Cover Story -- April 2003
By Ken Ortolon
When the Texas Medical Association joined parents, teachers, and other health advocates in 2001 to pass legislation to promote healthier lifestyles by increasing kids' physical activity in school, it seemed like a no-brainer. But nearly two years into implementation of Senate Bill 19, confusion over the difference between "physical education" and "physical activity"; budget problems; squabbles among school administrators, teachers, and parents; and pressure to do well on a new student proficiency test seem to have dampened enthusiasm for the effort.
The bottom line, say education officials and fitness advocates, is that no one is really sure how well Texas elementary schools are complying with SB 19 or if they're even trying.
And, in at least one large school district, the drive for children's fitness collided head-on with art and music advocates, leaving a recommendation to bolster physical instruction a tangled wreck.
Part of the problem is that after SB 19 became law, the State Board of Education (SBOE) adopted a rule requiring elementary schools to provide 30 minutes of physical activity daily or 135 total minutes per week. How the districts come up with those minutes is up to them. The rule does not require all 135 minutes to be in organized physical education classes supervised by a certified PE instructor. Instead, it simply calls for 135 minutes of physical activities that get the kids out from behind their desks and exerting themselves in some type of aerobic activity.
While offering physical education classes daily would be ideal, the rule allows for plenty of creativity for school administrators to fit physical activity into their schedules, says Tommy Fleming, director of health and physical education at the Texas Education Agency (TEA). "The whole point is to get kids active, but where you get them active is up to the school district."
Mr. Fleming says many school districts have misinterpreted the rule as a "physical education" rule rather than a "physical activity" rule and may think it requires spending money on more PE teachers and more equipment to comply.
"There appears to be, from some of the phone calls that I've received, a lot of misinformation about the intent of this particular rule," he said. Unfortunately, some health advocates say that misinformation may have arisen from lack of communication from TEA itself.
Mr. Fleming plans to measure the state's 4,000 public elementary schools' compliance with the law this spring. "Senate Bill 19, like so many other unfunded mandates, has no compliance feature to it," he said. "They're supposed to be complying but my gut feeling is, without any objective data, that administrators in many, many school districts have so many other things to think about that they've said, 'Forget it,' and they aren't doing anything."
As if that wasn't enough trouble, Gov. Rick Perry is proposing to eliminate the requirement as part of his Education Freedom Plan to spend more money in the classroom and less on mandates.
"Daily physical education is required even at campuses with no obesity problems or excessive numbers of students with type 2 diabetes. Eliminating this requirement could save $144 million a biennium," the governor's plan says.
Art Versus Sweat
Concern over the unhealthy lifestyles that children are leading peaked in 2001 when statistics showed Texas youngsters were getting fatter and the incidence of type 2 diabetes among children was soaring. Research even found evidence of adult-type heart disease in adolescents. So children's health advocates decided it was time to promote a healthier lifestyle by tearing the kids away from the Twinkies and getting them involved in physical activity.
The result was SB 19, authored by Sen. Jane Nelson (R-Lewisville), which required daily physical activity in elementary schools.
SB 19 had three major provisions. The first authorized the board to adopt rules requiring a minimum amount of physical activity each week for elementary students. The second expanded the scope of school health advisory committees -- which each school district already was supposed to have in place -- to include physical fitness, nutrition, and other health issues. The third required elementary schools to adopt by 2007 a coordinated school health program combining efforts of the physical education program, school nurses, the school cafeteria, and other related programs to alter children's behavior and improve their health and fitness.
But many health advocates now fear that budget tightening and efforts to achieve high scores on the new Texas Assessment of Knowledge and Skills (TAKS) test -- which students must pass to advance or graduate -- will divert teachers' attention from other areas and force physical education to compete with music, art, and other courses for time in the school day.
"There's so much pressure on the school districts to perform on the tests that they don't want to spend any time except on instructional activities," said Craig Tounget, executive director of the Texas PTA.
Mr. Fleming says many schools, including several in Houston, are successfully using recess time to augment their PE classes. Classroom teachers supervise activities such as jogging, jumping jacks, or other exercises for 15 to 20 minutes daily to fulfill the 135-minute requirement. Recess can be used to reinforce and practice what kids are learning during PE classes, he says.
But classroom teachers in other districts have resisted responsibility for this added activity.
In Austin, a physical education task force recently recommended cutting back on that type of physical activity and adding additional PE classes to the elementary schedule. Under the proposal, instead of rotating PE with art and music classes every third day, PE would be held every other day. The duration of PE, art, and music classes also would be lengthened from 45 to 55 minutes, and the amount of physical activity required during other times of the school day would be reduced.
Molly Lambdin, EdD, parent of an Austin student and the task force chair, says the proposal's intent was to address teachers' concerns that they were uncomfortable supervising the physical activity sessions.
She said a survey showed "the classroom teachers were overwhelmed and not able to deliver the kind of activity time that was needed. With all of the other pressure that we put on them, asking them to do another preparation and asking them to be responsible for this part of the curriculum wasn't reasonable."
The survey found most teachers do not feel adequately trained to carry out the physical activity program and that most elementary school principals don't believe their teachers have the knowledge or skills to do so safely and effectively. The irony of that, says Mr. Fleming, is that all certified elementary teachers in Texas are certified to teach PE.
Dr. Lambdin says students also said they like PE but dislike the physical activity time. That certainly is true of Katelyn Kinney, 10, a fourth grader at Davis Elementary School in Austin.
"When I'm focusing on what I'm doing in PE I'm not focusing on anything else. So I forget about what I was thinking about that morning," Katelyn said. "So I don't feel bad anymore." She says she does not enjoy the physical activity time as much because it usually consists of simply running around a track. One PE activity Katelyn likes is curl-ups, which are similar to sit-ups. "I like curl-ups. I'm really good at that."
Eleven-year-old Sierra Villarreal, a fifth grader at Sunset Valley Elementary School, also enjoys PE, particularly organized sports such as soccer. "You get to move around. You move and play games and have fun," Sierra said.
The PE task force and the Austin School Health Advisory Committee proposed that more physical education teachers be hired to lead the additional PE classes called for in the panel's recommendations.
But when Austin school superintendent Pascal D. "Pat" Forgione Jr., PhD, recommended that the increase in PE teachers be achieved by an equal decrease in art and music teachers to stay within budget limitations, it set up a showdown between physical activity and arts proponents. Austin school spokesperson Carmen Luevanos says some 200 citizens showed up at each of two public forums and most opposed the PE recommendations.
In February, Dr. Forgione shelved the task force recommendation and retained the three-day rotation between art, music, and PE, along with the current physical activity system. He said 91 percent of parents, teachers, and others surveyed favored retaining that system.
"Austin elementary schools presently have very strong curriculum-based programs in art, music, and PE, which are each highly valued by our community," Dr. Forgione said. "Continuing the three-day rotation best represents the values and expectations of Austin."
Straying From the Intent
Mr. Fleming says pitting PE against art and music as the Austin debate did violates the spirit of the law. "I don't think the intent of the bill was to increase the amount of activity for these kids at the sacrifice of fine arts education," he said.
Columbus internist Tom B. Hancher, MD, former TMA president and a staunch advocate of SB 19, adds that it should not come down to a trade-off between fine arts and health.
"It shouldn't be mutually exclusive," Dr. Hancher said. "We feel music and art are extremely important, and children should have opportunities to be exposed to both. But not at the expense of good physical education courses that will impact them the rest of their lives. The challenge to the school system is to achieve the proper balance of these things."
Art and music educators agree. Robert Floyd, executive director of the Texas Music Educators Association and chair of the Texas Coalition for Quality Arts Education, says the organizations did not oppose SB 19 in 2001 because they agree with its goals. But they are feeling the pinch between pressure from the TAKS test and the added physical activity requirements.
"I do know that some campuses have lost instructional time," Mr. Floyd said. "What we've seen through the years is a gradual eroding of instructional minutes in the arts because of high-stakes assessment established by the state and, now, the implementation of [SB 19]."
While the Austin school system debate touched off considerable local controversy, arts educators and officials with groups such as the Texas Association of School Boards and the Texas PTA say they are unaware of disputes between fine arts and health advocates in other districts. In fact, Mr. Fleming says several districts are doing a good job of implementing the requirements without hiring additional PE teachers or cutting back on other areas of the curriculum.
A case in point, he says, is the Northside Independent School District in San Antonio. Unlike Austin, where the classroom teachers said they felt uncomfortable supervising the additional physical activity requirements, Northside's physical education instructors realized they would need the teachers' cooperation to meet the daily physical activity requirements. They even drafted a how-to booklet and provided training to help the teachers fulfill the added responsibility. The teachers responded positively to that, says Mr. Fleming, and created a model of cooperation.
While school districts are struggling to juggle their schedules to fit in daily physical activity, they also face having to establish a coordinated school health program. Again, implementation of that portion of SB 19 has been slow, mainly due to lack of communication from TEA.
SB 19 requires school districts to implement a program approved by TEA. Peter Cribb, program director for the Center for Health Promotion and Prevention Research at The University of Texas School of Public Health at Houston, says the law essentially was written to support the use of the Coordinated Approach To Child Health (CATCH) program in the public schools. CATCH, developed by the UT School of Public Health, incorporates physical education, nutrition through the school cafeteria, and parental involvement.
While CATCH was the obvious choice to fulfill SB 19's requirements, when it came time for TEA to approve a program for elementary schools, vendors of similar programs asked to be considered, delaying the approval process.
But in October 2002, TEA approved CATCH for use by the schools. In January 2003, a second program, called The Body Shop, also was approved. But as of February, TEA had not yet informed either vendors or any elementary school in Texas that the programs had been officially approved to meet SB 19 requirements. Mr. Cribb says that may be because another vendor was protesting the selection process.
Mr. Fleming admits the process has been slow, but says he hopes that letters informing districts of their program options will go out shortly.
Despite that, some 1,000 elementary schools already are implementing CATCH. Again, Mr. Fleming says TEA has no idea where districts are in the implementation process because of the lack of accountability standards in SB 19. And, Mr. Cribb says the majority of those schools had purchased CATCH before the enactment of SB 19.
Still, in the past two years, CATCH has trained teams from some 370 schools to implement the curriculum. Most recently, CATCH trained some 300 personnel from 34 Brownsville elementary schools, which is significant, he says, because Brownsville has the highest rate in the state of children overweight or at risk of obesity.
Teams trained for each school include the food service manager, a PE specialist, and a classroom teacher.
While districts still are struggling to come to grips with SB 19, more physical education mandates may be on the horizon. Sen. Eliot Shapleigh (D-El Paso) has introduced legislation this year that goes far beyond simply mandating physical activity for elementary students.
Among other things, Senator Shapleigh's bill extends physical activity requirements to middle schools, bans high-fat and high-sugar content beverages and snack foods from campus vending machines, and creates an Obesity Prevention Coordinating Council.
The outcome of Senator Shapleigh's legislation couldn't be predicted at press time, but some education officials and health advocates say it would have a healthy price tag, which likely could spell doom in a session where lawmakers already are facing an urgent need to cut spending to solve a nearly $10 billion budget shortfall.
Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by e-mail at Ken Ortolon .
El Paso Initiative Holding Down Kids' Weight
A school health program focusing on physical activity and nutrition is helping to reduce obesity among elementary school students in El Paso, West Texas, and Southwest New Mexico.
Karen Coleman, PhD, a researcher at San Diego State University, says the Coordinated Approach To Child Health (CATCH) program launched in El Paso schools in 1997 appears to be slowing the rate of obesity and risk of obesity for children there.
Dr. Coleman presented her findings during the Promoting Healthy Weight in Texas Conference in San Antonio in February. She evaluated CATCH's success in El Paso schools while on the faculty of The University of Texas at El Paso.
CATCH is a comprehensive program that brings together classroom teachers, physical education instructors, cafeteria staff, and others to increase physical activity, serve healthy meals, and provide health education. CATCH was initiated in 18 El Paso schools in 1997 with $4.7 million from the Paso del Norte Health Foundation.
Today, the El Paso program includes some 50,000 children in 108 schools in El Paso and in several other districts in West Texas and Southwest New Mexico.
Dr. Coleman's study measured rates of obesity and risk of obesity in third graders in CATCH and non-CATCH schools during the 1999-2000 school year. The students were reevaluated as fourth graders and again as fifth graders.
Baseline data showed that 30 percent of girls and 40 percent of boys at the CATCH schools were at risk of obesity in the third grade. For girls, the rate increased to 32 percent in fourth grade and remained at 32 percent in fifth grade. Among non-CATCH schools, however, 26 percent of girls were at risk of obesity as third graders, increasing to 38 percent and 39 percent in fourth and fifth grades, respectively.
"That's a significant increase," Dr. Coleman said. "So CATCH was able to actually prevent the increase."
Boys in CATCH schools saw their obesity risk rise to 41 percent in both fourth and fifth grades, while boys in the non-CATCH schools saw their rates increase to 48 and 49 percent, respectively.
Researchers say children at or above the 85th percentile for ideal body mass index are at risk for obesity and children at or above the 95th percentile are overweight.
The percentage of children in the CATCH schools who were overweight rose more rapidly than those at risk of obesity during the three-year study, but not as fast as children in the non-CATCH schools.
Dr. Coleman says children's health advocates used the study to convince the El Paso school board to reject a $20 million, 10-year contract that would have given Pepsi exclusive rights to sell beverages in vending machines in El Paso schools.
"They agreed to table the proposal they were going to sign that day and renegotiate it," she said.
Eventually, the district approved agreements with Pepsi and Coca-Cola to stock elementary and middle school vending machines with bottled water, 100 percent fruit juice, and low-fat milk only.
Prevention Plan Targets Childhood Obesity
State health officials hope a new plan preventing childhood obesity will mean Texas will have fewer overweight adults in the future.
On Feb. 13, Texas Health Commissioner Eduardo Sanchez, MD, unveiled the Strategic Plan for the Prevention of Obesity in Texas, which he hopes will reduce the burden of weight-related disease by decreasing what he called "alarming" and "dangerous" rates of obesity.
"We have to change our kids' eating and exercise habits, or we're going to be in for an explosion of diabetes, heart disease, high blood pressure, stroke, and several other serious problems that will devastate lives and inundate our medical care system," Commissioner Sanchez said. "If we don't, we may be looking at a generation of kids whose lifespan actually will be shorter than that of their parents."
The strategic plan was developed over the past 18 months by a statewide obesity task force. The plan calls for increasing awareness of obesity as a public health threat; mobilizing families, schools, and communities to create opportunities for healthy lifestyles; promoting policies and environmental changes that support healthful eating habits and physical activity; and monitoring obesity rates and related behaviors and health conditions.
A study conducted for the Texas Department of Health by the School of Public Health at The University of Texas Health Science Center at Houston found that 39 percent of Texas fourth graders and 38 percent of eighth graders are overweight or obese. Another study shows that 61 percent of Texas adults are overweight or obese, up from 43 percent in 1990.
Task force Chair William Klish, MD, professor of pediatrics at Baylor College of Medicine, says the panel chose to focus the plan on prevention of obesity rather than treatment. "It's logical that we do this because treatment at its present state of the art is not very successful in regard to helping obese individuals," he said. "But even if it were, if we allow this epidemic to continue at its current rate, we would not have enough money to support the therapy that would be needed for the large number of people who have developed obesity."
The second focus of the plan is on children and their families, Dr. Klish says. "The roots of adult obesity fall within childhood," he said.
He says studies show that children who are overweight at age 12 have a 75 percent chance of becoming overweight adults. "We also know that at age 10 the risk of obesity in an adult is more related to the weight of that individual child than it is to the genetics of that child. So if you can prevent obesity in the child, you are going to prevent obesity in the adult."
TMA Foundation Promotes CATCH to Local Schools
Partnering with county medical societies and alliances, the Texas Medical Association and the TMA Foundation took the message about the importance of daily physical activity and proper nutrition directly to several local communities in 2002 and early 2003.
Operating with nearly $45,000 in medical community outreach grants from the foundation, six county societies and alliances in Houston, San Antonio, Lubbock, Tyler, Fort Bend County, and Hopkins County sponsored programs to increase awareness of the importance of exercise and nutrition in preventing cardiovascular disease and stroke. Four of the projects specifically were designed to help local school districts implement the Coordinated Approach To Child Health (CATCH) program or similar programs in elementary schools.
The grants were part of the third and final phase of TMA's Project WATCH , a public health initiative that focused public attention on weight, activity, tobacco, cholesterol, and high blood pressure, the five primary factors contributing to heart disease and stroke.
The foundation also provided funds to TMA to extend Project WATCH into local areas by promotion and awareness, program support, and materials and tools that can be used on the local level; and by urging county societies and alliances to undertake programs that encourage greater physical activity among schoolchildren through implementation of CATCH in their schools or through community health projects.
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