Transcript Obesity Prevention Education and Training for School Nurses

Arkansas Initiative
and Recommendation for BMI in
Schools
AR Preventive Nutrition and
Physical Activity Summit
• Purpose: to develop specific strategies to
control the obesity epidemic in Arkansas
• Occurred: March 8, 2003
• Funded by: National Institute of Health
Nutrition Academic Award
• Support from: UAMS, ADH, ACHI, ACH,
others
• State-wide summit
Act 1220 of 2003
• Creates an Arkansas Child Health Advisory
Committee
• Limits access to food/beverage vending
machines
• Reports ALL money received from food and
beverage contracts.
• Convenes an advisory committee in each school
district
• Incorporates nutrition/physical activity goals
into annual plans
Act 1220 of 2003 States:
“Require schools to include as part of the Student
Health report to parents an annual body mass
index percentile by age for each student; and
require schools to annually provide parents with
an explanation of the possible health effects of
body mass index, nutrition, and physical
activity.” (in a confidential, private and accurate
manner)
Act 201 of 2007
• Individual students will participate in BMI
assessments in kindergarten and in grades
2, 4, 6, 8, and 10.
• BMI measurements will be eliminated for
students in grades 11 and 12.
Act 201 of 2007
• Parents can provide written notice to the
school if they choose to exclude their
children from BMI assessments.
• Community Health Nurses will work with
schools to assure that proper protocol is
followed during the BMI assessments.
UAMS College of Public Health
Evaluation of Act 1220 (2007)
• Parents are maintaining their awareness of
short- and long-term health problems
associated with childhood obesity.
• 95% of parents read some or all of the Child
Health Report .
• No feared consequences of BMI measurements.
UAMS College of Public Health
Evaluation of Act 1220 (2007)
• Students reported purchasing more healthy
drinks, such as water and other unsweetened
beverages.
• Schools are more frequently offering
nutritional information for students.
• Significant increase in the percentage of
parents who are limiting screen time to give
their kids more time for physical activity.
AAP Recommendation
Accurately weigh and measure to monitor growth
Calculate and plot BMI once a year in all children
and adolescents
Use changes in BMI to identify rate of excessive
weight gain relative to linear growth
(AAP, 2003, reaffirmed in 2007)
NASN Position Statement
Overweight Children and Adolescents
It is the position of the National Association of School
Nurses that school nurses have the expertise to meet
the needs of children at risk for being overweight and
to assist those students
http://www.nasn.org/Default.aspx?tabid=236
Childhood BMI is gender
& age specific
CHILDREN
BMI – body mass index
Underweight
BMI-for-age < 5th percentile
Overweight / at risk
for obesity
BMI-for-age 85th to 94th
percentile
Obese
BMI-for-age ≥ 95th percentile
Normal
BMI-for-age - 5th percentile - <
85th percentile
(CDC, 2009)
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/defining.htm
BMI for Age and Gender:
Used for children and teens because of their rate of
growth and development
Provides a reference for adolescents that can track
body size throughout life
Compares well to laboratory measures of body fat
(Barlow, 2007)
Body Mass Index
What it is and is not!
An inexpensive, effective, easy-to-perform
screening tool for weight categories that
may lead to health problems –
Not intended to be used as the sole
diagnostic measure (CDC)
A number calculated from child’s weight &
height
A reliable indicator of / alternative for body
fatness for most children and teens
Perspectives About the Use of BMI
Measurement
Identify referrals and resources for
children and parents
Promote policies the  access to
healthful foods and daily physical activity
School Nurses - BMI
‘Measurements are more likely to be accurate and reliable when they
are conducted by trained professionals, such as school nurses.’
(Nihiser, 2007, p 14)
The results of one study support that height and weight screening by
school nurses can be private and reliable and provides an
opportunity for school nurses to intervene when children are at
high risk… (Stoddard, et al., 2008)
One study indicated that “mandates increased the number of school
nurses measuring and reporting student BMIs as a way to influence
healthy weight in school children and policies related to healthy
nutrition and physical activity.”
(Hendershot, et al, 2008)
CLINICAL INSTRUCTION FOR BMI
ASSESSMENT
Prior to Assessment
• Contact school administration and teachers.
• Determine assessment team.
– Screener
– Recorder
• Determine date and place and which
students to be assessed.
Day of Assessment
• Equipment
• Calibration of scales
• Station set up
• Preparation of child
• Data collection forms or computer
Recommended Equipment
• Stadiometer (page 4 in training manual)
– Measures height
– Portable or permanently affixed to wall
– Provided by ACHI
• Tape wood board to wall for stability
• Carpenter’s triangle for headpiece
Recommended Equipment
• Scales (page 4 in training manual)
– Tanita HD-314 Scale
• Portable
• Measures up to 330 lbs
• Digital read-out
– Tanita HD-351 Scale
• Portable
• Measure up to 440 lbs
• Digital read-out
• Colored tape placed over previous
weight readout for confidentiality
Recommended Equipment
• Step Stool
– Two-height step stool for height
measurements to ensure measurement
line is read at eye level
• Batteries
– Check type
– Check number of batteries required
Recommended Equipment
• Standard Weight (page 5 training manual)
– A standard weight should be used to test
the scale for accuracy (NOTE: do not use
non-standard weight such as bag of
sugar)
– If the readout is more than ½ pound off
then change the batteries in the scale
– If the readout is still more than ½ pound
off DO NOT use the scale
Recommended Equipment
• Name Tags
– Children
– Staff
• Office Supplies
• Container for personal items
Assessment Team
• Multiple stations
• Screener
– Performs heights and weights
• Recorder
– Records data on assessment forms
OR
– Enters data into web-entry system
Measurement Procedure
• Child should:
– remove as much outerwear as possible
– remove shoes (barefoot or wearing socks)
– empty pockets; remove jewelry and other
objects
– remove eyeglasses (to visualize Frankfort
Plane)
– remove hair barrettes, ties or rubber bands
Measurement Order
– Measurements in rotational order:
• 1st height
• Weight
• 2nd height
Height Measurement
• Child stands with back or other body part
touching the board with body straight.
• Legs are together and body weight is evenly
distributed on feet.
• Arms hang freely by side, palms facing
thighs.
• Position should be verified from FRONT and
LEFT of body.
• Position head in Frankfort Horizontal Plane.
Height Measurement
• Child inhales deeply and holds breath
WITHOUT moving head or body.
• Movable headpiece is brought to superior
point on head with hair compressed.
• Height is recorded to the nearest 1/8th inch.
• Greater than one inch difference between
two height measurements requires remeasurement
Recording Process
• Measurer takes first height
• Recorder calls number back to measurer
• Recorder records number in space
indicated for “1st Height”.
Weight Measurement
• “Zero” the scale if digital.
• Measurer has child step up on the center of
the scale and stands facing the back of the
scale (confidentiality) and indicates to
recorder that child is “ready”.
• Body weight is evenly distributed on feet.
• Head is up and facing straight ahead.
Recording Process
• Recorder obtains read-out number on scale
and records number in space indicated for
“Weight”.
• Weight is recorded to nearest 0.2 pounds (or
appropriate unit for the scale).
Recording Process
• Measurer re-measures height and “2nd
Height” recorded.
• Recorder checks two sets of height
measurements
• NOTE: The reading for weight measurement is
NOT called out by the measurer or recorder to
ensure CONFIDENTIALITY.
Height Measurement
• Recorder should place single line through
entries for first set of measurements if
greater than one inch difference, initial the
line, and record second set of height
measurements for “3rd” Height and “4th”
Height.
Height Measurement
• If after two trials, two height
measurements within the one-inch criteria
cannot be achieved, then the child’s
assessment is considered “Unable to be
Assessed”.
• Mark “Unable to be Assessed” and “Could
not get two measurements in range after
two repeats”.
Forms
• ACHI Calibration Log
• ACHI Measurement Station Information
• ACHI Height and Weight Data Collection
Scale Accuracy/Testing Log
• Required to verify the accuracy of each
scale.
• Scales verified day of scheduled
measurement.
• Scales should be placed in exact location
where measurements will take place prior
to being verified.
• Once verified, do not move scales.
• Verification with at least one know weight
important to minimize misreporting of
child’s BMI due to faulty equipment.
Scale Accuracy/Testing Log
• Verification Steps:
– “Zero” the scale, if digital model.
– Place known weight in center of scale
– Record scale reading in appropriate
column for known weight used.
Scale Accuracy/Testing Log
Measurement Station
Information Form
• Designed to document stadiometers and
scales.
• Type/model used determines appropriate
unit of measurements.
• Station form required for each station.
• When using web-entry system, form must
be completed before student’s data is
entered.
Measurement Station
Information Form – Top Half
Measurement Station
Information Form – Bottom Half
BMI Data Entry Form
• Height and weight may be recorded and
then entered into the web-entry system or
entered directly into web-entry system at
time of assessment.
• Check information for accuracy if student
had previous BMI assessment and student
information is already entered in web-entry
system.
BMI Data Entry Form
• If child is not able to be assessed, indicate why
the student data cannot be obtained under
“Unable to Assess”. Failure to do so will
impact (skew) school data.
• A written refusal from the parent is necessary
if the parent wishes for child not to
participate.
BMI Data
Entry Form
Parent Letter
• Schools are required to include as part of a
student health report to parents an annual
body mass index percentile by age for each
student
• School are required to annually provided
parents with an explanation of the possible
health effects of body mass index, nutrition
and physical activity
Guide for BMI Screening in Schools
A Training Manual for Height and Weight Assessment
http://www.achi.net/ChildObDocs/Height%20and%20Weight%20Measurement%20Training%20
Manual.pdf
Data Entry
BMI Screening Program Training Manual 2009 2010
http://www.achi.net/ChildObDocs/2009_2010_docs/100210%
20BMI%20Data%20Entry%20Manual.pdf
How to weigh
yourself and
get the most
accurate
result.
I can’t believe I was doing it
wrong all these years.
We must get the word out!
Best Practices and Prevention
Programs
[Center for Science in the Public Interest (CSPI)
http://www.cspinet.org/new/pdf/2006schoolreport.pdf
Childhood Obesity State Report Cards
www.childhealthdata.org/content/ObesityReportCards.aspx
Alliance for a
Healthier Generation
• Science-based and age-appropriate dietary
guidelines - developed in conjunction with nutrition
experts at the American Heart Association
•  Consume a variety of nutrient-dense foods and
beverages within / among the basic food groups
•  Promote nutrient-rich foods, fat-free and low-fat
dairy products and place limits on calories, fat,
saturated fat, trans fat, added sugar and sodium
http://www.healthiergeneration.org/about.aspx
The Alliance School
Beverage Guidelines
Elementary School
Middle School
High School
(At least 50% of
non-milk
beverages must
be water and noor low-calorie
options)
(compliance is voluntary)
Water
Any size
Any size
Any size
Fat-free or low fat regular
and flavored milk
with up to 150
calories / 8 ounces**
Up to 8 oz.
Up to 10 oz.
Up to 12 oz.
100% juice* with no
added sweeteners
and up to 120
calories / 8 ounces
Up to 8 oz.
Up to 10 oz.
Up to 12 oz.
No- or low-calorie
beverages with up to
10 calories / 8
ounces
NO
NO
Any size
Other drinks with no
more than 66
calories / 8 ounces
NO
NO
Up to 12 oz.
SCHOOL BEVERAGE TOOLKIT - http://healthiergeneration.org/beveragekit/
Alliance for a
Healthier Generation
Healthy Schools Program
• Increasing opportunities for students to
exercise and play
• Putting healthy foods and beverages in
vending machines and cafeterias
• Providing resources for teachers and staff to
become healthy role models
www.healthiergeneration.org/
Examples of School Programs - AHG
1. Recess before lunch
2. Active Healthy Fun, Before
the Bell
3. Healthy foods first - fruits
4. Salad bars
5. Cooking classes
6. Walk to school day
7. Dance Dance Revolution
(DDR)
http://www.ddrgame.com/
8. Kids Find New Favorite
Snacks and Activities at
School
9. Pedometer competition
between the staff/students
10.Teaching in-line skating in
regularly scheduled physical
education
11. School Wellness Council
with students
12. Jazzercise Away Pounds
13. Lunchtime walking club
14. Brown bag lunch menu for
parents who pack their
children’s lunches
http://healthiergeneration.org/schools
Action for Healthy Kids
• What's Working - Profiles of successful school-based
interventions, programs and practices
http://www.actionforhealthykids.org/resources.php
 A la Cart - Snack Fun
•
A la Cart - Breakfast Fun
•
Changing the Scene -- Improving the School Nutrition Environment
•
Physical Education in Schools - Both Quality and Quantity are Important
•
The Walking School Bus: Combining Safety, Fun and the Walk to School
•
School Health Index PowerPoint
•
Show Me the Money: A Guide to Selling Healthy Foods at School
Action for Healthy Kids:
Examples
• Breakfast Fun - eat a healthy breakfast
• Alternatives to Using Food as a Reward
• CookShop Program - engages children in
classroom-based cooking activities
• Food On the Run (FOR)
• Healthy Hearts
• bSAFE, bFIT!™ A Physical Activity and
Nutrition Program for Kids children’s
educational fitness program
Action for Healthy Kids:
Wellness Tool
http://www.actionforhealthykids.org/wellnesstool/index.php
CDC-Weight Management
Research to Practice Series
• Summarizes the science re: weight
management topics for health professionals
and the lay audience
• Overview of the science summary documents
appropriate for public health professionals
www.cdc.gov/nccdphp/dnpa/nutrition/health_
professionals/practice/index.htm
CDC - Weight Management Research
to Practice Series
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The following topics have handouts, power
points, brochures – some in Spanish
Does breastfeeding reduce the risk of pediatric
overweight?
Can eating fruits and vegetables help people to
manage their weight?
Do Increased portion sizes affect how much we
eat?
Does drinking beverages with added sugars
increase the risk of overweight?
ADA - What We Know About
Childhood Overweight
• Through the sponsorship of the ADA
Foundation (American Dietetic Association),
the ADA carried out an evidence analysis
project (2004) to determine what we know in
the area of childhood overweight and obesity
in order to develop professional, family, and
organizational tools to address this crisis.
Remove Sugar Sweetened Beverages
from Schools
• Consumption of sugar-sweetened beverages
has  dramatically among U.S. children and
adolescents
– …soft drinks were the 6th leading food source of
energy among children > 50% of total beverage
consumption
• Evidence -Intake of calorically-sweetened
beverages is positively related to adiposity in
children Grade II
Dairy and Calcium Intake and
Childhood Overweight
• Research indicates that a low intake of
calcium may be associated with increased
adiposity
• Grade III
• Research indicates that a low intake of dairy
may be associated with increased adiposity
among children
• Grade III
Plain Milk vs Flavored Milk
• Findings from this study suggest that
consumption of either [low fat] flavored or
plain milk is associated with a positive
influence on nutrient intakes by children and
adolescents and is not associated with
adverse effects on BMI measures.
Murphy, et al. 2008
Fruits and Vegetables
• Even though…fruit and vegetable availability
has slightly in recent decades (in comparison
to other food groups) they are most likely to be
consumed in inadequate amounts by children.
• …Evidence is consistent with a modest effect
of fruit and vegetable intake on protecting
against increased adiposity. Grade II
http://www.adaevidencelibrary.com/a_z_index.cfm
Use of Food as a Reward
• Arkansas reported a substantial increase in
the number of schools implementing this
policy to prohibit the use of food as reward
Policy - Changes in Fundraising
Policies and Practices
• Significant increase in schools that prohibit
students, faculty and parent from selling food
items for fundraising (Arkansas, 2008)
How effective are different schoolbased interventions
for childhood overweight?
• Multi-component programs
• Nutrition education
• Parental modeling
• Peer modeling
• Physical activity
• Sedentary behaviors
•Media Influences
Nutrition Education
• Using nutrition education to change food
eaten, food preferences, or eating patterns as
part of a school-based intervention may be
associated with changes in weight
status/adiposity.
Grade II
Multi-Component Programs
• Interventions to reduce pediatric overweight should
be multicomponent
• diet
• physical activity
• nutrition counseling
• parent / caregiver participation
Strong / Imperative
© 2007 ADA Evidence Analysis Library
Physical Activity
• Altering physical activity patterns as part of a
school-based intervention may be associated
with changes in weight status/adiposity
Grade II
Physical Activity in the Treatment of
Childhood / Adolescent Overweight
• Accumulate 60 minutes of at least moderate
physical activity on a daily basis
– briefer bouts of 10 to 20 minutes can be added up
for a total of 60 minutes
 Young people should select activities they
enjoy, that fit into their daily lives, & involve
a variety of activities
Pedometers
• Easy to use and can measure
– Number of steps
– Distance walked
– Calories expended
• 4000 steps in 30 minutes or 8000 steps in 60 minutes
meet current US physical activity recommendation
(Russell, et al, 2006, Journal of Sports Sciences)
Benefits Of Physical Activity On
Academic Performance
Various research studies indicate:
1. Physical education curriculum = small
positive gains in academic performance
2. Positive association between academic
performance and physical activity
3. Physical activity has a positive influence
on concentration and memory
(Strong, et al (2005) The Journal of Pediatrics)
Parent Involvement
• A more limited body of research indicates that
treating 6 to 12-year-old children without
parental participation is not effective.
Strong / Imperative
School Based Initiatives
• Promotion of healthy foods and restrictions /
discouragement of less healthy foods in the
cafeteria and vending machines.
• Health education regarding the importance of
nutrition and physical activity.
• Opportunities for activity in physical education
and recess programs.
(AMA-CDC Obesity Prevention Working Group, 2006)
References and Resources
VERB™ It’s What You Do
• National, multicultural, social marketing
campaign* coordinated by the U.S. Department
of Health and Human Services’ Centers for
Disease Control and Prevention
• The VERB™ campaign encourages young people
ages 9–13 (tweens) years to be physically active
every day.
http://www.cdc.gov/youthcampaign/index.htm
Behaviors Parents Are
Ready to Change
• decreasing meal portion sizes
• exercising as a family
• watching less TV
• eating less fast food (Asante, et al, 2005).
We Can! Parent Tips: Healthy Families, Healthy Weight
http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/physician2.pdf
Behaviors Parents Are
Ready to Change
• drinking less soda
• eating more vegetables
• eating together as a family
• eating more fruits
(Asante, et al, 2005)
.
We Can! Parent Tips: Healthy Families, Healthy Weight
http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/physician2.pdf
"5-2-1-0 is a public education campaign to bring awareness to the
daily guidelines for nutrition and physical activity. Its message is
simple and clear and represents some of the most important steps
families can take to prevent childhood obesity:
http://www.healthynh.com/fhc/initiatives/ch_obesity/5210.php
5 Fruits and vegetables…more matters! Eat
fruits and vegetables at least 5 times a
day. Limit 100% fruit juice.
2 Cut screen time to 2 hours or less a day.
1 Participate in at least one hour of moderate
to vigorous physical activity every day.
0 Restrict soda and sugar-sweetened sports
and fruit drinks. Instead, drink water and 3-4
servings/day of fat-free/skim or 1% milk.
http://www.sdchip.org/media/2867/Handouts-by-Category.pdf
Let’s Move
Four Pillars of the First Lady’s Let’s Move campaign
•Empowering parents and caregivers
•Providing healthy food in schools
•Improving access to healthy, affordable foods
•Increasing physical activity
http://www.letsmove.gov/
• NHANES data on the Prevalence of Overweight
Among Children and Adolescents: United
States, 2003-2004
• “Overweight and Obesity”, CDC
• Pediatric Nutrition Surveillance Report, 1999
• “Prevention of Pediatric Overweight and
Obesity”, Committee on Nutrition, American
Academy of Pediatrics
• “Trust for America’s Health” report F as in Fat:
How Obesity Policies are Failing in America,
2006.
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Arkansas Center for Health Improvement
Arkansas Department of Education
Arkansas Department of Health
Arkansas Government Act 1220 of 2003
Arkansas Government Act 201 of 2007
Arkansas Government Act 29 of 2003
• American Academy of Pediatrics
Recommendations for Prevention of Pediatric
Overweight and Obesity
• American Obesity Association Facts Sheets
• Assessment of Childhood and Adolescent
Obesity in Arkansas, Year Four (Fall 2006spring 2007)
• “Fact Sheet on Obesity in Arkansas”, Arkansas
BMI Task Force
• healthyamericans.org, “Obesity Report in
Arkansas 2006”
• NHANES data on the Prevalence of Overweight
Among Children and Adolescents: United
States, 2003-2004
• “Overweight and Obesity”, CDC
• Pediatric Nutrition Surveillance Report, 1999
• “Prevention of Pediatric Overweight and
Obesity”, Committee on Nutrition, American
Academy of Pediatrics
• “Trust for America’s Health” report F as in Fat:
How Obesity Policies are Failing in America,
2006.
• American Academy of Pediatrics
Recommendations for Prevention of Pediatric
Overweight and Obesity
• American Obesity Association Facts Sheets
• Assessment of Childhood and Adolescent
Obesity in Arkansas, Year Four (Fall 2006spring 2007)
• “Fact Sheet on Obesity in Arkansas”, Arkansas
BMI Task Force
• healthyamericans.org, “Obesity Report in
Arkansas 2006”
• ACHI
– http://www.achi.net
• Ark Dept of Health
– http://www.healthyarkansas.org
• ADE Coordinated School Health Website
– http://www.arkansascsh.org
• Community Health Nurse Specialists &
Community Health Promotion Specialists
– http://www.arkansascsh.org
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Arkansas Center for Health Improvement
Arkansas Coordinated School Health
Arkansas Department of Education
Arkansas Department of Health
Arkansas Government Act 1220 of 2003
Arkansas Government Act 201 of 2007
Arkansas Government Act 29 of 2003
http://www.achi.net
http://www.arkansascsh.org
• ACHI
– http://www.achi.net
• Ark Dept of Health
– http://www.healthyarkansas.org
• ADE Coordinated School Health Website
– http://www.arkansascsh.org
• Community Health Nurse Specialists &
Community Health Promotion Specialists
– http://www.arkansascsh.org