Nutrition Friendly Schools and Communities Model to Prevent Overweight in Children

1. Nutrition Friendly Schools and Communities Model to Prevent Overweight in Children Stephanie Vecchiarelli, Project Director Dr. Charlotte Neumann, Principal Investigator Dr. Mike Prelip, Co – Principal Investigator Dr. Wendy Slusser, Co – Investigator Aurora Cerda, School Liaison Sue LaVaccare, School Liaison Dr. Linda Lange Heather Weightman University of California, Los Angeles School of Public Health

2. Workshop Goal To introduce workshop participants to the Nutrition Friendly Schools and Communities (NFSC) model and facilitate a walk-through of the participatory action research (PAR) methodology in order to gain an understanding through active participation of the participatory action research method (PAR) used to develop the NFSC model.

3. Workshop Objectives Understand the NFSC environmental intervention to prevent/reduce childhood overweight. Identify the process which a school can take to meet the NFSC criteria. Demonstrate and apply the NFSC process to participants’ school/community environment.

4. Scope of Overweight Problem Over 1 billion adults, globally, are overweight (BMI > 25) with about 300 million of these adults considered obese (BMI > 30). It is estimated that 17.6 million children under 5 are overweight.

5. Why Increase in Overweight and Obesity? Increased energy intake and decreased physical activity resulting from: Modernization Globalization of food markets Economic growth Urbanization Marketing Use of automated transport Technology in the home Increase in passive leisure pursuits

6. Consequences of Overweight and Obesity Health related consequences include: increase in type 2 diabetes, cardiovascular disease, hypertension, stroke, and some cancers. Accounts for 2% - 6% of total health care costs in several developed countries.

7. Why Schools? Worldwide, the majority of children attend school for part of their childhood. Children must be healthy in order to learn. Schools that successfully combine instruction, health services, and a healthy school environment can improve not only the education, but also the health of future generations. The school has almost as much influence as family and educating children to make wise decisions and prevent the behaviors that lead to mortality and morbidity is a wise option for schools and communities to maintain a productive educational and social environment. The school community involves a variety of stakeholders including parents, teachers, staff, and students that can work together to influence and improve the health of all students.

8. Nutrition Friendly Schools and Communities Model Adapted important steps and concepts from the Baby Friendly Hospital Initiative and the Coordinated School Health Model.

9. Baby Friendly Hospital Initiative (BFHI) United Nations Children’s Fund and the World Health Organization collaborative launched in 1991. Aims: To increase breastfeeding rates. To encourage an international standard for maternity lactation services through evidence based Ten Steps to Successful Breastfeeding.

10. BFHI Process of Certification includes: Self-appraisal. Changes made to address gaps/deficiencies in meeting the criteria. Assessment of hospital from external trained assessors.

11. BFHI Over 16,000 hospitals worldwide have been designated as Baby Friendly. Reports in the literature demonstrate that hospitals with the Baby Friendly designation have: higher breastfeeding rates subsequent lower morbidity, mortality and cost savings.

12. Coordinated School Health Model (CSHM) Nutrition Education Physical Education School Health Services School Food Services Family and Community School Environment-Administration and Policy Staff Wellness School Psychosocial Services

13. CSHM

14. NFSC Goals Create and sustain healthy school environment Improve eating habits Increase physical activity Build capacity/Participatory Research Improve healthy eating and physical activity with long-term goal to decrease/prevent childhood overweight .

15. NFSC and WHO Global Strategy on Diet, Physical Activity and Health

16. Identify stakeholders Meeting/work groups Delphi survey 15 Steps Evidence-based verification review Self-assessment tool development

17. 15 StepsSM 1. School has written physical activity and nutrition policies. 2. School administration supports efforts to promote healthy eating and physical activity among all school community stakeholders. 3. There is collaboration throughout the school community regarding nutrition and physical education. 4. School has a standardized nutrition education curriculum integrated into other school subjects. 5. School Food Service provides healthy foods adhering to the USDA recommendations.   6. School staff and students have input into school meal planning. 7. School has a physical education curriculum/program that is adhered to by a minimum of 80% of eligible staff.    

18. 15 Steps 8. A minimum of 85% of classroom participate in a minimum of 20 minutes of moderate to vigorous daily physical activity. 9. The school has one nurse for every 750 students. 10. School Health Services identifies and refers students with nutrition and physical activity issues. 11. School has a staff wellness program. 12. School staff is committed to serve as role models for healthy behavior. 13. School includes family and community members in nutrition education and physical education. 14. Family and community members actively promote healthy eating and physical activity.   15. School Psychosocial Services supports healthy eating and physical activity.

19. NFSC Process Introduction to staff Recruit NFSC committee members Conduct self – evaluation Develop implementation plan Implement plan Monitor progress through ongoing data collection UCLA providing technical assistance

20. Study Schools East Los Angeles (4 intervention, 1 control) 3,946 students 2 year round, 2 traditional 87 – 100% students on free/reduced meals Majority (98%, est.) Latino students Spanish language spoken West Hollywood (4 intervention, 1 control) 1,630 students All traditional calendar Some students bussed from East Los Angeles Korean, Spanish, Chinese, and Russian languages spoken 64 – 91% students on free/reduced meals

21. NFSC Data Collection Instruments developed Pilot test instruments and procedures Refine instruments Schedule schools Collect baseline student and adult measures On-going collection of process measures. Collection of post – intervention student and adult measures

22. NFSC Data Collection Student 24 hour food recalls, height, weight, triceps skin fold, nutrition and physical activity knowledge and attitudes Adult nutrition and physical activity knowledge, attitudes, and behaviors Student level academic measures including test scores, attendance School measures including attendance, test scores, discipline records, nurse records School environment measures Process measures baseline and post - intervention

23. Sample Demographics Students 802 students Predominantly Hispanic/Latino, Multiracial, and African American Distributed evenly in 3rd – 5th grade, and geographically. Majority 8, 9, 10, and 11 years old. Adults 441 adults Predominantly Latino/Latin American, White, African American, and Multiracial Over half have Bachelor’s degree or higher, over 1/5 did not complete high school Distributed evenly geographically, and by type (parent or staff)

24. Preliminary Results – School Environment School self – evaluation – 15 Steps Step 1 (Policies): 62.5% No; 12.5% Partial; 25% Yes Step 2 (Administration): 62.5% Partial; 37.5% Yes Step 3 (Collaboration): 62.5% Partial; 37.5% Yes Step 4 (Nutrition education): 62.5% No; 37.5% Partial Step 5 (Food service): 37.5% Partial; 62.5% Yes Step 6 (Input into meals): 75% No; 25% Partial Step 7 (P.E. curriculum): 50% No; 12.5% Partial; 37.5% Yes Step 8 (Physical activity): 37.5% No; 50% Partial; 12.5% Yes

25. Preliminary Results – School Environment Step 9 (Nurse): 25% No; 12.5% Partial; 62.5% Yes Step 10 (Health service): 37.5% No; 12.5% Don’t Know; 25% Partial; 25% Yes Step 11 (Staff wellness): 100% No Step 12 (Staff as role models): 12.5% No; 75% Partial; 12.5% Yes Step 13 (Family & community): 25% No; 62.5% Partial; 12.5% Yes Step 14 (Family & community): 12.5% No; 75% Partial; 12.5% Yes Step 15 (Psychosocial services): 37.5% No; 12.5% Don’t Know; 12.5% Partial; 37.5% Yes

26. What Are Schools Doing to Meet the 15 Steps?

27. What Are Schools Doing to Meet the 15 Steps?

28. What Are Schools Doing to Meet the 15 Steps?

29. Preliminary Results - Students BMI 28.36% Overweight; 18.95% “At-risk” for overweight = 47.31% Physical Activity 180 minutes/day of physical activity including activity before, during, and after school Sedentary Activity 197 minutes/day of sedentary activity including watching TV, movies, playing video games, or using the computer

30. Preliminary Results - Adults BMI (based on self – reported height and weight) 29.26% obese and 27.93% overweight = 57.19% Compared to: 64.5% nationally, 54.4% California, and 55.5% of Los Angeles County Activity Participated in physical activity an average of 18.49 minutes per day.

31. Barriers to Improving School Nutrition and Physical Activity Environment Staff overwhelmed – too many mandates Funding Lack of time Not a priority Lack of collaboration among school community Use of “junk food” as fundraiser Lack of training in PE

32. Facilitators to Improving School Nutrition and Physical Activity Environment Funding Dedicated and committed school community UCLA Staff – part of community, flexibility, respectful Clustering Resources Building on existing teacher work

33. Participants One group review 15 Steps and adapt to be used globally. One group review self – evaluation tool for their school/agency. One group develop implementation plan based on self – evaluation.

34. Report Back Group 1 Group 2 Group 3

35. References Barrington-Ward, S. (1997). Putting babies before business. Nutrition Commentary: The Progress of Nations., from www.unicef.org/pon97/14-21.pdf Braun, M. L. G., Giugliani, E. R. J., Soares, M. E. M., Giugliani, C., Proenco de Oliveira, A., & Danelon, C. M. M. (2003). Evaluation of the impact of the Baby-Friendly Hospital Initiative on rates of breastfeeding. American Journal of Public Health, 93(8), 1277-1279. Chopra, M., Galbraith, S., Darnton-Hill, I. (2002). A global response to a global problem: the epidemic of overnutrition. Bulletin of the World Health Organization, 80(12), 952-958. Dodgson, J. E., Allard-Hale, C. J., Bramscher, A., Brown, F., & Duckett, L. (1999). Adherence to the ten steps of the Baby-Friendly Hospital Initiative in Minnesota hospitals. Birth, 26(4), 239-247. Marx, E., Wooley, S. F., & Northrop, D. (1998). Health is academic : a guide to coordinated school health programs. New York: Teachers College Press. O'Rourke, T. (1996). A comprehensive school health education program to improve health and education. Education, 116(4), 490-495. Philipp, B. L., Merewood, A., Miller, L. W., Chawla, N., Murphy-Smith, M. M., Gomes, J. S., et al. (2001). Baby-friendly hospital initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics, 108(3), 677-681. United Nations Development Programme. (2003). Human Development Reports. Retrieved March 31, 2004 from, www.hdr.undp.org/reports/global/2003/indicator/index.html. World Health Organization. (2003). Obesity and Overweight Factsheet. World Health Organization Global Strategy for Diet, Physical Activity, and Health.

36. Contact Information Stephanie Vecchiarelli, MPH, CHES University of California, Los Angeles School of Public Health Box 951772 Los Angeles, CA 90095-1772 310-267-2946, 310-794-1805 (f) stephv@ucla.edu