Unhealthy Children: TMA Leading the Charge to Change the Future Today

Public Health Feature -- January 2001  

By Laurie Stoneham
Contributing Editor  

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 downright bleak.

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 boat?

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 Project WATCH , 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 year.

Weighty statistics  

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 appeared.

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 AN.

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 undiagnosed.

"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 age?"

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.

School-based intervention  

"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. 

CATCH  

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 (1996;275:768-776) and 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 early adolescence.

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 years.

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 service personnel.

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."

Legislative dimension  

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 said.

"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 academically."

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 default."

"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."

SIDEBAR  

Health and physical education "requirements" in Texas schools

Grades 1-5: 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.

Grades 6-8 : 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.

Grades 9-12: 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 Education Agency  

SIDEBAR  

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.

Source: Karen J. Coleman, PhD, Behavioral Fitness Laboratory, The University of Texas at El Paso  

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