1. Healthy School Environments: State legislatures’ and policy makers roles in promoting nutrition and activity in school populations. Millicent Fleming-Moran, PhD Applied Health Science Indiana University, Bloomington

2. A growing problem… (obese)  The percentage has nearly tripled in past 30 years

3. A growing problem… The national picture of child obesity 15% of U.S. adolescents 12-19 exceed 95 th percentile BMI for gender/age 15% of U.S. adolescents 12-19 exceed 95 th percentile BMI for gender/age 1980 – 2000: 1980 – 2000: Doubled rate: Overweight 6 - 11 yr-olds Tripled rate: Overweight teens NHANES: Obesity Prevalence, 12-18 yr olds 1971-2000

4. Overweight health effects … Earlier sexual maturation Earlier sexual maturation Social stigma Social stigma Altered lipid, glucose and blood pressure risk factors Altered lipid, glucose and blood pressure risk factors 25% of 5 -10 year-olds have high cholesterol, high blood pressure, or other early risks for heart disease. Type 2 diabetes increase -- Cincinnati teen study 1982-94 NIDDM incidence increases 10-fold

5. 2004 IOM report: Child Obesity Diabetes Estimated 30 % of boys & 40 % of girls risk NIDDM diagnosis at some point in their lives.. Economic impact Tripled youth obesity-related hospital costs 1979-99: $35 M to $127 million.

6.  12% White youths  20%+ of African American & Hispanic youth Another Health disparity: Youth Obesity

7. The continuing legacy… Overweight adolescents have a 70-80% chance of becoming overweight or obese adults. Overweight adolescents have a 70-80% chance of becoming overweight or obese adults.

8. And the ultimate risk: Obesity challenges smoking… # 2 leading cause of preventable death # 2 leading cause of preventable death

9. National trends in youth nutrition & activity Only 2% of children eat a healthy diet 3-in-4 teens don’t eat the recommended 5-a-day servings of fruits and vegetables 3-in-4 children get more saturated fat than recommended 35% are physically inactive

10. Known risk factors: Less aerobic activity, More recreational inactivity, Greater sugar / fat % of calories Increased hours of TV /day = A net positive energy balance, above energy required for rapid growth in this age group = A net positive energy balance, above energy required for rapid growth in this age group

11. The current child obesity environment… Media: Targets families with kids for high fat, snack, and “fast foods”. Meals: Americans eat 2 out of 3 away from home. Meals: Americans eat 2 out of 3 away from home. Increased frequency of fast-& prepared foods. Schools Schools Sell commercial foods – to generate income; Pressures to reduce activity during & after school hours. Reliance on car transport Reliance on car transport Sedentary pass-times Sedentary pass-times

12. Healthy People 2010 Goals – a long way to go…. Obesity: < 5% youth Obesity: < 5% youth Diet: 75% youth have 2+ fruits /day 3 + vegetables / day Activity Activity:Vigorous= 20 min 3+ days/wk Moderate= 30 min 5 days /wk TV hours: < 2 hrs/ day

13. Indiana “figures” on obesity …. Indiana #2 in US for obese/overweight youth Indiana #2 in US for obese/overweight youth 1990-present: IN adult obesity rates exceed US averages 1990-present: IN adult obesity rates exceed US averages Part of the national “stroke belt” Part of the national “stroke belt” Increasing NIDDM rates in minority youth & teens Increasing NIDDM rates in minority youth & teens

14. Some IN policy results: 2003-04 Legislators bring youth obesity bill to General Assembly, 2002-03 Dept of Education /ISDH get CDC- funds for Comprehensive School Health Program. Dept of Health Commissioner Drafts state chronic disease plan. Targets obesity/ SMK

15. IN evolution of child obesity Legislation.. National Governors’ Association grant to develop State Chronic Disease Plan- prevention & management - ISDH Depts. of Education & Health – CDC funding for “Comprehensive School Health Program” Executive Branch:

16. IN evolution of child obesity Legislation.. ISDH Minority Health office created Disparities in NIDDM; CVD; obesity documented 2002-03 Gary Legislator – proposes eliminating school vending machines (fails) 2003-04 Budget Session: Revised HB 1017 adds activity, nutrition guidelines & BMI monitoring. Enrolled in Senate. No Action due to Budget debates. Interim Study Commission: takes up school health bills November 2004: “State Obesity Summit” Legislature Session 2004-05: Re-introduced Bill….. Legislative Branch:

17. HB 1017 Proposals: Develop recommendations re: School Meal Nutritional Content; Policies, using current nutrition science evidence to promote: (A) control of youth weight gain; (B) safe weight loss practices; (C) healthy eating habits; and (D) safe diet habits to avoid diseases. Tailored programs to K-6, middle and high school students 1. New DoE Division of School/ Community Nutrition

18. HB 1017: Dept of Education, cont… Nutrition Provisions: Food Sales Defines “Healthy” food for vended items: < 30% total Kcals from fat, (ex. nuts / seeds). < 10% total Kcals from saturated fats. Provides 10% + of USDA daily value of at least 1 one of: Vitamin A or C;Calcium, Iron Protein, Fiber Protein, Fiber “Healthy beverage”: Water, Milk, Fruit / Vegetable drinks (at least 50% juice) Fruit / Vegetable drinks (at least 50% juice) Except Items in : Except Items in : Areas inaccessible to students; Sold after school hours. In current vending contracts thru 2004. But can’t be renewed.

19. HB 1017 Proposals: Nutrition Provisions: Food Sales, cont.. At least 50% of vended foods must qualify as healthy foods (USDA standards). Non-healthy Foods not compete with School Lunch/Breakfast meals. Competitive prices for Healthy foods

20. HB 1017 Proposals: Physical Activity Physical Activity Provisions At least 30 min/ day of Physical Activity for K-6 Can include recess time. Indoor alternatives to be used in inclement weather in inclement weather

21. Evaluation: Student Health outcomes.. With the State Department of Health: Develop & disseminate model policies to measure student BMI Student's BMI : Disclosed to the parent on request, but not be included on report card.

22. Population-based evaluation, not individual

23. Barriers in Legislative Change: The vending contract NASSP 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”. 62% developed soft drink contracts 62% developed soft drink contracts 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.

24. Areas funded with soft-drink money… 66% Sports and PE equipment 59% After school activities 48% Instructional materials 46% Field trips 44% Arts Programs 42% Computers/Technology

25. Food fights: USDA, Schools & Vendors ….. USDA rules vs selling “Competitive foods”-- USDA rules vs selling “Competitive foods”-- Beverage industry sues to open schools to vending machines. Food services prohibited from Food services prohibited from selling soft drinks, but can selling soft drinks, but can “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% *

26. Changes in beverage consumption Soft Drinks Diet Soft Drinks 0 5 10 15 20 25 30 35 40 4545 19701975198019851990 1995 0 5 10 15 20 25 30 35 40 4545 197019751980198519901995 USDA, Economic Research Service Statistical Bulletin No. 939, 1997 Gal/ person/ year Milk Juice

27. Nationally, schools with vending or canteen access to soft-drinks 43% of K-6 schools, 43% of K-6 schools, 89.4% of middle schools 89.4% of middle schools 98.2% of high schools 98.2% of high schools

28. The vendors point of view.. Pepsi Bottling Group Inc.: Pepsi Bottling Group Inc.: “School sales make up < 1 % of total Pepsi revenue”. Coca-Cola Co. spokeswoman : Coca-Cola Co. spokeswoman : "We are in the schools because the schools are asking us to be there." Business Analyst: Business Analyst: " Soft drink & other food companies are in schools to make sales now and… cultivate brand loyalty..”

29. The other side of the obesity equation: Physical Education / Activity CDC guidelines: At least 30 min/day of PA for school kids: < 25% get even 20 minutes/day, 56% get “some” PE, 25% have no PE classes. 48 states mandate P.E. for some students, but Only 11 require P.E. for graduation. Only 6 - 8 % of US schools provide recommended daily PE class to all students.

30. Recent state PE changes.. Budget shortfalls & federal NCLB funding forces “choice” between academics and physical health (NASSP principals survey) Budget shortfalls & federal NCLB funding forces “choice” between academics and physical health (NASSP principals survey) Dropped PE requirements (OK, CO) Dropped PE requirements (OK, CO) Dropped recess periods (GA) Dropped recess periods (GA) Substitutions: Band; Sports (NM, FL, AK) Substitutions: Band; Sports (NM, FL, AK) PE requirements left to local level PE requirements left to local level

31. Trends in PE legislation States begin with non-legislative options: States begin with non-legislative options: Interim studies, resolutions, pilot programs or model bill (AL, WA, NM, MS) Usually do not start with a mandate for PE classes: Usually do not start with a mandate for PE classes: e.g. require hour(s) toward graduation credit (CT; FL)  Current legislative successes: -- TX- require 30-60 min/day of physical activity -- CN- require a “daily period” of activity -- LA - increased PE to required 30 min/day for K-6

32. 2003-04 State Nutrition legislation strategies… Remove: Remove: Vending machines – only AR (2003) Non-nutritious items from machines: NYC. Restrict:Vending access in schools Restrict:Vending access in schools (CO 2004; 23 states) Substitute: Substitute: Nutritious items; milk/water/juice (FL; HI) Items meet Education Code nutrition standards (CA, 2004)

33. 2003-04 State Nutrition legislation strategies Tax non-nutritious items (14 states) Tax non-nutritious items (14 states) SodaTax replaces schools’ vending funds (NC, MI) Junk food tax: 1% on items with < 20% RDI (AK) Divert Revenue: Divert Revenue: “Competitive foods”, sold during food service support school food service, or student activities. (NM) Incentive pricing: Incentive pricing: Healthy options sold at a lower prices (OK)

34. 2003-04: Other Legislative Strategies to reduce school age obesity.. Specify school meal nutrition (12 states) Specify school meal nutrition (12 states) Adjust PE requirements (11 states) Adjust PE requirements (11 states) Track BMI/ Parent notification (1 state) Track BMI/ Parent notification (1 state) Encourage safe walking/biking to school Encourage safe walking/biking to school

35. The bottom line: Children with regular activity perform better academically. FL: Children w/ higher GPAs had 3+ days activity/week NH: Obese children have lower grades

36. References Nestle, M. Food Politics, UC Press. CDC School Health Policies and Programs Study (SHPPS) 2000 survey Institute of Medicine, 2004 Preventing Childhood Obesity: Health in the Balance Preventing Childhood Obesity: Health in the BalancePreventing Childhood Obesity: Health in the Balance National Conference of State Legislatures www.ncsl.org, www.ncsl.org NCSL: Health Policy Tracking Service Issue Briefs Summary, April 1, 2003 Nutrition and Obesity 2004 Reuters Health July 14,2003. School Vending Machines 'Out' with Health Advocates Dietary Guidelines for Americans. Pinhas-Hamiel O, et. al. “Increased Incidence of Non-insulin-dependent Diabetes Mellitus among Adolescents.” Journal of Pediatrics 1996, 128: 608-615. Kann L, et al. Youth Risk Behavior Surveillance - United States, 1999. Morbidity and Mortality Weekly Report 2000, 4( SS-5): 1-96. Agricultural Research Service, US Department of Agriculture. Food and Nutrient Intakes by Children 1994-96, 1998 (1999). on August 17, 2001. Freedman DS, et al. “The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart Study.” Pediatrics 1999, 103: 1175-1182. Freedman DS, et al. “The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart Study.” Pediatrics 1999, 103: 1175-1182. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. “Natural History of Aortic and Coronary Atherosclerotic Lesions in Youth; Findings from the PDAY Study.” Arteriosclerosis and Thrombosis 1993, 13: 1291-1298. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. “Natural History of Aortic and Coronary Atherosclerotic Lesions in Youth; Findings from the PDAY Study.” Arteriosclerosis and Thrombosis 1993, 13: 1291-1298. Wang G, Dietz W. "Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979-1999." Pediatrics 2002, 109: e81.

37. Thank you!