For the first time in the past century, our children are expected to live shorter, less healthy lives than their parents. Childhood obesity rates have tripled in the past three decades, and today, nearly one in three children are overweight or obese. These children are at increased risk of developing heart disease, diabetes, and some types of cancer in their lives. Improving eating and activity habits of our children can have tremendous health, academic and economic benefits. To promote the health of children in the county, the Dakota County Public Health Department staff began a partnership in February 2009 with all nine public school districts to create the Smart Choices initiative which focuses on policy, system and environmental changes to support healthy choices. This initiative began as an effort to increase the access and availability of healthy food choices, especially fruit and vegetables, and to improve the eating habits of students and staff with the ultimate goal of improving health and academic outcomes.
Smart Choices now includes opportunities for physical activity before, during and after school. Intervention options for increasing healthy eating include: school breakfast, school lunch, cafeteria a ’la carte, snacks, classroom rewards, farm to school, school gardens, school fundraising, concessions, parties and celebrations and vending. Intervention options for physical activity include: active recess, active classrooms, before and after school physical activity opportunities, and creating safe routes for walking and biking to school. Dakota County, Minnesota, is the third largest county in the state, with a population of 398,552 (2010 Census). The target population for the Smart Choices program is the 72,312 students in the nine school districts (97 schools) in the county. Working with wellness committees and key stakeholders in each district, we have seen substantial and measurable improvements in the school environment that support healthy choices. The support among parents and key stakeholders is growing.
Between July 1, 2009 and June 30, 2011 all nine Dakota County school districts made policy or practice changes to increase healthy food choices:
• 97 schools in 9 districts made policy, system, environment changes to improve the nutrition environment for students, affecting 100% of the target population.
• 95 schools started offering healthier food and drink options at breakfast, lunch, and/or snacks affecting 72,272 students
• 60 schools changed their classroom practices to offer non-food rewards and to encourage healthy options during classroom parties and celebrations affecting 43,891 students.
Major activities include district wellness committee and countywide Smart Choices Leadership meetings, training, grant funding, assessment, action plan development and implementation, and evaluation. In addition to creating the infrastructure, school districts made 198 policy, systems, and environment changes. Changes supporting healthy nutrition include increasing healthy food and decreasing unhealthy food in meals, snacks, vending machines, classroom celebrations, school stores, rewards and fundraising. Changes supporting increased physical activity include increasing active recess, active classroom, before and after school activities, access to recreational facilities, and walking/biking to school. Startup costs of $125,000 was provided through a grant from Blue Cross and Blue Shield of Minnesota (BCBS) through its Prevention Minnesota initiative. Current funding is from BCBS and the Minnesota Department of Health’s Statewide Health Improvement Program. In addition, Dakota County and the school districts have contributed significant in-kind staff support for Smart Choices.
Childhood obesity rates have tripled in the past three decades, and today, nearly one in three children are overweight or obese. These children are at increased risk of developing heart disease, diabetes, and some types of cancer in their lives. Too many of our children are unhealthy and it is expected that 1 in 3 American children born in 2000 or later will develop diabetes. According to the 2010 Minnesota Student Survey, less than one in five students ate five or more servings of fruits and vegetables the previous day. The U. S. Department of Health and Human Service recommends 5-13 servings of fruits and vegetables per day. Research consistently shows that the majority of American children do not consume diets that meet the recommendations of the Dietary Guidelines for Americans, nor do they achieve adequate levels of daily physical activity. According to the 2010 Minnesota Student Survey, by the time they reach 12th grade only 20 percent of Dakota County students report being physically active for at least 30 minutes every day; the national recommendation is for children and adolescents to be active for at least 60 minutes per day. Schools offer many opportunities to promote children’s health by creating an environment in which children eat healthy foods, engage in regular physical activity and learn lifelong skills for healthy eating and active living. While schools alone cannot solve the obesity epidemic, without their support it is unlikely that we will succeed in reversing these trends. Children spend more time in schools than in any other environment away from home and consume a substantial portion (19 to 50 percent) of their total daily calories while at school (Gleason and Suitor 2001). Furthermore, obesity and poor diet disproportionately affect low-income and minority children and these children are much more likely to participate in the school breakfast and lunch programs, making schools a great avenue to improving the lives of those at greatest risk. (USDA Data, 2008)
In 2004, Congress passed the Child Nutrition and WIC Reauthorization Act requiring all schools to develop a wellness policy, including goals for physical activity and nutrition. Following that direction, all districts in Dakota County developed wellness policies that were implemented in the 2006-2007 school year. Although some progress was made, there was no funding provided to support this mandate. Most districts did not maintain their wellness committees or actively work on implementation, especially outside of the school breakfast and lunch program. In November 2007, Dakota County Public Health Department convened a Childhood Obesity Prevention Summit. More than 80 Dakota County community leaders participated, including elected officials, school administrators, childcare directors, physicians, dietitians, food service managers, park and recreation staff, public health staff, and community members. Summit participants identified two overall goals:
• Promote healthy eating and physical activity habits for all residents, with an emphasis on parents of pre-school and elementary school-aged children.
• Advocate for policies that support an environment that encourages healthy nutrition and increases physical activity.
Throughout this time period, the Dakota County Public Health Department staff have assisted schools in revitalizing wellness committees, including encouraging participation from a variety of school personnel, including food service, health services, curriculum, physical education, administration, parents and students. Representatives from the school wellness committees serve on the Smart Choices Leadership Team, keeping the groups connected. Funding from BCBS provided additional resources critical to formalizing the collaboration and processes now in place.
The guiding concept for Smart Choices is the idea that as a community we can make a difference by making it easier to make healthy choices for both our children and those who influence them, including staff and parents. The vision developed by the Leadership Team is that schools, staff and parents will provide an environment that supports healthy eating and activity choices so children establish lifelong healthy habits and are better equipped to learn. The mission is to increase opportunities for healthy eating and physical activity in Dakota County Schools to reduce the prevalence of obesity and chronic diseases such as heart disease, cancer, stroke, osteoporosis, and diabetes and associated health care costs. The Smart Choices long-term goal for nutrition is to facilitate policy, systems and environmental changes that increase the access, availability and intake of appealing and affordable healthy foods (especially fruits and vegetables) and decrease access to less healthy foods and beverages resulting in improved health among students, staff, their families and the broader community within the respective school districts. The Smart Choices long-term goal for physical activity is to facilitate policy, systems and environmental changes that integrate more physical activity into the day (before, during or after school), and increase access to school recreation facilities.
nine school districts in the county and the Dakota County Public Health Department.
Our funding partners, Blue Cross and Blue Shield of Minnesota through its Prevention Minnesota initiative and the Minnesota Department of Health’s Statewide Health Improvement Program, provided critical financial support and technical assistance.
Role of Stakeholders/Partners
Each school district identified two key leaders in the district to support this work and attend regular county-wide Smart Choices Leadership Team meetings. A Dakota County community health specialist is assigned to provide technical assistance to each district and assist in the formation of their district wellness committees and attend those meetings. Each wellness committee was expected to recruit a variety of key stakeholders to serve on the wellness committee, such as food service, health services, curriculum, physical education, administration, parents and students. In addition, each building in each district was asked to identify a “wellness champion” to support the Smart Choices activities and communication at the building level. In year two, when physical activity was added, parents were surveyed to determine their interest in adopting key policy and practice changes to support healthy eating and physical activity. Students were involved in taste testing, gave input into menu planning, and helped to promote the changes.
Public Health staff convene the countywide Smart Choices Leadership Team and provide guidance and information about best practices, such as IOM guidelines. They developed the assessment tool, assist with assessment, planning, providing training, managing grants, and evaluation. They encourage schools to make changes. Training and funding foster collaboration and contributed to successful outcomes. School staff complete the assessment and develop and implement action plans.
Public Health staff have worked closely with school districts for a number of years on a range of projects, including tobacco prevention and cessation, violence prevention, social norms, and alcohol and other drug use prevention. This relationship provided a strong foundation for collaboration on the Smart Choices project. Over the years, Public Health has emphasized the environmental approach to promoting health of students, and through a variety of training sessions and meetings staff have established strong, productive relationships with school personnel. In addition, having funds for small grants encouraged schools to come to the table and participate in Smart Choices.
Lessons learned included validation that key components of success are: strong school wellness champions, district-wide wellness committees, comprehensive assessment of the food environment, school district action plans, and Public Health support for schools. Also, schools were very responsive to the offer of relatively small grants. Administrators and food service directors could be champion advocates - or barriers to collaboration and progress. Vending companies did not always provide products that met IOM guidelines. Limited staff time and limited funding were also barriers.
Form the countywide Smart Choices Leadership Team and meet regularly. (February 2009 to present)
Identify “Wellness Champions” in individual school buildings. (February 2009 to present)
Reconvene district wellness committees (2009 and ongoing)
Assess the school nutrition environment. (March 2009)
Identify opportunities for improvement in schools. (April 2009 to present)
Identify training and technical assistance needs and develop plan to address (April 2009 to present)
District wellness committees develop action plans (April 2009 to present)
Smart Choices and district communication plans developed and implemented (April 2009 to present)
Parent and student engagement strategies identified and implemented by districts (April 2009 to present)
Provide grants to schools to implement strategies (December 2009 to present)
Conduct follow-up assessment of the school nutrition environment (March 2010, 2013)
Evaluation activities (July 2009 to present)
Process & Outcome
Overall, schools in Dakota County made significant progress toward achieving the key program goals of improving the school environment to support healthy eating and increased physical activity through sustainable policy, system, and environment changes:
97 schools in 9 districts made policy, system, environment changes to improve the nutrition environment for students
95 schools started offering healthier food and drink options at breakfast, lunch, and/or snacks affecting 72,272 students
60 schools changed their classroom practices to offer non-food rewards and to encourage healthy options during classroom parties and celebrations affecting 43,891 students
Key lessons learned from Smart Choices:
Formation of the Smart Choices Leadership Team was essential to maintain a unified project focus and direction, and to share experiences and build capacity within individual school districts.
Reenergized school district wellness committees were keys to buy-in and successful implementation.
It was important that the district wellness committees have participants from a range of departments and work focuses.
Activated “Wellness Champions” at the school building level were critical links from the district wellness committee to building staff and were change agents in their buildings. School staff have limited time to work on these initiatives in addition to their other duties, and it is important to minimize reporting and paperwork as much as possible. If funds permit, it is very helpful to provide stipends to staff to enable them to increase their hours or pay for substitutes.
Public Health Department staff served as critical links at the district and school levels to provide technical assistance and assure quality on key projects such as the nutrition environment assessment.
Grants were extremely helpful in bringing partners to the table and to enable implementation of action plans.
Engaging students and parents are essential to successfully implementing school-based projects.
Students responded positively to hands-on activities such as taste-testings and promotional campaigns.
In addition to sharing data, providing individual success stories helped promote the project to administrators, parents, and other stakeholders. (See below for more information about specific objectives)
There is clearly stakeholder commitment to sustain the policy, systems, and environmental changes schools have made to positively influence the school environment. The Smart Choices Leadership Team continues to meet as do the districtwide wellness committees. Many of the school districts have recently submitted formal letters of commitment indicating their support for the Public Health Department’s latest application for funding from the Statewide Health Improvement Program (SHIP) and their willingness to continue to be involved in the Smart Choices program.
Funding from the Blue Cross and Blue Shield of Minnesota grant ensures Smart Choices’ sustainability through 2013, including repeating the assessment of the school nutrition environment in early 2012. Schools will update and implement their action plans for the school years 2012-2013 and 2013-2014 and maintain active wellness committees. If the Dakota County SHIP grant is refunded, school districts will have additional resources (training, grants, staff time, equipment) to make new policy, system, and environmental changes in nutrition and physical activity and further engage staff, students, and parents. There would be additional evaluation and documentation of outcomes. Following a long tradition and commitment to community health promotion, Public Health staff will continue to serve every school district beyond the 2012-2013 school year. They will share best practices, connect schools to resources, and assist in planning, implementation, and evaluation.
I am a previous Model Practices applicant|Colleague in my LHD|NACCHO Exchange