Reduce Overweight and Obesity in North Dakota Children – 2019 Annual Report Narrative (October 1, 2018 – September 30, 2019):

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 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 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 2017-2018 National Survey of Children’s Health, 34.7% 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 27.7%. North Dakota children ages 12-17 were physically active 24.6% at least 60 minutes a day 4-7 days a week, while the national average is 23%.

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). 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 (134/200). The 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 are working 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 continue through September 2021. To evaluate the effectiveness of the strategies being implemented by the MCH grantees, the North Dakota Department of Health (NDDoH) contracted with staff from NDSU, Master of Public Health Program. They have conducted site visits to each grantee; reviewed grantee work plans, progress reports and developed a dashboard to track the grantees progress. For additional information on all grantees work, please refer to Section III. A.3., MCH Success Story and Section V., Supporting Documents.

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 2018 Child Care Profile-Child Care Aware of North Dakota, 70.4% 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. Local WIC staff conduct nutrition risk assessments (including collecting body mass index information), provide personalized nutrition education, 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. In 2019, data from LegeNDS (North Dakota WIC MIS) indicates that 12.4% of children were assigned the at risk of overweight or overweight children risk code and 8.9% were assigned the obese children risk code at certification. In North Dakota, childhood overweight/obesity is of concern among American Indian children who historically are more likely be obese then 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, as 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.

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 – 2019 Annual Report Narrative (October 1, 2018 – September 30, 2019):

The burden of oral disease is not uniformly distributed throughout North Dakota, as 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 cavities. 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 third grade 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, Seal!ND continued to increase access to preventive dental care to underserved populations. The program continued to employ two public health hygienists 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 Valley Community Health Center, Family Healthcare Center, Northland Community Health Center, the Ronald McDonald Care Mobile and Bridging the Dental Gap (safety net clinics) and eleven private practice dentists has enabled the OHP to expand preventive oral health services, showing the program exceeded their expectations of the original three to five private practice dentists to implement the school-based dental sealant program. 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, 2018 through September 30, 2019. 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. Also, Otto Bremer and Delta Dental grants were received to maintain and expand the Seal!ND program for the upcoming year.

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 2018-2019 school year, the OHP public health hygienists provided services in 30 schools, while private practice dentists and Federally Qualified Health Centers (FQHC’s) provided services to 18 schools. These 48 schools all met the criteria of 45% or greater of free and reduced fee lunch program. In these schools, 1,999 children received dental screenings, and of these, 956 students received a dental sealant. Additionally, 476 students were referred for urgent and restorative care. Accurate data collection has been a barrier due to inconsistent reporting from some private practices and FQHC’s, but this is being addressed with ongoing quality improvement.

In late 2016, the North Dakota Oral Health Coalition (NDOHC) was integrated into the 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 promote the Smiles for Life curriculum for interested stakeholders such as in medical schools and in physician assistant, nurse practitioner and nursing programs. A public health hygienist (PHH) provided one in-person training to the Health Facilities Surveyors team who survey the long-term care facilities, and 3 Lunch and Learns to the University of North Dakota medical residents utilizing the Smiles for Life curriculum.

North Dakota has strong community water fluoridation programs; 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 Health’s Community Water Fluoridation (CWF) program to sustain the community water fluoridation efforts and promote fluoridation as new water systems development. Continued trainings were provided quarterly for local water operator’s and systems were accessed for replacement equipment by the CWF program.