Case Study
by Pearl McElfish, phd, mba 1 ; Christopher long, phD 1 ; bonnie faitak, ma 2 ; emily english, DrPh 1
1
College of Medicine, UAMS Northwest, Fayetteville, Ark.
2
UAMS Northwest, Fayetteville, Ark.
School and Early Childhood Nutrition in Arkansas
Nutritional Needs in Children
Nutrition is an integral part of children’s growth
and development; proper nutrition is associated
with improved health and academic performance.
Poor childhood nutrition can have devastating
consequences. 1 Poor nutrition is associated with
childhood and adult obesity; 2 childhood and adult
chronic illness such as hypertension, diabetes, cardiovascular
disease, stroke, and sleep apnea; 2 poor
academic performance; 3 and mental and behavioral
health concerns, including depression and anxiety. 4
Most children are not getting the nutrition they
need to thrive. Fewer than 10% of American students
meet recommendations for fruit intake,
and only 2% meet the vegetable recommendations.
5 Almost 40% of total calories consumed
by children and adolescents are in the form of
empty calories (added sugar and saturated fat). 6
Sixty percent of youth consume a sugar-sweetened
beverage daily, contributing an average of
143 calories to their daily caloric consumption. 7
The results of poor nutrition are seen in the rise in
childhood obesity, which has doubled in the last 40
years. National rates of childhood obesity are at an
all-time high. One-third of school-aged children and
one-quarter of children aged two to five are now
categorized as overweight or obese. 8 The problem is
even more significant in Arkansas, where 31% of kindergarteners
and 39% of all students are overweight
or obese. 9 Nationwide, Arkansas has the highest rate
of obesity for children in grades nine through 12. 10
School and Early Childhood Education Nutrition
Sixty percent of preschoolers in the U.S. spend an
average of 26 hours per week in early childhood education
settings (ECEs), where they consume at least
one meal and one snack per day and most consume
two meals and two snacks. 11 Children aged five to 18
consume more than 50% of their daily caloric intake
in schools. 12 This makes ECEs and schools excellent
places to improve nutrition. These settings are
even more important for low-income children, who
receive the majority of their daily nutrition from early
childhood centers and schools.
School districts in California, Connecticut, and
Maine have implemented successful nutrition interventions
and have seen a range of positive results.
These results increased consumption of vegetables,
reduced consumption of sugar-sweetened beverages,
and reduced consumption of other, less healthy
foods. Most importantly, results indicated healthier
BMI trajectories. 13
Barriers to School and Early Childhood Education
Nutrition
While schools and early childhood centers are ideal
locations for addressing childhood nutrition, school
districts and ECEs face challenges that create significant
barriers to providing nutritionally-sound meals.
UAMS has met with 200 representatives from more
than 120 schools to understand their interest in, motivation
for, and challenges in implementing nutritional
improvements. Overall, the majority of school
districts are interested in and motivated to improve
nutrition, but schools face several challenges. The
most consistent challenges voiced by school district
leaders include budgetary constraints, insufficient
staff trainings, and lack of customized solutions.
UAMS is working with schools and ECEs to address
the barriers and ensure that they are empowered to
meet children’s nutritional needs through the implementation
of a Comprehensive Nutrition Enrichment
Program (Nutrition Program). UAMS provides nutrition
expertise to make changes manageable, successful,
and sustainable. School districts and ECEs
have significant choice in how they engage in the
Nutrition Program. The customized nutrition program
allows school and ECE leadership to choose
the right strategies for their students and allows
UAMS to develop individualized plans, policies, and
procedures based on each site’s specific needs. The
Nutrition Program does not provide a generic menu
or procurement list but instead works with each
school district and ECE’s current food vendors, budget,
and meal patterns to make customized nutritional
changes that will have significant impact and
are sustainable for the school district or ECE. The
Nutrition Program is implemented in three phases:
engagement, implementation, and sustainability.
Engagement
The engagement phase includes baseline evaluation,
engaging with stakeholders, assessing the food environment,
and customizing nutrition plans. Baseline
evaluation is collected at each school, and ECE and
is used to target program activities toward the areas
of greatest need.
UAMS works with each participating school district
or ECE to identify a core implementation
team. This team typically includes food preparation
staff, teachers, students, and parents.
To assess the schools and ECEs’ food environments,
UAMS partners with the child nutrition director to
assess infrastructure needs and conduct behavioral
economics assessments. This helps UAMS work
with the specific needs of each location and better
identify opportunities and barriers that exist. Based
on this assessment, UAMS develops customized
nutrition plans for each school/ECE. The customized
plans are designed to meet individual needs at each
school or ECE.
Implementation
The implementation phase includes meal and menu
modification, adjustment of procurement practices
to optimize nutrition, staff training, and behavioral
economic strategies to help nudge healthier choices.
In order to create modified meals and menus,
the UAMS evaluation team uses baseline data to
identify the least nutritious meals and items on the
menu being served in each location and recommends
menu modifications to improve nutrition
(e.g., ingredient substitutions, increase fruit and
vegetable offerings, limit simple/processed carbohydrates
and sugars, and increase water consumption).
Menu modifications are customized to meet
the budget and staffing constraints. See Table 1 for
examples.
UAMS conducts an in-depth review of each school
and ECE’s procurement histories, bid processes,
and purchasing contracts to develop customized
recommendations regarding the procurement
process that results in more nutritious food pur-
34 • The Journal of the Arkansas Medical Society www.ArkMed.org