Public Health Feature -- January 2001
By Laurie Stoneham
The children of Texas are in the midst of a health crisis.
They're overweight, not getting enough exercise, and acquiring
chronic diseases once seen only in adults. The statistics today are
alarming enough, but if current trends continue, the future is
Think about it. What's the outlook for a 300-pound, 11-year-old
boy in Corpus Christi who's just been diagnosed with type 2
diabetes? Where will that child be in 20 years? How productive will
he be? What will it cost to care for this adult, living with and
battling all the risk factors for heart disease and stroke? And
what kind of financial and resource burden will Texas be facing if
a large portion of the state's adult population is in the same
These are current and future trends the Texas Medical
Association wants to change. It's leading the charge on a number of
fronts to help improve the health and physical education (PE) of
children in elementary grades. The initiative kicks off Phase II of
, a collaborative effort of TMA and the TMA Alliance, funded by the
TMA Foundation. Project WATCH is a three-year initiative that
focuses on the five leading preventable risk factors for
cardiovascular disease: weight, activity, tobacco, cholesterol, and
high blood pressure. TMA and Texas physicians are working to
educate patients about these risk factors and decrease the number
of Texans who develop and die from cardiovascular disease each
What we're talking about is a lifestyle crisis. Kids, like many
adults in this country, are eating more and moving less. Hours a
day are spent in front of a television or computer screen. Most
organized sports provide little in the way of ongoing vigorous
movement, and PE in the schools is sporadic at best. The result is
spiraling inactivity and obesity that can lead to serious health
consequences, including diabetes, cardiovascular disease, and some
forms of cancer.
Nationally, children and adolescents have been gaining weight
for decades, as seen in the results of two multiyear studies, the
National Health Examination Survey and the National Health and
Nutrition Examination Survey (NHANES) (I-III), conducted from 1963
to 1991. The prevalence of obesity has doubled among children of
both sexes aged 6-11. For some groups, the numbers are even worse.
In 1963, for example, 2 percent of African-American boys aged 6-11
were considered obese, as defined by age-specific height-weight
charts. By 1991, 13.4 percent of African-American youngsters in
this age group were seriously overweight.
Texas youth is not faring much better. Karen J. Coleman, PhD,
and Edward M. Heath, PhD, with The University of Texas at El Paso,
received a grant from the American Heart Association to assess the
health of 915 primarily Hispanic third-graders in El Paso. They
found that 35 percent of the boys and 29 percent of the girls were
overweight, while 22 percent of the boys and 15 percent of the
girls were clinically obese.
Stephen Barnett, MD, chair of the TMA Child and Adolescent
Health Committee, believes that physicians must be aware of what's
happening. "We have to be sure that clinicians really understand
the prevalence of overweightness and obesity in children and
adolescents in our state. It's almost doubled in the last decade.
That is a striking increase in prevalence."
Adult diseases in kids
Dan Hale, MD, director of the Children's Center at the Texas
Diabetes Institute in San Antonio, tracked new cases of diabetes
among youth from 1990 to 1997. Type 2 diabetes, which until two
decades ago was thought to only affect adults, accounted for 18
percent of all new diagnoses. In 1990, there was only one case of
juvenile type 2 diabetes, while in 1997, 30 new cases in children
In 1999, the Texas Legislature funded a two-year program to
screen children in nine border counties for acanthosis nigricans
(AN), a condition that appears as a dark ring around the neck. AN
is a marker of suspected insulin resistance, which is an accepted
risk factor for type 2 diabetes but is not pathognomonic for it. In
the first year, 14.4 percent of the 102,733 children screened had
Stephen Ponder, MD, director of the Diabetes and Endocrine
Center at Driscoll Children's Hospital in Corpus Christi, says he
sees almost as many new cases of type 2 diabetes as type 1, which
used to be the only form of diabetes seen in juveniles. He notes
that obesity is the sentinel risk factor for the disease that, as
is the case with adults, may progress for many years
"I didn't see this kind of morbid obesity 10 to 15 years ago,"
said Dr. Ponder, who had a 347-pound, 11-year-old patient. Along
with hypertension and lipid problems associated with diabetes, Dr.
Ponder explains that many of these youngsters have a hidden problem
-- sleep apnea. "Because they are doing poorly academically, these
kids are often erroneously diagnosed with attention deficit
disorder and may be treated inappropriately with Ritalin."
Dr. Barnett says that while the overall number of children with
type 2 diabetes is not that high, the increasing incidence (number
of new cases diagnosed each year) is alarming. "We're seeing
diabetes attack a new part of the population because of obesity in
children and adolescents."
These statistics follow national trends for adults. A study
published in August 2000 by the Centers for Disease Control and
Prevention (CDC) found that type 2 diabetes increased by 70 percent
among people aged 30-39, 40 percent for those aged 40-49, and 31
percent for individuals aged 50-59.
Down the road
The demographics of Texas make these trends even more chilling.
TMA President Jim Rohack, MD, points out that the Hispanic
population is at increased risk of diabetes. "Knowing that by 2030
almost 50 percent of Texans will be Hispanic and thus at risk, we
really need to start right now working with kids who are ages 2, 3,
4, and 5. Otherwise, in 30 years when these individuals are in the
majority, they're going to be coming down with diabetes."
Dr. Rohack continues with a big picture overview. "The broader
perspective is, how are we going to pay for all this? How are we
going to pay for Medicare if individuals are going to have to leave
the workforce, disabled by complications of diabetes,
cardiovascular disease, heart attack, or stroke at a premature
Treating this population "becomes unbelievably expensive and
unmanageable," Dr. Barnett points out. Clinical management of
weight and glycemic control is extremely challenging for all
physicians, yet necessary to prevent the complications of heart
attack, stroke, renal failure, blindness, and loss of limbs. "If
there are ways to get in on the front end and try to prevent that
from happening, it's a small marginal cost and avoids enormous pain
and suffering," he said.
Dr. Rohack says part of the reason TMA is working with the TMA
Alliance and TMA Foundation on the project "is that it's not only
about good quality care, but also about the practical aspect of
being able to have a healthy workforce that continues to make Texas
productive in the years ahead."
Attacking the problem
To address this growing public health concern, TMA spearheaded
the formation of the Texas Coordinated School Health and Physical
Education Coalition, an alliance of statewide groups that
understand the vital short- and long-term consequences of improving
child and adolescent health in this state. It's comprised of TMA,
Texas Pediatric Society, Texas Association for Health, Physical
Education, Recreation, and Dance, Texas Parent Teacher Association,
the Center for Health Promotion & Prevention Research at the
School of Public Health at The University of Texas-Houston Health
Science Center, Texas Department of Health, Texas Diabetes Council,
Texas Cardiovascular Disease Council, American Heart Association,
American Diabetes Association, American Lung Association, American
Cancer Society, and Texas Bicycle Coalition.
The goal is to make a difference in the health and physical
education of youngsters in elementary schools by helping them make
better food choices and increase the amount of physical activity
they have during school hours.
Project WATCH is in the early stages of Phase II, which will
focus on physical inactivity in elementary school children. TMA has
produced bookmarks featuring Wags the Watchdog, with a message on
the importance of physical activity. The bookmarks, printed in
English and Spanish, will be distributed in collaboration with the
TMA Alliance, Texas Parent Teacher Association, Texas School Nurses
Association, and others. This project has been underwritten by
AstraZeneca and The Cooper Clinic.
"It would make perfect sense to promote physical activity and
better nutrition through the school system," said Thomas M.
Fleming, PhD, director of health/PE with the Texas Education Agency
(TEA). "After all, there are 4 million kids in the Texas system,
and they spend a huge amount of their early life in that system.
For behavioral changes to occur, kids have to be exposed to a
system of education that will assist in motivating them to change
lifestyle habits," he said.
The problem, according to Dr. Fleming, is that the health and PE
instructional system in Texas schools is inadequate. While health
and PE are listed as "required curriculum" in the Texas Education
Code, Dr. Fleming explains that health and PE courses only have to
be offered or made available. "That does not mean that kids are
required to take the subjects. Districts are free to offer the
subjects as electives rather than required subjects and to devote
as much time to instruction as they choose. Many districts,
primarily because of the emphasis on subjects that are tested as a
part of the state's accountability system, are devoting less and
less time to health education and PE," he said.
Over the years, a program known as CATCH (Coordinated Approach
to Childhood Health) has gained statewide attention and approval.
This innovative program was funded originally by the National
Heart, Lung, and Blood Institute and has been shown to increase
children's physical activity and improve health food choices in and
out of school.
The multidimensional program teaches and reinforces healthy
choices from a variety of sources. The program includes a classroom
curriculum for grades three through five, a physical education
curriculum, a food service program, and a family component.
In the classroom, children have colorful workbooks that show and
discuss healthy lifestyle choices. An in-class exercise may teach
students how to make a tasty snack such as "Ants on a Log," which
is peanut butter in celery, dotted with raisins. The Facts and
Activities About Chewing Tobacco and Smoking (FACTS) component
shows and tells kids what tobacco does to the body.
The goals of the program are relatively simple:
- Reduce fat and sodium content in school meals. Have all meals
average no more than 30 percent of calories from fat and contain
600-1000 mg sodium per meal;
- Increase intensity of physical activity. During PE class,
have kids spend at least 50 percent of their time in moderate to
vigorous physical activity;
- Encourage healthy lifestyles. Help children learn how to
prepare and choose healthier foods and stay more physically
active away from school; and
- Emphasize and reinforce the elements of a healthy diet and
physically active lifestyle through worksheets and activities
done with the family.
The Texas Department of Health has provided funding in the past
to assist schools with purchasing the classroom curriculum. The
program has been supported and promoted by both TEA and the State
Board of Education. Peter W. Cribb, CATCH project director for the
Center for Health Promotion and Prevention Research at The
University of Texas-Houston School of Public Health, says that
while the program has been adopted by more than 700 schools
throughout Texas, it has not been fully implemented and supported.
And ongoing support is key to the success of CATCH because it's
introducing, changing, and reinforcing new behaviors.
Measurable results oriented
CATCH is proven to work, as reported in the
Journal of the American Medical Association
Archives of Pediatrics & Adolescent Medicine
(1999;153:695-704). Two studies found that CATCH intervention was
successful in modifying the fat content of school lunches,
increasing the level of activity in PE classes, and improving the
eating and activity behaviors of children during three school
years. It also was found that the children who made positive
changes in elementary school years continued those behaviors into
These findings have been duplicated in the El Paso/Las Cruces,
N.M., area, where grant funds from the Paso Del Norte Health
Foundation and the American Heart Association have been used for
the last three years to reach some 52,000 students in 83 elementary
schools and their families. Because of the program's success,
funding has been granted to extend the program for two more
According to Dr. Coleman, who's directing the evaluation of
CATCH in El Paso and Las Cruces, the key to success is providing
ongoing feedback and support for teachers, PE instructors, and food
Mr. Cribb has found that a CATCH resource person regularly
visiting schools is extremely helpful in overcoming barriers and
resistance. "CATCH does not include all health education topics
that students at this age need to know," he admitted, "but it does
provide a firm foundation for the school from which to build, and
it complements other school health programs. The materials and
curriculum are flexible enough to be adapted to meet individual
class, school, and teacher's needs."
The coalition realized early that unfunded mandates to local
school districts weren't the way to go. "If we were going to go for
a mandate for physical education, we knew we'd be shooting
ourselves in the foot because of local control issues," said Karen
Batory, director of the TMA Division of Public Health and Quality.
"We need to advance this model because this program actually builds
on local control."
The coalition is proposing that a six-year program be funded to
phase in the CATCH program into 600 elementary schools, plus 160
feeder middle schools. Money would be used to hire CATCH
coordinators in each of the 20 education service centers in Texas,
and to pay for the materials, equipment, and professional training
of teachers, cafeteria staff, and PE instructors. Each phase of
implementation would be evaluated to measure the results of the
program. The aim is also to improve community awareness of the
program, its goals, and objectives.
Mr. Cribb says he ensures that the schools selected to be
involved with full training and support will serve as "leadership
or demonstrator schools" that will then influence other schools in
the area to adopt the program. "With this strategy, we have the
potential to impact 1 million kids." That would be 25 percent of
all students in Texas schools.
A shared vision
Dr. Barnett points out that children, parents, and schools will
see immediate results from CATCH. Parents will see increased
activity levels, better eating habits, healthier weights among
children, and a reduced likelihood to use tobacco, alcohol, and
other drugs. This will have a definite influence on family health
as well. "Schools will see less absenteeism, more positive
attitudes toward classwork, and less failure and lower dropout
rates. There are a number of indicators that aren't direct results
of this curriculum but have this indirect outcome," Dr. Barnett
"Teaching quality physical activity is a tool that you can use
for the rest of your life. It doesn't require a lot of money; it
just requires a commitment. You're going to learn better, you're
going to be in better shape, and you're going to have a better
quality of life long-term," Dr. Rohack said. "We should be focusing
not only on children's ability to point and click with a mouse, but
also on their ability to walk a mile within a 20-minute time
period," he added.
"If we expect to have an impact on the health of adults, we have
to address the health of our children," said TMA President-Elect
Tom Hancher, MD. He says a well-rounded education is not just about
reading, writing, and arithmetic. Physical and health education
have been pushed back because of time constraints. "We need to make
adjustments because healthy kids are those who will perform well
Dr. Fleming uses a quote from the book
Health Is Academic
in many of his presentations. "If we don't deal with children's
health issues by design, then we will deal with them by
"We believe this just gets to the roots of what we're all about
-- physicians caring for Texans," said Dr. Rohack. "But we also
know we're more powerful when we can link with our county societies
and develop coalitions with others who share common goals to
improve the health of all Texans."
Health and physical education "requirements" in Texas
There are no standard time or content requirements for physical
education (PE). Health education is extremely weak at this level
because of the emphasis on core subjects that are a part of the
state accountability system. Most of the health education
instruction is taught by PE teachers.
: No time or content requirements. Coaches teach most subjects and,
in many districts, focus on athletic responsibilities rather than
instruction. Many districts skip a grade level -- 7 or 8 -- during
which neither PE nor health are even offered.
One and one-half PE credits are required for graduation, but there
are eight different ways to substitute this requirement, including
off-campus PE, athletics, cheerleading, drill team, marching band,
fine arts dance, ROTC, and even some career and technology classes.
As a result of these waivers, only about 20 percent of Texas high
school students receive physical education. One semester of health
education is required in Texas. In many districts, the course is
taught by coaches who have the same demands regarding athletics
that middle school coaches have.
Source: Thomas M. Fleming, PhD, director, Health/PE, Texas
Weighing in on obesity
Here are the results of the National Health and Nutrition
Examination Survey III, conducted during 1988-1991. These figures
are based on age-specific height-weight charts. A child who is in
the 85th percentile is considered overweight, while one who is in
the 95th percentile is obese.
|Boys aged 6-11
|Boys aged 12-17
|Girls aged 6-11
|Girls aged 12-17
Source: Karen J. Coleman, PhD, Behavioral Fitness Laboratory,
The University of Texas at El Paso