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S C H O O L H E A LT H P O L I C Y

Lessons Learned While Implementing a Legislated School Policy: Body Mass Index Assessments Among Arkansas’s Public School Students ABSTRACT

MICHELLE B. JUSTUS, MSa KEVIN W. RYAN, JD, MAb JOY ROCKENBACH, BSEc CHAITANYA KATTERAPALLI, MSd PAULA CARD-HIGGINSON, BAe

BACKGROUND: To comprehensively address the childhood and adolescent obesity epidemic, Arkansas enacted Act 1220 of 2003. Among a series of community- and schoolbased interventions, the Act requires each public school student to have his/her body mass index (BMI) assessed and reported annually to parents. The process of implementing this policy on a statewide level and lessons learned are described in this article. METHODS: A confidential, standardized protocol to measure student BMIs and report results to parents was developed. Affordable, reliable, and durable equipment was selected and school personnel who conducted BMI assessments were trained to ensure standardization. To enhance the efficiency and ease of the measurement and reporting process and promote long-term and locally based sustainability, during the first 3 years of implementation, a transition from a paper-based system to a Web-based system was made. Confidential, individualized Child Health Reports have provided students’ parents with information about the health of their children. RESULTS: Participation by schools and students has been high as a result of collaboration between the health and education communities and the students and their families. Childhood obesity has not increased since Act 1220 was passed into law. CONCLUSIONS: Parents, schools, school districts, and the state are able to better understand the obesity epidemic and track progress using detailed annual data. Providing a standardized measurement protocol, equipment, and efficient data entry and report generation options has enabled Arkansas to institutionalize the BMI assessment process in public schools. Keywords: public health; school nurses; policy; health policy, child and adolescent health. Citation: Justus MB, Ryan KW, Rockenbach J, Katterapalli C, Card-Higginson P. Lessons learned while implementing a legislated school policy: body mass index assessments among Arkansas’s public school students. J Sch Health. 2007; 77: 706-713.

a Policy Analyst, ([email protected]), University of Arkansas for Medical Sciences, Arkansas Center for Health Improvement, 1401 W Capitol Ave, Suite 300, Victory Building, Little Rock, AR 72201. b

Executive Associate Director, University of Arkansas for Medical Sciences, Arkansas Center for Health Improvement and Assistant Professor, Fay W. Boozman College of Public Health, ([email protected]), University of Arkansas for Medical Sciences, 1401 W Capitol Ave, Suite 300, Victory Building, Little Rock, AR 72201.

c Formerly: Policy Specialist, University of Arkansas for Medical Sciences, Arkansas Center for Health Improvement and Currently: Act 1220 Coordinator, Arkansas Department of Education, ([email protected]), 2020 W 3rd St, Suite 320, Executive Building, Little Rock, AR 72205. d

Policy Analyst, ([email protected]), University of Arkansas for Medical Sciences, Arkansas Center for Health Improvement, 1401 W Capitol Ave, Suite 300, Victory Building, Little Rock, AR 72201. e Associate Director, ([email protected]), University of Arkansas for Medical Sciences, Arkansas Center for Health Improvement, 1401 W Capitol Ave, Suite 300, Victory Building, Little Rock, AR 72201.

Address correspondence to: Michelle B. Justus, Policy Analyst, ([email protected]), University of Arkansas for Medical Sciences, Arkansas Center for Health Improvement, 1401 W Capitol Ave, Suite 300, Victory Building, Little Rock, AR 72201.

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rior to the passage of Act 1220 of 2003 in Arkansas, more than 60% of adult Arkansans were either overweight (body mass index [BMI] 25-29.9) or obese (BMI  30), ranking adult Arkansans as 14th heaviest in the nation according to a 2002 Behavioral Risk Factor Surveillance System survey.1 Nationally, overweight prevalence tripled among those aged 6-19 years between 1980 and 2002, while the 2003-2004 National Health and Nutrition Examination Survey indicated that more than 17% of all US children and adolescents were overweight.2 This trend has important public health implications because approximately 50% of adolescents with a BMI  95th percentile become obese adults3 and 70% of these adolescents are more likely to become overweight or obese adults.4 In addition, childhood diabetes, hypertension, and sleep apnea are more likely to develop in overweight children.5,6 In response to the childhood obesity epidemic, the Arkansas legislature passed landmark legislation— Act 1220 of 20037—with the stated purpose ‘‘to combat childhood obesity.’’8 A key strategy employed by Arkansas and increasingly adopted by other communities9 is measuring the BMI of students in schools. Arkansas was the first state to pass legislation mandating statewide public school–based BMI assessments8 and since 6 other states have followed suit (Illinois, Maine, New York, Pennsylvania, Tennessee, and West Virginia).10 This article describes the process employed and lessons learned while implementing the legislatively mandated school policy of statewide BMI assessments among public school students in Arkansas. Legislation was passed in April 2003 with the explicit expectation that public schools would conduct BMI assessments beginning in the 2003/2004 school year and report the results to parents. Arkansas school districts receive general funding from the state based on the average number of students who attend the district; however, districts have discretion in how their state funds are spent. Further, the structure of the Arkansas Department of Education (ADE) allows school districts broad autonomy in implementing policies and procedures. In passing Act 1220, the legislature placed a series of healthrelated performance requirements on schools but did not provide additional supportive programmatic funding. As such, schools were eager to find a process that allowed them to adhere to the new policy while minimizing financial and staffing resources needed to comply. At the respective request of the ADE and Arkansas Department of Health, the Arkansas Center for Health Improvement (ACHI) was asked to lead in developing and implementing a statewide BMI assessment process. While ultimately each school district had autonomous authority to implement Journal of School Health

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assessment processes at their respective discretion, the ADE (through communications from the executive director) strongly encouraged them to follow the standardized protocol developed by ACHI. In the first year of implementation, for all districts that elected to adhere to the standardized protocol, ACHI calculated each district’s students’ BMIs and generated Child Health Reports. As described below, implementation of BMI assessments and reporting has been successful.

METHODS Equipment Selection To ensure consistent measurements across all schools, in fall 2003, ACHI evaluated and validated scales and stadiometers through a research collaboration with 9 schools; equipment was evaluated for accuracy, durability, and cost (Table 1).11 The Tanita (Arlington Heights, Ill) HD-314 scale was selected for use in all schools. This scale measures up to 330 pounds, is lightweight, readily portable, and has a digital readout that facilitates viewing and minimizes interpretation errors. Because of difficulties (ie, expense and availability of sufficient quantities) in procuring prefabricated, affordable stadiometers, the Arkansas Department of Corrections was commissioned to build stadiometers according to ACHI specifications. Stadiometers were constructed with an 84-inch metal ruler mounted to an 86-inch white-painted wooden board accompanied by a plastic carpenter’s square for the headpiece. These units were portable, durable, and reasonably priced. Using a grant from the Arkansas Department of Health, scales and stadiometers were then distributed to more than 1100 schools statewide at a total equipment cost of $60 per site. Protocol Development: Training and Certification To develop a statewide protocol, pilot schools were used to evaluate the necessity of repeated weight and/or height measures and the accuracy of scales and stadiometers.12 To standardize measurements across the state, a height and weight measurement training manual (adapted by J. Weber from Lohman et al13) was developed and used to train and certify a core group of community health nurses.12 A ‘‘train the trainer’’ teaching model was used. Community health nurses were trained by a team from ACHI and the Center for Applied Research and Evaluation in the Department of Pediatrics, University of Arkansas for Medical Sciences. Subsequently, the community health nurses trained school nurses and other school personnel across the state. In addition, a training video was developed from the manual and given to each school after

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Table 1. Scale and Stadiometer Comparisons* 95% CI of the Mean of the Differences LS Adjusted Means† Scales Different types of scales Balance vs spring Balance vs digital Spring vs digital Different digital scale brands Tanita HD-314 vs Taylor 7301 Tanita HD-314 vs Health-o-meter HDL 11-60 Tanita HD-314 vs Tanita BWB-800S Health-o-meter HDL 11-60 vs Taylor 7301 Stadiometers Different measures using same stadiometer ACHI board Schorr board Seca 206 bubble Different types of stadiometers Yard stick vs Stadi-o-meter Yard stick vs Schorr board Schorr board vs Seca 206 bubble ACHI board vs Schorr board Seca 206 bubble vs Yard stick

Unadjusted Means

% Times Differences ‚0 (r2)

1.30 to 1.58 0.69 to 0.97 0.75 to 0.47

1.28 to 1.59 0.70 to 0.95 0.74 to 0.47

91 (.99) 86 (.99) 70 (.99)

0.67 0.15 0.18 0.38

0.67 0.15 0.18 0.38

97 47 40 45

to 0.91 to 0.26 to 0.09 to 0.14

to 0.90 to 0.27 to 0.09 to 0.14

(.99) (.99) (.99) (.99)

0.10 to 0.11 0.13 to 0.18 0.08 to 0.13

0.10 to 0.12 0.13 to 0.18 0.08 to 0.14

NA (.99) NA (.99) NA (.99)

0.04 0.06 0.30 0.14 0.52

0.04 0.06 0.29 0.14 0.41

59 63 27 28 61

to 0.11 to 0.17 to 0.11 to 0.05 to 0.24

to 0.11 to 0.17 to 0.04 to 0.05 to 0.21

(.99) (.99) (.99) (.99) (.98)

CI, confidence interval; LS, least squares; NA, not available. *Source: Adapted from Bost et al.11 † Means were adjusted for age, gender, race, school, overweight classification, measurement device, and all significant interactions.

(5th percentile  BMI , 85th percentile), at risk for overweight (85th percentile  BMI , 95th percentile), or overweight (BMI  95th percentile). To eliminate an unintentional comparison of normal and abnormal, the term ‘‘healthy weight’’ is used in all reports, rather than the CDC classification of normal weight. A BMI is not calculated for any student whose date of birth, gender, height, or weight is missing or for students whose records are marked as ‘‘unable to be assessed.’’ Reasons students may be classified as unable to be assessed include absenteeism from school on day of assessment, physical disability, student or parent refusal to participate, no longer attending the school, pregnancy, could not get 2 height measurements within 1 inch, and weight exceeded the scale limit (reason added in year 4).

initial training was completed to ensure that all measurers had access to a single set of instructions on proper techniques. A BMI ‘‘hotline’’ was set up at ACHI to take calls from assessors in the field who needed assistance or had questions about the protocol. The BMI hotline receives approximately 400 calls a year (~600 the first year), with the majority of the calls from school nurses with questions regarding the process. In the first year, approximately 100 parents called the hotline with questions about confidentiality of the assessments, options for opting out of the assessment, and questions about the Child Health Report. Data Collected Early each school year, a data file of all public school students’ demographic information from the ADE is provided to ACHI. To ease the data entry burden on assessors, individual student-level data collection forms are generated. Schools then report data to ACHI to generate Child Health Reports (see reports) for distribution to each student’s parents. The mean of each student’s 2 measured heights and 1 weight measurement are used to calculate BMI as (weight in pounds/[height in inches]2) 3 703. Centers for Disease Control and Prevention (CDC) definitions of gender-and-age–specific BMI z scores and percentiles are calculated.14 Students are classified as underweight (BMI , 5th percentile), healthy weight 708

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Data Entry and Management: Transition From Paper to Electronic Data Entry For the 2003/2004 school year (year 1), a paperbased reporting system was developed and implemented. Subsequently, to make the process more efficient for school personnel and more accurate, an electronic, Web-based data entry and reporting system was developed and piloted in 2004/2005. Full implementation of this system began in 2006/2007 (Figure 1). d

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Figure 1. Data Collection—Transition From Paper- to Web-Based System

Year 1 Process Dept of Ed transferred data to ACHI

Data collected on paper forms by school personnel; forms returned to ACHI

ACHI generated individualized barcoded forms; mailed to schools for data collection

Data were entered using VBA program onto SQL server

~422,000 CHRs distributed to parents via US postal system

Individual CHRs generated by ACHI in specialized VBA program

Schools rec’d password-protected Excel file with student data; passwords mailed separately

Year 2 Process Paper-based System

Pilot Electronic System Paper Pocket PC Collect data on paper; key Enter data on Pocket PC; into Web site later upload to Web site

Schools print paper forms & collect data

5 schools (Watson Chapel District)

~442,000 students

6 schools (North Little Rock District)

Outsourced data entry ~5 ,700 students Data stored in secure Web-based system

Data transfer to ACHI

Child Health Reports generated by ACHI

Schools access CHRs via secure Web site

Year 3 Process Paper-based System

Web-based Pilot System Paper Collect data on paper; key into Web site later

Schools print paper forms & collect data ~304,000 students

Pocket PC Enter data on Pocket PC; upload to Web site

Outsourced data entry

216 schools in 16 districts ~130,000 students

Data transfer to ACHI

Data stored in secure Web-based system

Web Access Enter data directly into Web site while measuring

Child Health Reports generated by ACHI

Schools access CHRs via secure Web site

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Reports Act 1220 requires that schools report each child’s BMI to parents annually. ACHI developed 5 types of confidential, individualized Child Health Reports: 1 each, respectively, for students who were classified as underweight, healthy weight, at risk for overweight, overweight, or unable to be assessed. All reports explain the importance of collecting BMI information, what BMI means, and the student’s height, weight, and BMI classification (if available). Parents were advised to consult with their family doctor if they had questions or concerns and were provided with the American Academy of Pediatrics suggestions for a healthy lifestyle, such as offering healthy snacks, drinking fewer sodas and more water, limiting television, and increasing family activities. In the second year of the initiative, each type of Child Health Report was translated into Spanish and automatically created for those parents or guardians for whom Spanish was listed as the primary language spoken at home according to ADE records. In addition to the Child Health Reports, ACHI developed individual school and district aggregate reports and an annual statewide report. Care was taken in the creation and posting of these reports to ensure that no individual child could be identified, either by expressly or by implication. The schoollevel report describes the school and its geographic location and explains BMI assessments. The BMI classification is presented for male and female students by grade in both table and graphic form. School district reports combine data on all schools within a district. School participation in each district is shown. Tables and charts report BMI classification by gender and grade at the district level. All school and district reports are available on ACHI’s Web site, www.achi.net, and are made available to each school and district annually.

In the first year (2003/2004), approximately 450,000 blank data forms were generated, printed, and shipped to schools. Preprinted forms included demographic information and school data. Trained personnel measured students’ height and weight, hand-entered data, and returned forms to ACHI for entry into an electronic database. Once data entry was complete and quality checked, an individual Child Health Report was generated for each student. Report generation and mailing were supported by grant funding, thus were sent at no cost to the schools. In the second year (2004/2005), the majority (98%) of Arkansas school districts continued to participate in the paper-based assessment process. To evaluate the efficacy of electronic data collection options, in year 2, a Web-based program for data entry was developed and tested in 11 schools. This program offered schools 2 options for assessing students: in addition to paper-based reporting schools could (a) enter data into the Web-based program after recording measurements on forms or (b) collect data on pocket PCs then later upload data collected into the Web-based program. Data entry was outsourced to the University of Arkansas at Fayetteville Survey Research Center in year 2 for schools that continued using the paper-based system. The Web-based system provided interface-level error checking to screen some data entry errors and to ensure all required information was captured. The Web-based system also allowed the school nurse on site to search for students missing from the initial assessment roster across the state and transfer his/her name to the current school of enrollment. After data entry was completed and quality checked, Child Health Reports for each respective school’s students were made available to that school’s personnel through a secure Web site. All options provided schools maximum control over students’ records and allowed schools to select their own method for distributing reports to parents. The success of and positive response to the Webbased program, reported by those who participated, encouraged the expansion of the program in year 3 (2005/2006) to 16 school districts (216 schools) encompassing 130,000 students. The 16 school districts were geographically dispersed across the state and ranged in the number of students. In addition to the 2 Web-based options available in year 2, direct data entry into the Web-based system was made available for schools during year 3. This option allowed the assessor to select a student, pull up all pertinent demographic information, and enter height and weight measurements directly into the Web-based system. The schools not participating in the Webbased program continued using the paper-based system as they did in years 1 and 2. 710

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RESULTS School participation rates have been high each year ranging from 94% to 99% of public schools participation, while the submission of student assessment forms ranged from 90% to 95% of all public school students in the state. However, a BMI was not necessarily calculated for every student who had an assessment form submitted. Assessment forms were submitted for those students that were unable to be assessed, which represented 14-17% of the assessment forms received across the years. Absenteeism was the most common reason that students were unable to be assessed (of total reporting, 6.3% in year 1, 7.7% in year 2, and 6.7% in year 3). Annually, only 5-6% of students could not be assessed because they or their parents refused to allow participation. To be able to calculate a student’s d

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BMI, valid data for weight, height, age on the day of assessment, and gender must be available. The number of students who had valid data, enabling a BMI to be calculated has ranged from 82% to 86% of those assessed.15 Once the BMIs are calculated, a Child Health Report is mailed out to each student regardless of his/her assessment status. In year 1, 422,000 reports were mailed directly to parents or guardians with the schools’ return address. In subsequent years, reports were placed on ACHI’s Web site where they were password protected at the school level. Each school superintendent received a unique password via registered and certified US mail at the beginning of the school year. In year 2, the responsibility to deliver reports to parents was shifted from ACHI to each respective school. In year 2, 445,000 Child Health Reports were created and 434,000 in year 3. Year 4 reports became available to schools as soon as the information was entered into the Web-based system. Aggregated statewide results for year 4 are currently being analyzed. Arkansas BMI assessment results show that childhood obesity is a significant concern for the entire state, across all ethnicities, ages, and genders. Because the BMI assessments have begun, the percent of children who are overweight or at risk for overweight has remained steady. In the first year, 38.1% of children in Arkansas were either overweight or at risk for overweight, with 38.0% in the second year and 37.5% in the third year.15 DISCUSSION Act 1220 has afforded Arkansas parents detailed information about their children’s health, and importantly, communities, schools, and Arkansas policy makers now have longitudinal data needed to fully understand the scope of the obesity epidemic in the state and to track progress made in combating this epidemic. In developing and implementing a statewide BMI assessment process, lessons were learned that other states might benefit from. Communication that was regular, reliable, and systematic and that was disseminated throughout all levels of the program was very important. The exchange of information had to be bidirectional—between program leadership and staff conducting the assessments. The effort devoted to effective communication is an important factor in the success to date of the BMI initiative in Arkansas. The importance of school personnel and parental buy-in to this process is considered critical by many stakeholders and participants. Additionally, development and fielding of a standardized and simple measurement protocol was demonstrated to be critical. Arkansas is able to proJournal of School Health

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vide single-year crosscutting comparisons among schools and districts in the state. Data collected provides a unique analytic resource allowing for analyses of longitudinal trends. This robustness of analytic potential would not be possible without the creation of a standardized and dependable data set. During this project, it was determined that research-grade assessment equipment was not essential to dependably measure heights and weights on school children. In a state such as Arkansas with many rural and frequently underfunded school districts, it was critical that equipment be readily attainable, available in large quantities, not costly, and easy to use. The equipment discussed above met all these criteria. Arkansas is now in its fourth year of assessing the obesity risks of nearly half a million public school children and transmitting that information confidentially to parents. Schools presently have 2 options for participation in the BMI assessment process: (a) direct, Web-based data entry into the system or (b) data collection on paper forms, which must then be entered by school personnel into the Web site. Thus, schools now perform all data entry, eliminating the cost of and need for contracted data entry at the state level. Of the 2 options presently available for schools, it is believed that the Web-based system is the most efficient as it requires only a single data entry with the program performing immediate quality checks. The Web-based system does require the schools to have an Internet connection at their measurement sites. While not as efficient, the paper-based option does provide schools with more flexibility for measuring students at multiple sites and conducting data entry at a later time, although this feature may result in transcription error. Recently, in response to constituent concerns regarding annual assessments (ie, time away from class and impact on school personnel), the Arkansas legislature amended the periodicity of BMI assessments under Act 201 of 2007.16 As of the 2007/2008 school year, kindergartners and students in evennumbered grades through the 10th grade will be assessed. Students in odd-numbered grades will not be assessed. However, the law still does not address any penalties for those schools that do not participate. The amendment does address an opt-out option for a student. Parents must provide the school with a written refusal if they do not wish their child to participate. Also, under this newly enacted modification to the original statute, the community health nurses will be primarily responsible for quality assurance and adherence to the recommended assessment protocols. Because of the collaboration between health and education officials in the state and the standardized reporting process, participation has been high each year (Table 2).15 While the Arkansas program was initially very labor intensive, the potential

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Table 2. Statewide Participation in BMI Assessments* Year 1 (2003-2004) Category

Year 2 (2004-2005)

Year 3 (2005-2006)

Percent

Total

Percent

Total

Percent

Total

94.3 (1060) 92.6 (426,555)

1124 460,611

98.7 (1115) 95.1 (447,712)

1130 470,571

98.6 (1090) 90.2 (433,808)

1106 480,811

81.8 (348,710) 1.4 (5937) 16.9 (71,908)

426,555 426,555 426,555

83.2 (372,369) 1.1 (4784) 15.8 (70,559)

447,712 447,712 447,712

85.5 (371,082) 0.4 (1568) 14.1 (61,158)

433,808 433,808 433,808

†

Participation Public schools Students (PK-12) Student data available Valid for BMI calculation Not valid for BMI calculation Unable to assess‡

*Source: Adapted from ACHI.15 † Results include all data available for years 1 and 2, and data received by June 14, 2006, for year 3 analysis. Some public schools and districts merged after year 1 and year 2. ‡ The most common reason students were not assessed for BMI was absence from school (of total reporting, 6.3% in year 1, 7.7% in year 2, and 6.7% in year 3). Annually, only 5-6% of students could not be assessed because they or their parents refused to participate.

for ultimate long-term sustainability will increase as personnel time requirements decrease. Interactions with parents indicate their desire for dependable information regarding the health of their children. Receptivity to the annual Child Health Reports has been positive.17 To date, these reports have served as single point-in-time assessments of a child’s BMI status. In future years, the hope is to report both current BMI results and linking to prior year readings to show an individual student’s trend. Additionally, a comprehensive child health assessment that includes other health indicators routinely monitored by schools (eg, vision, hearing) would benefit parents by providing a detailed picture of the health of their children. The dramatic increase in obesity nationally across all age bands demonstrates the need for substantive interventions; that obesity is complex in its genesis informs the need for such interventions to be multifactorial in their design and implementation. Arkansas Act 1220 of 2003 was created to be a statewide, school-based policy impacting child health through a broad spectrum of channels (eg, BMI assessment and reporting, vending machine restrictions, increased healthy menu offerings). While it has yet to be determined which of these interventions has been most efficacious in arresting obesity rate increases in Arkansas (and ultimately, it may prove that these multiple interventions serve to complement each other), their merit and impact are demonstrated through the slowing of the obesity epidemic in Arkansas.15 While ongoing study is required to determine if this effect is sustainable, because early results are promising, it is critical for Arkansas to continue in these efforts, while other states should consider implementing similar programs immediately. Due to the press of other concerns and limited budgets of most school districts, it is unlikely (and understandable) that such efforts would be undertaken voluntarily. As such, legislative mandates may be required for other states to follow the example set in Arkan712

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sas. Creation and passage of this type of legislation will require substantive grassroots activities and coalition building on the part of child health stakeholders and interest groups to secure success. However, the long-term health of our nation requires such all out efforts be initiated immediately. The deleterious impact of childhood obesity on present and future generations, in both their physical and fiscal well-being, will become overwhelming unless addressed. Interventions demonstrating improvement must be communicated and implemented without delay; because of the mounting cost-related obesity, failure to intercede in a timely manner may result in irreversible harm to individuals’ health and the long-term viability of the US health care system.

REFERENCES 1. Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion. The Burden of Chronic Diseases and Their Risk Factors: National and State Perspectives. Atlanta, Ga: DHHS & CDC; 2004. 2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555. 3. Dietz WH. Childhood weight affects adult morbidity and mortality. J Nutr. 1998;128(2 suppl):411S-414S. 4. US Department of Health and Human Services. Fact Sheet: Overweight in Children and Adolescents (The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity). Rockville, Md: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001. 5. US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, Md: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001. Report no. GPO Stock #017-001-00551-7. 6. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998;101(3 pt 2): 518-525. 7. Arkansas Annotated Code 20-7-133-135; 2003. 8. Ryan KW, Card-Higginson P, McCarthy SG, Justus MB, Thompson JW. Arkansas fights fat: translating research into policy to combat childhood and adolescent obesity. Health Aff (Millwood) 2006;25(4):992-1004.

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9. Foxhall K. Beginning to begin: reports from the battle on obesity. Am J Public Health. 2006;96(12):2106-2112. 10. Levi J, Juliano C, Segal L. F as in Fat: How Obesity Policies Are Failing in America 2006. Washington, DC: Trust for America’s Health; 2006. 11. Bost JE, Harris MM, Thompson JW, Shaw JL, Ryan KW. Choosing a scale and stadiometer for the statewide BMI assessment of Arkansas school children—statistical results from the pilot schools. In: North American Association for the Study of Obesity, Annual Scientific Meeting. Las Vegas, Nev: Obesity Research; 2004. 12. Harris MM, Justus MB, Bost JE, Shaw JL, Ryan KW, Thompson JW. Development of school-based measurement protocol for statewide BMI assessment. In: North American Association for the Study of Obesity, Annual Scientific Meeting. Las Vegas, Nev: Obesity Research; 2004. 13. Lohman TG, Roche AF, Martorell R, eds. Anthropometric Standardization Reference Manual. Champaign, Ill: Human Kinetics Books; 1988.

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14. Centers for Disease Control and Prevention. Overweight and Obesity: Defining Overweight and Obesity (Data Source: Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion). Atlanta, Ga: Department of Health and Human Services; 2005. Available at: http:// www.cdc.gov/nccdphp/dnpa/obesity/defining.htm. Accessed May 11, 2007. 15. Arkansas Center for Health Improvement. Tracking Progress: The Third Annual Arkansas Assessment of Childhood and Adolescent Obesity. Little Rock, Ark: ACHI; 2006. Available at: http:// www.achi.net/BMI_Info/Docs/2006/Results06/ACHI_2006_ BMI_National_rpt.pdf. Accessed May 11, 2007. 16. Arkansas Annotated Code 20-7-135; 2007. 17. Fay W. Boozman College of Public Health. Year Two Evaluation Arkansas Act 1220 of 2003 to Combat Childhood Obesity. Little Rock, Ark: University of Arkansas for Medical Sciences; 2006. Available at: http://www.uams.edu/coph/reports/Act1220Eval. pdf. Accessed May 11, 2007.

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