2. Gina Smith, MSN, FNP-C & Christina Turbeville, CDM FirstHealth Montgomery County School Health Centers Meg McHenry, RD, MPH, LDN & Kara Richards, BA, MA Wake Teen Medical Services Childhood Obesity Prevention: Models of Successful Programs

3. Describe the magnitude of childhood obesity Discuss the role of School Health Centers in addressing childhood obesity Provide examples of successful SBHC programs utilizing best practices Summarize resources available to providers for assisting in implementation of childhood obesity programs Objectives

4. Obesity Trends* Among U.S. Adults BRFSS, 1986 ) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14 No Data <10% 10%–14 % www.cdc.gov 3

5. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% www.cdc.gov

6. Prevalence of At-Risk & Overweight Among Children and Adolescents Ogden, et al. (2006). JAMA, 295(13), 1549-1555. Ogden, et al. (2006). JAMA, 295(13), 1549-1555. ≥ 85%≥ 95% 5

7. Health Risks of Obesity Pulmonary Sleep disorders Asthma Obesity-linked hypoventilations Neurologic Pseudotumor cerebri 6

8. Health Risks of Obesity Orthopedic –Slipped capital epiphysis –Tibia vara (Blount’s disease) –Tibial torsion –Flat feet –Ankle sprain –Fractures 7

9. Health Risks of Obesity Cardiovascular Hypertension Dyslidemia Fatty deposits Left ventricular hypertrophy Other Systemic inflammation

10. Health Risks of Obesity Gastrointestinal Cholelithiasis Non-alcoholic fatty liver disease Gastro-esophageal reflux Endocrine Insulin resistance/Type II Diabetes Acanthosis nigricans Menstrual abnormalities Polycystic ovary syndrome Hypercoricism

11. Health Risks of Obesity: Psychological Obese children and their parents rate the quality of life as similar to pediatric cancer patients. Schimmer, Burwinkle, & Varni, 2003

12. Health Risks of Obesity: Psychological Actual and perceived overweight is an important risk factor for suicidal behaviors in youth Risk factor for suicidality even after controlling for alcohol and illicit drug use (Swahn, M., Reynolds, M., Tice, M., et. al, Journal of Adolescent Health, 2009.)

13. Significance of Problem 80% of obese adolescents will become obese adults - NASBHC, 2009

14. The Role of SBHCs in Addressing Childhood Obesity Leader in child health to emphasize prevention and early intervention Sensitive to unique needs of children and adolescents with the ability to provide culturally sensitive, age-appropriate services Opportunity for access to students with services provided regardless of the ability to pay Qualified, highly trained, interdisciplinary teams comprised of RD, nutritionist, FNP, RN

15. FirstHealth of the Carolinas Montgomery County School Health Centers, East & West East & West Middle Schools Comprehensive, credentialed centers 670 total registrants

16. BMI Data Collection 2007-08 Great partnership with Montgomery County Schools Collaboration with school nurses, teachers and students SBHC nurses SBHC Nutritionist SBHC FNP

17. BMI Discovery

18. Page Street Intervention – HEAP “Healthy Eating Active Play” 3 rd Graders – 39% obese; 16% overweight Intervention developed –RD, Nutrition Educator, FNP Nutrition Educator as instructor 4-week program Pretest of knowledge and behaviors One 45 minute class/week. Fun activities & healthy snacks focusing on healthy eating and increasing physical activity Post-test BMIs recalculated

19. Week 1 – What to Dump SODACHIPS SWEET TEACOOKIES KOOL-AID CANDY LEMONADEDORITOS SUNNY DELIGHTHOT FRIES POWERADECHEETOS GATORADELITTLE DEBBIES FRUITOPIACAKES &PIES YOOHOOBROWNIES CAPRI-SUNCHOCOLATE NABSHONEY BUNS RICE KRISPY TREATS KLONDIKE BARS

20. Week 1 – What to Pick Up 1% OR SKIM MILK WATER CAFFEINE FREE/ UNSWEETENED TEA CAFFEINE FREE / DIET SODA HOMEMADE LEMONADE WITH SPLENDA 100% JUICE ONCE A DAY ONLY LITE MICROWAVE POPCORN CELERY / PEANUT BUTTER CARROTS WITH LOW FAT DRESSING PEANUT BUTTER CRACKERS (whole wheat) APPLES-ORANGES-BANANAS-FROZEN GRAPES STRING CHEESE NUTS RAISINS, DRY CHEERIOS, PRETZELS FROZEN YOGURT

21. Week 2 WHAT FRUITS TO ADD TO BREAKFAST Bananas Raisins Apples Peaches Cut up fruit to top your waffles versus syrup Yogurt in place of syrup Eat your fruit & vegetables that come with lunch! FRUITS & VEGETABLES TO ADD TO LUNCH & SUPPER Carrots & celery sticks Cucumber slices Applesauce cups Apples, oranges, or bananas Bring salad to school Supper – ½ of your plate should be vegetables Try the vegetables your mom makes at least three times before you say you don’t like it.

22. Week 2 – Healthy Eating and Physical Activity Go Hand in Hand Exercise can be fun – in fact it’s child’s play! Make it a family affair Limit TV viewing time to 2 hours or less/day Be physically active for 60 minutes every day

23. Week 3 HOW SHOULD YOUR PLATE LOOK? One-half (1/2) of your plate should have vegetables One-fourth (1/4) of the plate should have your meat or protein One-fourth (1/4) of the plate should have your starches (bread, pasta, rice, potatoes)

24. Week 4 – Healthy Meals on the Run RESTAURANTSCHOICES McDonalds1% milk, mandarin oranges, unsweetened tea, apple dippers, or yogurt with fruit ZenosGrilled chicken, vegetable pizza, salad Sir PizzaSalad bar, fruit choices, vegetable pizza Mazatlan Ask the waiter to take the chips off the table when you sit down. Take ½ of your order home for a later meal. Penny’sOrder the small order and stay away from sauces. BoJanglesGrilled chicken, no biscuit. Ask for a bun instead. SubwayAsk for the kid’s meal, salad and no chips.

25. Results??? Results??? BMI – 1% decrease in obese students from 39% to 38% Correct answers: Pretest – 51% Post-test – 98%

26. 2008 NC Stars Fruit and Veggies Silver Award – Healthcare Division

29. Page Street 5th Graders 09-10 Page Street 5th Graders 2009-10 39% 20% 41% 0% BMI= 95% BMI 85%-94% BMI Normal BMI < 5%

30. Childhood Obesity Action Network. State Obesity Profiles, 2008. National Initiative for Children's Healthcare Quality, Child Policy Research Center, and Child and Adolescent Health Measurement Initiative.

31. 2008-09 Childhood Obesity Efforts Nutritional assessment utilizing HEAP quiz on all students enrolled at the SBHCs (EMS/WMS) Ht/wt/BMI calculated and plotted Early referrals made to SBHC nutritionist for BMI  85% Referral to SBHC RD for BMI ≥ 95% 2-3 nutritional counseling sessions – 1345 nutrition visits

32. SHC/school-wide 2008-09 Efforts Alignment with MCS system goals – “Promote a child-centered culture of health, rigor, and high expectations” Nutrition educator collaborated with school staff in forming after school walking clubs at both middle schools – 130 miles walked Health Eating Every Day (HEED) classes for school staff BMI data collection for all MCS students grades pre-K-12

33. SHC/school-wide 2008-09 Efforts HEAP presentations: Presented to Candor 3 rd graders – last year were most obese in MCS at 41% obese Green Ridge 3 rd graders Mt. Gilead 4 th graders 176 HEAP students this year

34. 2008-09 BMI Trends Montgomery County Schools BMI Data 2008-09 27% 19% 52% 2% BMI= 95% BMI 85-94% BMI Normal BMI < 5%

35. 2008-09 BMI Trends Childhood Obesity Action Network. State Obesity Profiles, 2008. National Initiative for Children's Healthcare Quality, Child Policy Research Center, and Child and Adolescent Health Measurement Initiative.

36. SHC BMI Trends

40. Overall decrease in BMI of OB/OW students: 71% n = 279

41. 2008-09 HEAP Results

43. 2008-09 HEAP Outcomes Candor/Green Ridge/Mt. Gilead Pretest – 58% Correct Post-test – 93% Correct

44. Additional School-wide efforts SPARK curriculum in K-8 www.spark.org Fitnessgram software to track BMI Healthy Kids/Healthy Communities grant School Nutrition Director developing healthier menus 3 schools received fruit grants

45. 2009-10 SHC Efforts Nutritional assessment on all SBHC enrollees Prevention/early intervention 5-3-2-1-Almost None Increased nutritional services for SHCS in 2009-10 by increased nutritional services to 4 days total/week Registered Dietician for students ≥ 99% Actively seek resources/funding for innovative methods for addressing childhood obesity

46. 2009-10 SHC BMI Trends Nutrition Referrals for OB/OW n=261 BMI ≥ 99% = 19% BMI ≥ 95-98 = 42% BMI 85-94% - 36% BMI <5% or other = 3% 61% obese!!

47. Additional Efforts Present HEAP program to Green Ridge 1 st graders – BMI: 33%OB/30%OW Fasting glucose, lipids, ALT, AST, etc. Actively seek resources/funding for innovative methods for addressing childhood obesity Look for ways to incorporate more physical activity into the SHC programs Collaborate on a local, state and national level in addressing childhood obesity

49. Childhood Obesity Prevention: Models of Successful Programs Be Fit, Get Moving Kara Richards, MA Meg McHenry, RD, MPH, LDN

50. Wake Teen Medical Services Wake Teen Medical Services is a non-profit medical service provider for adolescents through young adults ages 10 to 23 Services include: –Primary health care –Mental health care –Health education –Nutrition counseling

51. Wake Teen Medical Services Saw 1473 patients in the last year Patient demographics –975 female, 498 male –989 African American, 446 White, 38 Other/Unidentified –Over 30% of patients fall at or above the 85 th BMI percentile Wake County obesity prevalence –For ages 12-17, 21% classify as overweight and 30% as obese

52. Be Fit, Get Moving Kate B. Reynolds-funded multidisciplinary healthy lifestyle program that includes: –Health care screening –Individual nutrition counseling –Individual exercise counseling –Mental health counseling (if needed) –Weekly group educational seminars, exercise sessions, and field trips

53. Be Fit, Get Moving Target population: –Youth ages 10 through 23 –At or above the 85 th BMI percentile –Highly motivated to make a change Program Participants –Began October 2008 for Wake Teen patients only –In March 2009, we opened the program to outside participants (schools, physician offices, etc.) –We have served 65% of all participants referred, reaching well over 100 teens in Wake County –76% are female, 60% African American, 98% financially needy

54. Intended Outcomes and Results Intended Outcomes at 12 months Decreased BMI in 65% of participants 70% will be active for 20 min/5x/wk 85% show improvements in cardiovascular health 90% will increase nutrition knowledge 85% will eat healthy breakfast 5x/wk 90% improve self-perception Results at 9 months 31% decreased, 50% maintained 100% participants increased activity time, 70% active at least 5xwk 55% decreased resting heart rate, 80% decreased blood pressure 80% increased nutrition knowledge 65% eating breakfast daily; 100% increased from baseline 75% increased, 25% maintained or improved minimally

55. Measurement Tools Used BMI: Heights/weights taken at exercise appointments; CDC growth charts Activity: Exercise logs/self-report to exercise specialist Cardiovascular health: BP/RHR from exercise specialist or medical record Nutrition knowledge: 20-question quiz developed by staff nutritionist Healthy breakfast: food records/self-report to nutritionist Self-perception: 12-question quiz developed by mental health staff

56. Additional Outcomes WHR: 65% improved from baseline Pushups: 100% improvement Squats: 100% improvement Qualitative results –“If I had not participated in BFGM, I would still be drinking sugared drinks, eating chips all day, going to McDonald’s almost everyday – I would be extremely obese” M, 15 –“One achievement I’m proud of is that I lowered my blood sugar. When I first started this program, it was in the 300s’. Now I’m getting results in the low 80’s.” F, 18 –“Within two weeks of starting the program, I noticed my son is more confident – he wants to ride bikes with other kids, he is more willing to be active, and he smiles a lot more.” Mother of M, 14

57. Process Program Structure –Tuesday education seminars and neighborhood walk/boot camp –Thursday boot camp –Individual nutrition counseling –Individual exercise counseling –Field trips

58. Dining Out

59. Eating Out

60. Physical Activity

61. Community Support

62. Contact Information - Wake Teen Medical Services Kara Richards, Project Coordinator –krichards@waketeen.orgkrichards@waketeen.org Meg McHenry, Nutritionist –mmchenry@waketeen.orgmmchenry@waketeen.org Telephone: 919-828-0035 www.waketeen.org

63. Contact Information - FirstHealth Montgomery County School Health Centers Gina Smith, FNP, SHC Manager –rpsmith@firsthealth.orgpsmith@firsthealth.org Christina Turbeville, Nutrition Educator –cturbeville@firsthealth.orgturbeville@firsthealth.org Telephone: 910-428-9392, East; 910-572-1979, West

64. Resources USDA Food Guide Pyramid www.mypyramid.govwww.mypyramid.gov Eat Smart, Move More www.eatsmartmovemorenc.com www.eatsmartmovemorenc.com Shield, J. and Mullen, C.M. (2008). Counseling Overweight and Obese Children and Teens: Health Care Reference and Client Education Handouts. Chicago, Il: American Dietetic Association Videos: –“Obesity in a Bottle” www.learningzoneexpress.comwww.learningzoneexpress.com –“Fast Food Survival Guide” www.learningseed.comwww.learningseed.com

65. Resources NASBHC - http://ww2.nasbhc.org/RoadMap/CONVENTION09/D7_1. pdf http://ww2.nasbhc.org/RoadMap/CONVENTION09/D7_1. pdf NASBHC CQI Tool – http://www.nasbhc.org/site/c.jsJPKWPFJrH/b.2719357/k. 6312/EQ_Quality_Improvement.htm NICHQ – http://www.nichq.orghttp://www.nichq.org http://www.nichq.org/documents/coan-papers-and- publications/COANImplementationGuide62607FINAL.pdf

66. Resources Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report http://pediatrics.aappublications.org/cgi/reprint/120/Suppl ement_4/S164 CDC BMI Calculator for Children & Teens - http://apps.nccd.cdc.gov/dnpabmi/ NC Prevention Partners – www.ncpreventionpartners.org www.ncpreventionpartners.org NC Healthy Schools – www.nchealthyschools.orgwww.nchealthyschools.org

67. Questions??

68. Merry Christmas!!