The School’s Role in Promoting Healthy Lifestyles

1. The School’s Role in Promoting Healthy Lifestyles Presented by: Gail C. Christopher, D.N. Vice President Office of Health, Women and Families Joint Center for Political and Economic Studies

2. Good diet and physical activity are vital pathways to life-long health, from promoting healthy growth and development in children to maintaining well-being and an optimal quality of life in seniors. (Joint Center Health Policy Institute and PolicyLink, “A Place for Healthier Living, Improving Access to Physical Activity and Healthy Foods, 2004)

3. Alarming Trends  Obesity in this country has reached epidemic levels  Poor diet  Lack of exercise or regular physical activity  Adult diseases are showing up in children (Joint Center Health Policy Institute and PolicyLink, “A Place for Healthier Living, Improving Access to Physical Activity and Healthy Foods, 2004” and Team Nutrition, USDA, Food and Nutrition Services “Changing the Scene, Improving the School Nutrition Environment,” September 2000) Health Policy Institute

4. Childhood Obesity • From the late 1970s to 2000, the percentage of school-age children (ages 6-11 years) that are overweight more than doubled from 6.5% to 15.3%. • During the same time period, the percentage of overweight adolescents (ages 12-19 years) tripled from 5.0% to 15.5%. (The Center for Health and Health Care in Schools, GWU, “Childhood Obesity,What the research tells us”) Health Policy Institute

5. Childhood Obesity • Obesity is impacting young people of Mexican and African American descent particularly. • 27.5% of Mexican male teenagers are reported as overweight • 26.6% of non-Hispanic Black young women are reported as overweight (National Center for Health Statistics. United States, 2002 with chartbook on trends in the health of Americans. Overweight children and adolescents 6-9 years of age, according to sex, age, race and Hispanic origin: United States, selected years 1963-65 through 1999-2000, Hyattsville (MD):2002. Table 71) Health Policy Institute

6. Health Consequences of Childhood Obesity: Type 2 Diabetes • As many as 30,000 children have Type 2 diabetes, a type of diabetes that was once almost entirely limited to adults. • Studies in U.S. link obesity in children and adolescents to an increase in Type 2 diabetes that can cause blindness, heart and kidney disease, and loss of limbs. (Team Nutrition, USDA, Food and Nutrition Services “Changing the Scene, Improving the School Nutrition Environment,” September 2000, and The Center for Health and Health Care in Schools, GWU, “Childhood Obesity, What the research tells us”) Health Policy Institute

7. Other Health Consequences of Childhood Obesity • High blood pressure • Found more commonly in obese children and adolescents compared to non-obese peers (Dietz WH. “Health Consequences of obesity in youth: childhood predictors of adults disease,” Supp. Pediatr. 1998 101(3):518-525; Must A & Strauss RS. “Risk and consequences of childhood and adolescent obesity,” Int J Obesity. 1999;23(Supp 2):S2-S11; and Freedman DS et al., “The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart Study,” Pediatrics, Vol. 103, No. 6, June 1999, pp. 1175-1182) • Sleep apnea • A study of 41 obese children found that one-thirdreported symptoms consistent with sleep apnea. (Mallory GB, et al., “Sleep-associated breathing disorders in morbidly obese children and adolescents.” J Pediatr, 1989;115(6):892-897) Health Policy Institute Health Policy Institute

8. Other Health Consequences of Childhood Obesity Mental health • Obesity has been associated with low self-esteem, which can lead to increased rates of loneliness, sadness, and nervousness and to more likely use of alcohol and tobacco. • Hispanic and white females showed significant decreases in self-esteem by ages 13 and 14 compared with non-obese Hispanic and white females. • Obese African-American young women did not show a similar decline. (Strauss RS. “Childhood obesity and self-esteem. Pediatr. 2000;105(1):1-5) • Adult Obesity • Approximately 50% of children and adolescents who are obese will become obese adults. (The Center for Health and Health Care in Schools, GWU, “Childhood Obesity, What the research tells us”) Health Policy Institute Health Policy Institute

9. Adverse CVD Risk Factors in Children • Percent of children, aged 5-10, with 1 or more adverse CVD risk factor levels: 27.1 • Percent of overweight children, aged 5-10, with 1 or more adverse CVD risk factor levels: 60.6 (Freedman DS et al., “The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart Study,” Pediatrics, Vol. 103, No. 6, June 1999, pp. 1175-1182) Health Policy Institute

10. Adverse CVD Risk Factors in Children A study of a large national sample of Black, Mexican American and white children and young adults aged 6-24 years indicate strong ethnic differences in CVD risk factors among youths of comparable age and SES. The study shows: • The body mass index (BMI) levels were significantly higher for Black and Mexican American girls than for white girls, with ethnic difference evident by the age of 6-9 years and widening thereafter. • Blood pressure levels were higher for black girls than for white girls in every age group. • Glycosylated hemoglobin levels were highest for Black and Mexican American girls and boys in every age group. (Winkleby MA et al., Ethnic variation in cardiovascular disease risk factors among children and young adults: findings from the Third National Health and Nutrition Examination Survey, 1988-1994, JAMA, 1999 Mar 17;281(11):1006-13) Health Policy Institute

11. Percent of US youth who met dietary recommendations for calcium intake, by age and sex, 1988-94 Health Policy Institute

12. Beverages available in the US food supply (gallons/person/year) Health Policy Institute

13. Children Consuming Three or More Servings of Soft Drinks* Per Day Health Policy Institute Health Policy Institute

14. The school day accounts for a significant portion of a child’s food intake, with some children obtaining up to two meals and two snacks each day at school. (Joint Center Health Policy Institute and PolicyLink, “A Place for Healthier Living, Improving Access to Physical Activity and Healthy Foods,” 2004) Health Policy Institute

15. Children should expend about 50% of their daily energy expenditure while at school, depending on the length of their school day. (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

16. Physical Activity Among School-Aged Children In 2002, 38.5% of children aged 9-13 participated in organized physical activity. Hispanic (25.9%) and non-Hispanic Black (24.1%) children were significantly less likely to participate in organized physical activity compared to non-Hispanic White (46.6%) children. Children of parents with lower incomes and educational levels were also less likely to participate in organized physical activity. (US Centers for Disease Control and Prevention. Physical activity levels among children aged 9-13 year- United States, 2002.MMWR Weekly. 2003;52(33):785-788) Health Policy Institute

17. Physical Activity Among School-Aged Children 51.7% of US students in grades 9-12 were enrolled in a physical education (PE) class and 32.2% of them had daily physical education. Of the 51.7% enrolled in a PE class, 83.4% reported exercising at least 20 minutes during an average class. (US Centers for Disease Control and Prevention, Youth risk behavior surveillance – United States, 2001.MMWR Weekly. 2002;51(SS-4):1-57) Health Policy Institute

18. PE Standards and Guidelines in Schools 60.8% of the states required schools and school districts to follow national or state PE guidelines while nearly 25% of the states encouraged schools and school districts to follow national or state guidelines. More than 80% of the states and nearly 75% of school districts required schools to provide adapted PE, to include PE in individualized education plans (IEPs), and to mainstream students into regular PE, as appropriate. (Burgeson CR, et al. Physical education and activity: results from the school health policies and programs study 2000. J Sch Health.2001;71(7):279-293) Health Policy Institute

19. (Burgeson CR, et al. Physical education and activity: results from the school health policies and programs study 2000. J Sch Health.2001;71(7):279-293) Health Policy Institute

20. School Organized PE and Activity 8% of elementary schools, 6.4% of middle/junior high schools, and 5.8% of senior high schools provided daily PE during the school year. 48% of schools reported offering intramural activities or physical activity clubs for students. 71% of elementary schools provided “regularly scheduled recess” for students in K-5. (Burgeson CR, et al. Physical education and activity: results from the school health policies and programs study 2000. J Sch Health.2001;71(7):279-293; and US Centers for Disease Control and Prevention. School health policies and program study 2000. Fact sheet: physical education and activity.) Health Policy Institute

21. (Burgeson CR, et al. Physical education and activity: results from the school health policies and programs study 2000. J Sch Health.2001;71(7):279-293) Health Policy Institute

22. Schools can make a difference both in improving learning readiness today, and in improving eating and physical activity patterns for long term health. (Team Nutrition, USDA, Food and Nutrition Services “Changing the Scene, Improving the School Nutrition Environment,” September 2000) Health Policy Institute

23. Balancing food intake and physical activity 1 small chocolate cookie (50 calories)=10 minutes of brisk walking Difference between a large and small chocolate cookies is about 200 calories=40 minutes of raking leaves 1 jelly-filled doughnut (300 calories) = 1 hour of walking at moderate pace (20 minutes/mile) Fast food “meal” of double patty cheeseburger, extra large fries, and 24 oz. of soft drink (1,500 calories) = 2 ½ hours of running at a 10 minute/mile pace (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

24. Benefits associated with a healthful diet A low-fat, low-saturated fat, and low-cholesterol diet is associated with reduced risk of coronary health disease. Fruits and vegetable supply fiber that binds to lipids such as cholesterol and decreases their concentration in the blood, thereby decreasing the risk of coronary heart disease. Diets that are moderate in salt help prevent high blood pressure. (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

25. Benefits associated with a healthful diet Diets that are moderate in sugar help prevent tooth decay. Calcium maintains healthy bones and teeth and plays a vital role in nerve conduction, muscle contraction, and blood coagulation. Adequate calcium intake during childhood and adolescence is key to peak bone-mass development and the prevention of osteoporosis later in life. (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

26. Components to a Healthy School Nutrition Environment A commitment to nutrition and physical activity Quality school meals Other healthy food options Pleasant eating experiences Nutrition education Marketing (Team Nutrition, USDA, Food and Nutrition Services “Changing the Scene, Improving the School Nutrition Environment,” September 2000) Health Policy Institute

27. Taking action at various levels School Community Grass roots organizing and strategic advocacy for policy reform State State-level policies can provide a mandate for school districts to change and improve the foods that are being sold on school campuses National Health Policy Institute

28. Taking Action: School Level School-based interventions to improve food choices and dietary quality among students include one or more of the following components: Changes in food service and the food environment Promotional activities Classroom curricula on nutrition education and behavioral skills Parental involvement (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

29. Taking action: Community level The El Paso (Texas) Independent School District negotiated a beverage vendor contract that allowed the district more flexibility and control over beverages sold in El Paso schools. After its board voted to ban soft drinks sold in schools, the school district rejected a $20M, 10-year contract offered by a soft drink vendor for exclusive distribution rights. Instead, the school district and beverage company agreed on a 2-year contract to provide bottled water, 100 percent fruit juice, and non-fat milk in all elementary and middle schools. (Center for Science in the Public Interest (CSPI), “School Food Tool Kit: A Guide to Improving School Foods and Beverages, Part II – Case Studies, 2003”) Health Policy Institute

30. Taking Action: Community level The Fayette County (KY) Public School District set nutritional standards for snacks and renegotiated its vending contracts to shift proportion of healthy options from 21% to 72% of the beverage selections, and from 1% to 40% in the snack selections. In addition, the prices for healthier options will be lower and the machines will carry pictures of young people being physically active. These changes were the result of two years’ worth of advocacy. (CSPI, “School Foods Tool Kit,” Note 60, p.10) Health Policy Institute

31. Taking action: Community level The Portsmouth (NH) School Board replaced drinks high in sugar and caffeine with plain and flavored waters and fruit juice. Snacks and candy that have little nutritional value were replaced with crackers, Chex mix, raisins, and fruit snacks. Catalyst for change was a letter to the schoolboard by a local pediatrician criticizing the foods and warning of the growing obesity rates in kids. (CSPI, “School Foods Tool Kit,” Note 60, p.8) Health Policy Institute

32. Taking action: Community level The Oakland (CA) Unified School District, serving an urban, predominantly low-income, ethnically diverse student population, was one of the first school districts to pass a policy regulating a la carte food sales. Impetus was community mobilization against a potential $5M school district contract with Pepsi. The school board responded to community interest by developing a nutrition policy committee that ultimately set one of the strictest school food nutrition policies in the nation. (The California School Board Association and California Project LEAN, “Successful Students Through Healthy Food Policy,” Healthy Food Policy Resource Guide, West Sacramento, CA, 2003) Health Policy Institute

33. Taking action: State level In 2003, two states enacted laws regarding vending machines in schools: AK, House Bill 1583 (Act 1220): Bans elementary school students’ access to vending machines offering food and soda. CA, Senate Bill 677 (Chapter 415): Bans vending machine sales of carbonated beverages to elementary, middle and junior high school students and replaces them with milk, water and juice. (J. Rosenthal and D. Chang, State Approaches to Childhood Obesity: A Snapshot of Promising Practices and Lessons Learned, National Academy for State Health Policy, April 2004; and National Conference of State Legislatures, Vending Machines in Schools, enacted state legislations as of March 1, 2005.) Health Policy Institute

34. Taking action: State level In 2004, four states enacted laws regarding vending machines in schools: CO, LA, TN, and WA CO, Senate Bill 103 (Chapter No. 166): Encourages each school district board of education to adopt a policy on or before July 1, 2002 providing that, by the 2006-07 school year at least 50% of all items offered in vending machines in each school district be healthful foods or healthful beverages. (National Conference of State Legislatures, Vending Machines in Schools, enacted state legislations as of March 1, 2005) Health Policy Institute

35. Taking action: State level, 2004 legislations LA, Senate Bill 871 (Act No. 734): Establishes a 3-year pilot program in public schools to assess health-related fitness and changes in weight status. TN, House Bill 2783 (Chapter No. 708): Requires the state board of education, in consultation and cooperation with the dept. of education and the dept. of Health to promulgate rules to establish minimum nutritional standards for individual food items sold or offered for sale to pupils in K-8 through vending machines or other sources, including school nutrition programs. A school may permit the sale of food items that do not comply with the above as part of a school fundraising event if students sell food items off of school premises and at least one-half hour after the end of the school day. (National Conference of State Legislatures, Vending Machines in Schools, enacted state legislations as of March 1, 2005) Health Policy Institute

36. Taking action: State level, 2004 legislations WA, Substitute Senate Bill 5436 (Chapter 138): Requires the WA state school directors association, with the assistance of the office of superintendent of public instruction, the dept. of health, and the WA alliance for health, physical education, recreation and dance to convene an advisory committee to develop a model policy regarding access to nutritious foods, opportunities for developmentally appropriate exercise, and accurate information related to these topics. Requires that policy to address the nutritional content of foods and beverages, including fluoridated bottled water, sold or provided throughout the school day or sold in competition with the federal school breakfast and lunch program and the availability and quality of health, nutrition and physical education and fitness curriculum. It also requires the school directors association to submit the model policy and recommendations on the related issues and for local adoption to the governor and state legislature and post it on its web site by January 1, 2003. Requires each district’s board of directors to establish its own policy by August 1, 2005. (National Conference of State Legislatures, Vending Machines in Schools, enacted state legislations as of March 1, 2005) Health Policy Institute

37. Taking action: State level, 2005 introduced legislations Several states have introduced legislation specific to vending machines in schools. The states with current bills available online are: AZ, CA (an amendment to current law), CT, FL, HI, IL, IN, IA, KS, KY, MI, MS, MT, NE, NH, NJ, NM, NY, ND, OK, OR, PA, RI, TN, WV, and VA (National Conference of State Legislatures, Vending Machines in Schools, enacted state legislations as of March 1, 2005) Health Policy Institute

38. Taking action: State level TX has created a joint legislative and executive committee to study the nutritional content and quality of foods and beverages in public schools, including food service meals, a la carte foods, competitive foods, and vending machines. The first action is to review all school vending contracts in the state. Further, the state agriculture department amended the state school nutrition policy to severely restrict Foods of Minimum Value (FMNV) sold on school campuses. (Texas Dept. of Agriculture, “School District Vending Contract Survey, 2003: and Texas Dept. of Agriculture “Texas Public School Nutrition Policy,” March 3, 2004) Health Policy Institute

39. Taking action: State level In 2003, 4 states enacted legislation regarding vending machines in schools, physical education instruction, and establishing committees and councils to coordinate and assist school districts to combat childhood obesity and ensure local community values are reflected in the instructions. The states are: AK (a house and a senate bill); CA (2 senate bills and an assembly concurrent resolution); LA, and MS. (National Conference of State Legislatures, Nutrition and Physical Education) Health Policy Institute

40. Taking action: State level In 2004, several states passed legislation on nutrition and physical education: AL, CA, CO, IN, LA, NH, NY, TN, VT In TX, a Public School Nutrition Policy became effective 08/01/2004 under the auspices of the state’s Agriculture Commissioner, whom the governor authorized to administer the state’s National School Lunch Program, School Breakfast Program, and After School Snack Program. The policy limits the number of grams of fat and sugar that school children may be served each week and phases in an elimination of deep-fat frying for preparation of meals, snacks, and a la carte items. The policy also limits the sales of foods that compete with the breakfast, lunch and snack programs and schools can lose federal reimbursement up to $1.20 at breakfast and $2.19 at lunch for each meal lost to competitive food sales. (National Conference of State Legislatures, Nutrition and Physical Education) Health Policy Institute

41. Taking Action: National Level Full funding for the school meal programs could relieve the pressure on schools’ food services to generate extra funding through the sales of competitive foods. Such a policy may enhance food services by focusing on providing high-quality nutritious meals to encourage maximum participation and may also help alleviate any perceptions among students that only low-income individuals eat the school meals. (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

42. Taking action: National Level The Child Nutrition and WIC Reauthorization Act of 2004, S.2507, was signed into law (P.L. 108-265) on June 30, 2004, reauthorizing the School Lunch Program, School Breakfast Program, Summer Food Service Program, Child and Adult Care Food Program, and WIC for give years, through 2009. (National Conference of State Legislatures, Nutrition and Physical Education) Health Policy Institute

43. Taking action: National Level The Child Nutrition and WIC Reauthorization Act of 2004 contains a variety of provisions aimed at: Improving the nutrition of children by – authorizing funding to be made to state agencies to promote nutrition in child nutrition programs, requiring schools to offer milk in a variety of fat contents and provide a nutritionally-equivalent substitute to milk for children unable to consume milk, prohibiting schools from imposing restrictions on days or times when milk may be sold on school grounds, Requiring USDA to issue regulations for increased consumption of foods and food ingredients in accordance with the most recent Dietary Guidelines for Americans, authorizing USDA to provide grants and technical assistance to improve access to local foods in schools and institutions participating in the Child Nutrition Program, and directing local educational agencies to establish a local school wellness policy for schools. (National Conference of State Legislatures, Nutrition and Physical Education) Health Policy Institute

44. Taking Action: National Level The Child Nutrition and WIC Reauthorization Act of 2004 contains a variety of provisions aimed at: Expanding access to the National School Lunch and School Breakfast Programs and reducing the administrative burden of the programs. Increasing access to the Summer Food Service Program. (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

45. In conclusion, State and local education authorities and schools should: Ensure that all children and youth participate in a minimum of 30 minutes of moderate to vigorous physical activity during the school day. Expand opportunities for physical activity. Enhance health curricula to devote adequate attention to nutrition, physical activity, reducing sedentary behaviors, and energy balance, and to include a behavioral skills focus. (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

46. State and local education authorities and schools should: Develop, implement, and enforce school policies to create schools that are advertising-free to the greatest possible extent Involve school health services obesity prevention efforts (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

47. State and local education authorities and schools should: Conduct annual assessments of each student’s weight, height, and gender- and age-specific GMI percentile and make this information available to parents Perform periodic assessments of each school’s policies and practices related to nutrition, physical activity, and obesity prevention. (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005) Health Policy Institute

48. Federal and state departments of education and health and professional organizations should: Develop, implement and evaluate pilot programs to explore innovative approaches to both staffing and teaching about wellness, healthful choices, nutrition, physical activity, and reducing sedentary behaviors. Innovative approaches to recruiting and training appropriate teachers are also needed. (Institute of Medicine of the National Academies, Preventing Childhood Obesity, Health in the Balance, (Pre-publication copy), 2005)