Physicians Help Protect Athletes, Foster Health

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Public Health Feature – March 2013

Tex Med. 2012;109(3):47-51.

By Crystal Conde 
Associate Editor

Physicians play a pivotal role in assessing students' fitness for athletics and other extracurricular activities and in helping Texas schools adopt effective health policies. Whether they're on the sidelines at sports events, attending school health advisory council (SHAC) meetings, or examining patients in clinic, physicians can dramatically affect student health and well-being.

For the past 15 years, Stuart Rowe, MD, an Austin pediatric cardiologist, volunteered his time to conduct free physicals of uninsured and underinsured Austin Independent School District (AISD) students in athletics, band, and other school-sponsored extracurricular activities. The Travis County Medical Society (TCMS) hosts the annual event, which will include four evening clinics this year in April and May.

Dr. Rowe examines the students' cardiovascular system and reviews their cardiac history to identify any problems that exercise might exacerbate. The most common cause of sudden cardiac death in young athletes, he says, is hypertrophic cardiomyopathy.

"In past clinics, I have done follow-up evaluations of students who turned out to have hypertrophic cardiomyopathy. Every year, about five students I see warrant additional evaluation. If at all possible, I try to see them in my office for the sake of convenience and continuity of care. I will refer them to another pediatric cardiologist if necessary," Dr. Rowe said.

Middle school and high school students attend clinics at the Toney Burger Activity Center in South Austin or the Delco Activity Center in North Austin. TCMS Senior Director of Community and Government Relations Stephanie Triggs says about 100 physicians volunteer annually to conduct physicals of uninsured students and those who don't have access to a primary care physician.

She says the school district's athletics department "works with trainers and coaches at the schools to identify uninsured and underserved children who could benefit from these free physicals. They're good about getting the word out so these students can take advantage of the opportunity."

Wesley Foreman, MD, an Austin pain medicine physician, has volunteered to conduct free physicals at the event for the past five years.

"Something as simple as a physical could keep some children from participating in sports and other school activities. I volunteer as a way to give back and to ensure these kids can take part," Dr. Foreman said. 

Ms. Triggs says physicians oversee specific examination stations, which include ear, nose, and throat; orthopedics; heart and lung; and abdomen. Before students rotate through each exam station, nurses check their blood pressure and vision. Anywhere from 600 to 1,000 students participate in the free physicals each year, Ms. Triggs says.

Stephen Pont, MD, oversees the TCMS free annual student physicals as medical director of AISD's student health services program. He says the clinics give volunteer physicians an opportunity to teach students about the value of regularly seeing a primary care doctor.

"We see about 200 students each night, so this event gives us a chance to educate them before they begin their physical evaluations," he said.

Texas Medical Association policy on physician examinations for young athletes takes into account that these exams provide an entry point into health care for young Texans who may not have regular access to a primary care physician. Among its provisions, the policy outlines TMA's support of student involvement in sports and other physical activities and eliminating barriers that prevent students from participating. TMA supports changes in the Texas Education Code to require that only licensed physicians or appropriately supervised physician assistants or advanced practice nurses licensed in Texas conduct athletic preparticipation physical examinations for school-age children.

Dr. Rowe says the TCMS-sponsored free physical examinations represent a thorough well-child assessment for those students who may not have access to a medical home.

"The physicals also provide significant reassurance to the schools, parents, and coaches that these children can safely participate in athletics and other activities," he said.

Physicians Involved in School Health

For the past four years, Dr. Pont, medical director of the Texas Center for the Prevention and Treatment of Childhood Obesity, has been a member of the AISD SHAC. SHACs advise Texas school districts on coordinated health programming and its impact on students' health and learning. Texas law requires all school districts to have a SHAC.

Dr. Pont says AISD, which has about 90,000 students, values health as an important aspect of education and school performance. He works with the more than 130 AISD student health service staff members – nurses, school health assistants, and administrative staff – who are employees of Dell Children's Medical Center.

Dr. Pont attends monthly SHAC meetings and provides his medical expertise. He says the SHAC is instrumental in advocating for adequate physical activity and nutritional changes for students to prevent obesity and promote healthy eating.

For example, in 2009, when the legislature stopped requiring Texas high school students to complete one semester of health education and reduced the number of physical education (PE) semesters from three to two to graduate, the AISD SHAC took action. The SHAC recommended the school district maintain the requirements that all high school students take a semester of health and a year-and-a-half of PE, and the school board agreed.

"The ability of Austin's SHAC to develop and implement policy recommendations is part of what makes it a model for other school districts," Dr. Pont said.

The school district can enforce the health and PE curricula because the school board voted for the requirements, making them district policies.

The Austin SHAC also helped implement nutrition requirements for vending machines that make healthier snacks the most affordable options.

"The vending machines now contain foods with reduced amounts of fats and sugars. All beverages have to be 100-percent real fruit juice or low in sugar, and water is the cheapest beverage available. These state-of-the-art vending machines even have video monitors where the district can display health messages," Dr. Pont said.

AISD also hired a chef to oversee creation of a healthy school lunch menu that meets federal guidelines and requirements while incorporating as much locally grown produce as possible. In fact, some of the school district campuses have vegetable gardens on site.

Instituting these kinds of changes in the face of limited funding and dwindling public school resources is no small task.

Dr. Pont says the SHAC overcame barriers to improved health and nutrition in schools by identifying areas where the priorities of the SHAC and the school district align.

"Schools have to meet attendance and test score requirements. SHAC members know that the healthier children are, the better they do in school and the fewer classes they miss. Once we're able to make that connection between academic performance and health, it becomes easier to affect change in school health," Dr. Pont said.

A 2009 study by the Texas Education Agency (TEA) indicates physically fit students are more likely to perform well on tests and have fewer disciplinary problems in school.

Dr. Pont says school districts value having physicians and other health care professionals serve on local SHACs.

"Doctors are health leaders in the community. They can have a great impact on the health of children. People look to physicians for health information because doctors can supply them with accurate information from reliable sources," he said.

Physicians interested in joining their local SHAC can visit the school district's website for information or contact the school superintendent. Dr. Pont suggests physicians attend a SHAC meeting to get an idea of what's involved in membership and to see that it's a collaborative atmosphere.

Keller family physician Erica Swegler, MD, chair of the TMA Committee on Infectious Diseases, was Keller High School team physician for seven years. She says physician involvement in school health is beneficial.

"I valued my time on the sidelines. As a physician, I was able to work with the athletic trainers on assessing athletes for injury and on managing athletes with health conditions," she said.

A Healthy Foundation

Dr. Swegler recognizes the importance of building a foundation for healthy lifestyles in children.

"Obesity is one of the greatest health threats to our generation and subsequent generations. Healthy diet and adequate exercise are keys to good health in children, and those habits will follow them into adulthood," she said.

Keeping Texas children moving and ensuring healthy eating habits help curtail the state's obesity rate. The Texas Public Health Coalition (TPHC), of which TMA is a charter member, developed legislative recommendations that include the following obesity prevention priorities: 

  • Preserve funding for the Texas School Health Network within the Texas Department of State Health Services (DSHS) budget while supporting the chronic disease prevention exceptional item related to obesity prevention.
  • Restore a half-credit of PE in high school as well as health as a requirement for graduation.
  • Strengthen the TEA's prekindergarten health standards related to nutrition and physical activity. Allocate a specified percentage of the Texas Department of Agriculture's health and nutrition grants for programs serving young children.
  • Use local SHACs to make policy recommendations to school districts on the types and quantity of sugar-sweetened beverages sold in school vending machines and a la carte offerings.
  • Support policies that address obesity and a lack of access to affordable and healthy foods, including using vacant state land for community gardens and incentives for private landowners to offer a portion of their land for the same purpose.
  • Support establishing nutritional content standards and guidelines that set local food procurement targets for foods offered via vending machines and food service programs in state facilities and agencies. 

For a full list of TPHC legislative priorities and for information on the group's members, mission, and advocacy areas, visit the TMA website.

Joel Romo, senior director of government relations for the American Heart Association Southwest Affiliate, chairs the TPHC obesity subcommittee.

"In developing these recommendations, our subcommittee took a lot of time to examine all aspects of obesity prevention in order to garner support for addressing obesity in the classroom and at the kitchen table, on the school playground and at neighborhood parks," he said.

Sen. Jane Nelson (R-Flower Mound), chair of the Senate Health and Human Services Committee, says she shares the coalition's "overall goal to encourage Texans to take better care of their health."

In line with the coalition's recommendation to increase physical activity and health education requirements in public high schools, Senator Nelson introduced Senate Bill 134 this session to require one-and-a-half credits of PE and one-half credit of health education for high school graduation.

"One of the best ways to convince more Texans to live healthy lifestyles is to instill good habits during childhood, which is why I will fight for more physical education in our schools. Healthy habits mean Texans will live longer, better lives and incur fewer costs related to chronic illnesses associated with unhealthy behavior," Senator Nelson said.

TPHC's obesity prevention recommendations support DSHS' exceptional item request related to chronic disease prevention.

The department is asking the legislature for $8.57 million for 2014-15 to fund initiatives such as increasing tobacco prevention and cessation funding for Quitline counseling services and expanding the department's efforts to implement chronic disease reduction and prevention efforts in urban areas. DSHS exceptional items requests total about $352 million for the coming biennium.

Mr. Romo adds the state and nation are facing a critical time in regard to the obesity epidemic.

"Physicians, lawmakers, and public health officials need to make sure children have an opportunity to be active every day and parents are aware of what their children are eating and how it affects their health," he said.

 Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.

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