Health promotion from the early stages in life by fostering healthy eating practices and regular physical activity has the potential for a major impact on health and well-being during childhood and later stages in life.
School-based nutrition education should consider the needs and interests of students, teachers and the school. Educational strategies include efforts to increase health awareness, communication and skill building.
Previous literature reviews identified educational strategies directly relevant to a behavioural focus and theory-driven strategies among the elements conducive to successful programmes. Other features that contribute to gain effectiveness are the provision of adequate time and intensity for the intervention, involvement of families, particularly for younger children, and incorporation of self-assessment and feedback in interventions for older children. School meals provide a valuable opportunity for nutrition education. The emphasis on environmental and behavioural factors in successful school-based physical activity and nutrition interventions highlights the importance of involving parents and other community members.
Health promotion from the early stages in life by fostering healthy eating practices and regular physical activity has the potential for a major impact on health and well-being during childhood and later stages in life (CDC, 1996).
Children progressively acquire and learn eating habits and practices as they grow and develop. Initially, the family plays a key role in the process not only as responsible for feeding the child, but also by setting norms within the family, acting as role models, encouraging certain behaviours and rewarding or limiting other (Birch & Fisher, 1998).
During school age, the social environment of children diversifies and extrafamilial influences progressively become more important references. In this period, children are more independent, start making their own food choices and take personal decisions regarding what they eat. The family is less important for adolescents, while friends, peers and social models are the key influences on their eating practices (Story et al, 2002).
Scientific evidence supports that prevailing food patterns during infancy and childhood influence growth and development; have an impact on health not only during this period of life, but also on the potential development of risk and protective factors related to the onset of chronic diseases later in adulthood (Nicklas et al, 1993). Nutrition during childhood contributes to maintaining health and optimal learning capacities. Furthermore, food habits that persist during adolescence are more likely to track onto adulthood (Kelder et al, 1994).
Health promotion in the school setting
Policy measures and education within specific settings such as schools, workplaces, hospitals or cities are valuable strategies to influence health. Schools provide the most effective and efficient way to reach a large segment of the population: young people, school staff, families and community members (Aldinger & Jones, 1998; Dixey et al, 1999).
From a health promoting school approach, school-based nutrition education should consider the needs and interests of students, teachers and the school. This means that all the groups meeting in the school setting should be invited to become relevant actors in the project (Figure 1).
Policy strategies are formal and informal rules adopted on a collective basis to guide individual and group behaviour. Environmental strategies are measures that alter or control the legal, social, economic and physical environment to support health and well-being by creating opportunities for action and removing barriers to follow a healthy diet (Aldinger & Jones, 1998). In this context, the provision of food in the school either as school meals or in any other potential way plays an important role (ADA, 1999; Aranceta, 2001).
Educational strategies include efforts to increase health awareness, communication and skill building (Dixey et al, 1999). They should be relevant to programme goals and take into account what children already know and can do. Cultural relevance is of utmost importance. The message should be addressed in a way that children can understand, and should teach the skills and knowledge required to improve or strengthen healthy eating habits.
Previous literature reviews identified educational strategies directly relevant to a behavioural focus and theory driven among the elements conducive to successful programmes (Contento, 1995; Roe et al, 1997; Hoelscher et al, 2002). Other features that contribute to gain effectiveness are the provision of adequate time and intensity for the intervention, involvement of families, particularly for younger children, and incorporation of self-assessment and feedback in interventions for older children. Interventions that include actions to modify the school environment and those that involve the larger community are more likely to be effective (Birnbaum et al, 2002).
Several studies have identified poor access to fruits and vegetables among major determinants for low consumption. This has led in recent years to develop programmes aimed to increase intake of fruits and vegetables, which base their intervention strategies in the distribution of fruits and vegetables in schools. The strategy has proved to be effective so far (Eriksen et al, 2003).
Children and young people need to enhance their competence as informed consumers able to perform their food choices in a complex society with a wide variety of food available. School-based nutrition education should focus not only on nutrition information, but also develop skills and behaviours related to areas such as food preparation, food preservation and storage; social and cultural aspects of food and eating; enhance self-esteem and positive body image and consumer aspects (Dixey et al, 1999).
Recent successful programmes included lessons in other subjects (eg maths and language) (Baranowski & Stables, 2000; Nicklas & O'Neil, 2000) as cross-curricula area. In these studies, teachers were responsible for curriculum implementation and were supported by qualified programme staff (Pérez-Rodrigo & Aranceta, 1997; Story et al, 2000).
There is a wide array of teaching methods that can be used according to learning objectives: from classroom discussions, worksheets, keeping food records to shopping exercises, taste-testing, creating or drama, etc (Pérez-Rodrigo & Aranceta, 2001; Matheson & Spranger, 2001; Morris & Zidenberg-Cherr, 2002). Extra-curricular activities are also challenging, for example: school gardening, developing cooking skills, exhibitions and other workshop activities (Pérez-Rodrigo & Aranceta, 1997; Perry et al, 2002).
New technologies such as the Internet, the World Wide Web and CD-Roms also provide a chance for interactive learning experiences (DiSogra & Glanz, 2000). Tailored interventions based on specifically designed computer programs are becoming more popular and are among the promising innovative methods, which still need some refinement and further testing in the school setting (Brug et al, 1999). Characteristics of nutrition education programmes in schools that contribute to effectiveness are summarised in Table 1.
School nutrition education: who should be involved?
All the above considerations make it necessary to include health promotion related to dietary practices and physical activity within the school framework and the global educational programme. Nutrition education should be progressively part of the school curriculum for all ages, from the very early stages through secondary school. In fact, in many cases, educational objectives, contents and evaluation criteria related to food, nutrition and adequate diet already exist as part of National curricula (Dixey et al, 1999; Pérez-Rodrigo et al, 2001a, 2001b). However, these are often too vague and general. The degree of implementation often depends on the willingness of overloaded teachers to further develop the educational attainments and perform suitable activities through curricular projects.
Effective programmes in diverse communities must be tailored to community needs and take into consideration factors concerning individuals, such as cultural background and equity aspects (Pérez-Rodrigo et al, 2001a, 2001b).
Implementation is a complex and usually slow process. Characteristics of the teachers, educational materials and support provided by programme leaders and staff determine the level of implementation of the curriculum (Renaud et al, 1997; Baranowski & Stables, 2000; Kealey et al, 2000). Pretesting the curriculum allows adaptation and improvement in the design and time for the programme to gain acceptance (Hoelscher et al, 2002). Teachers often complain about the lack of explicit curriculum, suitable materials or training experience. Teacher training conceptualised as a behaviour change process with explicit teacher motivation components can promote effective implementation of behaviour change curriculum in the classroom (Kealey et al, 2000). Preservice as well as in-service training opportunities for teachers and educators should be in place (Nader et al, 1996; Kealey et al, 2000).
What needs to be improved
Nutrition education and physical activity in primary and secondary schools need to be reinforced across Europe. Self-assessment instruments to be used in schools can support schools in monitoring their own situation as a basis for action (USDHHS-CDC, 2000).
Nutrition education curricula should aim to provide students with the required knowledge and skills, support self-efficacy and encourage behaviour change conducive to adopt a healthful diet and physical activity levels in agreement with dietary guidelines (Contento, 1995; Gortmaker et al, 1999; Pérez-Rodrigo et al, 2001a, 2001b; Hoelscher et al, 2002). Time and resources should be allocated to achieve change. Research on teaching methods, novel approaches and intervention strategies are required as well.
School meals provide a valuable opportunity for nutrition education. Food provided at schools should be nutritionally adequate and consistent with classroom messages (Raizman et al, 1994; Aranceta, 2001). Staff dealing with school meals should be properly trained, supported and integrated with teaching staff (Fulkerson et al, 2002).
The emphasis on environmental and behavioural factors in successful school-based physical activity and nutrition interventions highlights the importance of involving parents and other community members (Nader et al, 1996; Pérez-Rodrigo et al, 2001a, 2001b). The provision of adequate information regarding school meals to families and facilitating occasions where parents can take part in the school should be encouraged (Aranceta, 2001) (Nicklas et al, 1998; Reynolds et al, 2000).
Adequate training contributes to increased awareness and motivates teachers and educators to support healthy lifestyles. It can also contribute to enhancing teachers' self-efficacy.
Evaluation of progress must be sensitive and involve collaboration of all participants. It is concerned with assessing the effectiveness and efficiency of interventions. However, it is important to follow the progress towards the major goals and to use the results of the evaluative process to encourage and enhance the strategy.
To be effective, nutrition-promotion strategies must be creative, engaging, inexpensive and widely disseminated.
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Cite this article
Pérez-Rodrigo, C., Aranceta, J. Nutrition education in schools: experiences and challenges. Eur J Clin Nutr 57, S82–S85 (2003). https://doi.org/10.1038/sj.ejcn.1601824
- nutrition education
- healthy eating practices
- educational strategies
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