HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS the LIFESPAN

Get Healthy California: Governor’s Plans and Activities for Obesity Prevention

CAROLE GARNER: Good morning to everyone. Let me get this up and going. What I wanted to step you through is looking at what’s been happening in our state specifically related to legislation issues and I’ve chosen the title From Contemplation to Action because it does take a lot of prior thought before you get something moving along and I’m trying to relate if you can think to your transtheoretical model of getting people moving, you know, stages of change, pre-contemplation and so forth and how do we get government moving along?

So here’s our model, pre-contemplation, contemplation, preparation, action and then hopefully maintenance without too much regression. For a little extra detail we’ll be talking about the pre-contemplation area, no intention to change behavior. How many of you all have seen that happening in your own states? Well, if we look back over time I found this in my files. Everyone knows I keep a lot of files and this was like 1978. Here’s the health and the science community talking about obesity already but did we see anything happening legislative wise? I don’t remember anything. Actually when I was cleaning out some files a couple of years ago I found an article from 1975 talking about the obesity epidemic in the U. S. I mean, it’s been floating around a long time, it’s just taken quite a number of years to bubble it up to get action going.

Okay. Let’s jump to 1990, the fattening of America. Again, in communities in health departments in academic areas there’s been research going on, there’s been activities but bubbling it up to where the population is paying attention to whether there’s money to really do something is taking again an extremely long time. Quite a bit of time you’ll hear obesity being connected to tobacco, you know, it’s taken 25 years to get motions and activities going on tobacco, prevention so it may take that long to get action and success going on obesity. If you think back into the ‘50’s, again, the health community, the science community was talking about problems with tobacco. Yet, again it took 25 plus years to bubble it up. The same thing’s what’s been happening with obesity, so let’s jump from ’90 to ’94, again, the fattening of America. This was an article that was reported on from JAMA. Then finally really it’s hitting the lay press, 2000 kids fat for life. If any of you all are in AARP this popped up in one of their journals in 2001. You know, we’re looking at across a lifespan and then finally last year, you know, big conferences, obesity, that’s the thing. It’s out there. It’s now gathered the awareness. People are taking big action. So we’ve generated the awareness, the problem exists and we’re thinking seriously about doing something.

Let me give you a little bit of history in Arkansas. We’ll go back to 1991 and we were able to get our legislature to put money forward to actually start school breakfasts in some of our counties. This was not the big national program that it is now but we were able to get some action going. At the time we were looking more at the hunger side of it but you know, as you know there’s a big impact of kids eating and their learning ability. In ’93 we had a resolution related to five a day. We get five a day going in this state, get people eating their fruits and vegetables and you’ll see that these are, like, every two years, our legislator just meets every other year, so it’s not that we’re, kind of, sitting around on the even numbered years. We just don’t have legislative action going on.

In ’97 the legislature passed a resolution asking the Arkansas Nutrition Advocacy Council to come up with a comprehensive policy and from this remember it’s comprehensive. We were dealing with issues on food insecurity as mentioned earlier. We were looking at problems with anemia. Obesity popped up though it wasn’t the big top item. We were looking at low birth weight. We were looking at breast-feeding. Again, getting the rights up not necessarily as obesity prevention but we knew that we needed to improve breast-feeding. We had issues related to nutrition education, nutrition surveillance, though we didn’t at that point realize it was going to jump into what we’ve done in the schools in the last two years. Physical activity and food safety. So again, it’s a comprehensive plan, this was 1999 when the legislature met there was a representative who put forward a resolution that this should be adopted as a guide for future legislation related to nutrition in the state. This representative’s name was Hershel Cleveland and I want you to remember his name because it’s going to come up important a few slides down.

Okay. In ’99 after they adopted that policy they charged the health department with coming up with a study looking at the impact of obesity in the state, the economics of it, the health implications, what were we doing on prevention, what could we do for treatment. So what came out of this was trying to raise awareness. It’s one of the identified recommendations, ensuring nutrition education and physical education, K12, looking at worksite wellness, creating a statewide obesity council, developing legislation, working with industry and doing prevention programs. Now, again all these ideas are percolating around but we haven’t gotten to any big action yet. It was, like, yes, this is really important but hey guys, there’s no money. How often have you heard that one? This study was a big collaborative effort. We pulled in people form education, from health, from the community, from industry trying to get input so that all the partners maybe could take something home and work with it. And I forgot the insurance. We couldn’t let those folks go away.

Okay. So we’ve developed all of these plans, all these ideas, all these recommendations and it’s, kind of, moving along, so we’re getting known to preparation. In 2002 we had a nutrition physical activity summit. We pulled together leaders from the community, again from health, from education, from the legislature. What can we do to take the obesity report, what can we do to take a recently at that point released report from The Governor’s Council on Fitness? They had put out a report card on how bad we were doing with physical activity and fitness in the state. So how can we take these recommendations and actualize them? So they pulled together the summit and during a day we had intense work groups that took all these recommendations that had already bubbled up. We didn’t want to spend more time developing the same thing over again and look at what can we do to move the states forward? I’ve just mentioned here some of the 14 recommendations that came up but these are ones that have stayed more at the forefront and truly have moved into action.

Again, we’re looking at healthier schools, you know, the idea of a state office of nutrition physical activity. Here was, kind of, the first start of obesity on--we said school district report cards. Not necessarily individual school report cards. Looking at fitness tests on school district report cards. Trying to get across the whole family looking at calories on restaurant menus and then also getting the BMI on clinical records as a vital sign. Because, you know, when you go in they’ll do temperature, blood pressure, those are all, you know, the vital signs, respiration and we wanted to, you know, get out to the practitioners to pay attention to individuals BMI.

Okay. If we get, you know, moving along this model we’ve moved into action, you know, overt behavioral changes but a lot of time, a lot of energy have to be committed from a variety of people. I’m so glad, you know, earlier talked about all the collaborative efforts you’ve done in California. Everything that was happening in Arkansas had to be collaborative, multiple agencies, organizations, multiple sectors of the population. So in 2003 our general assembly passed at 1220. This was establishing a state level child health advisory committee prohibiting vending in elementary schools, requiring reports from the schools on what they were doing with their vending money. Well, this act came about from that same representative I mentioned earlier, Hershel Cleveland. He was now speaker of the house and he had experienced a major heart attack, quadruple bypass surgery, you know, it was finally hitting at home on the issues of obesity and it was his push to the health department that said, okay, guys it’s time to take action. So here we have top leadership in the state in the legislature saying I’m behind you. Give me ideas of a legislative package and this was the outcome of that. Other things that came up in addition to these three was the BMI for age of every child in a report to be sent home to their parents, and also in the fall of 2004 that every school district would have their own nutrition and physical activity advisory committee. This was prior to what’s come out from USDA on their wellness policy requirements for all school districts participating in national school lunch and school breakfast.

Well, you may have seen things in the press and heard about Arkansas ’ going to measure all their kids. You have to work with your media. You have to have everybody on your team speaking, you know, in kind of a coordinated manner because what we’ve had coming at us is, oh, they’re going to grade the kids and if they flunk their fat test it’s going to go into the academic grade point. I’m, like, no, that’s not quite it, you know, we’re trying to get folks to think about all the screens we do in school with vision screening and hearing screening. It’s, like, we’re not giving a pass/fail, it’s another screening tool to help alert families to what’s going on with their children. We had national coverage, you know, Wall Street Journal was calling. What’s going on in Arkansas? What’s happening? What are you doing to the kids? We had all the major networks showing up, I mean, it was interesting that our little state was suddenly jumping out there.

Well, this is some of the data. It was a big surprise to everyone. We measured nearly 450,000 kids in 75 counties and at that time 310 school districts. We wanted things to be consistent so we cobbled together funds from a variety of sources so that we bought digital scales for every school in the state. We partnered with our department of corrections and their wood working shops to build stadiometers for every school in the state. We pulled in folks to develop, kind of, train the trainer material so that we could teach nurses in every school district across the state on how to actually weight and measure. Developed individual data entry forms for every child provided to the schools, because the legislation put all of this onto the school districts and they were, like, you know, what is this BMI that we’re supposed to measure and report on? So by, you know, taking the lead at the state level, providing the direction it really brought the school districts along to where we’ve had over 85% of all the kids weighed and measured for two years. But as you can see between our underweight kids which are 2% and then looking at our overweight and at risk for overweight kids it doesn’t match up with, you know, what (inaudible) and a lot of the other data has been talking about across the country. We’re looking at 38% of the kids having weight problems.

Along with this when we knew we were going to be sending letters home to every parent or guardian for every child we needed to have support in the community, so if the parents got these letters and the letters were telling them, you know, your child’s weight is and it gave specifics and then it put them on a continuum of healthy weight, underweight, at risk or overweight and then gave a recommendation that if they were underweight or in one of the overweight categories to see their healthcare provider. We wanted to be sure the healthcare providers knew what was going on. So a group of physicians and some behavior folks pulled together and online CE course for physicians and for nurse practitioners so that they could go online and look at what to do next and here comes this child and their parents with this letter. What do we need to do to take the screening and do more definitive work? What kind of intervention should we do? And then we were looking at, okay, if the physicians find problems and want to refer them, where can they refer them? So we went to the dietetic association and to the health educators to see if there folks in their community who would volunteer to see these children because at this point we didn’t have any insurance coverage for any in-depth counseling. And so we were able to develop again some lists which are online for physicians to access and for, you know, parents to access of who in their community they could go talk to.

This is also been reported by school district and by school, by gender, by age group so that at the local level the schools can look at where are there problems. When we look at the data for the districts there was some districts that only had maybe 20% of their kids at risk for overweight or overweight. We had a lot of districts that over 50% of their kids were overweight or at risk for overweight. You know, so it really was a huge--excuse the pun--but a big wake up call. Well, some of the other things that were going on with, okay, what’s in the school environment? So we participated with the National Alliance for Nutrition Activity looking at what was really in the vending machines in school. Could the kids make healthy choices? Sadly they couldn’t. Over 85% of the items and we just went in and counted, you know, row after row of item, over 85% were high fat, high sugar items. So the kids that wanted to make a healthy choice had very limited opportunity to do that.

Some of the other things that were coming out, we were working with action for healthy kids. Do you all work with that group in your state? Because if you don’t you need to find out who is your team chair. It’s a great coalition; grass roots activities focused on school healthy environments and you can go to actionforhealthkids.org and pull up for every state what’s going on. In Arkansas one of the first things we did was to pull together our own summit to where we could bring in folks at the local school level, the administrators, folks in PE, the teachers, child health advocates, parents, kids trying to give them some ideas of things that have worked and have been successful.

Also, the College of Public Health had received some funding from Robert Wood Johnson to try evaluate at 1220 to see what the impact was. And some of the interesting things that have come form that is that prior to any reports every going home to parents some of the questions to parents were, can you tell us, you know, what’s your child’s height, what’s your child’s weight and they were pretty right on knowing what it was. The downside was over half of the parents whose kids by their own self report put them at a BMI at risk for overweight or overweight over half of them didn’t think that was a problem. So even know they knew how big their kids were it was not a big issue to them. You know, they really needed a wakeup call. Also in this we looked at the issues of vending machines in a healthy school environment and there’s a lot of support to get either the machines out of the schools or to be sure that they were healthy choices in them and more than healthy choices and more available.

The evaluation also looked at policies that were going on trying to see, you know, if with physical activity or PE is it really being provided in the schools in a supported environment or is it being provided as a punishment? You know, think of if you were in a, say, on a football team and you did something the coach didn’t like and he’d make you drop and do, you know, 20 push ups, you know, we really didn’t want physical activity being used as a punishment. Or we didn’t want to the withholding of physical activity opportunities such as recess being used a punishment so we’re trying to look at the whole gamut of what was going on in schools. And then Child Nutrition Reauthorization Act from USDA was a big help and a big support. Are you all aware of the Child Nutrition Reauthorization Act and what it’s done with wellness policies? Because it’s requiring every school district to develop and have in place policies by the end of this current school year, so by next summer they have to have wellness policies in there or it’s going to majorly impact their school lunch school breakfast program. So it does have, you know, some teeth in getting people moving. So we’re trying to, you know, work in our state that, you know, you have what we’ve had in our state, they have 1220 requiring nutrition and physical activity local requirements and also we have things from the national level.

Well, since this is MCH I had to use a little bit of, you know, kind of, MCH stuff. So this, kind of, the gestation and birthing of act 1220. It got through the legislature fairly quickly, you know, the group of ideas that went forward from the health department to Hershel Cleveland and how he was able to work it through our system was pretty amazing. We did have some limitations on all vending. They, kind of, cut it down as you saw to vending within elementary schools but we also were able to add the BMI in there which had not initially been in the first packet of recommendations. But now the Child Health Advisory Committee that was created at the state level started in August of ’03 to develop its recommendations of what they thought should be done in schools related to the nutrition environment and physical activity environment. The members of this committee was designated by the law so it covered folks from pediatrics, from nutrition, from physical activity, from education, from school administrators. It really, you know, it tried to cover with the waterfront, bringing in the PTA, bringing in students. It took them a year of intense work to come up with the recommendations that they’ve then had to send to the Board of Education.

The Department of Ed had to convert the recommendations to proposed rules for the board to address and they divided what was in the full set of recommendations into two sections. One was to look at the certification and professional development of the child nutrition staff and then the other was all the other nutrition and physical activity recommendations. So you can see that in June of ’04 to education. In March of ’05 but you have to be patient, remember, this is a long gestation, in March of ’05 these finally made it to the Board of Education’s agenda. At least the nutritional physical activity standards were on their agenda in March. The child nutrition staff recommendations had somehow, kind of, breezed through, gotten approved, not at anybody’s radar screen but then when all the nutrition physically activity standards came up the Board of Education knew they had to put them out for public comment because this was looking at when can vending machines be on? The content of the vending machines, what about PE, what about certified teachers for all PE classes, all the inherent cost, issue on what could be used for Fund Raising are not--if you all are interested in a lot of the details of Act 1220 I can give you a website later.

So anyway, March and April was the first public comment period. During this time the media was out there. I mean, there was the survey of snacks in the schools, all the unhealthy things that were there. We had political cartoons. We had letters to the editor. I mean, it was really getting a lot of play in the state. Well, there was so much information, so much controversy generated that once all the comments came in the Board of Education said, you know, we’ve got to think about this some more because now we’ve tried to revise these comments, so we’re going to send them out to the public again. So we had another month of public comment period. And finally in August the Board of Education approved the rules and everyone’s like, yes, okay. Well, oh, well, wait a minute. One more step. The legislative rules committee have to, kind of, bless it and when we first went to the rules committee they said, no, this is putting too much on education. You’re asking teachers to come up with ways to incorporate physical activity in their classroom that they don’t know about. We really need to give them some help, so within, you can say less than a week the were a lot of discussions between education and the rules committee that, you know, we can provide this technical assistance if that’s the only thing holding it back, we will do this technical assistance. And so yes, we finally got approved.

Well, then you have to, you know, get into maintenance. You have to consolidate the gains during action. You don’t want a relapse, so what’s been happening. I’ve, kind of, moved this. We’ve birthed this kid. It’s now a toddler. Through this year Action for Healthy Kids has been helping a lot. They had an essay contest because we kept hearing from some of the naysayers that, oh, all of this BMI stuff, you know, you’re going to create all these eating disorders. You’re going to have all these problems; all these kids are going to be teased. It’s going to be horrible. So we just went out to all the kids and said, tell us what’s happened? And we got back so many positive--

CAROLE GARNER: --trying to help schools move things along. The College of Public Health pulled one together a couple of weeks ago, bringing in the impacts. The local district committees, trying to help them network with each other, what’s going on in your district, how can the district help each other, what things are out there nationally that can help the districts.

Through the Department of Education they have health action teams in some select schools, using money from CDC and Conference of School Health. We had some money from Blue and you to pull together (inaudible) in the Law Conference, again trying to develop more awareness with the legal community and other potential legislation.

Through another collaborative, this is the third year that we’ve had a statewide nutrition physical activity conference. The two day conferences again, bringing in resources technical assistance. How can we help people keep moving along? I think the big thing is we’ve used tobacco settlement money. Do you all use tobacco settlement money in your state for health? Because we have used every penny of it in Arkansas for health, it hasn’t gone off anywhere else. This was a governor’s initiative that went to the people and people said use all for health, and so part of it has been funding community nurses and community health promotions specialist. And these folks are stationed in the education co-ops around the states to help provide support, technical assistance to the school districts again where the action is.

And that’s kind of where Arkansas is in a holding pattern, moving along trying to keep this toddler steady as it takes a few step. Again enlisting the full community from grassroots through the state legislature, up through the governors office and you know really it can be done, it just takes a little bit of perseverance. Just think about gestation and birth and babies and raising kids. It works the same way.