[Obesity Discussion]

The School-Lunch Test
By LISA BELKIN
It was not yet 11 a.m. at the Partin Settlement Elementary School in Kissimmee, Fla., on a sunny day last October. But lunch service necessarily begins early when there are 838 children to feed, and the meal was already well under way. Danielle Hollar walked calmly amid the lunchroom chaos, holding a large, raw, uncut sweet potato in one hand and a tray filled with tiny cups of puréed sweet potatoes in the other. That Hollar does not get frazzled even among hundreds of jabbering children is one of the talents she brings to her job. That she is tall and blond and slim, and many of the students seem to have school-kid crushes on her, is another.

“This is a sweet potato,” she said, as she stopped at each table and gave each child a purée sample. “It has a lot of vitamin A and C and B6. Have you ever seen one of these?” Most of the children had not. “It’s like a regular potato, but it’s orange inside,” she said, which got their attention. “It has a lot more vitamins than a white potato.”

Angelina wanted to know why there were no marshmallows on top. Angel put down his lemon pie, tried the sweet potatoes and announced he preferred the pie. Mateo, however, was making a meal of what his classmates eyed so suspiciously. Collecting the cups of everyone around him, he ate a dozen of the tablespoon-size portions before a teacher cut him off.

“It’s sweet, which is why it’s called a sweet potato, but it’s also good for you,” Hollar said, as she moved from table to table, sounding one exclamation point short of a sales pitch. Eager as she was to get the children to taste what she offered, though, she pointedly refused to compare this vegetable to candy.

“I don’t like sweet potatoes,” said Jessica, who is in the second grade.

“Have you ever tried one?” Hollar asked.

“No,” Jessica said, making it clear she would stick with her Lunchables nachos and her Capri Sun drink, which she took out of her Mickey Mouse lunchbox.

Hollar and her sweet potatoes were wandering the lunchroom courtesy of the Agatston Research Foundation, founded in 2004 by Dr. Arthur Agatston, creator of the South Beach Diet. Having tackled the eating habits of obese adults, Agatston has turned his attention to children. A cardiologist who considers himself a scientist and who just happened to become a wealthy minicelebrity, Agatston is using the cafeterias of the Osceola County School District as a clinical laboratory. There are 19 elementary schools in the district, and the Agatston Foundation started by taking control of the menus at 4 of them, all within Kissimmee. They are testing whether a plan he calls HOPS — Healthier Options for Public Schoolchildren — can measurably affect children’s health.

“The success of the book gave me a bully pulpit and an opportunity to change the way Americans eat,” Agatston told me not long ago. “One of the obvious places to start is with children. And that means schools.”

By any health measure, today’s children are in crisis. Seventeen percent of American children are overweight, and increasing numbers of children are developing high blood pressure, high cholesterol and Type 2 diabetes, which, until a few years ago, was a condition seen almost only in adults. The obesity rate of adolescents has tripled since 1980 and shows no sign of slowing down. Today’s children have the dubious honor of belonging to the first cohort in history that may have a lower life expectancy than their parents. The Centers for Disease Control and Prevention has predicted that 30 to 40 percent of today’s children will have diabetes in their lifetimes if current trends continue.

The only good news is that as these stark statistics have piled up, so have the resources being spent to improve school food. Throw a dart at a map and you will find a school district scrambling to fill its students with things that are low fat and high fiber.

In rural Arkansas, a program known as HOPE (Healthy Options for People through Extension) seeks to make nutrition a part of the math, science and reading curriculums. At the Promise Academy in Harlem, all meals served in the cafeteria are cooked from scratch, and the menu (heavily subsidized by private donations) now includes dishes like turkey lasagna with a side of fresh zucchini. In Santa Monica, Calif., there is a salad bar at every school in the district, with produce brought in from the local farmer’s market. At Grady High School, outside Atlanta, the student body president, a vegetarian, persuaded the company that runs the cafeteria to provide tofu stir fry, veggie burgers and hummus. In Irvington, N.Y., a group of committed parents established No Junk Food Week last March, where all unhealthy food was removed from the cafeteria and replaced with offerings from a local chef called Sushi Mike and donations from a nearby Trader Joe’s. At the Hatch Elementary School in Half Moon Bay, Calif., children learn songs like “Dirt Made My Lunch” and then taste fruits and vegetables they have grown in their own garden.

School lunch (and actually, breakfast, because schools that provide free and reduced-cost lunches must also provide breakfast) is now a most popular cause. Any number of groups, from the W.K. Kellogg Foundation and Kaiser Permanente (they both underwrite many of the above programs) to the William J. Clinton Foundation (it brokered an agreement among soft-drink manufacturers to stop selling soda in elementary and middle schools) have gotten in on the act.

But there is one big shadow over all this healthy enthusiasm: no one can prove that it works. For all the menus being defatted, salad bars made organic and vending machines being banned, no one can prove that changes in school lunches will make our children lose weight. True, studies show that students who exercise more and have healthier diets learn better and fidget less, and that alone would be a worthwhile goal. But if the main reason for overhauling the cafeteria is to reverse the epidemic of obesity and the lifelong health problems that result, then shouldn’t we be able to prove we are doing what we set out to do?

The smattering of controlled prevention studies in the scientific literature have decidedly mixed findings. “There just isn’t definitive proof,” says Benjamin Caballero, the principal investigator on the largest study, of 1,704 students over three years in the 1990’s, which showed no change in the body-mass index of those whose schools had spent $20 million changing their menus, exercise programs and nutritional education. A second study, of more than 5,000 students undertaken at about the same time, came to similar conclusions. “There are a few smaller studies with more promising results,” Caballero went on to say, “but right now we can’t scientifically say that all the things that should work — by that I mean improving diet, classroom nutrition education, physical activity, parental involvement — actually do work.”

And yet districts keep trying. Until recently, most were spurred by determined parents or energetic administrators, but now they have a Congressional incentive, too. This coming school year is the first when schools receiving federal lunch subsidies will have to create a wellness plan — a detailed strategy for how nutrition will be provided and taught. In addition, the actual nutrition requirements set by the government for school meals are expected to become more rigorous this coming spring, on the heels of the revised “food pyramid.”

Agatston’s HOPS program is but one example of the scramble to create systems that are replicable and economical enough to meet these demands and to prove, while doing so, that they have a measurable effect on children’s health. As such, the year I spent observing the successes and the setbacks of this particular experiment is a window into why it is so hard to do something that seems so straightforward and simple — feed school children better food.

In taking on this challenge, the Agatston team weighed and measured thousands of children at the start of the last school year, then weighed and measured them again in June. In the months in between, they wrestled with finicky eaters, reluctant administrators, hostile parents and uncooperative suppliers. So there was a lot riding on Hollar every time she presented a tray of sweet potatoes, or broccoli served with dabs of reduced-fat ranch dressing, or tiny cups of salsa. Would this bring schools closer to a solution? Or was it just another false start?


The reason that children are currently too fat is, in part, because they used to be too thin. During World War II, potential enlistees were regularly turned away because they were undernourished, and after the war the director of the Selective Service System declared malnutrition to be a national emergency. One result was the National School Lunch Act, signed by President Harry S. Truman in 1946, guaranteeing a hot lunch for every schoolchild who could not afford one.

Another result was also a complex web of regulations and restrictions, overseen by the United States Department of Agriculture. These rules have morphed and grown over the decades, adding free and reduced-cost breakfast during the Lyndon Johnson years; being pared back during the Reagan Administration, which, memorably, was lampooned for proposing that ketchup be declared a vegetable; and stressing nutrition under the Clinton Administration, which set a limit on fat at 30 percent of calories in a weekly menu (though, rules or no, the national average has never fallen below 34 percent for lunches).

Tweaks aside, the twofold effects of the School Lunch Act are much the same now as 60 years ago. First, the act put the government in the school-food-supply business, buying surplus product from farmers and sending it along to the schools. Twenty percent of the foods served in school cafeterias today are Agriculture Department commodities, which include everything the federal government buys a lot of and needs to pass along, from flour and sugar to fruits and vegetables. While the quality has improved somewhat in recent years, terms like farm-fresh and organic rarely apply. At the same time, the act put schools in the restaurant business, requiring that their lunchrooms manage to at least break even, reimbursing them between 23 cents and $2.40 a meal. It is a system in which pennies are necessarily looked at as closely as sodium content, perhaps even more.

Agatston knew next to nothing about the arcane intricacies of the system two years ago, other than that he wanted to do something about school lunch. As it happened, a lot of his cardiac patients worked as teachers, and for years he had heard about classroomwide sugar highs after lunch and children who seem to expand from year to year. He hired Hollar, whose background was not in nutrition or school food systems — she has a Ph.D. in public administration and policy — and teamed her with Marie Almon, a registered dietician who had worked with him for 20 years and created nearly all of the recipes for the original South Beach Diet book. She also had no experience in schools.

“Looking back, we were unprepared for the complexities,” Almon said this summer, reflecting on the prior two years. “But maybe that turned out to be best, because I might have been overwhelmed if I had known.”

In the spring of 2004, Almon, Hollar and Agatston set out to find a school district that would welcome their experiment. They wanted one with a relatively poor population, where a good portion of the children receive free or reduced-cost lunches (and breakfasts), where the food provided at school served the purpose originally intended under the law — to be the most nutritious meals a child had all day. And they wanted a place where the parents were less likely to have the economic or organizational clout to make change happen on their own.

The Osceola County School District met many of these requirements. The school-age population in the four chosen elementary schools — the first stage of the program would include only kindergarten through sixth grade on the theory that like language, teaching nutrition to younger children would have a higher “stick” rate — is 42.6 percent Hispanic, 41.3 percent white but not Hispanic and the rest divided among other ethnic groups. At these four schools — Partin Settlement Elementary, Mill Creek Elementary, Kissimmee Charter Academy and P.M. Wells Charter Academy — many students are from homeless families. Fifty-five percent qualify for free or reduced-cost meals. “We have kids who go shopping in the gas station across from the homeless shelter or who live in the Howard Johnson’s,” says Eileen Smith, Partin Settlement’s principal. “They are not going to get anything fresh.”

The Agatston group presented its proposal to the leadership of the Osceola district during the summer of 2004. The plan included changing the food served in the cafeteria; creating small gardens at each school to allow children to get their hands dirty; providing teachers with guides for incorporating nutrition lessons into Florida’s existing curriculum — inserting them into math class or social studies, for instance — so that the schools would stay on track in terms of their teaching schedule; and providing special programs, whether food tastings or creative assemblies, to reinforce the message.

Jean Palmore, the director of food services in Osceola, was at that meeting and was impressed by what she heard. “It sounded like it was workable; it sounded simple,” Palmore says. She liked the fact that two other Kissimmee elementary schools would be set aside as control schools, so that there would be a way to compare her standard menu, the one that would remain in effect at all the other schools in the district, with the HOPS revisions. She was particularly pleased that the foundation would reimburse the district for any costs over what was already budgeted for food. And she added a requirement — that HOPS also reimburse Osceola if the “participation rate” of students decreased to the point that the cafeterias could not break even. In other words, if the students refused the healthier food, Palmore would still meet her $19.5 million budget.

A contract was signed in July 2004. School opened in August. Instead of spending the first year learning and planning — which, in retrospect, might have been a good idea — the team jumped in and ran right into the realities of school nutrition.

For instance, nearly all the food for the coming school year had been ordered months earlier. Commodities, which can be had free from the government, must be requested as early as March, and those orders, once approved, cannot be changed. (Which does not mean, however, that the government cannot change its mind about what it sends, just that schools cannot change their requests. The summer before Hollar and Almon arrived, for example, a year’s supply of puréed prunes simply showed up at the Osceola warehouse. Federal law says that commodities must be used — they cannot be sold or thrown out or even given away — and Palmore’s staff spent a few months experimenting with baking recipes that used prunes in place of butter or oil.)

In turn, all noncommodity orders, both to huge companies like U.S. Foodservice and Sysco and to smaller regional producers, had been finalized the previous May. A year of menus based on those orders had already been set by Palmore. And because Osceola is part of a 24-county consortium of school districts, which join together to negotiate better prices, there was even less flexibility than there might otherwise have been.