1. Start Early for Success The Role of School Breakfast Programs in Improving the School Nutrition Environment
Presented by Hannah Campbell, MPH student
Walden University PH
Instructor: Dr. Rebecca Heick
Winter Quarter, 2009
My name is Hannah Campbell, I am a Masters of Public Health student at Walden University, and I am pleased to present this program on the role of the school breakfast program in improving the school nutrition environment.

2. Prospective Audience School Administrators Principals Teachers
The prospective audience for this presentation includes school administrators, principals, and teachers as a part of the cohesive school organization team.

3. Purpose Describe the need for a universal school breakfast program
Evaluate barriers to the implementation of a breakfast program
Discuss implementation solutions for a universal school breakfast program
The purpose of this presentation is to describe the need for, barriers to, and implementation solutions regarding a universal school breakfast program.

4. Learning Outcomes
Elucidation of the food insecurities of many United States students.
Understanding of the consequences of malnutrition on the learning capabilities of students.
Finding new methods for schools to provide universal breakfast programs.
The expected learning outcomes of this presentation include: the elucidation of the food insecurities of many U.S. students, understanding of the consequences of malnutrition on education, and new methods for schools to provide breakfast to their students.

5. The Growing Trend of Obesity
12.6% adult obesity in 1990
―> 34% adult obesity in (Johnson, 2010)
1/3 of all U.S. children are overweight/obese (Ehrlich, 2008)
Ehrlich, G. (2008, October). Health = Performance: Efforts to increase student achievement also should address physical activity and a good diet. American School Board Journal,
Johnson, M. (2010). Human Biology. San Francisco, CA: Benjamin Cummings, 344.
There has been a growing trend in weight gain among adults for quite some time with rates increasing from 12.6% obesity in 1990, to 34% obesity in 2006, but obesity among children is also a growing trend (Johnson, 2010). Currently, the Centers for Disease Control and Prevention reports that one third of all U.S. children and adolescents are overweight or obese (Ehrlich, 2008).

6. Malnourishment Among U.S. Children
Most overweight/obese children are from low socioeconomic status families and are malnourished. (Johnson, 2010)
Readily available energy sources are high in:
Saturated fats
Simple sugars
Readily available energy sources are low in:
Proteins
Fibers
Vitamins
(Murphy, 2007)
Johnson, M. (2010). Human Biology. San Francisco, CA: Benjamin Cummings, 344.
Murphy, J. (2007). Breakfast and learning: An updated review. Current Nutrition and Food Science, 13,
Rather than representing just over-nourishment, the majority of obese children are from low socioeconomic families and are malnourished (Johnson, 2010). Their energy sources for the day are high in simple sugars and saturated fats, and are lacking in the proteins, fibers, and vitamins that children require for mental and physical growth and development (Murphy, 2007).

7. Breakfast Trends
38% of U.S. children report skipping breakfast (5% breakfast skipping in 1965)
56% of low-income currently skip breakfast
Missing breakfast is associated with chronic disease, obesity, and diabetes
Skipping breakfast leads to hunger
Hunger leads to overeating
Overeating leads to obesity
Murphy, J. (2007). Breakfast and learning: An updated review. Current Nutrition and Food Science, 13, 3-36.
Currently, U.S. breakfast trends are strongly associated with childhood obesity as skipping breakfast leads to hunger, which leads to overconsumption of available foods, ultimately leading to overweight (Murphy, 2007). In 1965, only 5% of school children reported not eating breakfast while 38% of children currently report breakfast skipping (Murphy, 2007). 56% of low-income students report skipping breakfast making them the most at risk group for malnutrition (Murphy, 2007). With this meal missing, at-risk children face the nearly impossible feat of making up for their nutritional needs with the two remaining meals of the day. Long-term, breakfast skipping is associated with increased chronic disease, obesity, and diabetes (Murphy, 2007).

8. Psychological Impact of Malnutrition
Poorer cognitive function
Decreased school attendance
Diminished academic achievement (Taras, 2005)
Lower grades in mathematics
More likely to repeat a grade
Increased school problems
Tardiness
Absence (Murphy, 2007).
Attention problems
Display for aggression
Depression
Anxiety (Kleinman, Murphy, &Little 1998).
Kleinman, R., Murphy, J. & Little, M. (1998). Hunger in children in the United States: Potential behavioral and emotional correlates. Pediatrics, 101(1), e3.
Murphy, J. (2007). Breakfast and learning: An updated review. Current Nutrition and Food Science, 13, 3-36.
Taras, H. (2005, August). Nutrition and student performance at school. Journal of School Health, 75(6),
Just as important as a child’s physical health needs, malnutrition and morning hunger have a detrimental effect on mental function as well. “In the United States, food insufficiency was associated with significantly poorer cognitive functioning, decreased school attendance, and diminished academic achievement” compared to children with adequate nutrition (Taras, 2005, p. 208). Hungry children also have more school problems, attention problems, and display more aggression, depression, and anxiety than other groups of children (Kleinman, Murphy, & Little, 1998; Murphy, 2007). School problems include tardiness, absence, and poorer performance in mathematics (Murphy, 2007). A study on breakfast eating and academic function among school children found that children who had decreased school breakfast program participation had an average of 0.9 lower grade points in math classes, 1.6 days increased absence, and 0.9 days increased tardiness compared to a control, and were 1.44 times more likely to repeat a grade (Murphy et al., 1998; Alaimo, Olson, & Frongillo, 2001). In contrast, children with increased school breakfast program participation had average increases of 0.3 grade points in math classes, 0.1 days decreased absence, and 0.4 days decreased tardiness when compared to a control group (Murphy et al., 1998).

9. Benefits of School Breakfast Programs
Physical benefits
Improved height to weight ratio
Decreased obesity
Better school attendance (Powel, Walker, Change, & Granthan-McGregor, 1998)
Mental benefits
Improved verbal skills
Improved math skills
Improved memory, creativity, and attention (Taras, 2005)
Behavioral benefits
Decreased hyperactivity
Decreased aggression (Dillon, 2010)
Dillon, N. (2010, January). It’s the most important meal of the day, are your students getting what they need? American School Board Journal,
Powel, C., Walker, S., Chang, S., & Granthan-McGregor, S. (1998). Nutrition and education: A randomized trial of the effects of breakfast in rural primary school children. American Journal of Clinical Nutrition, 68,
Taras, H. (2005, August). Nutrition and student performance at school. Journal of School Health, 75(6),
The benefits of school breakfast programs affect both the body and mind of students. Physically, children who participate in school breakfast programs have an improved height to weight ratio, decreased obesity, and better school attendance (Powel, Walker, Chang, & Granthan-McGregor, 1998). Mentally, students provided with breakfast display improved “verbal fluency, arithmetic, tests of attention, memory, creativity, and general tests of academic achievement and cognitive function” (Taras, 2005, p. 213). Understandably, low-income children appear to benefit the most from school breakfast programs. Teachers report that full bellies in the morning are associated with better behavior among students who had previously been hyperactive and aggressive without the breakfast programs (Dillon, 2010).

10. Types of Breakfast Foods are Important
Meals for home and bought from vendors
May be high in saturated fats and sugars
May be low in essential nutrients
Vending machines selling sugary drinks and snacks should be reduced or eliminated on campus
School breakfast programs based around hot meals
Pancakes and bacon are high in sugar and saturated fat
Ready to eat cereal (RTEC) with milk and fruit
Regular consumption linked to decreased BMI
Rosado, J., Arellano, M., Montemayor, K., Garcia, O., & Caamano, M. (2008, September). An increase of cereal intake as an approach to weight reduction in a randomized controlled trial. Nutrition Journal, 7(28), 1-9.
Not only has breakfast eating been proven to be beneficial to the health and learning of children, but the types of breakfast foods which children eat are important for proper growth and development as well. Meals brought from home or bought from other vendors may be high in saturated fats and sugars, and low in essential nutrients. Increased saturated fate intake is associated with obesity risk and increased sugar consumption leads to more hyperactivity and aggressive behavior in the classroom (Ehrlich, 2008). Schools wishing to improve the health of their students would do well to reduce or eliminate vending machines which sell sugary drinks and snacks on campus, or at least limit what these vendors are able to sell to students. School breakfast programs based around hot meals such as bacon and pancakes are also high in sugars and saturated fats. In contrast, regular consumption of ready to eat cereal (RTEC) has been linked to a decreased body mass index among children (Rosado, Arellano, Montemayor, Garcia, & Caamano, 2008).

11. RTEC Consumption Among At-Risk Children
Four groups of children compared
Group 1 ate one meal of RTEC with milk per day
Group 2 ate two meals of RTEC with milk per day
Group 3 ate one meal of RTEC with milk per day with nutritional education
Group 4, the control group, had no intervention
After 12 weeks of evaluation
Only group 3 had statistically significant lower body mass average
Rosado, J., Arellano, M., Montemayor, K., Garcia, O., & Caamano, M. (2008, September). An increase of cereal intake as an approach to weight reduction in a randomized controlled trial. Nutrition Journal, 7(28), 1-9.
In a recent study, the RTEC consumption among obese, low socioeconomic status children was explored. In this study, four groups of children were compared. The first group ate one meal of RTEC with low fat milk per day for 12 weeks (Rosado et al., 2008). The second group of children ate two meals a day of RTEC with milk (Rosado et al., 2008). The third group consumed one meal of RTEC with milk per day and also received nutrition education, and the fourth group acted as the control (Rosado et al., 2008). After 12 weeks of evaluation, the children who receive one serving of RTEC per day with nutritional education had a statistically significant lower body mass average (Rosado et al., 2008). Other test groups also had decreased body weight after the study but did not differ significantly from the control group.

12. Understanding Nutrition and Nutrition Education
2 classes of 10th graders compared
Class 1 was provided with free breakfast every morning and nutrition education
Class 2 received only nutrition education
After 16 weeks of evaluation
Class 1 showed weight reduction toward a healthier BMI
Class 2 showed significant weight gain
Ask, A., Hernes, S., Aarek, I., Johannessen, G., & Haugen, M. (2006, December). Changes in dietary pattern in 15 year old adolescents following a 4 month dietary intervention with school breakfast: A pilot study. Nutrition Journal, 5(33), 1-6.
To understand why nutrition education alone is not a sufficient means to decrease obesity and encourage healthy eating among high risk children, we must look to another study. In a separate 16 week study, two classes of students were compared, with one class receiving a free breakfast with nutrition education, and the other receiving the nutrition education alone (Ask, Hernes, Aarek, Johannessen, & Haugen, 2006). Measurements and weights were taken at baseline and evaluated at the end of the study. After 16 weeks, the class receiving free breakfast showed weight reduction toward a healthier body mass index, while weight increased significantly among the class who received nutrition education alone (Ask et al., 2006).

13. Other Benefits of RTEC with Milk
Low in saturated fats and sugars
Provides ¼ RDA of energy
Proteins, carbohydrates
Vitamin A, vitamin C
Iron
Calcium
Murphy, J. (2007). Breakfast and learning: An updated review. Current Nutrition and Food Science, 13, 3-36.
Not only is RTEC with milk an alternative to a breakfast high in saturated fats and sugars, but this meal is able to provide one quarter of the day’s recommended daily allowance of energy in the form of healthful proteins and carbohydrates, along with vitamins A, C, iron, and calcium in accordance with United States Department of Agriculture guidelines (Murphy, 2007).

14. Barriers to Breakfast Eating at Home
Working parents lack time in the morning
Economic insecurity leads to food insecurity at home
Food insecurity effects 21% of U.S. children
8% of U.S. children are chronically hungry
Murphy, J. (2007). Breakfast and learning: An updated review. Current Nutrition and Food Science, 13, 3-36.
Barriers to breakfast eating in the home include lack of time in the morning among working parents, as well as food insecurities at home. As stated earlier, a busy family life is contributing to the growing trend of the missing morning meal, but food insecurity also affects 21% of U.S. children, with 8% of U.S. children being defined as chronically hungry (Murphy, 2007). With economic insecurities drastically affecting so many families with young children, the burden of providing adequate nutrition to fuel education and childhood health falls to schools.

15. Barriers to Universal School Breakfast Programs
Scheduling problems (Hentzler, 2010)
Lack of participation from:
Children
Parents
School staff (Greves, Lozano, Liu, Busby, Cole, & Johnston, 2007; Murphy, 2007)
Economic constraints
Greves, H., Lozano, P., Liu, L., Busby, K., Cole, J., & Johnston, B. (2007, December). Immigrant families’ perception on walking to school and school breakfast: A focus group study. International Journal of Behavioral Nutrition and Physical Activity, 4(64), 1-9.
Hentzler, J. (2010, January). Fuel for success: A strong nutrition program can help both your students and your district. American School Board Journal,
Murphy, J. (2007). Breakfast and learning: An updated review. Current Nutrition and Food Science, 13, 3-36.
Though the benefits of a school breakfast program have been demonstrated by several extensive studies, barriers to universal school breakfast programs still persist. Barriers include scheduling problems, lack of program participation by children, parents, and school staff, and economic constraints. Scheduling concerns include the need for children to arrive at school early enough to eat breakfast. Though 85% of U.S. schools involved in the universal school lunch program also serve breakfast, it is usually served before school when buses may not have arrived (Hentzler, 2010). Participation concerns include the lack of participation from parents who may not get their children to school early enough to participate, children who would rather play than sit down to breakfast, and school staff who don’t wish to prolong their day by supervising children in the morning (Greves, Lozano, Liu, Busby, Cole, & Johnston, 2007; Murphy, 2007). Economic constraints must be considered before a breakfast program may be implemented. Cost must be considered not just for food supplies, but for the salaries of kitchen staff who will prepare these early meals.

16. Universal School Breakfast Program Solutions
Scheduling breakfast within the school day
Bus-riding children will not miss the meal
Breakfast participation could increase by 400% (Hentzler, 2010)
Involve children with meal program taste tests (Dillon, 2010; Greves et al., 2007)
Dillon, N. (2010, January). It’s the most important meal of the day, are your students getting what they need? American School Board Journal,
Greves, H., Lozano, P., Liu, L., Busby, K., Cole, J., & Johnston, B. (2007, December). Immigrant families’ perception on walking to school and school breakfast: A focus group study. International Journal of Behavioral Nutrition and Physical Activity, 4(64), 1-9.
Hentzler, J. (2010, January). Fuel for success: A strong nutrition program can help both your students and your district. American School Board Journal,
Solutions to SBP implementation problems include scheduling breakfast within the school day so that late bus arrival does not cheat children out of their breakfast opportunities. Studies suggest that school breakfast programs provided during the school day could increase breakfast program participation by 400% (Hentzler, 2010). Schools in Pennsylvania, San Diego, and Atlanta have all reported success when serving breakfast in the classroom during instructional time (Dillon, 2010). Involving children and parents in programs with taste tests and parental input could increase parent and child participation (Greves et al., 2007).

17. Universal School Breakfast Program Solutions, continued
Economic concerns
Provision 2 (Dillon, 2010)
Universal School Breakfast Program (Hentzler, 2010)
Could increase participation by reducing stigma of subsidized meals
RTEC with milk and fruit
Provides needed nutrition
Easy to provide within the classroom
Minimal kitchen staff required to provide
Dillon, N. (2010, January). It’s the most important meal of the day, are your students getting what they need? American School Board Journal,
Hentzler, J. (2010, January). Fuel for success: A strong nutrition program can help both your students and your district. American School Board Journal,
Economic constraints for school breakfast programs could also be lightened with the passage of the universal school breakfast program, now under consideration. In the mean time, Provision 2 allows for schools, not parents, to collect and submit data for subsidized meal reimbursement (Dillon, 2010). Headcount data is recorded daily but economic data on school children only has to be submitted every three years which significantly lessens the paperwork burden of government subsidizing (Dillon, 2010). However, it is believed that a universal breakfast program would lessen the stigma associated with subsidized meals and, hopefully, increase participation among the children who need the program most (Hentzler, 2010). RTEC with milk and fruit are again recommended as the most valuable school breakfast meal because the cost to provide this meal is not prohibitive to schools. Kitchen staff required to provide this breakfast is minimal and there should be little to no wastage, as left-over RTEC servings may be saved for the next day’s breakfast.

18. Conclusion Low socioeconomic status children are at risk for:
Obesity
Impaired cognitive function
Food insecurity
Also at risk for chronic health problems
behavioral problems
poor school performance
RTEC with milk and fruit
allows for a meal within the school day with minimum extra staff and cost
In conclusion, low socioeconomic status children are at risk for obesity and impaired cognitive function which is compounded, not controlled, by food insecurity and a missing morning meal. These children are both at risk for chronic health problems, behavioral problems, and poor school performance. Though there are many barriers to providing meals at school for children, RTEC with milk and fruit may be the best solution which allows for a meal within the school day with minimum extra staff and cost.

19. Sources for Additional Reading
Alaimo, K., Olson, C., & Frongillo, E. (2001). Food insufficiency and American school-aged children’s cognitive, academic, and psychosocial development. Pediatrics, 108(1), Child nutrition and WIC programs renewed (2009, December). State Legislatures, 35(10), 10. David, J. (2009, December). School meals and learning. Educational Leadership, Murphy, J., Pagano, M., Nachman, J, Sperling, P., Kane, S., & Kleinman, R. (1998). The relationship of school breakfast to psychosocial and academic function: Cross-sectional and longitudinal observations in an inner-city school sample. Archives of Pediatric and Adolescent Medicine, 152, Murphy, J., Wehler, C., Pagano, M., Kleinman, R., Little, M., & Jellinek, M. (1998). Relationship between hunger and psychosocial functioning in low-income American children. Journal of the American Academy on Child Adolescent Psychiatry, 37,