Transcript NO TIME FOR TURF - American Academy of Pediatrics

The Perfect Pair:
How Schools & Pediatric Health Care
Professionals Can Work Together to Address
Obesity Prevention
Thursday, May 25, 2006
10:00 am to 11:30 am PST
11:00 am to 12:30 pm MST
12:00 noon to 1:30 pm CDT
1:00 pm to 2:30 pm EST
Howard Taras, MD, FAAP Robert Murray, MD, FAAP
J. Gary Wheeler, MD, FAAP
As a Result of Today’s Presentation You
will be able to Identify:
 Who you need to know
 The key decision makers and players and their
power in schools and school districts
 What you need to know
 The touch points for nutrition and physical activity
in schools
 Why you need to know it
 The experiences of one pediatrician in his
partnership with schools
Physicians’
recipe for
success when
working with
schools:
Learn the culture!
Howard Taras, MD, FAAP
University of California, San Diego
Division of Community Pediatrics and School Health
Why Work with Schools?
 Larger impact
 Ultimately save time
 Image of physicians
and image of your
practice
Children grow up
In 3 environments
HOME
COMMUNITY
SCHOOL
Schools are a
Another “Home”
 55 million students in U.S. schools
 35-40% of daily calories from food are
consumed at school;
 12,000 hours spent in school by graduation
provides unique opportunity to influence:
 what children know about nutrition and activity and
bring home
 the calories consumed and burned while at school.
French, Am J Pub Health 2003; 93:1161
Importance of Knowing
how Schools & Districts
Work
 Take care to not over-simplify
 Knowledge of system helps your
efforts achieve maximum efficiency
and impact
Who Does What?
Governor
State level
Legislature
State board of education
Chief state school officer
State education agency staff
School board
School district
level
Local government
Superintendent
Central office staff
School level
Principal
School staff
School Improvement Council
Structure of Educational
System -- 101
 Districts vary considerably in size
 School Boards: Responsible for:
vision, budget choices, policies
within state/federal laws, (curricula)
Structure of Educational
System -- 101
 Superintendents: Hired by school
board; provide leadership; translate
board policy to actual operations
Structure of Educational
System -- 101
 Principals supervise school
programs in their school and enforce
regulations.
 Some have discretion over:
schedules, curriculum, food
services.
 Key gatekeepers; support is crucial
Structure of Educational
System -- 101
 Food Service Directors:
 Day-to-day decisions on: school lunch,
breakfast, cafeteria staffing, food
safety, food environment.
 Responsible for being within budget
and complying with regulations
 Varying influence on vending contracts
and school advertisements
Structure of Educational
System -- 101
 The School Nurse:
 Most natural “ally” and point of entry
for a physician into schools.
 Role varies. Sometimes only one
nurse per entire school district (or less)
 Sometimes one full-time nurse in a
school.
Structure of Educational
System -- 101
 Governors propose budgets, programs
 State legislatures make laws that govern school
budgets
 State Boards of Education set education goals
and standards, identify adoptable textbooks
 Also at state level: Dept of Ed; Chief state school
officer
 Federal Level (USDA, other federal funds)
To Get Started:
Take a Good History!
 Recent efforts to change curricula?
Food choices? Phys Ed?
 Are there existing mandates for food, PE,
health ed? Are they followed?
 Are there model school programs within
district or similar district nearby?
 Who are your allies within and outside of
school system?
Think about your desired
and perceived role(s):
 Purely an Advocate?
 Provider of sound expert advice to
educational policy-makers?
Avoid exaggeration
Seek and quote evidence
Think about your desired
and perceived role(s):
 Paid consultant to school?
 Advising an advocating coalition?
 Worker-bee?
 Spokesperson for School? For a Coalition?
 Evaluator / Research?
(See references)
“Coordinated School Health”
8 component Model
Community Input into
School Health Programs
 School Wellness Councils
 School Health Advisory Councils
School Administrators:
What do they perceive to
be their responsibility to
student health?
Administrators’ Goals for
School Health
1. “I would like to improve health, but it’s
secondary to educational goals. My
schools will close or lose funds if we
don’t improve literacy rates. I cannot
add recess and PE.”
2. “Costs of hiring new staff to teach
health or PE are high. And it is difficult
with teacher contracts to change that
decision if funding decreases.”
Administrators’ Goals for
School Health
3. “I simply want to send each child
home in a condition no worse than
how they arrived at school”
Administrators’ Goals for
School Health
4.
“I know achievement will improve with
school health programs. But I have too little
time and resources to operationalize these
programs.”
5.
“There is no sense in teaching these children
to be educated and productive citizens, if
they will not live long enough to use these
skills.”
Administrators’ Goals for
School Health
6.
“My students have little access to outside
health care. So, I must provide those
services at school. Students need to be well
to do well.”
7.
“Yes, student health is important. But it is
the public and private health sectors who
must take care of it” (either within or outside
of schools).”
Physicians Need Schools
to
Battle Obesity
Robert Murray, MD, FAAP
Professor of Pediatrics
Director, Center for Healthy Weight & Nutrition
Children’s Hospital
The Ohio State University
Columbus, OH
Kids & Energy-Dense,
Nutrient-Poor Foods
 EDNP foods = >30% of daily energy
 Total daily calories
increased
 Energy from carbohydrates
increased
 Energy from fat
increased
 Displace: Protein, fiber, vitamins, folate, calcium,
magnesium, iron, zinc
Kant Arch Ped Adol Med 2003; 157:789
Children are Overfed
But Undernourished
% Children
Consuming
Daily
Recommended
Intake
Critical
Age
120
100
80
Iron
Phosphorus
60
Zinc
Vitamin C
40
Vitamin A
Magnesium
Folate
Calcium
20
0
6-11 Mo.
1 Yr.
1-4 Yrs.
5-8 Yrs.
9-14 Yrs.
Data compiled by Dr. John Lasekan, Ross Labs
from NHANES 1999-2000 and the Continuing Food Survey 1994-96, 1998
15-19 Yrs.
The USDA Meal Programs
 The National School Lunch Program
 School Breakfast Program
 Summer Food Service
 After-School Snacks
 Special Milk Program
 Child and Adult Care Food Program
Nutritional Contributions of
School Breakfast Program
 Greater energy/ day
 Vit C
 Phosphorus
 Calcium
 Magnesium
 Riboflavin
 Fiber
Energy and micronutrients not consumed in SBP
are not made up over 24 hrs in non-participants
Eating a School Lunch
Promotes Better Nutrition
 Twice the servings of fruits and vegetables
 Higher intake of milk
and dairy
 More meats
 More grains
 More vitamins and minerals
The impact holds true for lunch
and also for 24-hour intake
USDA Food and Nutrition Report No. CN-01-CD1
School may be the Only Place a Child Learns
Portion & Proportion
How the School Lunch
is Balanced
 Must meet the recommendations of Dietary
Guidelines for Americans
 No more than 30% fat / 10% saturated fat
 Provide 1/3 RDA for:
 Protein
 Iron
 Calories
 Calcium
 Vits A &C
 Local school decides which foods and how to
prepare them
Free* and Reduced** Price
Lunch
Meal
Free
Reduced
Paid Lunch
Breakfast
$1.27
$0.97
$0.23
High need
$1.51
$1.21
$0.23
Lunch
$2.32
$1.92
$0.22
High need
$2.34
$1.94
$0.24
Supplemental cash/commodities worth 17.5 cents per meal
Commodities
Supports American farmers
60% from surplus food stocks
Comprise 20% school food, totaling 1.1 billion pounds
States each select and administer commodity items
*Free = <130% of poverty, **Reduced=130-185%
What New USDA Regulations
Might Improve the NSLP?
 Adjust to the new Dietary Guidelines for Americans
 Ease total fat restriction to 35% of calories
 Restrict saturated and trans fats
 Use more beneficial fats (MUFA/ PUFA)
 Emphasize whole grains and fiber
 Encourage more fruits, vegetables and dairy
 Adjust commodities to aid the food service
 Create national standards for competitive foods
Food Choices at School Go
Way Beyond the USDA
Programs
HEALTHY
FOOD
ZONE
A la Carte Sales
School Parties
Fundraisers
School Stores
Vending
Boosters
Athletics
Student Clubs
Federally
Regulated
School Meal
Programs
Foods of Minimal Nutritional
Value
 Defined: < 5% of RDA per serving of any of 8 nutrients
 4 categories of prohibited foods:
 Soda
 Water ices
 Chewing gum
 Certain candies






Hard candy
Marshmallow
Jellies & gums
Taffy
Licorice
Spun candy
 Candy-coated popcorn
 Cannot be sold in school food service areas during the meal
Schools have few options
to enhance revenue
1.
Increase the number of federal
meals
2.
Increase the price of full-paid
meals
3.
Expand a la carte and catered
items

In one study the total revenue
from a la carte = 43% of sales

90% of schools offer an a la
carte lunch

School Meal participation is
inversely related to a la carte
sales
Top 10 Foods in High School
A la Carte Lines
 Fresh fruit
100%
 Cookies
98%
 Skim milk
98%
 Whole/ 2% milk
96%
 Chips
87%
 Pizza
77%
 Juice drinks
75%
 Doughnuts
72%
 Sandwiches
72%
 Snack cakes
64%
Story et al, JADA 1996; 96:123
A la carte Foods
Hamper Nutrition
 Non-participants in NSLP consume 3x
more sugars (21% vs 64%)
 Top sellers: pizza, chips, soda, french
fries, candy and ice cream
 Access to a la carte and snack bar meals
 lower fruit, vegetable and milk
 higher sweetened beverages and fried veggies
Cullen, Am J Pub Health 2004; 94:463
Soft Drink Contracts are
Common in School
 School Health Policies and Programs Study (SHPPS)
 Surveyed 51 state education agencies, 523 school
districts, 841 school food service, and 927 schools
 School Districts
 33% allowed advertising in buildings
 50% had soft drink contract
 80% gave the school a share of sales
 Student access to soft drinks
 58% elementary, 83% middle, 93% high schools
 70% had access during lunch
Wechsler et al, J Sch Health 2001; 357:505
Teens consume
an average of
2 cans per day
(300 calories and
20 tspns of sugar)
So soft drink
contracts in
Schools…
… are a concern for
the American Academy of Pediatrics
Committee on School Health Policy Statement, Pediatrics, Jan 2004
Soft Drinks In School
The AAP Policy Statement
 Pediatricians should work to eliminate
sweetened soft drinks in schools
 Offer water, milk, veggie & 100% fruit juices
 Speak to school boards, superintendents,
teachers and students – promote nutritious
vended and a la carte foods
 Serve on school health advisory councils
The American Beverage Association withdrew
sweetened soft drinks from school contracts – 5/3/06
Recess Before Lunch
Simple Policy Solutions
 67 kids
Grades 1-3
 Plate-waste pre-/post Milk: 38.9% vs 27.6%
 Meat: 35.3% vs 21.1%
 Vegs: 53.2% vs 24.8%
 Fruit: 18.3% vs 14.7%
 Bread: 30.5% vs 25.%
Overall waste fell from 34.9% to 24.3% of food offered
Not Just Physical
Education
Physical Fitness
 Fitness activities daily
 Active recess
 Physical Education
 After-school programs
 Intramural programs
 Community/ School
recreation programs
 Summer programs
In 3-4th grade PE the average
time spent in continuous
movement was 2 minutes
Promote After-School Programs
Sleep
Screens
School
A high school grad has spent
over 15-18,000 hrs on TV &
only 12,000 in school
The Neighborhood
Playgrounds
After School Programs
Recreation & Community Centers
Greenspaces Gardens
Skate-board parks
Bike and Hike trails
Community Service Clubs
A Planned Community
An Open Invitation to
Physicians
Child Nutrition Reauthorization 2004
Title IV: Child Obesity Prevention Through Nutritional Quality
 Establishes school wellness policies by Fall, 2006
 Food service director is responsible for all foods on campus
 All foods, nutrition education, physical education, activities,
environment
 Creates a wellness advisory council – an opportunity for
physicians
What’s in a
School Wellness Policy?
 District aims
 Contracted services
 A Wellness Advisory
Council
 Vended foods
 School Food Service
Director
 Food environment
 Nutrition and Physical
Education
 Foods on campus
 Commercial contracts
 After-school programs
 Recess
We can achieve Healthy People 2010
goals only if school policies are
aligned
One Ideal School
Day
 daily school
breakfast
 teens start late
 no soda in class
 recess before lunch
 science-based nutrition
policies
 vending policy
 daily fitness activities
 strong NSLP
 phys ed: fitness goal
 no “open schools”
 after-school program
 high nutrient foods
 p.m. recreation
 subsidize key foods
Should School Health
Programs be Evidence-based?
Health Education Programs:
 Evidence-based programs are critical.
 Avoid mistakes of teaching classes, and
creating your own curricula.
Should School Health
Programs be Evidence-based?
 Interactive
“skills-based”
 Taught by
trained
educators
Should School Health
Programs be Evidence-based?
Recommend those health education
programs where:
 Program’s effects are researched
 Feasibility is researched
 Family involvement
 Coordinated with other school areas
 “Sequential”
Should School Environment
Changes be Evidence-based?
 Changing one school environmental factor may do
more to improve diet or activity than another factor;
 But, this degree of benefit is not readily available.
 Generally accepted to improve school
environment, without evidence.
Changing Environment /
Opportunities
 eg. “Walking
School Bus”
 helps students in
un-safe
neighborhoods
WALK to school
Should School Health
Programs be Evidence-based?
 Environmental
Changes:
 eg. change in vended
foods;
 eg. availability of
aerobic exercise.
Lessons from the Trenches
J. Gary Wheeler, MD, FAAP
Co-Director
Center for Health Promotion
UAMS/COM
Little Rock, AR
School Pressures
 Dollars
 Time
 Performance Measures
 No Child Left Behind
Level of Contribution
 Health Expert
 School, district, state, national
 Policy Advocate
 AAP
 Academic
 Non-profit collaborative
Humility
 Start small
 Get to know the problems before you
try to fix them; they are more complex
than your realize
 Volunteer to teach a health class
 Assist in health screens, School Health Index
 Function as a consultant to a school nurse
Respect
 Be aware of the
professional world you
are entering and respect
the commitment of these
professionals
 Learn what you do not
know
Relationships
 Earn your relationships
 Invest for the long haul
 Find out what they need, not what you want to
give: they have more than enough work to do.
They love it if you can do some of it.
 Never burn a bridge
Collaboration
 Services
 Funding/Grants
 Public relations
 Research
Examples
 Elementary School
 Health screenings
 Technology for grants
 Playground equipment (safety and phys activity)
 Consultant to school nurse
 Take care of the Governor’s child
 Oversee the child of the Speaker of the House in your lab
 Met the district school nurse coordinator
Examples
 Middle School
 NAA award: component for community
 White paper/Academic partners
 State policy board (health think tank)
 State partners
 Governor runs marathon/pediatrician runs ¼ marathon
 Act 1220: stars line up
 BMI, NPAACs, Vending
Examples
 High School
 School District NPAAC co-chair
 Partnered with agency and state chief medical officer
 Governor reverses position on soft drinks
 Governor and President Clinton broker deal with soft
drink industry
Nutrition and Physical
Activity Advisory Committee
 Curriculum reform
 Understand the school day
 Best resources are teachers and principals
 How to integrate recess and Phys Activity and
Nutrition education reform
 Beware of certification issues
 Vending contracts
Nutrition and Physical
Activity Advisory Committee
 USDA guidelines may not be standard of care.
 Academics vs regulatory world
 Rules/habits
 4% milk
 Money is the root of most behaviors
 If it costs money, it’s going to be tough to get approved
 Salaries are huge (physical activity agenda)
 Competitive foods (competition between needs)
Nutrition and Physical
Activity Advisory Committee
 Public relations
 Public (now highly educated) is quick to recognize the
unhealthy environment in schools, aesthetics are big
 Professionals from the community can have great
influence through partnerships
 Advocate from within
 Physical plant
 School cafeterias and free meal lines are dungeonesque
 Physical activity opportunities are limited
Nutrition and Physical
Activity Advisory Committee
 Be prepared for inertia from key individuals
 They have earned it
 Learn how to challenge and partner one’s way
to negotiation
 Righteousness doesn’t usually work
Some possible next steps…
 Visit www.schoolhealth.org to check out some
additional resources
 Contact your Action for Healthy Kids state team
to find out how you can help http://www.actionforhealthykids.org/state.php
 Get in touch with the local wellness council at
your child’s school to find out what your local
district or school is doing
Useful References
 “Health, Mental
Health and Safety
Guidelines for
Schools”
 Purchase at AAP
publications;
www.aap.org
 Information also on internet:
www.nationalguidelines.org
“How Schools Work
and How to Work
With Schools”
Order at:
www.nasbe.org
Useful References
Obesity and student performance at
school. Journal of School Health 2005; 75(8):291-295.

Taras H, Potts-Datema W.

Taras H, Potts-Datema
W. Childhood asthma and student
performance at school. Journal of School Health 2005; 75(8):296312

Taras H, Potts-Datema W.
Chronic health conditions and student
performance at school. Journal of School Health 2005; 75(7):255266.
Sleep and student performance at
school. Journal of School Health 2005; 75(7):248-254.

Taras H, Potts-Datema W.

Taras H.

Taras H.

AAP Council on School Health.
Nutrition and student performance at school. Journal
of School Health 2005; 75(6):199-213.
Physical activity and student performance at school.
Journal of School Health 2005; 75(6):214-218.
School Health Policy & Practice.
American Academy of Pediatrics 2004. 6th Edition.