National Performance Priority Area: Physical Activity and Nutrition (Overall Obesity Prevention) (October 1, 2020 – September 30, 2021):
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 mainly 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 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 physical education (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 2019-2020 National Survey of Children’s Health, 27% of North Dakota children ages 6-11 were physically active at least 60 minutes a day, 4-7 days a week. 40% of North Dakota children 6-11 were physically active at least 60 minutes 7 days a week, while the national average was 26% were active 7 days a week. North Dakota children ages 12-17 were physically active 35% at least 60 minutes a day 4-7 days a week, while the national average was 26%. 26% of North Dakota children ages 12-17 were physically active at least 60 minutes 7 days a week, while nationally, 15% were active 7 days a week.
Additional explanation regarding trends in North Dakota data may be found in Section V. Supporting Documents, Supporting Document 2 - FFY 2021 Midterm Report Card.
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 was 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). 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 2017 through September 2018, 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 (2018-2019-134/200). The work continued in 134 and added 8 additional schools (2019-2020-142/200). In 2020-2021 as priorities changed due to the COVID-19 pandemic the grantees were able to continue work with the 142 schools and added five new schools (2020-2021-147/200). The North Dakota Department of Health (NDDoH) continued to encourage the grantees to 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) in June of 2018, when they worked with schools on updating their wellness policies.
The Title V Director, MCH Nutritionist and the School Health Specialist continued to work in coordination with these grantees by providing technical assistance through quarterly calls and assuring consistent communication among grantees through the development of a communication plan for grantees. Funding for these grantees started in April 2016 and will continued through September 2021. To evaluate the effectiveness of the strategies being implemented by the MCH grantees, the NDDoH contracted with staff from NDSU, Master of Public Health Program. They have conducted site visits to each grantee; reviewed grantee work plans and progress reports, and developed a dashboard to track the grantees’ progress. A North Dakota MCH 2016-2020 five-year evaluation summary report was also completed.
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 age12 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, which is a slight increase from 2019 (70.7%). 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 has partnered 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. Local WIC staff conduct nutrition risk assessments (including collecting body mass index information), provide personalized nutrition education to families, promote and support breastfeeding, provide tailored food packages that include fresh fruits and vegetables, whole grains, and low-fat dairy products, and make referrals to other community and health services. As of September 2021, data from eWIC LegeNDS (North Dakota WIC MIS) indicates that 11% of children were assigned the “at risk of overweight” or “overweight child” risk code and 10% were assigned the “obese child” risk code at certification.
Additional explanation regarding trends in North Dakota data may be found in Section V. Supporting Documents, Supporting Document 2 - FFY 2021 Midterm Report Card.
In North Dakota, childhood overweight/obesity is of concern among American Indian (AI) children who historically are more likely be obese then non-AI child participants. There were four mini grants allocated to tribal communities to implement overweight/obesity prevention activities. COVID-19 prevented three of the four communities to move forward with their planned activities.
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, (https://fargond.gov/city-government/departments/fargo-cass-public-health/nutrition-fitness/child-care-physical-activity-health-code).
“Fast Fuel” (healthy concession options being implemented by MCH grantee FCPH) https://fargond.gov/city-government/departments/fargo-cass-public-health/nutrition-fitness/fast-fuel and Go!Bismarck-Mandan (MCH grantee NDSU Extension is an active member of this committee). Multiple health related professional development opportunities were offered to teachers, administrator, school food professionals, and other school faculty (being implemented by MCH grantee SEEC). 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 is also an integral work component of the MCH Nutritionist. Information regarding breastfeeding strategies and activities are discussed in the Perinatal/Infant Health domain, breastfeeding priority.
In addition to physical activity strategies for children, the NDDoH was selected for an opportunity to develop a state model in MCH for nutrition integration which will take place through September 30, 2025. The Association of State Public Health Nutritionists (ASPHN), a nonprofit that provides state and national leadership on food and nutrition policy, programs, and services, has been leading the efforts. Further information can be found on their website: https://asphn.org/chw-state-capacity-building-program/. During the 2020 – 2021 program year North Dakota's project focused on food and nutrition security and ways to integrate into MCH programs by building workforce, data, and evidence capacity. North Dakota was one of three states selected to participate. During this first program year (2020 – 2021) a kickoff meeting was hosted to introduce all state teams and the project officers. After the kickoff meeting, monthly meetings were held with the project manager to discuss progress, along with quarterly progress reports. Successes from the project included: establishing baseline nutrition-relevant data sources; adding nutrition related questions to the Pregnancy Risk Assessment Monitoring System, beginning with the May 2022 survey; and developing relationships through the North Dakota Public Health Nutritionists group, which brings together local and state level nutritionists. Meetings were held on January 11, 2020; May 26, 2021, and August 16, 2021.
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. The end of the Diabetes, Heart Disease, Obesity and School Health (DHDOSH-1305) funding and not receiving any further money to enhance school health made it much more challenging to the improvement of a healthy school environment. The COVID-19 pandemic also caused many challenges to the overweight/obesity prevention strategies. The grantees and NDDoH staff shifted priorities to provide response efforts to North Dakota citizens. In August 2019 the NDDoH School Health Specialist was realigned at the department to lead the COVID-19 School Response team. The COVID-19 School Response team consisted of 17 NDDoH employees. The team’s responsibility was to work with schools when positive cases were identified. The school and the team worked together to identify all close contacts that were in close contact with the positive case. The School Health Specialist met with all of North Dakota’s Local Public Health Units to identify who in their unit would specifically work with the schools. Some of the smaller units were at capacity and were not able to work with the schools in their regions, therefore, those schools became the responsibility of the NDDoH School Response Team. There were close contact letters that were developed by the NDDoH School Response Team and were disseminated to schools. Along with the close contact letters there were many resources developed by the team to help schools keep the doors open. The School Health Specialist was involved in many meetings and different teams to provide guidance as an expert in schools. The School Health Specialist participated on a team (Healthy Return to Learning) that was formed with the North Dakota Superintendent, the North Dakota Department of Human Services, Executive Director, the NDDoH Field Medical Officer, and contracted with three individuals (medical doctor, retired assistant superintendent, and a retired local public health administrator). The team worked tirelessly to develop a handbook that was distributed to school superintendents to provide them with the most up to date guidance to open the doors to their schools. This team also held weekly townhalls with school administrators to answer any questions that surrounded COVID-19 and schools. The School Health Specialist facilitated a weekly meeting with Local Public Health Units and school nurses that provided the most up to date guidance from the CDC and the NDDoH Disease Control Section. This meeting also served as a means to answer any questions they had that were unique to their communities. The School Health Specialist participated on a Local Public Health call weekly and provided any needed updates on emerging COVID-19 school issues. The NDDOH along with the North Dakota National Guard also oversaw contact tracing throughout the state. The realignment of work priorities due to the pandemic essentially took away from MCH job duties for 17 months in this domain, due to heavy involvement and leadership required of the School Health Specialist who also leads this MCH domain.
Critical Partners continued to include but were not limited to:
• 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
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