Updated, July 22, 2011
For many years, it seemed that schools' obligations in the realm of student health were limited to treating playground injuries, conducting head-lice searches, and providing a central location for children's vaccinations.
Today, in part because of rising rates of obesity, diabetes, and asthma among adolescents, schools are being asked to take a much more active role in promoting students' physical well-being. Attention has been focused in particular on physical activity, nutrition and health, and environmental conditions in school buildings.
From the mid-1960s to 2008, the percentage of American children who were obese more than quadrupled—rising from 4.2 percent to 16.9 percent among children ages 6-11, and from 4.6 percent to 18.1 percent among teenagers, according to the federal Centers for Disease Control and Prevention (CDC, 2010a). Experts often cite lack of physical activity as a leading cause of the rising obesity rate among children, pointing to the increasingly prevalent roles of cars, television, and computers in children's lives (CDC, 2011; U.S. Department of Health and Human Services, 2001).
While much of this sedentary time is passed outside of school, many parents look to schools to fix the problem. In a 2011 national survey by the C.S. Mott Children's Hospital at the University of Michigan, for example, 94 percent of parents of children ages 6 to 11 said it was very important for elementary-age children to have physical activities during the school day, and one-third said their children didn't get enough at school. Providing opportunities for daily physical activity is also at the core of past recommendations for schools from the U.S. Surgeon General (C.S. Mott Children's Hospital, 2011; U.S. Department of Health and Human Services, 2001).
While physical education is not viewed as a core academic subject in many states, adequate physical activity by students has been linked to higher academic achievement. Some studies show that students who devote a significant amount of time to physical activity exceed the academic achievement of those who do not; active students often exhibit higher energy and greater concentration (Dwyer et al., 2001; Shepherd, 1997; Davis, et al, 2011).
The success of schools in promoting physical activity among children and adolescents has been mixed. In 2009, only 56 percent of high school students attended physical education classes, and only 33 percent did so on a daily basis, down from 42 percent in 1991 (CDC, 2010b). Some school systems have had to reduce recess and physical education time and limit after-school sports because of funding constraints and rising pressures to meet state academic demands (Borja, 2002).
High obesity rates and a growing concern about student nutrition have also caused states, schools, and the federal government to reconsider cafeteria menus.
During the 1990s, schools participating in the National School Lunch Program—the federal government's subsidized-meals program for students—made significant improvements in the nutritional value of the lunches they provided, including reductions in fat and saturated fat levels (U.S. Department of Agriculture, 2001). As the prevalence of pre-packaged and processed foods in schools, as well as obesity, continued to increase, however, lawmakers saw a need for greater involvement.
The Healthy, Hunger-Free Kids Act, passed in 2010, required sweeping changes to school breakfasts and lunches. The U.S. Department of Agriculture proposed regulations related to the act that would require schools to serve more fruits and vegetables, more whole grains, and limit sodium and calories. The regulations also would require water to be provided at lunch, would ban flavored milk that isn’t fat-free, and would regulate contents of vending machines in schools (Education Week, 2011).
While some complaints surfaced about the costs to schools to meet the regulations, such as new equipment and more expensive food, several districts began moving forward with their own improvements. The Los Angeles Unified School District was among several districts that dropped chocolate milk from their cafeteria options in 2011. Others began embracing locally grown food and farm-to-school programs, often with state support (Farm to School, 2010).
Still, other sources of food in schools have fallen short. In particular, vending machines and school-run shops frequently offer students enticing selections of junk foods and high-sugar sodas, which have been linked to an increased risk of childhood obesity (U.S. General Accounting Office, 2003; Ludwig, et al, 2001).
In a study published in the online Journal of Adolescent Health in 2011, researchers examined the impact of vending machine food on nearly 6,000 students’ food choices and found that those whose elementary schools had vending machines containing food with minimal nutritional value, such as chips, soft drinks and candy, tended to eat more sweets, while those whose school vending machines contained fruit or vegetables, such as carrots, ate more produce than their counterparts in other schools (Rovner, et al, 2011). Food-group representatives have objected to regulations, however, saying that, rather than restrict students' choices, schools should educate students about making sensible eating decisions (GAO, 2003; Borja, 2002).
In addition to providing adequate nutrition with their meals, schools increasingly must be vigilant in ensuring the safety of the food. From 1999 to 2008, the Centers for Disease Control and Prevention’s outbreak data identified 478 foodborne outbreaks associated with schools that affected at least 10,770 children (GAO, 2010). In the Child Nutrition and WIC Reauthorization Act of 2004, Congress required schools involved in federal meal programs to be inspected twice a year in an effort to improve food safety (Center for Science in the Public Interest, 2007).
While food-borne disease poses a significant health risk to students, the most common chronic illness among students by far is asthma, with nearly 7.1 million children affected (American Lung Association, 2010). Environmental irritants found in schools—particularly mold, cockroaches, and dander—can cause asthma attacks in students to be more pronounced and common. According to the U.S. Environmental Protection Agency, asthma accounts for more than 14 million missed school days per year. It can also disrupt students' sleep and daily routines (U.S. Environmental Protection Agency, 2011b).
To combat the problem, the EPA advises schools to take systematic action to rid their buildings of asthma "triggers" and to develop comprehensive "asthma management plans" that coordinate treatment for affected children. Calling attention to the complexity and breadth of the epidemic, meanwhile, a panel of national experts on asthma has called for a greater national coordination of efforts to treat and prevent the illness (including programs for schools), as well as a greater commitment of resources (EPA, 2011b; Lara et al, 2002).
School environments can also affect students through allergens, poor ventilation, and dangerous chemicals. Following a 1999 U.S. Department of Education finding that 43 percent of schools in the United States reported at least one unsatisfactory environmental condition, the EPA launched a public-awareness campaign to help school employees and parents prevent, identify, and correct air-quality problems. The agency has found that poor air quality can have measurable effects on both student health and academic performance (EPA, 2011a).
In approaching all of these student health issues, a common recommendation has been the adoption of comprehensive school health policies that bring physical and health education into regular classroom instruction, encouraging healthy choices as part of academic learning. Some schools in low-income communities have developed school-based clinics to bring services that children might otherwise not get.