Reduce Overweight and Obesity in North Dakota Children – 2020 Annual Report Narrative (October 1, 2019 – September 30, 2020):

According to the 2019 Youth Risk Behavior Survey (YRBS), 30.5% of North Dakota students in grades 9 through 12 had a body mass index (BMI) of 85% or greater (overweight and obese). This number has increased over time: 23.4% in 2007, 24.4% in 2009, 25.5% in 2011, 28.6% in 2013, 28.7% in 2015 and 31.3% in 2017.

The YRBS also indicated in 2019 that 25.2% of North Dakota students in grades 9 through 12 were physically active for a total of at least 60 minutes per day the past seven days. Although, this does represent a 0.9% decrease from 2017 of 26.1%, it remains to represent an increase from the 2007 level of 21.8%. The amount of time students are required to spend in a physical education (PE) course varies. In North Dakota, elementary grades one through six must offer a minimum of 90 minutes of PE each week. Students in grades 9 through 12 must have at least one credit of PE, of which half can be health education.

According to the 2018-2019 (two-years combined) National Survey of Children’s Health, 28.4% of North Dakota children ages 6-11 were physically active at least 60 minutes a day 4-7 days a week. The national average is 28.0%. North Dakota children ages 12-17 were physically active 31.3% at least 60 minutes a day 4-7 days a week, while the national average is 27.3%.

A balanced diet and regular physical activity benefit the health of children and adults. Poor diet and physical inactivity contribute to many serious and costly health conditions, including obesity, heart disease, diabetes, some types of cancer, unhealthy cholesterol and high blood pressure. Title V recognizes that a multi-pronged approach is needed to make a meaningful change.

One approach taken to reduce overweight and obesity in children is through the work of three Maternal and Child Health (MCH) grantees (Fargo Cass Public Health, North Dakota State University (NDSU) Extension Services and the South East Education Cooperative). Each community has been awarded funding since April 2016, when a new North Dakota Maternal and Child Health (MCH) competitive grant process was established. Communities will continue to receive funding to reduce overweight and obesity in children until September 30, 2021. Each year grantees determine their community needs, complete an action plan with objectives and activities linked to evidence-based, evidence-informed and/or promising practices. During the 2019-2020 program year each grantee had the following successes:

• Fargo Cass Public Health –Worked with the Fargo Civic Center for a Gymnastics meet on January 18-19, 2020 to implement their Fast Fuel and Healthy Concessions strategies (https://fargond.gov/city-government/departments/fargo-cass-public-health/nutrition-fitness/fast-fuel). Many healthy options were added to the menu including fruit and grilled sandwiches with whole wheat buns. A mini-fridge, fruit shoot, and bowls were also purchased. The event went over very well and the manager shared that training staff on selling the product could have potentially increased sales.
• NDSU Extension – Offered training and coaching sessions for Family and Community Wellness Extension Agents to promote and increase the capacity of Policy, System and Environment work. NDSU Extension wrote and was awarded a 2019-20 Walmart Foundation 4-H Healthy Habits. The National 4-H Council has secured a national partnership with the U.S. Soccer Foundation to help broaden our reach to underserved audiences, drive family engagement, and enhance our program options. Add-on grants of $7,500 are available to 10 land-grant universities (LGUs) to build the capacity and give the resources needed to launch a local soccer program using the Soccer for Success curriculum and implementation information. Funds can be used to train volunteers, purchase equipment and materials, and any required attend trainings with the intent to create consistent programming across the country. NDSU Extension has partnered with Magic City Soccer F.C. in Bismarck, North Dakota to implement the grant objectives.
• South East Education Cooperative – Grew partnerships and identified agencies who could provide resources for school’s needs. One example was partnering with NDSU Extension to provide nutrition training, which was a need.
• In addition, the MCH Nutritionist and the School Health Specialist continued to work in coordination with grantees by providing technical assistance through quarterly calls. Staff from North Dakota State University (NDSU), Master of Public Health Program, assisted with evaluation during the 2019-2020 program year. To access Success Stories and additional information on all grantees work, please refer to MCH Success Stories | Department of Health (nd.gov).

The Evidence-Based or Informed Strategy Measure (ESM) for reducing overweight and obesity in children is defined as the numbers of schools MCH grantees worked in to reduce overweight and obesity in North Dakota children. Monitoring this ESM provided a basis for monitoring the reach of program efforts. From October 2019 through September 2020, the three grantees reached 113 out of 200 individual school buildings within their service areas. The grantees have continued this work in the 113 schools and added 21 additional schools in their service area (134/200). The NDDoH continued to encourage the grantees to engage already existing stakeholders to continue the use the Wellness Policy template that was vetted by NDDoH, North Dakota Department of Public Instruction (NDDPI) and the North Dakota School Board Association (NDSBA), when they are working with schools on updating their wellness policies. The NDDoH continued to provide technical assistance to all three grantees and stakeholders to increase the number of participants in the MCH overweight and obesity work in their communites. By doing this, the NDDoH was able to provide the already developed resources to other communities around the state (Fast Fuel and Healthy Concessions Strategies, Child Care Physical Activity Ordinance Trainings (Growing Futures Training) and Family Table resources).

Establishing healthy behaviors at an early age has been supported by research in the New England Journal of Medicine noting “excess weight gained before age five increased the chances of obesity at age 12 by four times the rate as compared to normal weight children.” According to the 2020 Child Care Profile-Child Care Aware of North Dakota, 71.2% of children ages 0 to 5 had both parents in the labor force. With the large percentage of children in North Dakota spending time in care outside of their home, the early care and education setting is one of the best places to reach young children with obesity prevention efforts

Title V staff partner with the Women, Infants and Children (WIC) Program and their work to reduce obesity and increase physical activity. WIC is an important partner in addressing healthy weight among the MCH population. In their day-to-day interactions with families, WIC staff help address obesity by: providing personalized nutrition education, after a thorough nutrition assessment, and referrals to appropriate health care providers for additional services as needed; promoting nutrition and physical activity messages that support a healthy weight such as family meals and the division of responsibility in feeding, choosing low fat dairy products, increasing intakes of whole grains, fruits, and vegetables, appropriate beverage consumption, increasing physical activity, breastfeeding promotion and support, etc.; collecting Body Mass Index and providing education or counseling as appropriate; and encouraging the full use of the WIC food package and providing nutrition education on WIC food selection and preparation. In 2020, data from eWIC LegeNDS (North Dakota WIC MIS) indicates that 11.4% of children were assigned the at risk of overweight or overweight children risk code and 9.2% were assigned the obese children risk code at certification. While there appears to be slight decrease in at risk of overweight/overweight from the prior year (12.4%), WIC staff were not always able to obtain timely and current height and weight measurements due to Covid-19 restrictions. Therefore, the data may not accurately reflect the changes. In North Dakota, childhood overweight/obesity is of concern among American Indian children who historically are more likely be obese than non-Native child participants.

Title V staff also followed and supported a number of promising initiatives within local communities that impacted childhood obesity such as the Child Care Physical Activity ordinance in Cass County (being implemented by MCH grantee Fargo Cass Public Health) and Go!Bismarck-Mandan (MCH grantee NDSU Extension is an active member of this committee). While these are not statewide initiatives, these models can be replicated in other communities/counties.

When it comes to obesity prevention, breastfeeding has been proven to help reduce obesity. Breastfeeding promotion and support are also an integral component work of the MCH Nutritionist. Information regarding breastfeeding strategies and activities are discussed in the Perinatal/Infant Health domain, breastfeeding priority.

Challenges remained in schools. North Dakota is a local controlled state, which means each district can ultimately determine what they will and won’t do when coming to policy. COVID-19 put up many barriers for all of the grantees and their stakeholders. COVID-19 limited access to schools, child care facilities, children, teachers and administrators to implement the programs provided by the grantees. Because this is still a very important issue and more progress can be achieved, this will remain as a priority for the next five-years going forward.

Critical Partners:

• North Dakota Department of Public Instruction
• NDSU University Extension
• Fargo Cass Public Health
• South East Education Cooperative
• NDSU, Master of Public Health Program
• North Dakota School Board Association
• Regional Education Associations
• Dakota Medical Foundation
• Child Care Aware of North Dakota

Increase Preventive Dental Services to Children – 2020 Annual Report Narrative (October 1, 2019 – September 30, 2020):

The burden of oral disease is not uniformly distributed throughout North Dakota, access to oral health services is an ongoing concern and challenge. Vulnerable and underserved populations face a variety of barriers to oral health care, including transportation issues, lack of insurance or ability to pay for care, inability to take time off work to go to the dentist or transport their children, limited availability of providers accepting Medicaid and lack of understanding of the importance of good oral health and its impact on overall health. The limited oral public health infrastructure, particularly in rural counties and lower economically impacted state regions, has provided limited options for families in need. The existing oral health safety-net facilities are overburdened and cannot take on more patients without expanding their infrastructure.

Disparities in oral health exist among specific population and age groups in North Dakota. A significantly higher proportion of minority children have decay, experience untreated tooth decay, and have urgent dental needs. According to the 2017-2018 Oral Health Basic Screening Survey (BSS), one in five (23%) third-grade students ages 8-11 assessed has untreated caries. American Indian (AI) children in third grade experienced more dental caries (tooth decay) than white children (93% vs. 63%); had more untreated dental decay (43% vs. 17%); and had lower rates of sealants than white children (46% vs. 50%). Third-grade children at schools with more than 50% of students eligible for the National School Lunch Program (NSLP) had higher rates of tooth decay (81%) compared to schools with less than 25% of children enrolled in NSLP (64%). These children also had higher rates of untreated decay (31% compared to 16%). 

According to the 2018-2019 kindergarten BSS, approximately 70% of children screened had some tooth decay experience. Of those, 49% had untreated decay and approximately 23% had rampant tooth decay. American Indian kindergarteners were especially vulnerable with 93% reporting some tooth decay and 65% reporting untreated decay.

North Dakota adolescents are also at risk for dental caries. According to the 2019 Youth Risk Behavior Survey (YRBS), only 67% of high schoolers reported brushing their teeth seven days a week and approximately 1.3 of middle schoolers and 1.8% of high school students reported not having had a dental visit within the previous 12 months.

The State Oral Health Program (OHP) has conducted an Oral Health Basic Screening Survey (BSS) every other year. The BSS is a non-invasive, open-mouth survey developed by the Association of State and Territorial Dental Directors (ASTDD) to assess and monitor the oral health status of key populations such as third graders, kindergarteners, Head Start and/or older adults. A BSS was conducted in the 2017-2018 school year on third graders per ASTDD guidance and due to the need for more trend data among third grade students. A kindergarten BSS was also conducted in the 2018-2019 school year.

Established in 2008, SEALl!ND continued to increase access to preventive dental care to underserved populations. The program continued to employ one public health hygienist that provided services in schools. Services offered with this program included: oral health screenings, oral health education, dental sealants, fluoride varnish and referral to a dental home if needed. Fluoride varnish and sealants are best practice strategies in reducing dental decay in children. The collaboration and partnership with Spectra Health, Family Healthcare Center, Northland Community Health Center, Spirit Lake Health Center, the Ronald McDonald Care Mobile and Bridging the Dental Gap (Federally Qualified Health Centers (FQHC)/safety net clinics) and six private practice dentists has enabled the OHP to expand preventive oral health services. Additional partnerships are anticipated to expand the program.

Funding for SEAL!ND program was provided through the Health Resources and Services Administration (HRSA) Oral Health Workforce Grant and the Centers for Disease Control and Prevention Oral Health Grant (CDC) from October 1, 2019 through September 30, 2020. These grants focused on building and strengthening connections for medical/dental collaborations to occur and enhanced the oral public health infrastructure and capacity for placement of a public health hygienist into a medical facility to provide oral health screenings, fluoride varnish, education, referrals and care coordination to the low-income and uninsured population.

The Evidence-Based or Informed Strategy Measure (ESM) for increasing preventive dental services to children has been defined as the number of children that received dental sealants per school year. In the 2019-2020 school year, the OHP public health hygienist, private practice dentists and FQHCs provided services to 80 schools. In these schools, 3,578 students had a dental screen, 3,617 students received fluoride varnish applications, 6,225 new sealants were placed and 849 students were indicated for follow-up care (urgent or early dental care). Accurate data collection has been a barrier due to inconsistent reporting from some private practices and FQHC’s, but this is continually improving with ongoing quality improvement efforts.

In late 2016, the North Dakota Oral Health Coalition (NDOHC) was integrated into the North Dakota Dental Foundation (NDDF). The NDDF assists with helping individuals in North Dakota who do not have access to dental care through education and workforce initiatives. The alignment in priorities and activities between the NDOHC and the NDDF allowed for a smooth transition to better serve North Dakota’s oral healthcare needs. The OHP Director participated in quarterly North Dakota Oral Health Coalition meetings.

In 2011, the North Dakota Department of Health (NDDoH) and the NDOHC developed the Burden of Oral Disease and the Oral Health State Plan for the Future years 2012-2017. This publication is comprised of two reports addressing oral health in North Dakota, Burden of Oral Disease and the State Plan for the Future. The Burden of Oral Disease reports provides a comprehensive overview of demographic, socioeconomic and health status inequalities through the state. The State Plan for the Future outline’s key actions and quality improvement strategies to prevent oral health disparities and provide access to dental care, thereby preventing and reducing oral diseases and improving the overall health of North Dakota citizens. This document was not updated due to insufficient time, and changes in personnel. The OHP continued to collaborate with the Office of The State Epidemiologist to update and revise the Burden of Oral Disease document. 

The OHP continued to build connections and strengthen opportunities for medical/dental collaborations to occur (e.g., placed a dental hygienist in a medical practice and supported blood pressure measurement in dental offices). The OHP partnered with 5 new dental offices, dental providers conducted 14,266 blood pressure screenings on individuals 18 and older. There were 1,369 individuals identified with high blood pressure, 332 individuals were referred to a primary care provider and 151 individuals completed follow-up. 

The OHP promoted the Smiles for Life curriculum for interested stakeholders in medical schools and physician assistant, nurse practitioner and nursing programs. There were 261 courses taken on-line by various professionals with 114 individuals completing the entire series. A public health hygienist (PHH) provided two Lunch and Learns to the University of North Dakota medical residents utilizing the Smiles for Life curriculum. Additionally, the PHH provided 298 patients with a dental screening, 152 patients with fluoride varnish applications and 107 patients were indicated for follow-up care (urgent or early dental care).

North Dakota has a strong community water fluoridation program; 96% of North Dakota’s population receives optimally fluoridated water through community water systems, which are monitored on a monthly basis utilizing the Water Fluoridation Reporting System. The OHP has continued to work collaboratively with the North Dakota Department of Environmental Quality’s Community Water Fluoridation (CWF) program to sustain the community water fluoridation efforts and promote fluoridation as new water systems were developed. Continued trainings were provided quarterly for local water operator’s and systems were accessed for replacement equipment by the CWF program.

The OHP PHH, private practice dentists and FQHCs provided services to 80 schools despite being in a pandemic. Increasing partnerships with private dental offices and schools across the state helped with increasing the number of schools served during the period of October 1, 2019-September 30, 2020. Continued collaboration and partnerships will continue and grow over the upcoming years with both dental and medical professionals across North Dakota. All mentioned activities will continue above.