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RJ Manchester and Erica Asti, staffers at the Florida Hospital for Children, along with Dr. Angela Fals and her team, spent years working with obese children and families in their Central Florida CCFW clinic.
The local childhood overweight and obesity rates ranged from 32% in Orange County (28.7% Latino population) to 64% in Osceola County (48.6% Latino).
The team was growing increasingly concerned about younger and younger patients with obesity-related health complications.
“We were having some of the youngest patients we’ve ever had in the weight and wellness clinic with pre-diabetes and diabetes,” Asti said.
They wanted to step up in a big way.
An underlying issue: No P.E.
Asti and Manchester and the CCFW team discovered that many parents misidentified their overweight or obese child as a “normal weight.” Therefore, many parents were unable to assess their child’s increased risk of diabetes and other obesity-related diseases.
“The word ‘normal’ is something that society and the families we work with have misconceptions about,” Manchester said. “What they are calling a healthy weight is actually obese.”
At the same time, Manchester and Asti and the CCFW team learned from parents about another part of the obesity problem: P.E. and health classes were continuously being edged of schools and kids weren’t participating in recommended levels of physical activity.
This is particularly a problem in schools with large Latino populations. Studies show minority majority schools are less likely provide 20 minutes of recess daily or 150 minutes of P.E. weekly compared to schools with large white populations.
Manchester and Asti, who were already running a healthy weight and wellness clinic for obese children and families struggling with pre-diabetes and diabetes, decided to try to take prevention to the schools.
They wanted to develop a prevention curriculum to complement their intervention work at the CCFW in order to reach children before they became patients in the hospital.
“We had a weight and wellness intervention program, but we weren’t really actually working on that prevention piece in the community,” Asti said. “We didn’t just want to be intervening, we wanted to be preventing.”
Creating a wellness curriculum
In late 2009, Manchester and the CCFW team began developing partnerships and researching physical activity programs for kids that aligned with the hospital’s philosophy of health and wellness.
The goal was to “extend the hospital’s philosophy of health and wellness out into the community and into the schools,” Manchester said.
Florida Hospital for Children decided to partner with Beacon Health Systems in South Bend, Ind., which sponsors the HealthWorks! Kids’ Museum, as well as Sanford Health, which sponsor WebMD FIT; they used WebMD FIT information to determine what kids should be doing and had HealthWorks! Kids’ Museum help develop a curriculum.
They also integrated the hospital’s health and wellness philosophy, which is based on the Healthy 100 movement and the culture of CREATION Health. The Healthy 100 movement and culture of CREATION Health were adopted from research about the behaviors and lifestyles of centenarians—people who live past age 100. Research has found that centenarians tend to live in small communities and share similar characteristics. These similarities are the foundation of the culture of CREATION Health, which encompasses the whole person (mentally, physically, and spiritually) with the eight universal principles of health: choice, rest, environment, activity, trust, interpersonal relationships, outlook, and nutrition.
The FIT team started to envision a health program for students that would teach students the importance of a holistic approach to wellness (physical fitness, nutritional fitness, emotional fitness and restorative fitness) in a fun, interactive way.
In 2008, the hospital celebrated its 100th anniversary with a goal of increasing their commitment to prevention in the community.
The FIT team wanted their curriculum, which they soon started calling Mission: FIT Possible, to become a part of the hospital’s greater commitment to the community.
Mission: FIT would use the hospital’s name and reputation when attending community events. Back by the hospitals name, they would inform community members about the program, demonstrate Mission: FIT activities, and ask parents to contact their child’s principal and request the program.
Through parental advocacy, Mission: FIT had a line of eager schools willing to participate.
But support was already growing.
The FIT team didn’t encounter much resistance to the development of Mission: FIT. In fact, before the development of Mission: FIT, schools had already reached out to the hospital requesting programs and resources to improve student health.
Additionally, the program does not charge participating schools and is funded by multiple sources (partnerships with school, hospital, and community foundations, like Winterpark, and fundraising events).
The timing of Mission: FIT was right.
Covering the bases of child health
In additional to already eager principles, the FIT team continued to generate support to implement Mission: FIT.
“If you don’t have the [school] principal to stand next to you and agree, you are really an outsider,” Asti said.
Mission: FIT partnered with schools, school health advisory councils, local governing bodies, the YMCA, other hospitals and even General Mills.
“The more programs and the more places we can be, the more kids we are going to reach,” Manchester said.
Manchester said the best way they did marketing was by going to community events and having families advocate for the program in their kid’s schools.
Linsy Joyner, the REACH Program Coordinator at Christ School, heard about the program from a parent. Joyner thought it would be great for her students to bring Mission: FIT Possible in to teach about a healthy lifestyle.
Mission: FIT was designed as a childhood obesity and disease prevention program to complement the hospital’s clinical intervention programs by reaching kids in schools.
The program provides physical activity, nutrition education, and wellness education for elementary school students at the ground level without charging schools, without burdening teachers with more work, and without burdening parents with more things they “should” do for their children’s health.
The program was developed over several iterations over two years through their partnerships with HealthWorks! and WebMD FIT.
Implemented for free in schools by hospital staff, Mission: FIT instructors, also known as “agents,” and “Edutainers,” teach holistic wellness in a fun interactive way to appeal to kids. They use secret agent badges and missions that require kids to uncover secret clues related to healthy living based on the following four main concepts, also known as missions, based on the principles of CREATION Health:
- Food Mission: Nutritional fitness
- Move Mission: Physical fitness
- Mood Mission: Emotional fitness
- Recharge Mission: Restorative fitness
“The whole program is based on the kid’s reaction. Our lessons are all based on the kids learning something, having a great time, laughing, eewing, awing. If we aren’t getting those things in our lessons, then we’re not doing it right,” Asti said. “So it’s all about engagement.”
Joyner refers to the Mission: FIT instructors as “edu-tainers” because they entertain the students while they educate them.
“They have scripts that they follow,” said Joyner “It’s almost like a comedy act. The kids are so engaged and so involved and they really remember what they are taught.”
In January of 2012, Florida Hospital for Children piloted Mission: FIT in nine schools for the spring semester. The schools provided feedback and a majority of them asked Mission: FIT to return the following semester.
Bringing the program to more schools
Mission: FIT agents provide five 30-minute visits per school, per semester. They complete one of the four missions per visit and integrate all four missions into the final visit.
Manchester and Asti agree that having Mission: FIT agents on the ground is a vital aspect of implementation.
“It’s special that we go out to the schools and bring them the program,” Asti said. “Other schools already have so much weight on them and so much that they have to do. This is just another thing. So to be able to have someone come into the schools and not only teach the things that we teach, but touch on schools standards, I think it’s really valuable.”
Although Mission: FIT staff implement the program, a teacher or coach provides support and monitors student behavior.
Evaluation is also an important aspect of implementation. Mission: FIT conducts pre- and post-screenings at the first and final visit. They assess knowledge, self-report behavior, and body mass index (BMI). Screening is an important part of evaluation to determine the program’s effectiveness and to potentially obtain funding; however, Mission: FIT faced slight resistance when trying to get schools on board with the screening process.
By their second semester (fall 2012), they were already in 17 schools and have averaged 18-20 schools per semester ever since.
When Mission: FIT provides free obesity prevention and health education programs in schools, they reduce barriers related to cost, accessibility, and time for both parents and schools. Those barriers might otherwise prevent students from participating in physical activity or learning about holistic wellness.
It is particularly important to reduce these barriers in Latino communities, which disproportionately lack physical activity opportunities and nutritious food.
That’s why Mission: FIT is developing Spanish-language curriculum in the near future. In the past, they provided a Spanish-speaking instructor and the hospital provides Spanish brochures. They don’t just want to translate the current program into Spanish, but they want their secret agents, secret clues and missions to also be culturally relevant.
According to Manchester and Asti, the program’s success and sustainability are illustrated by increasing demand for the program in area schools, anecdotal stories of behavior changes, and hospital and clinic results.
The team continue to hear about and witness healthy changes in their community. They hear how parents, teachers, coaches and principles get inspired, and they see changes in their community’s attitudes and behavior.
Asti said they go to schools that don’t have health initiatives, and the next thing you know they are providing an event on health and wellness and they are changing their cafeteria.
Parents say that kids bring the information home and teach their families, and principles say that kids are teaching other kids at school. Asti refers to this as a trickle-down effect and she attributes it to supporting people that don’t typically feel like they have support.
“Mission: FIT can’t do it all, so it is cool seeing community members do even more with it,” Asti said.
In the weight and wellness clinic, the CCFW team see kid’s actual blood work change and they see pre-diabetes goes away. Of the children that have gone through Mission: FIT, Asti said they have seen improvement in all areas—knowledge, self-report for all behavior, and body mass index (BMI):
- 92% spend less time in front of a screen
- 94% exercise more
- 89% are in a better mood
- 96% are sleeping better
- 92% report eating less sugar
- 95% reporting eating more fruits and vegetables
These are changes that will have a positive impact on the students for the rest of their lives, Asti said.
In addition to assessing community feedback and outcome objectives, Mission: FIT’s staff constantly evaluates their processes and seeks ways to improve. For example, when they worked with large groups, they realized the program wasn’t as effective and the engagement was slightly lost when compared to working with smaller groups. They value the engagement component of the program and don’t want to spread themselves too thin.
To avoid spreading the program too thin, both the sustainability and the expansion of Mission: FIT are dependent on additionally funding. The program is currently at capacity in 20 schools per semester. However, there is demand for more teams and a more expansive curriculum. There is an actual waiting list of schools that want their programs. There are least 25 elementary schools in each of the three counties served by the Florida Hospital for Children, and that doesn’t include surrounding counties that also request the program.
Mission: FIT staff also seeks new ways to improve through continued education and collaboration with obesity prevention professionals, such as Manchester’s attending the 8th Biennial Childhood Obesity Conference.
Mission: FIT Possible’s goal is very wide-scale, yet very doable.
“Within a few three-ring binders, anyone can recreate this program just about anywhere in the world, if the funding exists,” Manchester said.
By The Numbers
33
percent
of Latinos live within walking distance (<1 mile) of a park
This success story was produced by Salud America! with support from the Robert Wood Johnson Foundation.
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