Gina Smith, MSN, FNP-C & Christina Turbeville, CDM

FirstHealth Montgomery County School Health Centers

Meg McHenry, RD, MPH, LDN & Kara Richards, BA, MA

Wake Teen Medical Services

Childhood Obesity Prevention: Models of Successful Programs

• Describe the magnitude of childhood obesity

• Discuss the role of School Health Centers in addressing childhood obesity

• Provide examples of successful SBHC programs utilizing best practices

• Summarize resources available to providers for assisting in implementation of childhood obesity programs

Objectives

Obesity Trends* Among U.S. AdultsBRFSS, 1986

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person))

No Data <10% 10%–14No Data <10% 10%–14%

www.cdc.gov 3

Obesity Trends* Among U.S. AdultsBRFSS, 2007

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

www.cdc.gov

Prevalence of At-Risk & Overweight Among Children and Adolescents

0

2

4

6

8

10

12

14

16

18

20

1963-1970

1971-1974

1976-1980

1988-1994

1999 2003-2004

Ogden, et al. (2006). JAMA, 295(13), 1549-1555Ogden, et al. (2006). JAMA, 295(13), 1549-1555..

≥ 85%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

1999-2000

2001-2002

2003-2004

2-5 yrs6-11 yrs12-19 yrs

≥ 95%

5

Health Risks of Obesity

• Pulmonary• Sleep disorders• Asthma• Obesity-linked

hypoventilations• Neurologic

• Pseudotumor cerebri

6

Health Risks of Obesity

• Orthopedic– Slipped capital

epiphysis– Tibia vara (Blount’s

disease)– Tibial torsion– Flat feet – Ankle sprain– Fractures

7

Health Risks of Obesity

• Cardiovascular• Hypertension• Dyslidemia• Fatty deposits• Left ventricular hypertrophy• Other• Systemic inflammation

Health Risks of Obesity

• Gastrointestinal • Cholelithiasis• Non-alcoholic fatty liver disease• Gastro-esophageal reflux• Endocrine• Insulin resistance/Type II Diabetes• Acanthosis nigricans• Menstrual abnormalities• Polycystic ovary syndrome• Hypercoricism

Health Risks of Obesity: Psychological

Obese children and their parents rate the quality of life as similar to pediatric cancer patients.

Schimmer, Burwinkle, & Varni, 2003

Health Risks of Obesity: Psychological

• Actual and perceived overweight is an important risk factor for suicidal behaviors in youth

• Risk factor for suicidality even after controlling for alcohol and illicit drug use

(Swahn, M., Reynolds, M., Tice, M., et. al, Journal of Adolescent Health, 2009.)

Significance of Problem

80% of obese adolescents will becomeobese adults

- NASBHC, 2009

The Role of SBHCs in Addressing Childhood Obesity

• Leader in child health to emphasize prevention and early intervention

• Sensitive to unique needs of children and adolescents with the ability to provide culturally sensitive, age-appropriate services

• Opportunity for access to students with services provided regardless of the ability to pay

• Qualified, highly trained, interdisciplinary teams comprised of RD, nutritionist, FNP, RN

FirstHealth of the CarolinasMontgomery County School Health

Centers, East & West

• East & West Middle Schools• Comprehensive, credentialed centers• 670 total registrants

BMI Data Collection 2007-08

• Great partnership with Montgomery County Schools

• Collaboration with school nurses, teachers and students

• SBHC nurses• SBHC Nutritionist• SBHC FNP

BMI DiscoveryPage Street 3rd Graders

2007-08

39%

16%

44%

1%

BMI ≥ 95%

BMI 85%-94%

BMI Normal

BMI < 5%

Page Street Intervention – HEAP“Healthy Eating Active Play”

• 3rd Graders – 39% obese; 16% overweight• Intervention developed –RD, Nutrition

Educator, FNP• Nutrition Educator as instructor• 4-week program• Pretest of knowledge and behaviors• One 45 minute class/week . Fun activities &

healthy snacks focusing on healthy eating and increasing physical activity

• Post-test• BMIs recalculated

Week 1 – What to Dump

SODA CHIPSSWEET TEA COOKIESKOOL-AID CANDYLEMONADE DORITOSSUNNY DELIGHT HOT FRIESPOWERADE CHEETOSGATORADE LITTLE DEBBIESFRUITOPIA CAKES &PIESYOOHOO BROWNIESCAPRI-SUN CHOCOLATENABS HONEY

BUNSRICE KRISPY TREATSKLONDIKE BARS

Week 1 – What to Pick Up

1% OR SKIM MILKWATER

CAFFEINE FREE/ UNSWEETENED TEACAFFEINE FREE / DIET SODA

HOMEMADE LEMONADE WITH SPLENDA100% JUICE ONCE A DAY ONLY

LITE MICROWAVE POPCORNCELERY / PEANUT BUTTER

CARROTS WITH LOW FAT DRESSINGPEANUT BUTTER CRACKERS (whole wheat)

APPLES-ORANGES-BANANAS-FROZEN GRAPESSTRING CHEESE

NUTSRAISINS, DRY CHEERIOS, PRETZELS

FROZEN YOGURT

Week 2Week 2WHAT FRUITS TO ADD TO BREAKFAST

BananasRaisinsApples

PeachesCut up fruit to top your waffles versus syrup

Yogurt in place of syrupEat your fruit & vegetables that come with lunch!

FRUITS & VEGETABLES TO ADD TO LUNCH & SUPPER

Carrots & celery sticksCucumber slicesApplesauce cups

Apples, oranges, or bananasBring salad to school

Supper – ½ of your plate should be vegetables Try the vegetables your mom makes at least three times before you say

you don’t like it.

Week 2Week 2 – Healthy Eating and Physical Activity Go – Healthy Eating and Physical Activity Go Hand in HandHand in Hand

Exercise can be fun – in fact it’s child’s play!

Make it a family affair

Limit TV viewing time to 2 hours or less/day

Be physically active for 60 minutes every day

Week 3Week 3

HOW SHOULD YOUR PLATE LOOK?

One-half (1/2) of your plate should have vegetables

One-fourth (1/4) of the plate should have your meat or protein

One-fourth (1/4) of the plate should have your starches (bread, pasta, rice, potatoes)

Week 4 – Healthy Meals on the RunWeek 4 – Healthy Meals on the Run

RESTAURANTS CHOICES

McDonalds 1% milk, mandarin oranges,

unsweetened tea, apple dippers, or yogurt with fruit

Zenos Grilled chicken, vegetable pizza, salad

Sir Pizza Salad bar, fruit choices, vegetable pizza

Mazatlan Ask the waiter to take the chips off the table when you sit down. Take ½ of your order home for a later meal.

Penny’s Order the small order and stay away from sauces.

BoJangles Grilled chicken, no biscuit. Ask for a bun instead.

Subway Ask for the kid’s meal, salad and no chips.

Results???Results???

BMI – 1% decrease in obese students

from 39% to 38%

Correct answers:

Pretest – 51%

Post-test – 98%

2008 NC Stars Fruit and Veggies Silver Award – Healthcare Division

Page Street 5th Graders 09-10Page Street 3rd Graders

2007-08

41%

14%

45%

0%

BMI ≥ 95%

BMI 85%-94%

BMI Normal

BMI < 5%

Page Street 5th Graders2009-10

39%

20%

41%

0%

BMI = 95%

BMI 85%-94%

BMI Normal

BMI < 5%

47

33.930.6

0

5

10

15

20

25

30

35

40

45

50

Percentage of Obese/Overweight

Montgomery CountySchools

North Carolina United States

Montgomery County Adolescent BMI2007-08

Childhood Obesity Action Network. State Obesity Profiles, 2008. National Initiative for Children's Healthcare Quality, Child Policy Research Center, and Child and Adolescent Health Measurement Initiative.

2008-09 Childhood Obesity Efforts

• Nutritional assessment utilizing HEAP quiz on all students enrolled at the SBHCs (EMS/WMS)

• Ht/wt/BMI calculated and plotted• Early referrals made to SBHC nutritionist for

BMI 85%• Referral to SBHC RD for BMI ≥ 95%• 2-3 nutritional counseling sessions –1345

nutrition visits

SHC/school-wide 2008-09 Efforts

• Alignment with MCS system goals – “Promote a child-centered culture of health, rigor, and high expectations”

• Nutrition educator collaborated with school staff in forming after school walking clubs at both middle schools – 130 miles walked

• Health Eating Every Day (HEED) classes for school staff

• BMI data collection for all MCS students grades pre-K-12

SHC/school-wide 2008-09 Efforts

• HEAP presentations:• Presented to Candor 3rd graders –

last year were most obese in MCS at 41% obese

• Green Ridge 3rd graders• Mt. Gilead 4th graders• 176 HEAP students this year

2008-09 BMI TrendsMontgomery County Schools BMI Data

2007-08

26%

19%

53%

2%

BMI ≥ 95%

BMI 85-94%

BMI Normal

BMI < 5%

Montgomery County Schools BMI Data 2008-09

27%

19%

52%

2%

BMI = 95%

BMI 85-94%

BMI Normal

BMI < 5%

2008-09 BMI Trends

47 47

33.9 33.930.6 30.6

0

5

10

15

20

25

30

35

40

45

50

Percentage of Obese/Overweight

Montgomery CountySchools

North Carolina United States

Montgomery County Adolescent BMI

2008

2009

Childhood Obesity Action Network. State Obesity Profiles, 2008. National Initiative for Children's Healthcare Quality, Child Policy Research Center, and Child and Adolescent Health Measurement Initiative.

SHC BMI TrendsBMI after 2nd Nutrition Visit

SHC East 2008-09

55%

8%

37%

BMI DECREASED

BMI UNCHANGED

BMI INCREASED

SHC BMI TrendsBMI after 3rd Nutrition Visit

SHC East 2008-09

56%

19%

25%

BMI DECREASED

BMI UNCHANGED

BMI INCREASED

SHC BMI TrendsBMI after 2nd Nutrition Visit

SHC West 2008-09

43%

14%

43%

BMI DECREASED

BMI UNCHANGED

BMI INCREASED

SHC BMI TrendsBMI after 3rd Nutrition Visit

SHC West 2008-09

69%

6%

25%

BMI DECREASED

BMI UNCHANGED

BMI INCREASED

SHC BMI Trends

Overall decrease in BMI of

OB/OW students: 71%

n = 279

2008-09 HEAP Results

Candor 3rd Graders 2008-09 BMI

48%

15%

37%

0%

BMI ≥ 95%

BMI 85%-94%

BMI Normal

BMI < 5%

Candor 3rd Graders 2009-10 BMI

48%

11%

41%

0%

BMI ≥ 95%

BMI 85%-94%

BMI Normal

BMI < 5%

2008-09 HEAP ResultsGreen Ridge 3rd Graders

2008-09 BMI

29%

29%

40%

2%

BMI ≥ 95%

BMI 85%-94%

BMI Normal

BMI < 5%

Green Ridge 3rd Graders 2009-10 BMI

37%

21%

42%

0%

BMI ≥ 95%

BMI 85%-94%

BMI Normal

BMI < 5%

2008-09 HEAP Outcomes

Candor/Green Ridge/Mt. Gilead

Pretest – 58% Correct

Post-test – 93% Correct

Additional School-wide efforts

• SPARK curriculum in K-8

www.spark.org• Fitnessgram software to track BMI• Healthy Kids/Healthy Communities

grant • School Nutrition Director developing

healthier menus• 3 schools received fruit grants

2009-10 SHC Efforts

• Nutritional assessment on all SBHC enrollees

• Prevention/early intervention• 5-3-2-1-Almost None• Increased nutritional services for SHCS in

2009-10 by increased nutritional services to 4 days total/week

• Registered Dietician for students ≥ 99%

• Actively seek resources/funding for innovative methods for addressing childhood obesity

2009-10 SHC BMI Trends

Nutrition Referrals for OB/OWn=261

• BMI ≥ 99% = 19%• BMI ≥ 95-98 = 42%• BMI 85-94% - 36%• BMI <5% or other = 3%

61% obese!!

Additional Efforts

• Present HEAP program to Green Ridge 1st graders – BMI: 33%OB/30%OW

• Fasting glucose, lipids, ALT, AST, etc.• Actively seek resources/funding for innovative

methods for addressing childhood obesity• Look for ways to incorporate more physical

activity into the SHC programs• Collaborate on a local, state and national level in

addressing childhood obesity

Childhood Obesity Prevention: Models of Successful Programs

Be Fit, Get Moving

Kara Richards, MA

Meg McHenry, RD, MPH, LDN

Wake Teen Medical Services

• Wake Teen Medical Services is a non-profit medical service provider for adolescents through young adults ages 10 to 23

• Services include:– Primary health care– Mental health care– Health education– Nutrition counseling

Wake Teen Medical Services• Saw 1473 patients in the last year• Patient demographics

– 975 female, 498 male– 989 African American, 446 White,

38 Other/Unidentified– Over 30% of patients fall at or above

the 85th BMI percentile • Wake County obesity prevalence

– For ages 12-17, 21% classify as overweight and 30% as obese

Be Fit, Get Moving

• Kate B. Reynolds-funded multidisciplinary healthy lifestyle program that includes:– Health care screening– Individual nutrition counseling– Individual exercise counseling– Mental health counseling (if needed)– Weekly group educational seminars,

exercise sessions, and field trips

Be Fit, Get Moving• Target population:

– Youth ages 10 through 23– At or above the 85th BMI percentile– Highly motivated to make a change

• Program Participants– Began October 2008 for Wake Teen

patients only– In March 2009, we opened the program to

outside participants (schools, physician offices, etc.)

– We have served 65% of all participants referred, reaching well over 100 teens in Wake County

– 76% are female, 60% African American, 98% financially needy

Intended Outcomes and Results

Intended Outcomes at 12 months• Decreased BMI in 65% of

participants

• 70% will be active for 20 min/5x/wk

• 85% show improvements in cardiovascular health

• 90% will increase nutrition knowledge

• 85% will eat healthy breakfast 5x/wk

• 90% improve self-perception

Results at 9 months• 31% decreased, 50% maintained

• 100% participants increased activity time, 70% active at least 5xwk

• 55% decreased resting heart rate, 80% decreased blood pressure

• 80% increased nutrition knowledge

• 65% eating breakfast daily; 100% increased from baseline

• 75% increased, 25% maintained or improved minimally

Measurement Tools Used

• BMI: Heights/weights taken at exercise appointments; CDC growth charts

• Activity: Exercise logs/self-report to exercise specialist

• Cardiovascular health: BP/RHR from exercise specialist or medical record

• Nutrition knowledge: 20-question quiz developed by staff nutritionist

• Healthy breakfast: food records/self-report to nutritionist

• Self-perception: 12-question quiz developed by mental health staff

Additional Outcomes• WHR: 65% improved from baseline• Pushups: 100% improvement• Squats: 100% improvement• Qualitative results

– “If I had not participated in BFGM, I would still be drinking sugared drinks, eating chips all day, going to McDonald’s almost everyday – I would be extremely obese” M, 15

– “One achievement I’m proud of is that I lowered my blood sugar. When I first started this program, it was in the 300s’. Now I’m getting results in the low 80’s.” F, 18

– “Within two weeks of starting the program, I noticed my son is more confident – he wants to ride bikes with other kids, he is more willing to be active, and he smiles a lot more.” Mother of M, 14

Process

• Program Structure– Tuesday education seminars and

neighborhood walk/boot camp – Thursday boot camp– Individual nutrition counseling– Individual exercise counseling – Field trips

Dining Out

Eating Out

Physical Activity

Community Support

Contact Information - Wake Teen Medical Services

• Kara Richards, Project Coordinator–krichards@waketeen.org

• Meg McHenry, Nutritionist–mmchenry@waketeen.org

• Telephone: 919-828-0035• www.waketeen.org

Contact Information - FirstHealth Montgomery County School Health Centers

• Gina Smith, FNP, SHC Manager–rpsmith@firsthealth.org

• Christina Turbeville, Nutrition Educator–cturbeville@firsthealth.org

• Telephone: 910-428-9392, East;

910-572-1979, West

Resources

• USDA Food Guide Pyramid www.mypyramid.gov• Eat Smart, Move More

www.eatsmartmovemorenc.com • Shield, J. and Mullen, C.M. (2008). Counseling

Overweight and Obese Children and Teens: Health Care Reference and Client Education Handouts. Chicago, Il: American Dietetic Association

• Videos:– “Obesity in a Bottle” www.learningzoneexpress.com– “Fast Food Survival Guide” www.learningseed.com

Resources

• NASBHC - http://ww2.nasbhc.org/RoadMap/CONVENTION09/D7_1.pdf

• NASBHC CQI Tool – http://www.nasbhc.org/site/c.jsJPKWPFJrH/b.2719357/k.6312/EQ_Quality_Improvement.htm

• NICHQ – http://www.nichq.org

http://www.nichq.org/documents/coan-papers-and-publications/COANImplementationGuide62607FINAL.pdf

Resources

• Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report http://pediatrics.aappublications.org/cgi/reprint/120/Supplement_4/S164

• CDC BMI Calculator for Children & Teens - http://apps.nccd.cdc.gov/dnpabmi/

• NC Prevention Partners – www.ncpreventionpartners.org

• NC Healthy Schools – www.nchealthyschools.org

Questions??

Merry Christmas!!