The Marshall County Health Department is a single county health department located in far Western Kentucky. The department provides services for the approximately 31,300 citizens of the county. Marshall County has one public school district, which, during school year 2017-2018, has an enrollment of 4,650 students. In 2005, the Marshall County Health Department, partially in response to the pushdown from the Kentucky Department for Public Health to increase physical activity in school-aged children, created Team Ultra. Marshall County is a rural area and the opportunities for after-school activities, outside of organized sports, are limited. The county does not have organizations such as the YMCA or public fitness centers for school-aged children. The Marshall County Health Department had to be creative in how to meet the promotions advocated by the State. Thus, with the help of an established elementary school running club, Team Ultra was born. Team Ultra revolves around teaching students about physical activity, good nutrition and good character. The program started in one elementary school and has grown into all six elementary schools in the county for 3rd 5th graders and this year has piloted a Team Ultra 2 program for one of the county's middle schools. Students stay for one and a half hours after school, one day a week, with adults from the Health Department, school system and other community agencies. The response has been so great for Team Ultra participation that two of the elementary schools have two sessions per week with different participants. A pilot program, Team Ultra 2, has been launched, this year, at one of the middle schools in response to middle school students expressing they missed Team Ultra from their days participating as elementary students.
According to Kentucky Behavioral Risk Factors Surveillance System (BRFSS) data, Marshall County ranks worse than the state, as a whole, in areas of lack of physical activity (adults), prevalence of obesity (adults), prevalence of overweight adults, recommended fruit and vegetable intake (adults) and prevalence of hypertension (adults). 2015 CDC data indicated that 19% of high school aged students in Kentucky are obese (as indicated by BMI for age that is equal to or greater than the 95% percentile), which tied for the most obese high school students in the country. It is obvious there is a concern in Kentucky and Marshall County. It is apparent that Kentucky residents are at risk for higher than normal percentages of obese and overweight people.
It is also a known and documented fact that traits and habits learned early in life, will carry over into adulthood. It is the intent, that through the collaboration between Marshall County Health Department and Marshall County School District, in the way of Team Ultra and possibly Team Ultra 2, healthy behaviors and practices can be instilled and reinforced in the participants' minds so that healthy behaviors and practices become a way of life. If the children of today become more healthy and adopt positive behavior patterns, that will make them healthier, more productive adults of tomorrow. This program has been funded primarily by local tax monies from its inception, indicating the value and importance of this program. However, recently Team Ultra has received grant money from Wellcare, a Kentucky Managed Care Organization, to supplement local tax money used. Team Ultra has been successful due to the dedication of key individuals in the Health Department that designed, implemented and are carrying out this program. Additionally, this program would not be sustainable without the continued support and participation of the Marshall County School District and other community volunteers. The program has grown to all elementary schools and often has a â€˜waiting list' for students to participate.
Additional information about the program can be found on Marshall County (KY) Health Department website at http://www.marshallcohealthdepartment.com/
CDC Data shows that childhood obesity is a problem in the Commonwealth of Kentucky with 19% of high school aged students classified as obese (as indicated by BMI for age that is equal to or greater than the 95% percentile). Current data from kentuckyhealthfacts.org and Kentucky Behavioral Risk Factor Surveillance System (BRFSS) indicate that Marshall County adults rank worse than the state average percentage in areas of lack of physical activity (adults), prevalence of obesity (adults), prevalence of overweight adults, recommended fruit and vegetable intake (adults) and prevalence of hypertension (adults). All of these indicators are addressed in the Team Ultra curriculum. Studies have shown that habits acquired during childhood and adolescent years are more likely to carry over into adulthood. Many chronic diseases faced by adults, and now younger people (e.g., Type 2 diabetes, hypertension, heart disease), can be prevented, or the severity decreased by implementing healthy behaviors (i.e., increased physical activity, good nutrition choices, and character building).
The target audience for Team Ultra (TU) (not including the pilot of Team Ultra 2) is 3rd â€“ 5th grade elementary students in the Marshall County School District. For the 2017 â€“ 2018 school year, a total of 1064 3rd â€“ 5th grade students, which are predominantly Caucasian and of moderate socio-economic status, are enrolled in the school district. Of those, 308 students participate in TU at some point during the week. Since TU's inception, the program has grown to all six elementary schools and two school have two sessions a week, with different students. Currently, Team Ultra reaches ~29% of the target audience. There is a waiting list for students to be involved with Team Ultra.
Different approaches to teach elementary aged students about the importance of physical activity, good nutrition and good character are always being tried. The after-school approach utilized by Team Ultra gives a time for additional instruction to be given to students in non-classroom style setting. Team Ultra uses games to increase physical activity and will utilize outside personnel (not the classroom teachers the students are accustomed to seeing) to teach the nutrition and character components of Team Ultra. When teaching physical activities, it is done without expensive items or equipment, making physical activity available to anyone. Students participate in physical activities that can be replicated at home to help encourage physical activity amongst the entire family unit. A unique aspect of Team Ultra is the character building lesson the coaches incorporate into each session. Team Ultra designers felt reinforcing good character traits, such as respect for yourself and others, courtesy, fairness and citizenship would assist in guiding the participants to productive lifestyles.
The approach Team Ultra uses is innovative in that it uses existing evidenced based components (e.g., MyPlate for nutrition information, dietary label reading and understanding, increased physical activity to ward off chronic disease onset) in a way that students respond to. The fact that there is a waiting list for elementary students to participate in Team Ultra and that middle school students, and parents, requested that Team Ultra be continued in the middle schools, show that the approach used works. In 2013, TU was awarded the Promising Practice designation from NACCHO and since that time, Team Ultra coordinators have worked to address the improvement suggestions given. Team Ultra has been honored by at Kentucky Managed Care Organization (MCO), Wellcare, by receiving grant funding to supplement local tax money to fund Team Ultra. Wellcare sees such value in this program, that their organization promotes Team Ultra across the Commonwealth as a practice other communities could implement to address similar issues in their hometowns. From the information distributed by Wellcare, several local health departments and communities have contacted Team Ultra coordinators regarding implementation of a similar program in their area.
Nutrition, Physical Activity, and Obesity
Team Ultra (TU) has relied on collaboration since its inception. What started out as an after school running club at one elementary school has now grown to all six elementary schools. This would not be possible without the assistance and support of the Marshall County School District. For this current school year, there are 11 school district staff that assist with Team Ultra. Additionally, Family Resource Center staff also assist, as needed. Five Marshall County Health Department staff members are involved in facilitating the lesson plan and physical activity each week. These staff members are assigned to a particular school and rotate, as needed. The Marshall County Health Department Board of Health is supportive of Team Ultra in that the Board of Health allocates local tax money to help fund Team Ultra.
The goals and objectives of the program are to promote good nutrition, increased physical activity and good character traits in program participants. Team Ultra runs for approximately 23 weeks during the school year. Each week a different lesson related to nutrition, character and/or physical activity is taught.
Before the receipt of grant money from Wellcare (approximately $6000.00), TU was run entirely on local tax money (MCHD staff salary) and in-kind contributions from the Marshall County School district in the way of staff salary and the utilization of the elementary school facilities. The cost to Marshall County Health Department, to run Team Ultra, is ~$19,000 per fiscal year.
When looking at long term lifestyle changes, it is difficult to measure improvement in health status in the short term. To help Team Ultra Coordinators evaluate knowledge learned during a year, a pre- and post-knowledge test is given to the participants. The pre-knowledge test is given at the very first Team Ultra session of the school year with no prompting or help from facilitators. The Post-knowledge test is given to TU participants at the conclusion of the Team Ultra year and completion of all lesson plans. For the 2016-2017 school year, aggregate data from all the schools pre- and post-knowledge test showed a knowledge increase of ~15% (pretest 59% vs. posttest 68%). All six elementary schools showed increases in pre and post assessment percentages.
TU coordinators, along with Marshall Co School personnel, work to collected yearly Body Mass Index (BMI), for age, data for students. In 2015 a MCHD dietetic intern was able to analyze Team Ultra participant data for the 2014-2015 school year a copy of her analysis is included below
Team Ultra as a group had the higher percentage decrease of overweight and obese with a 12% decrease while the Non Team Ultra group had an increase of 26%
Team Ultra females showed the greatest decrease in obesity of all females with a -13% effect. And the greatest overweight decrease of -12%, totaling the percent change to -25%; whereas the group minus team ultra females showed the greatest increase of overweight at 21% for females and males. They also had the smallest obesity change for females at -10%. All males both Team Ultra and Non Team Ultra showed no change of the percentage that are obese and a 7% increase of overweight but not obese for the males not in Team Ultra. There was no change in overweight percentage for Team Ultra males.
Team Ultra third graders had the greatest decrease by grade level with a 6% decrease of obesity and a 29% decrease in overweight, making a total of a 35% decrease while the Non Team Ultra 3rd grade had a combined increase of 26%. Team Ultra 4th grade had a decrease in obesity of 4% while maintaining the same percentage of overweight. Non Team Ultra 4th grade has a 9% decrease in obesity and a 6% increase in those overweight, making its combined total a 3% increase in overweight or obese. Team Ultra 5th grade had a 7% decrease in obesity with a 20% increase in overweight children whereas Non Team Ultra 5th grade had a decrease of 20% in obesity but an increase of 26% in overweight children.
The greatest effect that Team Ultra appears to have is on females and on 3rd graders. With the exception of 5th grade, Team Ultra had the more positive affect across the board in comparison to those not enrolled.
The students in the Non Team Ultra group had on average the lesser deviation of the zscore for children of the same sex and age in the United States for both the initial and final measurements, with an average of .76 and .85 respectively. Team Ultras were .92 and 1.02 respectively.
In the United State children aged 2-19, have an overweight percentage of 14.9% for both males and females, and 16.9% are obese. The children in Marshall County in grades third through fifth have an overweight percentage of 18% and an obesity percentage of 25% (NHANES, 2009-2010).
Boys in the United States between the ages 2-19 are 14.4% overweight with 18.6% being obese, while boys in Marshall County between the 3rd and 5th grade are 16% overweight and 27% obese (NHANES, 2009-2010).
Girls in the United States between the ages 2-19 are 15.4% overweight with 15% being obese. Girls in Marshall County between the grades 3rd-5th are 20% overweight and 22% obese (NHANES, 2009-2010).
The percentages of overweight and obese children in the state of Kentucky are 16% and 19.7% respectively (NCSL, 2011). The children in Marshall County exceed the rates of Kentucky and the United State by 6.3% in Kentucky and by 11.2% in the United States.
In these calculations all children without two sets of data were excluded so that all children included would have comparable sets to measure the gain and loss of BMI% points that correlate with being overweight and obese. These calculations show that Team Ultra does have a positive effect on children in this age group with the exception in this sample of the 5th grade.
In future years, Team Ultra coordinators will explore relationships with persons who have statistical knowledge to produce reports similar to the one above. With the assistance of the Marshall County Health Coalition Obesity Workgroup, efforts are underway to establish the ability to acquire, record and track/monitor BMI-for-age data for Marshall County youth as they progress from kindergarten through 12th grade. The effort involves the Marshall County Health Department (health education and school nurses), school district staff (acquiring height and weight data according to established standards and developing policies/procedures to record the data into Infinite Campus each year) and Marshall County Board of Education staff (to generate Infinite Campus data reports generated from the data collected throughout the entire district). The goal is to have this monitoring/tracking system in place by June 2018.
A reason that Marshall County Health Department (MCHD) has been able to sustain the Team Ultra program is that the Board of Health is willing to allocate local tax money to fund MCHD staff salary. The collaboration between the MCHD and the Marshall County School district is instrumental in providing facilities and physical activity equipment for the sessions and school district personnel to attend and help facilitate Team Ultra session. The recent addition of the Well Care funds have been utilized in the timely manner to supplant local money.
Since Team Ultra has been around since 2005 the sustainability of the program, from the student interest standpoint is evident. Also, there is obvious value in a program where â€˜graduated' students and parents are requesting the program to be continued in the middle schools.
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