None of the five schools participating in the study had full kitchens; they had minimal equipment such as sinks and warming ovens. Meals were prepared at the school district's central kitchen and then heated in each school's kitchen, giving schools little control over food offered in the cafeteria. Focus group participants described the effects they believed food service policies and practices had on student food choices, saying that their schools did not provide enough healthy choices for students. One teacher explained:
We tell them to eat well, and we serve them french fries every day, and I know that they're baked, I know they're not actually fried, but, come on. Everything's in cellophane. [We teach them] don't eat prepackaged foods, they're not as nutritious as the fresh cooked foods, and everything they get they have to unwrap the little cellophane wrapper. It's disgusting.
Two staff members at another school made similar observations, expressing their frustration with the ways that food service policies and practices undermined nutrition education efforts:
Participant 1: One thing that I've noticed is that a lot of kids, like probably 60% or 70%, eat chips for lunch. And on the snack cart that they have — they have a regular lunch that kids can get free or buy — but on the cart they don't have any nutritious things, just ice cream and all the junk stuff.
Participant 2: There is a health class, but you see contradictions. The kids come out of health class, and they go down to the cafeteria — the system undermines [the health messages]. It's swimming upstream.
Some teachers reported that during the school year, the students began to notice the contradictions between nutritional behaviors encouraged by teachers and the options provided in the school cafeterias. One teacher said the following about the students:
They talk about the cookies and the chips and some of the food [offered in the cafeteria]. And they go, "Well, if all these things are so bad for us, you know, and they're supposed to serve us healthy lunches and balanced lunches, why are they serving what they're serving . . . all this stuff that's going to kill our arteries, and knock us out?"
A theme that emerged from all the focus groups was that Planet Health and other nutrition education efforts needed to be incorporated into the school food services. One staff member explained, "I think the easiest thing to do really would be align Planet Health with the cafeteria. It would really make a greater impact. And then what we do is piggyback off of that." At another school, a teacher suggested that Planet Health "would have a lot more impact if they [the students] could see the lessons reflected in the food they are served."
Many faculty and staff members said that they believed the widespread problem of overweight, especially among African American and Latino children and children from low-income families, made it imperative to serve healthier food in their schools. They believed that it was the responsibility of the school to compensate for the lack of nutritious food in many of the students' homes. Faculty and staff members explained that some of their students were living in households without enough food because the families did not always have enough money for groceries. They said that these children would often arrive at school having eaten little at home, or they would bring to school inexpensive but nonnutritious foods such as soda, potato chips, and candy that they had purchased at convenience stores close to the school. A teacher described one student who found it nearly impossible to adhere to the dietary restrictions recommended by her doctor because of a lack of food at home and a lack of nutritious offerings at school: "I have another kid, in eighth grade, who won't eat lunch because the lunch has too much sodium, too much this, all these things in it that she can't have. . . . And she should bring a lunch from home, but there's nothing at home to bring."
Teachers said that they had students who did not qualify for the subsidized meal program according to the current federal eligibility restrictions but nevertheless could not afford to buy lunch at school. Teachers stated that students' fears about seeming poor or hungry made them reluctant to ask for or accept money or food offered by school staff. Faculty and staff members mentioned that some students who did qualify for free or reduced-price meals felt self-conscious as they passed through the lunch line because they knew that peers near them would find out that they were receiving subsidized meals. One teacher explained:
Two years ago, I realized that half my class was not eligible for the free lunch. And they were not bringing any money. I have offered to pay for their lunch, and they say, "I'm not hungry," because it's embarrassing. And then, some of them even say things such as "I don't want to get fat" just to pretend that they're on a diet, because they really cannot afford it, yet they're not eligible for it.
Some participants described instances in which school cafeterias had too little food to serve all the students who wanted to purchase lunch. One teacher described several occasions on which she believed her school cafeteria did not have enough food to last through all lunch periods in a day or until the end of the week.
Many participants commented on the influence that cultural background and teasing by peers had on student food choices. Some believed that while at school, students whose families had recently immigrated to the United States were not eating some of the healthy ethnic food they typically ate at home either because the food was not available in the cafeteria or because they were teased for bringing the food from home. One teacher offered the following perspective:
We serve a high immigrant population. Most of the parents — the vast majority of the parents — are immigrants. And kids first come to the United States, they may have ate healthy in their homeland. They come to the United States, it's not cool to play soccer, it's not cool to do other things, eat fresh fruit. . . . The immigrant parents are very aware of health but their offspring are coming at it just the other way and saying, "I want to be an American. Americans eat chips, hot dogs." So it's, you know, it must be very hard for parents to offset this.
Physical activity opportunities
Participants identified many school-related barriers to student participation in physical activity. Factors included academic and medical examination requirements for participation in athletic teams, infrequent PE classes and after-school physical activities, and a lack of outdoor playing space. For example, various extracurricular sports teams were available at each of the schools; however, students were required to maintain a C average to qualify for participation. In addition, schools required students to get a medical examination before joining a sports team, which was financially difficult for low-income families and prevented some students from participating.
PE class scheduling was inconsistent in some of the schools. Some students had daily PE class during the first semester but no classes at all during the second semester. In other schools, students in certain grades were not offered PE classes during certain times of the year; in one school, an entire grade did not have PE class for the whole school year because of a scheduling error. Many of the schools did not have outdoor grass fields where students could play sports. Some schools improvised by having students play on a parking lot near the school campus. The lack of outside play space limited the types of activities offered in PE class and the number of sports teams that the schools could support.
Even when PE classes were offered, staff members explained that several barriers kept many students, especially girls and overweight students, from participating fully in class. They said many girls were uncomfortable playing sports with boys and thought they did not have enough privacy in locker rooms. In PE classes in which girls outnumbered boys, girls seemed to enjoy participating in class. One teacher described the way her class of primarily girls compared with other classes: "They seem to love gym. I would always see them carrying their gym clothes and deodorant and all these little things. Whereas other kids, I go pick them up from gym, and they wouldn't have anything; they wouldn't have gym clothes." Many staff members commented that students were reluctant to change in front of each other in the locker rooms. One teacher explained, "There's no shower, and there's no privacy in the changing area. For someone who's self-conscious, especially one who might be on the obese side, there's no [private] bathing, shower facilities."
Teachers pointed out that some students who disliked PE classes and found the PE class environment unsupportive enjoyed physical activity in other settings. A teacher at one school recalled her experience coaching an after-school Special Olympics program:
There are several students that really, really hate gym that participate [in the Special Olympics program]. I do Special Olympics track, in the spring, it's an after-school activity. And all the students with [disabilities] have partners that are just the regular kids that help them. And a lot — I mean, I want to say almost all of my partners that run after school, do the routines after school, work out with their special partners — are the same ones that hate gym. So it's not the physical activity that they hate. . . . They'll run when they're helping out a girl with Down syndrome, but they don't want to do it in front of the eighth-grade boys.
Weight-related teasing and concerns
Participants observed that weight-related teasing is very common in their middle schools, and one teacher even described it as "brutal." Participants thought that weight-related bullying was not taken seriously enough by administrators and reported that their schools did not have explicit policies on preventing or managing incidents. They pointed out that teachers were expected to manage weight-related teasing and harassment on their own, whereas sexual harassment incidents received immediate attention from the administration. A staff member spoke about how changes needed to occur on the school level to decrease weight-related and other bullying in schools:
It's not only your class. It's the school thing, and it involves a different message. And maybe we should embrace that. We can embrace that we want all of our kids to be literate. We also want to be bully-free. . . . So I think that's a campaign that we need to do as the whole school.
Many teachers expressed concern about how their students' weight-control behaviors seemed to negatively affect their eating patterns. They noted that some students were not eating balanced meals because of weight concerns, a poor body image, and peer pressure to diet. One faculty member explained: "There are a lot of issues, I think especially with the girls, with eating. We have [everything from] girls that won't eat the school lunch, don't eat anything — who are very thin — to girls watching their weight."
At one school, staff members discussed the way a student who they believed had an eating disorder had been affecting other students. The girl had been eating very little, and the other students in her class, especially the girls, were aware of her unhealthy weight-control behaviors. One teacher explained, "She was influential because she told the others, 'This is how you're supposed to look.' The students . . . they wouldn't even eat lunch last year. None of them would eat lunch, none of them." The teachers said they explained to the other girls that the student was not an appropriate role model for proper eating habits, but the peer pressure to participate in unhealthy weight-control behaviors was strong. Several staff members said that they wanted training on recognizing and addressing eating disorders in addition to the training they received on promoting healthy nutrition and physical activity through the Planet Health intervention.