Walking today through Somerville, Mass.'s Winter Hill Community School during school hours differs markedly compared to just a few years ago. Gone are the greasy potato chips and chocolate-chip cookies from the a la carte offerings in the cafeteria. Missing are the late morning fundraisers when children would fill up on cupcakes and other sweets before lunch. And banished are the student rewards of candy in the classroom.
Today children in all Somerville public schools can eat an unlimited amount of whole fruit at breakfast and lunch. Fresh salads, often made with local produce including greens from schoolyard gardens, are offered every day. A la carte options include bottled water, yogurt and other low-fat, low-sugar snacks. In some schools, students receive 30 minutes to eat lunch and play. And teachers frequently request Vegetable of the Month taste tests delivered to their rooms from the cafeteria to integrate into their math, science and/or social studies lessons.
How did the Somerville Public Schools make such a dramatic change in the health habits of students?
A Coordinated Approach
In early 2002, Christina Economos, a researcher and assistant professor of nutrition at Tufts University's Friedman School of Nutrition Science and Policy, approached the city of Somerville about creating a community-based intervention to prevent obesity in children in grades 1-3.
Somerville, a diverse city of 77,000 people just north of Boston, is the most densely populated city in New England. It's an eclectic mix of blue-collar families, young professionals, college students and recent immigrants from countries as diverse as E1 Salvador, Haiti and Brazil. The public schools serve nearly 5,000 students in grades pre-K through 12-64 percent of whom are eligible for free or reduced-price school meals.
By 2002, the leadership in the school district was becoming concerned about the growing problem of childhood obesity and its relationship to student performance. "In an era of high-stakes testing, we knew that we could not have our students falling asleep at their desks because of high-sugar diets," says Bob Snow, Somerville's assistant superintendent of curriculum at the time.
Emerging pockets of people throughout the city were organizing to improve nutrition and physical activity opportunities for children. Several schools had implemented the Planet Health curriculum. None of the elementary schools had vending machines accessible to students. The Universal School Breakfast program recently had been launched, and the new food service director, Mary Jo McClarney, a registered dietitian, was eager to bring in more fresh fruits and vegetables.
Multiple Tactics
But there was still much to address. In addition to the a la carte offerings and unhealthy treats available throughout the day, menu options at the cafeteria were limited and relied heavily on processed foods. Aside from those required by the state and federal government, no school policies governed food services or physical activity for students. Most alarming was that 44 percent of the city's 1st through 3rd graders were overweight or at-risk of being overweight (a body mass index at the 85th percentile or above).
The resulting Shape Up Somerville project targeted the before-school, school day, after-school, home and community environments to expand opportunities for physical activity and availability of healthful foods. The specific interventions of this multifaceted campaign included:
• Increasing fresh fruits, vegetables, whole grains and low-fat dairy in the school menu;
• Removing high-sugar/high-fat foods from a la carte offerings;
• Initiating a walk-to-school campaign;
• Implementing curriculum in 1st through 3rd-grade classrooms that included weekly 30-minute nutrition and physical-activity lessons in line with state curriculum frameworks and 10-minute daily "Cool Moves" allowing students to move around in their rooms;
• Enhancing recess with new equipment and game cards to encourage children to be active;
• Creating professional development for school staff and local pediatric/family medicine clinicians;
• Starting Healthy Eating Active Time Clubs, also known as HEAT, in all of the city's after-school programs;
• Circulating bimonthly newsletters for parents with coupons for free and reduced-price healthy foods;
• Staging family events and parent nutrition forums that target local ethnic groups;
• Creating and mailing annual health report cards to parents for each student that include body mass index measurements and resources to address weight concerns;
• Developing a list of Shape Up-approved area restaurants (21 joined the campaign);
• Organizing an annual Shape Up 5K Family Fitness Fair;
• Maintaining a regular presence in local media, including a monthly column in The Somerville Journal; and
• Devising a physical activity guide, annually revised, for children, adults and families.
Generating Buzz
To create enthusiasm for this multilayered intervention, Economos met with the superintendent, assistant superintendents, members of the school committee, principals, city leaders and a local nutrition task force numerous times to build a strong foundation of support and to develop an intervention that would leverage existing energy to address the city's challenges.
The Shape Up initiative "catalyzed what was already happening in the city," remembers Roberta Bauer, chairperson of the Somerville School Committee. "They provided a vision, coordination, professional development and the tools to move us to the next level and beyond. They created a buzz that could be felt everywhere in the city."
But a successful communitywide campaign does not happen on the strength of buzz alone. Within the Somerville Public Schools, administrators sought improvements in cafeteria menu options and meal preparation. The leadership added 30 minutes of nutrition and wellness instruction each week to the curriculum and revamped recess to incorporate new equipment and facilitated games that encourage more activity. Bake sale fundraisers, while lucrative to the PTA, were curbed before lunch.
To successfully start and maintain programs districtwide required a cultural shift among staff, students and families. "I needed to be sure that our staff did not perceive Shape Up as something extra on their plates," says Snow, who was assistant superintendent from 1992 to 2006. "They needed to hear about the entire project so they could see their role was one small and important part in a communitywide effort." Feeling a part of a team, he believes, helped teachers and administrators to embrace the changes that were asked of them.
Mary Jo McClarney, Somerville's food service director, echoes that sentiment. "The initial resistance in the cafeteria was shorter lived than I anticipated because children were getting the message about healthy eating everywhere--in the classroom, at after-school programs, from their parents, in local restaurants, etc." Adds Tim O'Keefe, former physical education teacher and now K-12 supervisor of health and physical education: "Teachers who had received complaints for banning unhealthy snacks and treats in their classroom now felt community- and schoolwide support to stand by their principles."
Selling Shape Up as a team effort was aided by the enormous amount of support given to the school district by Economos, New Balance chair in childhood nutrition, and her colleages at Tufts. They provided the curricular materials, professional development, afterschool support and assessment and reporting services, enabling teachers to focus on the small changes they were being asked to make without compromising teaching time.
Risks and Patience
Shape Up Somerville found one of its best community champions in McClarney, the food service director who joined the district in 2002. And not surprisingly, the food services department committed to several policy and environmental changes.
To move away from dependence on processed foods, kitchens were decentralized for more onsite cooking. The department purchased better equipment and rebuilt the organizational structure to better manage fresh foods. McClarney changed a la carte offerings to meet the Massachusetts Action for Healthy Kids. The district renegotiated its union contract in 2004 with the food service staff to require food preparation staff to use raw ingredients in their meal offerings.
McClarney says these changes would have been impossible without support from the top administration. "Every time I went to the assistant superintendent with a new idea, I was told, 'Try it.' We succeeded because the administration was willing to take the risks necessary to make substantial improvements in what we were feeding our students."
But change wasn't always easy. While she had the support of her superiors, McClarney found resistance among students, food service staff and even some teachers.
"When we first made changes to the a la carte menu, there was a huge uproar among students and teachers. Sales plummeted. It required an enormous amount of patience on everyone's part," McClarney says. "But then an amazing thing happened. Our school lunch participation increased. Without access to sugary and high-fat treats and with messages about healthy eating coming from everywhere, students began to opt for our meals with fruits and vegetables. And the increase in meals served covered the loss from a la carte sales. Now we never hear complaints--these changes have become the new normal."
Changing the culture among her staff also has come slowly. To engage the staff, Shape Up Somerville provided numerous training sessions on basic nutrition, safe knife usage for preparing fresh produce, meal presentation and personal health and wellness.
Conducting taste tests and educational outreach as part of Vegetable of the Month has put food service staff in direct contact with students. "They are beginning to see the customer service piece of their jobs more clearly and have become more engaged in providing healthier meals for our kids," adds McClarney. "The Shape Up trainings built their confidence in the kitchen and proved that offering more fresh foods isn't necessarily more work."
And the result of all of this effort? In 2002-2003, the food service department spent $90,000 for fresh produce. In 2006-2007, they spent $160,000 to meet demand. And while price increases account for some change, during the same time period, the district's student population decreased 10 percent. Children are eating more fresh produce than ever before.
Social Change
When the School Committee first met with Economos, the members knew they wanted to do something to address the childhood obesity epidemic, but they also wanted it done well. What impressed them about Shape Up?
Roberta Bauer, a school committee member for the last 10 years, recalls that Tufts was enormously flexible in finding places where change was possible and not demanding outcomes that would never be realized. "For example, we knew that we couldn't make substantial changes in physical education, other than providing professional development, so we worked around that," she says.
Snow agrees, saying Economos and her team were willing to be partners in the process. "We could have honest conversations about what would fly in the Somerville Public Schools and make adjustments accordingly," he adds.
More importantly, the school board's biggest concerns were addressed. Bauer adds, "We were most anxious about the health report cards. We didn't want to upset children's self-esteem by reporting their BMI scores to their parents. But Dr. Economos and her team assured us that children would be measured backward, so that they wouldn't know the results of their weight or height until the letters went home. And letters went to everyone--overweight children weren't singled out. Over the last four years, we've only received a handful of calls, mostly from parents looking for more help for their children."
Another major concern: The impact on the traditional fundraising events held during school hours. Like many school systems nationwide, Somerville schools relied on food-based fundraisers (mostly selling baked goods, candy and other treats) to supplement their ever-tightening budgets. In the elementary schools, food sales often were held just before students went to lunch, where they used their lunch money to fill up on less-than-nutritious food.
Although the school district's award-winning wellness policy requires that food-related fundraising activities no longer can be scheduled before lunch periods, no mandate bans the sale of unhealthy treats altogether. "Many of our schools are trying alternatives--as encouraged in our school wellness policy," says Superintendent Tony Pierantozzi. "But this issue was one of the most contentious in the community and encouraging change, instead of demanding it, seemed like the most reasonable approach."
Sustaining Change
All of the hard work over the last five years has paid off. On average, Shape Up Somerville reduced approximately one pound of excess weight gain over eight months for an 8-year-old child. On a population level, this reduction in weight gain would translate into large numbers of children moving out of the overweight category.
Economos, who published the first-year results of the Shape Up study in the research journal Obesity in May 2007, admits that the Somerville school leadership took a risk when they signed on for this intervention. But the commitment from all levels of the school district and the community made all the difference and will continue to have an enormous impact on the health of children. "They should be applauded," she says.
What's next? Since the intervention ended in 2005, efforts continue to improve children's nutrition and physical activity options throughout the city.
Somerville developed an award-winning school wellness policy. This eight-page document was created under the leadership of Snow, former assistant superintendent, and a diverse committee organized by the Shape Up Somerville team that included school administrators, school committee members, teachers and parents. An annual Wellness Policy survey is now conducted to assess staff and family familiarity with the policy to keep the school district on track with its wellness messaging and practices.
On a community level, the city's Recreation Department has increased its intramural sports offerings for children; the Health Department started Fitness Buddies programs for city employees and their families, new restaurants have been designated "Shape Up Approved," the annual Shape Up 5K and Family Fitness event continues to be hosted by the chair of the Somerville Board of Health, and the city is negotiating to extend its community bike path into Boston.
Plans to release results from the second year of the intervention are under way. But in the meantime, the Somerville Public Schools is committed to helping children develop healthy lifestyles that last into adulthood. Says McClarney: "Eating is a life endeavor. When homework is done or even after you've graduated, you still have to decide what to eat and how to be active. Giving our students the tools they need to make healthy choices is one of the greatest lessons we can teach them."
Related Article: Reducing Collective Weight: Starting Suggestions
Environmental change--in a school system or any other organization--doesn't come cheaply.
Shape Up Somerville: Eat Smart. Play Hard was funded by the Centers for Disease Control and Prevention as a three-year intervention to prevent obesity in culturally diverse, high-risk, early-elementary school children. Additional support came from Blue Cross Blue Shield of Massachusetts, Dole, Stonyfield Farm, U.S. Potato Board and Whole Foods Market.
Even with resources in hand, it can be hard to get started. The Shape Up Somerville team offers these tips:
Identify and Nurture Champions. These can include food service directors, principals and school committee members. Some may need a little nudge to get things started on their own; others are already leading.
Secure Buy-In From the Principal. This is key. Principals have the authority and on-the-ground relationships to implement new policies and programs.
Keep Everyone Informed of What You are Doing. This means everyone from the school committee to parents. Continuous communication can build support for change.
Provide Training. Periodic professional development allows for growth in relationships and continued empowerment for those being asked to do their work in very different ways.
Build on Community Assets. It's the best way to ensure sustainable success and will have the most meaningful impact on the students you serve.
Additional Resources
Over the last five years, several electronic resources have been developed to help school administrators, food service directors, physical education teachers and classroom teachers implement anti-obesity efforts in schools. Here are a few samples:
• Action for Healthy Kids (www.actionforhealthykids.org) was created out of the 2002 Healthy Schools Summit and has affiliates in all 50 states and Washington D.C. The affiliates focus on making changes in the school environment to address healthy eating and active living for children.
• Children in Balance (www.childreninbolance.org) is the umbrella initiative at Tufts University that engages in childhood obesity research and disseminates the tools and resources from this research, including Shape Up Somerville.
• National Alliance for Nutrition and Activity (www.schoolwellnesspolicies.org) has compiled a clearinghouse of resources for school administrators to improve, implement and evaluate their School Wellness Policies.
• PELINKS4U (www.pelinks4u.org), based at Central Washington University, offers a comprehensive array of news and resources for physical education professionals sewing grades K-12.
• The School Nutrition Association (www.schoolnutrition.org) and Framingham State's John Stalker Institute (www.johnstalkerinstitute.org) provide a number of tools for food service directors including continuing education credits, and ways to promote and cook healthier meals in schools.
Sarah Cluggish is the associate director of Children in Balance at Tufts University in Boston, Mass. E-mail: sarah.cluggish@tufts.edu.
Gretchen Kinder is the coordinator of research and development, information and grants with the Somerville Public Schools in Somerville, Mass.
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