While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
The challenge. More than 23 million U.S. children and teens—nearly one in three young people—are either overweight or obese. Schools are fundamental settings for providing children and adolescents a healthy environment where they can consume nutritious food, get regular physical activity and develop lifelong healthy behaviors.
In 2004, Congress passed the Child Nutrition and WIC Reauthorization Act. It requires schools that participate in the National School Lunch Program and receive other subsidies to establish school wellness policies. These policies specify goals for nutrition education, physical activity, food provision and other school-based activities to promote student wellness.
Marlene Schwartz, Ph.D., senior research scientist and deputy director of the Rudd Center for Food Policy and Obesity at Yale University, realized that in order for school wellness policies to drive improvements in nutrition and physical activity programs, school administrators, state government and local policy-makers would have to be able to document the impact of those policies and make changes based on reliable information. She wanted to develop a user-friendly tool to provide quantitative data on the comprehensiveness and strength of district school wellness policies.
RWJF Approach. The Robert Wood Johnson Foundation (RWJF) is committed to reversing the childhood obesity epidemic by 2015 and has established several programs to achieve that goal. Healthy Eating Research: Building Evidence to Prevent Childhood Obesity is a national program that supports research about environmental and policy strategies with strong potential to promote healthy eating among children to prevent childhood obesity. The program places special emphasis on reaching the children at greatest risk for obesity: Black, Latino, American Indian, Alaska Native, Asian-American and Pacific Islander children as well as children who live in lower-income communities. Target populations include children and adolescents ages 3 to 18 and their families.
An early start to an interest in healthy eating. Schwartz knew early on what her life's work would be. In sixth grade, she wrote a science report on nutrition. "There were only four food groups back then," she says with a laugh. "I guess I've always been interested in understanding different types of food and nutrients from food."
Schwartz grew up in Columbia, Md., and although her childhood was not all that long ago, her nutritional landscape differed from the one she sees today. For one thing, there were none of the vending machines that are now scattered throughout schools selling snack foods and sugared sodas. "We drank milk and there were water fountains," she says. "The whole idea of soda machines in school was foreign to me. I was surprised as an adult to see what happened."
For Schwartz, early lessons in healthy eating began at the kitchen table where the family would have dinner together just about every night. "Mom definitely cared about nutrition, "she remembers. "We hardly ever went to fast food restaurants and we didn't have soda or sugared cereal in the house." If Schwartz wanted a between-meal snack, mom would tell her to have a piece of fruit.
A liberal arts education shapes a lifelong commitment. After graduating from high school, Schwartz chose Haverford College outside Philadelphia. She found the liberal arts college both philosophically and politically important in shaping who she would become. "Haverford taught the value of helping society as a whole," she says. Schwartz majored in psychology and wrote her senior thesis about how three- and four-year-olds, interacted with objects and each other in the preschool environment.
Becoming a clinician. After Schwartz graduated Haverford with high honors and a bachelor's degree in psychology in 1988, she took a job at the National Institutes of Health (NIH) as a research assistant. "I was working in a lab where they were studying family interactions and the effect of maternal mental illness on the whole family," she says. The research aspect of the work appealed to Schwartz and was essential to her plans to obtain a Ph.D. degree, but she found she was most interested in the clinical component. "I decided to pursue clinical psychology so I would have the opportunity to work directly with people as a health professional," she says.
A mentor shapes a field of study. After working two years at NIH, Schwartz applied to graduate schools and in 1990 enrolled at Yale University, in New Haven, Conn. Early in her graduate studies, Schwartz took classes in health psychology, eating disorders and obesity taught by Kelly Brownell, Ph.D., director of the Rudd Center for Food Policy and Obesity. Brownell is an internationally known obesity expert who appeared in the Academy Award-nominated documentary Super Size Me and is the author of Food Fight: The Inside Story of the Food Industry, America's Obesity Crisis, and What We Can Do About It.
Schwartz found her calling in Brownell's classroom. "I thought: this is what I'm really interested in," she remembers. Brownell would ask Schwartz to work with him as a graduate student, and a twenty-year working relationship and friendship began.
In 1992, Schwartz obtained a master's degree in clinical psychology and in 1996 completed her doctorate in clinical psychology at Yale.
She also started her family at that time. "I defended my dissertation when I was five months pregnant," she says. Three months after her daughter Anna was born (she also has identical twins, Charlotte and Molly), Schwartz began working part-time at the Yale Center for Eating and Weight Disorders, where Brownell has fostered a family-friendly environment. "His [Brownell's] philosophy is that treating people respectfully both at work and as parents is the best way to have a successful work environment," Schwartz noted. "That attitude has trickled down throughout the center."
The cookie-eating contest. Family life was instrumental in steering Schwartz towards school food policy. One day Anna came home from first grade with a flyer announcing a cookie-eating contest. It was bad enough that the school was selling Pop Tarts and ice cream in the cafeteria, Schwartz thought, but this was more than she could stomach. "I basically went ballistic," she remembers, "How do you plan a cookie-eating contest when we are in the middle of a childhood obesity epidemic?" She called the principal of the elementary school to discuss the situation. As it turned out, the principal had long wanted to improve the food environment in her school, but did not think she had the support of the Parent Teacher Organization. "So the principal and I formed an immediate alliance, which continued for years and years," Schwartz says. "We created the district's first health advisory committee and really worked to change the food culture in the schools."
Making the connection with RWJF. Schwartz says her alliance with RWJF grew out of pure luck and very good timing. At the time Congress passed the Child Nutrition and WIC Reauthorization Act, Healthy Eating Research was beginning to fund studies examining the nutrition content of foods served in schools. Schwartz says, "Because almost all school districts had to develop a wellness policy, RWJF's interest in this issue presented the perfect opportunity to look at the impact of those policies."
Schwartz received a Healthy Eating Research grant to analyze school wellness policies and see how sociodemographic features of the school district related to the strength of the policies (ID# 057923).
A surprise in Connecticut. With her first grant, Schwartz analyzed the school wellness policies developed by districts in her home state of Connecticut. One finding surprised her. She notes, "I wanted to see whether wealthier districts had better policies than the poorer districts. It turned out, I couldn't have been more wrong. The poorer districts tended to write stronger policies. I think that was partly because they recognized that childhood obesity was a serious problem in their schools." She continues, "I think in these districts, the school system takes more responsibility, while in other districts the parents are less likely to think the school system should be in charge of these issues."
Collecting data: giving schools a tool. A major goal of Schwartz' research was to develop and validate a coding system that researchers could use to quantitatively evaluate school wellness policies. To arrive at a reliable tool, Schwartz collaborated with Healthy Eating Research investigators pursuing similar goals in other states.
The collaborators produced a rigorous, statistically validated, 96-item School Wellness Policy Evaluation Tool. The tool systematically collects and records information about seven aspects of school wellness policies: nutrition education, nutrition standards for school nutrition programs and meals, nutrition standards for competitive and other foods and beverages (such as those in vending machines), school physical education, physical activity, communication and promotion and evaluation.
Schwartz and her colleagues published the results of the research in the July 2009 issue of the Journal of the American Dietetic Association. (Abstract available online.)
Converting a research tool to a practical one. As part of the Healthy Eating Research study, Schwartz worked with the Connecticut State Department of Education to send every district in the state their scores from the policy coding. "We said: 'Here's your score; here's the state average; and here's how your score compares to comparable school districts.' This led some districts to go back to their policies and strengthen them."
"We wanted to promote this type of feedback in other states, but knew the 96-item coding tool was only usable for researchers," Schwartz says. They wanted the tool to be used by people in state government and school systems—people who could change policy to use the tool. "So that's when we got the idea to create the Web site," she says.
Results. With a second grant from RWJF (ID# 065118), the original group of researchers and a national advisory committee pared the original 96-item coding tool down to 50 items and renamed it WellSAT (Wellness School Assessment Tool). "We reviewed the different items and cut out as much as we could, and tried to clarify to the best of our ability," she says. Schwartz believes the Web site offers the first quantitative assessment of school wellness policies that can be completed by individuals without research training.
The result is a streamlined, easy-to-use Web site—www.wellsat.org—that targets an audience including school officials, advocacy groups and legislators. The current version of the Web site features four easy-to-navigate tabs entitled: Who Should Use This Tool?, FAQ, Resources, and For Researchers. There are also five sections for users to complete and receive their results on a "scorecard."
Impact. www.wellsat.org has been up and running since the beginning of 2010 and its popularity is increasing. According to Schwartz, the site has received 3,500 visitors and 42,000 page views. Some 42 states have accessed the online tool. Several states, including New York, Indiana, Illinois, Arizona, North Dakota and Alaska, have used the site extensively.
Schwartz hopes that someday the tool will motivate school districts across the country to improve their school wellness policies much the same way as they use test scores to improve education.
It's personal. "The reason I love my job so much is that it's completely connected to what is important to me personally," says Schwartz. "I look at my children and I think I can provide so much for them, but every child deserves to grow up in a healthy environment." Though the influence of the industry that delivers unhealthy food to children makes her task daunting, Schwartz believes she can help change the world. "I want to do everything I can to make sure kids are not going to school and being exposed to a whole bunch of junk that's going to make them sick," she says. "I sort of feel responsible for that."
Building on this work. RWJF has awarded Schwartz additional grants to look at food marketing to children (ID#s 61216 and 065013) and to examine food and physical activity in child care and preschool settings in Connecticut (ID#s 063150 and 064093).
RWJF perspective. Healthy Eating Research solicits scientifically rigorous, solution-oriented proposals from investigators representing diverse disciplines and backgrounds. The program's overall aims are to identify the most promising strategies likely to have important population-level impacts and to provide decision- and policy-makers with evidence to guide and accelerate effective action to reverse childhood obesity.
RWJF Distinguished Fellow and Senior Scientist C. Tracy Orleans, Ph.D. notes:
"The Healthy Eating Research Program provides decision-makers and key policy-makers with evidence they can use to improve children's nutrition and access to healthy foods. Working in collaboration with other national research funders, we are working to build solid evidence for action, with a major focus on understanding and changing the policy and environmental drivers of childhood obesity epidemic, with a focus on the lower-income and racial/ethnic communities at highest risk. Our goal is to fund rigorous, solution-oriented studies, to build a diverse and robust network of researchers and communicate findings effectively to inform policy and guide action. National Program Director Dr. Mary Story has provided pioneering vision and leadership that are critical to the program's success and national progress towards reversing the childhood obesity epidemic."
At the annual grantee meeting, researchers, policy-makers, advocates, funders and others come together to share study findings and the latest thinking and research methods related to healthy eating and childhood obesity prevention. Healthy Eating Research also develops research briefs and syntheses and commissioned papers that address major policy issues in childhood obesity.
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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