BMI SURVEILLANCE IN COLORADO PUBLIC SCHOOLS

SARAH WESTMORELAND COLORADO SCHOOL OF PUBLIC HEALTH

UNIVERSITY OF COLORADO ANSCHUTZ MEDICAL CAMPUS DECEMBER 2013

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Table of Contents

...........................................................................................................................3 Project Background ......................................................................................................................... 3 Project Goals.................................................................................................................................... 3 Related Work ................................................................................................................................... 4 BMI and Other Weight Assessment Tools ....................................................................................... 4

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Adams County .......................................................................................................................7 Adams County School District 12 (Adams 12 Five Star Schools) .................................................... 7 Adams 14 School District ................................................................................................................. 8 Adams-Arapahoe School District (Aurora Public Schools) ............................................................. 9

Alamosa County ................................................................................................................... 10 Alamosa, Sangre de Cristo, and Del Norte School Districts ........................................................... 10

Arapahoe County ................................................................................................................. 11 Englewood School District 1 .......................................................................................................... 12

Bent County ......................................................................................................................... 12 Las Animas School District ............................................................................................................. 12

Denver County ..................................................................................................................... 13 Denver County School District 1 (Denver Public Schools) ............................................................ 13

Huerfano County ................................................................................................................. 14 La Veta School District RE-2 ........................................................................................................... 15

Lake County ......................................................................................................................... 15 Lake County School District R-1 ..................................................................................................... 15

Larimer County .................................................................................................................... 16 Poudre Valley School District R-1 .................................................................................................. 16

Routt County ....................................................................................................................... 17 Hayden, SOROCO and Steamboat Springs School Districts ........................................................... 17

Saguache County ................................................................................................................. 18 Center, Mountain Valley and Moffat School Districts ................................................................... 18

Yuma County ....................................................................................................................... 19 Idalia School District RJ-3 .............................................................................................................. 19

Tri-County Health Department ............................................................................................. 20

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Project Background At a time when childhood obesity is at the forefront of public health discussion, surprisingly little is documented about BMI surveillance in Colorado. This report serves to capture where BMI screening and surveillance is happening in Colorado and provide insight into why it is (or why it is not) being collected at the public school level.

The public health community and other stakeholders generally rely on the Youth Risk Behavioral Surveillance System and in Colorado, the Healthy Kids Colorado Survey to report on childhood obesity trends. This data is self-reported and only collects information from students in grades 6-12. This means that there is a large gap in data for younger children, and the height and weight data may not be reliable given the self-report data collection method. To this end, it is important to document which other entities are collecting BMI data on children in the state.

This report is part of the effort by LiveWell Colorado to capture more information about the state of BMI surveillance in Colorado. Information collected for this report spans June 2013 – November 2013. Early on in the project, information was gathered from LiveWell Colorado partners including the Colorado Health Foundation, Colorado Legacy Foundation, Colorado Health Institute, CDPHE and CDE to gain a better understanding of related projects and to target additional informants.

After the initial interviews, LiveWell Community Coordinators around the state were interviewed to provide insight into what is happening in their communities in regards to BMI data collection. These informants often directed questions to a school nurse, a school wellness coordinator, or a school principal.

Interview questions included:

1. Is BMI data collected for children enrolled in your school or district?

2. How is the data collected? (i.e. do you conduct screenings for height and weight? do you use FitnessGramTM? other?)

3. What is done with the data? (i.e. does data from screenings get shared with students and parents? does the data get passed into a central repository for surveillance?)

4. Does your school or district provide resources for students identified at risk for obesity, overweight or underweight?

5. What challenges have you encountered in attempting to collect, or collecting, BMI data for children in your school or district?

6. In your opinion, what is the value of collecting BMI data?

Project Goals This report aims to summarize a sample of the work that Colorado schools and districts are conducting in regards to BMI data collection. The sample range includes a wide variety of schools from small rural districts to large urban districts. This is not a comprehensive report of all school districts in the state. Of the 179 school districts in Colorado, informants from 23 schools and districts in 13 counties provided material. [Some material was redacted from this version of the report at the informant’s request.]

A recent article in EdNews Colorado, A few districts lead the way in tracking body mass index1, aimed to compile similar information. That article and this report show a growing demand for information on BMI data collection in the state.

1 “A Few Districts Lead the Way in Tracking Body Mass Index,” ednewscolorado.org, November 26 2013, http://www.ednewscolorado.org/news/a-few-districts-lead-the-way-in-tracking-body-mass-index

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Related Work Before beginning this work, Julie Marshall at the Colorado School of Public Health was interviewed to obtain information about a survey of school nurses that she worked on with two MPH students in 2004. This survey collected information similar to what was collected in this report, but only from school nurses across the state. That survey could be repeated, but is not part of this report.

Amy Dyett of Colorado Legacy Foundation began a similar report earlier this year in which she compiled a short list of districts in Colorado that are collecting BMI data on their students. Her report also looked at arguments for and against BMI data collection in schools and gave a summary of how other states are proceeding with efforts to collect this data.

BMI and Other Weight Assessment Tools Body Mass Index (BMI) is a number calculated from a person's weight and height using the following formula:

weight (kg) / [height (m)]2

BMI is generally seen as an easy and inexpensive way to screen for overweight, obesity and underweight and has therefore been recommended for use by the Center for Disease Control and Prevention and the American Academy of Pediatrics beginning at age two. BMI is generally seen as an acceptable measure of weight status at a population level and can be used as a screening tool for individuals to determine if they need further diagnostics such as skinfold thickness measurements, diet and physical activity assessments, or other health evaluations.

The correlation between the BMI number and body fatness is fairly strong; however the correlation varies by sex, race, and age2. For adults,

2 “About BMI for Adults” cdc.gov, last modified September 13 2011, http://www.cdc.gov/ healthyweight/assessing/bmi/adult_bmi/index.html#Definition

BMI is not dependent on sex and age, while for children this plays a major factor.

Youth BMI weight status categories and the corresponding percentiles are shown in the following table2.

Weight Status Category

Percentile Range

Underweight Less than the 5th percentile

Healthy weight 5th percentile to less than the 85th percentile

Overweight 85th to less than the 95th percentile

Obese Equal to or greater than the 95th percentile

The CDC’s Executive Summary on Body Mass Index Measurement in Schools offers multiple considerations that address the recent movement of schools to conduct BMI screenings. It begins by making the important distinction between surveillance and screening:

“BMI surveillance programs assess the weight status of a specific population (e.g., students in an individual school, school district, or state) to identify the percentage of students who are potentially at risk for weight-related health problems. Surveillance data are typically anonymous and can be used for many purposes, including identifying population trends and monitoring the outcomes of interventions. BMI screening programs assess the weight status of individual students to identify those at risk and provide parents with information to help them take appropriate action.”3

3 Nihiser AJ et al. Body mass index measurement in schools: CDC Executive Summary on Body Mass Index, http://www.cdc.gov/healthyyouth/obesity/BMI/pdf/BMI_execsumm.pdf

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Sometimes the use of BMI data to assess an individual student's health is criticized for its inaccuracy and misplacement of some students into the wrong BMI percentile. This could happen because of incorrect measurements, excess clothing during measurement, or because a student has more muscle mass than his or her peers.

Some schools choose to use FitnessGramTM, a fitness assessment program4, to report on a child’s health instead of conducting height and weight screenings to calculate BMI. Proponents claim that it gives a more rounded and accurate picture of a child’s health and fitness status, while not categorizing and possibly stigmatizing students. Opponents argue that without real height and weight data it is impossible to know if a student is healthy. Some schools choose to use FitnessGramTM and do BMI screening concurrently because each provides a different and important picture of a child’s health status.

Findings

As more attention is drawn toward the rising obesity rates in the country, federal mandates to implement wellness policies and to improve school nutrition have triggered schools to make changes. Schools have reached a point where the growing body of data showing a strong correlation between health and academic achievement can no longer be ignored.

In addition to complying with federally mandated expectations, some schools have implemented healthy eating and active living (HEAL) goals. Schools need to know if these efforts and increased expenditures are paying off. Tracking their progress is done in a variety of ways: demonstrating an increase in physical education time and healthier options in the cafeteria, or by showing an expansion of a nutrition education program or safer routes to school.

4 “FitnessGramTM,” Program Overview. accessed November 20 2013, http://www.fitnessgram.net/ programoverview/assessreporteducate/

BMI data collection is another way to track this progress. BMI screenings are not mandated in Colorado schools, yet more and more schools around the state have decided it is beneficial to conduct them in order to show a more concrete effect of HEAL programs on students’ weight.

BMI screening, like many non-academic activities conducted in schools, has proponents and opponents. Without a legislative mandate in a local-control state, the decision to implement and maintain an active and accurate BMI data collection program in schools is driven by leaders who are motivated by the advantages they see in doing this work. The decision also requires a calculated process of weighing the following advantages and disadvantages.

Proponents argue that BMI screening, much like hearing and vision screening, is an essential component in determining a student’s health, and their health has a direct correlation with their academic performance. Knowing a student’s BMI can allow for education and intervention on an individual level, with the school being the only likely place a student is exposed to this information. Additionally, population level data can put a school in a position to demonstrate the success of HEAL programming, leveraging funding for continued investment in these activities.

Opponents argue that a student’s weight is not the responsibility of the school and that a discussion about BMI should only occur between a child’s family and their doctor. Opponents may be in full support of increased HEAL programming, but that is where the school’s responsibility ends. Additionally, a student’s weight can be a sensitive subject and overweight students may feel stigmatized or be bullied if BMI is addressed in a school setting.

Proponents and opponents generally agree that BMI screening takes additional time, resources, and a dedicated effort by administration, nurses, volunteers and others to collect accurate information that can be used in analysis. While there is an increasing trend to gather BMI data, many schools remain on the sidelines, either deciding they aren’t ready to address the challenges they may encounter if they do BMI

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screening, or that they don’t have the recourses to fully invest in screening.

A cornerstone of this challenge is the fact that BMI surveillance cannot exist in a vacuum. Aggregate data must start with collecting individual student data, and once the school has that student data, health professionals feel an obligation to follow up and provide resources to students at risk.

Although many schools want to have aggregate BMI data to show the overall health of their student population, they often don’t have the resources to get to that point. If they do find ways to offer resources to students and are able to collect the data systematically, they may not have the capacity or knowledge to do accurate analysis on aggregate data. This is where partnerships with local health departments or other groups can be of great value.

As the conversation about childhood obesity continues to draw attention, it is likely that more and more schools will decide to invest in BMI screening as one way to move toward a solution to the growing problem. However, there are still thousands of schools in Colorado that cannot or do not want to collect this information. It will take a concerted effort by schools and their community stakeholders to address the problem from multiple angles. The advantage of the diverse approaches Colorado schools take to address the problem is an ability to learn from our neighbors. Great work and continued collaboration across the state are keystones to Colorado’s future success.

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Adams County

Adams County is the fifth most populous county in Colorado. Part of the county overlaps with many urban Denver neighborhoods, and towards the eastern portion, the communities are rural and sparsely populated. Adams County is home to about 500,000 residents and is seeing significant growth from year to year5.

Adams County includes the following school districts. Districts profiled in this report are highlighted.

Adams County School District 12 (Adams 12 Five Star Schools)

Adams County School District 14

Adams County School District 50 (Westminster School District 50)

Adams-Arapahoe School District 28J (Aurora Public Schools)

Bennett School District 29J

Brighton School District 27J

Mapleton School District 1 (Mapleton Public Schools)

Strasburg School District 31J

5 “About Adams County,” Adams County Colorado. accessed November 20 2013, http://www.co.adams.co.us/index.aspx?NID=871

Adams County School District 12 (Adams 12 Five Star Schools) Informant:

TJ Ricciardi, M.S., CSCS, CES District Wellness Coordinator Adams 12 Five Star Schools

Located just north of downtown Denver, in Western Adams County, Adams 12 Five Star Schools serves 43,000 students in five different communities: Broomfield, Federal Heights, Northglenn, Thornton and Westminster (hence the piece of its name: “Five Star”).

TJ Ricciardi, the District Wellness Coordinator, explained that there is no district-wide BMI data collection in Adams 12, but some PE teachers do collect it. Each PE teacher is different in his or her collection methods for BMI and fitness, using FitnessGramTM, or measuring height and weight to calculate BMI. PE teachers routinely perform FitnessGramTM on a yearly basis in most elementary schools in the district. Ricciardi notes that some teachers do share fitness assessment results with parents. He says he is not aware of student data being tracked over time.

In Ricciardi’s opinion, “Simply using BMI numbers to look at the health of individual students is not as useful as other measurements. BMI can be a poor indicator in adults, and even worse in children who are still in the growth and development process. BMI is highly variable from one individual to another. Although it may be useful in looking at large population numbers, it is preferable to have more solid data such as body fat percentage. Additionally, collecting weights, percentages, etc. from students has become controversial among some parent groups (not specific to Adams 12, but in general).”

Adams 12 has made a concerted effort to make healthy eating and active living activities commonplace in their schools. They have created school gardens, cooking classes for students and parents, fitness challenges and health fairs. Adams 12 recently implemented a district-wide wellness policy, which focuses mostly on healthy meals and

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snacks as well as physical activity for all students in every grade.

Adams 14 School District Adams 14 School District is located just north of Denver in Commerce City. Adams 14 consists of 13 schools, in which they enroll almost 8,000 students. They have School-based Health Centers (SBHC) in four of their schools that serve students and the community.

The content in this section is provided by Amy Dyett of Colorado Legacy Foundation.

Informant:

Nina McNeill, Nurse Practitioner Adams City Middle School SBHC

BMI is not systematically collected at all Adams 14 schools, but may be done from time to time based on the priorities of the nurses or the PE teachers in the schools.

Throughout the years, McNeill has worked creatively to collect BMIs on as many students as possible and even had BMIs for the entire school a few years ago that she collected during the orientation process at the beginning of the school year. However, as administration changed, so did the level of support, and this is no longer possible.

At Adams City Middle School, McNeill screened all 7th graders for heights and weights during the 2012-2013 school year. This was as much as she had permission to do given the busy academic schedule. McNeill is determined to include all 6th graders in future years and has been working creatively with the school schedule to allow for this. For instance, she may be able to incorporate this into the 6th grade orientation prior to the start of school, or to work with the PE teacher and find a way to fit BMI screening into the PE curriculum.

When BMI is collected, all BMI findings are reported to parents, and McNeill rechecks and focuses follow up on BMIs over 95%. If the student is already enrolled in the SBHC’s system, permission to follow up on a student’s weight can be gained from the student. If not, the SBHC must

contact the parent and ask permission to discuss concerns about their child’s growth. When permission is not given, McNeill recommends that the family follows up with their general practitioner and informs them of their adolescent's BMI and related health consequences.

McNeill believes in the benefits of collecting BMI to show trends in the obesity rate in the community. “With this information, strategies would be readily available to help develop awareness in preventing those from becoming overweight and obese.”

McNeill has been able to use the data collected to drive prevention services and time management decisions. She is able to target a specific grade that has the highest need of health information regarding weight, physical activity and nutrition education. “From the data last year, the trend showed that I needed to concentrate on the 6th graders who were steadily gaining weight rather than the 8th graders, which is when I normally go into the classroom to share this information.”

Even as a SBHC, McNeill reveals that finding time at the center to schedule BMI measurements is a challenge. Another challenge is lack of staff and experts that can take accurate heights and weight measurements.

“I believe our interest in students’ growth shows we are committed to a healthy life for them”, McNeill explains. Obesity can be a sensitive topic and schools can provide an opportunity for them to express their feelings and thoughts about their weight. Motivational interviewing with a nurse practitioner allows students to choose their own, attainable strategies toward a healthy weight. If they are not ready for change, McNeill is at least able to bring some awareness to their health. As McNeill explains, “Often times, the students are aware of their unhealthy weight and need support in communicating this to their family. And vice versa, parents are aware and need support in a discussion with their adolescent.”

As McNeill struggles with finding time for BMI measurements year by year, she discusses the difficulties that schools without SBHCs would have in attaining such information. “Even with medical professionals at a SBHC it is hard to obtain the

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measurement at a large scale and ensure that the data is accurate; without a SBHC, I do not see how a school would be able to do so.”

One of McNeill’s biggest concerns is for schools to be sharing inaccurate information with students and parents. “The youth BMI weight percentiles are not simple and weight and height vary based on the time of day, types of clothing, etc.” She is also concerned with a school’s ability to follow up and provide resources and actionable next steps for youth with a high BMI. “As a SBHC, students can receive medically accurate and up-to-date information to work on and maintain a healthy lifestyle.” Without follow up or minimally, informative resources, the BMI score can become a label, a stigma that can create depression, learned helplessness and a sense of disconnect for students without support.

Adams-Arapahoe School District (Aurora Public Schools) Informants:

Jimikaye Beck, MS 5th Gear KidsTM Project Coordinator

Lacy Scott, BSN, RN Aurora Public Schools

Adams-Arapahoe School District-28J, better known as Aurora Public Schools (APS), enrolls almost 40,000 students in 55 different schools. APS has one of the largest student enrollments in the state, and the students come from a wide range of socioeconomic backgrounds.

To better promote healthy eating and active living in their schools, APS implemented the District Coordinated School Health Teams (DCSHT) in 2007. In 2010, a federal grant, “Communities Putting Prevention to Work,” provided for a fulltime Healthy Schools Coordinator who could facilitate school-level Coordinated School Health Teams. (CSHTs). Schools were invited to form teams, assess needs of their schools, set goals and plan activities to improve staff and student wellness. Membership by teachers and staff was voluntary.

The CSHTs were instrumental in bringing the Flat 14ers program to APS schools and they also support programs like Go! Slow! Whoa!, 5-2-1-0, and Jam Sticks, among others6. Each CSHT has autonomy to implement the programs and activities that its members regard as useful to their mission and the advancement of their work. Eleven school teams were formed, with the help of the district’s Healthy Schools Coordinator. Another program instrumental in health promotion in APS is 5th Gear KidsTM 7. This program works jointly between APS and Cherry Creek School District to educate 5th graders about energy balance and to challenge them to choose healthy meal options and to take part in physical activity.

In APS, BMI screening is not systemic and there is not a district mandate or expectation to collect or report on this data. However, APS does collect BMI data twice a year in PE class through FitnessGramTM testing for children in grades 3-5. After 5th grade, most APS schools only collect this data for students enrolled in PE, which is only a portion of the student body.

5th Gear KidsTM collects BMI data on all 5th graders in three APS schools, once in the fall and once in the spring. Additionally, a few CSHTs collect BMI data for their students, share this information with students and parents, make referrals, and aggregate the data for school and district staff.

Lacy Scott, one of 30 APS school nurses, is a member of several of the CSHTs in schools where she is also the nurse. Serving on a CSHT is outside of normal job duties, and Scott notes that most members are teachers, staff and parents who feel inspired to promote healthy eating and active living.

Regarding BMI data collection, Scott believes the data collected from FitnessGramTM, although useful in certain instances, does not provide a complete picture of individual and aggregate student health. One of the drawbacks of FitnessGramTM is that it

6 “Wellness in APS,” Coordinated School Health Teams. last modified February 25 2011, http://wellness.aurorak12.org/csht/ 7 “5th Gear KidsTM,” About Us. accessed on November 20 2013, https://5thgearkids.org/

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only provides a BMI number, not a percentile which is crucial in determining whether a student is underweight, a healthy weight, overweight, or obese. She thus decided, with her supervisor’s permission, to collect BMI data herself through height and weight measurements, mapping this data to CDC child growth charts. For a number of years Scott has collected this data for each student in the four schools she serves. It is often done alongside vision and hearing screenings, requiring several volunteers and a handful of days to complete this process. When Scott began collecting BMI data she was astounded by the high number of students that were overweight or obese.

Scott notes that this process is very time consuming and she cannot continue collecting this data without more help and resources. Scott does not have the recourses or time to analyze the data she collects; therefore, the data resides in her personal files without undergoing analysis to show changes in her student population over time. Scott does use the data to follow up with families of students who are at risk by sending home letters informing them of their student’s BMI and the risks associated with being overweight, obese or underweight. She gives them her personal phone number in case they want to ask questions about the measurements or request resources. She receives minimal negative feedback from parents, in part due to continued revisions to the parent notification process to ensure privacy and provide information regarding why she collects BMI data.

Outside of FitnessGramTM measurements, Scott believes she is one of the few nurses in APS who collects BMI data consistently and has a process for sharing the information with parents. She thinks school nurses should have incentives for conducting BMI screenings in schools and districts where it is not commonplace. She also believes that “BMI Screening Teams”, hired at the district level to collect BMI data, would be efficient and useful in ensuring that BMI is routinely and accurately collected for all students.

Scott is leery of the lack of resources for students who are overweight or obese. She thinks it would be important to have a “toolkit” for school nurses, teachers and administrators in order to streamline

efforts and resources available to students and parents.

Alamosa County

Informants:

Liza Marron, Executive Director San Luis Valley Local Foods Coalition

Dr. Julie Marshall Professor, Colorado School of Public Health Director, Rocky Mountain Prevention Research Center

Alamosa County, wedged between two mountain ranges in the middle of the San Luis Valley of south central Colorado, has approximately 15,000 residents. Industries such as agriculture, solar power production, higher education and tourism are all staples of the county’s economy. Alamosa County is home to Alamosa RE-11J and Sangre De Cristo RE-22J School Districts.

Alamosa, Sangre de Cristo, and Del Norte School Districts Alamosa County Public Health has gone to great lengths to make overweight and obesity prevention a priority in the county. The Alamosa County Public Health Department Improvement Plan 2013-2018 denotes Obesity Prevention as the

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number one priority8. A main component of the obesity prevention efforts in this plan relies on the work of the Coordinated Health Assessment & Management Program, or CHAMP. CHAMP collects health data in Alamosa, Sangre de Cristo, and Del Norte School Districts as part of the school registration process each fall9. In addition to collecting heights and weights, this coordinated program also allows for immunizations, mental health assessments, and oral and lung health checkups for all children in these schools. Surveillance data gathered from this program is instrumental in guiding the intervention efforts outlined in the public health improvement plan.

CHAMP is a coordinated effort between local and outside entities including Alamosa County Public Health, National Jewish Health, the San Luis Valley Regional Medical Center (SLVRMC), Rocky Mountain Prevention Research Center, Alamosa and Sangre de Cristo Schools, and Adams State University. After a brief period as a pilot program, the County received a grant from CDPHE in 2012 to continue CHAMP. A press release last year explained that, “The goal of the grant is to continue to complete yearly school-based health assessments in Alamosa County to identify early risk factors of chronic illness such as being overweight or obese and to identify children with asthma or hypertension in order to provide education, support and training to modify risk factors and improve management of chronic conditions. Children and their families identified with a health concern will be provided opportunities to participate in evidence-based

8 “Alamosa County Public Health Department Improvement Plan 2013-2018,” accessed August 30 2013, http://www.chd.dphe.state.co.us/chaps/ Documents/ALAMOSACOUNTYPUBLICHEALTHIMPROVEMENTPLAN2012.pdf

9 “Rocky Mountain Prevention Research Center,” http://www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/RMPRC/Pages/welcome.aspx, “CHAMP Program Summary,” last modified July 6 2011, http://www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/RMPRC/projects/Documents/Project%20Briefs/CHAMP%209.2012.pdf

programs that will help them adopt healthy habits.”10

The data collected by the CHAMP program, including BMI data, allows for healthy eating and active living activity promotion and assists Alamosa County in assessing the effectiveness of its prevention programs.

Arapahoe County

Arapahoe County, southeast of the Denver metro area, is the third most populous county in Colorado. Home to more than 500,000 residents, the western portion of the county consists mostly of urban and suburban communities while the eastern portion mostly rural.

Arapahoe County includes the following school districts. Districts profiled in this report are highlighted.

Adams-Arapahoe School District 28J (Aurora Public Schools) – see Adams County

Byers School District

Cherry Creek School District 5

Deer Trail School District

Englewood School District 1

Littleton Public Schools

10 “Alamosa County Public Health Brings New Health Recourses to the Valley,” (Alamosa: Strnad, 2012) http://www.alamosacounty.org/index.php?option=com_content&view=article&id=349:public-health-department&catid=67:news-a-announcements

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Sheridan School District

Englewood School District 1 Informant:

Dale Lumpa, District Wellness Coordinator Englewood Public Schools

Englewood School District, located just south of downtown Denver, serves 3,000 students in four elementary schools, two middle schools and two high schools. With support by its fairly affluent community, the district is known for its innovative offerings, including an International Baccalaureate program, full-day Kindergarten, an AVID college preparatory program, state–of-the-art sciences labs, and more11.

Dale Lumpa, PE teacher and District Wellness Coordinator for Englewood Public Schools, reported that in the district, PE teachers use FitnessGramTM to collect fitness measurements for all students in grades 3-8 every year. It is also used for some 9th and 10th graders. Currently, data is stored in individual student files and also shared with the student and their parents.

ESD is working to develop a system where data would be reported at a district level so that aggregate data could be used to look at changes over time, but currently the focus is at the school and individual student level.

Lumpa is very supportive of continuing the effort to collect BMI data and sees the program as an important piece of wellness education for students and parents. He believes, “It is important for students and parents to see real data that is specific to them,” and he is also happy with the efforts EPS makes to provide healthy eating and active living programs for its students.

11 “Englewood Schools” Our District. accessed on October 20 2013, http://englewoodschools.net/ modules/cms/pages.phtml?pageid=178737&sessionid=18ef93207c321429b5df39a035261818&sessionid=18ef93207c321429b5df39a035261818

For students who are at risk of overweight or obesity, the P.E teachers make an effort to follow up. With the assistance of the FitnessGramTM ideas for healthy living, PE teachers help inform students and parents about lifestyle changes they could make to achieve a healthy weight.

Bent County

Informant:

Tammy Westerman-Pryor Program Coordinator, LiveWell Bent County Las Animas, CO

Bent County, along the southeastern plains of Colorado, has a population of about 6,000 people. Industry consists mostly of agriculture, with smaller economies of tourism, health care and a correctional facility. The largest city in Bent County is Las Animas, home to about 3,000 people. There are two school districts in Bent County, each with less than 1,000 students: Las Animas School District RE-1 and McClave School District RE-2.

Las Animas School District Las Animas School District consists of an elementary, middle and high school. Las Animas has made the news with their concerted effort to tackle the obesity problem in their town, which is reported to have one of the highest rates in Colorado.

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A report in July of 2012, The Town That's Tackling Obesity12, by Health Policy Solutions, documented a myriad of solutions to the obesity problem in Las Animas. An enthusiastic LiveWell Program Coordinator, Tammy Westerman-Pryor, who envisions safer routes to school, community gardens, and more pedestrian friendly sidewalks in the town, leads the effort. She and other advocates seek ideas and assistance from the youth in their community to advance their obesity prevention plans. Westerman-Pryor has several roles within Bent County. In addition to working as the county’s LiveWell coordinator, she also drives a school bus and is quite active in school activities. A large portion of her work in the community is centered around advocacy.

In Las Animas School District, heights and weights are collected for all students every year. This process began in 2007 for reporting purposes on obesity related work being done at a public health level. They have continued this effort throughout the years logging data on their school database, Go-EduStar. Heights and weight screening is done by the school nurse, who then using the standard formula to calculate BMI.

Student data is tracked over time and is shared with parents. The district does not provide referrals or resources for students identified at risk since it is mostly used as a surveillance tool.

Las Animas School District sees the value in collecting BMI data mostly to gauge whether intervention programs have been effective in changing obesity rates, and for future funding opportunities.

12 “The Town That’s Tackling Obesity; A report by Health Policy Solutions,” rmpbs.org, July 13 2012, http://www.rmpbs.org/topics/health/town-s-tackling-obesity/

Denver County

Informants:

Scott Romero Health Specialist, Healthy Schools Team Denver Public Schools

Emily McCormick Epidemiologist Denver Public Health

Denver County School District 1 (Denver Public Schools) Denver Public Schools is one of the largest districts in Colorado with 172 schools serving 85,000 students from a variety of backgrounds, income levels, and communities13. In many ways, DPS is at the forefront of school wellness promotion. In 2010, DPS launched the Health Agenda 2015, a five-year plan outlining 13 different goals that the district is aiming to achieve. To advance the Health Agenda, DPS formed the Healthy Schools Team within the Division of Student Services14.

Part of the work that the Healthy Schools Team coordinates is BMI data collection. DPS is collecting more data and conducting more analysis on that data than any other district in Colorado. Scott

13 “Denver Public Schools,” District & School Overview. accessed on Nov 20 2013, http://planning.dpsk12.org/ district-enrollment-basics/district-school-overview 14 “Denver Public Schools,” Healthy Schools. accessed on Nov 20 2013, http://healthyschools.dpsk12.org/

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Romero of the Healthy Schools Team reported that BMI has been collected consistently since 2007 in DPS alongside hearing and vision screenings. Teams within DPS’s Nursing and Student Health Services conduct the screenings each year on all Early Childhood Education (ECE), 1st, 2nd, 3rd, 5th, 7th, and 9th graders. Additionally, all new students coming into DPS, regardless of grade, are screened, and students with significant health conditions are screened annually. Romero notes that this data collection has become routine and a system is in place to ensure training and equipment consistency from year to year. Romero noted that PE teachers in DPS also use FitnessGramTM consistently across the district to collect additional fitness measurements.

When asked why the DPS data collection process is worth the effort, Romero notes, “Data helps departmental managers and the Healthy Schools team plan population-level strategies to improve health and positively impact academic achievement. It guides and stimulates the work we do with our community partners to address items related to healthy eating and active living.”

The continued effort to conduct BMI screenings have paid off whereby most students, parents, teachers and administrators know the screening is part of regular school processes. The fact that this has become routine creates an expectation in the DPS community that it will continue and data will be used to improve school wellness policies and activities.

BMI data resides in Infinite Campus (IC), DPS' student database. Since many students have been tracked since 2007, DPS is able to report on changes over time. What differentiates DPS from other districts that do BMI screenings is their partnership with Denver Public Health to analyze their data beyond what DPS could accomplish in-house.

Emily McCormick at Denver Public Health is the main epidemiologist working with the DPS data. McCormick reported that there are 199,000 usable BMIs in the DPS dataset, going back to 2007. There is some additional data from pre-2007, but mostly for younger children. Additionally, there is more than one data point for about 40,000 students so

she is able to look at changes over time. Two PhD students at University of Colorado are working with this data and planning publications using DPS BMI data look at trends and risk and protective factors.

McCormick consistently shares reports with Romero and the rest of the DPS team. They are very excited to keep the momentum of this project going. Additionally, McCormick recently presented various reports at a school nurses’ meeting who seemed very supportive of the project. Right now, BMI can be analyzed alongside race/ethnicity, gender and school. Eventually they would like to look at data based on zip code, but currently that presents multiple challenges.

Huerfano County

Informants:

Cindy Campbell LiveWell Program Coordinator Spanish Peaks Outreach Clinic

Bree Lessar, Superintendent and Principal La Veta School District

Huerfano County, in south-central Colorado, has a population of just under 7,000 residents. Huerfano County is home to two school districts, Huerfano School District RE-1 and La Veta School District RE-2.

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La Veta School District RE-2 La Veta School District has not put a lot of attention toward BMI data collection. Programs that advance physical activity and nutrition goals have moved forward, but BMI surveillance is not a priority given time and resource constraints in the district. There is a perception among some residents that the school district is not facing an obesity problem. Furthermore, there are challenges with the confidentiality issues that exist around BMI and some individuals feel it should not be the responsibility of the schools to collect or know this information. Additionally, there is some resistance to collecting BMI data without first implementing resources to help students identified as overweight and obese.

Lake County

Informants:

Katie Baldassar Coordinator, Lake County Build a Generation

Cheryl Wells Lake County School District Nurse and Chair of LiveWell Collaborative

Lake County, in the central mountain region of Colorado, is home to 8,000 people. Known as a place for tourism, hiking, skiing and water sports, its county seat is Leadville, the highest incorporated city in the U.S. The high-elevation town of Leadville, Lake County School District R-1,

is the only district in the county, which hosts 1,300 students in four schools.

Lake County School District R-1 There is no routine BMI data collection in Lake County schools, but in partnership with Summit Community Care Clinic funded by a grant from The Summit Foundation15, students are able to get optional dental and BMI screenings. The screenings are offered to 5th, 7th, and 9th grade students, and Wells estimates that about one half of the eligible students take part in the dental screenings. Approximately one third opt to do the BMI screening. The screenings require active consent, which Wells think may deter some students from participating. The data from these screenings is not shared with an entity that could provide surveillance measurements. Wells noted that the schools don’t have many resources for students identified to be at risk for obesity, but they can refer these students to local health clinics and doctors.

Wells has the impression that the community is interested in programs that promote healthy living and would be supportive of height and weight collection in their schools. However, a roadblock seems to be a lack of mandate and therefore no strong push or obligation to make it happen at this point. There is also a lack of information about how effective BMI surveillance is in moving HEAL projects forward. Wells imagines that as their county moves forward in the LiveWell Communities program there will be more motivation to move forward with these efforts.

15 “The Summit Foundation Surpasses 12.4 Million in Total Grant and Scholarship Awards.” thesummitfoundation.org. last modified June 13 2013. http://www.summitfoundation.org/wp-content/ uploads/2010/08/2010-Spring-Grant-Awards.pdf

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Larimer County

Informants:

Virginia Clark, MS, RD Poudre Valley Health System CanDo Coordinator, Ft. Collins, CO

Jessica Hinterberg Obesity Prevention Coordinator, Loveland, CO

Larimer County is the sixth largest county in Colorado based on population. Parts of the county are very populous near the cities of Ft. Collins and Loveland while other parts are quite rural where farming and ranching are staples. Several large employers are housed in Larimer County including Hewlett-Packard, Celestica, LSI Logic, Anheuser Busch, Teledyne WaterPik and Colorado State University. Rocky Mountain National Park brings in millions of tourists each year16.

Larimer County includes the following school districts. Districts profiled in this report are highlighted.

Estes Valley Schools (Park School District R-3)

Poudre Valley School District R-1

Saint Vrain Valley School District RE-1J

Thompson School District R-2J

The greater Larimer County area is home to a forward-thinking program called Coalition for Activity and Nutrition to Defeat Obesity, better

16 “Larimer County,” About Larimer County, accessed on Nov 15 2013, http://www.larimer.org/about/about.htm

known as CanDo17. CanDo, supported by University of Colorado Health, partners with Poudre Valley and Thompson School Districts to promote healthy eating and active living. CanDo promotes a “Coordinated School Health Model” and has published the “School Wellness Recourses Kit” to share with other schools seeking guidance in this area.

Poudre Valley School District R-1 Poudre Valley School District is one of the largest in Larimer County, enrolling about 27,000 students. A key piece of the work that CanDo does is BMI data collection in public schools. Through this work they have BMI surveillance data on 2,000-3,000 students in Poudre Valley School District that is collected each year, spanning a period of ten years18. Heights and weights are carefully collected according to CDC guidelines. This effort takes place in coordination with other health screenings including vision and hearing. School nurses and volunteers come together to do the screening each year. Data is kept in the district’s student database in such a way that it can be shared with the local health department.

Participation in the CanDo program is up to each school principal. Hinterberg reports that about 80% of schools are in full support of the CanDo program. Students wanting to opt-out must return a signed waiver to the school prior to the screening period.

Even with such an advanced program that has demonstrated years of success, CanDo faces some obstacles. Not all schools want to participate, and there is a constant question about whether resources should be expended on fitness and nutrition programs rather than on BMI data collection. Currently, CanDo focuses on younger

17 “CanDo Online,” CanDo Schools. accessed on Nov 15 2013, http://www.candoonline.org/schools 18 “Current Trends in Overweight & Obesity in Our Community, CanDO Ft. Collins Coalition Meeting 8/9/2011,” candoonline.org. last modified August 9 2011, http://www.candoonline.org/sites/ default/files/Obesity_Data_Trends_8-9-2011.pdf

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children, but there is an effort to expand the program to high school students in the district.

Routt County

Informant:

Barb Parnell, Ph.D. LiveWell Northwest CO Community Coordinator

There are just under 25,000 residents of Routt County. About half of these residents live in Steamboat Springs, home to the popular Steamboat Ski and Resort. Incomes in Routt County range significantly, with an affluent portion of the population able to own a vacation home and another portion working in low-paying, seasonal service jobs. The economy is largely based on tourism, but there is a large agriculture sector as well. The three school districts in Routt County are Hayden School District RE-1, South Routt School District RE-3 (SOROCO) and Steamboat Springs School District RE-2.

Hayden, SOROCO and Steamboat Springs School Districts There are six schools in Routt County in three different districts: Hayden, SOROCO and Steamboat Springs. There are six schools in Routt County in three different districts: Hayden, SOROCO and Steamboat Springs. Hayden and SOROCO each have about 400 students, while Steamboat Springs has nearly 2,500. Routt County became a LiveWell Community in 2009 under the name “LiveWell Northwest Colorado”. It was

around this time that BMI data began being collected each fall in all three of the school districts for all students K-12. Livewell collects the data in Steamboat Springs School District while the school nurse or PE teacher collects it in Hayden and SOROCO. Prior to LiveWell’s involvement, Steamboat Springs did not collect BMI for any students, and Hayden and SOROCO only collected it for elementary students, so it is clear that LiveWell has made an impact in these districts.

Students’ heights and weights are generally stored in their nurse’s chart and the data is not reported to the student or shared with the parents. There is no formal follow-up procedure or resources, but school nurses and PE teachers often make an effort to track an individual student over time and talk to parents or make a referral in certain cases.

At one time, data was shared on FitnessGramTM, but concerns from administrators caused this process to be discontinued. Only certain administrators can view the data and they report deidentified aggregate data to the school districts and to the Routt County community. They look for countywide trends and the data helps them measure whether their interventions are significant.

Parnell has concerns that the districts will not be able to continue BMI data collection without funding from LiveWell Colorado. She thinks it is valuable to collect this information to educate people who have a misconception that obesity isn’t affecting children in Routt County. She now has data to show that interventions are important in the Routt County community.

In addition to starting to collect BMI data, LiveWell Northwest Colorado is also implementing these measures in the schools in Routt County:

Promote fruit and veggie of the month campaign with taste tests, classroom activities and fun facts at 4 elementary schools

Replace non-healthy food fundraisers

Offer 10 minute physical activities throughout the day in all elementary and middle schools

Provide safe routes to all schools

Upgrade school wellness policies

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Promote the 5-2-1-0 Campaign in all three school districts

Improve the quality of PE programs through a grant from the CO Health Foundation

Provide safe active play areas at South Routt and Hayden Elementary School playgrounds

Develop and implement staff wellness programs

Saguache County

Informant:

Della Vieira, RN, MPH Director, Saguache County Public Health

Saguache County, located in south-central Colorado, has about 6,000 residents. It is one of the largest counties in the state by land mass but only has four schools in three different schools districts with 100-200 students in each. These districts include Center Consolidated School District 26 JT, Mountain Valley School District RE-1, and Moffat Consolidated School District 2.

Center, Mountain Valley and Moffat School Districts A community health assessment indicated obesity was a priority for Saguache County and officials further prioritized youth obesity prevention. They were able to take advantage of programs already in place in county schools for physical activity and nutrition. They expanded from this foundation and

are making progress toward BMI data analysis, developing a resource toolkit and expanding intervention programs.

Collecting heights and weights is part of the Public Health/Registered Nurse’s routine annual screenings. Data is collected from all students in all grades from two schools, and a portion of students from a third school (around 75% of students).

Beginning in the 2011-2012 school year, the schools started to share deidentified height and weight data with the Saguache County Public Health Department. With this data, the health department calculates individual BMIs and plots them on CDC BMI-for-age charts to give a “snapshot” of BMI for the student population by age.

Students are “flagged” green, yellow and red, corresponding to normal weight (5-90th %), overweight (90-95th %ile), and obese (>95th %ile) or underweight (<5th %ile). Those in the red categories may receive a care referral and/or care planning by the school nurse, especially if the child has a second risk factor (HTN, diabetes, asthma, etc) that was also identified at the health screening by the nurse.

Charted data is shared back with the schools for planning and fundraising purposes. The local health department does not have identifiers in the data that is shared, but when it is given back to the schools the nurses are able to identify individual students in the low and high risk ranges, to track them over time, and/or to intervene with care planning and/or referrals. The health department plans to continue this work with the school in order to track students over time and to gather data from the fourth school in their county.

They are developing School Nurse Toolkits to encourage nurses to track high-risk students over time. The toolkits include height and weight measurement protocol, a data collection table, BMI growth charts, slides presenting last year’s data, sample care plans, family education materials and local referral lists. The lists include resources for physical activity and healthy eating opportunities. They also have an obesity/overweight care plan developed by their

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Public Health Nurse alongside an asthma care plan. They are planning to expand that set of care plans as needed for other chronic disease risk factors as the school nurses become more accustomed to using the toolkit resources.

In Vieira’s words, “The aggregate data is useful for schools for monitoring their own interventions, observing trends, and raising funds for obesity prevention programming. The individual data will be useful to school nurses to help students and families develop healthy lifestyles to reduce risk for obesity and chronic disease in the student’s present or future. It may also flag students for further testing: e.g. HTN, elevated cholesterol, etc.”

Yuma County

Yuma County, in the northeast corner of the state, is home to just under 10,000 residents. The economy is centered mainly on agriculture and is a main trade corridor for Colorado, Nebraska and Kansas19.

There are four school districts in Yuma County including Idalia School District RJ-3, Liberty School District J-4, Wray School District RD-2, and Yuma School District 1.

19 “Yuma County,” About Yuma County. Accessed on Nov 15 2013, http://consideryumacounty.com/ about_yuma_county.html

The content in this section is provided by Amy Dyett of Colorado Legacy Foundation.

Informant:

Kylie Chamberlain PE Teacher and Assistant Principal Idalia School District

Idalia School District RJ-3 Idalia School District RJ-3 is one Pre-K through 12th grade school. Height and weight data has been collected on some students in grades K-5 on an annual basis since the 2011-2012 school year. Height and weight screening and BMI calculation is done during PE class by the PE teacher. Not all classes are included due to time restrictions and class size.

The BMIs are calculated using Tri-fit Software, which allows a printed graph for each child showing healthy versus unhealthy BMI range. During PE class, general discussion and learning takes place about BMI, what it is and the possible consequences weight has on long-term health. According to Chamberlain, “We had great discussions and I could tell kids were thinking even about their parents’ health!” They also spend class time discussing health, nutrition and the importance of being physically active.

Student-specific BMI data is kept confidential and reported only to the parent during the parent-teacher conferences and to the student during a one-on-one meeting with the PE Teacher. Together, they create a “staying healthy” goal (strategies to lose, maintain or gain weight as appropriate).

Permission slips are sent home to parents explaining that the information remains confidential and is shown only to parents. If parents do not want their child to participate, they have the option to opt out. However, in the first two years, Idalia has seen full participation.

Idalia has created an environment where it is comfortable and acceptable to talk about BMI, weight and obesity issues. They have done

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extensive work to create awareness and educate parents on the issues related to lack of physical activity and good nutrition. This includes a parent handbook that is given to every family at the beginning of the school year with information on the wellness initiative, the wellness team, nutrition, culturally relevant and healthy recipes, ideas for family physical activity (including family game nights in the school’s gymnasium) and a place for parents to store and track their child’s BMI and “staying healthy” goal. This effort has opened the door to parents who are concerned about their children and allows for conversations regarding diet, exercise, and creating a healthy lifestyle.

Idalia has yet to use the data for any school-related decisions, but in the future hopes it can help guide the district’s food service menus and vending machine choices, as well as inform and support stronger recess and physical education requirements. Idalia is also looking at expanding the grade levels for BMI screening. Although starting with elementary grades, Chamberlain believes that the information would be more beneficial for older students as they begin to look at lifelong activity and healthy choices.

Although already working on this effort, Idalia would still be very hesitant to apply for a grant that required BMI collection and would dissent legislation mandating BMI due to time restraints and lack of staff. As Chamberlain explains, “It is hard to advocate for an effort that takes so much time and can't be used for a grade.”

Tri-County Health Department Informant:

Patty Boyd, RD MPH Strategic Partnerships Manager Tri-County Health Department

Tri-County Health Department serves the 1.3 million residents of Adams, Arapahoe and Douglas Counties.

Patty Boyd, Strategic Partnerships Manager at Tri-County Health Department, reported that BMI data

is not routinely collected in schools in these counties. Periodically, certain schools are collecting this data, usually via BMI screenings for individual students. Although Tri-County Health does not systematically receive reports of BMI data from schools, it has received aggregate data from one district and is doing some analysis of that data.

Despite not collecting BMI data, Tri-County Health has made great strides in obesity prevention. Most notably, they were the only Colorado health department to receive a CDC grant in 2010 called Communities Putting Prevention to Work. They received $10.5 million over a two-year period to strategically implement healthy eating and active living initiatives to reduce obesity rates in these three counties20.

Success rates were measured in the numbers and types of policy, systems and environmental changes that made healthy living easier for the residents of their jurisdiction. Success was intentionally not measured by reductions in obesity rates, which will take a much longer time to appear. Therefore, BMI collection was not part of this grant. The project involved 15 school districts and 323 schools in the Tri-County area. Work resulted in creating or improving School Wellness Policies, increasing access to healthy food and/or limited access to unhealthy food, increasing non-food or healthy food-related parties or rewards in the classroom, and increasing weekly physical activity through Flat 14er Initiative.

RMC Health and the Colorado Legacy Foundation have also been generous in their grant money awarded to Adams County School Districts 14 and 50. These districts needed assistance in implementing wellness initiatives, and using the grant money, they both adopted a Coordinated School Health approach that has made an impact on three-quarters of their students21.

20 “Tri-County Health Department CPPW Final Report,” tchd.org. accessed on Oct 20 2013, http://www.tchd. org/pdfs/cppw_colorado_final_report.pdf 21 “Colorado School Districts Adams 14 and 50 Support Healthy School Initiatives with Assistance from RMC Health,” rmc.org. accessed on Oct 20 2013, http://www.rmc.org/wp-content/uploads/ 2012/03/Case_Study_RMCHealth-Adams2012.pdf