We recognize that schools must prioritize academic
achievement and that in the current school funding
climate, health is often perceived as secondary, at best.
However, results from this study and others indicate
that creative approaches that integrate curricular
and noncurricular school-wide efforts to promote
healthy behaviors among all students are worth the
investment. Examining the odds of achieving goal
or above on all 3 standardized tests for each of the
individual health assets, it appears that not having
a television in the bedroom, being at a healthy
weight and physically fit, being food secure, and
eating at fast-food restaurants 1 time or less per
week are the most important predictors of academic
achievement in this study. Further, children who
drink less soda and other sweetened drinks, are
emotionally healthy, have quality sleep, feel safe in
their neighborhoods, and are also significantly more
likely to achieve goal on standardized tests. But beyond
each individual health asset, it appears that any and
all additional health-promoting effort cumulatively
impacts academic achievement. Individual targeted
initiatives may be insufficient to promote change;
therefore, we must advocate against diffusion of
responsibility (eg, just taking soda machines out of
schools won’t impact health or grades, so why bother)
and for a more comprehensive approach.
Solutions must take a systems-oriented, multilevel
framework that recognizes the importance of interventions
and policies to alter contextual features in
schools, homes, and neighborhoods.48 Communityand
family-based efforts coordinated with comprehensive
school-based approaches may be essential
to reduce disparities in both health and academic
achievement. Many urban families sadly face the harsh
challenges of persistent poverty. Health and social disparities, including academic achievement, are
increasing. These disparities result in profound human,
social, and economic costs. Those of low socioeconomic
status, including low educational attainment,
as well as people of color, are more likely to get
sick from nearly all causes, and do so earlier in life,
thus adversely affecting quality of life and ability to
contribute to economic sustainability of families and
communities.49-51 We must recognize that improving
education, employment, and housing may also
be considered health-promotion strategies.52 Woolf53
suggested that correcting disparities in educationassociated
mortality could save 8 times as many lives
as those saved by top medical advancements and treatments.
Limitations and Strengths
There are several limitations of this study. First,
students were primarily poor and minority, and
therefore, results are not generalizable to all students
across the United States. However, this is also a
strength of the study insofar as they represent students
of greatest need. According to recent US data, of the
>48.5 million students in public school nationally,
46% are eligible for free/reduced-price lunch.54
Considering racial/ethnic background of public school
students nationally, 17.0% are Black, non-Hispanic
and 20.5% are Hispanic.54 Therefore, whereas results
of this study are not generalizable to all students, they
may certainly be generalizable to many students across
the United States.
Second, our measures were limited due to study
focus and considerations of student confidentiality and
burden. We were not able to include a comprehensive
dietary assessment, nor did we have indicators related
to other health risk behaviors (eg, substance use,
bullying) or family or school climate. Importantly, we
did not have any strong measures of social class such as
household income or occupation; we were limited to
a ‘‘proxy’’ measure of social class measured by free or
reduced price lunch.55 A priori, we wanted to create
an index that would be easy for schools to use and
interpret; therefore, we chose to dichotomize variables
according to national standards and recommendations
when applicable. However, this does reduce power by
restricting variability. Nonetheless, separate analyses
demonstrated the associations between health and
academic achievement remained significant when the
health index was categorized and when maintained as
continuous.