Challenging Dogma - Fall 2011

Saturday, December 24, 2011

Improving the Efficacy of Nutritional Improvements to the National School Lunch Program with Adolescent Students – Sara Woolcock

Obesity in the present day is not just a concern for adults. From 1999-2002, it was found that the prevalence of overweight children and adolescents was about 16%, largely due to obesogenic environments for both physical activity and dietary intake. (1) During their school years, children and adolescents are learning eating behaviors and knowledge that they will carry on into adulthood. (2) Considering that one half of kids and adolescents get at least one of their meals at school through the National School Lunch Program (NSLP), (3) programs have been put under a critical eye for its efficacy of promoting healthy food choices. Parents, legislators, and public health officials have cited the sales of low nutrient, energy-dense foods as a major environmental cause to childhood obesity. (2)

Improving the School Lunch Program at local schools is often logistically difficult for administrators and food service personnel. Public school districts work under very restricted budgets, and school food service employees have little monetary room to make healthful changes. While concerned parties want to work with administrators to make positive changes, administrators see many barriers to implementing healthy lunches in schools, including funding, students’ preferences for unhealthy foods, lack of communication between food service staff and teachers, and short lunch times. (4)

Recognizing that changes need to happen, school administrators have largely resorted to district-wide wellness policies to address the concerns of public health officials and parents while also working within their barriers to improve school lunches. Wellness policies try to improve the nutrition of foods served at schools, mostly through a la carte snack bars, and vending machines. Junk foods sold in these places are usually referred to as “competitive foods” because they limit the sales of whole lunches in school cafeterias. Studies have found a positive correlation between the number of competitive foods in school and the poor quality of students’ diets in middle schools. (5) In response to similar studies, many schools have limited sales of sodas during school hours, the sugar content of beverages sold during lunch, the offerings of competitive foods – such as brand-name chips, cookies, and snacks – a la carte (6), and the number of days fried foods can be sold. (7) Public health officials have applauded these changes as progress toward preventing obesity and chronic disease. (8) However, the effectiveness of the policies with the older students in the middle and high schools is questionable.

District-wide wellness policy often implement changes to the middle and high school students together with younger students in primary school without regard to the students’ differing beliefs, values, and behaviors. In general, adolescence is a life stage when young adults desire to build their independence and sense of autonomy. (9) While children in younger grades will accept school wellness policy changes, adolescents view these changes as a loss of their freedom. One health coordinator in a school in Massachusetts stated that in her district, “high school students were furious this year when French fry sales were limited to three days a week.’’ Administrators often attribute this outcry to their students’ preference for unhealthy foods, (4) while failing to recognize that this reaction is typical of students in their age group. Therefore, it is important for school food service officials to consider designing changes to the school lunch programs that specifically target adolescents in the middle and high schools.

Adolescents Do Not Perceive The Urgency Of A Healthful Diet

One major flaw of applying wellness policies to adolescents is that these policies are often rationalized as obesity and chronic disease prevention efforts. It is assumed that students should be willing to adopt a healthier diet because they are concerned about chronic disease. (10) This rationale is based on the Health Belief Model (HBM) of behavior change.

The basic principle of the HBM is that there are basic “beliefs” that motivate individuals to adopt new health behaviors. These beliefs are the perceived benefits of adopting a new behavior (i.e. the severity of chronic diseases related to unhealthful behaviors), and the perceived barriers to adopting a new behavior. (11) Using this model to modify the diet of adolescents is flawed because none of the beliefs in the HBM motivate adolescents to adopt healthy behaviors.

The perceived threat of a disease is the weakest motivator of the HBM, (11) and in the case of adolescents, this belief has little to no effect on their behavior. Adolescents do not have little to any perception of the threat of chronic disease. Most adolescents are concerned with issues of immediacy, such as their performance and appearance. (10) Members of this age group often state that they have time to worry about a healthy diet when they are older. Studies measuring adolescents perceived benefits of a healthy diet have found that what truly motivates adolescents to eat healthy is their appearance, performance, having energy throughout the day, and their self-esteem. (12)

Researchers have also independently studied many of the perceived barriers to eating healthy with adolescents. Different groups of adolescent have often listed similar barriers that are outside their ability to control, including time/convenience of junk foods, peer reinforcement of unhealthy behavior, higher perceived palatability of junk food versus healthy foods, availability of healthy foods at home and at school and cost of healthy foods. (10,12) Interestingly, in one study that assessed adolescents’ knowledge of nutrition, researchers found that lack of knowledge is not a barrier preventing adolescents from adopting healthy eating behaviors. Participants in this study identified “balancing” their diet with “fruits, vegetables, meat, nuts, and milk” and adding a vitamin as ways to improve their diet. (10)

High school and middle school students have also been studied to find their perceived barriers to healthy eating in schools. Even adolescents identify that the quality of foods served in schools needs to improve. However, they suggest that just removing unhealthy choices will not get them to purchase a better lunch, and that they want healthy choices that are also palatable. (13,14) Based on these studies, policies that seek out nutrition education to remedy adolescents’ resistance to changes to school lunch programs will find that these efforts will have little efficacy with this age group, instead school food service officials should focus on improving the barriers that students identify as keeping them from purchasing a healthy lunch at school.

Adolescents View Changes to School Lunch as a Threat to Their Freedom

Studies in school food service operations have found that the more competitive foods sold in schools increases the likelihood that their students will have a poor diet. (15,16) School administrators and food service personnel’s first reaction to objections over the sales of competitive foods in school cafeterias is often a limitation on sales. Policies such as this have been implemented to limit the sale of sodas, chips, and fried foods. (17) However, these officials often do not consider that adolescents will view these restrictions as a loss of freedom and display psychological reactance.

Brehm conducted one of the first key studies describing psychological reactance. She studied children who were given two toys for play; one behind a barrier and another unrestricted, and she observed that many children desired to only play with a toy behind a barrier. (18) Studies of this phenomenon in the average adult consumer have found that even most adults react negatively to external pressures to force a behavior, causing an increased desirability for a restricted item or behavior. (19)

Health messages that try to direct behavior can also provoke psychological reactance, so while these messages may have good intentions for health promotion, the consumers of these messages often do not react well to restrictions in their behavior. Adolescents in particular, who are in a stage of life when they are building their independence, react much stronger to these threatening health messages than adults. (20)

School policies that limit junk food sales in middle and high schools usually also cause psychological reactance from students. Studies have found that restricting certain foods from children invoke psychological responses that result in increased desire and motivation to obtain that particular restricted food. (21) Research on the effect of wellness policies in middle schools has resulted in similar effects with students. In a study of wellness policy changes in a middle school in Houston, Texas, researchers found that after removing all snacks, potato chips, candy, sweet desserts, and sugar-sweetened beverages for sale in cafeterias and vending machines for one year there were significant declines in sales of such items. However, on further investigation, they found there was no significant change in dietary intake of these foods from baseline. Researchers speculated that despite these policy bans, students started bringing these foods in from home or obtaining them from vendors outside of school. (17) These results indicate that most students displayed reactance to the policy ban by increasing their intake of prohibited foods.

It is important for interventions in school lunch programs to be tested to see if they contain any factors that cause this psychological reactance. Studies of health messages have found that there are three factors that influence the degree of reactance: controlling language, lexical correctness, and restoration of freedom.

Controlling language is used in messaging that is very directive. This language often includes phrases with “must” and “should”. The most controlling and directive messages will get the most negative reactions and be least effective. (20) If school officials state that students “must” restrict their diet of fried foods to be healthy, it is likely that students will react by increasing their consumption of fried foods.

Lexical correctness is related to if a message conveys explicit or vague details. If a message contains more explicit detail, it will cause less reactance. (20) Usually bans on unhealthy foods in schools only cite vague reasons of obesity prevention, (17) which is not relevant or a motivator for adolescents.

Restoration of freedom is when a message ameliorates reactance and gives the receiver the ability to self-determine their fate. If this technique is used in a message, reactance will be minimal. (20) Restoration of freedoms are often ignored in messages to adolescents, because it is a long prevailing thought that adolescents lack maturity to make healthy choices. (22) In order for school lunch interventions to be effective with adolescents, messaging to middle and high school students need to consider these three factors of psychological reactance, especially the often-ignored restoration of freedom, to ensure these changes are not threatening freedom.

Marketing To Adolescents Is Underutilized in School Lunch Programs

Marketing is a useful tool that school lunch programs can use to “sell” healthy changes to adolescents. It is often underutilized, but officials could use marketing to address students’ concerns about the barriers they perceive to eating healthy and offer messages that restore students’ freedom to choose.

Advertising and marketing are two strategies that are constantly being used by companies to successfully sell their products to adolescents. Successful marketing campaigns demonstrate how different products can resonate with consumers “desires, values, and behaviors.” These campaigns must have three components: a core message, appeals to target audiences’ beliefs and values, and utilize appealing images and music to support their message. (22)

Market research can be a valuable tool to determine how to effectively craft the three components into a campaign that will identify with adolescents. (23) Market research is important so that campaign creators know the audience of their campaigns. Understanding, “ how [adolescents] feel, what they care about and what motivates them” can direct the messaging of an effective marketing campaign. Strategies such as purchasing observations and focus groups are both successful tools for market research in adolescents. (22)

When making changes to school lunch programs, most school administrators or food service personnel do not create a core message for their efforts. The message that usually reaches students is that it is for preventing obesity and chronic disease. (10) This core message assumes that the threat of disease as per the Health Belief Model is effective in motivating adolescents. It may also elicit psychological reactance because students perceive that choices are being taken away from them. Market research with adolescents on their opinion of school lunch has found that students mostly are concerned with the taste and convenience of foods sold in cafeterias. (22) Focusing a core message that addresses these concerns will most effectively resonate with adolescents.

Most adolescents share some very similar values and beliefs related to their age group. Adolescents strongly believe in freedom because they are developing their autonomy and independence. Marketing strategies that appeal to these values can also work to restore the freedom of their target audience. Marketing messages that give students more choices would be effective in assuaging any treats to freedom and would appeal to adolescents’ core values.

Advertising techniques and channels also have a great impact on how adolescents respond to messages. (23) Adolescents like to see advertisements that are especially innovative and use their peers as content creators. (24) Today’s adolescents are part of generation Z, or digital natives. They have the most comfort connecting online and prefer media that simple and interactive. (25) Marketing through social media is a valuable tool to reaching these consumers because they can interact with favorite brands. (26) Effective marketing strategies in schools will utilize these concepts to reach out to adolescents.

One such intervention that attempted to use media to market fresh fruits and vegetables to students was the Gimme Five campaign. It sought to address barriers that students identified as reducing their consumption of these foods: inconsistent taste, availability, and lack of variety, notably similar barriers that students have identified with eating healthy lunches at school. The campaign used media such as posters and PSAs broadcasted in the mornings to reach out to students in 12 high schools in New Orleans, Louisiana. Researchers simultaneously increased the number of fruits and vegetables available during lunch. (27) The messages used in the campaign were positive and focused on motivators of good nutrition that are effective with teenagers: appeals to performance, energy, and appearance. (22) Other than the PSAs, which students associated with administrator communications, the media component of the campaign was successful. About 85-97% of students rated the media outreach component as “thumbs up.” Researchers hypothesized this success was largely due to their targeting approach to appeal to the priorities and values of adolescents. (22)

These types of campaigns are rarely used in conjunction with school lunch programs yet have been measured to have a great impact on students’ perceptions of nutrition programs. Marketing is a valuable tool to frame changes to school lunch programs and policies in a way that is non-threatening to adolescents. Effective campaigns can address adolescents’ concerns with healthy eating and appeal to their own values through marketing channels most familiar to them.

Address Adolescent-Identified Barriers to Healthful Eating

Considering barriers that adolescents identify as important are much more effective than barriers that are most often considered, including knowledge and a lack of urgency about health. The most important barriers that students identify to eating healthy are time, taste, price, and the availability of healthy foods. (10,12) Even in schools that offer healthy options, barriers that prevent adolescents from purchasing these options are the lack of quality and variety. (14)

School food service directors need to create and serve healthy options that are of equal or greater quality to their usual product quality standards. This will improve the appeal of these options to their adolescent customers. However, these food options also need to have other characteristics that are important to adolescents. Most importantly, they should taste good, and be equal or greater in acceptable flavor and texture when compared to other options. These options should also be convenient to eat and prepare, addressing students’ concerns over time. (14) Optimally healthy products should be of equal or lesser price so as to not lessen their appeal for economic reasons.

Some of these acceptable healthy options available to food service operations include whole hand-fruit, such as apples, pears, and oranges. These fruits are easy to carry in students’ hands and eaten “on the go”. They are also much less expensive than prepared fruit slices. Putting hand-fruit in large, attractive fruit bowls even has the potential to double fruit sales. (29) Other options are salad bars with a variety of colorful vegetables, or vegetables like carrots, celery, and bell peppers cut into convenient-to-eat strips with healthy dipping sauces. All these products can be taste tested with students to see if they meet acceptability and if customers are likely to purchase them.

Provide a Variety of Options to Restore Adolescents’ Freedom to Choose

Adolescents are concerned with the lack of variety in their school cafeterias, (14) so when bans on the sales of particular foods are enacted, middle and high school students usually respond with reactance. However, variety can be employed in another way to increase sales healthy options in school cafeterias. A study in a university cafeteria found that they were able to significantly increase sales of fruits and vegetables when the variety of options of these foods were doubled and price was reduced. (29)

Sales of healthier options in middle and high school cafeterias could be promoted by offering a larger selection of choices for students to choose. Middle school cafeterias in California and Texas were studied after implementing changes in their cafeteria. These changes did not include any bans but instead increased the variety of fruits, vegetables, and decreased the portion sizes of high calorie snacks and drinks available to students. Researchers found that surveyed students rated changes as positive and favorable. (30)

School food service operations can offer more than two or three different options of fruit and vegetables available to students for sale. Even though these are both healthy options, giving students the ability to choose between the two restores their freedom to make their own choices. Less healthy options can also be modified and included in the variety to guide students to making healthier choices. For example, decreasing the portion sizes of French fries while also offering sweet potato fries gives students the option to choose while also offering better nutrition. Varieties of cooking techniques, such as pressure frying, baking and grilling, can also be explored to give students more healthful options to choose from.

Employ Marketing Techniques to Sell Changes to Students

The key to successfully implementing the changes to the quality, types, and variety of healthy foods offered in middle and high schools is successfully marketing these changes in a way that resonates with adolescents. Effective marketing can go a long way to getting students on board with any changes that food service officials and administrators want to make. However, in order to have an effective marketing plan, officials must consider using market research, core messages and values, and appropriate communication techniques.

Market research is essential for accurately targeting a marketing campaign to a particular group of adolescents. Each food service operation should conduct market research on their unique group of students to truly understand what unique motivates students at their school. Focus groups are effective ways of getting adolescents’ input on a marketing plan, and also making the students feel involved in changes at their school. Well-directed focus groups can reveal what students are interested in, what is important to them, and what motivates them to purchase foods. (22)

Market research can help guide campaign designers to goals and core messages that would appeal to adolescents in a marketing strategy. Changes made to make school lunch programs healthier should be marketed as a way to give students better quality, taste and variety rather than for health concerns. (22) Messages that emphasize choice can appeal to adolescents’ value of freedom and independence. Also, justifying changes with evidence that supports adolescents’ reasons for eating healthy: such as energy, performance, and appearance, gives students reasoning for changes that is relevant to their motivations and goals.

This generation of adolescents grew up in the digital age, and they are mostly exposed to marketing messages through online channels. Social media and websites can be a familiar way for adolescents to communicate. (25) One benefit of campaigns using social media is that designers can elicit instantaneous feedback from students on each day’s menu offerings. School food service personnel that communicate with students through social media can make students feel like their opinions are important, which is very important to adolescent consumers. (25)

Campaign messaging can utilize print, video and audio media that are popular and resonate with adolescents. Adolescents today enjoy interactive media and media that allow them to be content creators, (24) as seen with such websites as YouTube, which allows users to submit their own videos to a personal profile. Video, art, and music contests about the campaign can be another channel to make students feel like they are a part of the changes being made.

In conclusion, making healthful changes to school lunch programs can be more challenging with adolescents, but there are several different ways these changes can be presented and marketed to students so they are more acceptable. It may seem like a daunting task, but presenting changes to school lunches in a way that is non-threatening to middle and high school student can have big payoffs. There is the obvious benefit of preventing obesity and chronic disease. However, these changes also have the potential to increase student participation in the school lunch program, which can have profound implications on budgets and finances. The key to success is working with adolescents’ concerns, and making changes with the students as a guide.


(1) Hedley A. Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 1999-2002. Journal of the American Medical Association 2004; 291:2847-2850.

(2) Story M. Schools and Obesity Prevention: Creating School Environments and Policies to Promote Healthy Eating and Physical Activity. The Milbank Quarterly 2009. 87:71-100.

(3) Wechsler H. Food Service and Foods and Beverages Available At School: Results from the School Health Policies and Programs Study 2000. Journal of School Health 2001. 71:313-324.

(4) Cho H. Understanding Barriers to Implementing Quality Lunch and Nutrition Education. Journal of Community Health 2004. 29:421-435.

(5) Cullen KW. Fruits, Vegetables, Milk, and Sweetened Beverages Consumption and Access to a la Carte/Snack Bar Meals at School. American Journal of Public Health 2004. 94:463-467.

(6) Kubik MY. The Association of School Food Environment with Dietary Behaviors of Adolescents. American Journal of Public Health 2003. 93:1168-1173.

(7) O'Toole TP. Food Service and Foods and Beverages Available At School: Results from the School Health Policies and Programs Study 2006. Journal of School Health 2007. 77:500-521.

(8) Neumark-Sztainer D. School Lunch and Snack Patterns among High School Students: Associations of School Food Environments and Policies 2005. International Journal of Behavioral Nutrition and Physical Activity 2005, 2:1-7.

(9) Stang J. Nutrition in Adolescence. In: Mahan LK, ed. Krause’s Food and Nutrition Therapy. St. Louis, MO: Saunders Elsevier, 2008.

(10) Story M. Adolescents’ Views on Food and Nutrition. Journal of Nutrition Education 1986. 33:1-6.

(11) Champion VL. The Health Belief Model. In: Health Behavior and Health Education. San Francisco, CA: Jossey-Bass, 2008.

(12) O'Dea JA. Why do Kids Eat Healthful Food? Perceived Benefits of and barriers to healthful eating and physical activity among children and adolescents. Journal of the American Dietetic Association 2003. 104:497-501.

(13) Bauer KW. “How Can We Stay Healthy when you’re Throwing All of this in Front of Us?” Findings from Focus Groups and Interviews in Middle Schools on Environmental Influences on Nutrition and Physical Activity. Health Education and Behavior 2004. 31:34-46.

(14) Meyer MK. Variable affecting high school students’ perception of school food service. Journal of the American Dietetic Association 1998. 12:1424-1431.

(15) Templeton SB. Competitive Foods Increase the Intake of Energy And Decrease the Intake of Certain Nutrients by Adolescents Consuming School Lunch. Journal of the American Dietetic Association 2005. 105:215-220.

(16) Marlette MA. Food Type, Food Preparation, and Competitive Food Purchases Impact School Lunch Plate Waste by Sixth-Grade Students. Journal of the American Dietetic Association 2005. 105:1779-1782.

(17) Cullen KW. Exploring changes in middle-school student lunch consumption after local school food service policy modifications. Public Health Nutrition 2005. 9:814-820.

(18) Brehm SS. Physical Barriers and Psychological Reactance: 2-Year-Olds’ Responses to Threats to Freedom. Journal of Personality and Social Psychology 1977. 11:830-836.

(19) Clee MA. Consumer Behavior and Psychological Reactance. Journal of Consumer Research 1980. 6: 389-405.

(20) Miller CH. Psychological Reactance and Promotional Health Messages: The Effects of Controlling Language, Lexical Correctness, and the Restoration of Freedom. Human Communication Research 2007. 33:219-240.

(21) Fisher JO. Restricting Access to Palatable Foods Affect Children’s Behavioral Response, Food Selection, and Intake. American Journal of Clinical Nutrition 1999. 69:1264-1272.

(22) Mixon HH. Marketing Nutrition in Middle Grades: Adolescent Food Habits and Strategies that Work. University, MS: National Food Service Management Institute, 2001.

(23) Kraak V. How Marketers Reach Young Consumers: Implications for Nutrition Education and Health Promotion Campaigns. Family Economics and Nutrition Review 1998. 11:31-41.

(24) Mintel. Media Advertising. In: Spending Power of the Teen Consumer – US – April 2008. Mintel Media Group Ltd, 2008.

(25) Grail Research. Consumers of Tomorrow: Insights and Observations about Generation Z. Grail Research LLC, 2011.

(26) Mintel. Social Networks. In: Spending Power of the Teen Consumer – US – April 2008. Mintel Media Group Ltd, 2008.

(27) Niklas TA. Outcomes of High School Program to Increase Fruit and Vegetable Consumption: Gimme 5 – A Fresh Nutrition Concept for Students. Journal of School Health 1998. 68:248-253.

(29) Wasnick B. Lunch Line Redesign. The New York Times. 21 Oct 2010. Accessed 3 Dec 2011.

(29) Jeffery RW. An Environmental Intervention to Increase Fruit and Salad Purchases in a Cafeteria. Preventative Medicine 2004. 23:788-792.

(30) Cullen KW. Improving the School Food Environment: Results from a Pilot Study in Middle Schools. Journal of the American Dietetic Association 2007. 107:484-498.

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