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Howard Taras, MD, FAAP Robert Murray, MD, FAAP J. Gary Wheeler, MD, FAAP

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.

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Howard Taras, MD, FAAP Robert Murray, MD, FAAP J. Gary Wheeler, MD, FAAP

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  1. 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

  2. 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

  3. 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

  4. Why Work with Schools? • Larger impact • Ultimately save time • Image of physicians and image of your practice

  5. Children grow up In 3 environments HOME COMMUNITY SCHOOL

  6. Schools are aAnother “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

  7. Importance of Knowing how Schools & Districts Work • Take care to not over-simplify • Knowledge of system helps your efforts achieve maximum efficiency and impact

  8. Who Does What? Governor Legislature State board of education Chief state school officer State level State education agency staff Local government School board School district level Superintendent Central office staff School Improvement Council School level Principal School staff

  9. Structure of Educational System -- 101 • Districts vary considerably in size • School Boards: Responsible for: vision, budget choices, policies within state/federal laws, (curricula)

  10. Structure of Educational System -- 101 • Superintendents: Hired by school board; provide leadership; translate board policy to actual operations

  11. 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

  12. 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

  13. 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.

  14. 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)

  15. 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?

  16. 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

  17. 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)

  18. “Coordinated School Health” 8 component Model

  19. Community Input into School Health Programs • School Wellness Councils • School Health Advisory Councils

  20. School Administrators: What do they perceive to be their responsibility to student health?

  21. Administrators’ Goals for School Health • “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.” • “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.”

  22. Administrators’ Goals for School Health • “I simply want to send each child home in a condition no worse than how they arrived at school”

  23. Administrators’ Goals for School Health • “I know achievement will improve with school health programs. But I have too little time and resources to operationalize these programs.” • “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.”

  24. Administrators’ Goals for School Health • “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.” • “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).”

  25. 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

  26. 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

  27. Children are OverfedBut Undernourished % Children Consuming Daily Recommended Intake Critical Age Iron Phosphorus Zinc Vitamin C Vitamin A Magnesium Folate Calcium Data compiled by Dr. John Lasekan, Ross Labs from NHANES 1999-2000 and the Continuing Food Survey 1994-96, 1998 Data compiled by Dr. John Lasekan, Ross Labs from NHANES 1999-2000 and the Continuing Food Survey 1994-96, 1998 NHANES, CFSII data compiled by Dr. John Lasekan, Ross Labs

  28. 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

  29. The National School Breakfast and Lunch Programs

  30. Nutritional Contributions ofSchool 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

  31. 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

  32. School may be the Only Place a Child LearnsPortion & Proportion

  33. 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

  34. 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%

  35. 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

  36. HEALTHY FOOD ZONE Food Choices at School GoWay Beyond the USDA Programs A la Carte Sales School Parties Fundraisers School Stores Vending Boosters Athletics Student Clubs Federally Regulated School Meal Programs

  37. 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

  38. Schools have few options to enhance revenue • Increase the number of federal meals • Increase the price of full-paid meals • 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

  39. Top 10 Foodsin High SchoolA 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

  40. 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

  41. 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

  42. 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

  43. Soft Drinks In SchoolThe 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

  44. Recess Before LunchSimple 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

  45. Not Just Physical EducationPhysical 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

  46. 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

  47. The Neighborhood Playgrounds After School Programs Recreation & Community Centers Greenspaces Gardens Skate-board parks Bike and Hike trails Community Service Clubs A Planned Community

  48. An Open Invitation to PhysiciansChild 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 opportunityfor physicians

  49. District aims A Wellness Advisory Council School Food Service Director Nutrition and Physical Education Recess Contracted services Vended foods Foods on campus Food environment Commercial contracts After-school programs What’s in a School Wellness Policy? We can achieve Healthy People 2010 goals only if school policies are aligned

  50. daily school breakfast teens start late no soda in class recess before lunch strong NSLP no “open schools” high nutrient foods subsidize key foods science-based nutrition policies vending policy daily fitness activities phys ed: fitness goal after-school program p.m. recreation One Ideal School Day

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