and Behavior  Volume 44, Number 6, 2012
Journal of Nutrition Education and Behavior  Volume 44, Number 6, 2012 Watts et al 475

and behaviors developed during

childhood are maintained throughout
life, they may reduce chronic disease
risk in adulthood.22,23 The school
setting provides a valuable oppor-
tunity to positively influence
children's health behaviors through
nutrition education, school policies,
and food service that reinforce
classroom instruction.24,25 In addi-
tion, research has shown a positive
relationship between appropriate
nutrient intakes and improved
cognition and academic performance
in children.26-28
In 1966, the federal government
passed the Child Nutrition Act, which
underscores the importance of proper
nutrition at an early age and its role
in development and learning. In
2004, Congress passed legislation
that requires all federally funded edu-
cational institutions participating in
the School Breakfast and Lunch
program to establish a local wellness
policy that includes goals for nutrition
education, physical activity, and other
school-based activities.29,30 School
districts are now required to develop
and implement local wellness
policies, supported by specific
nutritional guidelines for food service Figure. School environment and the teacher-led nutrition education instructional pro-
and an established nutrition cess description using the General Systems Theory.
education plan. These policies can
have far-reaching potential if properly tions with outside agents, as it exists schools, with a zip code within 75
developed, properly implemented, to achieve educational objectives.32 miles of New York City (N ¼ 1,358).
and regularly evaluated. It is extremely Few studies describe teacher-led These schools were contained in a Mi-
important that persons involved in de- school nutrition education efforts at crosoft Access (version 2003, Micro-
veloping local wellness policies under- the state or district level. The available soft Corporation, Redmond, WA,
stand the issues that support or limit literature has focused on a single 2003) database, in which each school
the teacher-led nutrition instruction. school district or pooled teachers for was matched with its locale and re-
In designing this study, the authors statewide analysis.33-36 There are few gional codes assigned by the National
used General Systems Theory to de- data comparing teacher-led nutrition Center for Education Statistics and
scribe the school environment and education by school location, income sorted according to region: urban,
the teacher-led nutrition education level, or student ethnic profile; these suburban, and rural.37 Thirty schools
instructional process (Figure). General factors may enhance the understand- were randomly selected from each re-
Systems Theory focuses on the com- ing of how teachers address food and gion using the ‘‘Rnd’’ function in Ac-
plexity and interdependence of the nutrition in the classroom. Therefore, cess, for a final count of 90 schools
components of a system.31 Teacher- the purpose of the present study is to from 11 counties. Recruitment letters
led nutrition education is the describe the nature of teacher-led nu- and study packets were mailed to the
outcome of interest in this study. A trition education offered in selected principals of these schools. After re-
variety of factors influences the scope counties in New York State elemen- ceiving consent from the principal to
of nutrition instruction in the class- tary schools (kindergarten through conduct the survey, packets for each
room. School environments are medi- fifth grade [K-5]) and explore how teacher were delivered to participant
ated by federal, state, and district nutrition information is taught in schools' consenting principals. Substi-
policies, community characteristics, the classroom. tute and special education teachers
school characteristics, and teacher were excluded from the study. Princi-
characteristics. The multidisciplinary METHODS pals at participating schools did not
quality of General Systems Theory allow the investigator to administer
provides an organized approach to de- Eligible schools included all elemen- the survey. All principals agreed to dis-
scribing the dynamic, multifaceted tary schools in the New York State tribute and collect the completed sur-
school environment and its interac- Education Department's directory of veys. The act of filling out and
476 Watts et al
returning the survey was considered
informed consent. Each principal
was given specific instructions to dis-
tribute the survey during a faculty
meeting to maintain consistency in
the survey environment. Principals
were contacted soon after surveys
were delivered to determine a timeline
for survey distribution and collection.
Completed surveys were returned by
mail or retrieved by the researcher.
All procedures were approved by
New York University's Committee on
Activities Involving Human Subjects.
The survey used in the study was
adapted from the Nutrition Education
in Public Elementary School Class-
rooms, K-5 Survey and the Nutrition
Education in Public Elementary and
Secondary Schools, K-12 Survey.35,36
Questions were pooled from both
surveys and duplicates were removed,
for a total of 41 questions including
demographic questions. Most
questions addressed the extent to
which teachers used certain teaching
methods, resources, and topics when
teaching nutrition. The original
survey was minimally modified. The
survey assessed community, school,
and teacher characteristics and
nutrition-related instructional prac-
tices. A question about the cultural sen-
sitivity of teaching resources and
methods and an open-ended question
asking about ways to encourage nutri-
tion education were added. A pilot-
test was conducted to refine the
research protocol. For the pilot, a sam-
ple of 50 teachers was randomly se-
lected from a database of teachers
maintained by an after-school tutoring
program. Teachers were mailed a copy
of the survey, which was made accessi-
ble online. A modified Dillman proce-
dure was used to maximize survey
response.38 Of those contacted, 10
teachers mailed the completed survey
and 2 completed it online, for an overall
response rate of 24%. No changes were
deemed necessary as a result of the pi-
lot, but it was decided to mail the survey
instead of administering it online.
Analysis
The analysis reported here examined
the association between community
and teacher characteristics and nutri-
tion instruction. Data were analyzed
using the Statistical Package for Social
Sciences (version 16.0, SPSS Inc.,
Journal of Nutrition Education and Behavior  Volume 44, Number 6, 2012
Chicago, IL, 2008). Descriptive analy-
ses, including frequencies, means,
and crosstabs with a chi-square statis-
tic, were used to describe teaching
methods and nutrition-related re-
sources. Analysis of variance models
were calculated with time spent
teaching nutrition as the dependent
variable and community charac-
teristics including school location,
socioeconomic status (SES), and
student ethnic profile as the indepen-
dent variables. School SES was based
on student free or reduced-price lunch
eligibility, a commonly used measure
of SES in school-based research.39-41
The dependent variable was tested
for normality using the Shapiro-Wilk
Test of Normality and was normally
distributed. Two-tailed P < .05 was
considered statistically significant.
RESULTS
Demographic Characteristics
Eighteen of the 90 principals to whom
invitations were sent (7 urban, 5 sub-
urban, and 6 rural schools) agreed to
participate in the study, for a response
rate of 20%. Approximately 578 sur-
veys were mailed to principals at
participating elementary schools,
and 139 surveys were returned, for
an overall response rate of 24%. The
highest return rate was from suburban
schools (46%). Two incomplete sur-
veys were excluded from the analysis.
Table 1 shows teacher characteristics
(n ¼ 137): 53 were completed by ur-
ban teachers, 58 were completed by
suburban teachers, and 26 were com-
pleted by rural teachers. Most of the
teachers were female (87%). The aver-
age age of teachers in the urban (38 
13 years) and suburban (37  8 years)
schools were similar. Eighty-four per-
cent of teachers described themselves
as white. The 12% of teachers who de-
scribed themselves as black all taught
in urban schools. The majority of
teachers had earned master's degrees,
and two thirds reported elementary
education as their major field of study.
Nutrition Instruction
Most teachers (83%) taught some
nutrition during the 2007-2008 aca-
demic school year. Teachers taught
an average of 9.0  10.5 hours of nu-
trition instruction during the year.
Approximately half of the teachers
(n ¼ 72) reported that they dedicated
an adequate amount of time to nutri-
tion. Those teachers spent signifi-
cantly more time teaching nutrition
(13.4 hours) compared with teachers
who reported that they did not dedi-
cate adequate time to nutrition
instruction (4.9 hours, P < .001).
Teachers reported to a great or moder-
ate extent teaching lessons about
finding and choosing healthy food
(61%), the relationship between diet
and health (54%), MyPyramid (52%),
dietary guidelines (43%), and nutri-
ents and their food sources (43%).
Topics taught less frequently included
body image, preparing healthy food,
and factors that influence food choice
such as culture, advertising, or beliefs.
Twenty-eight percent of teachers
taught nutrition as a separate subject.
However, 72% reported combining
nutrition instruction with health or
physical education and 62% with
science to a great or moderate extent.
Only 38% reported integrating nutri-
tion to a great or moderate extent
with reading/language arts, 21% with
mathematics, and 17% with history/
social studies.
When asked about the methods
they used to teach nutrition, teachers
most often reported using active class-
room discussion (68%) to a great or
moderate extent. They also reported
using collaborative or cooperative
work (47%), lecturing (38%), hands-
on learning (37%), and demonstra-
tions (35%) to a great or moderate
extent. A smaller proportion of
teachers reported using the other
methods listed in the survey to a great
or moderate extent: computers or
other advanced technology (27%),
student projects (27%), field trips
(26%), media presentations (25%),
role playing (26%), special events
(17%), and guest speakers (12%).
Teachers used supplementary ma-
terials (54%), curriculum guides
(41%), and newspapers or magazines
(43%) in their nutrition instruction
to a great or moderate extent
(Table 2). Only 35% reported using
audiovisual aids, 24% used computer
software, 22% used textbooks, and
17% used culturally sensitive re-
sources to a great or moderate extent.
Overall, more than half of all teachers
reported using the materials listed ei-
ther to a small extent or not at all.
Journal of Nutrition Education and Behavior  Volume 44, Number 6, 2012 Watts et al 477

evaluation of the nutrition-related

Table 1. Demographic Characteristics of Participating Teachers in New York City
Learning Standards. Despite the ab-
Vicinity
sence of nutrition core curriculum,
83% of teachers surveyed reported
All Urban Suburban Rural teaching some nutrition. More
(n ¼ 137) (n ¼ 53) (n ¼ 58) (n ¼ 26) teachers in this study reported teach-
Average age, y (mean  SD) 39  10 38  13 37  8 46  8 ing nutrition than teachers in a local
Sex (n [%]) assessment of teachers in an urban
Male 17 (13) 6 (5) 9 (7) 2 (2) Connecticut school district (56%),33
Female 116 (87) 45 (34) 47 (35) 24 (18) and a similar proportion of teachers
Race/ethnicity (n [%]) taught nutrition in a statewide assess-
White 105 (84) 25 (20) 54 (43) 26 (21) ment in Minnesota.34 The data in this
Black 15 (12) 15 (12) 0 (0) 0 (0) study were also comparable to national
Asian-Pacific Islander 5 (4) 4 (3) 1 (< 1) 0 (0) data from the 2000 NCES K-5 survey, in
Hispanic 7 (5) 5 (4) 1 (< 1) 1 (< 1) which 88% of teachers taught nutri-
Highest degree (n [%]) tion and the 2006 School Health Poli-
Bachelor’s 13 (10) 8 (6) 5 (4) 0 (0) cies and Programs Study, in which
Master’s 107 (81) 36 (27) 46 (35) 25 (19) 90% of teachers taught nutrition.35,42
> 1 Graduate degree 9 (7) 4 (3) 5 (4) 0 (0) In the present study, teachers re-
Other 4 (3) 2 (2) 1 (< 1) 1 (< 1) ported integrating nutrition with
Major field of study (n [%]) health or physical education and sci-
Elementary education 87 (66) 32 (24) 38 (28) 19 (14) ence to the greatest extent. This was
Other 45 (34) 19 (14) 18 (13) 10 (5) also the case in the national survey.
Few teachers integrated nutrition
Note: The number of teachers answering specific demographic questions varied
with reading/language arts, history/
owing to missing data.
social studies, or mathematics. When
considering how nutrition education
could fit into current curriculum,
Teachers at suburban schools (12.4 However, in 2006 the School Health both mathematics and reading/lan-
 12.5 hours) taught nutrition signif- Policies and Programs Study reported guage arts are topic areas that could
icantly (P < .05) more hours than a median of 3.4 hours of nutrition mesh well with nutrition informa-
rural teachers (4.2  3.9 hours; and dietary behavior instruction for tion. Providing teachers with appro-
Table 3). The number of hours spent elementary schools.41 Contento et al priate curriculum could facilitate
teaching nutrition did not differ by suggest a minimum of 15 hours of nu- planning and implementing inte-
school SES. However, the average trition education to establish change grated nutrition instruction.
number of hours spent teaching nutri- in knowledge and 50 hours for elicit- Resources used to teach nutrition
tion differed significantly by the ing lasting changes in attitudes and were an important consideration in
schools' ethnic profile. Teachers at behaviors.43 this study. The NCES elementary
schools with fewer than 80% non- New York State incorporates guide- school assessment did not report on
white students taught significantly lines for nutrition education into its what resources teachers used in the
(P < .05) more hours (10.4  11.4 Learning Standards for Health, Physi- classroom.35 In this study, teachers re-
hours) than teachers at schools with cal Education, and Family and Con- ported using supplementary mate-
more than 80% nonwhite students sumer Sciences, Standard 1.44 A rials, newspapers or magazines, and
(5.6  6.4 hours). review of the New York State Depart- teaching guides to the greatest extent.
ment of Education Web site shows no In the Connecticut study, teachers
DISCUSSION established curriculum for nutrition also primarily used newspapers or
education or a systematic method of magazines, but they also had access
This study focused on teacher-led nu-
trition instruction in selected counties
in New York State elementary schools Table 2. Frequency of Use of Materials to Teach Nutrition, n (%)
(K-5) and explored how nutrition in-
formation is taught. Although more Small Moderate Great
than half of the teachers surveyed be- Materials Not at All Extent Extent Extent
lieved that they dedicated an ade- Curriculum guides 49 (36) 31 (27) 31 (23) 25 (18)
quate amount of time to nutrition Supplementary materials 23 (17) 39 (29) 50 (37) 24 (18)
instruction, they reported an average Newsletters or magazines 36 (27) 41 (30) 36 (27) 22 (16)
of 9 hours of nutrition instruction Textbooks 77 (56) 28 (20) 18 (13) 12 (9)
during the 2007-2008 academic year. Audio and visual aids 44 (33) 43 (32) 37 (27) 11 (8)
This finding was lower than the na- Computer software 68 (50) 35 (26) 27 (20) 5 (4)
tional average of 13 hours reported Culturally sensitive resources 71 (56) 36 (28) 15 (12) 6 (5)
in the 2000 National Center for Edu-
cation Statistics (NCES) K-5 survey.35
478 Watts et al
Table 3. Mean Number of Hours Spent Teaching Nutrition by School Demographic
Characteristics
Characteristics n mean ± SD
Locale
Urban 47
Suburban 47
Rural 22
SES
Low SES 41
High SES 75
School ethnic profile
< 80% nonwhite 86
> 80% nonwhite 30
SES indicates socioeconomic status.
Values with different letters are significantly different from each other, P < .05.
a,b
Note: P values are from multiple regression analyses representing the difference
between mean number of hours and school characteristics.
to nutrition curriculum made avail-
able by the school district.34 Overall,
more than half of the teachers sur-
veyed reported either not using all of
the teaching materials presented in
the survey or using them to a small ex-
tent. More than half of the teachers re-
ported not using textbooks, computer
software, or culturally sensitive re-
sources at all. All teachers citing access
to nutrition-related teaching materials
or reference materials spent signifi-
cantly greater time teaching nutrition.
The authors of the present study asked
an open-ended question about what
could be done to encourage teachers
in providing nutrition education. The
majority of teachers cited access to
a nutrition curriculum and teacher
training as factors that would support
greater in-class instruction.
The lack of use of these resources
does contrast the wide availability of
nutrition-related educational re-
sources for teachers. For example, there
are numerous classroom curricula and
activities available through Team Nu-
trition. Team Nutrition is a school-
based intervention developed by the
United States Department of Agricul-
ture Food and Nutrition Service. It
provides teachers and foodservice per-
sonnel training, technical support,
and comprehensive nutrition educa-
tion resources aimed at improving
children's lifelong eating and physical
activity habits.45-47 The Team
Nutrition Demonstration Project
1999-2002 acknowledged teacher
constraints such as limited
Journal of Nutrition Education and Behavior  Volume 44, Number 6, 2012
F P
5.340 .006
7.9  9.5a,b
12.4  12.5a
4.2  3.9b
0.276 .60
8.3  10.0
9.4  10.9
5.994 .02
10.4  11.4
5.6  6.4
instructional time and emphasized
the importance of integrating the
Team Nutrition lessons into other
subject areas.48 District and school ad-
ministrators should make resources
for nutrition instruction accessible to
teachers, while providing integrated
lesson plans and ongoing teacher
training.
Strengths and Limitations
This study provides a snapshot of how
nutrition is taught in public elemen-
tary schools in selected counties in
New York State and is the first to com-
pare time spent teaching nutrition
across different regions, varying eth-
nic distributions of the student popu-
lation, and school SES. This study also
adds to the literature on the underly-
ing issues that influence ethnic health
disparities in the US. Teachers at
schools with the lowest SES and great-
est ethnic diversity taught the least
amount of nutrition during the aca-
demic year. Research has shown that
these populations are at greatest risk
for chronic disease and that school-
aged children are more likely to
make poor dietary decisions and
have less knowledge about healthy
eating.49-52 These populations are in
greatest need of nutrition education
that support healthy eating behaviors.
Although the schools were ran-
domly selected from certain counties,
because of the low response rate, the
sample is essentially a convenience
sample, which limits its generalizabil-
ity. Schools were recruited from a sub-
set of counties in New York State. The
administrative environments at the
school and district level were inconsis-
tent and often difficult to navigate. As
a result, a number of principals were
interested in participating, but district
policies and regulations restricted re-
searcher access. The varying adminis-
trative environment at each school/
district, numerous gatekeepers, and
not having the researcher administer
surveys may have hampered the
study's response rate and limited op-
portunities to answer questions or col-
lect additional information from
teachers. When all of these constraints
are taken into consideration, the time
teachers in this study spent teaching
nutrition is more than twice what has
been reported in the most recent na-
tional examination.
Further research, with more direct
access to teachers, would better deter-
mine how teachers present nutrition
content in their classrooms. Such
research would also provide a more
thorough understanding of how differ-
ences among schools, districts, and
communities, and characteristics of
the student body and the school loca-
tion, influence nutrition instruction.
The survey used in this study in-
cluded questions about the teaching
process. There may have been a ten-
dency for participants to respond in
a personally favorable manner or
give socially desirable responses that
bias results.53 This bias may have
been amplified by the method in
which the surveys were distributed.
The principal or the administrative
staff distributed and collected surveys
at each school. In an effort to counter
this bias, all respondents were assured
that their completed survey responses
would remain completely confiden-
tial and anonymous. Even with the
potential for this bias, the number of
hours teachers spent on nutrition in-
struction was considerably lower
than the 2000 national average and
below teaching recommendations.
IMPLICATIONS FOR
RESEARCH AND
PRACTICE
Public schools provide a practical set-
ting in which to systematically im-
prove the health of children.27,54
Journal of Nutrition Education and Behavior  Volume 44, Number 6, 2012 Watts et al 479

Schools can help establish healthful
dietary and lifestyle behaviors in
children by providing knowledge,
promoting positive images of health,
and teaching effective health-related
decision-making skills. Nutrition is
not a core subject area in New York
State and is not integrated in the
core curriculum. Teachers should be
provided with training and resources
to incorporate nutrition into their
teaching and encouraged to teach
about nutrition and healthy eating.
This study adds to the limited liter-
ature on classroom-based, teacher-led
nutrition education in public elemen-
tary schools. However, a more com-
prehensive survey with a larger
sample and higher response rate
would add considerably to the under-
standing of teacher-led nutrition in-
struction. Additionally, research that
explores nutrition-related teaching re-
sources and teaching methods would
be helpful in understanding how to
maximize classroom instruction in
school environments where nutrition
is not a priority.
Much of the research on nutrition
education in elementary schools has
focused on school-based nutrition in-
terventions. Many of these interven-
tions are implemented by external
agencies with little or no teacher in-
volvement.55-62 This study focused
on teachers and the instructional
process. Future research should
further examine how traditional
teachers provide nutrition education
to students, what factors support
teacher-led nutrition instruction, and
how best to increase the amount of
nutrition-related instructional time
in traditional educational settings.27
These efforts should also examine
the impact of nutrition education on
student knowledge and specific be-
havioral outcomes.
ACKNOWLEDGMENTS
The analysis described in this article is
part of a larger dissertation project
(SOW) that examined additional mea-
sures and practices of teachers in se-
lected counties in New York State
elementary schools.
REFERENCES
1. Mokdad AH, Marks JS, Stroup DF,
Gerberding JL. Actual causes of death
in the US, 2000. JAMA. 2004;291:
1238-1245.
2. Ogden CL, Carroll MD, Curtin LR,
et al. Prevalence of overweight and
obesity in the United States, 1999-
2004. JAMA. 2006;295:1549-1555.
3. Wang Y, Beydoun MA. The obesity
epidemic in the United States – gender,
age, socioeconomic, racial/ethnic, and
geographic characteristics: a systematic
review and meta-regression analysis.
Epidemiol Rev. 2007;29:6-28.
4. Dietz WH. Health consequences of obe-
sity in youth: childhood predictors of
adult disease. Pediatrics. 1998;101:518-525.
5. Hesketh KD, Wake MA, Cameron FJ.
Health-related quality of life and meta-
bolic control in children with type 1 di-
abetes. Diabetes Care. 2004;27:415-420.
6. Wang SS, Brownell KD, Wadden TA.
The influence of the stigma of obesity
on overweight individuals. Int J Obes
Relat Metab Disord. 2004;28:1333-1337.
7. Hansen ML, Gunn PW, Kaelber DC.
Underdiagnosis of hypertension in chil-
dren and adolescents. JAMA. 2007;298:
874-879.
8. Gaylor AS, Condren ME. Type 2 dia-
betes mellitus in the pediatric popula-
tion. Pharmacotherapy. 2004;24:871-878.
9. Kempf K, Rathmann W, Herder C.
Impaired glucose regulation and type
2 diabetes in children and adolescents.
Diab Metab Res Rev. 2008;24:427-437.
10. Ludwig DS, Ebbeling CB. Type 2 dia-
betes mellitus in children: primary care
and public health considerations.
JAMA. 2001;286:1427-1430.
11. Messiah SE, Arheart KL, Luke B,
Lipshultz SE, Miller TL. Relationship
between body mass index and meta-
bolic syndrome risk factors among US
8- to 14-year-olds, 1999 to 2002. J Pe-
diatr. 2008;153:215-221.
12. Sulit LG, Storfer-Isser A, Rosen CL,
Kirchner HL, Redline S. Associations
of obesity, sleep-disordered breathing,
and wheezing in children. Am J Respir
Crit Care Med. 2005;171:659-664.
13. Sinha R, Fisch G, Teague B, et al. Prev-
alence of impaired glucose tolerance
among children and adolescents with
marked obesity. N Engl J Med. 2002;
346:802-810.
14. US Department of Health and Human
Services. Healthy People 2010: Volume
I. 2nd ed. Washington, DC: US Depart-
ment of Health and Human Services,
US Government Printing Office; 2000.
15. Epstein LH, Paluch RA, Beecher MD,
Roemmich JN. Increasing healthy eat-
ing vs reducing high energy-dense
foods to treat pediatric obesity. Obesity.
2008;16:318-326.
16. Nicklas TA, Yang SJ, Baranowski T,
Zakeri I, Berenson G. Eating patterns
and obesity in children. The Bogalusa
Heart Study. Am J Prev Med. 2003;25:
9-16.
17. Veugelers PJ, Fitzgerald AL. Effective-
ness of school programs in preventing
childhood obesity: a multilevel compari-
son. Am J Public Health. 2005;95:432-435.
18. Cullen KW, Baranowski T, Owens E,
Marsh T, Rittenberry L, de Moor C.
Availability, accessibility, and preferences
for fruit, 100% fruit juice, and vegetables
influence children’s dietary behavior.
Health Educ Behav. 2003;30:615-626.
19. Boutelle KN, Fulkerson JA, Neumark-
Sztainer D, Story M, French SA. Fast
food for family meals: relationships
with parent and adolescent food intake,
home food availability and weight sta-
tus. Public Health Nutr. 2007;10:16-23.
20. Gross SM, Pollock ED, Braun B. Fam-
ily influence: key to fruit and vegetable
consumption among fourth- and fifth-
grade students. J Nutr Educ Behav.
2010;42:235-241.
21. Pearson N, Biddle SJ, Gorely T. Family
correlates of fruit and vegetable con-
sumption in children and adolescents:
a systematic review. Public Health
Nutr. 2009;12:267-283.
22. Dietz WH, Gortmaker SL. Preventing
obesity in children and adolescents.
Annu Rev Public Health. 2001;22:337-353.
23. Must A, Strauss RS. Risks and conse-
quences of childhood and adolescent
obesity. Int J Obes Relat Metab Disord.
1999;23:S2-S11.
24. Briggs M, Fleischhacker S, Mueller CG.
Position of the American Dietetic Asso-
ciation, School Nutrition Association,
and Society for Nutrition Education:
comprehensive school nutrition services.
J Nutr Educ Behav. 2010;42:360-371.
25. Wechsler H, Devereaux RS, Davis M,
Collins J. Using the school environment
to promote physical activity and healthy
eating. Prev Med. 2000;31:S121-S137.
26. Bellisle F. Effects of diet on behaviour
and cognition in children. Br J Nutr.
2004;92(suppl 2):S227-S232.
27. Kleinman RE, Hall S, Green H, et al.
Diet, breakfast, and academic perfor-
mance in children. Ann Nutr Metab.
2002;46:24-30.
28. Mahoney CR, Taylor HA, Kanarek RB,
Samuel P. Effect of breakfast composition
on cognitive processes in elementary
school children. Physiol Behav. 2005;85:
635-645.
480 Watts et al
29. The Child Nutrition and WIC Reau-
thorization Act of 2004, 42 USC
§1751 (2004).
30. Special Supplemental Nutrition Pro-
gram for Women, Infants, and Chil-
dren, 42 USC §1786 (2011).
31. Bertalanffy L. General System Theory:
Foundations, Development, 245 Applica-
tions. New York, NY: George Braziller;
1968.
32. Bowen GL. Social organization and
schools: a general systems theory per-
spective. In: Allen-Meares P, ed. Social
Work Services in Schools. 5th ed. Boston,
MA: Pearson Education, Inc; 2007:60-80.
33. Perez-Escamilla R, Haldeman L,
Gray S. Assessment of nutrition educa-
tion needs in an urban school district in
Connecticut: establishing priorities
through research. J Am Diet Assoc.
2002;102:559-562.
34. Stang J, Story M, Kalina B. Nutrition
education in Minnesota public schools:
perceptions and practices of teachers.
J Nutr Educ. 1998;30:396-404.
35. Celebuski C, Farris E. Nutrition Education
in Public Elementary School Classrooms,
K-5: Statistical Analysis Report. Wash-
ington, DC: US Government Printing
Office; 2000.
36. Celebuski C, Farris E, Carpenter J. Nu-
trition Education in Public Elementary and
Secondary Schools. Washington, DC:
US Government Printing Office; 1996.
37. National Center for Education Statis-
tics. Identification of Rural Locales.
Common Core of Data (CCD) Web
site. http://www.nces.ed.gov/ccd/ru-
ral_locales.asp. Accessed April 13, 2012.
38. Dillman D. Mail and Telephone Surveys:
The Total Design Method. Pullman,
WA: John Wiley and Sons; 1978.
39. Webber MP, Carpiniello KE,
Oruwariye T, et al. Burden of asthma
in inner-city elementary school chil-
dren. Arch Pediatr Adolesc Med. 2008;
157:125-129.
40. Rimm-Kaufman SE, Fan X, Chiu Y,
You W. The contribution of the Re-
sponsive Classroom Approach on chil-
dren’s academic achievement: results
from a three-year longitudinal study. J
School Psychol. 2007;45:401-421.
41. Johnson SB, Pilkington LL, Debb LC,
et al. Prevalence of overweight in
North Florida elementary and middle
school children: effects of age, sex, eth-
Journal of Nutrition Education and Behavior  Volume 44, Number 6, 2012
nicity, and socioeconomic status. J Sch
Health. 2007;77:630-636.
42. Contento I, Balch FI, Bronner YL.
Nutrition education for school-aged
children. J Nutr Educ. 1995;27:298-311.
43. New York State Education Depart-
ment. Health, Physical Education, Fam-
ily and Consumer Sciences Resource
Guide. http://www.emsc.nysed.gov/
guides/health. Updated June 12, 1998.
Accessed April 13, 2012.
44. Kann L, Telljohann SK, Wooley SF.
Health education: results from the
School Health Policies and Programs
Study 2006. J Sch Health. 2007;77:
408-434.
45. United States Department of Agricul-
ture Food and Nutrition Service. About
Team Nutrition. Team Nutrition Web
site. http://www.teamnutrition.usda.
gov/about.html. Updated February
21, 2012. Accessed April 13, 2012.
46. Kennedy E. Healthy meals, healthy food
choices, healthy children: USDA’s team
nutrition. Prev Med. 1996;25:56-60.
47. United States Department of Agricul-
ture Food and Nutrition Service. Edu-
cators. Team Nutrition Web site.
http://www.teamnutrition.usda.gov/
educators.html. Updated February 21,
2012. Accessed April 13, 2012.
48. United States Department of Agricul-
ture Food and Nutrition Service. Team
Nutrition Demonstration Project 1999-
2002. Food and Nutrition Service Web
site. http://www.fns.usda.gov/ora/
menu/published/NutritionEducation/
Files/TNDP99-03.htm. Updated Feb-
ruary 17, 2012. Accessed April 13, 2012.
49. National Center for Health Statistics.
Health, United States, 2010: With Spe-
cial Feature on Death and Dying. Cen-
ters for Disease Control and Prevention
Web site. http://www.cdc.gov/nchs/
hus.htm. Published February 2011. Ac-
cessed June 25, 2011. DHHS Pub No.
2011-1232.
50. Fahlman MM, McCaughtry N,
Martin J, Shen B. Racial and socioeco-
nomic disparities in nutrition behaviors:
targeted interventions needed. J Nutr
Educ Behav. 2010;42:10-16.
51. Xie B, Gilliland FD, Li YF,
Rockett HR. Effects of ethnicity, fam-
ily income, and education on dietary
intake among adolescents. Prev Med.
2003;36:30-40.
52. Gans KM, Burkholder GJ, Risica PM,
Lasater TM. Baseline fat-related dietary
behaviors of white, Hispanic, and black
participants in a cholesterol screening
and education project in New England.
J Am Diet Assoc. 2003;103:699-706.
53. Van de Mortel TF. Faking it: social
desirability response bias in self-report re-
search. Austr J Adv Nurs. 2008;25:40-48.
54. Story M. School-based approaches for
preventing and treating obesity. Int J
Obes Relat Metab Disord. 1999;23(suppl
2):S43-S51.
55. Donnelly JE, Jacobsen DJ, Whatley JE,
et al. Nutrition and physical activity
program to attenuate obesity and pro-
mote physical and metabolic fitness in
elementary school children. Obes Res.
1996;4:229-243.
56. Harrell JS, McMurray RG,
Bangdiwala SI, et al. Effects of
a school-based intervention to reduce
cardiovascular disease risk factors in
elementary-school children: the Cardio-
vascular Health in Children (CHIC)
study. J Pediatr. 1996;128:797-805.
57. Harris KJ, Paine-Andrews A,
Richter KP, et al. Reducing elementary
school children’s risks for chronic dis-
eases through school lunch modifica-
tions, nutrition education, and physical
activity interventions. J Nutr Educ.
1997;29:196-202.
58. Hopper CA, Munoz KD, Gruber MB,
Nguyen KP. The effects of a family fitness
program on the physical activity and nu-
trition behaviors of third-grade children.
Res Q Exerc Sport. 2005;76:130-139.
59. Kreisel K. Evaluation of a computer-
based nutrition education tool. Public
Health Nutr. 2004;7:271-277.
60. Perry CL, Bishop DB, Taylor G, et al.
Changing fruit and vegetable consump-
tion among children: the 5-a-Day Power
Plus program in St. Paul, Minnesota. Am
J Public Health. 1998;88:603-609.
61. Powers AR, Struempler BJ, Guarino A,
Parmer SM. Effects of a nutrition educa-
tion program on the dietary behavior
and nutrition knowledge of second-
grade and third-grade students. J Sch
Health. 2005;75:129-133.
62. Reynolds KD, Franklin FA, Binkley D,
et al. Increasing the fruit and vegetable
consumption of fourth-graders: results
from the High 5 project. Prev Med.
2000;30:309-319.