Community Needs Assessment
Title: Pediatric Obesity in School Age children of Marion County, Indiana
Prepared by Joan Temmerman, MD
Online MPH in Nutrition, University of Massachusetts, Amherst
Statement of the Nutritional Problem:
Pediatric obesity is one of the most urgent health issues today (World Health Organization, 2003). Nationally, more than one-third of children ages 10-17 are obese (16.4%) or overweight (18.2%), and higher obesity rates are present in minority and disadvantaged populations (Ogden et al, 2010). Indiana ranks 27th for pediatric obesity, with 30% of children ages 6-19 obese or overweight (F as in Fat, 2010). Numerous serious illnesses occur in obese children (Gunturu & Ten, 2007), as well as serious psychosocial sequelae (Tsiros et al, 2009) and early death (Franks et al, 2010). Overweight children are very likely to become overweight adults (Singh et al, 2008). The family environment is of utmost importance: parental obesity is the greatest predictor of obesity in a child (Freedman et al, 2005). Genetics and environmental factors are both important. Early intervention is most effective, and parental involvement is critical; one of the most effective measures is for parents or guardians to adopt and model a healthy lifestyle and avoid obesity themselves (Olstad & McCargar, 2009). The school environment is also very important for health promotion, as children are reached repeatedly and continuously. Interventions that are both school-based and family-centered show the greatest promise (Brug et al, 2010; Zenzen & Kridli, 2009).
Definition of the Community: Marion County, Indiana
Purpose of the Assessment:
1. To obtain information about the obesity rates in school age children and determine whether an intervention tool would be of value
2. To identify types of school and family-based wellness tools and evaluate effectiveness for encouraging healthy lifestyle behaviors and habits
Target Population: School age children in Marion County
Overall Goal of Assessment: Identify childhood obesity prevalence and contributing factors. Identify interventions, with a focus on family-centered behaviors and health.
Goal A: Identify childhood obesity prevalence and risk factors, within 6 months:
· Objective 1: Assess prevalence of obesity in school age children in Marion County
· Objective 2: Compare Marion County obesity rates to state and national rates
· Objective 3: Identify contributing factors which affect obesity
Goal B: Research various lifestyle intervention tools reported in the literature for pediatric obesity, within 6 months:
· Objective 1: Identify school and family-based models for pediatric obesity treatment
· Objective 2: Identify effective behavioral strategies for school age children
· Objective 3: Determine an effective lifestyle intervention tool for primary school age children and their families
Data Collected
Background Conditions
Indiana State Department of Health, the Indiana State Department of Education, and the Marion County Health Department collaborated to implement the Indiana School Weight and Height Collection Program, to determine overweight and obesity prevalence and patterns over time. Height and weight measurements were collected at participating schools (voluntary). Majority of schools decided not to participate; 19,091 student records were analyzed.
· 17% overweight; 20% obese; 2% underweight; 61% normal weight
· Nationwide, 16% overweight; 13% obese (NHANES 2005)
· Compared to Indiana’s Youth Risk Behavior Surveillance System (YRBS), actual obesity rates higher than self-reported (2005 Indiana YRBS 15% obese, 14% overweight)
Healthy eating patterns ≥ 2 years (USDA ARS)
● 14% met vegetable recommendation
● 17% met fruit recommendation
● 17% met dairy recommendation
Health behaviors of high school students in Indiana, 2009 YRBS:
● 84% ate < 5 fruit and vegetable servings daily
● 30% drank at least one can of soda daily
● 44% are meeting recommended physical activity levels
● 65% did not attend any PE classes in a average week
● 29% watched TV at least 3 hours on an average school day
● 24% used computers at least 3 hours on an average school day
Subjective Data from a Teacher: “My teaching career began in a suburban high school where the lunchroom was a happy place. Posters advertising fruits, vegetables, and exercise covered the walls, and every day the kids could choose from a hot meal or the salad bar. The line for the salad bar was often longer than the pizza line. Few of the kids were overweight, even fewer were obese…I spent the next two years teaching at an inner-city high school where, as my friend Sarah put it, "half the girls in my Algebra class are too obese to fit in their desks." The cafeteria served hot meals, but fruits and vegetables were few and far between. Posters advertising cookies and pizza covered the walls. Instead of a salad bar, there was a slushy machine. “Childhood obesity isn't just a public health issue, it's a social justice issue. It disproportionately affects the poor and minorities.” Eric Tipler; Childhood Obesity is a Social Justice, Too. Retrieved Sept. 28, 2010 from http://www.huffingtonpost.com/eric-tipler/childhood-obesity-is-a-so_b_518083.html?view
Subjective Data from the First Lady: “And let's be honest with ourselves: our kids didn't do this to themselves. Our kids don't decide what's served in the school cafeteria or whether there's time for gym class or recess. Our kids don't choose to make food products with tons of sugar and sodium in supersize portions, and then have those products marketed to them everywhere they turn. And no matter how much they beg for fast food and candy, our kids shouldn't be the ones calling the shots at dinnertime. We're in charge. We make these decisions.” Michelle Obama; Michelle on a Mission. Retrieved Sept 28, 2010 from www.newsweek.com/2010/03/13/michelle-on-a-mission.html
Community Characteristics, Marion County
Health behaviors (2010 Indiana County Health Rankings):
● ranked 80/92 health outcomes 2010 (reflects overall health; morbidity & mortality)
● ranked 87/92 health factors (what influences health: health behaviors, clinical care, social and economic issues, and physical environment factors)
Marion County Census data 2009 (Marion County, Indiana. Stats Indiana):
· Marion County population 890,879; includes Indianapolis (county seat: population 807,584; 91% of county)
· School age (< 19 years old) 28%; 19-64 years 61%; 65-84 years 9%; 85+ years 2%
Socioeconomic Characteristics (Marion County, Indiana. Stats Indiana):
· Income and poverty:
o per capita personal income (2008) $38,272;
o median household income $48,823
o Annual unemployment rate 9 %
o 17% living in poverty; children in poverty 23%
o Inadequate social support 22%
o Access to healthy foods 50%
o Free and reduced fee lunch (2009) 82,494
· Demographics 2009:
o 26% Black; 70% White; 2% Asian; 7% Hispanic
o 18% married with children; 23% married without children; 32% living alone
o 13% single parent households
· Education:
o High school graduation 62%
o Some college 82%
o B.A. or higher degree 27%
Environmental Characteristics (Nutrition Services, Marion County Health Department):
● Community nutrition services include 5-a-Day for Better Health Program, Girls on the Run, WIC, ABC’s of Diabetes Program, and Heart Alive! Program
Target Population Data (Child Health & Wellness Initiative Results, Marion County Health Department:
BMI percentile statistics reported 2007 for 90,147 public school students in Marion County, reveal:
· 18% overweight; 22% obese K-12; 1% underweight; 58% normal weight
· Pattern fairly consistent across gender, race and age
· By age, heaviest group 9-15 years old
· Among Hispanic males, 20% overweight; 31% obese
· Results much worse than YRBS (YRBS uses self-reported height and weight)
· Demographics: 48% White; 39% Black; 8% Hispanic; 4% Multiracial; 1% Asian/Pac. Is.
Analysis of Strategies for Pediatric Obesity
Public health needs to focus on obesity prevention, and prevention efforts must be comprehensive. Efforts should begin very early, as obesity is likely to persist into adulthood. The approach must be family-centered: a wealth of literature supports the importance of parental involvement in childhood obesity prevention (Zenzen & Kridl, 2009).Simple prevention messages should include eating ≥ 5 servings fruit and vegetables each day, decreasing sugar-sweetened drinks, decreasing TV and screen time to < 2 hours daily, increasing activity ≥ 1 hour daily, preparing more meals at home, eating at the table as a family, eating a healthy breakfast, and involving the whole family in lifestyle changes (Barlow et al, 2007). In addition to a healthy diet and increased physical activity, adequate sleep should be considered in obesity intervention, as a significant relationship exists between short sleep duration and childhood obesity (Chen et al, 2008). Family members need both knowledge and skills to change behaviors (Maibach & Cotton, 1995).
Schools play a central role in helping children adopt and maintain healthy eating and physical activity behaviors, so the school environment offers a great opportunity for health promotion. Interventions ideally should be both school-based and family-involved: parental involvement is an essential component to school-based intervention (Zenzen & Kridli, 2009; Brug et al, 2010). Lifestyle interventions target diet, activity, healthy lifestyle education, and family involvement. School-based obesity prevention programs are not consistent in terms of content and length of interventions. An integrative review found that many programs were 6 months or less, which appears to be inadequate to achieve significant behavioral change or significant BMI changes ((Zenzen & Kridli, 2009). The type, amount, intensity and duration of physical activity varied as well. Another review examining controlled trials of school-based lifestyle interventions again found inconsistent results; because the studies were heterogeneous, it was difficult to judge which interventions were effective (Brown & Summerbell, 2009). A more uniform, cohesive and long-lasting approach, using evidence-based strategies for a theoretical framework is necessary. Because of cultural and economic diversity, programs should be modified to meet the individual community’s needs. Successful and sustainable programs must include dietary education, physical activity, healthy lifestyle education, and parental involvement. Healthy lifestyle education and physical fitness should be implemented in all schools (Zenzen & Kridli, 2009).
Health programs for children and adolescents work best when they are fun, informative, and geared toward a specific health or nutritional objective (Boyle & Holben, 2010). Simpler interventions are more effective than complex (Noar et al, 2008)). Using pictures to support key points increases attention to and recall of health education information (Houts et al, 2006). One recent study in kindergarten used cartoons, tasting parties and junior cooking classes along with letters to parents with tips on encouraging their kids to eat fruit and vegetables, and vegetable intake doubled (Pediatric News, Stone Hearth Newletter 8/6/2010). Lifestyle interventions may be more successful in younger children (Brown & Summerbell, 2009), so obesity prevention should start early in life (before adolescence), and target specific health behaviors for a healthy energy balance. A family-based wellness tool initiated during primary school that targets increased activity, improved eating patterns, decreased sedentary behaviors, and adequate sleep, by using pictures and cartoons with simple health messages, may prove effective.
Executive Summary
Pediatric obesity is a crucial health issue and is associated with serious co-morbidities and a high likelihood of persistence into adulthood. Family involvement and early interventions are critical.
· Higher prevalence of obesity and overweight are present in children living in Marion County compared to statewide data.
· Marion County is ranked quite low for both health outcomes and health behaviors. Twenty-two % of the population lack social support; only 50% have access to healthy foods; 23% of children live in poverty, and 13% of households headed by a single parent.
· Pediatric obesity interventions that target healthy lifestyle habits and that are school-based with family outreach can be effective. Lifestyle intervention should provide simple messages about specific behaviors. Using pictures enhances health education, and cartoons can improve health behavior in young children.
· A family-based wellness tool initiated during primary school, targeting increased activity, improved eating patterns, and adequate sleep, by using pictures or cartoons with simple health messages, may benefit the children of Marion County.
Feedback
My goal of providing a wellness tool that includes family involvement was shared with Cathy Whaley, Steering Committee Chair, Action for Healthy Kids Indiana Steering Committee. She was very enthusiastic about an educational tool to benefit AFHK. Cathy suggested that a brochure or a series of PDF flyers could potentially be downloadable on the Indiana Action for Healthy Kids website. This would enable wide access.
I shared my Community Needs Assessment findings with 2 fellow employees: M. Tuckman, former school RN, and A. Furiya, RD. Both have experiences with Indiana school systems both outside and within Marion County. Their consensus was that Marion County is challenged in terms of poverty, SES and school systems, and would benefit from a lifestyle educational tool, especially aimed at younger ages. A big discrepancy exists between urban, suburban and rural schools in Indiana.
References
1. Barlow S and the Expert Committee. Recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120:S164-S192.
2. Boyle MA, Holben DH. Community Nutrition in Action: An Entrepreneurial Approach. 5th edition. Belmont, CA: Wadsworth, Cengage Learning; 2010.
3. Brown T, Summerbell C. Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: an update to the obesity guidance produced by the National Institute for Health and Clinical Excellence. Obesity reviews 2009;10:110-141.
4. Brug J, te Velde SJ, Chinapaw MJ, et al. Evidence-based development of school-based and family-involved prevention of overweight across Europe: The ENERGY-project’s design and conceptual framework. BMC Public Health 2010;10:276.
5. Chen X, Beydoun MA, Wang Y. Is sleep deprivation associated with childhood obesity? A systematic review and meta-analysis. Obesity (Silver Spring) 2008;16(2)265-74.
6. Child Health and Wellness Initiative Results, Marion County. Retrieved Sept. 27, 2010 from www.mchd.com/CHWI_results_report.htm
7. Children’s Vegetable Intake Linked to Cartoons: University Study. Pediatric News, Stone Hearth Newsletter Friday August 6, 2010. Retrieved August 9, 2010 from http://shpediatrics.blogspot.com/2010/08/childrens-vegetable-intake-linked-to.html
8. Community Health Status Indicators (CSHI). U.S. Department of Health and Human Services. Retrieved on Sept. 15, 2010 from http://communityhealth.hhs.gov/
9. Franks PW, Hanson RL, Knowler WC, Sievers ML, Bennett PH, Looker HC. Childhood obesity, other cardiovascular risk factors, and premature death. NEJM 2010;362(6):485-493.
10. Freedman DS, Kettle Khan L, Serdula MK, Dietz WH, Srinivasan SR, Bereson GS. The relationship of childhood BMI to adult adiposity: The Bogalusa Heart Study. Pediatrics 2005;115(1):22-7.