Arkansas’s data-driven strategies to effect change Dr Joe Thompson, MD MPH Surgeon General, State of Arkansas Director, Arkansas Center for Health Improvement February

Arkansas Center for Health Improvement Mission Be a catalyst for improving the health of Arkansans through evidence-based research, public issue advocacy and collaborative program development. Vision To be a trusted health policy leader committed to innovations that improve the health of Arkansans Core Values Trust, Innovation, Initiative, Commitment

The national obesity epidemic

1995 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1995, 2005 (*BMI 30, or about 30 lbs overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

NHANES data sources: Ogden et al. Prevalence and Trends in Overweight Among US Children and Adolescents, JAMA 2002;288(14): Ogden et al. Prevalence of Overweight and Obesity in the United States, JAMA 2006;295(13): Percent Overweight US 6-11 yr US yr National childhood obesity trends

Strategy to combat childhood obesity in Arkansas

84th General Assembly Act 1220 of 2003 Goals: Change the environment within which children go to school and learn health habits everyday Engage the community to support parents and build a system that encourages health Enhance awareness of child and adolescent obesity to mobilize resources and establish support structures An act to create a Child Health Advisory Committee; to coordinate statewide efforts to combat childhood obesity and related illnesses; to improve the health of the next generation of Arkansans; and for other purposes.

Act 1220 requirements Elimination of all vending machines in public elementary schools statewide Requirement of professional education for all cafeteria workers Public disclosure of “pouring contracts” Establishment of parent advisory committees for all schools Establishment of a Child Health Advisory Committee Child health report (CHR) delivered annually to parents reporting individual BMI assessments

Arkansas Board of Education regulation: Access to foods and beverages Per Act 1220, no vending machines in elementary schools During school day, vending machines access restricted until 30 minutes after last lunch period (middle, junior, high schools) –Addresses both content and habit New/renewed vending contracts for beverages limited to no more than 12oz Exceptions: foods provided by parents to individual students, school nurses, special needs students, school events

Arkansas Board of Education regulation: Standards for foods and beverages Nutrition standards applied to all foods/beverages sold or made available (except USDA governed meals) Maximum portion sizes Choices of fruits and juices available in conjunction with competitive foods 50% of vended beverages to be healthy choice (water, 100% fruit juice, low-fat/fat- free milk)

Arkansas Board of Education regulation: Physical education/activity standards Schools to establish strategy to achieve 30 minutes of physical activity per day (K-12) If PE, student:teacher ratio established Certification requirements for instructors In 2007–2008 –K–6th grade to receive 150 minutes/week of physical activity (includes 60 minutes of PE) –7–8th grade to receive 150 min/week of PA –9–12th grade to take one semester of PE and receive 150 min/week of physical activity

Arkansas health care environment response Local school, community and faith-based initiatives Development of first continuing medical education program for clinicians Regionalization of secondary and tertiary care (e.g., Fitness Clinic at AR Children’s Hospital) Elimination of fiscal barriers to reimbursement (Medicaid / SCHIP) Increased awareness of physical activity needs (Mini-marathon) Changes to built environment

Three years of statewide BMI assessments: 2004 to 2006

Child Health Report (2004) Source: Arkansas Center for Health Improvement, Little Rock, AR, 2004.

Spanish Child Health Report (2005) Source: Arkansas Center for Health Improvement, Little Rock, AR, 2005.

Participation in Arkansas BMI assessments Year 1 (’03–’04)Year 2 (’04–’05)Year 3 (’05–’06) CategoryPercentTotalPercentTotalPercentTotal Participation* Public schools94.3%1, %1, %1,090 Students (PK–12)92.6%426, %447, %433,808 Student data Valid for analysis81.8%348, %372, %371,082 Invalid1.4%5,9371.1%4,7840.4%1,568 Unable to assess16.9%71, %70, %61,158 *Results include all data available for years 1 and 2 and data received by June 14, 2006 for year 3 analysis. Some public schools and districts merged after year 1 and after year 2. Data source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005–Spring 2006). Little Rock, AR: ACHI; September 2006.

Reasons for “unable to assess” Reason Year 1 (’03–’04) Year 2 (’04–’05) Year 3 (’05-’06) Absent from school 6.3%7.7% 6.7% Not attending that school 3.8%1.4%0.4% Parent refused to allow measurement 3.7%3.2%3.3% Student refused measurement 1.7%2.6%2.7% No 2 mx w/in 1 in 0.02%0.005%0.009% Other 1.1%0.6% Disability prohibited measurement 0.2% Student was pregnant 0.1% Source: Arkansas Center for Health Improvement, Little Rock, AR, 2006.

Percentage of students classified as overweight or at risk for overweight by Arkansas public school district (2005–2006) Source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005–Spring 2006). Little Rock, AR: ACHI; September 2006.

NHANES data sources: Ogden et al. Prevalence and Trends in Overweight Among US Children and Adolescents, JAMA 2002;288(14): Ogden et al. Prevalence of Overweight and Obesity in the United States, JAMA 2006;295(13): AR grades K-6 AR grades Percent Overweight US 6-11 yr US yr National and Arkansas childhood obesity trends Arkansas data source: Arkansas Center for Health Improvement, Little Rock, AR, August N=2, N=981 Ave N=152,052 Ave N=209,536

Percentage of Arkansas students by weight classification CategoryYear 1 Year 2Year 3 (’03–’04)(’04–’05)(’05–’06) Overweight20.9%20.8%20.4% At risk for overweight 17.2% 17.1% Healthy weight60.1% 60.6% Underweight1.8%1.9% Total students assessed 348,710372,369371,082 *Results include all data available for years 1 and 2 and data received by June 14, 2006 for year 3 analysis. Data source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005–Spring 2006). Little Rock, AR: ACHI; September 2006.

Percent by gender and ethnic group (2005–2006) Source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005– Spring 2006). Little Rock, AR: ACHI; September 2006.

Percent by grade (2005–2006) Source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005– Spring 2006). Little Rock, AR: ACHI; September 2006.

Percent by gender and grade (2005–2006) Source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005– Spring 2006). Little Rock, AR: ACHI; September 2006.

UAMS College of Public Health Evaluation of Act 1220 (2006) Surveys: school personnel, parents, teens “Change is beginning to occur” Parents’ awareness of obesity-related health problems continued to increase The majority of parents continue to report that they are comfortable receiving Child Health Reports from the school. Students comfort with the Child Health Report from school has increased Fay W. Boozman College of Public Health. Evaluation of Act 1220 of 2003 Highlights of Third Year Evaluation Findings. Presented to Public Health, Welfare, and Labor Committee Arkansas House of Representatives: January 23, 2007.

UAMS College of Public Health Evaluation of Act 1220 (2006) Majority of parents continue to believe vending machines should not be located in middle and high schools The average number of student purchases from vending machines declined and there has not been a substantial decline in vending revenues for most schools Parents did not report significant changes in individual or their families’ nutrition or physical activity patterns Neither parents nor students reported any of the feared negative consequences of BMI measurements, such as teasing, misuse of diet pills, or excessive concern about weight Fay W. Boozman College of Public Health. Evaluation of Act 1220 of 2003 Highlights of Third Year Evaluation Findings. Presented to Public Health, Welfare, and Labor Committee Arkansas House of Representatives: January 23, 2007.

ACHI’s future activities

Planned research activities Confidential Do Not Distribute Longitudinal analyses of BMI data using individually matched students –Overall change in BMI classification for matched 3-year cohort –Individual transitions across BMI categories –Group change scores by BMI classification, age, gender, ethnic group, geographic location, school environment, etc. Child Obesity Risk Classification System –Longitudinal analyses –Disease prevalence –Identification strategies for high risk children Risk Communication Strategies –Parents –Clinicians Impact of obesity on Medicaid / SCHIP –Disease burden –Utilization impact –Associated costs