Arkansas Initiativeand Recommendation for BMI in

Schools

AR Preventive Nutrition and Physical Activity Summit

• Purpose: to develop specific strategies to control the obesity epidemic in Arkansas

• Occurred: March 8, 2003

• Funded by: National Institute of Health Nutrition Academic Award

• Support from: UAMS, ADH, ACHI, ACH, others

• State-wide summit

Act 1220 of 2003

• Creates an Arkansas Child Health Advisory Committee • Limits access to food/beverage vending machines • Reports ALL money received from food and beverage

contracts.• Convenes an advisory committee in each school district• Incorporates nutrition/physical activity goals into

annual plans

Act 1220 of 2003 States: “Require schools to include as part of the Student

Health report to parents an annual body mass index percentile by age for each student; and require schools to annually provide parents with an explanation of the possible health effects of body mass index, nutrition, and physical activity.” (in a confidential, private and accurate manner)

Act 201 of 2007

• Individual students will participate in BMI assessments in kindergarten and in grades 2, 4, 6, 8, and 10.

• BMI measurements will be eliminated for students in grades 11 and 12.

Act 201 of 2007

• Parents can provide written notice to the school if they choose to exclude their children from BMI assessments.

• Community Health Nurses will work with schools to assure that proper protocol is followed during the BMI assessments.

UAMS College of Public Health Evaluation of Act 1220 (2007)

• Parents are maintaining their awareness of short- and long-term health problems associated with childhood obesity.

• 95% of parents read some or all of the Child Health Report .

• No feared consequences of BMI measurements.

UAMS College of Public Health Evaluation of Act 1220 (2007)

• Students reported purchasing more healthy drinks, such as water and other unsweetened beverages.

• Schools are more frequently offering nutritional information for students.

• Significant increase in the percentage of parents who are limiting screen time to give their kids more time for physical activity.

AAPAAP RecommendationRecommendationAccurately weigh and measure to monitor growth

Calculate and plot BMI once a year in all children and adolescents

Use changes in BMI to identify rate of excessive weight gain relative to linear growth

(AAP, 2003, reaffirmed in 2007)

NASN Position StatementNASN Position Statement

It is the position of the National Association of School Nurses that school nurses have the expertise to meet the needs of children at risk for being overweight and to assist those students

http://www.nasn.org/Default.aspx?tabid=236

Overweight Children and Adolescents

Childhood BMIChildhood BMI is is gender gender & age& age specificspecific

CHILDREN BMI – body mass index

Underweight BMI-for-age < 5th percentile

Overweight / at risk for obesity

BMI-for-age 85th to 94th percentile

Obese BMI-for-age ≥ 95th percentile

Normal BMI-for-age - 5th percentile - < 85th percentile

(CDC, 2009) http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/defining.htm

BMI for Age and Gender:BMI for Age and Gender:

Used for children and teens because of their rate ofgrowth and development

Provides a reference for adolescents that can track body size throughout life

Compares well to laboratory measures of body fat (Barlow, 2007)

Body Mass IndexBody Mass IndexWhat it is and is not!

An inexpensive, effective, easy-to-perform screening tool for weight categories that may lead to health problems –

Not intended to be used as the sole diagnostic measure (CDC)

A number calculated from child’s weight & height

A reliable indicator of / alternative for body fatness for most children and teens

Perspectives About the Use of BMI Perspectives About the Use of BMI MeasurementMeasurement

Identify referrals and resources for Identify referrals and resources for children and parentschildren and parents

Promote policies the Promote policies the access to access to healthful foods and daily physical activityhealthful foods and daily physical activity

School Nurses - BMISchool Nurses - BMI ‘‘Measurements are more likely to be accurate and reliable when they

are conducted by trained professionals, such as school nurses.’ (Nihiser, 2007, p 14)

The results of one study support that height and weight screening by school nurses can be private and reliable and provides an opportunity for school nurses to intervene when children are at high risk… (Stoddard, et al., 2008)

One study indicated that “mandates increased the number of school nurses measuring and reporting student BMIs as a way to influence healthy weight in school children and policies related to healthy nutrition and physical activity.” (Hendershot, et al, 2008)

CLINICAL INSTRUCTION FOR BMI ASSESSMENT

Prior to Assessment

• Contact school administration and teachers.

• Determine assessment team.– Screener– Recorder

• Determine date and place and which students to be assessed.

Day of Assessment

• Equipment

• Calibration of scales

• Station set up

• Preparation of child

• Data collection forms or computer

Recommended Equipment

• Stadiometer (page 4 in training manual)– Measures height– Portable or permanently affixed to wall– Provided by ACHI

• Tape wood board to wall for stability• Carpenter’s triangle for headpiece

Recommended Equipment• Scales (page 4 in training manual)

– Tanita HD-314 Scale• Portable• Measures up to 330 lbs• Digital read-out

– Tanita HD-351 Scale• Portable• Measure up to 440 lbs• Digital read-out• Colored tape placed over previous

weight readout for confidentiality

Recommended Equipment• Step Stool

– Two-height step stool for height measurements to ensure measurement line is read at eye level

• Batteries – Check type– Check number of batteries required

Recommended Equipment• Standard Weight (page 5 training manual)

– A standard weight should be used to test the scale for accuracy (NOTE: do not use non-standard weight such as bag of sugar)

– If the readout is more than ½ pound off then change the batteries in the scale

– If the readout is still more than ½ pound off DO NOT use the scale

Recommended Equipment• Name Tags

– Children– Staff

• Office Supplies

• Container for personal items

Assessment Team

• Multiple stations • Screener

– Performs heights and weights• Recorder

– Records data on assessment formsOR

– Enters data into web-entry system

Measurement Procedure• Child should:

– remove as much outerwear as possible– remove shoes (barefoot or wearing socks)– empty pockets; remove jewelry and other

objects– remove eyeglasses (to visualize Frankfort

Plane)– remove hair barrettes, ties or rubber bands

Measurement Order

– Measurements in rotational order:• 1st height• Weight• 2nd height

Height Measurement• Child stands with back or other body part

touching the board with body straight.• Legs are together and body weight is evenly

distributed on feet. • Arms hang freely by side, palms facing

thighs.• Position should be verified from FRONT and

LEFT of body.• Position head in Frankfort Horizontal Plane.

Height Measurement• Child inhales deeply and holds breath

WITHOUT moving head or body. • Movable headpiece is brought to superior

point on head with hair compressed. • Height is recorded to the nearest 1/8th inch.• Greater than one inch difference between

two height measurements requires re-measurement

Recording Process

• Measurer takes first height

• Recorder calls number back to measurer

• Recorder records number in space indicated for “1st Height”.

Weight Measurement• “Zero” the scale if digital.

• Measurer has child step up on the center of the scale and stands facing the back of the scale (confidentiality) and indicates to recorder that child is “ready”.

• Body weight is evenly distributed on feet.

• Head is up and facing straight ahead.

Recording Process

• Recorder obtains read-out number on scale and records number in space indicated for “Weight”.

• Weight is recorded to nearest 0.2 pounds (or appropriate unit for the scale).

Recording Process • Measurer re-measures height and “2nd Height”

recorded.

• Recorder checks two sets of height measurements

• NOTE: The reading for weight measurement is NOT called out by the measurer or recorder to ensure CONFIDENTIALITY.

Height Measurement

• Recorder should place single line through entries for first set of measurements if greater than one inch difference, initial the line, and record second set of height measurements for “3rd” Height and “4th” Height.

Height Measurement• If after two trials, two height

measurements within the one-inch criteria cannot be achieved, then the child’s assessment is considered “Unable to be Assessed”.

• Mark “Unable to be Assessed” and “Could not get two measurements in range after two repeats”.

Forms

• ACHI Calibration Log

• ACHI Measurement Station Information

• ACHI Height and Weight Data Collection

Scale Accuracy/Testing Log

• Required to verify the accuracy of each scale.

• Scales verified day of scheduled measurement.

• Scales should be placed in exact location where measurements will take place prior to being verified.

• Once verified, do not move scales.• Verification with at least one know weight

important to minimize misreporting of child’s BMI due to faulty equipment.

Scale Accuracy/Testing Log

• Verification Steps:– “Zero” the scale, if digital model.– Place known weight in center of scale– Record scale reading in appropriate

column for known weight used.

Scale Accuracy/Testing Log

Measurement Station Information Form

• Designed to document stadiometers and scales.

• Type/model used determines appropriate unit of measurements.

• Station form required for each station.• When using web-entry system, form must be

completed before student’s data is entered.

Measurement Station Information Form – Top Half

Measurement Station Information Form – Bottom Half

BMI Data Entry Form

• Height and weight may be recorded and then entered into the web-entry system or entered directly into web-entry system at time of assessment.

• Check information for accuracy if student had previous BMI assessment and student information is already entered in web-entry system.

BMI Data Entry Form• If child is not able to be assessed, indicate why

the student data cannot be obtained under “Unable to Assess”. Failure to do so will impact (skew) school data.

• A written refusal from the parent is necessary if the parent wishes for child not to participate.

BMI Data Entry Form

Parent Letter

• Schools are required to include as part of a student health report to parents an annual body mass index percentile by age for each student

• School are required to annually provided parents with an explanation of the possible health effects of body mass index, nutrition and physical activity

Guide for BMI Screening in Schools

A Training Manual for Height and Weight Assessment

http://www.achi.net/ChildObDocs/Height%20and%20Weight%20Measurement%20Training%20Manual.pdf

Data Entry

BMI Screening Program Training Manual 2009 2010

http://www.achi.net/ChildObDocs/2009_2010_docs/100210%20BMI%20Data%20Entry%20Manual.pdf

I can’t believe I was doing it wrong all these years.

We must get the word We must get the word out!out!

How to weigh yourself and get the most accurate

result.

Best Practices and Prevention Programs

[Center for Science in the Public Interest (CSPI) http://www.cspinet.org/new/pdf/2006schoolreport.pdfhttp://www.cspinet.org/new/pdf/2006schoolreport.pdf

Childhood Obesity State Report CardsChildhood Obesity State Report Cards

www.childhealthdata.org/content/ObesityReportCards.aspx

Alliance for a Alliance for a Healthier GenerationHealthier Generation

• Science-based and age-appropriate dietary guidelines - developed in conjunction with nutrition experts at the American Heart Association

• Consume a variety of nutrient-dense foods and beverages within / among the basic food groups

• Promote nutrient-rich foods, fat-free and low-fat dairy products and place limits on calories, fat, saturated fat, trans fat, added sugar and sodium

http://www.healthiergeneration.org/about.aspx

The Alliance School The Alliance School Beverage GuidelinesBeverage Guidelines

(compliance is voluntary)

Elementary School Middle School High School (At least 50% of non-milk beverages must be water and no- or low-calorie options)

Water Any size Any size Any size

Fat-free or low fat regular and flavored milk with up to 150 calories / 8 ounces**

Up to 8 oz. Up to 10 oz. Up to 12 oz.

100% juice* with no added sweeteners and up to 120 calories / 8 ounces

Up to 8 oz. Up to 10 oz. Up to 12 oz.

No- or low-calorie beverages with up to 10 calories / 8 ounces

NO NO Any size

Other drinks with no more than 66 calories / 8 ounces

NO NO Up to 12 oz.

SCHOOL BEVERAGE TOOLKITSCHOOL BEVERAGE TOOLKIT - - http://healthiergeneration.org/beveragekit/

Alliance for a Alliance for a Healthier GenerationHealthier Generation

Healthy Schools Program• Increasing opportunities for students to

exercise and play • Putting healthy foods and beverages in

vending machines and cafeterias • Providing resources for teachers and staff to

become healthy role models

www.healthiergeneration.org/

Examples of School Programs - AHGExamples of School Programs - AHG

1. Recess before lunch2. Active Healthy Fun, Before

the Bell3. Healthy foods first - fruits4. Salad bars 5. Cooking classes6. Walk to school day7. Dance Dance Revolution

(DDR) http://www.ddrgame.com/

8. Kids Find New Favorite Snacks and Activities at School

9. Pedometer competition between the staff/students

10.Teaching in-line skating in regularly scheduled physical education

11. School Wellness Council with students

12. Jazzercise Away Pounds 13. Lunchtime walking club 14. Brown bag lunch menu for

parents who pack their children’s lunches

http://healthiergeneration.org/schools

Action for Healthy KidsAction for Healthy Kids• What's Working - Profiles of successful school-based

interventions, programs and practices http://www.actionforhealthykids.org/resources.php

• A la Cart - Breakfast Fun A la Cart - Snack Fun

• Changing the Scene -- Improving the School Nutrition Environment

• Physical Education in Schools - Both Quality and Quantity are Important

• The Walking School Bus: Combining Safety, Fun and the Walk to School

• School Health Index PowerPoint

• Show Me the Money: A Guide to Selling Healthy Foods at School

Action for Healthy Kids: Action for Healthy Kids: ExamplesExamples

• Breakfast Fun - eat a healthy breakfast• Alternatives to Using Food as a Reward• CookShop Program - engages children in

classroom-based cooking activities • Food On the Run (FOR) • Healthy Hearts  • bSAFE, bFIT!™ A Physical Activity and

Nutrition Program for Kids children’s educational fitness program

Action for Healthy Kids: Action for Healthy Kids: Wellness ToolWellness Tool

http://www.actionforhealthykids.org/wellnesstool/index.php

CDC-Weight Management CDC-Weight Management Research to Practice SeriesResearch to Practice Series

• Summarizes the science re: weight management topics for health professionals and the lay audience

• Overview of the science summary documents appropriate for public health professionals

www.cdc.gov/nccdphp/dnpa/nutrition/health_professionals/practice/index.htm

CDC - Weight Management Research CDC - Weight Management Research to Practice Seriesto Practice Series

• The following topics have handouts, power points, brochures – some in Spanish

• Does breastfeeding reduce the risk of pediatric overweight?

• Can eating fruits and vegetables help people to manage their weight?

• Do Increased portion sizes affect how much we eat?

• Does drinking beverages with added sugars increase the risk of overweight?

ADA - What We Know About ADA - What We Know About Childhood OverweightChildhood Overweight

• Through the sponsorship of the ADA Foundation (American Dietetic Association), the ADA carried out an evidence analysis project (2004) to determine what we know in the area of childhood overweight and obesity in order to develop professional, family, and organizational tools to address this crisis.

Remove Sugar Sweetened Beverages Remove Sugar Sweetened Beverages from Schoolsfrom Schools

• Consumption of sugar-sweetened beverages has dramatically among U.S. children and adolescents– …soft drinks were the 6th leading food source of

energy among children > 50% of total beverage consumption

• Evidence -Intake of calorically-sweetened beverages is positively related to adiposity in children Grade II

Dairy and Calcium Intake and Dairy and Calcium Intake and Childhood OverweightChildhood Overweight

• Research indicates that a low intake of calcium may be associated with increased adiposity

• Grade III• Research indicates that a low intake of dairy may be

associated with increased adiposity among children• Grade III

•

Plain Milk vs Flavored MilkPlain Milk vs Flavored Milk

• Findings from this study suggest that consumption of either [low fat] flavored or plain milk is associated with a positive influence on nutrient intakes by children and adolescents and is not associated with adverse effects on BMI measures.

Murphy, et al. 2008

Fruits and VegetablesFruits and Vegetables

• Even though…fruit and vegetable availability has slightly in recent decades (in comparison to other food groups) they are most likely to be consumed in inadequate amounts by children.

• …Evidence is consistent with a modest effect of fruit and vegetable intake on protecting against increased adiposity. Grade II http://www.adaevidencelibrary.com/a_z_index.cfm

Use of Food as a Reward

• Arkansas reported a substantial increase in the number of schools implementing this policy to prohibit the use of food as reward

Policy - - Changes in Fundraising Policies and Practices

• Significant increase in schools that prohibit students, faculty and parent from selling food items for fundraising (Arkansas, 2008)

How effective are different school-How effective are different school-based interventions based interventions

for childhood overweight? for childhood overweight? • Multi-component programs • Nutrition education• Parental modeling• Peer modeling• Physical activity• Sedentary behaviors•Media Influences

Nutrition EducationNutrition Education

• Using nutrition education to change food eaten, food preferences, or eating patterns as part of a school-based intervention may be associated with changes in weight status/adiposity.

Grade II

Multi-Component ProgramsMulti-Component Programs

• Interventions to reduce pediatric overweight should be multicomponent

• diet • physical activity • nutrition counseling • parent / caregiver participation

Strong / Imperative © 2007 ADA Evidence Analysis Library

Physical ActivityPhysical Activity

• Altering physical activity patterns as part of a school-based intervention may be associated with changes in weight status/adiposity

Grade II

Physical Activity in the Treatment of Physical Activity in the Treatment of Childhood / Adolescent OverweightChildhood / Adolescent Overweight

• Accumulate 60 minutes of at least moderate physical activity on a daily basis – briefer bouts of 10 to 20 minutes can be added up

for a total of 60 minutes

Young people should select activities they enjoy, that fit into their daily lives, & involve a variety of activities

PedometersPedometers

• Easy to use and can measure– Number of steps– Distance walked– Calories expended

• 4000 steps in 30 minutes or 8000 steps in 60 minutes meet current US physical activity recommendation

(Russell, et al, 2006, Journal of Sports Sciences)

Benefits Of Physical Activity On Benefits Of Physical Activity On Academic PerformanceAcademic Performance

Various research studies indicate:1. Physical education curriculum = small

positive gains in academic performance2. Positive association between academic

performance and physical activity3. Physical activity has a positive influence on

concentration and memory

(Strong, et al (2005) The Journal of Pediatrics)

Parent InvolvementParent Involvement

• A more limited body of research indicates that treating 6 to 12-year-old children without parental participation is not effective.

Strong / Imperative

School Based InitiativesSchool Based Initiatives

• Promotion of healthy foods and restrictions / discouragement of less healthy foods in the cafeteria and vending machines.

• Health education regarding the importance of nutrition and physical activity.

• Opportunities for activity in physical education and recess programs.

(AMA-CDC Obesity Prevention Working Group, 2006)

References and Resources

VERBVERB™™ It’s What You Do It’s What You Do

• National, multicultural, social marketing campaign* coordinated by the U.S. Department of Health and Human Services’ Centers for Disease Control and Prevention

• The VERB™ campaign encourages young people ages 9–13 (tweens) years to be physically active every day.

http://www.cdc.gov/youthcampaign/index.htm

Behaviors Parents AreBehaviors Parents AreReady to ChangeReady to Change

• decreasing meal portion sizes

• exercising as a family

• watching less TV

• eating less fast food (Asante, et al, 2005).

We Can! Parent Tips: Healthy Families, Healthy Weight

http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/physician2.pdf

Behaviors Parents AreBehaviors Parents AreReady to ChangeReady to Change

• drinking less soda

• eating more vegetables

• eating together as a family

• eating more fruits (Asante, et al, 2005).

We Can! Parent Tips: Healthy Families, Healthy Weight

http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/physician2.pdf

http://www.healthynh.com/fhc/initiatives/ch_obesity/5210.php

"5-2-1-0 is a public education campaign to bring awareness to the daily guidelines for nutrition and physical activity. Its message is simple and clear and represents some of the most important steps families can take to prevent childhood obesity:

5 Fruits and vegetables…more matters! Eat fruits and vegetables at least 5 times a day. Limit 100% fruit juice. 2 Cut screen time to 2 hours or less a day.1 Participate in at least one hour of moderate to vigorous physical activity every day.0 Restrict soda and sugar-sweetened sports and fruit drinks. Instead, drink water and 3-4 servings/day of fat-free/skim or 1% milk.

http://www.sdchip.org/media/2867/Handouts-by-Category.pdf

Let’s MoveFour Pillars of the First Lady’s Let’s Move campaign

•Empowering parents and caregivers •Providing healthy food in schools •Improving access to healthy, affordable foods •Increasing physical activity

http://www.letsmove.gov/

• NHANES data on the Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004

• “Overweight and Obesity”, CDC• Pediatric Nutrition Surveillance Report, 1999• “Prevention of Pediatric Overweight and

Obesity”, Committee on Nutrition, American Academy of Pediatrics

• “Trust for America’s Health” report F as in Fat: How Obesity Policies are Failing in America, 2006.

• Arkansas Center for Health Improvement• Arkansas Department of Education• Arkansas Department of Health• Arkansas Government Act 1220 of 2003• Arkansas Government Act 201 of 2007• Arkansas Government Act 29 of 2003

• American Academy of Pediatrics Recommendations for Prevention of Pediatric Overweight and Obesity

• American Obesity Association Facts Sheets• Assessment of Childhood and Adolescent

Obesity in Arkansas, Year Four (Fall 2006-spring 2007)

• “Fact Sheet on Obesity in Arkansas”, Arkansas BMI Task Force

• healthyamericans.org, “Obesity Report in Arkansas 2006”

• NHANES data on the Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004

• “Overweight and Obesity”, CDC• Pediatric Nutrition Surveillance Report, 1999• “Prevention of Pediatric Overweight and

Obesity”, Committee on Nutrition, American Academy of Pediatrics

• “Trust for America’s Health” report F as in Fat: How Obesity Policies are Failing in America, 2006.

• American Academy of Pediatrics Recommendations for Prevention of Pediatric Overweight and Obesity

• American Obesity Association Facts Sheets• Assessment of Childhood and Adolescent

Obesity in Arkansas, Year Four (Fall 2006-spring 2007)

• “Fact Sheet on Obesity in Arkansas”, Arkansas BMI Task Force

• healthyamericans.org, “Obesity Report in Arkansas 2006”

• ACHI– http://www.achi.net

• Ark Dept of Health– http://www.healthyarkansas.org

• ADE Coordinated School Health Website– http://www.arkansascsh.org

• Community Health Nurse Specialists & Community Health Promotion Specialists– http://www.arkansascsh.org

• Arkansas Center for Health Improvement• Arkansas Coordinated School Health• Arkansas Department of Education• Arkansas Department of Health• Arkansas Government Act 1220 of 2003• Arkansas Government Act 201 of 2007• Arkansas Government Act 29 of 2003

http://www.achi.net

http://www.arkansascsh.org

• ACHI– http://www.achi.net

• Ark Dept of Health– http://www.healthyarkansas.org

• ADE Coordinated School Health Website– http://www.arkansascsh.org

• Community Health Nurse Specialists & Community Health Promotion Specialists– http://www.arkansascsh.org