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Community Assessment of students within Grand Rapids Public High Schools

Ashley Bridges, Nicole Chambers, Lynda Chase, Jim Harrington, Sheila Lucas, Denise Lyon, Rebekkah McConnell, Dana Sartorius

Ferris State University

Abstract

A growing concern in the country is the poor health and nutrition of the children in the United States, which is leading to multiple health disparities. This article is an analysis of data regarding the health of students in Grand Rapids Public High Schools related to poor nutrition. The authors discuss the related factors associated with excess rates of chronic health problems within this population, compared against the state averages. The article also analyzes the community resources and the roles of the community and the community health nurse in addressing these issues. The ultimate objective is to improve the health of our children in public high school.

Key words: obesity, chronic health problems, community health

Community Assessment of students within Grand Rapids

It is well known that the consequences of a poor diet can lead to many chronic problems. In America poor nutrition has led to an epidemic of increased health disparities in children. It can lead to energy imbalance and can increase one’s risk for being overweight and obesity which may result in an increased risk for cardiovascular disease, diabetes, and stroke. “A poor diet also can increase the risk for lung, esophageal, stomach, colorectal, and prostate cancers” (Centers for Disease Control and Prevention [CDC], 2012, p. 2).

All of us consume some type of comfort food at one time or another. Eating fast food increases the chance for obesity in our youth. Many parents contribute to their children’s weight gain by allowing the consumption of sugar-sweetened beverages like pop and the energy drinks that are ever so popular. We should be encouraging our teens to drink water to fuel their body for a healthy alternative. Many families are a two income households; this pays the bills but causes disruption within the family. Many families have to work opposite shifts so they don’t have the added expense of child care and therefore the evening meal is only attended by one parent and the child. Some families are without funds to purchase food and utilize food banks, WIC or other resources to put food on the table. In turn, under nutrition can negatively affect overall health, cognitive development, and school performance. Diet and academic performance go hand in hand. “Eating a healthy breakfast is associated with improved cognitive function (especially memory) reduced absenteeism and improved mood” (CDC, 2012, p. 9).

The following are eating behaviors of young people:

“Most U.S. youth do not meet the recommendations for eating 2½ cups to 6½ cups* of fruits and vegetables each day. Children do not eat the minimum recommended amounts of whole grains (2–3 ounces* each day) and they eat more than the recommended maximum daily intake of sodium (1,500–2,300 mg* each day). Empty calories from added sugars and solid fats contribute to 40% of daily calories for children and adolescents aged 2–18 years, affecting the overall quality of their diets. Approximately half of these empty calories come from six sources: soda, fruit drinks, dairy desserts, grain desserts, pizza, and whole milk. Adolescents drink more full-calorie soda per day than milk. Males aged 12–19 years drink an average of 22 ounces of full-calorie soda per day, more than twice their intake of fluid milk (10 ounces), and females drink an average of 14 ounces of full-calorie soda and only 6 ounces of fluid milk” (CDC, 2012, p. 8).

According to USA Today (Shaver, 2010), the contents of school vending machines contribute to bad eating habits and poor nutrition. Almost 6,000 students were examined regarding the impact that vending machine food had on them in over 150 schools. Minimal nutrition value, including chips, sodas and sweets were sold in over 82% of the schools. Putting fruits and vegetables in the vending machines proved that students made a healthier choice. “We are supposed to be teaching proper nutrition in the schools, and having a vending machine inside of the school doesn’t make sense. Schools are introducing foods that every nutritional scientist in the world knows are dangerous,” reports Dr. Joel Fuhrman, a nutritional researcher who specializes in preventing and reversing disease (2010).

The following data report will give an indication of what factors contribute the chronic health problems of high school age students. There are numerous ways that we can improve the nutrition of our youth in Kent County. In schools there are usually health education classes offered but many times are poorly attended. According to the Centers for Disease Control and Prevention (CDC), healthy eating is associated with reduced risk for many diseases, including several of the leading causes of death: heart disease, cancer, stroke, and diabetes. “Healthy eating in adolescence is important for proper growth and development and can prevent health problems such as obesity, dental caries, iron deficiency, and osteoporosis” (CDC, 2012, p. 1).

Our diet should consist of fruits and vegetable, whole grain, and low-fat dairy products for anyone older than two years. The US is one of the most obese countries in existence. Unfortunately, most young people are not following the recommendations set forth in the Dietary Guidelines for Americans. Kent County has improved their schools food environment to make a positive effect on their students’ dietary choices while at school.

Our schools attempt to ensure proper nutrition and healthy snacks for our children. Without proper teaching or guidance, beginning at home, teens continue to make poor food choices. Even though the schools have high caloric and high fat containing foods, they do provide education within their curriculum and an opportunity for students to learn and practice good choices.

Kent county schools measure up! They provide The School Breakfast Program which provides at least one fourth of the recommended levels for key nutrients. Average monthly number of total participants in the National School Lunch Program in Michigan in 2009 was 911,527. The percentage of students eligible to participate in the National School Lunch Program under the Free Lunch Program in Kent County is 32.50%. The state is only 30.72%. The percentage of students eligible to participate in the National School Lunch Program under the Reduced-price Lunch Program in Kent County is 6.80% compared with 9.35% in the state (“Food,” 2010).

Although recent state and federal guideline revisions are beginning to positively impact school lunch programs, the diets plans available to children in the older age groups appear to present less healthy options than to the younger group. A portion of the Grand Rapids Public School lunch value spreadsheets was evaluated in September 2012, which indicated a significantly higher ratio of sodium, carbohydrates, and fats per total caloric volume in lunches served to middle and high school students than in the elementary lunch plan. A review of USDA recommended daily allowances indicates that sodium content of lunches offered to middle and high school students in the Grand Rapids Public Schools (Kent County Schools) makes up approximately 77% (avg. sodium 1856 mg /2400mg) of the total recommended daily value. According to a study performed by the American Academy of Pediatrics high levels of dietary sodium are positively associated with increased risk for pre-high blood pressure and high blood pressure among US children and adolescents (Quanhe, 2012). See Appendices A-C.

Existing resources in Kent County for high school students in regards to promoting health are adequate. The best source of information found is a brochure provided by the Kent County Coordinated School Health Program Partners. This brochure is put together by a collaborative group of community partners in the county that work to help local schools implement a school wellness policy. Two of the web sites listed in the brochure supply a lot of information: Michigan Action for Health Kids: and Healthy School Action Tools: schools.

Action for Healthy Kids addresses childhood undernourishment, obesity and prevention by working with schools to help kids learn to eat right and be active every day. Action for Healthy Kids helps school districts and schools, especially those without the resources, facilities and expertise to improve the quality of food in schools, enhance nutrition education, improve physical education, and increase opportunities for kids to be active. They provide programs and services and lead advocacy efforts to ensure that in school, all children learn healthy eating habits and the need for daily physical activity; and all children eat healthy foods and have daily physical activity.

A healthy school environment gives students clear and consistent messages, accurate health information, and ample opportunity to apply it. The Healthy School Action Tools (HSAT) website provides access to online tools to help your school create a healthier school environment.

The Kent Intermediate School District (KISD) provides services to twenty local public districts and to all non-public schools within its boundaries. Directly or indirectly, it serves almost 400 schools, more than 120,000 students and 7,000 educators. One of the 57 intermediate school districts in Michigan has a website that provides a wide range of health, safety, and services to meet the needs of the educators, families, and communities served; Kent County ISD (“Health,” 2012).

One of the direct ways the Grand Rapids Public Schools helps kids get and/or stay active is through the program Fit Kids 360. This program is offered free of cost to children ages 5-16 that are in the 85th% or higher of BMI. They provide basic education about nutrition, behavior and exercise combined with fun activities to get kids and families moving. The downside to this program is that it ends at age 16 and it requires a healthcare provider’s referral to attend – which may deter some families that do not have the adequate resources to see a doctor.

Harness and DeMarco state that “Community health nursing is the use of systematic process to deliver care to individuals, people, families and community groups with a focus on promoting, preserving, protecting and maintaining health” (Harness & DeMarco, 2012, p. 9). The problem of excess rates of chronic health problems in high school age children would be appropriate for community health nursing because it affects a large part of the population and assessing and fixing the problem could help to prevent an increased prevalence of health problems within this population and prevent long term affects. According to the Center for Disease Control and Prevention about 17 % of kid’s ages 2-19 years of age are obese and over the past thirty years this number has almost tripled (Stein, 2012). As community nursing is concerned, this is a big problem that needs to be address to stop the climbing obesity rate and promote a healthy life style for children. As stated earlier, childhood obesity has been linked to increase incidences of cardiovascular disease, stroke, diabetes and cancer.

Diabetes has continued to grow as obesity in adolescents has increased. A 10 year study done by the CDC revealed that in 1999, 9 % of adolescents (12-19 year olds) were considered to have “pre-diabetes” and in 2008 the number had grown to 23 %. In Kent county diabetes and heart disease are among the top twenty leading causes for hospitalizations in children 0-18 years of age and among the top 10 leading causes of death in Kent County (“Hospitalizations,” 2012). Childhood obesity can lead to high cholesterol and high blood pressure which is a risk factor for heart disease and stroke. 25.6 % of deaths in Kent County are attributed to heart disease which makes it the number one cause of death among Kent County residents (“Hospitalizations,” 2012). Heart disease is also the number one cause of death in Michigan residents with 26.5 % of all deaths related to heart disease (“Critical,” 2011).

In addition to heart disease, another long term effect of obesity in adolescents is cancer. Types of cancers include: cervical, prostate, colon, breast, multiple myeloma, gall bladder, thyroid and Hodgkin’s lymphoma among others (CDC, 2012). The exact pathophysiology of how obesity causes to cancer risk is up for debate. Obesity can affect estrogen levels or increase your chance for GERD which can be related to uterine and esophageal cancer respectively. Cancer risk factors affect both treatment options and mortality rates. “The American Cancer Society reports that about 14 to 20 percent of cancer deaths in the U.S. can be attributed to excess weight or obesity problems (Flegal, Carroll, & Ogden, 2011, para 5).

The community health nurse is only one aspect of the solution; there are many other disciplines that should be involved in addressing the insufficient nutrition in the adolescents of the Grand Rapids Public Schools. Parents are the major influence in children’s lives that can positively impact a change toward proper nutrition. They can make sure the kids eat properly at home and can educate on proper food choices when they are away from home. Parents can also provide a good example through their own good food choices. Teachers in school have another major role in ensuring proper nutrition in the adolescents. They can incorporate nutrition education during classes and help to inspire the kids to want to make positive changes. Primary care physicians can also help to monitor the health of the adolescents to ensure that they are having adequate nutrition. During visits, they can educate on proper food choices and encourage the children and parents to maintain good health. The community as a whole can become involved in promoting good nutrition through community based interventions. Local government can also promote healthy nutrition by supporting proposed changes to the community and support interventions in the community. Other possible positive influences could be churches and local media to spread the message of the importance of proper nutrition.

According to the CDC, “The dietary and physical activity behaviors of children and adolescents are influenced by many sectors of society, including families, communities, schools, child care settings, health-care providers, faith-based institutions, government agencies, the media, and the food and beverage industries and entertainment industry. Each of these sectors has an important independent role to play; while improving the dietary and physical activity behaviors of young persons” (CDC, 2011, p. 4).

There are many possible community and personal barriers that are faced when talking about increasing the health and nutritional intake of high school children. Most prevalent may be poverty. Poverty can have negative effects on a person’s ability to seek medical attention or involvement in community wellness groups. Low income also provides for lack of proper funding to provide for different types of learning related to proper nutrition and activity. Many times people that fall below the poverty level have difficulty accessing not only medical care but also, psychological care to provide for their mental care. Along with this is the lack of family and community support in regards to assisting the individual find these resources. All of these barriers; poverty, lack of education, access to proper education, medical and mental health can impact the nutritional choices a person makes.

Additionally there was an interesting study done by Kerri N. Boutelle. According to Boutelle, “The number of meals and snacks eaten away from home is believed to contribute to excess calories consumed by children, and this number has increased dramatically in the past 30 years” (Melina, 2011, p. 3). 30% of youth report consuming fast food. 36 and 51% of daily calories in children come from calories, and 35% of those calories are from fat.

While surveying parents, they were asked to share their receipts from this most recent fast food restaurant purchases. For preschoolers, the most bought foods included French fries, soda, chicken nuggets, cheeseburgers, and hamburgers. A majority of fast food restaurants offer milk, juice, fruit, etc., but according to the survey, parents chose food that contains a high amount of calories and fat.

Boutelle also stated, "Considering the high prevalence of fast-food consumptions by adults as well as kids, it's important to recognize the impact of fast food and its impact on the current obesity epidemic in the U.S. Bottom line, we need to educate families on making health decisions when in a fast-food restaurant," (Melina, 2011, p. 11).

There are many community groups in Kent County that are possible resources to address the inadequate nutrition problem in adolescents in the Grand Rapids Public Schools. The Kent County Health Department has nutrition services. They have a registered dietician that provides individualized nutrition counseling, presentations, educational materials, and grocery store tours. Most of the services are free, but the presentations may require fees. The services are available for individuals and schools, as well as community groups.

Individualized counseling addresses personal needs and goals and is a way to formulate a plan to improve an individual’s nutrition. The presentations cover many topics like preparing healthy snacks, portion control, and eating healthy outside of the home. The educational materials cover information to help promote proper nutrition. Grocery store tours are utilized to help individuals learn how to shop for nutritious food and make healthy choices.

The next community group that could be a helpful resource is the Kent County Coordinated School Health Program. It is a program that works with schools that are interested in improving the health of the students. They visit schools and assess the current health conditions like nutritional intake of the students and identify areas that can be improved. An action plan is formulated based on the school and the program helps to implement it. The program helps the school access community resources that will support the action plan. The program also helps to make changes in the school environment that support the action plan and makes sure they are able to be maintained long term. A downloadable brochure can be found at .

As stated earlier, Action for Healthy Kids is another community resource that could be used to help the problem of nutrition in adolescents of Grand Rapids Public Schools. “Action for Healthy Kids is the nation’s leading non-profit and largest volunteer network fighting childhood obesity and undernourishment by partnering with schools to improve nutrition and physical activity to help our kids learn to eat right, be active every day, and be ready to learn” (“School,” 2012). The coalition is comprised of many different disciplines that work to make positive changes in their communities and schools. Michigan has the largest Action Team in the country.

Childhood obesity continues to be a growing trend in America and in the Grand Rapids area. There have been many factors stated that relate to the problem and the solution. The groups above are just a sample of what could be utilized to help address this problem. There are many more resources available in Kent County to help with the problem of inadequate nutrition in Grand Rapids Public School adolescents.

Appendix A

| Grand Rapids Public Schools | | | |

|Elementary School Lunch Portion Value Spreadsheet | | | |

|Sept 25, 2012 |Portion | |Mg |G |G |

| |Size |Cals |Sodm |Carb |Fat |

|Chicken Drums, Fry & Roll-E1 |1 Each |482 |671 |56 |18.5 |

|PBJ Uncrustable-E12 |1 Each |430 |580 |49 |18 |

|Apple, Fresh |1 EACH |55 |1 |14.64 |0.18 |

|Raisins, Box |Each |113 |4 |29.98 |0.17 |

|Baby Carrots - MP |1 Each |22 |30 |5.63 |0 |

|Side Salad - E12 |1 Each |22 |9 |3.96 |0.43 |

|Fruit Cocktail Cup |1 EACH |65 |7 |16.93 |0.08 |

|Pudding cup,chocolate,swiss |1 Ea |140 |150 |22 |4.5 |

|1% White Milk |Each |110 |125 |13 |2.5 |

|Nonfat Chocolate Milk |Each |130 |230 |23 |0 |

|Lactose-Free 1% Milk |Carton |110 |130 |13 |2.5 |

|Catsup Packet |Each |6 |67 |1.51 |0.02 |

|Dressing, Ranch Cup |1 Each |120 |200 |2 |12 |

|BBQ Sauce Packet |1 Each |15 |85 |4 |0 |

| | | | | | |

(“Grand Rapids,” 2012)

Appendix B

| Grand Rapids Public Schools |  |  |

|Middle and High School Lunch Portion Value Spreadsheet | | |

|Sept 25, 2012 |Portion |  |Mg |G |G |

| |Size |Cals |Sodm |Carb |Fat |

|Enchilada & Tots-S12 |Servings |733 |1893 |97.63 |27.23 |

|Sandwich, Deli #1 - S12 |1 EACH |463 |1796 |37.27 |27.03 |

|Sandwich, Deli #2 - S12 |1 EACH |560 |1735 |38.68 |33.28 |

|Sandwich, Deli #3 - S12 |1 EACH |542 |1933 |37.52 |36 |

|Sandwich, Deli #4 - S12 |1 EACH |480 |1927 |41.78 |29.4 |

|Pepperoni Pizza-S12 |Slice |368 |760 |34.1 |17.4 |

|Cheese Pizza-S12 |Slice |320 |304 |28.5 |15.8 |

|Green Salad with Bagel: S12 |1 Each |558 |1160 |63.96 |21.8 |

|1% White Milk |CARTON |110 |125 |13 |2.5 |

|Nonfat Chocolate Milk |CARTON |130 |230 |23 |0 |

|Juice, Orange, 4 oz. |1 EACH |50 |0 |13 |0 |

|Juice, Apple, 4 oz. |1 EACH |50 |0 |14 |0 |

|Side Salad - S12 |1 Each |33 |15 |5.4 |0.73 |

|Pudding Cup: Vanilla |1 Each |190 |200 |30 |6 |

|Lett./Pickle/Tom. Cup |1 EACH |9 |174 |1.88 |0.05 |

|Apple, Fresh |1 EACH |55 |1 |14.64 |0.18 |

|Orange, Fresh |1 EACH |45 |0 |11.28 |0.12 |

|Baby Carrots |1 Each |12 |16 |3 |0 |

|Catsup Packet |1 Packet |6 |67 |1.51 |0.02 |

|Mustard Packet |Pkt 5g |3 |57 |0.27 |0.2 |

|Dressing, Ranch Cup |1 Each |120 |200 |2 |12 |

(“Grand Rapids,” 2012)

Appendix C

Reference Values for Nutrition Labeling

(Based on a 2000 Calorie Intake; for Adults and Children 4 or More Years of Age)

|Nutrient |Unit of Measure |Daily Values |

|Total Fat |grams (g) |65 |

|Cholesterol |milligrams (mg) |300 |

|Sodium |milligrams (mg) |2400 |

|Total carbohydrate |grams (g) |300 |

(“How,” 2012)

References

Centers for Disease Control and Prevention. (2011). MMWR weekly: School health guidelines to promote healthy eating and physical activity. Retrieved from

Centers for Disease Control and Prevention. (2012). MMWR weekly: Nutrition – facts- adolescent and school health. Retrieved from

Drewnowski, A., & Specter, S. E. (2004). Poverty and obesity: The role of energy density and energy costs. American Society for Clinical Nutrition,79(1), 6-16. Retrieved from

Flegal, K. M., Carroll, M. D., & Ogden, C. L. (2011). Cancer from obesity. Retrieved from

Harkness, G.A. & DeMarco, R.F. (2012). Community and Public Health Nursing. Philadelphia, PA: Lippincott Williams & Wilkins

Healthy Schools, Healthy Students. (2012). The healthy school action tools. Retrieved from schools

Kent County Administration. (2012). School wellness: AccessKent. Retrieved from

Kent County Coordinated School Health Program. (n.d.). Empowering students and staff success through healthy school environments. Retrieved from

Kent County Health Statistics Tables. (2012). Hospitalizations and rates. Retrieved from

Kent ISD. (2012). Grand Rapids public schools lunch portion value spreadsheets.

Retrieved from

Kent ISD. (2012). Health, safety, service. Retrieved from

Melina, R. (2011, August 05). Unhappy meals: Parents don't choose healthier fast foods. Retrieved from

Michigan Department of Community Health. (2011). Critical health indicators. Retrieved from

Quanhe Y. (2012). Sodium intake and blood pressure among US children and adolescents. Pediatrics 2012. 130:4 611-619. doi: 10.1542/peds.2011-3870

Stein. R. (2012). A dire sign of the obesity epidemic: Teen diabetes soaring, study finds. Retrieved from

U.S. Food and Drug Administration. (2012). How to understand and use the nutrition facts label. Retrieved from

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