Public Health - January 2009
Tex Med . 2009;105(1):29-34.
By Crystal Conde
The sheer weight of fat is smothering our children and our wallets.
As Texas children, adolescents, and young adults grow bigger and continue to make unhealthy lifestyle choices, they also increase their chances of developing heart disease, stroke, type 2 diabetes, disabling musculoskeletal conditions, end-stage renal disease, arthritis, sleep apnea, and asthma. (The February issue of Texas Medicine will be a special issue on the emergence of adult diseases in children.)
An American Heart Association (AHA) report finds that obese children are at increased risk for developing heart disease. The AHA study involved 70 children aged 6 to 19 years.
To prevent children from developing life-threatening diseases and to cut the fat and save both lives and money, the Texas Medical Association has joined with a host of public and private organizations.
Herminia Palacio, MD, MPH, Harris County Health Department executive director and chair of the Texas Public Health Coalition, says the collaboration of stakeholder organizations places an emphasis on the health of Texas communities, not just individual patients.
"I think it's great to have physicians recognize and support focusing on the preservation of health rather than on treating the consequences of illnesses. The coalition represents an opportunity to link medicine and the public's health, to concentrate on prevention and making a difference at the state level," she said.
And Texas is in dire need of a public health turnaround. A 2007 report by the Texas Comptroller of Public Accounts estimates that obesity cost Texas businesses $3.3 billion in 2005. And the comptroller's report places the state's total obesity-related health care expenditures in the neighborhood of $114 billion.
Obesity threatens the future Texas workforce, as well. In 2005, 42 percent of Texas fourth graders, 39 percent of eighth graders, and 36 percent of 11th graders were overweight and obese. (See " Prevalence of Overweight and Obesity Among Texas Children, 2004-05 .") The comptroller's report projects that overweight children have a 70-percent chance of becoming overweight or obese adults.
The Texas Education Agency (TEA), the Texas Department of Agriculture (TDA), and the Texas Department of State Health Services (DSHS) are collaborating to reverse this alarming trend through nutrition education, physical activity, and access to healthy foods. Together, they're requesting more than $140 million in funding from the Texas Legislature for 2010-11 to achieve their goals. (See " TDA, TEA, and DSHS Legislative Funding Package .")
All three organizations are represented in the Texas Public Health Coalition, of which TMA is a charter member. The coalition developed legislative priorities and community calls to action to promote prevention and healthy lifestyles throughout the state. (See " Texas Public Health Coalition Legislative Priorities for Obesity .")
The Public Health Coalition also urges physicians to become involved in schools and communities to improve children's diets and promote exercise. State initiatives and local programs offer health care professionals an opportunity to make a difference.
Assessing Children's Fitness Levels
The 2007 Texas Legislature passed Senate Bill 530, which requires public schools to assess the fitness levels of all students in grades 3 through 12, beginning with the 2007-08 school year. TEA approved FitnessGram as the official testing vehicle last year.
The first-ever FitnessGram test shows dismal results for high school students. Among 11th grade students, about only 11 percent of girls and 12 percent of boys achieved a healthy fitness zone on all six test items. The percentages are lower for high school seniors, with only 8 percent of girls and about 9 percent of boys able to reach a healthy fitness zone on all six tests. (See " FitnessGram Test Results .")
Kenneth Cooper, MD, founder of The Cooper Institute in Dallas, developed the FitnessGram test and helped raise donations to implement it at schools across the state. He hopes the test results shock Texans into reality and into action.
"We must immunize children against obesity while in elementary school so that as they age they are more likely to stay healthy and fit," he said in a TEA news release. "By the time students graduate, they should be ready mentally and physically to achieve their dreams. We have an incredible opportunity and responsibility before us to improve the health of Texas children."
Part of the reason for low attainment on the FitnessGram test could be the physical education (PE) requirement for high school students, who have to complete only one-and-a-half credits of PE to graduate.
To make sure high school students get more active, the Texas Public Health Coalition recommends legislation and funding to require physical activity programming in all grade levels.
Marissa Rathbone, director of school health in TEA's Division of Health & Safety, says she expects the FitnessGram numbers to improve over time.
"Last year was the first time the FitnessGram had been administered, and it will be interesting to see how these percentiles change this year," she said. "The students will come to understand that this is an effort to get a baseline of where they are and how they can improve their health."
FitnessGram's six test items measure students' aerobic capacity; muscular strength and endurance; flexibility; and body composition. The test items include:
- An option of a 20-meter shuttle run increasing in intensity as time progresses, a one-mile run, or a one-mile walk;
- A skin fold measurement or calculation of body mass index;
- Curl-ups to measure abdominal strength;
- Trunk lifts to measure muscular strength and endurance;
- Push-ups, modified pull-ups, or flexed arm hang; and
- Back-saver sit and reach or shoulder stretch to measure flexibility.
Once students' fitness levels have been assessed, the FitnessGram software recommends physical activity options to help students reach healthy fitness zones in those areas in which they need to improve.
Ms. Rathbone hopes parents will share their children's test scores with their physicians, who can suggest practical ways to guide students in eating healthier and exercising more.
TMA's Web site offers physicians an opportunity to learn best practices in treating obese patients from other skilled health care professionals. Informative slides and handouts are available for downloading. To access the PDFs, click here .
In addition, Ms. Rathbone says physicians need to be aware of the fitness assessment exemptions for students with permanent or temporary disabilities. Examples include chronic asthma, broken bones, and physical and mental impairments.
She says some students might not need a full exemption from the FitnessGram test but instead may need physicians to specify which portions of the test they are able to complete. For example, students with asthma might not be able to do the shuttle run but may be able to do the shoulder stretch or the push-up test.
"With each individual situation, there are a number of ways to modify the test. Some students might be able to do one or two of the six different test items, but not all of them," she said . "We'd like physicians to ensure that schools assess children who are able to be tested."
The FitnessGram test is part of a concept known as coordinated school health, which encompasses evidence-based programs designed to prevent obesity, cardiovascular disease, and type 2 diabetes in elementary, middle, and junior high school students. State law requires TEA to make available to each school district one or more coordinated school health programs or allow for the development of school district programs. Each program must provide for coordinating health education; physical education and physical activity; nutrition services; and parental involvement.
Eduardo Sanchez, MD, MPH, BlueCross and BlueShield of Texas vice president and chief medical officer and former state health commissioner, stresses that coordinated school health programs, while effective, are only one part of a multipronged approach necessary to reduce obesity levels and change lifestyle behaviors.
"No one program is a magic bullet. To reverse childhood obesity, coordinated school health programs are one part of what would be a comprehensive set of programs in a community," he said. "What happens in school forms the hub, but you have to have other complementary things happening at home, in after-school programs, and in physical activity programs made available for children of all income levels. All those things together can have a transformative effect."
Getting Involved in Schools, Communities
To help address the parental involvement component of coordinated school health programs, schools have set up school health advisory councils (SHACs).
State law requires every Texas school district to establish a SHAC to advise the district on coordinated school health programming and its impact on student health and learning. A majority of SHAC members must be parents not employed by the school district.
The Texas Public Health Coalition has a list of community calls to action to address those priorities that don't warrant legislation. The coalition supports and encourages local, community-based initiatives to encourage participation in SHACs and supports SHACs' efforts to collect data that can evaluate the effectiveness of obesity reduction efforts, including increased physical activity.
SHACs also provide a great opportunity for physicians to become active at the school level. Physicians can contact the superintendants of their school districts for more information about becoming a member of the local SHAC.
Tracy Lunoff, Austin Independent School District (AISD) health services coordinator, says having physicians on the school district's SHAC has been invaluable.
"The benefits of having health care professionals on the SHAC go two ways. From the medical side, they can give SHAC members the perspective of how health conditions caused by obesity affect children's learning. From the school's perspective, it's good to educate the medical community about how school systems work," she said.
Having physician members also gives SHACs more credibility in the community, Dr. Sanchez says.
"Those councils would benefit greatly, as would the schools, from the kind of perspective and expertise that a physician could bring to the table. It would also give those councils a certain amount of credibility and political weight, if a physician were involved. Physicians hold a high esteem in communities," he said.
With the help of parents and physicians, AISD's advisory council has enacted some worthwhile practices and policies, according to Ms. Lunoff. The district requires healthy, more nutritious snacks in vending machines and has developed a wellness policy for staff members and students.
Physicians can have an impact on childhood obesity during office appointments, says State Epidemiologist Vince Fonseca, MD.
"When I was doing primary care and dealing with chronic conditions in children, I engaged the parent," he said. "Generally, the parents became more motivated in changing behavior on behalf of their children."
But to be successful in modifying lifestyle, Dr. Fonseca says, physicians should emphasize that young patients make small, incremental modifications in diet and exercise. Encouraging children to walk more and to incorporate fruits and vegetables slowly in their meals will seem more manageable than abrupt, drastic changes in diet and exercise.
In addition, Texas Agriculture Commissioner Todd Staples has some specific examples of how physicians can make a difference in the fight against childhood obesity. He says doctors can ensure that students in after-school or summer programs have access to physical activity and healthy snacks outside the school day or speak to classrooms and parent organizations about the importance of healthy choices.
Healthy eating is an effective weapon in the fight against obesity. TDA is working to reduce the prevalence of obesity among children.
"Obesity is a choice. We need our children to make the right choice early in life and carry it on into their adult years," Commissioner Staples said. "I am not looking for feel-good initiatives; I want results. Our three agencies [TDA, TEA, and DSHS] work with stakeholders to ensure our programs are purposeful and practical. We can have measurable outcomes that are not only achieved, but also embraced."
According to Kathy Golson, government liaison for food and nutrition at TDA, about 25 schools participate in TDA's Fresh Fruit and Vegetable Program. Thanks to additional funding through the 2008 federal Farm Bill, the department will be able to expand it to more than 200 schools over the next three years.
Schools that participate in the Fresh Fruit and Vegetable Program receive federal reimbursement for providing fresh produce to students any time before, during, or after the school day.
In addition, TDA has made progress in altering the Texas Public School Nutrition Policy to ensure children consume reasonable portion sizes of nutritious foods. Changes include offering fruits and vegetables daily in school cafeterias, reducing the purchase of products that contain trans fats, and eliminating deep-fat frying of foods.
Ms. Golson says schools are looking for creative ways to prepare and offer healthy foods to students. More innovative schools allow children to help plan menus and taste-test fresh fruits and vegetables. Some schools have incorporated nutrition in their health programs.
"The awareness of childhood obesity has prompted a lot of folks to get children interested in nutrition. But you still have the competition of what children see advertised on TV and at convenience stores and fast-food restaurants," Ms. Golson said.
The Texas Public Health Coalition recommends the 2009 legislature fund TDA's Public School Nutrition Policy to meet or exceed the 2005 Dietary Guidelines for Americans. Right now, policy requires schools to follow the 2000 dietary guidelines.
The 2005 guidelines for federally reimbursable school meals require more whole grains; fat-free or low-fat milk; and inclusion of fiber-rich fruits, vegetables, and whole grains as often as possible. The 2000 guidelines aren't as specific. For example, the 2000 guidelines require only a variety of grains and two to three cups of milk. And they don't include a fiber recommendation.
Ms. Golson says the U.S. Department of Agriculture (USDA) encourages schools to meet the 2005 guidelines. USDA provides school districts with different meal plans they can use in their menu planning to give them some flexibility in what they feed the students. School districts are free to follow the more restrictive 2005 dietary guidelines, but Ms. Golson is unaware of how many districts are doing so.
Barbara Keir, manager of the DSHS Chronic Disease Prevention Branch, says the department wants to change nutrition policies in schools and make the environment outside schools more conducive to healthy choices.
This year, DSHS funded six community projects, three of which will help set up farmers' markets to improve access to fresh produce in low-income areas of the state. The other three will help establish community support for mothers who breastfeed. Breastfed infants have lower obesity rates later in life, Ms. Keir says.
Dr. Fonseca says these types of approaches make healthier choices easier choices.
"We all want to be healthier and make healthier choices. For most of us, it's pretty hard, so we don't. But if we made the choices easier, that's when that individual behavior intersects with policy and environmental changes. Individual behavior is important but operates optimally when you have healthy choices everywhere that are convenient and as cheap as unhealthy foods," 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 e-mail at Crystal Conde .
TDA, TEA, DSHS Legislative Funding Package
The Texas Department of Agriculture (TDA), the Texas Education Agency (TEA), and the Texas Department of State Health Services (DSHS) are collaborating to make sure they're enhancing one another's programs while fulfilling the needs of Texas' school systems and communities.
Their 2010-11 budget requests entail:
- $63 million for TEA to support effective health and fitness programs in school districts and to create a Health and Fitness Best Practices Network. The network would identify best practices and model programs that every campus could replicate. A network of school health professionals, housed at each of the 20 education service centers in Texas, would help schools implement coordinated school health programs by working with the new wellness coordinator on every elementary, middle, and junior high and high school campus. The coordinator would serve on related campus committees and as a liaison for community services, with the goal of providing a coordinated community wellness message to the campus.
- $50 million increase in funding for TDA's nutrition programs, including a Healthy Rewards Program grant of $20 million for schools that meet criteria for healthy eating. For example, grants could be awarded to schools that add fresh produce to school meals in innovative ways or that add salad bars to their cafeterias. At the preschool and prekindergarten level, a $15 million grant would fund a Fresh Start Program to address nutrition education for children aged 3 to 5 years. A $10 million grant would fund community initiatives to incorporate nutrition education in programs such as after-school and summer day camps. A $5 million grant administered through TDA would go toward promoting the Healthy Rewards Program, Fresh Start Program, and community and faith-based initiatives.
- $8 million to DSHS to fund a healthy communities/healthy people program that would include community prevention and health promotion. These would address obesity through interventions to improve nutrition and increase physical activity; cardiovascular disease and stroke through evidence-based policies and programs in health care sites and worksites; and changing systems of care to ensure compliance with evidence-based guidelines for screening, diagnosis, and treatment.
- $20 million grant administered through TEA and the Texas Comptroller of Public Accounts to continue the Texas Fitness Now Program, which offers on-site physical education, nutrition, and fitness programs to students in grades six through eight who attend schools where enrollment is at least 75 percent economically disadvantaged. About 700 schools and more than 270,000 students could benefit from Texas Fitness Now grants. The minimum grant is $1,500; schools could receive more, based on their enrollment.
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Texas Public Health Coalition Legislative Priorities for Obesity
- Support funding for the Texas Education Agency's (TEAs) efforts to provide rigorous implementation of coordinated school health;
- Support legislation and funding for the Texas Department of Agriculture's (TDA's) Public School Nutrition Policy efforts to meet or exceed the 2005 Dietary Guidelines for Americans for all reimbursable and nonreimbursable meals;
- Support TDA's request to promote and reward the implementation of best practices in nutrition education in schools and early childhood environments, as part of the effort with TEA and the Texas Department of State Health Services (DSHS);
- Support legislation and funding to require physical activity programming in early childhood environments and all grade levels and support school environments that promote physical education; and
- Support funding for the DSHS request to reduce the impact of chronic diseases through prevention of obesity, heart disease, and stroke.
Texas Public Health Coalition Community Calls to Action for Obesity
- Support and encourage local, community-based initiatives to encourage participation in school health advisory councils (SHACs);
- Support SHACs' efforts to collect data that can evaluate efforts of obesity reduction, including increased physical activity;
- Support local labeling initiatives and ordinances that promote sodium reduction in food preparation; and
- Increase physical activity throughout the lifespan by using community and evidence-based programs.
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Report Ranks Texas High in Obesity
F as in Fat: How Obesity Policies Are Failing in America , a 2008 report from the Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation (RWJF), ranks Texas the 15th most obese state in America. The state's adult obesity rate is 27.2 percent, an increase from 2007.
Nationally, adult obesity rates rose in 37 states from 2007 to 2008. Rates increased for a second consecutive year in 24 states and for a third consecutive year in 19 states. No state saw a decrease in rates.
Though many promising policies have emerged to promote physical activity and good nutrition in communities, the report concludes that they aren't being adopted or implemented at levels needed to turn around this health crisis.
"America's future depends on the health of our country. The obesity epidemic is lowering our productivity and dramatically increasing our health care costs. Our analysis shows that we're not treating the obesity epidemic with the urgency it deserves," said Jeff Levi, PhD, executive director of TFAH. "Even though communities have started taking action, considering the scope of the problem, the country's response has been severely limited. For significant change to happen, combating obesity must become a national priority."
More than 25 percent of adults are obese in 28 states, an increase from 19 states in 2007. More than 20 percent of adults are obese in every state except Colorado. In 1991, no state had an obesity rate above 20 percent.
In 1980, the national average of obese adults was 15 percent. Now, an estimated two-thirds of American adults are overweight or obese, and an estimated 23 million children are either overweight or obese. The report does not include 2008 state-level data for children.
Rates of type 2 diabetes increased in 26 states in 2007, including Texas. Four states now have diabetes rates that are above 10 percent, and all 10 states with the highest rates of diabetes and hypertension are in the South.
Texas ranks 11th highest in type 2 diabetes, with 8.8 percent of the population affected, and it ranks 27th highest for hypertension.
The report also found a relationship between poverty and obesity levels. Seven of the 10 states with the highest obesity rates are also in the top 10 for highest poverty rates, including Mississippi, Louisiana, Kentucky, Alabama, Arkansas, Tennessee, and West Virginia. Rounding out the top 10 for highest poverty rates are the District of Columbia, New Mexico, and Texas.
The report also annually reviews state and federal policies aimed at reducing or preventing obesity in children and adults. It shows that many policies are missing critical components or require a more comprehensive approach to be truly effective.
Among the examples highlighted:
- While all 50 states and the District of Columbia have passed laws related to physical education and/or physical activity in schools, only 13 states include enforceability language. Texas does not have enforceability language. Of these states, only four - Arkansas, Florida, New Mexico, and Oklahoma - have sanctions or penalties for failure to implement the laws.
- While the Dietary Guidelines for Americans were updated in 2005, the U.S. Department of Agriculture (USDA) school meal program has yet to adopt the recommendations.
- Eighteen states have enacted legislation requiring school meals to exceed USDA nutrition standards. Texas has enacted this type of legislation. However, only seven states - Alabama, Arkansas, Connecticut, Kentucky, Nevada, Oregon, and Texas - have specific enforcement provisions, and only Kentucky and Texas include sanctions if the requirements are not met.
- Ten states do not include specific coverage for nutrition assessment and counseling for obese or overweight children in their Medicaid programs. Texas doesn't include this type of specific coverage.
- Twenty states explicitly do not cover nutritional assessment and consultation for obese adults under Medicaid. Texas doesn't provide this coverage.
- Only two states - Georgia and Vermont - have specific guidelines for treating obese adults in their Medicaid programs. In Nebraska and South Carolina, the Medicaid programs specifically state that obesity is not an illness and is therefore not covered.
- Forty-five states allow using obesity or health status as a risk factor to deny coverage or raise premiums. Only five states - Maine, Massachusetts, New Jersey, New York, and Vermont - do not allow using obesity or health status to deny coverage or raise premiums.
The F as in Fat report concludes with a recommendation that the country set a national goal of reversing the childhood obesity epidemic by 2015. To help achieve that goal, the report's top recommendation calls on the federal government to convene partners from state and local governments, businesses, communities, and schools to create and implement a realistic, comprehensive National Strategy to Combat Obesity.
Some key policy recommendations include improving the nutritional quality of foods available in schools and child care programs and increasing the amount and quality of physical education and activity in schools and child care programs.
The full report, with state rankings in all categories, is available on TFAH's Web site and RWJF's Web site . A grant from RWJF funded the report.
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