Section III.E.2.c State Action Plan Narrative by Domain

MCH Population Domain: Child Health

National Performance Priority Area: Physical Activity and Nutrition (Overall Obesity Prevention)– 2021 Annual Plan Narrative (October 1, 2020– September 30, 2021):

A balanced diet and regular physical activity benefit the health and quality of life of all ages. Obesity in children in the United States is on the rise. North Dakota recognizes a poor diet and physical inactivity contribute to many serious and costly health conditions at a younger age and increases the risk into adulthood that include: overweight and obesity, cardiovascular disease, hypertension, Type II diabetes, some types of cancer, and osteoporosis. The North Dakota Department of Health (NDDoH) Title V program recognizes by continuing to promote and increase the capacity for policy, system and environmental changes this will provide the essential building blocks to fight childhood obesity in North Dakota.

According to the 2019 Youth Risk Behavior Survey (YRBS), 14% of North Dakota grades 9 through 12, who are obese (BMI at or above the 95th percentile). This number has increased over time: 11% in 2009, 11.1% in 2011, 13.5% in 2013,13.9% in 2015 and a slight decrease in 2019 from 14.9% in 2017. Reported by the National Survey for Children’s Health (NSCH), 2017-2018 (combination of two years) 13.4% of children ages 10-17 are obese (BMI at or above the 95th percentile), while the national average is 15.3%.

The YRBS also indicates in 2019 only 25.2% of North Dakota students in grades 9 through 12 were physically active for a total of at least 60 minutes/day on all seven days, while grades 6-8 are physically active 33.1% on all seven days. The amount of time students are required to spend in a physical education (PE) course varies. In North Dakota, elementary grades one through five 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.

The NSCH, 2017-2018 (combination of two years) indicate 34.2% of North Dakota children ages 6-11 are physically active at least 60 minutes a day seven days a week, while the national average is 27.7%. North Dakota children ages 12-17 are physically active 18% 60 minutes a day seven days a week, while the national average is 17.5%.

The YRBS and NSCH both indicate that as North Dakota children get older and standards for physical education requirements decrease, the percentage of inactivity in grades 9-12 significantly increase and also the prevalence of obesity rises. 

The NDDoH took a new approach for the development of the 2020-2025 MCH work plans. The Child Health domain convened a stakeholder group from multi-sector agencies (state, local, university and other entities) that share the same objective (increase physical activity and improve nutrition in North Dakota children). The stakeholder group (23 participants) met twice. During these meetings the goal was to give an overview of what MCH is, the purpose and objectives of the grant. Also, explanation was given to how and why the NDDoH Title V leadership team identified reducing overweight/obesity as a priority in the Child Health Domain. The idea of convening a diverse group of our colleagues was to learn about their successes, barriers and ways that the NDDoH can collaborate to increase physical activity and improve nutrition in North Dakota children. There was targeted discussion around what has happened in the past, what is happening now and what needs to happen in the future to combat this public health crisis in North Dakota children. After the meeting adjourned the MCH School Health Specialist (MCHSHS) and MCH Nutritionist (MCHN) identified three emerging issues from the stakeholder meetings:  ways to build systems in schools, provide technical assistance to Early Care and Education (ECE) implementation of physical activity and nutrition trainings and to establish a state level workgroup consisting of the NDDoH, the North Dakota Department of Public Instruction (NDDOPI) and the North Dakota Department of Human Services (NDDHS). This workgroup will begin discussions on how to create and promote consistent wellness messaging statewide.

In year 2020-2021, the NDDoH will continue partnership with three current MCH grantees (Fargo Cass Public Health (FCPH), North Dakota State University Extension Services (NDSU Extension) and South East Education Cooperative (SEEC)). SEEC will continue their work to provide a variety of wellness professional development opportunities to teachers, administrators, paraprofessional, school nurses and food service professionals. These trainings are to increase the level of expertise in the professionals that work with students daily in multiple capacities (before, during and after school time). FCPH will continue work in ECE to provide online and in-person trainings to licensed childcare providers. Anticipated expansion of the Child Care Physical Activity Ordinance that is in place in Fargo, West Fargo and 3 surrounding rural communities. https://download.fargond.gov/1/child_care_ordinance.pdf. This ordinance is a part of the AMCHP Toolkit for NPM8. http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/Documents/NPM8_North%20Dakota.pdf. 

NDSU Extension Services will continue to provide standardized health curriculum to grades K-5 delivered by field agents into four western North Dakota counties, along with multiple trainings for after school staff and summer camp counselors on the importance of teaching children tools that they can utilize to make healthy choices in their lives. Go! BismarckMandan https://www.gobismarckmandan.org/ (MCH grantee NDSU Extension Services is an active member of this committee). Grantee serves on the executive committee for Go!

The Evidence-Based or Informed Strategy Measure (ESM) for reducing overweight and obesity in children is defined as the number of schools the MCH grantees will work with to reduce overweight and obesity in North Dakota children. The NDDoH MCHSHS and MCHN will monitor this ESM to provide a basis of the reach of each programs efforts. From April 2016 through July 2020, the three grantees were able to reach 134 out of 200 individual school buildings within their service areas. The MCHSHS and MCHN will continue to work in coordination with the grantees by providing technical assistance to assure consistent communication among grantees and to provide guidance to complete their 2020-2021 program work plan. The three MCH grantees will submit a quarterly progress report to the NDDoH. The NDDoH will hold quarterly calls with the grantees to share success and barriers with the NDDoH staff and other grantees. Through the quarterly progress report the NDDoH assess the grantees' workplan.  If the NDDoH identifies concerns that the grantee is not accomplishing an objective, the NDDoH makes direct contact with the grantee. The NDDoH will provide TA to overcome the barriers that are limiting the success to meet objectives.

As the NDDoH closes the year with the MCH overweight/obesity grantees, we will begin work to shape the vision in years 2021-2025. MCH staff time in 2020-2021 will start to partner with the Blue Zone project (lead by the Health Promotions Division Director, NDDoH) to find ways that the MCH physical activity and nutrition objectives may align with the work that will be done in selected North Dakota cites that are identified as “Blue Zone” communities. These projects may include the promotion of development and use of infrastructure that facilitates physical activity and access to healthy foods. The vision also includes a state level workgroup made up of (NDDoH, NDDPI, NDDHS) to identify opportunities to advance changes at the community, environmental or system-level to create state-wide consistent messaging to promote physical activity in children. The NDDoH will identify individuals within the NDDPI and NDDHS who should be involved in the workgroup, convene meetings at least quarterly with partners and the MCH staff will create and send out a pre-survey to outline the objectives of the group and a post-survey to measure the effectiveness of the work group’s objectives by September 30, 2021.

In addition to creating a vision for physical activity in the 2020-2021 program year, the NDDoH was selected for an opportunity to develop a state model in MCH for nutrition integration. The Association of State Public Health Nutritionists (ASPHN), a nonprofit who provides states and national leadership on food and nutrition policy, programs and services, applied to a Notice of Funding Opportunity released by the Maternal and Child Health Bureau to develop three state models in MCH nutrition integration, focused on workforce capacity and data and evidence capacity. The NDDoH MCH Nutritionist is a member of ASPHN and was one of three states, selected to participate in the project, which would take place over the next five-years, September 2020-September 2025. This was a competitive opportunity with tentative notice of award in August 2020. If ASPHN is selected, the first year, October 1, 2020 – September 30, 2021, would be dedicated to developing state and local partnerships to assist with developing a five-year strategic direction and to provide opportunities for workforce development and training on nutrition in MCH. As a first starting point, the MCH has planned a kickoff meeting with a North Dakota Public Health Nutritionist group in July – August 2020.   

When it comes to obesity prevention, breastfeeding has been proven to help reduce obesity. Breastfeeding promotion and support is also an integral component to work of the state MCH Nutritionist.

Title V staff partner with the Women, Infants and Children (WIC) Program and their work to reduce obesity and increase physical activity. Over the past 40 years, WIC has improved at-risk children’s health, growth and development and prevented health problems. Since WIC reaches so many infants and children, it has a key role to play in helping children maintain a healthy weight. North Dakota WIC promotes breastfeeding as the normal way to feed infants and young children because it reduces the likelihood of childhood obesity; offers breastfeeding classes, support groups, peer counselors, and breast pump supplies to WIC moms to support them in their decision to breastfeed; and provides nutritious foods to participants such as fresh fruits and vegetables and whole grains. To reduce the amount of fat in the WIC food package, only fat-free or 1 percent milk is allowed along with less amounts of cheese. All WIC juices are 100 percent juice and provide the appropriate amount of juice to be consumed each day. WIC cereals are low in sugar and provide a good source of iron, and many are high in whole grains. WIC also offers participant-centered nutrition education on proper nutrition across the life cycle; healthy meal planning and family meals; and ways to be physically active as a family. Healthy eating habits are important for even our youngest participants. Parents are taught how to understand their baby’s behavior and feeding cues and the proper guidelines for feeding infants (how often to feed, when to introduce complimentary foods, etc.). WIC collects height and weight measurements (including body mass index or BMI) frequently on participating children and provides counseling and referrals to their healthcare providers as appropriate.

Title V has will continue to work with new and existing critical partners including but not limited to:

• North Dakota Department of Public Instruction- The NDDoH and the NDDPI collaborate in sharing resources on physical activity and nutrition. The NDDPI sends out quarterly newsletters to schools on safe and healthy related topics and wellness professional development opportunities happening in the state. The NDDoH supports this newsletter by providing any resources that are made available to the department. Partnership in the development of a state level work group to build consistent wellness messaging.

• North Dakota Department of Human Services- Partnership in the development of a state level work group to build consistent wellness messaging.

• North Dakota State University Extension Services- MCH overweight and obesity grantee. The NDDoH will continue to provide technical assistance to NDSU Extension Service provide physical activity and nutrition “On the Move” curriculum (grade K-5) to four western North Dakota counties.

• Fargo-Cass Public Health-MCH overweight and obesity grantee. The NDDoH will continue to provide technical assistance to FCPH to provide online and in person trainings to Childcare Providers. Along, with the promotion of the “Fast Fuel” toolkit for school/communities to use and implemented healthy concession stand options

• South East Education Cooperative-MCH overweight and obesity grantee. The NDDoH will continue to provide technical assistance to SEEC to organize and implement a variety of wellness professional development opportunities for educators, administrators, school nurses, social workers, food service professionals and school staff.

• Regional Education Associations (REA)- the NDDoH will continue partner and collaborate on health-related activities that are happening in each of the seven REA’s.

• Indian Affairs Commissions Office (IAC)-collaborate and create consistent communication between the NDDoH and IAC to share wellness resources to tribal communities.

• Child Care Aware (CCA)-Child Care Aware is a training and information hub for child care providers and offers parents customized referrals to licensed child care options. CCA works to build the capacity of child care in North Dakota and insure that children have the opportunity to play and learn in a safe and healthy environment. The NDDoH will seek out partnership with the CCA Child Care Wellness Coordinator to begin conversations about the needs in North Dakota Early Childhood and Education.