1 Statement of the National Assembly on School-Based Health Care on the Role of School-Based
Health Centers in Addressing and Preventing Childhood Obesity Task Force on Childhood Obesity
U.S. Department of Agriculture
U.S. Department of Health and Human Services U.S. Department of Education
Submitted for the Record March 26, 2010
Children spend most of their time in school where they eat at least one meal, often two, and sometimes even three – as well as consume snacks during school hours. This makes schools a logical first place to begin addressing childhood obesity. Schools have a responsibility to provide students with healthy places to learn, and school-based health centers (SBHCs) are a critical partner to help address obesity and create healthy school environments.
SBHCs provide access to comprehensive, quality health care services for children and teens who would otherwise go without medical attention by bringing the doctor’s office to the school. They are a crucial part of our nation’s health care safety net. Common characteristics of school-based health centers include:
They are located in or near a school facility and open during school hours
They are organized through school, community, and health provider relationships They are staffed by qualified health care professionals
They are focused on the prevention, early identification, and treatment of medical and behavioral concerns that can interfere with a student’s learning.
SBHCs contribute to a healthy school environment, and often take a leadership role in addressing obesity through services, programs, and advocacy.
According to NASBHC’s most recent census of the 2,000 SBHCs across the country, 90 percent of clinics that responded offer nutrition, fitness, and/or weight management services to students through individual care, small-group care, and school-wide care – and often to their families and the community as well.
For example, health providers are able to identify children at risk of obesity early and start intervention right away:
“We had a child (8) who was already developing Type 2 Diabetes. She met with a pediatric nutritionist. She lost 15 pounds and had normal blood sugar and looked great, esteem improved, so did her grades. Her mom worked with the school to make good choices about limiting carbs… she is a different kid.” Pamela O'Hara, MHCM, RN, NCSN, School Nurse, Roger Bell Elementary School, Havelock, NC
2 SBHC staff are on the front-lines of children’s health, witnessing every day the impact that lack of access to healthy foods and opportunities to exercise has on students and communities. To the extent they are able while operating within budget and staffing constraints, SBHCs offer a wide range of programs and services for the youth that they serve.
But tackling the obesity problem goes beyond individual action; broader treatment and prevention strategies are crucial. Recognizing this, many SHBCs have helped to establish programs and policies both within and outside the walls of their school buildings. From educating kids on nutrition and providing after-school fitness clubs, to influencing the food choices that schools offer and the level of physical activity students engage in during school time, school-based health centers have made real change in both students’ lives and school environments. SBHCs also advocate for national, state, and community-level policies and programs that increase access to healthy food and physical activity for children and adolescents.
SBHCs are often the catalysts for change and improvement from the school to the community level. As a newly federally-authorized program, SBHCs have the opportunity to bring these vital services to more children and adolescents across the country – but they need to be included in funding opportunities. The National Assembly on School-Based Health Care put out a request for comments to incorporate in to this statement to SBHC staff and advocates across the country, and immediately received a flood of responses from community advocates, school nurses and nurse practitioners, pediatricians, health center administrators, and non-profit leaders from the school-based health sector. Their unique insights and expertise are included in the comments below.
3. Which Federal government actions aimed at combating childhood obesity are especially in need of cross-agency coordination?
The health care reform legislation includes a new federal authorization program for school-based centers, and it is important that it is funded. SBHCs should be considered across agencies as a
strategy to address obesity, and therefore made eligible for funding from the DOE, the DOA, and HHS, among other governmental agencies.
“We need to focus on school-based health/wellness multi-disciplinary curriculum in elementary schools developed to assist students in developing critical thinking skills to help them make healthy lifestyle decisions/choices (encompassing other risky behaviors, tobacco, alcohol, drugs, etc.) focused primarily on improving nutrition/food and beverage choices and increasing levels of physical activity. The
curriculum needs to be integrated into core academic subjects. Key health and wellness
education/information and activities should be integrated into teacher's existing lesson plans in all standard subject areas and be application based whenever possible and appropriate. The K-5 elementary curriculum should also have a pre-k version, and after-school version and take home components for the family. The curriculum should support other programs/activities in the school (PE, cafeteria, etc.) as well as community activities such as school and community gardens, adoption of
3 farm to school program, family/community walks/runs, health fairs, obesity screenings, etc. Children should become the messengers and take home these healthy lifestyle messages to engage the entire family. This in turn will have a lasting and sustainable "trickle out" effect into the community.” Stuart C. Reese, Executive Director, Institute for America’s Health, Tallahassee, FL
4. For each of the four objectives, what are the most important actions that private, nonprofit, and other nongovernmental actors can take?
At the nexus of health and academics, school-based health centers are in the ideal position to serve as a partner to other private and nonprofit actors. The comments below are examples of how SBHCs address the 4 objectives of the Task Force.
Objective (1) Ensure access to healthy, affordable food
• SBHCs help students plant and cultivate community gardens.
• SBHCs take students on their families on shopping trips to local farmers markets and grocery stores to learn about purchasing healthy and affordable foods.
A SBHC in Worcester, Massachusetts, helped students create a community garden to grow their own food and to learn more about nutrition. The students sell their vegetables at the school and at a local farmer’s market in a lower-income neighborhood, distributing nutrition factsheets with the produce. The student’s ultimate goal is to provide fresh produce to their school’s cafeteria.
Objective (2) increase physical activity in schools and communities Schools:
• Initiate peer-to-peer programs where students learn from each other about healthy living. • Require that physical education be taught in each grade.
• Physical educators should be teaching fitness activities that can be maintained for a lifetime. • Recess should not be withheld for punishment.
Communities:
• Safe places to play (repair playgrounds, update equipment, and add increase security around public facilities).
• Add sidewalks and bicycle paths.
• Offer a tax incentive for the purchase of fitness club memberships.
In the Laguna and Acoma Pueblos in New Mexico, members of the school-based health center’s youth advisory group mentored middle school and elementary students over the summer, providing
instruction on selection of healthy snacks, and started a baseball team to provide peers with an opportunity to engage in physical activity and offer an alternative to risk-taking behavior such as drinking and drug-taking.
4 “Wayne State University Medical Students come to the school every Monday after school to host a running club called RunDetroit. The med students are mentoring and running with elementary students on the school track.” Cathy Wenz, FNP, BC, Newton Health Center, Detroit, MI
Objective (3) provide healthier food in schools
• School improvement plans should address how they will increase the health of the children. • Breakfast should be offered in the classroom.
• Limit prepackaged meals.
• Fresh produce should be available.
• Limit school fundraisers to selling healthy items. • Vending machines need healthy options.
In the nation’s largest school district, New York City, school-based health centers led efforts to replace whole milk with 1% skim milk and skim chocolate milk in all public school lunchrooms.
The school-based health center for a combined middle and high school in Baldwin, Michigan, took the lead in developing and implementing policies and programs for the school’s wellness plan including persuading school officials to replace unhealthy snacks in the school’s vending machines with nutritious food and beverages and to drop Coca-Cola as a sponsor of the school’s sports team.
“Our school/district has been working for several years to decrease obesity. We are located in inner city Phoenix. We have had an active Wellness committee for both the student issues and the staff issues for several years. The Food Services Director has turned around the school menu in 3 short years to be amazingly more nutritious. She got the students involved creating different recipes with competitions with the winner receiving a classroom hands on cooking lesson. The district website has the nutritional facts for every meal and this is also sent home every month as many don't have
computer access.” Lynette Cook, Phoenix, AZ
Objective (4) empowering parents with information and tools to make good choices for themselves and their families.
• SBHCs provide individualized medical and mental health services and counseling for students and their parents.
• Conduct cooking classes for parents.
• Develop a media campaign that reinforces key health messages.
“School-based health centers could play more of a role in prevention and identification – especially in the younger populations before bad habits are so ingrained – so that we can work with parents to help them understand and make changes.” Ricki Waltz, Director, Lincoln Academy School Based Health Center
“In a survey of parents conducted at two public schools, common responses included: ‘I cannot buy vegetables and fresh fruit because they are too expensive,’ and ‘It is difficult to cook homemade meals daily due to working outside the home.’ It is time to address the price of food and how to help young
5 parents learn healthy cooking habits if we are to combat obesity.” Leonor M. Leon-Stanley, MSN, ARNP, PNP-BC, Health Connect In Our Schools
13. Specifically with regard to objective 2 (healthier foods in schools): What are the most promising steps that can be pursued by the Federal, State, and local governments, schools, communities, the private sector, and parents to ensure that children are eating healthy food in schools and child care settings?
• SBHCs need access to additional resources to bring nutritionists and health educators on staff to design programs and interventions that will lead to behavior change and reinforce the messages students receive in clinical encounters.
• Increase meal reimbursement rates for child nutrition programs. • Strengthen nutrition standards for school meals.
• Provide mandatory funding for grants to schools through Section 122 of the Child Nutrition Act: Access to Local Foods and School Gardens.
• Encourage purchase of fresh, local produce through the USDA’s Fresh Fruit & Vegetable Program
“I feel that eliminating sugar based beverages from schools (Juice, Soda, etc) would make a dramatic improvement in the health of our overweight and obese children.” Jenny Bush, MD, Pediatrician “When fast foods are available so close to a school (especially middle and high schools) kids come late to school, cut class, leave early, and "do lunch" in these establishments. There should be enforced rulings that children cannot be served at these facilities during school hours (including immediately before and immediately after school). There should be limitations on the location of these
establishments close to schools.” Linda M. O'Neill RNCS, CFNP, System Clinical Manager for Baystate Medical Center's School-Based Health Center Program and Nurse Practitioner at Putnam Voc. Tech. SBHC, Springfield, MA
15. Specifically with regard to objective 4 (physical activity): What steps can be taken to improve quality physical education and expand opportunities for physical activity during the school day, in local communities and neighborhoods, and in outdoor activities and other recreational settings?
“I feel one of the keys to solving this problem is fixing the school environment. There are so many demands to keep test scores up to qualify for funding that many schools count physical education as an elective and cut it from children's schedules at the middle school level. There are children here who are not getting any more than 12 weeks of PE per school year. Physical activity could be incorporated in many core curriculum classes through brain gyms and activities to reinforce concepts in math, science and language arts. Teachers need to be given additional training on how to do this and be required to take it as CEU's.” Judy Pruim, Hackley Community Care Center, School Based Health Program
6 “I propose a mandatory staff/student recess where everyone is physically active for 30 minutes during the school day. This will allow for positive role modeling, supervision of exercise, better concentration, and an overall improved sense of well being in the school. This doesn’t have to cost a lot of money, walk around the track, play basketball, jump rope, dance. If this was mandatory we all would have improved health.” Jenny Holliday, MSN, CNP, Family Nurse Practitioner, Bernalillo Public Schools “To increase physical activities in schools and communities, the federal state and local governments should allocate money to support greenways, sidewalks, bike paths and crosswalks. Walking and biking safety courses should be provided in schools. Funding should be provided for afterschool programs that have exercise, nutrition, food preparation components.” Tracey Armstrong, RN, Irwin Middle SHC, Asheville, NC
Conclusion
School-based health centers contribute to a healthy school environment in many ways, including: Providing physical and mental health care and prevention services to keep students healthy and
in school, learning.
Impacting school policies and provide programs to improve the school environment, including: o Designing and implementing mandated school wellness plans and coordinated school
health programs
o Offering education classes, after-school programs and workshops for students (and sometimes parents) that encourage healthy lifestyles
Advocating for policies and practices at the school district, local, state and national levels to improve the school environment and benefit the local community.
The Taskforce on Childhood Obesity should include SBHCs in formulating a national action plan to solve this critical problem within a generation. We look forward to working with you.
Thank you for this opportunity to provide our input. Sincerely,
Linda Juszczak, DNSc, MPH, CPNP, RN Executive Director
