In 2010, four out of ten South Carolina children were overweight or obese. Habits formed in childhood are difficult to shake as adults. The future health of a generation of South Carolinians looked bleak.
Making a dent in numbers like that can seem a daunting challenge.
And yet, less than a decade later, the state’s obesity rankings have improved dramatically for preschoolers (from 15th to 45th lowest) and significantly for teens (from 3rd to 8th lowest).
How did South Carolina begin to tip the scales in the pediatric obesity epidemic? How might further gains be made for the state’s teens, who risk taking bad lifestyle choices into adulthood?
Part of the answer lies in scaling up locally successful programs so that children across the state can benefit. The Community-Engaged Scholars Program (C-ESP), directed by Michelle G. Nichols, Ph.D., RN, has supported such efforts by providing pilot funding and community-based research training to academic-community teams targeting pediatric obesity.
This is a tale of two pediatric obesity interventions that have received CES-P support. One is a mature, school-based initiative known as the Docs Adopt School Health Initiative©, led by the Boeing Center for Children’s Wellness, which has already been implemented by school districts across the state with impressive results. The other is a fledgling initiative, but with potential to scale, which is examining how Smartphone apps can help teens better track and share their progress with their primary care providers.
CES-P is currently accepting applications for pilot funding for new research projects on any aspect of community-based health research from academic-community partners. For more information, contact Keesha Corbin of the South Carolina Clinical & Translational Research Institute.
Reaching children and teens through schools
The Boeing Center for Children’s Wellness, directed by Janice D. Key, M.D., was founded in 2007 as a collaboration between the MUSC Health Division of Adolescent Medicine and the Charleston County School District to prevent obesity in children by providing healthier school environments. In 2010, with funding from Boeing, the Center began to scale up its Docs Adopt initiative, making it available to more school districts across the state.
Convincing other school districts to implement the initiative, however, would require metrics that they would find relevant and compelling.
“We have found improvement in both the health and academic performance of children attending these schools. Our original hypothesis is true: healthy kids are better learners.”
Dr. Janice Key, director of the Boeing Center for Children's Wellness
With pilot funding from C-ESP, the Boeing Center for Children’s Wellness worked with Robert Stevens of the Charleston County School District to find out which metrics resonated with the schools. Not surprisingly, schools were especially interested in how the wellness initiative affected educational metrics, such as attendance or retention rates.
“For this initiative to expand, we needed to have buy-in from district superintendents,” said Sarah Piwinski, MPA, the assistant director of the Center. “If this innovative wellness initiative had a positive impact on student outcomes, schools would be more likely to participate.”
The data showed that for every four years of participation, a school’s attendance increased by 5%. Impressed by such metrics, eleven school districts across the state, in addition to Charleston County School District, signed on to participate. The initiative was expanded to benefit school staff as well. In total, the Docs Adopt initiative was implemented in 193 South Carolina schools, serving approximately 135,000 children. In addition, it has since been adopted by 24 schools in Pottstown PA, enrolling more than 14,000 students.
Docs Adopt, as the name suggests, encourages health care professionals to serve on the wellness committees of local schools.
It also invites schools to document their wellness efforts using a School Wellness Checklist©, which credits each school with points for programs, practices and policies in seven areas relevant to wellness.
Schools can receive a monetary award to be used for their wellness initiative by earning at least 50 points across the seven areas. They can earn points for a large variety of activities. They can host a quarterly fruit and vegetable tasting. They can provide a water-filling station. Or they can require exercise breaks during regular classes or plant a school garden.
Schools then compete with each other to see who can earn the most points on the checklist, with the winner awarded additional monies and a trophy.
Data from participating schools show that schools with a higher score on the School Wellness Checklist had lower student body mass index scores. Indeed, for every 70-point increase in the School Wellness Checklist score, the mean body mass index of students decreased by one unit. In Charleston County School District, the rate of obesity in fifth-graders decreased from 26% to 16% from 2008 to 2017.
“You can’t say it’s all because of schools’ participation in a wellness initiative,” said Piwinski. “But something about participating in a wellness initiative such as this had an impact on school culture and led to fewer obese students.”
An evaluation is under way to gauge the program’s effects on obesity rates and school performance, using data from all participating school districts in South Carolina. Although the final results won’t be released until next year, preliminary findings suggest a positive effect on both.
“Schools participating in our Docs Adopt School Health Initiative© do incredible work that reaches students and staff,” said Key. “We have found improvement in both the health and academic performance of children attending these schools. Our original hypothesis is true: healthy kids are better learners.”
Reaching teens through technology
For her CES-P project, Christine San Giovanni, M.D., a pediatrician at MUSC Children’s Health, partnered with community pediatrician Michelle Steffen, M.D., of Riverside Pediatrics in Georgetown, SC to study which features of existing Smartphone fitness apps are preferred by obese teens to meet their fitness goals. Teens were enrolled both at MUSC Children’s Health and Riverside Pediatrics, with most patients being enrolled by Steffen at the rural Georgetown practice.
“Teen obesity is a very large issue across the nation, not just for us here in South Carolina, because of poor nutrition and a sedentary lifestyle” said Steffen. “So it's definitely an uphill battle, and apps could help us in that battle.”
“I wanted to test the apps that are already out there and find the features that adolescents preferred using instead of just testing the efficacy of any feature that I chose,” said San Giovanni.
“So I love the idea that the kids liked the social connection and I love that they wanted their providers to be following their progress.”
Dr. Christine San Giovanni
San Giovanni had earlier surveyed pediatricians in the South Carolina Pediatric Practice Research Network (SCPPRN), a practice-based research network of pediatric providers in Coastal and Central South Carolina, about their use of and attitude toward fitness apps. Only a very few (15%) used apps in their practice to help obese teens meet their fitness goals, but many more (as high as 45%) would be willing to do so if they were more familiar with app features. San Giovanni hopes that these physicians will be more likely to use the apps in their practice if they are educated on the app features that teens like best.
Teens in the study did become frustrated when an app was not easy to use. However, they found most features very helpful. For example, they liked being able to track their steps or scan products to find nutrition information and learn about healthier options. They also liked app features that allowed them to share their progress towards fitness goals with their friends and, most surprisingly, their pediatricians.
“So I love the idea that the kids liked the social connection and I love that they wanted their providers to be following their progress,” said San Giovanni. “I was really surprised that they would like that idea so much.”
With funding from the Department of Pediatrics, San Giovanni is now conducting a trial in six SCPPRN practices. The trial will assess whether enabling a pediatrician to track a teen’s progress toward fitness goals via an app’s social networking feature will improve outcomes. If results are encouraging, she is hoping to scale up these efforts through the SCPPRN so that more South Carolina teens can benefit from these free, easily available electronic resources.