Lessons learned while implementing a legislated school policy: body mass index assessments among Arkansas's public school students

BACKGROUND: To comprehensively address the childhood and adolescent obesity epidemic, Arkansas enacted Act 1220 of 2003. Among a series of community- and school-based interventions, the Act requires each public school student to have his/her body mass index (BMI) assessed and reported annually to parents. The process of implementing this policy on a statewide level and lessons learned are described in this article. METHODS: A confidential, standardized protocol to measure student BMIs and report results to parents was developed. Affordable, reliable, and durable equipment was selected and school personnel who conducted BMI assessments were trained to ensure standardization. To enhance the efficiency and ease of the measurement and reporting process and promote long-term and locally based sustainability, during the first 3 years of implementation, a transition from a paper-based system to a Web-based system was made. Confidential, individualized Child Health Reports have provided students' parents with information about the health of their children. RESULTS: Participation by schools and students has been high as a result of collaboration between the health and education communities and the students and their families. Childhood obesity has not increased since Act 1220 was passed into law. CONCLUSIONS: Parents, schools, school districts, and the state are able to better understand the obesity epidemic and track progress using detailed annual data. Providing a standardized measurement protocol, equipment, and efficient data entry and report generation options has enabled Arkansas to institutionalize the BMI assessment process in public schools.     

The relationship among state laws, district policies, and elementary school-based measurement of children's body mass index

BACKGROUND: School‐based measurement of children's body mass index (BMI) is a useful tool for tracking childhood obesity rates, and may be an effective intervention strategy for reducing the increasing trends in obesity. This article examines the relationship between state law, district policy, and school‐level BMI measurement practices. METHODS: Data were collected during 3 school years (2006‐2007, 2007‐2008, 2008‐2009) as part of an annual study on health policies and practices in a nationally representative sample of US public elementary schools. Data collected included school‐level data via a mailed questionnaire, and district‐level policies and state laws from publicly available sources. We examined whether state laws and district policies were linked to school‐level BMI measurement, either directly, or via a mediation effect. RESULTS: Schools were most likely to measure student BMI if there was a state law in place (65.0% of schools) than where there was not a state law regarding BMI measurement (38.4% of schools; χ² = 120.91, p < .001). However, school‐level BMI measurement did not differ by whether the district had a relevant policy or not (49.8% vs. 49.2%, ns). These effects held up in multivariate logistic regression models controlling for relevant school‐level covariates (region, race/ethnicity, location, school size, and socioeconomic status). Schools in the south and those with a majority of White students were most likely to measure students' BMI. CONCLUSION: State laws are associated with school‐level BMI measurement, and therefore may be a helpful tool in monitoring and addressing childhood obesity.     

Body mass index measurement in schools

BACKGROUND: School-based body mass index (BMI) measurement has attracted much attention across the nation from researchers, school officials, legislators, and the media as a potential approach to address obesity among youth. METHODS: An expert panel, convened by the Centers for Disease Control and Prevention (CDC) in 2005, reviewed and provided expertise on an earlier version of this article. The panel comprised experts in public health, education, school counseling, school medical care, and a parent organization. This article describes the purposes of BMI measurement programs, examines current practices, reviews existing research, summarizes the recommendations of experts, identifies concerns, and provides guidance including a list of safeguards and ideas for future research. RESULTS: The implementation of school-based BMI measurement for surveillance purposes, that is, to identify the percentage of students in a population who are at risk for weight-related problems, is widely accepted; however, considerable controversy exists over BMI measurement for screening purposes, that is, to assess the weight status of individual students and provide this information to parents with guidance for action. Although some promising results have been reported, more evaluation is needed to determine whether BMI screening programs are a promising practice for addressing obesity. CONCLUSIONS: Based on the available information, BMI screening meets some but not all of the criteria established by the American Academy of Pediatrics for determining whether screening for specific health conditions should be implemented in schools. Schools that initiate BMI measurement programs should evaluate the effects of the program on BMI results and on weight-related knowledge, attitudes, and behaviors of youth and their families; they also should adhere to safeguards to reduce the risk of harming students, have in place a safe and supportive environment for students of all body sizes, and implement science-based strategies to promote physical activity and healthy eating.     

Frequent fliers, school phobias, and the sick student: school health personnel's perceptions of students who refuse school

BACKGROUND: This study explored school personnel's perceptions of school refusal, as it has been described as a “common educational and public health problem” that is less tolerated due to increasing awareness of the potential socioeconomic consequences of this phenomenon. METHODS: In‐depth interviews were conducted with school personnel at the middle school (N = 42), high school (N = 40), and district levels (N = 10). The findings focus on emergent themes from interviews with school health personnel (N = 12), particularly those themes related to their perceptions of and role in working with school‐refusing students. RESULTS: Personnel, especially school health services staff, constructed a typification of the school‐refusing student as “the sick student,” which conceptualized student refusal due to reasons related to illness. Personnel further delineated sick students by whether they considered the illness legitimate. School health personnel referenced the infamous “frequent fliers” and “school phobics” within this categorization of students. Overarching dynamics of this typification included parental control, parental awareness, student locus of control, blame, and victim status. These typifications influenced how personnel reacted to students they encountered, particularly in deciding which students need “help” versus “discipline,” thus presenting implications for students and screening of students. CONCLUSIONS: Overall, findings suggest school health personnel play a pivotal role in screening students who are refusing school as well as keeping students in school, underscoring policy that supports an increased presence of school health personnel. Recommendations for school health, prevention, and early intervention include the development of screening protocols and staff training.     

The relationship of school absenteeism with body mass index, academic achievement, and socioeconomic status among fourth-grade children

BACKGROUND: Data from a school‐based study concerning fourth‐grade children's dietary recall accuracy were linked with data from the South Carolina Department of Education (SCDE) through the South Carolina Budget and Control Board Office of Research and Statistics (ORS) to investigate the relationships of children's school absenteeism with body mass index (BMI), academic achievement, and socioeconomic status (SES). METHODS: Data for all variables were available for 920 fourth‐grade children during 2 school years (2005–2006, 2006–2007). Number of school days absent for each child and eligibility for free/reduced‐price school meals (SES measure) were provided to ORS by SCDE. Children's weight and height were measured by research staff; age/sex‐specific BMI percentile was calculated and grouped into categories. For academic achievement, Palmetto Achievement Challenge Tests scores were provided by the school district. The associations of absenteeism with BMI, academic achievement, SES, and school year were investigated with logistic binomial models using the modified sandwich variance estimator to adjust for multiple outcomes within schools. RESULTS: The relationships between absenteeism and each of BMI percentile category and SES were not significant (all coefficient p values > .118). The relationship between absenteeism and academic achievement was inversely significant (p value < .0001; coefficient = ?.087). CONCLUSIONS: These results support the inverse relationship between absenteeism and academic achievement that was expected and has been found by other researchers. The lack of significant results concerning the relationships between absenteeism and both BMI and SES differs from earlier, limited research. More research to investigate these relationships is needed.     

Are school vending machines loaded with calories and fat: an assessment of 106 middle and high schools

BACKGROUND: The purpose of this study was to describe the extent to which vending offerings in 106 schools in the St. Paul‐Minneapolis, Minnesota metropolitan area, met criteria for types of beverages, fat, and calories based on selected criteria offered by the Institute of Medicine. METHODS: Schools where youth participants were attending for the 2006–2007 school year were identified and invited to participate in the study (n = 143); 81% of schools (n = 116) agreed to participate. RESULTS: Of the 116 schools, 106 had vending machines. Across schools with vending machines (n = 106), 5085 food and 8442 beverage items were offered. Overall, only 18% of beverage items met criteria for calories and type of beverage; significantly more items in public schools met the criteria as compared to private schools (19% vs 12%; p < .01). This difference was also significant for high schools as compared to middle schools (18% vs 22%; p < .01). For food items, 41% met calorie criteria, 45% met fat criteria, and 22% met both fat and calorie criteria. Significantly more food items met both criteria in public than private schools (22% vs 18%; p = .01), while high schools (22%) and middle schools (21%) were similar. A very small proportion of foods (<5%) would have met the full criteria suggested by the Institute of Medicine for competitive foods. CONCLUSION: Overall, foods and beverages offered in vending machines continue to be high in fat and calories. Public schools are doing a slightly better job of providing healthy foods as compared to private schools.     

Ecological strategies to promote healthy body image among children

Background: Personal habits of children and adolescents related to healthy body image (BI) are influenced by various determinants in the micro‐ and macroenvironment. These include attitudes and behaviors about eating; exercise and physical appearance modeled by parents, teachers, and peers; as well as opportunities to learn new habits and social praise for healthy choices. The coordinated school health program (CSHP) is compatible with the 5 levels of an ecological approach to developing new health behaviors. Methods: Authors systematically applied the ecological model to all 8 components of coordinated school health. Next, strategies for each of the components were developed using the professional literature as well as author expertise in the areas of health education, exercise science, and dietetics. Results: For each strategy, applicable health and physical education standards, as well as goals for each strategy and additional Web resources, were provided to assist educators and administrators in supporting healthy BI among students. Conclusions: Educators may effectively use a coordinated approach to guide multiple intervention activities aimed at increasing healthy habits among adolescents and their families. The strength of the CSHP is its collaborative nature with active participation by students, faculty members, family caregivers, agency professionals, community residents, and health care providers.     

Developing public health nursing: barriers perceived by community nurses

OBJECTIVES: To understand the key issues for field nursing in developing their public health role within five primary care trusts (PCTs) in Merseyside, in the North West of England. DESIGN: Qualitative study. METHODS: Fourteen school nurses and 30 health visitors participated in 11 focus groups consisting of others from their profession working within the same PCT, and 24 practitioners responded to a questionnaire. RESULTS: The findings suggest that there are a number of shared obstacles that need to be overcome before the public health approach can be fully developed within community nursing. These include: the need for facilitation to deal with organisational change, lack of clarity around the public health role, inadequate administrative support, general practitioner attachment problems, poor interprofessional partnerships, competing priorities and resistance to change. CONCLUSIONS: The development of public health nursing in England envisaged in current government policy will not occur in full unless the kind of issues identified in this study are adequately addressed. This will require participative, interprofessional approaches to redesigning services by all relevant public health practitioners.     

School-based screening of the dietary intakes of third graders in rural Appalachian Ohio

BACKGROUND: Children in Appalachia are experiencing high levels of obesity, in large measure because of inferior diets. This study screened the dietary intake of third graders residing in 3 rural Appalachian counties in Ohio and determined whether the Food, Math, and Science Teaching Enhancement Resource Initiative (FoodMASTER) curriculum improved their dietary intake. METHODS: Dietary intake was measured for 238 third graders at the beginning of the 2007 to 2008 school year and for 224 third graders at the end of that year. The FoodMASTER curriculum was delivered to 204 students (test group). Intake was measured using the Block Food Frequency Questionnaire 2004. The final analysis included 138 students. RESULTS: The FoodMASTER curriculum did not significantly affect the diets of the students in the test group, as no significant differences in intake of macronutrients, specific nutrients, or food groups were found between the test and control groups. Majorities of students did not meet the Recommended Dietary Allowance or Adequate Intakes for fiber, calcium, iron, vitamin A, and vitamin E. The students as a whole did not meet the MyPyramid recommendations for any food group, and nearly one fifth of their calories came from sweets. Significant differences in percentages of kilocalories from protein and sweets and in servings of fats, oils, and sweets were seen between groups of higher and lower socioeconomic status. CONCLUSIONS: Energy-dense foods are replacing healthy foods in the diets of Ohio children living in rural Appalachia. The prevalence of poor dietary intake in Appalachia warrants further nutrition interventions involving programming for nutrition, such as future FoodMASTER curricula.     

Variation in school health policies and programs by demographic characteristics of US schools, 2006

BACKGROUND: To identify whether school health policies and programs vary by demographic characteristics of schools, using data from the School Health Policies and Programs Study (SHPPS) 2006. This study updates a similar study conducted with SHPPS 2000 data and assesses several additional policies and programs measured for the first time in SHPPS 2006. METHODS: SHPPS 2006 assessed the status of 8 components of the coordinated school health model using a nationally representative sample of public, Catholic, and private schools at the elementary, middle, and high school levels. Data were collected from school faculty and staff using computer-assisted personal interviews and then linked with extant data on school characteristics. RESULTS: Results from a series of regression analyses indicated that a number of school policies and programs varied by school type (public, Catholic, or private), urbanicity, school size, discretionary dollars per pupil, percentage of white students, percentage of students qualifying for free lunch funds, and, among high schools, percentage of college-bound students. Catholic and private schools, smaller schools, and those with low discretionary dollars per pupil did not have as many key school health policies and programs as did schools that were public, larger, and had higher discretionary dollars per pupil. However, no single type of school had all key components of a coordinated school health program in place. CONCLUSIONS: Although some categories of schools had fewer policies and programs in place, all had both strengths and weaknesses. Regardless of school characteristics, all schools have the potential to implement a quality school health program.     

Physical activity levels of overweight and nonoverweight high school students during physical education classes

Background:  This study examined physical activity (PA) levels of overweight and nonoverweight African American and Caucasian students (n = 198) during game play in physical education classes.
Methods:  Body fat percentages (%BFs) were determined using the skinfold technique and Slaughter et al prediction equations. Girls were classified as overweight if their %BF was ≥32; boys were classified as overweight if their %BF was ≥25. PA was monitored using pedometers during flag football, ultimate Frisbee, and soccer game play. Three 2 (weight classification) × 2 (gender) × 2 (race) factorial analyses of variance were conducted.
Results:  Results indicated no significant difference in steps per minute between overweight and nonoverweight students regardless of game. Males were more active than females, and Caucasians were more active than African Americans.
Conclusions:  The most important implication of the current study is that the overweight and nonoverweight students accumulated similar amounts of PA during physical education. This emphasizes the importance physical education plays in providing both overweight and nonoverweight students with opportunities for PA. For many students, it may be their only source of regular PA.     

Changing nutrition standards in schools: the emerging impact on school revenue

BACKGROUND: Although great focus has been placed on nutritional and other consequences of changes in food-related policies within schools, few reports exist describing the impact of such changes on school revenue. This review provides an overview of the few revenue-related studies published recently, as well as information from a sampling of state reports on the subject. METHODS: A systematic review of the literature was conducted. Four peer-reviewed papers and 3 state-based reports were identified that assessed the impact on revenues of either targeted policy changes or overarching, district-wide changes in food-related policies. RESULTS: Thus far, few data exist to substantiate the concern that changes in nutrition standards in schools lead to a loss in total revenue. An interesting phenomenon of increased participation in the National School Lunch Program was noted in a number of reports and might play a role in buffering financial losses. CONCLUSIONS: A renewed focus on school policies related to health provides the opportunity for researchers to investigate how nutrition-related policy change can affect, if at all, food service and overall school revenues.     

健康是促进人的全面发展的必然要求——论中国特色的卫生发展战略

目的了解上海市金山区中小学生身体健康现况及主要影响疾病,为制定学生健康促进策略和措施提供科学依据。方法评价内容包括视力不良、龋齿、贫血、肠道蠕虫感染、肥胖、营养不良、器质性疾病7类疾病,按照各病种扣分标准进行扣分计算,满分100分为健康,小于100分为不同程度的不健康; 通过疾病总扣分顺位,评价疾病对学生健康的影响。结果2017年上海市金山区中小学生总健康率为13.38%。综合比较健康率、健康得分、不健康程度等情况,得出男生的健康状况比女生差,初中生健康状况比小学生和高中生差的现况。按照疾病总扣分进行排序,对学生健康影响最大的前5位疾病为器质性疾病、重度视力不良、肥胖、超重、龋齿。结论身体健康评价可以综合评估疾病患病率和危害程度对健康的影响,可为有关部门评价学生健康状况和主要影响病种提供有益的参考。     

School travel planning: mobilizing school and community resources to encourage active school transportation

BACKGROUND: Active school transport (AST), school travel using an active mode like walking, may be important to children's overall physical activity. A “school travel plan” (STP) documents a school's transport characteristics and provides an action plan to address school and neighborhood barriers to AST. METHODS: We conducted a pilot STP intervention at 12 schools in 4 Canadian provinces. Facilitators and school personnel created and implemented AST action plans. Parent's self‐reports (N = 1489) were the basis for evaluating the intervention. A content analysis identified type, frequency, and perceived success of initiatives. RESULTS: School travel plans emphasized education and promotion, and AST activities and events. Capital improvement projects were more common at schools in older suburban neighborhoods, whereas enforcement was more common at schools in newer suburban neighborhoods. Rates of active transportation increased from 43.8% to 45.9%. At follow‐up, 13.3% of households reported less driving. Parents/caregivers cited weather, convenience, and trip chaining as primary reasons for continued driving. CONCLUSION: The STP process may facilitate changes to patterns of school travel. An STP can expand a school's capacity to address transportation issues through mobilization of diverse community resources. Future STP initiatives may benefit from addressing convenience, safety through enforcement, and by examining how schools can be supported in implementing infrastructure improvements.     

Reliability of Height and Weight Measurements Collected by Physical Education Teachers for a School‐Based Body Mass Index Surveillance and Screening System

BACKGROUND: To address the obesity epidemic among children and youth, school‐based body mass index (BMI) screening and surveillance is proposed or mandated in 30 states. In Cambridge, MA, physical education (PE) teachers are responsible for these measurements. This research reports the reliability of height and weight measures collected by these PE teachers. METHODS: Using Bland‐Altman plots, mean absolute differences, and intraclass correlation coefficients (ICC), we estimated intra‐ and inter‐rater reliability among PE teachers in a controlled setting and PE teacher‐vs‐expert inter‐rater reliability in a natural classroom setting. We also qualitatively assessed barriers to reliability. RESULTS: For the controlled setting, of 150 measurements, 3 height (2.0%) and 2 weight (1.33%) measurement outliers were detected; intra‐rater mean absolute differences for height/weight were 0.52 inches (SD 1.61) and 0.8 lbs (SD 3.2); intra‐ and inter‐rater height/weight ICCs were ≥0.96. For the natural setting, of 105 measurements, 1 weight measurement outlier (0.9%) was detected; PE teacher‐vs‐expert‐rater mean absolute differences for height/weight were 0.22 inches (SD 0.21) and 0.7 lbs (SD 0.8), and ICCs were both 0.99. Equipment deficiencies, data recording issues, and lack of students' preparation were identified as challenges to collecting reliable measurements. CONCLUSION: According to ICC criteria, reliability of PE teachers' measurements was “excellent.” However, the criteria for mean absolute differences were not consistently met. Results highlight the importance of staff training and data cleaning.