April 28, 2014
Chief, School Programs Branch
U.S. Department of Agriculture
Policy and Program Development Division,
Child Nutrition Programs, Food and Nutrition Service
P.O. Box 66740
St. Louis, MO 63166-6740
Re: RIN 0584-AE25 (Local School Wellness Policy Implementation under the Healthy, Hunger-Free Kids Act of 2010)
Dear Ms. Brewer:
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the United States Department of Agriculture (USDA) Food and Nutrition Service’s (FNS) February 28, 2014 proposed rule "Local School Wellness Policy Implementation under the Healthy, Hunger-Free Kids Act of 2010." With over 75,000 members comprised of registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States committed to improving the nation’s health through food and nutrition across the lifecycle. The Academy’s members demonstrate this commitment through direct, caring work in child nutrition programs at the local, state, and national levels; as researchers and educators; as corporate dietitians supplying products or services to school foodservice operations; and as consultants in school nutrition and wellness. We also wish to acknowledge Academy members who serve in the USDA and their positive influence on nutrition policy.
It is the position of the Academy that strong wellness policies promote environments that enhance nutrition integrity and help students to develop lifelong healthy behaviors.2The Academy supports the proposed rule and offers its comments (together with consensus comments developed as a member of the National Alliance for Nutrition and Activity) below.
We believe the proposed rule strengthens the existing guidelines around local wellness policies by assuring that schools have goals for nutrition promotion and education, physical activity, food marketing and advertising, as well as other school-based activities that promote student wellness. Research shows that significant changes already have been made to school environments as a result of the implementation of the wellness policies.3 The proposed rule also improves accountability and public reporting to provide transparency with parents, students and the community on implementation, progress and regular review of the wellness policy. Additionally, it assures adequate representation on the wellness committee by key stakeholders, including leadership by one or more local education agency (LEA) or school official(s), to optimize the development, implementation and coordination of the LWP across the school environment and community with input and accountability from those involved.
The Academy notes that the rule appears to lack a timeline for implementation and strongly support the inclusion of a timeline in the final rule. We propose that LEAs be required to implement this rule at the beginning of the school year that is not earlier than one year and not later than two years following the date on which the regulations are finalized. To the extent possible, we would like to see the rule implemented for school year 2015-16, and encourage USDA to finalize the rule quickly to provide schools with sufficient time to comply with the new requirements. The Academy also asks that USDA provide guidance for encouraging communities to form groups of concerned citizens to work with LEAs regarding these policies.
The Academy also notes our members' concerns with the impact of the proposed rule on LEA budgets. The significant implementation, monitoring, and maintenance requirements of an effective wellness policy can be time-intensive and may necessitate a new full- or part-time staff position, depending on the size of the LEA. The impact of new school marketing requirements on funding should also be addressed and we encourage USDA to provide guidance as to how presently compliant LEAs have been able to make up revenue lost when they ended certain fundraisers. Although USDA-provided resources are invaluable, accessing and using them appropriately requires technical assistance. Academy members report stressful environments in schools that are trying to meet standards without adequate resources.
And, although the proposed rule will not apply to private or parochial schools, many turn to USDA for guidance for their own wellness policies and guidelines. To the extent appropriate, USDA should encourage such schools to adopt wellness policies aligned with those detailed in the proposed rule.
We encourage USDA to incorporate the guidance and details in the preamble into the toolkits and resources that USDA provides LEAs to assist in implementation. In the rule itself, we encourage USDA to expand the definitions section [210.30 (b)] to include definitions of particular terms and offer the following model language:
- School wellness policy includes both the school board-approved local wellness policy as well as any superintendent regulations, rules, and/or procedures that accompany the school board-approved wellness policy, where applicable.
- Nutrition promotion and education refers to all activities that engage students directly or indirectly in classroom settings, foodservice venues, or throughout the school campus, during the school day, that are designed to facilitate adoption of healthy food choices, in addition to enhancing and encouraging participation in school meal programs, and other food- and nutrition-related behaviors consistent with the most recent Dietary Guidelines for Americans.
- Food and Beverage Marketing and Advertising means an oral, written, or graphic statement or representation, including a company logo or trademark, made for the purpose of promoting the use or sale of a product by the producer, manufacturer, distributer, seller, or any other entity with a commercial interest in the product. This covers any property or facility owned or leased by the school district or school (such as school buildings, athletic fields, transportation vehicles, parking lots, or other facilities) and used at any time during the school day.
- Physical education teaches students the basics of physical literacy and how to integrate exercise into their lives in order to establish a lifetime of healthy living. A quality physical education program provides learning opportunities, appropriate instruction, meaningful and challenging content for all children, as well as student and program assessment. Physical education should be the cornerstone of increasing the overall quantity of physical activity in school.
- Physical activity is bodily movement of any type and may include recreational, fitness and sport activities, such as jumping rope, playing soccer, lifting weights, as well as daily activities, such as walking or taking the stairs, and reducing sedentary time. Opportunities to accumulate physical activity during the school day include time spent in physical education class, classroom-based movement, recess, walking or biking to school, and recreational sport and play that occurs before, during and after school.
Comments on Specific Provisions of the Proposed Rule
Local School Wellness Policy Leadership
We strongly support the requirement that there be one or more LEA or school official(s) who serves as the designated contact for the wellness policy and is ultimately responsible for implementation, conveying progress, and ensuring regular reviews and updates of the wellness policy and assuring school compliance with the policy. It is important that the LEA make the name, position title, and contact information for the designated official(s) available on the district and individual school websites, in communications to parents, in school newsletters, and/or in other school communications. We encourage USDA to provide additional guidance to LEAs on what "authority" means.
Public Involvement in Local School Wellness Policy Development
We support the requirement that schools seek to involve a broad array of stakeholders to participate in the development, implementation, and periodic review and update of the local wellness policy to assure coordination across the school environment and throughout the community. The Academy's RDN and DTR members have been particularly capable and beneficial additions to committees developing wellness policies and result in policies with improved nutrition education provisions. The LEA should be required, rather than encouraged, to make available the names and position titles or relationship to the school of the wellness committee members (but not contact information) to foster transparency, accountability, and communication. We are pleased that USDA will encourage wellness committees at both the LEA and school level.
We think that it is excellent that there is mention in the preamble of coordinating with SNAP-Ed coordinators and educators, and per the new Farm Bill, these educators should be prepared to incorporate physical activity into SNAP-Ed resources and technical assistance. We also encourage USDA to include other government resources/agencies/programs, such as CDC grantees, local departments of health working on school nutrition and physical activity, and transportation departments (on walking and biking to school) in your guidance to LEAs as applicable.
Content of the Local School Wellness Policy
We support the areas of coverage of the proposed rule, including nutrition promotion and education, physical activity, nutrition guidelines for all foods, food and beverage marketing, and other school-based activities and resources that promote student wellness. Improved coordinated school health programs will augment prevention efforts and help improve fitness, academic performance, mental health, physical health and well-being across the school environment.
We believe that the resources, toolkits and model policies that will be provided by USDA will be essential to ensuring schools' success in implementing local wellness policies. We encourage USDA to incorporate the resources of other organizations (such as the Alliance for a Healthier Generation's Smart Snack calculator and other resources) and provide access to these resources in your supporting materials. We strongly agree that wellness policy goals should be measurable over the short and long term and should elucidate who will make what change, by how much, where and by when, and that this should be applicable for ALL aspects of the rule, not just the content of the local school wellness policy. We are pleased that USDA will provide guidance to and models for LEAs on how best to create strong, clear goals with specific and measurable objectives and benchmarks.
Nutrition Promotion and Education
Effective nutrition education and promotion must: 1) focus on specific behaviors; 2) address the interests and motivations of the intended audience; 3) allow enough time and intensity to achieve positive results; 4) deliver sequential curricula in an organized manner; 5) involve several aspects of the child's environment, both at home and at school; and 6) provide professional staff development. Fifty hours of nutrition education in the classroom that is based on sequential instruction and skill building and that incorporates family involvement is need to impact behavior change.4 Unfortunately, we note that the median number of instructional hours in elementary schools devoted to nutrition in 2006 was only 3.4 hours.5
We strongly support continuing to include nutrition promotion and education in the wellness policy. The examples that USDA provides on how schools might implement nutrition promotion and education activities (e.g. integrated into core and elective subjects, posters, participatory activities, information provided to families, etc.) are helpful, and we encourage USDA to provide strong guidance and resources to LEAs to accompany these recommendations. The Academy also recommends its recently developed its Guide for Effective Nutrition Interventions and Education (GENIE), a validated online checklist tool available to help nutrition education program planners and program evaluators that can be accessed at sm.eatright.org/GENIE.
Integrating nutrition education throughout the curriculum is an effective way to implement nutrition education in the school environment, and we encourage USDA to utilize the resources developed by the Institute of Medicine in this area in your guidance to LEAS.6 The Academy notes schools have improved nutrition integrity in schools with a variety of indicators of effective integration, including:
- School gardens and other local food production are integrated into the curricula;
- Nutrition information about food items and menus is readily available;
- School nutrition staff, administrators, and teachers participate in staff development to learn more about scientifically factual nutrition;
- Nutrition is integrated into all subject areas, including language arts, science, and mathematics;
- Nutrition curricula are sequential, comprehensive, and adequate to result in behavioral changes;
- Nutrition education messages target specific behaviors, using multiple components, such as policy change and social marketing;
- Nutrition education strategies are innovative and appeal to students' interests and motivations;
- School cafeteria is used as a learning laboratory where students can apply nutrition content learned in the classroom; and
- School nutrition personnel are actively involved in nutrition education at the school level.
In addition, engaging with families through school-sponsored family wellness activities is important in ensuring that lessons are brought home. Providing students and parents with nutrition education and information can help encourage students to make healthy choices both inside and outside of school. Informing parents about how the school is addressing nutrition, nutrition education and physical activity, and providing ideas and resources about how families can reinforce these lessons is important.
The Academy strongly supports including physical activity in the local school wellness policy. We recommend that the USDA specifically mention in its guidance to LEAs and model LWPs that school-age children should accumulate at least 60 minutes per day of physical activity and avoid prolonged periods of inactivity. The key method for achieving this goal is physical education supplemented by additional opportunities for physical activity before, during, and after the regular school day.7 USDA should include recommendations to limit screen time and long periods of sedentary behavior during the school day. Once again, we feel it is important for USDA to define physical education and physical activity within the actual rule and provide examples of physical activity opportunities before, during and after school and reiterate the importance of physical education as the cornerstone for physical activity.
We are glad that the agency has prominently mentioned the importance of incorporating the quality and quantity of physical education into the local wellness policy. We encourage the agency to include recommendations for physical education curricula, increasing the number of classes offered, improving teacher training, and coordinating with additional educational or home-based components as part of model policy.8 9 10 11 12
In the preamble, USDA mentions developing recommendations for waivers and exemptions from physical education classes and physical activity. In model policies, USDA should provide language that disallow waivers and substitutions for physical education, including:
- Disallow automatic waivers or substitutions for physical education.
- Disallow assigning or withholding physical activity as punishment.
- Do not allow waivers for students with disabilities, but rather provide modifications or adaptations that ensure physical education courses meet the needs of students with disabilities.
- Do not allow students to opt out of physical education to prepare for other classes or standardized tests.
We appreciate that USDA mentions shared use as a possible component of the local wellness policy. Opening school buildings and grounds during non-school hours for community use is an important way to foster physical activity opportunities in communities. Incorporating a policy around shared use into the local wellness policy will give schools the opportunity to think through how they want to craft shared-use opportunities with individual community members, community groups, or school or public agencies during non-school hours for use of their facilities.
The Academy encourages USDA to offer guidance on the Presidential Youth Fitness Program and recommend that local wellness policies encourage schools to participate in all three aspects of the program (assessment, professional development and recognition). As part of local school wellness policies, LEAs should be encouraged to report their results from the Presidential Youth Fitness Program in an aggregate manner to the community and the relevant state agency to improve tracking of physical fitness data across the United States and inform efforts to strengthen local wellness policies to improve student physical activity and physical fitness.
Other School-based Wellness Activities
The Academy endorses the examples USDA provided for other LEA activities that integrate nutrition and health into the school environment. USDA should provide those examples to schools through its guidance and model LWP, including on school gardens and Farm to Cafeteria activities, healthy fundraisers, the HealthierUS School Challenge, outreach to families, and staff wellness activities and professional development opportunities that inspire school staff to serve as role models for students. We also think it is important that LEAs are encouraged to assess their progress using CDC's School Health Index. USDA and CDC should offer regular trainings to schools on how to complete the School Health Index.
Nutrition Guidelines for All Foods
We fully support coordination and alignment with USDA's school meal and Smart Snack standards. We agree that LEAs should be encouraged to describe whether and how their food and beverage offerings comply with the new meal and Smart Snack standards, including whether in-school fundraisers that involve food and beverages meet the Smart Snacks standards.
USDA should provide model local wellness policy language and guidance on promotion of information such as school menus on school websites, school meal program participation and compliance reporting, meal timing and duration (including recess before lunch), and the availability of free drinking water throughout the school day and during school meals. USDA also should encourage schools through guidance and model policies to extend the USDA standards beyond the school day to cover after school activities.
In addition, we support that local wellness policies address standards for foods and beverages available on campus, including through classroom parties and celebrations and food rewards and incentives. In a study done by Turner et al., only 11.9% of districts were found to have policies addressing food as a reward and found that having a district level policy addressing food as a reward was effective at reducing it.13 Schools should not only teach children how to make healthy choices, but also should provide an environment fostering healthy eating. Providing food based on performance or behavior connects food to mood. This practice encourages children to eat treats even when they are not hungry and can instill lifetime habits of rewarding or comforting themselves with food. Rewarding children with food during class also reinforces eating outside of meal or snack times, and can teach children to value reward food in an unhealthy manner. In addition, USDA should provide greater guidance as to the applicability of the proposed rule to vending machines present in schools, consistent with USDA's competitive foods rule.
We encourage USDA to provide guidance and model policy language to LEAs on how to address standards for all foods and beverages available on campus, including alternatives to serving foods that do not meet Smart Snacks standards during classroom parties and alternatives to using food as rewards.
Policies for Food and Beverage Marketing
The Academy supports that the proposed rule requires schools to include food marketing and advertising in their local wellness polices. Advertising and marketing to children in schools requires special consideration because students are in an environment where parents have little or no oversight or ability to consent, and because students should have a learning environment that does not include messages undermining important standards for nutrition and health education.
We agree that the Smart Snack standards should be used for school marketing to maintain consistency with the school food sales environment, to facilitate implementation and help to reduce confusion, and we encourage USDA to assure LEAs that they are free to implement stronger standards for marketing. For example, LEAs could extend the marketing standards beyond the school day, and they could choose to use their local or state competitive foods standards if those standards go beyond the Smart Snack standards. In so doing, LEAs could align their marketing standards with their food sales standards. Many schools raise substantial funds from such promotions as Box Tops for Education, and the Academy encourages USDA to finalize the rule such that partnerships could continue with food manufacturers if, for example, redeemable foods are limited to healthy-designated foods.
Through guidance and model LWPs, USDA should help schools to understand and address the full range of food marketing in their schools, including:
- Signs, scoreboards, or posters;
- Curricula, textbooks, websites promoted for educational purposes (ex. coolmathgames.com), or other educational materials;
- Vending machine exteriors, food or beverage cups or containers, food display racks, coolers
- Equipment, uniforms, school supplies (ex. pencils, notebooks, textbook covers);
- Advertisements in school publications, on school radio stations, in-school television(such as Channel One), computer screen savers and/or school-sponsored Internet sites, or Announcements on the public announcement (PA) system;
- Branded fundraisers and corporate-sponsored programs that encourage students and their families to sell, purchase or consume products and/or provide funds to schools in exchange for consumer purchases of those products (ex. McTeacher's night, Labels for Education, Box Tops for Education);
- Corporate incentive programs that provide children with free or discounted foods or beverages (ex. Pizza Hut Book It! Program);
- Sponsorship of materials, programs, events, or teams;
- Market research activities;
- Corporate-sponsored scholarships; and
- Free samples, taste-tests, or coupons.
USDA should clarify in guidance which types of marketing would be exempt from the standards, including:
- Marketing on clothing with brand images worn on school grounds;
- Marketing contained on product packaging that is not sold by the school; and
- Marketing that students view incidentally through media that is used for education purposes and is not produced or controlled by the local education agency, school, faculty, or students (such as ads in magazines used in an art class)
USDA should also clarify in the final rule which marketing is covered in education materials. Marketing that students view only incidentally through media that is used for educational purposes and is not produced specifically for schools or controlled by the local education agency, school, faculty, or students, such as ads in magazines used in an art class, should be exempt. However, corporate marketing placed in curricula and textbooks, websites designed for use in schools, such as coolmathgames.com, and ads on in-school radio stations or in-school television, such as Channel One, should be covered by the local wellness policy.
USDA should give guidance to schools about how to address brand advertising. Brand advertising features general brand depictions, such as brand logos, product line logos, or spokes characters, in the absence of a prominent focus on a specific product (for example, showing the company brand on a sign at a sponsored event, Ronald McDonald on a t-shirt, or a Gatorade logo on a soccer uniform). If a brand is marketed rather than a specific product, then all the products within the marketed brand or product line should meet the Smart Snack guidelines. Alternatively, schools can replace the brand marketing with marketing for a specific product that meets the Smart Snack guidelines.
USDA should provide guidance, model policies and resources to support implementation of the final rule. Those resources should include data and materials regarding revenue from school marketing to assist schools that are concerned about possible financial ramifications and help schools identify healthy, practical and profitable ways to raise funds (such as the attached document demonstrating the success of schools in Iowa and Georgia or the document).
In addition, we encourage USDA to assess implementation and impact of the final rule on the food marketing environment in schools by incorporating food marketing into future School Nutrition Dietary Assessment studies. USDA should use the resulting data to inform its work in creating and supporting future resources and guidance for schools as they evaluate and improve their policies. Additionally, we encourage USDA to incorporate food marketing policies into all levels of the HealthierUS School Challenge.
Informing the Public
The Academy supports the requirement that LEAs provide periodic and detailed public notices on the LEA's wellness policy. We agree with USDA that the LEA must actively notify households regarding its wellness policy, to ensure that families receive the information. This provision will strengthen the impact of local school wellness policies by improving implementation, accountability, and transparency. We urge USDA to move quickly to propose the transparency requirements under Section 209 of the Healthy, Hunger-Free Kids Act.
Length of School Mealtimes
The Academy believes that sufficient time to eat meals is crucial to eating enough and reducing plate waste. In a compressed time frame, students may eat their favorite foods first, leaving others to be discarded. This aspect of the school food environment is controlled locally and could be addressed by the wellness policy. A plate waste study using length of the lunch period as the independent variable resulted in elementary students with a 20 minute lunch period wasting 43.5% of their meal, whereas students had a 27.2% waste rate during a 30 minute lunch period.14 The Academy encourages USDA to urge adoption of at least 30 minutes for lunch in guidance. More broadly, rushed mealtimes contribute to a problematic eating culture in which food and eating together is regarded merely as a necessary function rather than an enjoyable shared experience.
Implementation, Assessment and Updates
The Academy supports USDA's proposal requiring that LEAs issue a detailed annual progress report, as well as triennial comprehensive assessments on its LWP. However, we encourage USDA to provide clearer guidance in the final rule on the difference between what should be included in the progress report versus the assessment. We envision the triennial assessment as an opportunity to conduct strategic planning around local wellness policies, and we ask USDA to encourage LEAs to incorporate their wellness policy implementation into the school district and school level strategic plan, which would further enhance implementation, impact, and accountability. We agree that LEAs should determine the frequency with which they update their LWP. However through guidance and model policies, USDA should encourage LEAs to update their policy every three years in concert with the triennial assessment.
We envision the one-year progress report as an opportunity for the wellness committee to determine how well the LWP is being implemented in each school and if adjustments, resources, training, or other implementation measures are needed. USDA should offer more detail in the preamble and in accompanying guidance and model language about what constitutes minimally acceptable reporting and what would be ideal. We recommend the Bridging the Gap Report as a resource for informing the reporting requirements.15 In addition, USDA and state child nutrition agencies should review school reporting and use the results to determine what guidance, technical assistance, and resources LEAs need.
We also support USDA's recommendations around recordkeeping, technical assistance, and offering resources that promote best practices. These should be widely available and easily accessible. We strongly support the requirement that an assessment of the local wellness policy be included in the district's compliance review. The compliance review should include the official designated by the LEA who is responsible for the local wellness policy (in addition to the food service professional responsible for implementing the school meal and Smart Snack standards). Currently, there is not adequate accountability and enforcement of LWP, which undermines the credibility and effectiveness of the policies, and contributes to their inconsistent implementation in schools. Including the LWP in the compliance review will help to reinforce with LEAs that the policies are important.
We support the record-keeping requirements as an opportunity to increase transparency. To avoid added burden on schools, USDA should clarify that record-keeping is the same as the annual and three-year assessments, with the main difference being that the assessment is communicated out to state agencies and public.
Lastly, we note that the Academy's Kids Eat Right website16 has resources for working with wellness policies.
In conclusion, we commend USDA for developing a robust rule for local school wellness policies that will strengthen existing policies and lead to more effective leadership, implementation, stakeholder involvement, accountability, assessment, and transparency. We are pleased that USDA will be providing comprehensive model policies, toolkits, and technical assistance. We urge USDA to include additional definitions in the final rule for each of the key areas to be covered in the LWP and provide schools with about a year for compliance with the final rule.
We hope you will provide further guidance to schools on reporting requirements and use this reporting to inform USDA's work in supporting LEAs' wellness policies. The Special Nutrition Program Operations Study (SN-OPS), USDA's multiyear study designed to provide the Food and Nutrition Service (FNS) with a snapshot of current state and school food authorities policies and practices and a baseline for observing the improvements resulting from the implementation of the Healthy, Hunger-Free Kids Act, also should provide important feedback to USDA that can then be translated into resources and toolkits that support local school wellness policies.
The Academy appreciates the opportunity to comment on this important initiative and hopes to discuss these recommendations in greater detail in the near future. We are glad to serve as a resource if we can be of any help as LEAs move forward in implementing these updates for local school wellness policies. Please contact either Jeanne Blankenship at 202-775-8277 ext. 6004 or by email at email@example.com or Pepin Tuma at 202-775-8277 ext. 6001 or by email at firstname.lastname@example.org with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs
Academy of Nutrition and Dietetics
1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 Bergman E. Position of the American Dietetic Association: Local Support for Nutrition Integrity in Schools. Journal of the American Dietetic Association. 2010;110(8):1244-1254.
3 Longley CH, Sneed J. Effects of federal legislation on wellness policy. J Am Diet Assoc. 2009;109:95-101.
4 Society for Nutrition Education. State of Nutrition Education & Promotion for Children & Adolescents. http://www.sneb.org/documents/SNENENPreport630_Final_000.pdf. Accessed April 23, 2014.
5 Society for Nutrition Education. State of Nutrition Education & Promotion for Children & Adolescents. http://www.sneb.org/documents/SNENENPreport630_Final_000.pdf. Accessed April 23, 2014.
6 National Research Council. Nutrition Education in the K-12 Curriculum: The Role of National Standards: Workshop Summary. Washington, D.C.: The National Academies Press, 2013.
7 Institute of Medicine. Accelerating Progress in Obesity Prevention. Solving the Weight of the Nation. May 8, 2012.
8 Kriemler S, Zahner L, Schindler C, Meyer U, Hartmann T, Hebestreit H, Brunner-La Rocca HP, van Mechelen W, Puder JJ. Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren: cluster randomised controlled trial. BMJ. 2010;340:c785.
9 Harris KC, Kuramoto LK, Schulzer M, Retallack JE. Effect of school-based physical activity interventions on body mass index in children: a meta-analysis. CMAJ : Canadian Medical Association Journal (Journal de l'Association Medicale Canadienne). 2009;180:719-726.
10 Jago R, McMurray RG, Bassin S, Pyle L, Bruecker S, Jakicic JM, Moe E, Murray T, Volpe SL. Modifying physical education: piloting strategies to increase physical activity. Pediatric Exercise Science. 2009;21:171-185.
11 Jansen W, Borsboom G, Meima A, Zwanenburg EJ, Mackenbach JP, Raat H, Brug J. Effectiveness of a primary school-based intervention to reduce overweight. International Journal of Pediatric Obesity. 2011;6:e70-77.
12 McKenzie TL, Sallis JF, Rosengard P. Beyond the stucco tower: Design, development, and dissemination of the SPARK physical education programs. Quest. 2009;61:114-127.
13 Turner L, Chriqui JF, Chaloupka FJ. Food as a reward in the classroom: school district policies are associated with practices in US public elementary schools. J Acad Nutr Diet. 2012;112(9):1436-42.
14 Bergman EA, Buergel NS, Englund TF, Femrite A. The relationship between the length of the lunch period and nutrient consumption in the elementary school lunch setting. J Child Nutr Manage. 2004;28(2). Accessed April 24, 2014.
15 Bridging the Gap. Local School Wellness Policies. 2013. Accessed April 24, 2014.
16 Academy of Nutrition and Dietetics. Kids Eat Right. Accessed April 24, 2014.