Fit Kids-Obesity Community Nursing 340 Ferris State University

1. Fit Kids-Obesity Community Nursing 340 Ferris State University Lori Van Zoeren et.al

2. “Obesity, now defined as an epidemic, is the fastest growing health problem in the United States”(Maurer & Smith, 2009, p.776). • Obesity is often the end result of an overall energy imbalance due to poor diet and limited physical activity. Obesity increases the risk for health conditions such as coronary heart disease, type 2 diabetes, cancer, hypertension, dyslipidemia, stroke, liver and gallbladder disease, sleep apnea and respiratory problems, and osteoarthritis. (County Health Rankings, 2011).

3. Analysis • Host • “Childhood obesity is a major epidemic in the United States (US). The prevalence of overweight children and adolescents in the US has more than doubled over the past 20 years, and an estimated 17% of today’s youth ages 2-19 years are considered overweight” (Roseman, Riddell, and Hayes, 2011, p. 2). • Risk factors • Lack of available healthy and affordable meal options • Limited healthy choices in restaurants • Home environment • Education level • Lack of community resources • Poverty • Agent • “Inactivity, poor eating behavior, lack of parental control regarding what children eat, and eating too much were identified by over 80% of the parents as causes of childhood obesity” (Montoya, 2010, p.309).

4. Analysis • Physical and chemical agents • Sedentary lifestyle • High caloric beverage consumption • Processed food intake • High fat and sugar consumption • Environment • Environments where children spend the majority of their time, have a great impact on their dietary intake and physical activity (Foster et al, 2008). • Socioeconomic factors and access to health services • Poverty • Rural community • Decreased access to healthcare

5. Benchmarks • Local data regarding obesity- compare/contrast to benchmarks • United States • 17% of 2-19 year olds are overweight (Roseman, Riddell, and Haynes, 2011). • Michigan • 12.4% (Anderson, Lyon-callo, Boivin, Monje, and Imes, 2009) • Mecosta County • 9.6% (Mecosta County, 2010)

6. Contributing Factors • Poverty within the community • Mecosta County ranks 29th among Michigan Counties on the number of individuals living in poverty (County Health Rankings, 2011). • “Although some dietary choices are the result of cultural influences, income-related restrictions on diet choices play a greater role in nutritional deficiencies in all groups, especially minorities” (Maurer and Smith, 2009). • Supporting theory • Dorothy Johnson’s theory • “Clients attempt to adjust to environmental factors. Strong inputs from the environment might cause imbalance and require excess energy to the point of threatening the existence of the client. Stable environments help clients” (Maurer and Smith, 2009, p. 10).

7. National School Lunch Program • The National School Lunch Program subsidizes schools enabling them to provide nutritionally balanced meals to more than 31 million children in schools across the nation. This federally funded program helps schools supply meals to those children that meet 130% of the poverty level. (USDA, 2010)

8. Target Population • Obesity is a nationwide epidemic potentially affecting all citizens. • Target population for this power point is school-aged children of Mecosta County.

9. Existing Resources • Federal mandates pertaining to school lunches • 57.5% of school children receive free or reduced lunches in Mecosta County ("Students receiving free," 2009) • Community parks and campgrounds • Indoor fitness centers and gymnasiums • Golf courses • Walking trails (Mecosta County Park Commission, 2008)

10. Scope of Community Health Nurses • Maintain a healthful environment • Teach about health promotion and prevention of disease • Identify those with inadequate standards of living and health care services • Collaborate to develop appropriate, adequate acceptable health care services • Ensure quality nursing care (Maurer and Smith, 2009, p. 14)

11. Community Group Involvement • “Get started by initiating a conversation about childhood obesity in your community. Bring together everyone who has a role –parents, city offices, faith-based and community-based organizations, schools, parks and recreation departments, businesses, childcare facilities and hospitals. Then, work together to make neighborhoods healthier by creating opportunities for physical activity and access to healthy, affordable food”. (letsmove.gov, 2010, para. 3)

12. Nursing Diagnosis • Risk of childhood obesity related to lack of physical and nutritional education.

13. Plan • Primary Prevention • Considering the risks of obesity in adults, tackling the problem of obesity should start early on in childhood. • “Prevention through integrated nutrition education and physical education should be a focused school health intervention in a coordinated school health program” (Maurer & Smith, 2009, p. 776). • Secondary Prevention • Secondary prevention of reducing childhood obesity includes the promotion of exercise and reduction of sedentary lifestyles in K-12th.

14. Evidenced-Based Practice Guidelines • According to Healthy People 2010, nutrition education should be targeted at school-aged children (Maurer & Smith, 2009). • “A 2005 Institute of Medicine report presented a strong argument in favor of addressing childhood obesity as a collective responsibility involving many different sectors, including federal, state, and local governments; schools, industries; media; and families (Roseman, Riddell and Haynes, 2011, p.2). • Intervening to affect the wellness of the school food environment is considered as essential component of the Institute of Medicine’s focused action plan to decrease obesity” (Kubik and Lytle, 2011, p. 150).

15. Literature Review • The literature suggests that nutritional education should be taught in schools to promote healthy lifestyle decisions. • Reinforcements of behaviors and parent education through newsletters also seemed to be helpful in short-term nutritional modifications. • Nurses need to get involved in community education to promote healthful nutritional choices to aid in primary prevention of obesity. (Roseman, Riddell and Haynes, 2011)

16. Encouragement of Prevention Measures • “Parental attitudes and behavior, including risk knowledge and physical activity, may affect adolescent physical activity” (Rutkowski and Connelly, 2011, p. 53).

17. Encouragement of Prevention Measures • “Adolescent obesity risk knowledge may influence their physical activity” (Rutkowski and Connelly, 2011, p. 53). • “Lifestyle management through behavior change has been identified as an arena to inform the development of prevention and early intervention weight management strategies” (Rutkowski and Connelly, 2011, p. 53).

18. Measuring Outcomes • Monitoring body mass index (BMI) • Monitoring food choices of school children post nutrition education • Primary care evaluation for physical activity • A long-term outcomes includes decreased adult obesity rates

19. Goals • Primary and secondary measures should be implemented to reduce sedentary lifestyles and increase awareness and selection of health food choices in children.

20. Interventions • Improving eating habits and increasing physical activity are two critical strategies needed to decrease childhood obesity (Foster et al. 2008).

21. Interventions • It is necessary to simultaneously address nutritional intake and the promotion of exercise to effectively combat the issue of childhood obesity (Sharma, 2011). • The White House Task Force on Childhood Obesity has created a plan to solve the problem of childhood obesity within a generation with the LET’S MOVE program.

22. Barriers to overcoming childhood obesity in Mecosta County • Studies have suggested that children living in rural environments are more likely to be overweight or obese than children living in urban environments (Lutfiyya, Lipsky, Behounek, Martinkus, 2007). • 71% of Mecosta County residents live in rural areas (citymelt.com, 2009). • Children from a lower socioeconomic status are more likely to become obese (Lutfiyya et al., 2007). • 20.9 % of Mecosta County’s total population live at or below the poverty level (citymelt.com, 2009).

23. Potential Interventions (letsmove.gov, 2010)

24. Best Intervention • LET’S MOVE is a comprehensive program created in response to the ever growing epidemic of childhood obesity. LET’S MOVE offers specific action plans for parents, schools, mayor’s and community leaders. • Encouraging Mecosta County Public Schools to follow the LET’S MOVE action plan will likely provide the best approach to this major health concern. (letsmove.gov, 2010)

25. Best Intervention • School-based initiatives are likely to be the most effective in dealing with childhood obesity. • Children often spend half of their waking hours and consume more than half of their daily calories while at school (Sharma, 2011). • LET’S MOVE offers a specific school-based initiative (letsmove.gov, 2010).

26. Five Simple Steps to Success • Create a School Health Advisory Council • Form a multidisciplinary team made up of parents, students, teachers and administrators • Encourage healthy eating behaviors such as avoiding high calorie beverages and vending machine foods that are poor quality • Encouraging fruit consumption for birthdays and holidays • Identify safety issues that inhibit children from walking to school • Discourage withholding recess as a form of punishment • Join Healthier US Schools Challenge • Key components that promote nutrition and active lifestyles are identified and criteria for adherence is established for the following areas: • Quality of food served in schools • Participation in food programs • Physical activity • Physical and nutritional education (letsmove.gov, 2010)

27. Five Simple Steps to Success • Make School a Healthy Worksite • Promotion of physical activity of school employees • Identify employee interests related to physical activity and nutrition • Offering special days for students and employees to walk or bike to school • Nutritional and Physical Education Incorporated into School Curriculum • Inform all children and parents of need for 5 servings of fruits and vegetables a day, 4 servings of water, 3 servings of low-fat dairy, 2 hours or less of screen time a day and 1 hour or more of physical activity • Encourage schools to allow recess before lunch • Encourage activity throughout the day, not just during gym or recess. • Provide alternatives to television and video game time for after school play (letsmove.gov, 2010)

28. Five simple steps to success • Plant a School Garden • The rural nature of Mecosta County makes planting a school garden an easy activity. • Children may be more likely to sample fruits and vegetables if they have assisted in the planting and harvesting process. • Local farmers can be invited to share knowledge. • Increased exposure to a variety of fruits and vegetables may encourage reluctant eaters to try healthier foods. (letsmove.gov, 2010)

29. Needed Local Resources • Lets Move Program • One of the major benefits of the Lets Move program is that little outside assistance is needed as many of the needed resources already exist in the community. Educating children and their parents on the benefits of a balanced diet and physical activity is key in establishing patterns of behavior that may last a lifetime (Riley, Locke and Skye, 2011). • The problem of childhood obesity did not occur overnight and will not be solved immediately. It is necessary to involve families, schools and the entire community in order to effectively combat this major health concern.

30. Let’s Move additional resources • The Robert Wood Johnson Foundation Leadership for Healthy Communities • The National League of Cities: Combating Childhood Obesity Action Plan for Municipal Leaders • Institute of Medicine, National Academies: Local Government Actions to Prevent Childhood Obesity • Centers for Disease Control and Prevention: Recommended Community Strategies and Measurements to Prevent Obesity in the United States • Special permission would be needed from school administrators to initiate this program (letsmove.gov, 2010)

31. Implementation • Focusing on the nutrition education component of the “Five Simple Steps”: • Design an easily accessible nutrition education after-school program • Meet bi-weekly throughout the school year • Provide and encourage the use of a food journal worksheet. • Focus • Identifying healthy food choices • Identifying healthy beverage choices • Whole grains versus enriched • Recommended daily allowances of food groups and the best way to get them • Serving size

32. Example Food Journal Worksheet • http://www.cnpp.usda.gov/Publications.htm

33. Implementation • Taught by: • Volunteer nursing students: FSNA • Community health nurse • Permissions: • Obtain permission to enter school • Present proposal to school board • Information for parents explaining program objectives and encouraging participation.

34. Implementation • Focusing on the physical activity component of the “Five Simple Steps”: • Organize a summer vacation youth activity group • Weekday activities promoting physical activity and offering alternatives to television and video games. • Age appropriate activities • Sports/games • Track/field • Utilize parks for weekend “field trips” • Ball park • Public parks • Public pool

35. Implementation • Led by: • Local volunteers, High school students • Background check • CPR certification • Permission: • Informative letter sent home to parents outlining program, calendar, and permission slip for participation.

36. Evidence Based Evaluation • “Both theory and research suggest that a healthy school food environment provides meaningful physical and social support to students that enables and encourages more nutritious choices” (Kubik and Lytle, 2011). • Additional studies monitoring long-term outcome measures would be helpful in promoting physical and nutritional education in schools.

37. Evidence Based Evaluation • APPLE Project as published by the American Journal of Clinical Nutrition: • 2 year study of community based obesity prevention in primary school-age children. • Nutrition and Activity assessment • BMI at baseline and periodically throughout the program • Dietary intake journal • Including frequency, portion size, food and beverage • No nutrition intervention introduced until halfway through program to establish baseline • Physical activity journal • 7 day intermittent journal • Activity rating 1-5 • Time spent watching television/video games (Taylor, McAuley, Barbezat, Strong, Williams & Mann, 2007)

38. Evidence Based • Comprehension – comparison of initial and final scores. • Healthy Food Quiz administered before the first class begins and again after the end of the last class • Identify the healthiest food/beverage choices • What does a serving size look like for these specific foods? • How many servings should I have of each food group daily?

39. Evaluation • Objective • Participation • The number of participants initially vs. those who completed the entire program. • BMI- listed as one of the best tools for evaluating a population for overweight or obesity (CDC.gov) • For those who are interested, BMI and body weight recorded confidentially at the beginning, mid point and end of class. • Food Journal • Food journals to be kept for specific dates • Week long journals to be kept one week before class starts to establish a baseline and then one continuous week each month throughout the course.

40. Evaluation • Holistic Outcome Measurements: early indicators of change (Pender, Murdaugh & Parsons, 2011) • Lifestyle Change: • Questionnaire sent home with initial enrollment package and again at the end of the school year • Parent’s to rate children’s behavior related to: • Recreation choices • Television/video game time • Willingness to try new healthy foods • Snack choices • Consumption of vegetables • Consumption of fruits • Serving size

41. Policy • Local, state and federal funding • “The enactment of the Child nutrition and WIC Reauthorization Act of 2004, required school districts participating in the federal school meals program to establish by the start of 2006-2007 school year wellness policies that included nutrition guidelines for all foods available at school” (Kubik and Lytle, 2011).

42. Policy • Child Nutrition Reauthorization Healthy, Hunger-Free Kids Act of 2010 • This allows for federal funding to increase access to healthy food for low income kids • Sets basic standards for school wellness programs • Expands access to drinking water (USDA, 2011). • National Initiative for Children’s Healthcare Quality • Michigan is one of only two state to require childcare centers to provide meals and snacks consistent with the Dietary Guidelines for Americans (DRC, 2010).

43. Policy • Positive influences • Eligible kids are receiving healthy meal choices while in school. • Negative influences • Foods of minimal nutritional value are still readily available to children in many school systems • Wage barriers causing limited access to government funded school lunch programs • Budgets cuts that decrease number of extracurricular activities that schools offer • Lack of participation in government offered programs • Boys and Girls clubs not represented in the county • American Recovery and reinvestment Act not awarded to any schools in this area (CDC, 2010).

44. Citizen Groups Riverview Elementary Mission Statement To instill in all Riverview students a healthy self-image, a love of learning and the desire to achieve their best in tomorrow's world (Riverview Elementary, 2011, para. 3). • Bob King, the program director for the lunch program at Riverview Elementary, was interviewed regarding the state mandated requirements for the school lunch content in Mecosta County. He said that they must go through a state review every five years to make sure they are providing the USDA’s required nutritional value meals to their students. He said that their program received high marks for compliance last fall. He stated that he believes that all the schools in Mecosta County follow the USDA’s recommendations, otherwise, they would not be reimbursed for their meal program. (B. King, personal communication, March 18, 2011)

45. Citizen Groups • Bob King also stated that most of the schools in Mecosta County use the offer versus serve approach. This means that the kids are offered all of the requirements. The schools must provide all children with a bread, meat, 2 fruits and or vegetables and a milk. The problem with this system is a piece of pizza and carton of milk meets the requirement by the USDA (B. King, personal communication, March 18, 2011). http://www.fcps.edu/fs/food/images/5-StarLunch.jpg

46. Opposing Groups • Having funds to address prevention education must come from support of the community. Data was not available for opposing groups to childhood prevention in Mecosta County. • The conclusion of this group was that since 64% of the population is 18-64 years of age and 13.2% is elderly, increases in taxes would be required to facilitate funds for programs to address childhood obesity. (MSUE, 2011)

47. Overcoming Opposition • Educating the public to risk factors of childhood obesity and the long term effects is essential to gain approval for interventions needed in communities. • Forming more groups, such as the Better Child Care & Coalition located at the Mecosta-Osceola County Intermediate School District (MOISD), will help the cause. This Coalition offers monthly educational opportunities for the people of Mecosta and Osceola Counties. • On June 16th the MSU Extension is presenting Healthy Meals Kids Love at the MOISD (MOISD, 2010).

48. Conclusion • Obesity is a multifaceted problem. • When devising a plan to make an impact on this epidemic, one must look at all factors that contribute to being overweight. • With the costs of healthcare skyrocketing, Michigan can no longer remain passive in efforts to address this disease. • Programs need to be created in each school system to ensure parents and children are educated on the benefits of healthy foods and exercising regularly.