Healthy Children Task Force

Recommendations

Table of Contents

                                                                                                                            Page

Senate File 2251............................................................................ 1-3

Executive Summary....................................................................... 4

Challenge Statement....................................................................... 5

Healthy Children Task Force Final Recommendations..................... 6-7

Details of Final Recommendations 

I.  Iowans Need Physical Activity on a Daily Basis

         -Physical education minimums (K-12).................................... 8

         -Daily recess (K-6)  .............................................................. 9

         -Student health assessment   ................................................. 10

II.  Iowans Deserve the Opportunity to Access Health Services

     Without Barriers

         -Registered nurses in schools................................................ 11

         -Nutrition counseling reimbursed by insurance....................... 12

         -Dental examinations............................................................. 13

         -Licensed dietitians available for schools................................ 14

         -Large school districts and registered nurses.......................... 15

         -Licensed dietitians for Area Education Agencies................... 16

III.  Iowans Deserve Access to Affordable Foods that have

       Nutritional Value

         -State nutrition standards....................................................... 17-18

         -Fresh fruits and vegetables in schools................................... 19

         -Beverages in preschool........................................................ 20

  Appendices................................................................................. 21

     A. Groups represented in the Healthy Children Task Force

     B. Background

Whereas,          Healthy kids are ready to learn

                                    Healthy adults are ready to work

                                    And healthy communities are ready to grow

The Healthy Children’s Task Force presents these recommendations for policy and statutory changes to enhance the well being of children in Iowa.  The Task Force members recognize improving the health of children now, creates a healthier Iowa for the future.  The opportunity to impact the health of children in Iowa through these recommendations demonstrates how Iowa can lead the nation in making children’s health a priority. 

The 69 original recommendations from the Healthy Children’s Task Force members were unanimously classified into five focus areas.

1.      Community collaborations

2.      Physical education and activity

3.      Health services

4.      Nutrition

5.      Health Education

Through a process of prioritizing, the initial 69 recommendations were narrowed to 13 priorities, of which 12 require legislative action. The final recommendations focus on physical education and activity, health services, and nutrition. Community collaboration and health education continue to be essential, but Task Force members felt these recommendations are embedded within other recommendations in this report or initiatives such as Iowans Fit for Life.  The Task Force also supports legislative and policy initiatives aimed to modify cultural and societal factors impacting health services, poor nutrition, and physical inactivity of children for future legislative sessions. The final recommendations build upon the progress already being made in creating a healthier Iowa and healthier school environments.

The Task Force recommendations identify strategies to address current significant health concerns and provide a foundation of prevention efforts to improve the overall health of children. The effort to move children to a higher level of health requires ongoing attention and resources from the state and communities. Successful implementation of these recommendations will require collaborative and coordinated efforts between public and private entities and a commitment of resources. These recommendations provide a stepping-stone for a healthier Iowa.  

While the Iowa Department of Public Health and the Iowa Department of Education convened the task force and concur with the concern for the health of Iowans, the specific recommendations contained herein do not necessarily represent policy recommendations of either state agency.

   Submitted:       Sharon Yearous                                  Task Force Chair

                                      Anne Tabor                                        Task Force Vice Chair

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Good health, evidenced by physical activity, good nutrition and access to health services, is critical throughout the life span. Overweight and obesity are quickly becoming leading public health and education challenges in Iowa. The rate of overweight and obesity has dramatically increased among children, to a level that the new concept of an obesity epidemic is widespread in the public health and education dialogue. Data shows a significant increase in the overweight rate of children from 11.5 percent in 2002 to 14.3 percent in 2004. Physical activity, good nutrition and access to health care are important socializing and normative factors during childhood and adolescence. Sedentary lifestyles, poor nutrition and overweight/obesity in children contribute to an adult life with increased risk for diabetes, heart diseases, rheumatic conditions, cancer, immune disorders, and psychosocial problems such as depression.

A worrisome correlation exists between weight problems and poor academic achievement.  Research has found that severely overweight children and adolescents are four times more likely than their healthy weight peers to report “impaired school functioning.”  Research identifies that overweight children are also more likely to have abnormal scores on the Child Behavior Checklist (a commonly used measure of children’s behavior problems).

There are significant fiscal and human costs to poor health related to physical inactivity, poor nutrition and reduced access to health services.  Obesity-related health problems cost Iowans $783 million annually. Medicaid and Medicare cover 46 percent of these costs and the remaining 54 percent is covered by employers and individuals through health insurance costs. Annual Medicaid costs in Iowa in the year 2005 due to obesity were estimated by CDC to be $198 million. Iowa’s hospital cost for obesity related health problems has been estimated at over $73 million annually, not including secondary cost from complications of obesity such as cardiovascular diseases and stroke.  While these costs primarily refer to adults, today’s unhealthy children will grow into tomorrow’s unhealthy adults.  By intervening now with children, we can begin to reduce the health care costs for adults in the future. 

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Iowans need physical activity on a daily basis.

Iowans deserve the opportunity to access health services without barriers.

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Iowans deserve access to affordable foods that have nutritional value.

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Physical Education Minimums (K-12)

I.     Recommendation:   Require minimum number of minutes of physical education every week (K-12).

II.    Key points, justification, supporting evidence

·        Physical education curriculum should be a planned, sequential, developmentally appropriate, K-12 curriculum that provides cognitive content and learning experiences in a variety of activity areas such as basic movement skills; physical fitness; rhythms and dance; games; team, dual and individual sports, tumbling and gymnastics; and aquatics. Instruction shall be evidence-based and health-related meeting national standards that emphasize enjoyable participation in physical activity that help students develop the knowledge, attitudes, motor skills, behavioral skills, and confidence required to adopt and maintain physically active lifestyles. These classes should allow participation by children regardless of ability, illness, injury, and developmental disability, including those with obesity and those disinterested in traditional competitive team sports.

·        Elementary Program, grades pre-K-6, physical education will be taught by a well-supported specialist physical education teacher for 150 minutes each week, preferably daily. Class sizes will be similar to other subject areas (fully implemented five years from date of legislation).

·        Junior high program, grades 7-8, physical education will be taught by a well-supported specialist physical education teacher for 225 minutes each week, preferably daily. Class sizes will be similar to other subject areas (fully implemented seven years from date of legislation).

·        Senior high program, grades 9-12, taught by a well-supported specialist physical education teacher for 225 minutes each week, preferably daily, all four years. Class sizes will be similar to other subject areas. Two units required for graduation (fully implemented 10 years from the date of legislation).

III.       Code change: Iowa Code 256.11(3); 256.11(4); 256.11(5) (g)

IV.  Fiscal implications, other considerations:         Requires funding to increase the number of physical education teachers.

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Daily Recess

I.             Recommendation: A resolution stating that all school children, grades K-6 should be provided with at least one daily period of recess.

II.          Key points, justification, supporting evidence

·  The American Academy of Pediatrics (2006) identifies several challenges in the epidemic of pediatric obesity, among those “convincing school boards that PE and other school-based physical activity opportunities are as important to long-term productivity as are academics…”

·        National recommendations for preschool-age children are:

       60 minutes of unstructured physical activity daily. Sixty minutes is the minimum recommended amount of time for unstructured physical activity in a day.  Unstructured activity is when the choice of activity is left to the child, it could include riding toys, climbing, playing with moveable objects (e.g., balls), running and so forth.

No more than 60 continuous minutes of sedentary time.  Preschoolers should not be sedentary for more than 60 continuous minutes except when sleeping.

·        National recommendations for elementary school-age (5-12 years) children are:

No more than two hours of continuous sedentary time. Children should not experience extended periods of inactivity, especially during the daytime. Two hours is the maximum continuous sedentary time for children, except when sleeping.

III.       Code change: None

IV.        Fiscal implications, other considerations: None

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Student Health Assessment

I.             Recommendation: A resolution stating that student assessment in physical education be increased.

II.          Key points, justification, supporting evidence:

·  Quality physical education begins with standards and benchmarks, such as the National Content Standards for Physical Education, a curriculum that flows directly from those standards, and an evaluation system that informs instructors, stakeholders and learners.

·  Student assessment in physical education is part of the educational accountability system.

·  As Iowa Department of Education curriculum is revised, it should be based on standards and benchmarks, and assessment should be included.

·  The focus of assessment should include the knowledge, skills, and behaviors for a lifetime of physical activity.

·  As Iowa Department of Education curriculum is revised, a plan for assessment should be developed.

·  According to the American Academy of Pediatrics and CDC, states should hold schools accountable for delivering physical education programs that meet national standards for quality and quantity (i.e., includes assessment, 150 minutes per week for grades K through 8 and 225 minutes in grades 9 through 12).

III.       Code change: None

IV.  Fiscal implications, other considerations: None

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Registered Nurses

I.       Recommendation: Employ minimum of one registered nurse (RN) per school district.

II.     Key points, justification, supporting evidence:

·  In 2004-2005, 94 school districts did not employ a registered nurse.

·  Research links healthy students to academic achievement.

·  Physical, emotional, and social health conditions impact student’s ability to succeed.

·  Every child deserves to have access to a school nurse who is available to assess health concerns and intervene on his or her behalf.

·  Over one-half of students have a health condition.

·  Twenty school districts in Iowa have >50 percent free and reduced lunch.

·  School nurses identify and manage physical and emotional health issues of children and their families.

·  School nurses monitor and screen students for weight and growth concerns and complications from the lack of physical activity.

·  School nurses have the knowledge, skill and professional training to work with nutritional staff, teachers, administrators, and other professionals in the school in order to improve the health and well-being of students.

·  School based health services reduce absenteeism.

·  School nurses assist with enrollment efforts in health insurance programs such as hawk-i and other affordable health programs.

·  School health services provide health promotion and disease prevention in children.

·  School health services promote and support healthy staff which in turn model healthy behaviors.

III.       Code change:

Iowa Code 256.11

IV.       Fiscal implications, other considerations:

            Requires funding for registered nurses.

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Nutrition Counseling Reimbursed by Insurance

I.          Recommendation:  Primary health care provider assesses and facilitates the need for nutrition counseling and such counseling is reimbursable by insurances.

II.        Key points, justification, supporting evidence and rationale:

·        There has been underutilized and inconsistent coverage of nutritional services provided by licensed dietitians in Iowa’s Medicaid Program.

·        Medicaid claims data shows less than one percent of Iowa’s Medicaid population received paid nutrition counseling services from 2003-2005 for all diagnoses.

·        Individuals with disability and children, especially low-income children, have high nutrition risk and higher prevalence of nutrition-related conditions such as obesity.

·        Review of nutrition counseling benefits has been addressed by Iowa Medicaid Enterprise under HF 841 and needs to continue.

·        Current level of reimbursement for licensed dietitians is low and should be increased to be comparable with other allied health practitioners with similar educational/training background.

·        Costs associated with obesity diagnosis include a new fee schedule for expanded dietary and nutritional counseling services for licensed dietitians needs to be covered by health insurance.

·        Nutritional counseling (Medical Nutrition Therapy) is effective for disease prevention and wellness.

·        Medical nutrition therapy increases productivity, satisfaction levels and can reduce hospitalization; prescription drug use; and doctor visits.

·        Medical nutrition therapy coverage achieves positive patient outcomes, lowers health care expenditure; satisfies plan members.

·        The U.S. Department of Defense saved $3.1 million in the first year of medical nutrition therapy given by registered dietitians.

·        Medical nutrition therapy has widespread support nationally.

Code change: This would require a change in Iowa insurance code. 

III.       Fiscal implications, other considerations: Funding is needed to support reimbursement to licensed dietitians for medical nutrition therapy.

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Dental Examinations

I.       Recommendation: Parents will provide proof of dental exam for all children before child enters first grade.

II.        Key points, justification, supporting evidence:

·  Poor oral health has been related to decreased school performance decreased self esteem, poor social relationships, and less success later in life.

·  Dentists would see an increased examination rate but a decrease in emergent care.

·  Teachers would experience fewer students with missed days for toothaches and dental treatment, as well as fewer students whose concentration and learning are adversely affected by dental pain.

·  An estimated 51 million school hours per year are lost because of dental-related illness.

·  Students ages 5-17 missed 1,611,000 school days in 1996 due to acute dental problems—an average of 3.1 days per 100 students.

III.       Code change: Yes

IV.    Fiscal implications, other considerations: This will be a parental, out-of-pocket cost or insurance.

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Licensed Dietitians Available for Schools

I.              Recommendation: Registered and licensed dietitians are regularly available for  
 consultation or on-site monitoring to all schools.

II.        Key points; justification; supporting evidence

·        Currently the primary role of licensed dietitians in Iowa’s schools is only within the food service area.

·        Adequate and appropriate nutritional intake is well recognized as the major determinant for optimal growth and development.

·        Nutrition care is often part of individual education plans and requires licensed dietitian to implement and monitor.

·        Nutrition education and health related services are part of the expanding role of schools as part of wellness committees; licensed dietitians are the nutrition experts.

·        Nutrition is a vital component of any and all weight management and/or healthy lifestyle programs and licensed dietitians are the nutrition professionals to plan and implement these programs.

·        Children with functional limitations and special health care needs have greater risk of obesity and overweight.

·        Full time regional nutrition professionals can fill gaps in local community based primary care level, tertiary care level and acute care hospital nutrition services.

·        Current administrative rules language refers to community based nutrition services (assumed WIC) that do not have the capability to provide this level of service.

III.             Code change: Yes

IV.       Fiscal implications, other considerations:  Requires additional funding to increase the number of licensed dietitians.

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Large School Districts and Registered Nurses

I.          Recommendation: School districts with greater than 750 students have a pro-rated number of RN’s.

II.        Key points, justification, supporting evidence:

·        Given 50 percent of children have health concerns it is inconceivable to provide safe and effective care to more than 750 students.

·        The absence of a school nurse leaves unqualified school staff to make judgments related to children’s health concerns.

·        Healthy People 2010 recommends a ratio of one school nurse to every 750 students.

·        Iowa Department of Public Health recommends one school nurse to every 750 students.

·        Iowa Department of Education recommends one school nurse to every 750 students.

·        The National Association of School Nurses recommends a ratio of one school nurse to every 750 students.

·        Iowa Nurses Association supports the need for adequate nursing staff to provide safe and effective care to all citizens in Iowa. 

III.       Code change: Iowa Code 256.11

IV.       Fiscal implications, other considerations:

            Requires funding for registered nurses.

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Licensed Dietitians for Area Education Agencies

I.             Recommendation: Area Education Agencies (AEAs) have registered and licensed dietitians for families with children covered by Early ACCESS (birth to three-children with special needs).

II.        Key points; justification; supporting evidence

·  Nutrition services are listed as one of the mandated service areas in Iowa Administrative Code relating to Part C IDEA.

·  Currently there are no systematic comprehensive nutrition services in Iowa’s Early Access Program.

·  Nutrition care is a component of Individual Family Service Plans and require licensed dietitians to develop, implement and monitor.

·  Currently the primary role of licensed dietitians in Iowa’s schools is only within the food service area.

·  Adequate and appropriate nutritional intake is well recognized as the major determinant for optimal growth and development.

·  Establishing healthy eating habits early, along with increasing parental knowledge and skill in providing healthy environment reduces risk of childhood obesity and improves overall health outcomes.

·  Children with functional limitations and special health care needs have greater risk of obesity and overweight.

·  Full time regional nutrition professionals in Early Access can fill gaps in local community based primary care level, tertiary care level and acute care hospital nutrition services.

III.    Code change: Yes

IV.    Fiscal implications, other considerations: Salary support for licensed dietitians: travel and office support.

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State Nutrition Standards for Schools

1.                  Recommendation: The Healthy Children Task Force recommends legislative action to establish a task force/work group charged with establishing state-level guidance for nutrition guidelines standards for licensed pre-K programs, K-6, middle and high schools. 

II.                Key points, justifications, supporting evidence

Establish state-level guidance for nutrition standards for foods sold on school campuses outside of the school nutrition programs.

The standards would be phased in over time and would be developed to:

·      Assist schools in meeting the nutrition standards requirement of Public Law 108-625, Section 204 (a), Local Wellness Policy.

·      Provide standards that are based on a compilation of scientific evidence and standards established by other states. 

·      Assist food vendors/industry by promoting consistency among schools requesting affordable and healthier foods and beverages based on standard nutrient content and package size. 

·      Maintain local control through varying levels of participation in the nutritional standards while encouraging more healthful choices. 

Other supporting evidence:

·        Students consume an estimated 25-50 percent of their calories in school.

·        School a la carte and vending programs tend to sell food and beverages that are high in calories and low in nutrients.  The trend of offering less healthy choices continues from elementary throughout middle school and into high school where vending is more prevalent. 

·        According to the Institute of Medicine (2005), governments and schools need to develop and apply nutrition standards for all foods and beverages sold in schools that compete with federally reimbursed meals, including products sold in stores and vending machines or for fundraising.  The federally mandated school wellness policy addresses this very issue by requiring all local education agencies to establish nutrition guidelines for all food sold on the school campus.

·        A national poll by the Robert Wood Johnson Foundation found that 90 percent of parents and teachers support conversion of school vending to healthy beverages and foods.

·        This recommendation will ensure that food available on school campuses will meet the Dietary Guidelines for Americans, which are scientifically-based recommendations to promote optimal health.

·        The recommendation includes levels of nutrition standards where the local districts can decide whether they want to meet minimum, good or best practice regarding nutrition standards.

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III.                   Code change: Yes

Creating a one-year task force would take legislative action.

IV.                    Fiscal implications, other considerations: Funding for a task force would require resources for travel/expenses of task force members.

This task force/work group should include representation from: two school administrators/business managers (one large, one small district), two school food service directors (one large, one small district), two parents, two students, School Nutrition Association representative, Iowa Dietetic Association representative, Iowa Partners: Action for Healthy Kids representative, School Nurses Association representative, Bureau of Nutrition and School Transportation (DE) representative, food industry/vending representative.

Establishing state-level guidance will decrease the time and cost that would be experienced by local school districts in establishing nutrition standards. The Legislature should place the cost of identifying foods meeting the established nutrition guidelines/standards on the food vendors/industry to ease the burdens on schools.  This will save the local school districts time and cost in the identification of foods that meet the standards. The Legislature should consider funds to provide an incentive for schools electing the more stringent level of compliance.

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Fresh Fruits and Vegetables

I.                   Recommendation: Resolution to encourage Iowa schools to increase availability of fresh fruit and vegetables.

II.                Key points, justifications, supporting evidence

·        Iowans are not eating enough fruits and vegetables.  The CDC’s 5 A Day data for 2003 showed only 17.9 percent of Iowans consumed five or more fruits and vegetables daily.  Only one state in the U.S. had a smaller percentage.

·        Having fresh fruits and vegetables available more frequently would increase student consumption as they seem more likely to eat fresh. 

·        Fresh products have less sugar and sodium. 

·        Increased consumption of fruits and vegetables has a positive relationship in reducing risk of certain diseases. 

·        Providing choices for fruits and vegetables daily will increase familiarity so students can learn to include them in their usual diet.

·        Schools are an especially important location to teach the life skill of healthy diet choices because over 95 percent of young people are enrolled in schools. (National Center for Education Statistics, 2005)

III.       Code change:  None

IV.       Fiscal implications, other considerations:

Fresh fruits and vegetables have a higher cost per serving related to additional preparation time and initial cost of product.  Providing fresh product requires more labor to prepare thus lunch prices would increase.  Fresh foods have an increased waste factor due to their perishable state.

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Beverages in Preschools

I.       Recommendation: Require that only water, milk, unsweetened fruit drink with at least 50 percent fruit juice be served in licensed daycare/preschool settings (recommendation to Department of Human Services).

II.          Key points, justifications, supporting evidence

·              Energy intake is positively associated with consumption of non-diet soft drinks.   Studies have shown that children have higher calorie intake if they drink soft drinks.  One study showed the average intake of nine ounces of soft drinks daily for school age children. 

·              Children who drink soft drinks consume less milk and fruit juice.

·              Among toddlers, juices and fruit-flavored drinks are the second and third most important sources of energy – rather than foods – contributing to poor development of lifelong eating habits.

·              Excessive intake of sweetened beverages is associated with excessive calorie intake and increase risk of obesity.

·              Overall, on any given day, only 42.6 percent of toddlers consumed all meals and snacks at home.

·              Juices, fruit drinks, and carbonated beverages appear to displace milk in toddlers' diets.

·              Preschool children drink less milk than the 2005 Dietary Guidelines for Americans recommendation of 16 ounces per day. Only 8.6 percent drink low-fat or skim milk, as recommended for children who are older than 2 years. On average, preschool children drank < 6 ounces per day of 100 percent fruit juice.

III.         Code change:

NOTE: The Department of Education (DE) interpretation would be that all meals and snacks under current licensing standards and procedures must meet USDA Child Adult Care Food Program (CACFP) meal pattern requirements. Those requirements require any juice to be served as part of a meal or snack, to be 100 percent fruit juice. Milk would be required as part of breakfast, lunch or supper unless there is a need to substitute for medical reasons. 

IV.  Fiscal implications, other considerations:  Minimal fiscal implication.

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Appendix

Pursuant to Senate File 2251: The Department of Public Health and the Department of Education convened a Healthy Children Task Force to complete the following:

·        Assess current policies and statutes affecting the health of children, specifically physical activity, physical education, food and nutrition, and nutrition education for children ages three through eighteen.

·        Develop recommendations for policy and statutory changes to enhance the health and well being of children including, but not limited to, physical activity, food and nutrition, and education related to these topics.

·        Submit findings and recommendations to the governor and the general assembly no later than January 1, 2007.

Invitations were extended to eight legislative members; 34 associations/agencies; and the Governor was asked to appoint three parents or guardians, one middle school student and one high school student from each of the five congressional districts as detailed in SF 2251.

Three meetings were held by the Task Force with numerous e-mail communications between meetings:  

1.      September 18, 2006, 2:00 p.m. - 4:00 p.m. (38 members attending)

      Information was presented on the current policies and statutes affecting the health of children to provide a basis for discussion of potential recommendations. Members agreed to submit recommendations prior to the next meeting.

2.      October 24, 2006,       1:00 p.m. - 4:30 p.m. (32 members attending)

Recommendations from the Task Force members (69) were reviewed and voted on to identify higher priority areas. Task Force members self-identified subcommittee areas in which to work. The charge to each of the five subcommittees was to prioritize recommendations within that area and report back to the entire Task Force for members to review prior to the next meeting. The five subcommittees were:

·        Iowans, in their communities, deserve access to resources and models to achieve healthy lifestyles

·        Iowans need physical activity on a daily basis.

·        Iowans deserve the opportunity to access health services without barriers.

·        Iowans deserve access to affordable foods that have nutritional value.

·        Iowans need knowledge and ability to apply practices for healthy lifestyles.

3.      November 29, 2006, 1:00 p.m. - 4:00 p.m. (35 members attending)     

Subcommittees reported on their work and provided justification for recommendations prior to the meeting and responded to questions from other members. At the meeting final votes were taken narrowing the recommendations to the 13 priorities as detailed in the report.

Note: Attendance at meetings was a challenge for students because of school schedules. To provide an additional opportunity for their input, a special ICN meeting was held with the Task Force student members choosing to participate. This meeting was led by the Task Force Chair, Sharon Yearous, Vice Chair, Anne Tabor and representatives from the Department of Public Health and the Department of Education.