Research ArticleNeed for Specific Sugar-Sweetened Beverage Lessons forFourth- and Fifth-GradersJennifer W. Bea, PhD1,2,3; Laurel Jacobs, DrPH, MPH2; Juanita Waits, EdD4; Vern Hartz, MS3;Stephanie H. Martinez, BS5; Rebecca D. Standfast2; Vanessa A. Farrell, PhD, RD2;Margine Bawden, BS6; Evelyn Whitmer, MEd7; Scottie Misner, PhD, RD2

1Departm2Departm3Univer4Univer5BureauPhoenix6Univer7UniverAddress85724-05�2015 Shttp://dx

36

ABSTRACT

Objective: Consumption of sugar-sweetened beverages (SSB) is linked to obesity. The authors hypoth-esized that school-based nutrition education would decrease SSB consumption.Design: Self-selected interventional cohort with random selection for pre and post measurements.Setting: Arizona Supplemental Nutrition Assistance Program–Education Program–eligible schools.Participants: Randomly selected (9%) fourth- and fifth-grade classroom students.Intervention: The University of Arizona Nutrition Network provided general nutrition educationtraining and materials to teachers, to be delivered to their students. The University of Arizona NutritionNetwork administered behavioral questionnaires to students in both fall and spring.Main Outcome Measure(s): Change in SSB consumption.Analyses: Descriptive statistics were computed for student demographics and beverage consumption onthe day before testing. Paired t tests evaluated change in classroom averages. Linear regression assessedpotential correlates of SSB consumption.Results: Fall mean SSB consumption was 1.1 (� 0.2) times; mean milk and water intake were 1.6 (� 0.2)and 5.2 (� 0.7) times, respectively. Beverage consumption increased (3.2%) in springtime, with increasedSSBs (14.4%) accounting for the majority (P ¼ .006). Change in SSB consumption was negatively asso-ciated with baseline SSB and water consumption but positively associated with baseline milk fat (P# .05).Conclusions and Implications: The results suggest the need for beverage-specific education toencourage children to consume more healthful beverages in warmer weather.Key Words: Supplemental Nutrition Assistance Program (SNAP-Ed), nutrition education, sugar-sweetened beverage, school, adolescent (J Nutr Educ Behav. 2015;47:36-43.)

Accepted August 2, 2014. Published online September 16, 2014.

INTRODUCTION

Childhood obesity remains a pressingpublic health concern in the US.Fifteen percent of US children aged6–11 years are obese.1 An additional30% of children are at risk of becomingoverweight or obese.2 Obesity is asso-

ent of Medicine, University of Arizoent of Nutritional Sciences, Universit

sity of Arizona Cancer Center, Tucsonsity of Arizona Cooperative Extension,of Nutrition and Physical Activity,, AZsity of Arizona Cooperative Extension,sity of Arizona Cooperative Extension,for correspondence: Jennifer W. Bea,24; Phone: (520) 626-0912; Fax: (520)OCIETY FOR NUTRITION EDUC.doi.org/10.1016/j.jneb.2014.08.004

ciated with early onset of type 2 dia-betes in youth3 and comorbiditiesthroughout the lifespan,4 which haveserious health implications for individ-uals, the medical and public healthsystems, and society.

There have been dramatic shiftsin beverage consumption patterns in

na, Tucson, AZy of Arizona, Tucson, AZ, AZNavajo County, Holbrook, AZArizona Department of Health Services,

Apache County, St. Johns, AZCochise County, Sierra Vista, AZPhD, 1515 N Campbell Ave, Tucson, AZ626-5348; E-mail: jbea@uacc.arizona.eduATION AND BEHAVIOR

Journal of Nutrition Education and Beh

the US in the past 30–50 years.Sugar-sweetened beverages (SSB)have gained prominence in variousforms including soft drinks, bothcarbonated and noncarbonated, fruitdrinks (not 100% juice), vitamin andother sugared waters, and energydrinks. Although SSB consumptionhas declined slightly since its peak in2000, consumption among youth isapproximately 2 times what it was inthe 1970s and SSB consumptiontriples between the ages of 2–6 and13–18 years.5 Limited data also sug-gest that unflavored milk intakeamong young children has declinedwhereas flavored (sugar-sweetened)milk and fruit juice have increased.6

These trends are clinically relev-ant because of SSB consumption linksto obesity through excess caloricintake,7,8 as well its displacement ofmore nutritive foods in an indivi-dual's diet.9 Emerging evidence also

avior � Volume 47, Number 1, 2015

Journal of Nutrition Education and Behavior � Volume 47, Number 1, 2015 Bea et al 37

demonstrates associations betweenSSBs and adverse cardiometabolicprofiles in children.10,11 These types ofoutcomes imply that an individual'sbeverage consumption patterns earlyin life may have lasting effectsthroughout the lifespan.6

Emerging research in the US andother nations suggests that reducingSSB intake at school and at homemay diminish excess weight gainamong youth.12 The largest per-centage (36%) of added sugars in theAmerican diet derives from soda,energy drinks, and sports drinks;thus, the US Dietary Guidelines forAmericans recommend limiting one'sintake of SSBs.13 Multiple calls toaction, particularly targeting low-income individuals, have been issuedin the US and other nations toattempt to address the problem ofexcess SSB intake in youth (ChildNutrition and WIC ReauthorizationAct of 200414; World Health Organi-zation 2010 resolution WHA63.1415),including reducing the availability ofSSBs in schools with the intent ofdecreasing obesity.16 However, littleis known about the impact of nutri-tion education on overall fluid intakein youth.

The aim of this study was to eval-uate change in beverage consumptionpatterns in fourth- and fifth-gradeclassrooms that qualified for theSupplemental Nutrition AssistanceProgram–Education Program (SNAP-Ed). It was hypothesized that generalnutrition education would result indecreased SSB consumption in favorof milk and water consumption.Correlates of SSB consumption wereexplored.

METHODSStudy Design

This study used a self-selected in-tervention cohort with random selec-tion for pre and post measurements.The researchers assessed change inbeverage consumption patterns afterperiodic general nutrition educationamong fourth- and fifth-graders.The cohort was defined as SNAP-Ed–eligible elementary schools thatpartnered with the University ofArizona Nutrition Network (UANN)to provide nutrition education at the

schools. The UANN uses the train-the-trainer model (TTT) model to pro-vide age-appropriate general nutritioneducation to teachers, administrators,and staff,13 as well as direct nutritioneducation to students by a profes-sional nutrition educator. The studywas limited to the partner schools in5 of 7 counties served by the UANNthat used the same delivery model,TTT, and logged nutrition educationhours with the UANN accordingto the national SNAP-Ed reportingrequirements for the Education andAdministrative Reporting System(EARS). The 2 excluded countieseither (1) employed direct nutritioneducation only or (2) had not yetobtained relevant tribal human sub-jects protection program approval.Other counties in the state, not servedby the UANN, either did not receiveSNAP-Ed services or received themfrom local health departments thatused diverse delivery models.

The TTT model provided teachers,administrators, and staff with statehealth department–approved train-ing, lessons, and materials. It guidedthem to integrate nutrition educationinto multiple school settings such asmath, reading, art, music, science,and other lessons; classroom, cafe-teria, and school-wide activities;signage, menus, and handouts; andclassroom or public address systemschool-wide announcements. TheTTT model was tailored accordingto the readiness of the school, teach-ers, and staff to maximize trainerimplementation. Educational mate-rials were derived from state healthdepartment–approved evidence-based curricula, individual lessons,presentations, handouts, and othersupportive educational tools in align-ment with the US Department ofAgriculture (USDA) guidelines. TheUSDA guidelines and tip sheets, aswell as the state-approved materials,included the recommendation thatintake of SSBs should be limited,13

but at the time of the study therewas no approved SSB-specific curri-culum or beverage-specific set ofactivities.

The frequency, intensity, and dura-tion of programming varied fromclassroom to classroom and schoolto school based on the tailoredapproach. On average, new materialsand lessons were provided to schools

on a monthly basis after a minimumof 1–2 hours of initial training. Thetypes of resources provided weregauged locally based on site readinessand the need for technical support af-ter the initial training and includedany or all of the resources or contacttypes listed in Table 1. Monthlyattempts to increase engagement andadvance services in schools that werein the initial stages of program imple-mentation were made via e-mail orphone. In an end-of-year sub-studyof 2 of the counties, 89% of educatorsconfirmed that they had receivedresources from their UANN programrepresentative at least once per monthduring the school year (unpublisheddata). Participating schools submit-ted hours dedicated to nutritionand nutrition-integrated physical ac-tivity monthly, in alignment withEARS topics. Topics tracked by EARSincluded: Fat Free and Low-Fat Milkor Equivalent (and alternative calciumsources); Fats andOils; Fiber-RichFoods;Food Shopping/Preparation; Fruits andVegetables; LeanMeat and Beans; LimitAdded Sugars or Caloric Sweeteners;MyPyramid/MyPlate–Healthy EatingPlan; Physical Activity Lesson/Demon-stration; Promote Healthy Weight; So-dium and Potassium; Whole Grains;Food Safety; Other–Breast Feeding;Other–Folic Acid; Other–All contentareas; Other–Hydration.

Once all participating classroomswere identified in the 5 countiesfrom historical time logs, the UANNrandomly selected 8% of fourth- andfifth-grade classrooms, with a mini-mum output of 2 classrooms perUANN county-level team forced intothe randomization model. The finalyield was 9% of UANN classrooms(n ¼ 46 classrooms) (Figure 1). Teach-ers in selected classrooms were invitedto participate in the administration ofa brief survey to children in theirclassroom.

Survey Instrument andProctoring

The Youth Nutrition and PhysicalActivity Survey combined validatedquestions from 2 age-appropriatesurveys with good validity andreliability. Nutrition questions wereadapted from the School PhysicalActivity and Nutrition survey, and

Table 1. Resources Provided Monthly to Participating Schools to Support Nutrition and Physical Activity Education

Resource/Contact Types Contents

Newsletter/e-mail � Lessons� Student worksheets� Information to build teacher nutrition and physical activity knowledge� Grant opportunities (to further their nutrition/physical activity mission)� Simple behavior change strategies targeted at teacher, staff, and

administrators� Links to additional online activities and resources� Recommendations to promote healthy celebrations in classroom and school

Trainings and technical support � Integration of nutrition education into classroom curricula� Evidence-based curricula (ie, Serving up My Plate, WE Can!)� University of Arizona Nutrition Network–sponsored teacher conferences/

workshopsMaterial distribution � Nutrition education reinforcement items (ie, water bottles)

� Recipe cards, newsletters, and fact sheets� Teaching toolkits for classroom

Promotions � By teacher request and program-driven initiative, such as Go for the Greens,Healthy Holidays, National Nutrition Month

Reporting � Nutrition education strategies included in monthly time log reminders� Booster trainings to reinforce nutrition education concepts

38 Bea et al Journal of Nutrition Education and Behavior � Volume 47, Number 1, 2015

physicalactivityquestions fromtheDayin theLifeQuestionnaire.17-21Nutritionexperts at the University of Arizonareviewed the combined survey (n ¼ 21questions) for content face validity,feasibility, and survey layout. It wastested for clarity and interpretationusing a convenience sample of 3recreation groups participating inUANN summer programs. Theprotocol, instructions, and scripts wereassessed with these pilot groups. Basedon feedback from teachers, staff, andparticipants, modifications were madeto the protocol and questions. Surveyswere then administered across Arizonaby the UANN staff or classroomteachers in the fall and spring (Octoberto December, 2011 and April to May,2012, respectively).

All proctors used the providedprotocol and script to ensure consis-tent survey administration acrossclassrooms. Children were informedthat the survey was anonymous andvoluntary; it could be filled out inpart, in full, or not at all; and that itwould not affect their grades in schoolor ability to participate in school orthe UANN program activities. Whenstudents stated that they had finishedtheir surveys or stopped working onthem, the surveys were collectedwith no attempt to review them forcompleteness during the proctoringperiod. Total administration timewas approximately 20 minutes. The

usual nutrition education supportedby the UANN was delivered duringthe interceding months via the TTTmodel. Support by UANN of nutritioneducation in all schools remained sta-ble regardless of study participationstatus.

Surveys were scheduled Tuesdaysthrough Fridays and none followed aschool holiday, to target reme-mbrance of a normal weekday. Allbehavior questions were phrasedsimilarly, referring to ‘‘yesterday,’’and had mutually exclusive multiplechoice answer options. For example,‘‘Yesterday, did you drink any regular(non-diet) soda, punch, Kool-Aid,sports drinks, or other fruit-flavoreddrinks? Do not count 100% fruitjuice.’’ Answer options for ‘‘yesterday’’included 0, 1, 2, and $ 3. Beverageconsumption frequency questionsincluded milk, water, and SSBs onthe prior day. The survey also evalu-ated type of milk consumed, classifiedas whole, 2%, 1% or fat-free, ornondairy milk. Non-drinkers andthose who did not know the typeof milk they consumed were alsocaptured. Students were queriedregarding fruit, vegetable, and whole-grain consumption. After-school acti-vity and physical education answeroptions were presented in 30-minuteincrements in a multiple choiceformat. Break times and transporta-tion to and from school had categori-

cal answer options of sit, stand, walk,or run for break and by walking,bicycle, bus, or car for transportation.They were classified by active vspassive for analysis. Recognition ofUS vegetable, fruit, whole-grain, andphysical activity recommendationswas measured.13 The University ofArizona Institutional Review Board re-viewed the study protocol and instru-ment and designated it as exemptbefore the initiation of the study.

Data Analysis

The researchers computed descriptivestatistics for student demographicsand beverage consumption on theprior day. Because of the anonymousnature of the questionnaires, pairedt tests were used to evaluate changein classroom averages between fall(pre) and spring (post) rather thanchange in individual behaviors.Models were weighted by the pre-survey class size. To assess correlatesof change in SSB consumption, regres-sion models were constructed by indi-vidual behavior and knowledgevariables. Individual variables associ-ated with change in SSB consumption,at P ¼ .2, were place in a backwardstepwise regression model together.The model with the greatest adjustedR2 value and significance is presented.Only surveys that were $ 90% com-plete were included in the analyses.

Figure 1. Consort diagram describing recruitment and enrollment of fourth- and fifth-grade participants in a survey of nutrition andphysical activity knowledge and behaviors. UANN indicates University of Arizona Nutrition Network.

Journal of Nutrition Education and Behavior � Volume 47, Number 1, 2015 Bea et al 39

Nodatawere imputed for skippedques-tions and questions with unintendedmultiple answers were excluded fromanalyses. To normalize data distribu-tion, milk consumption frequencywas transformed using the square rootandwater was log transformed. Signifi-cance was set at P < .05. Stata, version10.1 (StataCorp LP, College Station,TX, 2008) and SAS version 9.3 (SASInstitute Inc, Cary, NC, 2011) wereused for all statistical analyses.

RESULTS

Nearly three quarters of the fourth-and fifth-grade classrooms selectedfor participation completed the sur-vey process for both fall and spring(Figure 1). A total of 98% of the preand post nutrition education surveyswere included in the analyses. Atbaseline, 51% of the children were

girls (49% female at follow-up) and71% were fourth-graders. The meanage at baseline was 9.7 years (� 0.7years), which increased at follow-up(10.1 � 0.7 years; P < .001).

Mean frequency of SSB consump-tion on the previous day was 1.1 �0.2 times in the fall. Milk wasconsumed 1.6 � 0.2 times and waterwas consumed 5.2 � 0.7 times. Thefall sum of mean SSB, milk, and waterwas 7.8 � 0.9 times. In the spring,SSB and milk consumption frequencyincreased (P< .05) without significantchanges in water or total beverages(Figure 2). Table 2 demonstrates thesechanges relative to baseline value ofthe respective beverage (as a percent-age). The significant increase in SSBconsumption accounted for the great-est relative proportion of the overallchange in beverage consumption.Differences between counties were

observed for total beverage intake butnot for other categories (P< .05).Over-all, the prevalence of any amount ofSSB consumption increased betweenfall and spring (66.6% to 71.1%). Thisreflectedadecrease in those consumingno SSBs and those consuming SSBs 1time the prior day in the springcompared wit the fall (no SSBs: 33.4%to 29.0%; 1 SSB: 39.9% to 37.2%).Sugar-sweetened beverage consump-tion of 2 times (15.2% to 19.7%) and$ 3 times increased (11.5% to 14.1%).As a percentage of total beverageintake, milk was 20.2% at baselineand 20.6% at follow-up. Water was66.5% at baseline and 64.5% atfollow-up. The SSB intake was 13.4%at baseline and 14.8% at follow-up.

Table 3 lists correlates of change inSSB consumption over the surveyperiod. The final regression model ex-plained 57% of the variance. Several

Figure 2. Mean beverage consumption by category among Arizona fourth- and fifth-graders during the fall and spring.

40 Bea et al Journal of Nutrition Education and Behavior � Volume 47, Number 1, 2015

variables emerged as independentlypredictive of change in SSB consum-ption. Change in SSB intake was nega-tively associated with baseline SSBconsumption (P < .001) and waterconsumption (P ¼ .01) but was posi-tively associated with milk fat con-sumption (ie, type of milk selected)(P¼ .05). Change in SSB consumptionbetween fall and spring was positivelyassociated with accurate knowledge ofrequired vegetable intake for the agegroup and negatively associated withunderestimation of required fruitintake (P # .05).

DISCUSSION

The researchers hypothesized that gen-eral nutrition educationwould result indecreased SSB consumption in favor of

Table 2. Change in Mean Beverage ConsuConsumed)

Beverage Category

MilkWaterSugar-sweetened beveragesTotal beverage intake

*P < .05; **P < .01; aPost-survey averagedata weighted by pre-survey class size (SNote: The base unit is classroom (n ¼ 33)

milk and water consumption. Incontrast, nutrition education encom-passing thebreadthof theUSDArecom-mendations did not positively affectSSB consumption in this sample. Anon-significant increase in overallbeverage consumption between falland spring was driven by a significantincrease in SSB consumption. Increasedbeverage consumption in warmermonths isexpected,but increasedwaterintake is preferable.

These results are not unique. Regu-lar, unsweetened milk intake declinedand sugar-sweetened milk and fruitjuice consumption have increasedamong young children over the pastfew decades.6 Other studies haveshown over 50% of total beveragesconsumed by fourth- through sixth-graders were sugar sweetened22 and

mption by Category on Prior Day (Times

Change (%)a Pb

5.5 .03*0.2 .86

14.4 .01**3.2 .09

– pre-survey average; bPaired t test forAS, Proc TTEST)..

an approximate tripling of soda andfruit drink consumption betweenpreschool and high school years. Thesedata reinforce the window of opportu-nity for nutrition education in elemen-tary school–aged children. Althoughmore recent data demonstrate a correc-tive trend in SSB intake from the peakearlier in the century, children aged6–12 years still drink daily sodas(45%), fruit drinks (35%), and sportsdrinks (7%).23 If these data representeddifferent individuals, consumption ofcombined SSBs in 70% of the fourth-and fifth-grade children in the currentstudy is consistent with the NationalHealth and Nutrition Examination Surveyreport. In the current study, milk con-sumption was aligned with the recentUS estimates among children 6–12years of age (13 oz) if it is assumedthat milk consumed represented an8-oz serving size.23,24

This study explored correlates ofSSB consumption to aid in generatinghypotheses for future studies tar-geting SSB consumption and foundthat several baseline knowledge andbehavior variables were associatedwith change in SSB consumptionover the school year. These resultsdiffer from other published studies inthat observed associations wererelated to change in SSB consumptionrather than cross-sectional associa-tions, but the data were in alignmentwith cross-sectional findings. Forexample, baseline selection of higher-fat milk, an energy-dense food, wasassociated with increased SSB con-sumption over the year, which isconsistent with prior research showingthat energy-dense food consumptiontracks with higher SSB consumption.8

Cullen et al22 found similar positivecorrelations between fourth- throughsixth-grade SSB consumption andhigh-fat vegetable consumption, aswell as negative SSB associations withfruit consumption. In the currentstudy, change in SSB consumptionwas not associated with fruit consump-tion in itself, but it was associated withknowledge of the guidelines for fruitand vegetable consumption.

In addition to comparisons withother studies, the strengths andlimitations of this study should beconsidered when interpreting theresults. Multisite, random selectionof the UANN participating classroomsin diverse regions was a strength of

Table 3. Knowledge and Behavior Characteristics Among Arizona Fourth- and Fifth-Graders Regressed on Change in Sugar-Sweetened Beverage Consumption

Independent Variables Standardized b Coefficient P

Gradea �0.058 .65

Baseline knowledge of US Department of Agriculture recommendationsb

Accurate vegetable intake (%) 0.307 .04*Underestimated fruit intake (%) �0.336 .01**Underestimated physical activity (%) 0.266 .10

BehaviorsMilk fat, baseline (%) 0.251 .05*Sugar-sweetened beverage consumption, baseline (times) �0.518 < .001**Change in water (times) �0.431 .01**

*P # .05; **P # .01; aForced into the model, which was weighted by baseline class size (weighted least squares; n ¼ 33);bPercentage of classroom.Note: Adjusted R2 ¼ .57.

Journal of Nutrition Education and Behavior � Volume 47, Number 1, 2015 Bea et al 41

the study, which supports generaliz-ability across Arizona fourth- andfifth-graders. Another strength of thestudy was the reading and compre-hension level–appropriate surveyinstrument. Limitations includedmodest sample size (n ¼ 33 class-rooms) and age range; combinedbeverage consumption categories onthe survey instrument; difficulty inidentifying 100% juice drinks amongyouth; insufficient detail in the educa-tional logging system; and the lack ofcontrol groups. The study did notinclude control groups, to eliminatedelay or withholding of entitlementservices in qualified schools and toavoid introducing gross demographicdifferences in non-qualifying schools.The delay of services in some schoolsor use of non-qualifying schools ascontrols is a relevant option, but itcan be difficult to fund such a study.The following study limitations maybe viewed as strengths: Lack of servingsize information is a limitation, yetelementary school children have diffi-culty identifying serving sizes withoutparental assistance. Flexible program-ming also may be considered a limita-tion, but it allows programming to betailored to school and trainer readi-ness, which has previously improvedadoption and adherence to approvedcurriculum in the state.

IMPLICATIONS FORRESEARCH ANDPRACTICE

A significant proportion of youth sur-veyed in this study demonstrated

inadequate milk and water intakeand SSB consumption $ 2 times on atypical day. These results suggest aneed for beverage-specific education toshift beverage consumption patternsamong children and diminish thecontribution of SSBs to daily caloriesand added sugar,8,9,23,24 with attentionto potential racial/ethnic and so-cioeconomic disparities.8,22,25-27 Al-though SSB associations with weightstatus and other health outcomes havevaried across studies,28 addressing SSBconsumption in youth has limitedpotential harm and has great potentialto affect long-term consumptionpatterns,29 increase diet quality,30

manage weight and body composi-tion,7,9,12,29,31-36 and affect lifelonghealth.6,37

Evidence suggests that reducingSSB availability in schools, withoutcomplementary strategies, does notalter overall intake.38 One tactic hasbeen to educate children about theenergy and sugar contents of allbeverages39 in addition to the typicalnutrition education. In addition, theparental characteristics, environment,and dietary component influenceson SSB consumption patterns notedby others22,40 may be consideredin future research, particularly whenengaging in public health app-roaches. The new SNAP-Ed guidance41

explores various public health ap-proaches that may be used to manageSSB consumption in schools, homesettings, and elsewhere24,37,42 in con-junction with other stakeholders atschools and school districts, in-cluding parents and communityleadership. Comprehensively testing

beverage-specific curriculum, inter-ventions, andpublic health approacheswould facilitate the appropriate expan-sion of evidence-based practices thatbalance SSB consumption with morehealthful practices in schools and othersettings.

Future research instruments couldexpand beverage categories andcollect climate information to garnermore detailed beverage informationand control for seasonality. More pre-cise recording of SSB-specific teachingtime would allow for estimation ofdose in the absence of control groups.The EARS system is slated for revisionin 2017 with opportunity for publiccomment, which may provide theability to better capture the TTTmodel inputs and SSB-specific educa-tion time with students and parents.Finally, measurement of height andweight simultaneous with surveyswould further advance research toevaluate associations betweenbeverage consumption patterns andweight status among low-income in-dividuals.

Overall, this study suggests theneed for beverage-specific education,in conjunction with general nutritioneducation, to encourage more health-ful choices. Further research is neededto assess beverage consumptionpatterns longitudinally and assessSSB-specific interventions in schoolsand other settings.

ACKNOWLEDGMENTS

This work was made possible byUSDA grant HI050073 SNAP-Ed and

42 Bea et al Journal of Nutrition Education and Behavior � Volume 47, Number 1, 2015

National Institutes of Health grant5P30CA023074 from the NationalCancer Institute. The contents of thisarticle are solely the responsibility ofthe authors and do not necessarilyrepresent the official views of theUSDA or the National Institutes ofHealth. The University of ArizonaNutrition Network thanks the teach-ers, staff, administrators, and studentsof participating schools and class-rooms across Arizona.

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