Healthy School Healthy School Environments: Environments:

State legislatures’ and policy State legislatures’ and policy makers roles in promoting makers roles in promoting

nutrition and activity in school nutrition and activity in school populations.populations.

Millicent Fleming-Moran, PhDMillicent Fleming-Moran, PhDApplied Health ScienceApplied Health Science

Indiana University, BloomingtonIndiana University, Bloomington

A growing problem…A growing problem…

(obese)(obese)

The percentage The percentage has nearly has nearly tripled in past 30 tripled in past 30 yearsyears

A growing problem…A growing problem… The national picture of child The national picture of child

obesityobesity 15% of U.S. 15% of U.S.

adolescents 12-19 adolescents 12-19 exceed 95exceed 95thth percentile percentile BMI for gender/ageBMI for gender/age

1980 – 2000:1980 – 2000:

Doubled rateDoubled rate: : Overweight 6 - 11 yr-Overweight 6 - 11 yr-olds olds

Tripled rateTripled rate: : Overweight teensOverweight teens

0

2

4

6

8

10

12

14

16

1971-74

1976-80

1988-94

1999-2000

NHANES: Obesity Prevalence, NHANES: Obesity Prevalence, 12-18 yr olds 1971-200012-18 yr olds 1971-2000

Overweight health effectsOverweight health effects…… Earlier sexual maturationEarlier sexual maturation Social stigmaSocial stigma

Altered lipid, glucose and Altered lipid, glucose and blood pressure risk factorsblood pressure risk factors

25% of 5 -10 year-olds 25% of 5 -10 year-olds havehave high cholesterol, high high cholesterol, high blood pressure, blood pressure, or other or other early risks for heart early risks for heart diseasedisease..

Type 2 Type 2 diabetesdiabetes increase --increase --Cincinnati teen study 1982-94Cincinnati teen study 1982-94NIDDM incidence increases NIDDM incidence increases 10-fold10-fold

2004 IOM report: Child 2004 IOM report: Child Obesity Obesity

Diabetes Diabetes

Estimated 30 % of boys & 40 % of girls Estimated 30 % of boys & 40 % of girls risk NIDDM diagnosis at some point risk NIDDM diagnosis at some point in their lives..in their lives..

Economic impactEconomic impact

Tripled youth obesity-related hospital Tripled youth obesity-related hospital costscosts1979-99: $35 M to $127 million. 1979-99: $35 M to $127 million.

12% White youths12% White youths

20%+ of African American 20%+ of African American

& Hispanic youth & Hispanic youth

Another Health disparity: Another Health disparity: Youth ObesityYouth Obesity

The continuing legacy…The continuing legacy…

Overweight Overweight adolescents adolescents have a 70-80% have a 70-80% chance of chance of becoming becoming overweight or overweight or obese adults.obese adults.

And the ultimate risk:And the ultimate risk:Obesity challenges smoking…Obesity challenges smoking…

##2 leading 2 leading cause of cause of

preventable preventable deathdeath

National trends in youth National trends in youth nutrition & activitynutrition & activity

Only 2% of children eat a healthy Only 2% of children eat a healthy dietdiet

3-in-4 teens don’t eat the 3-in-4 teens don’t eat the recommended 5-a-day servings of recommended 5-a-day servings of

fruits and vegetables fruits and vegetables

3-in-4 children get more saturated 3-in-4 children get more saturated fat than recommendedfat than recommended

35% are physically inactive35% are physically inactive

Known risk factors:Known risk factors:

Less aerobic activity, Less aerobic activity,

More recreational inactivity, More recreational inactivity,

Greater sugar / fat % of caloriesGreater sugar / fat % of calories

Increased hours of TV /dayIncreased hours of TV /day

= A = A net positive energy balancenet positive energy balance, , above energy required for rapid above energy required for rapid growth in this age group growth in this age group

The current child obesity The current child obesity environment…environment…

Media: Media: Targets families with kids for Targets families with kids for high fat, snack, and “fast foods”.high fat, snack, and “fast foods”.

MealsMeals: Americans eat 2 out of 3 away from home.: Americans eat 2 out of 3 away from home.Increased frequency of fast-& prepared foods.Increased frequency of fast-& prepared foods.

SchoolsSchools Sell commercial foods – to generate income; Sell commercial foods – to generate income; Pressures to reduce activity during & after school Pressures to reduce activity during & after school hours. hours.

Reliance on Reliance on car transportcar transport Sedentary pass-timesSedentary pass-times

Healthy People 2010 Goals Healthy People 2010 Goals – a long way to go….– a long way to go….

ObesityObesity: < 5% : < 5% youthyouth

DietDiet: :

75% youth have75% youth have

2+ fruits /day 2+ fruits /day

3 + vegetables / 3 + vegetables / dayday

ActivityActivity::

Vigorous= Vigorous=

20 min 3+ days/wk20 min 3+ days/wk

Moderate=Moderate=

30 min 5 days /wk30 min 5 days /wk

TV hours: TV hours:

<< 2 hrs/ day2 hrs/ day

Indiana “figures” on obesity ….Indiana “figures” on obesity …. Indiana #2 in US for Indiana #2 in US for

obese/overweight obese/overweight youthyouth

1990-present: IN adult 1990-present: IN adult obesity rates exceed obesity rates exceed US averages US averages

Part of the national Part of the national “stroke belt” “stroke belt”

Increasing NIDDM rates Increasing NIDDM rates in minority youth & in minority youth & teensteens

0

5

10

15

20

25

30

35

40

BMI- IN BRFSS 2002

<2525-2930+

Some IN policy results: 2003-04Some IN policy results: 2003-04

Legislators bring youth Legislators bring youth obesity bill to obesity bill to General General AssemblyAssembly, 2002-03, 2002-03

Dept of EducationDept of Education /ISDH get /ISDH get

CDC- funds for ComprehensiveCDC- funds for Comprehensive

School Health Program.School Health Program.

Dept of HealthDept of Health CommissionerCommissioner

Drafts state chronic disease Drafts state chronic disease plan. Targets obesity/ SMK plan. Targets obesity/ SMK

IN evolution of child IN evolution of child obesity Legislation..obesity Legislation..

National Governors’ Association grant to National Governors’ Association grant to develop develop

State Chronic Disease Plan- State Chronic Disease Plan- prevention & management - ISDHprevention & management - ISDH

Depts. of Education & Health – Depts. of Education & Health – CDC funding for “Comprehensive CDC funding for “Comprehensive

School Health Program”School Health Program”

Executive Branch:Executive Branch:

IN evolution of child obesity IN evolution of child obesity Legislation..Legislation..

ISDH Minority Health officeISDH Minority Health office created createdDisparities in NIDDM; CVD; obesity documentedDisparities in NIDDM; CVD; obesity documented

2002-03 Gary 2002-03 Gary LegislatorLegislator – proposes eliminating – proposes eliminating school vending machines (fails)school vending machines (fails)

2003-04 Budget Session: 2003-04 Budget Session: Revised HB 1017Revised HB 1017 adds activity, nutrition guidelines & BMI adds activity, nutrition guidelines & BMI monitoring. Enrolled in Senate. No Action due to monitoring. Enrolled in Senate. No Action due to Budget debates.Budget debates.

Interim Study Commission: takes up school health Interim Study Commission: takes up school health billsbills

November 2004: “November 2004: “State Obesity SummitState Obesity Summit””Legislature Session 2004-05: Re-introduced Bill…..Legislature Session 2004-05: Re-introduced Bill…..

Legislative Branch:Legislative Branch:

HB 1017 Proposals:HB 1017 Proposals:

DevelopDevelop recommendations re:recommendations re:

School Meal Nutritional Content; School Meal Nutritional Content; Policies, Policies, using current nutrition science evidence to using current nutrition science evidence to

promote:promote:

(A) control of youth weight gain;(A) control of youth weight gain;(B) safe weight loss practices;(B) safe weight loss practices;(C) healthy eating habits; and(C) healthy eating habits; and(D) safe diet habits to avoid diseases.(D) safe diet habits to avoid diseases.

Tailored programs to K-6, middle and high school Tailored programs to K-6, middle and high school studentsstudents

1. 1. New DoE Division of New DoE Division of School/ Community NutritionSchool/ Community Nutrition

HB 1017: HB 1017: Dept of Education, cont…Dept of Education, cont…

Nutrition Provisions:Food Sales

Defines “Healthy” food for vended items:Defines “Healthy” food for vended items:< 30% < 30% total Kcals from fat, (ex. nuts / seeds).total Kcals from fat, (ex. nuts / seeds).< 10% total< 10% total K Kcals from saturated fats.cals from saturated fats.

Provides 10% + of USDA daily value of at least 1 one of:Provides 10% + of USDA daily value of at least 1 one of:Vitamin A or C;Vitamin A or C; Calcium, IronCalcium, Iron

Protein, FiberProtein, Fiber

““Healthy beverage”:Healthy beverage”: Water, Milk, Water, Milk, Fruit / Vegetable drinks (at least 50% Fruit / Vegetable drinks (at least 50%

juice)juice) Except Items in : Except Items in :

Areas inaccessible to students; Sold after school hours.Areas inaccessible to students; Sold after school hours.In In current vending contractscurrent vending contracts thru 2004. But can’t be renewed. thru 2004. But can’t be renewed.

HB 1017 Proposals:HB 1017 Proposals:

Nutrition Provisions:Food Sales, cont..

At least At least 50% of vended foods50% of vended foods must must qualify as healthy foods (USDA qualify as healthy foods (USDA standards).standards).

Non-healthy Foods not compete with Non-healthy Foods not compete with School Lunch/Breakfast meals.School Lunch/Breakfast meals.

Competitive pricesCompetitive prices for Healthy foods for Healthy foods

HB 1017 Proposals:HB 1017 Proposals:

Physical Activity Physical Activity Provisions

At least 30 min/ day of At least 30 min/ day of

Physical ActivityPhysical Activity for K-6 for K-6

Can include recess time. Can include recess time.

Indoor alternatives to be usedIndoor alternatives to be used

in inclement weatherin inclement weather

Evaluation: Student Health Evaluation: Student Health outcomes.. outcomes..

With the State With the State Department of Department of Health:Health:

Develop & disseminate Develop & disseminate model policies to model policies to

measure student BMImeasure student BMI

Student's BMI :Student's BMI :

Disclosed to the parent Disclosed to the parent on request, buton request, but

notnot be included on be included on report card.report card.

Population-based evaluation, not Population-based evaluation, not individualindividual

Barriers in Legislative Barriers in Legislative Change:Change:

The vending contractThe vending contractNASSP survey of principalsNASSP survey of principals:: 1/3rd report “school funding worse than 5 years ago” 1/3rd report “school funding worse than 5 years ago”

92% agree school-business partnerships 92% agree school-business partnerships ““enhance educational programs”.enhance educational programs”.

62% developed soft drink contracts 62% developed soft drink contracts to generate revenue.to generate revenue.

Large high schools can earn $2,000 a month.Large high schools can earn $2,000 a month. Seattle district: $330,000/year vending contracts.Seattle district: $330,000/year vending contracts.

Areas funded with soft-drink Areas funded with soft-drink money…money…

66% Sports and PE 66% Sports and PE equipmentequipment

59% After school activities 59% After school activities

48% Instructional materials48% Instructional materials

46% Field trips46% Field trips

44% Arts Programs 44% Arts Programs

42% Computers/Technology42% Computers/Technology

Food fights: USDA, Schools & Food fights: USDA, Schools & VendorsVendors…..…..

USDA rules vs selling “Competitive foods”--USDA rules vs selling “Competitive foods”--Beverage industry sues Beverage industry sues to open schools to vending machines.to open schools to vending machines.

Food services prohibited fromFood services prohibited from selling soft drinks, but can selling soft drinks, but can ““give-away” pop with other food purchases.give-away” pop with other food purchases.

1985 – ‘97. National school milk 1985 – ‘97. National school milk purchases decline 30%; purchases decline 30%; Soda-pop increased by 1,100% *Soda-pop increased by 1,100% *

Changes in beverage consumptionChanges in beverage consumption

Soft Drinks

Diet Soft Drinks

05

1015202530354045

1970 1975 1980 1985 1990 19950

5

10

15

20

25

30

35

40

45

1970 1975 1980 1985 1990 1995

USDA, Economic Research Service Statistical Bulletin No. 939, 1997

Gal/ person/ year

Milk

Juice

Nationally, schools with vending or Nationally, schools with vending or canteen access to soft-drinkscanteen access to soft-drinks

43% of K-6 schools, 43% of K-6 schools, 89.4% of middle 89.4% of middle

schoolsschools 98.2% of high 98.2% of high

schools schools

0

10

20

30

40

50

60

70

80

90

100

K to 6

Middle

High Schools

The vendors point of view..The vendors point of view..

Pepsi Bottling Group Inc.: Pepsi Bottling Group Inc.: ““School sales make up < 1 % of total School sales make up < 1 % of total Pepsi revenue”.Pepsi revenue”.

Coca-Cola Co. spokeswomanCoca-Cola Co. spokeswoman: : "We are in the schools because the schools are "We are in the schools because the schools are

asking us to be there."asking us to be there."

Business Analyst: Business Analyst: ""Soft drink & other food companies are in schools Soft drink & other food companies are in schools to make sales now and… cultivate brand to make sales now and… cultivate brand loyalty..”loyalty..”

The other side of the obesity The other side of the obesity equation:equation:

Physical Education / ActivityPhysical Education / ActivityCDC guidelines: At least 30 min/day of PA for school CDC guidelines: At least 30 min/day of PA for school

kids:kids:

< 25% get even 20 minutes/day, < 25% get even 20 minutes/day, 56% get “some” PE,56% get “some” PE,

25% have no PE classes25% have no PE classes. .

48 states mandate P.E. for 48 states mandate P.E. for somesome students, but students, butOnly 11 require P.E. for graduationOnly 11 require P.E. for graduation..

Only 6 - 8 % of US schools provide recommended Only 6 - 8 % of US schools provide recommended daily PE class to all students. daily PE class to all students.

Recent state PE changes..Recent state PE changes..

Budget shortfalls & federal NCLB Budget shortfalls & federal NCLB funding forces “choice” between funding forces “choice” between academics and physical health academics and physical health ((NASSP principals survey) NASSP principals survey)

DroppedDropped PE requirements (OK, CO) PE requirements (OK, CO) Dropped recess periods (GA)Dropped recess periods (GA) SubstitutionsSubstitutions: Band; Sports (NM, FL, AK): Band; Sports (NM, FL, AK) PE requirements left to local levelPE requirements left to local level

Trends in PE legislation Trends in PE legislation States begin with States begin with non-legislative optionsnon-legislative options: :

Interim studies, resolutions, pilot programs or Interim studies, resolutions, pilot programs or model bill (AL, WA, NM, MS)model bill (AL, WA, NM, MS)

Usually do Usually do notnot start with a mandate for PE start with a mandate for PE classes:classes:e.g. require hour(s) toward graduation credit (CT; e.g. require hour(s) toward graduation credit (CT; FL)FL)

Current legislative successes:Current legislative successes:-- TX- require -- TX- require 30-60 min/day30-60 min/day of of physical physical activityactivity-- CN- require a “daily period” of activity-- CN- require a “daily period” of activity-- LA - increased PE to required 30 min/day for K-6-- LA - increased PE to required 30 min/day for K-6

2003-04 State 2003-04 State Nutrition legislation Nutrition legislation

strategies…strategies…

RemoveRemove::Vending machines – only AR (2003)Vending machines – only AR (2003)Non-nutritious itemsNon-nutritious items from machines: NYC.from machines: NYC.

RestrictRestrict:: Vending access in schools Vending access in schools (CO 2004; 23 states) (CO 2004; 23 states)

SubstituteSubstitute:: Nutritious items; milk/water/juice (FL; HI)Nutritious items; milk/water/juice (FL; HI)Items meet Education Code nutrition Items meet Education Code nutrition standards standards (CA, 2004)(CA, 2004)

2003-04 State 2003-04 State Nutrition legislation Nutrition legislation

strategiesstrategies TaxTax non-nutritious itemsnon-nutritious items (14 states) (14 states)

SodaTax SodaTax replaces schools’ vending funds (NC, replaces schools’ vending funds (NC, MI)MI)Junk food tax: Junk food tax: 1% on items with < 20% RDI (AK)1% on items with < 20% RDI (AK)

Divert RevenueDivert Revenue: : ““Competitive foods”, sold during food service Competitive foods”, sold during food service support school food service, or student support school food service, or student activities. (NM)activities. (NM)

Incentive pricingIncentive pricing: : Healthy options sold at a lower prices (OK)Healthy options sold at a lower prices (OK)

2003-04: Other Legislative 2003-04: Other Legislative Strategies to reduce school age Strategies to reduce school age

obesity..obesity..

Specify school meal nutrition (12 Specify school meal nutrition (12 states)states)

Adjust PE requirements Adjust PE requirements (11 states)(11 states) Track BMI/ Parent notification (1 Track BMI/ Parent notification (1

state)state)

Encourage safe walking/biking to Encourage safe walking/biking to schoolschool

The bottom line:The bottom line:

Children with regular Children with regular activity activity

perform better perform better academicallyacademically..

FL: Children w/ higher FL: Children w/ higher GPAs had 3+ days GPAs had 3+ days activity/week activity/week

NH: Obese children have NH: Obese children have lower gradeslower grades

ReferencesReferencesNestle, M. Nestle, M. Food PoliticsFood Politics, UC Press. , UC Press. CDC School Health Policies and Programs Study (SHPPS) 2000 surveyCDC School Health Policies and Programs Study (SHPPS) 2000 survey

Institute of Medicine, 2004 Institute of Medicine, 2004 Preventing Childhood Obesity: Health in the BalancePreventing Childhood Obesity: Health in the Balance

National Conference of State Legislatures National Conference of State Legislatures www.ncsl.orgwww.ncsl.org, , NCSL: Health Policy Tracking Service NCSL: Health Policy Tracking Service Issue Briefs Summary,Issue Briefs Summary, April 1, 2003 Nutrition and Obesity April 1, 2003 Nutrition and Obesity

20042004

Reuters Health July 14,2003. School Vending Machines 'Out' with Health Advocates Reuters Health July 14,2003. School Vending Machines 'Out' with Health Advocates Dietary Dietary Guidelines for AmericansGuidelines for Americans..

Pinhas-Hamiel O, et. al. “Increased Incidence of Non-insulin-dependent Diabetes Mellitus among Pinhas-Hamiel O, et. al. “Increased Incidence of Non-insulin-dependent Diabetes Mellitus among Adolescents.” Adolescents.” Journal of PediatricsJournal of Pediatrics 1996, 128: 608-615. 1996, 128: 608-615.

Kann L, et al. Youth Risk Behavior Surveillance - United States, 1999. Kann L, et al. Youth Risk Behavior Surveillance - United States, 1999. Morbidity and Mortality Morbidity and Mortality Weekly ReportWeekly Report 2000, 4( SS-5): 1-96. 2000, 4( SS-5): 1-96.

Agricultural Research Service, US Department of Agriculture. Agricultural Research Service, US Department of Agriculture. Food and Nutrient Intakes by Food and Nutrient Intakes by Children 1994-96, 1998Children 1994-96, 1998 (1999). <http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm> on (1999). <http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm> on August 17, 2001.August 17, 2001.

Freedman DS, et al. “The Relation of Overweight to Cardiovascular Risk Factors Among Children Freedman DS, et al. “The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart Study.” and Adolescents: The Bogalusa Heart Study.” PediatricsPediatrics 1999, 103: 1175-1182. 1999, 103: 1175-1182.

Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. “Natural Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. “Natural History of Aortic and Coronary Atherosclerotic Lesions in Youth; Findings from the PDAY History of Aortic and Coronary Atherosclerotic Lesions in Youth; Findings from the PDAY Study.” Study.” Arteriosclerosis and ThrombosisArteriosclerosis and Thrombosis 1993, 13: 1291-1298. 1993, 13: 1291-1298.

Wang G, Dietz W. "Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979-1999." Wang G, Dietz W. "Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979-1999." PediatricsPediatrics 2002, 109: e81. 2002, 109: e81.

Thank you!Thank you!