1. Analysis of Washington State School District Nutrition and Fitness Policies Janice Kao MPH Candidate Thesis Presentation August 8, 2006 University of Washington Interdisciplinary Graduate Program in Nutritional Sciences

2. Overview of Presentation General background and statistics on overweight in youth Context for a policy analysis study in WA Background on school-based policies Study Aims Methods Results and Discussion Limitations Implications for future research Conclusions

3. Youth Overweight: Prevalence Nearly one-third of youth aged 6-19 years are overweight or at risk of overweight. (1,2) 2004 WA HYS results for 8th, 10th, 12th graders show similar numbers (3) Trajectory over past 20 years (4,5): Numbers have tripled in adolescents, and Doubled in children

4. Youth Overweight: Consequences Long-term Increased likelihood of obesity as adults (2,6-8) Higher risk of hypertension, diabetes, high cholesterol, asthma, joint problems, mortality (9-12) Short-term Higher incidence of type 2 diabetes and having cardiovascular risk factors as children (7,13) Development of social and psychological problems (14,15) Economic Costs of treating obesity-related illness are enormous (16) Annual hospital costs for youth: $127 M (17)

5. Youth Overweight: Causes Trends in society: Sedentary lifestyles (18) Increased access to fast food, pre-packaged food, and larger portion sizes (19) School environment is not immune Access to competitive foods through VMs, school stores, special sales, a la carte sales (20-24) Less than 10% of schools require daily PE (25)

6. Youth Overweight: Solutions Need cost-effective, preventive strategies Need to establish healthy behaviors during childhood Need comprehensive, policy-level efforts to effect change (26-27) Schools are an important place to start (26-30)

7. Context for Study State-level: Senate Bill 5436 requires school districts to develop a nutrition and physical fitness policy by August 2005 National-level: Child Nutrition and WIC Reauthorization Act of 2004 requires wellness policies by July 2006

8. Context For Study SB 5436 does not require anything specific about policy content, though federal Child Nutrition Act does Sample policy and procedures were provided, but districts expected to create their own individualized policies (31) Variation is expected - There are 296 school districts in WA

9. School-Based Policies and Programs: Whats in Place Now? National initiatives to improve school health Coordinated School Health Program (32-34) USDA Fruit and Vegetable Program (35) Steps to A Healthier US Initiatives (36,37) School Health Profile for Washington (38) 55% of schools have health advisory committees 64% of schools offer intramural activities 18% prohibit students from buying snack foods from VMs, student stores, etc. during lunch time

10. Findings from SHPPS 2000 for WA (39) IN PLACE Teach and test on health topics, such as nutrition and dietary behavior, and PA and fitness Follow PE stds or guidelines Adopted PE goals and objectives New PE teachers must have training NOT IN PLACE Regularly scheduled recess PE skill or fitness tests Specific student-to-teacher ratios in PE Prohibition of junk food in VMs, a la carte Prohibition of use of food as reward Requires certification for FS coordinators and managers Any faculty/staff health promotion

11. School-Based Policies: Recommendations for Success Findings from policy implementation in other states or nations: Barriers (20,40-43) Contributions (44-47) Suggestions for best practices (48,49): Stakeholder buy-in and formation of advisory committee Implementation plans that include evaluation, funding, and target dates

12. Study Aims 1.What is the content of these policies? 2.Is content associated with school district characteristics? Findings can help to direct technical assistance and training efforts needed currently and to evaluate policy impact in the future

13. Methods: Development and District Recruitment Collaboration with school policy database workgroup: Requested and posted school district policies October 2005 – January 2006 Helped determine what variables to use and how to code policy content areas Helped with data requests for school district characteristics variables

14. Methods: Measurements Policy content components Similarity to sample Inclusion of procedures Inclusion of implementation plans Meets fed wellness policy reqs Meets all 5 policy content areas (Handout) Specific content areas and components School district characteristics Demographics: location; size; race/ethnicity, bilingual, eligible for F/R price meals enrollments Academic indicators: pass rates for WASL standards, annual dropout rates Environmental factors: active PTA, county obesity rate, federal grant recipient

15. Methods: Procedures Policies downloaded from Healthy Schools website Coded according to coding scheme (Handout) Corresponding districts characteristics entered Several of these variables were transformed to match unit of measurement

16. Methods: Statistical Analysis To describe content, used descriptive frequencies To determine associations, used independent t-tests, chi-square tests, and Somers d tests Inter-rater reliability tested for policy content coding on a sample of policies

17. Presentation of Results 1.Description of districts submitting materials 2.Results follow study aims 1.Content 2.Relationships 3.Discuss simultaneously

18. Study School Districts: Location and Size District Characteristic N (%) Location by County Urban64 (53.3) Mixed Urban0 Large Town20 (16.7) Small Town/Rural22 (18.3) Mixed Rural14 (11.7) Size Large (>2000 students enrolled)64 (53.3) Small ( 2000 students enrolled)56 (46.7)

19. Aim 1: Similarity to WSSDA Sample Policy Policy Content ComponentN (%) Similarity to sample policies (N=120) Similar91 (75.8) Not Similar29 (24.2)

20. Aim 1: Indices of Policy Quality Policy Content ComponentN (%) Included procedures (N=120)75 (62.5) Includes plans for implementation and/or phase-in (N=120) 27 (22.5) Meets federal wellness policy requirements (N=107) 40 (37.4) Meets all five policy content areas (N=107)50 (46.7)

21. Aim 1: Specific Components By Policy Content Area Area 1: Setting nutrition education goals (N=114) Districts materials address: a. Classroom teaching 98 (86.0) b. Education, marketing, and promotions outside classroom links with school 69 (60.5) c. Teacher training 46 (40.4) Policy Content ComponentN (%)

22. Area 2: Setting physical activity goals (N=107) Districts materials address: b. PE (time, frequency, and/or intensity) 86 (80.4) c. PE (teacher-to-student ratio) 42 (39.3) d. PE (standards/req based) 46 (43.0) e. PE (staff training/certification) 47 (43.9) f. PA outside of PE 6 (5.6) g. Recess to promote PA 82 (76.6) h. Walking or biking to school to promote PA 38 (35.5) Policy Content Component N (%) Aim 1: Specific Components By Policy Content Area

23. Area 3: Establishing nutrition standards (N=120) Districts materials address: a. Nutritional value of foods and beverages 115 (95.8) b. Portion size 30 (25.0) c. A la carte, vending, student stores, concession stands 96 (80.0) d. After-school programs, field trips, school events 27 (22.5) e. Parties, celebrations, meeting 27 (22.5) f. Food rewards 64 (53.3) g. Food-related fundraising 92 (76.7) h. Food or beverage contracts 81 (67.5) i. Qualifications of foodservice staff 6 (5.0) Policy Content ComponentN (%) Aim 1: Specific Components By Policy Content Area

24. Area 4: Setting goals for other activities promoting student wellness (N=120) Districts materials address: a. Access to school nutrition programs 102 (85.0) b. Time and scheduling for meals 53 (44.2) c. Surroundings for eating 53 (44.2) d. Marketing of food and/or beverages 53 (44.2) e. Sustainable food practices 15 (12.5) f. Access to facilities for PA after school-hours (N=108) 71 (65.7) g. After-school programs (N=108) 74 (68.5) h. Coordinated school health approach 0 i. School health councils 54 (45.0) j. Community/family involvement 59 (49.2) k. Staff wellness 7 (5.8) Policy Content ComponentN (%) Aim 1: Specific Components By Policy Content Area

25. Area 5: Setting Goals for Measurement and Evaluation (N=120) Districts materials address: a. Funding support for policy 3 (2.5) b. Monitoring and evaluation 68 (56.7) Policy Content Component N (%) Aim 1: Specific Components By Policy Content Area

26. Aim 1: Composite Scores for Each Policy Content Area Area 1: Setting nutrition education goals (N=114) Submitted materials: Exceed the area 74 (64.9) Meet the area 25 (21.9) Do not meet the area 15 (13.2) Area 2: Setting physical activity goals (N=107) Submitted materials: Exceed the area 36 (33.6) Meet the area 45 (42.1) Do not meet the area 26 (24.3) Area 3: Establishing nutrition standards (N=120) Submitted materials: Exceed the area 62 (51.7) Meet the area 38 (31.7) Do not meet the area 20 (16.7) Area 4: Setting goals for other activities (N=108) Submitted materials: Exceed the area 54 (50.0) Meet the area 34 (31.5) Do not meet the area 20 (18.5) Area 5: Setting Goals for Measurement and Evaluation (N=120) Submitted materials: Exceed the area 2 (1.7) Meet the area 67 (55.8) Do not meet the area 51 (42.5) Policy Content ScoreN (%)Policy Content ScoreN (%)

27. Aim 1: Policy Content Summary Most districts submitted policies similar to the WSSDA sample policy Many districts submitted procedures, but few submitted implementation plans Almost two-thirds are not meeting the federal wellness policy requirement Only half meet all 5 AFHK content areas, though most meet Areas 1-4, individually Policy content components that were not included in the WSSDA sample policy and procedures are included in fewer school districts materials

28. Recap of School District Characteristics Variables School district characteristics Demographics: location; size; race/ethnicity, bilingual, eligible for F/R price meals enrollments Academic indicators: pass rates for WASL standards, annual dropout rates Environmental factors: active PTA, county obesity rate, federal grant recipient

29. Aim 2: Relationships Similarity to WSSDA Sample Policy Characteristics of districts associated with submitting non-similar policies: Categorical: Size** (large), having a PTA*, participating in a federal nutrition grant* Continuous: lower % enrollment for F/R price meals*, higher WASL pass rates for 4 th*, 7 th*, 10 th* grade students, lower county obesity rates * = p-value <.05, ** = p-value <.01

30. Aim 2: Relationships Indices of Policy Quality Characteristics of districts associated with: Inclusion of procedures higher % enrollment for F/R price meals*, lower WASL pass rates for 7 th** graders Inclusion of implementation plans Size* (large), having a PTA*, grant recipient*, higher WASL pass rates for 4 th* graders * = p-value <.05, ** = p-value <.01

31. Aim 2: Relationships Indices of Policy Quality Characteristics of districts associated with: Meeting federal wellness policy requirements Location** (large and small towns, rural areas), size** (small), no PTA*, higher % enrollment for F/R price meals* Meeting the 5 AFHK policy content areas Location** (large and small towns, rural areas), size* (small), higher % enrollment for F/R price meals*, lower WASL pass rates for 7 th** graders * = p-value <.05, ** = p-value <.01

32. Aim 2: Relationships Individual Policy Content Areas Total WASL Significant negative association with meeting Area 1: Nutrition Education Trend for negative association with Area 2: Physical Education Location Urban school districts met Areas 2, 4, 5 significantly less frequently than expected

33. Aim 2: Relationships Rare Policy Content Components Recap: (2f) PA outside of PE (3b) Portion size (3d) Foods/beverages allowed after school (3e) Food/beverages at parties/celebrations (3i) Qualifications of food service staff (4e) Sustainable food practices (4k) Staff wellness (5a) Funding support for policy

34. Aim 2: Relationships Rare Policy Content Components District characteristic3b3d3e Size (large)****** Active PTA** *** Grant recipient**-*** * = p-value <.05, ** = p-value <.01, *** = p-value <.001 For 3i, 4e, 4k: Grant recipient districts also include 3i, 4e, and 4k more frequently than expected (p-value <.05) –Steps program participants associated with 3i –USDA program participants associated with 4e, 4k

35. Aim 2: Relationships Summary Similar district characteristics associated with: – including procedures, meeting federal requirements, and meeting AFHK areas –Including implementation plans and submitting non-similar policies Districts that are large, have active PTAs, and are grant recipients, more frequently meet components not included in WSSDA sample Non-urban districts more frequently meet some indices of policy quality and individual AFHK policy content areas Districts with high WASL pass rates associated with non- similarity, implementation plans, and not meeting Areas 1&2 Other district characteristics: race/ethnicity, bilingual, dropout rates, obesity rates unable to distinguish any pattern

36. Limitations Convenience sample Methodology has not been validated Variable selection limited by study feasibility Policy content scoring limited to AFHK tool Lack of specificity in content analysis

37. Implications Technical assistance and training efforts should be directed towards helping school districts with: Planning for implementation and how to best phase-in different elements of their policy Identifying sources for funding How to monitor, evaluate, and enforce their policies

38. Implications More research is needed to explore some of the relationships found in this study Questions/issues to consider: Comprehensive versus individualized policies Stakeholder involvement in policy development Findings about having PTAs and grant teams Perceived barriers and effects on policy WASL testing, % eligibility for F/R price meals District characteristics Different results with state-wide sample Consider including political climate (East vs. West)

39. Conclusions Less variation than expected Many school districts have gone above and beyond whats required by SB 5436 Training and assistance in implementation could be beneficial Future research should include in-depth qualitative content analysis and key informant interviews with school districts

40. Thank you Donna, Louise, Glen for guidance and support; Krista for advice on statistical analysis Molly and the school policy database workgroup for helping me develop the methodology and providing data WA State school districts for sending in their policies

41. Questions?

42. References Please see attached.