Glancing Back, Moving Forward

Glancing Back, Moving Forward Howell Wechsler, EdD, MPH Director, Division of Adolescent and School Health Healthy Maine Partnerships Annual Meeting Augusta ME, January 20, 2011 National Center for Chronic Disease Prevention and Health Promotion Division of Adolescent and School Health

Blaine House Summit on a Healthy Maine October 2000 Governor Angus King

10 Years of Great Accomplishments • Smoke-free environment policies • Decrease in teen pregnancy rates • Graduated licensing system for teen drivers • 43 School Health Coordinators; 11 intensive coordinated school health SAUs • Elimination of soda sales in schools • Wellness activities with tribal governments and schools • Restaurant menu labeling legislation

Overview • How Are We Doing? • A Systematic, Integrated Approach • Strategies for Nutrition and Physical Activity • Outlook for the Future

Percent of Maine High School Students Engaging in Selected Health Risk Behaviors, 1997 and 2009 Source: CDC, Youth Risk Behavior Survey

Maine High School Students Were LessLikely Than US High School Students to: • Be in a physical fight (23% - 32%) • Feel sad or hopeless (23% - 26%) • Use tobacco products (23% - 26%) • Drink alcohol (32% - 42%) • Have sex with >4 partners (12% - 14%) • Watch too much TV (25% - 33%) • Have no days with >60 minutes of physical activity (18% - 23%) Source: CDC, 2009 Youth Risk Behavior Survey

Maine High School Students Were MoreLikely Than US High School Students to: • Be bullied at school (22% - 20%) • Smoke cigarettes frequently (9% - 7%) • Sniff glue (15% - 12%) • Use a needle to inject drugs (5% - 2%) • Not eat fruit (13% - 11%) • Vomit or take laxatives to lose weight (7% - 4%) • Not be enrolled in a PE class (58% - 44%) Source: CDC, 2009 Youth Risk Behavior Survey

Maine Youth Risk Behavior Survey, 2009 Number of students in a high school class of 30 who: Attempted suicide1(7.9%) Smoked cigarettes2 (18.1%) Used marijuana2(20.5%) Had been in a physical fight1(22.8%) Had at least one drink of alcohol2 (32.2%) Had ever had sexual intercourse (46.0%) Did not eat enough fruit3 (70.9%) Did not get enough physical activity3 (82.1%) 2 5 6 7 10 14 21 25 1 - During the past 12 months; 2 – During the past 30 days; 3 – During the past week Source: Maine Youth Risk Behavior Survey

Percentage of Secondary Schools that Prohibited All Tobacco Use in All Locations* 18% - 41% 42% - 50% 51% - 58% 59% - 73% No Data *Prohibited the use of all tobacco, including cigarettes, smokeless tobacco, cigars, and pipes; by students, faculty and school staff, and visitors; in school buildings; outside on school grounds; on school buses or other vehicles used to transport students; and at off-campus, school-sponsored events; during school hours and non-school hours. School Health Profiles, 2008

Percentage of Secondary Schools that Prohibited All Tobacco Use in All Locations* 18% - 41% 42% - 50% 51% - 58% 59% - 73% No Data MAINE: 59% *Prohibited the use of all tobacco, including cigarettes, smokeless tobacco, cigars, and pipes; by students, faculty and school staff, and visitors; in school buildings; outside on school grounds; on school buses or other vehicles used to transport students; and at off-campus, school-sponsored events; during school hours and non-school hours. School Health Profiles, 2008

Percentage of Secondary Schools that Provided Tobacco Cessation Services for Students, Faculty, and Staff at School or Through Arrangements with Providers Not on School Property 11% - 19% 20% - 25% 26% - 30% 31% - 48% No Data MAINE: 38% School Health Profiles, 2008

Percentage of Secondary Schools that Offered Opportunities For All Students to Participate in Intramural Activities or Physical Activity Clubs 40% - 56% 57% - 65% 66% - 78% 79% - 85% No Data MAINE: 79% School Health Profiles, 2008

Percentage of Secondary Schools That Taught 15 Key Tobacco-Use Prevention Topics in a Required Course 33% - 42% 43% - 49% 50% - 58% 59% - 79% No Data MAINE: 44% School Health Profiles, 2008

Percentage of Secondary Schools That Taught 14 Key Nutrition and Dietary Behavior Topics in a Required Course 42% - 55% 56% - 63% 64% - 69% 70% - 85% No Data MAINE: 57% School Health Profiles, 2008

Percentage of Secondary Schools that Worked With Local Agencies or Organizations on Efforts To Reduce Tobacco Use During the Two Years Before the Survey 36% - 47% 48% - 53% 54% - 60% 61% - 84% No Data MAINE: 45% School Health Profiles, 2008

Government Agencies Family YOUTH

Sets priorities based on relevant data, rigorous analysis, and available resources Carefully examines scientific evidence of effectiveness for specific interventions Allows for community involvement and ownership Needed: A Systematic Approach to Prevention

Recognizes that many youth engage in multiple risk behaviors that share common antecedents and can be prevented through common protective factors Applies existing, categorical, evidence-based interventions in a strategic and sustained fashion Implements cross-cutting interventions that address multiple outcomes simultaneously Needed: An Integrated Approach to Prevention

Coordinated School Health: The Components Health Education Physical Education Family and Community Involvement Health Services Health Promotion for Staff Nutrition Services Healthy and Safe School Environment Counseling, Psychological, and Social Services

Coordinated School Health:The Process • Promoting health is embraced as a fundamental part of the school mission • Strong administrative and school board support • School health council / school health team • School health coordinator • Health goals included in school improvement plan

Coordinated School Health:The Process • Priorities determined through a systematic assessment and planning process that • Is evidence-based and data-driven • Includes extensive input from the school and community

State Actions to Support Coordinated School Health • Require each school district establish and maintain a School Health Council with designated responsibilities (AR, FL, IN, MD, MS, NC, NM, OH, OK, RI, SC, TN, TX, VA) • Require a school health coordinator for district (KY, MS, TN) • Require use of School Health Index by schools (AR, HI, TN) • Include health goals and objectives in School Improvement Plan (AR, DE, RI, WV)

Key Strategies for Nutrition • Ensure that all foods and beverages sold or served are nutritious and appealing • Promote fruit and vegetable intake through procurement, marketing, salad bars, and Farm to School strategies • Increase access to plain drinking water • Use marketing strategies and behavioral economics • Increase the professional qualifications of child nutrition program managers and directors

Maine’s Nutrition Standards for Competitive Foods in Schools (2006) • Sale of foods of minimal nutritional value (e.g., sodas, gum, licorice) prohibited 24/7 (exceptions allowed for public events and sales to school staff) • Only foods and beverages that contribute to the nutritional needs of children shall be sold • Only healthy foods and beverages may be advertised on school grounds

Existence of State Policies Establishing Nutrition Standards for Competitive Foods in Schools * = Has Standards for Competitive Foods = Developing Standards = No State Standards

Federally reimbursable school nutrition programs should be the main source of nutrition in schools. Opportunities for competitive foods should be limited. If competitive foods are available, they should consist primarily of fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products.

Standards for Food Content(1-6) • ≤35% calories from fat, ≤10% calories from saturated fat, zero trans fat • Total calories ≤ 200 • ≤35% of calories from total sugar • ≤ 200 mg sodium snacks, ≤480 mg for à la carte entrée • No caffeine in food and beverage & limits non-nutritive sweeteners • Standards for the School Day (7-11) • Drinking water available to all students free of cost • Food and beverages not used as reward or discipline • Sports drinks not available during the school day • Minimize marketing of foods and beverages • Standards for the After School Setting (12-13) • Standards for on-campus fundraisers and after school activities

West Virginia Policy for Competitive Foods and Beverages in Schools (2008) Per product/package: • <200 total calories • <35% of calories from total fat and <10% from saturated fat (excluding nuts, seeds or cheese); <0.5 grams of trans fat • <35% of calories from sugar (excluding fruits) • <200 mg of sodium • Prohibited • Caffeine containing beverages with >trace amounts • Foods containing non-nutritive sweeteners • Use of food and beverages as a reward or punishment • FMNV all day throughout elementary and middle school campus also • Guidelines for foods brought from the home to the classroom • Availability of fresh drinking water at no cost

Financial Implications of Nutrition Standards • Schools can have strong nutrition standards and maintain financial stability • WV – 80% of principals: little or no change in revenue • CT–Pilot study (5 schools): increase in NSLP, no changes in school finances • Making It Happen – 15/16 schools and districts reported increase or no change in revenue • Careful selection and clever marketing of healthier choices can minimize financial risk

Key Strategies for Nutrition • Ensure that all foods and beverages sold or served are nutritious and appealing • Promote fruit and vegetable intake through procurement, marketing, salad bars, and Farm to School strategies • Increase access to plain drinking water • Use marketing strategies and behavioral economics • Increase the professional qualifications of child nutrition program managers and directors

Key Strategies for Physical Activity High quality physical education as foundation • Elementary school: daily recess period • Physical activity throughout the school day • Extra-curricular physical activity programs • Inclusive, intramural programs and physical activity clubs • High school: Interscholastic athletics • Walk/bike to school program (“safe routes”) • Staff wellness program

Based on national standards Emphasizes lifetime physical activity Meets the needs of all students Keeps students active most of class time Is enjoyable High Quality Physical Education

Adequate time (150 min/week for elementary; 225 min/week for secondary) Highly qualified teachers Adequate facilities and supplies Reasonable class sizes A written curriculum Student assessment High Quality Physical Education Requires

Implement policies to increase time for PE Require time for daily physical activity Promote standards-based curricula and evidence-based programs Implement student assessment for PE Prohibit use of physical activity to punish Collect data on youth fitness How States and Districts Are Helping

Resistance to change Ongoing pressures for accountability based on standardized test scores Budget crises Aging population Some Reasons for Pessimism

Agenda for action and data systems in place Growing evidence of effectiveness Federal funding and national leadership Support from key sectors of society Some Reasons for Optimism

Other Federal Initiatives • Communities Putting Prevention to Work • Patient Protection and Affordable Care Act • Child Nutrition Act Re-authorization • Physical Education Program (PEP)

A Survey of >400 Employers # 1 factor that will have the largest impact on the workplace over the next five years: #1 emerging content area in terms of its importance for future graduates entering the U.S. workforce in the next five years: Rising Health Care Costs Making Appropriate Choices Concerning Health and Wellness (76% of employer respondents rated it as “most critical”)

Estimated Financial Costs of Our Failure to Sufficiently Address Youth Health Problems • Among 15-24 year olds in 2000: • Total lifetime costs of injuries: $79.8 billion1 • Costs of new cases of STDs: $6.5 billion2 • Average annual costs associated with a child born to a teen mother in 2004: $9.1 billion3 • Total costs for treating asthma in 2006: $8 billion4 1 - Finkelstein EA et al. The Incidence and Economic Burden of Injuries in the United States.2006 2 - Chesson HW et al. Perspectives on Sexual and Reproductive Health 2004; 36(1):11-19 3 - The National Campaign to Prevent Teen Pregnancy. By the Numbers: The Public Costs of Teen Childbearing 4 - AHRQ. Statistical Brief # 242. April 2009

Economic Costs Associated with Obesity are High Direct health care costs of obesity and overweight: 1998:$74 billion 2008: $147 billion ½ of costs publicly financed by Medicare or Medicaid Obesity accounts for 9.1% of annual medical spending Finkelstein EA,Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer and service-specific estimates. Health Affairs. 2009;28(4)

Weight Issues Plague the Military • The Department of Defense estimates as many as 1/3 of military-age youth are ineligible for service because of their weight.2 • In 2007, approximately 15,000 military recruits failed the entrance physical exam because of weight/body fat limits; this was the most common reason for medical disqualification among applicants for active duty enlisted service.3-4 1. Mission Readiness press release , Feb 9, 2010 2.Hsu et al. J Adolesc Health. 2007 3. AMSARA Annual Report 2008. 4. Reading, Willing , and Unable to Serve, 2010.

Obesity: A National Security Threat “Obesity rates threaten the overall health of America and the future strength of our military. We must act, as we did after World War II, to ensure that our children can one day defend our country, if need be.” -Retired U.S. Army Gens. John M. Shalikashvili and Hugh Shelton Source: The Washington Post, April 30, 2010

Obesity: A National Security Threat “We urge Congress to: • Get the junk food and high-calorie beverages out of our schools. • Upgrade the quality of meals served in schools. • Develop research-based strategies, implemented through our schools, to help parents and children adopt healthy habits.” -Retired U.S. Army Gens. John M. Shalikashvili and Hugh Shelton Source: The Washington Post, April 30, 2010

Keys to Success

Glancing Back, Moving Forward