Lifetime Goals: Becoming A Family Medicine Physician

Friday, November 19, 2021 8:33:39 AM

Lifetime Goals: Becoming A Family Medicine Physician

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You and your partner will have less stress if the transition into a new family system is smooth. Less stress often means better health. At some point in your relationship, you and your partner will decide if you want to have a baby. Some couples know going into a relationship that they do not want children. Parenting is one of the most challenging phases of the family life cycle. The decision to have children is one that affects your individual development, the identity of your family, and your relationship. Children are so time-consuming that skills not learned in previous stages will be difficult to pick up at this stage. Your ability to communicate well, maintain your relationships, and solve problems is often tested during this stage.

Introducing a child into your family results in a major change in roles for you and your partner. Each parent has three distinct and demanding roles: as an individual, a partner, and a parent. As new parents, your individual identities shift along with how you relate to each other and to others. The skills that you learned in the Independence and Coupling stages, such as compromise and commitment, will help you move to the Parenting stage. Along with the joy that comes from having a child, you may feel a great deal of stress and fear about these changes. A woman might have concerns about being pregnant and going through childbirth. Fathers tend to keep their fears and stress to themselves, which can cause health problems.

Talking about your emotional or physical concerns with your family physician , obstetrician , or counselor can help you deal with these and future challenges. Adapting children into other relationships is a key emotional process of this stage. You will take on the parenting role and transition from being a member of a couple to being a parent. While you are still evolving as individuals, you and your partner are also becoming decision-makers for your family. Continuing to express your individuality while working well together as a couple results in a strong marriage. Your child's healthy development depends on your ability to provide a safe, loving, and organized environment.

Children benefit when their parents have a strong relationship. Caring for young children cuts into the amount of time you might otherwise spend alone or with your partner. If you did not fully develop some skills in previous phases, such as compromise for the good of the family, your relationship may be strained. For example, divorce or affairs may be more likely to occur during the years of raising young children if parents have not developed strong skills from earlier life stages.

But for those who have the proper tools, this can be a very rewarding, happy time, even with all of its challenges. Optimally, you develop as an individual, as a member of a couple, and as a member of a family. Parenting teenagers can be a rough time for your family and can test your relationship skills. It's also a time for positive growth and creative exploration for your entire family. Families that function best during this period have strong, flexible relationships developed through good communication, problem solving, mutual caring, support, and trust.

Most teens experiment with different thoughts, beliefs, and styles, which can cause family conflict. Your strengths as an individual and as part of a couple are critical as you deal with the increasing challenges of raising a teenager. Strive for a balanced atmosphere in which your teenager has a sense of support and emotional safety as well as opportunities to try new behaviors. An important skill at this stage is flexibility as you encourage your child to become independent and creative. Establish boundaries for your teenager, but encourage exploration at the same time. Teens may question themselves in many areas, including their sexual orientation and gender identities. Because of what you learned when you developed your identity in the earlier stages of life, you may feel more prepared and more secure about the changes your child is going through.

But if you did not work through these skills at earlier stages of life, you may feel threatened by your child's new developments. Flexibility in the roles each person plays in the family system is a valuable skill to develop at this stage. Responsibilities such as the demands of a job or caring for someone who is ill may require each person in the family to take on various, and sometimes changing, roles. This is a time when one or more family members may feel some level of depression or other distress. It may also lead to physical complaints that have no physical cause somatization disorders such as stomach upsets and some headaches along with other stress-related disorders.

Nurturing your relationship and your individual growth can sometimes be ignored at this stage. Toward the end of this phase, a parent's focus shifts from the maturing teen to career and relationship. Neglecting your personal development and your relationship can make this shift difficult. You also may begin thinking about your role in caring for aging parents. Making your own health a priority in this phase is helpful as you enter the next stage of the family life cycle. The stage of launching adult children begins when your first child leaves home and ends with the "empty nest. If your family has developed significant skills through the family life cycle , your children will be ready to leave home, ready to handle life's challenges.

Free from the everyday demands of parenting, you may choose to rekindle your own relationship and possibly your career goals. Developing adult relationships with your children is a key skill in this stage. You may be challenged to accept new members into your family through your children's relationships. You may focus on reprioritizing your life, forgiving those who have wronged you maybe long ago , and assessing your beliefs about life.

If you struggled with previous life phases, your children may not have learned from you all the skills they need to live well on their own. If you and your partner have not transitioned together, you may no longer feel compatible with each other. But remember that you can still gain the skills you may have missed. Self-examination, education, and counseling can enhance your life and help ensure a healthy transition to the next phase. This is a time when your health and energy levels may decline. Some people are diagnosed with chronic illnesses. Symptoms of these diseases can limit normal activities and even long-enjoyed pastimes.

Health issues related to midlife may begin to occur and can include:. You may also be caring for aging parents in this phase, which can be stressful and affect your own health. During the retirement phase of the family life cycle , many changes occur in your life. Welcoming new family members or seeing others leave your family is often a large part of this stage as your children marry or divorce or you become a grandparent. This stage can be a great adventure where you are free from the responsibilities of raising your children and can simply enjoy the fruits of your life's work. Challenges you may face include being a support to other family members, even as you are still exploring your own interests and activities or focusing on maintaining your relationship.

Many people are caring for elderly parents at this time. You may feel challenged by their emotional, financial, and physical needs while trying to help them keep their independence. You may experience declining physical and mental abilities or changes in your financial or social status. Sometimes you must deal with the death of other family members, including your partner. The quality of your life, in part, depends on how well you adjusted to the changes in earlier stages. Bard, I discovered a passion for medicine and patient interaction. In order to further my knowledge, I began volunteering in emergency medicine at my local county hospital.

One morning, I was asked to help with wound care of a patient who had fallen off a ladder. He was shrieking in anguish as I tried to assuage him while simultaneously positioning the basin and his arm in place for the nurses to irrigate the wound. The intensity of this situation taught me how to establish a genuine relationship with a patient while still providing effective care. Despite the chaos of the ER environment, I noticed many doctors still strived to connect with their patients and develop a relationship during treatment. To observe dedicated physicians serving all their patients with the utmost level of care reaffirmed my decision to pursue medicine. I knew that one day I wanted to apply my medical knowledge to make the same emotional impact on people.

Teaching is a catalyst through which strong relationships can be forged and beneficial outcomes can be achieved. Walking in, I noticed the Ramirez family was living with the bare minimum. As I brought in the guitar, I saw 5 year-old Edgar waiting eagerly at the front door, with his eyes wide open and a massive smile across his face. I offered to teach him how to play a few chords and he quickly agreed. The feeling of teaching Edgar was very similar to how I felt observing the doctors I shadowed help their patients. As he started to pick up the different fingerings, his sense of joy became palpable, and I was elated knowing my efforts had benefitted him. It was deeply rewarding to contribute to a positive change in this child. During my tenure, I returned to a middle school where I gave a presentation on nutrition.

As I entered the auditorium, I saw some familiar faces looking relieved to be missing class for my presentation. I was shocked and elated that someone had actually remembered my lesson from the previous year. Throughout the presentation, I noticed several students remembered bits and pieces of information about the 5 food groups. In that moment, I got a glimpse of how Dr. Bard felt with her pre-diabetic patient. Although all of my experiences vary from one another, each experience has similarly impacted me by further developing my ability to establish relationships and influence people to live a healthy lifestyle.

I have learned that health care occurs through several different modalities, such as preventative care, secondary care, or health outreach and instruction. All of these different components of health care have broadened my view of what it means to be a medical professional and how vital it is to have this holistic mindset. This newly developed mindset coupled with my fascination of learning and understanding biological phenomena has confirmed my decision to pursue a career as a medical doctor. I had just finished packing my suitcase for my first trip to see snow when the phone rang.

She cried out hysterically and looked over helplessly at my father, who nodded solemnly at her, as if he already knew. It was at this moment that my sunny, snow-tipped Utah mountains turned into the gloomy reality that my father had a brain tumor. It was devastating to imagine losing my father, my idol, at the mere age of eleven. Tremendous despair loomed over us for months, until we made our way to Richmond, Virginia. The encounter that followed helped tame the tornado that my life had become over the past six months. Who knew that a savior could look so modest? The surgeon, Dr. Roberts, assuaged our worries and assured us that the future was brighter than expected. He seemed unfazed by our endless barrage of questions, handling the situation with the compassion and empathy that was vital for our fragile states at the time.

This was probably just another day at the office for him, but it had a profound impact on me—my hero, my father, would continue to walk this earth. I longed to leave a similar everlasting impression on others and commenced my journey towards a career in medicine. Unbeknownst to me at the time, a five-year-old presenting with a fever of and neck pain would evolve into a situation where I would be able to emulate Dr.

She presented to the office of Dr. Mitchell Soo, where I have served as a medical assistant for nearly two years now. Her family was in shambles due to her abysmal condition. Soo, being the thorough, persistent physician that he is, provided me the opportunity to keep tabs on her progress. This consisted of daily phone calls with her parents, followed by persistently checking in on the preliminary blood culture results and relaying updates to Dr. Soo for feedback. Fast-forward to about six months down the road, when this patient returned for her Well Child Check. During the work-up, she was full of energy, going from toy to toy, grinning so big that an outsider would have thought it was Christmas morning.

Seeing the stark improvement in the child made our previous encounter that much more rewarding. Most importantly, this job has offered me an avenue to see into Dr. Luckily, Dr. Furthermore, through my incessant prying, I have gained invaluable practical knowledge, from why he primarily starts with lisinopril to combat hypertension to what indicates possible ischemia on an EKG to why protein may be found in urine. Working under him, I have noticed that, even after practicing for 20 years, he constantly reads up on medical literature to add to his arsenal of skills and to stay current with the new advancements in the field. On an otherwise relatively quiet Thursday afternoon, I found myself in a position where I needed to expand my own knowledge.

One of the patients called in a frenzy because his INR was down to 1. Due to an upcoming Orthopedic injection, he needed to bring his INR down to 1. That night, with questions still looming from this encounter, I decided to do some of my own research to better serve patients if this question came about in the future. I read articles explaining how the INR value was calculated, the various target ranges for different types of patients, and when a Lovenox bridge is applicable.

In hindsight, this extracurricular activity served me well, as the patient called again the next day because his INR was still too high and Dr. This newly acquired knowledge allowed me to keep up with her and get this patient the answers he needed before the weekend. Despite my modest role in their care, the patients genuinely appreciate my approach and dedication to the job. Throughout college I juggled various cooking jobs on top of my rigorous premedical class schedule. For centuries, Indian culture has placed a high value on holistic health. Despite growing up in rural Arkansas, far from my extended family in India, this emphasis on health defined much of my upbringing.

A grocery store trip often turned into a social event, with my mother stopping to catch up with numerous patients or their family members. I passed up Saturday morning cartoons to follow my mother through rounds at the hospital, amazed by the trust patients place in their doctor. From a young age, I was drawn to medicine because of my desire to form meaningful relationships with people from all walks of life within my community, and to work together to care for their health. At Vanderbilt, I was excited to continue my journey to becoming a doctor.

Yet, my premed courses did not emphasize the human aspect of medicine—the integral element to which I was attracted. I wanted to engage with patients and learn about healthcare from their perspective. So, I enrolled in a study abroad program in Mexico where I conducted community-based public health field research. I explored the attitudes surrounding chronic diseases in Guerrero, a state with the second highest poverty rate in the country. While I understood diabetes to be a manageable disease in the U.

Without basic knowledge of diabetes, the community members equated it with amputated limbs and blindness. But explaining that people with diabetes could live long lives with the proper medications and a healthy diet was not enough. Tierra Caliente, a rural region where I spent several weeks, was a food desert and residents lacked access to healthy foods. I helped the woman make more informed diet choices given the options, while recognizing that she was already at a disadvantage due to socioeconomic factors, such as her inability to afford insulin.

My group and I also helped form a support group where women with chronic diseases gather to share their health problems and also to discuss personal and social challenges facing their community. Addressing these sociocultural factors, by having the community pool their resources and share their enhanced knowledge of diabetes, was crucial in helping them manage the previously mysterious disease. Through my work in Mexico, and later in North Carolina and Virginia, I have learned that exploring local understandings of health, to discover systemic factors that affect individual patients will be an important part of my work as a doctor, though not the only one.

I must also employ this knowledge to provide patients with the social support they need to navigate the health system confidently, which, in turn, will increase favorable health outcomes. I attempted to apply this approach while working as a medical scribe in Virginia, where I met a heavily tattooed, muscular patient who apologized for what might be a long visit, as he had not seen a doctor recently. His blood pressure was sky high and he was at an immediate risk for a stroke; he had run out of his medication months ago.

When the doctor left the room to call his pharmacy, I stayed behind to review his medical history. I inquired about his past surgery. He further disclosed that his life was devoid of fear, even after a year prison sentence and homelessness. In this vulnerable moment, my instinctive reaction was to reassure him that he would be okay, as he was in good hands. After the visit ended, I took a few extra minutes to explain where he could get his medications, an X-ray, and a follow-up appointment, as he was not familiar with navigating a healthcare environment.

This small amount of support went a long way for this man who was estranged from his family and struggling financially. I could sense his relief as he walked out of the clinic, visibly transformed, with the newfound self-confidence that he could care for his health and forge a new life. As a doctor, I will diagnose symptoms and give my patients the necessary treatment they need. But more importantly, I will practice with compassion and work to uncover the hidden sociocultural factors that may be underlying their diagnoses.

This concept of holistic health is rat the heart of my desire to become a doctor. As a doctor, I will immerse myself in my community, get to know my patients personally, and advocate for their health. I partly grew up in Bangkok, a city in which there are more shopping malls than there are psychiatrists. I did this math as soon as I found out that my older sister had attempted suicide outside of a shopping mall.

The stigmatization of mentally illness is still widespread in Thailand and as a result, the hospital and my family treated her case as anything but a suicide. At the time, I was reading The Yellow Wall Paper in school, a story about inadequately treated postpartum depression in the s. I saw parallels, as my sister had begun to look gray after the birth of her daughter.

I repeatedly voiced my concern, but no one listened to me. No one was addressing her health from a broader perspective, and as a result, she was left to fend for her own mental health. She was powerless, and I felt powerless too. This blindness for mental wellbeing in my society confounded me, so I chose to study it further at UT Austin. When I began working at the Dell Seton Medical Center, however, my idealism about patient-centered care was quickly put to the test when I was regarded with cynicism due to my own identity.

One afternoon, a diabetic patient approached me for assistance in applying for food stamps. Although he was visibly in discomfort, he refused the chair I pulled out for him. While we gathered information, he gruffly asked me where I was from. Unsatisfied with my answer, he repeated his question eight more times until I caved and answered with my ethnicity. Following this, he grew impatient and kept insisting he could complete the process with another shift. But I knew arranging transport would be difficult and costly. Determined to turn the interaction around, I soldiered on with the application process. I uncovered that he had a daughter, and I inquired after her interests. He grew animated as he talked lovingly about her, and I completed my work.

Commuting home in the dark, I beamed; I was able to build rapport and assist someone who did not initially believe in me. I strove to supplement my education with parallel experiences in research and volunteer work. In a course about stigma and prejudice, I discovered that minority status was a marker for increased IL-6 inflammation, and that individuals primed with stereotypes about race, sex, or disease suffer greatly, but often invisibly. Walking out of lecture, I planned out how I could implement these findings in my own work. During data collection for a community sleep study, I applied my renewed perspective on the phone with a participant. I sensed exasperation in her voice, so I sincerely thanked her for her time.

Suddenly, she began to wail into the phone. As her personal story unraveled, I found out that experiences of racial discrimination had breached every area of her life, including her healthcare—as a result, she felt alienated and left with inadequate treatment. When she expressed thoughts of suicide, I began to panic. But I kept my voice composed, reinforced her resilience, and gained a verbal confirmation that we would speak the next day. But this time, I was equipped with my education. The more I learned about the social determinants of health, the clearer it became that healthcare was inherently social. This solidified my interest in medicine and motivated me to pursue research in social psychology. As I trained on how to code facial expressions for my honors thesis, I shadowed Dr.

Sekhon, a geriatric psychiatrist, at an assisted living facility. One of his patients was an injured former athlete who was having trouble standing. Instead of altering medications or suggesting tests, he encouraged his patient to stand for 10 seconds longer each day. There was a shift in the room, and I could measure it by the expressions on their faces. The way a physician could read facial expressions to address what the patient did not verbalize was incredibly powerful—I was awestruck. Inspired by this observation, I wrote my honors thesis on the relationship between power and health outcomes.

Experiences of disempowerment and of illness magnify one another—but a doctor can empower someone in their most vulnerable moments by connecting with them. Much like my sister, many patients need clinicians that address both physical and invisible hardships. I am eager to be part of a new generation of healthcare providers with sensitivity to the diverse ways that people communicate distress and wellbeing. One patient at a time, we can shift archaic mindsets deeply rooted in our communities, and ensure that every life we touch receives socially and culturally competent care.

For me, studying medicine means being part of something bigger by empowering others—and myself along the way. Elijah is a 12th grader in the South Bronx who has no less promise than I did. And yet, he had no plans on attending college. I met Elijah through a mentorship program at his high school; he was steps ahead of his peers. When asked about college, he looked despondent. He explained that his housing project, built during World War II and notorious for lead poisoning, would be demolished by the end of the year with no promise of housing afterwards.

During our conversation, he looked away and lowered his voice as he muttered that he could not even consider starting college when he was unsure if he would even have a home in July. Elijah was later forced to move to an even cheaper project, continuing a damning cycle of poverty. Having worked closely with the underserved populations of New York City, I am acutely aware of the inequality in education and health that many face. The fact that every social determinant of health I witnessed was preventable was deeply disconcerting.

Determined to learn how community health can drive change, I joined a free clinic in the Bronx. In the clinic, a young woman named Alicia showed me how NY is truly a tale of two cities; neighborhoods just a few miles apart reflect grossly disproportionate access to care. As I guided Alicia through the stations at a health fair, her anxiety showed, especially when I offered a flu vaccine. Her continued reluctance with preventative care showed me that helping the underserved goes far beyond the delivery of care; it involves building a more intimate relationship with the community served and developing prolonged trust.

The health inequity propelled me to improve healthcare through a social lens in communities most in need. My exposure to direct care through the clinic motivated me to pursue a career in using clinical medicine to address social determinants of health. To further explore this idea, I spent time conducting prostate cancer research at the Shanghai International Hospital in China. I conducted patient interviews to investigate why the vast majority of men forgo early detection screenings.

No doctor ever told me. At the same time, I felt motivated to pursue medicine and directly change thousands of lives. I left knowing that preventative health education is as much in the hands of physicians as it is of the education system, and direct, culturally competent work with patients in the clinic is paramount. In the clinic, I observed the role of social class and race in prostate cancer treatment outcomes. Through patient interviews, we found that the majority of early stage symptoms went unrecognized due to a lack of information on the disease, both in the patient and medical communities. Subsequently, we created and implemented educational techniques to bridge the gap in medical knowledge of prostate cancer, for which I presented my findings to a medical audience at a conference.

I understood that to confront the health disparities I witnessed in New York in the most tangible way possible, I would need to focus my efforts such that the clinic functions as a classroom. In New York, the magnitude of health disparities has shaped my passion to pursue medicine. I am determined to take a more comprehensive approach to medicine by investing in community- level health programs while working in the clinic to stay in touch with the populations I aspire to treat. Identifying educational disparities, the clinical outcomes they drive, and engaging them directly will be the template for my career. My experiences with disadvantaged communities in the clinic and classroom have helped me such that the next time I meet an Elijah or Alicia in the clinic, the interaction is comprehensive, culturally competent, and combats the source of their inequity.

I am privileged to have the chance to pursue medicine to gain the necessary tools in conjunction with my own experiences to be able to better provide holistic healthcare and education attuned to the communities I hope to serve. Each time I acquire a new language, I rewire my mind. Japanese, Spanish, and American Sign Language each introduce a unique set of grammatical structures, tones and prosodies, and idiomatic expressions. If the mental gymnastics of acclimating to new linguistic mechanics are not challenging enough, truly communicating with a native speaker is an entirely separate difficulty. Years of intensively studying Japanese bred a sense of proficiency, but even a whole summer of immersive learning at the University of Tokyo only scratched the surface of authentic communication.

Though challenging, my experience there reaffirmed why I love learning languages; it connects people. Similarly, connections are made through medicine, a different kind of language. In medicine, I can communicate support and forge bonds through my passion for healthcare. Similarly to when practicing language, flexibility, perseverance, and empathy enhance my ability to pursue medicine, steering not only my education and interests, but my desire to become a physician. Effective communication, in both linguistics and medicine, is crucial for effective leadership. This was evident when I led a seminar and week-long immersion trip to New Orleans to experience and work to improve the environmental and economic climate of the area.

Intending to support the construction of new homes in the Lower Ninth Ward, our plans fell through when a miscommunication led us to arrive without the appropriate tools. This prompted last minute improvisation, and as the leader, it was mine to design. We found ourselves participating in unexpected tasks, such as marking cemetery graves. Initially disappointed by the mix-up, further reflection revealed how our flexibility and unexpected interactions established a unique understanding of people and culture.

Mutual engagement gives meaning to service, whether in a hospital, or dilapidated cemetery. An appreciation for this reciprocal relationship built through communication is what excites me for the dynamic connections between colleagues and patients in healthcare. I explored language from a developmental perspective in my research at the Child Development Lab. Under Dr. Kirkland I investigated factors contributing to, and downstream effects of early language abilities. Maintaining a level of intellectual curiosity is a necessary component to successful learning, and is something I have fostered not just in research, but in my premed studies.

This curiosity pushes me to go beyond what I see and learn, to find deeper connections between science and its applications. I am excited to foster and fuel this curiosity as I delve deeper into the medical field. Unfortunately, common language does not necessitate perfect communication. I witnessed this firsthand while volunteering at the county hospital. My responsibilities of taking vitals, rooming, and stocking taught me much about the operations of a medical clinic.

In a clinic focused on the underserved, a recurrent theme was how often patients would fail to comply with prescriptions or appointments. Being exposed to such unfortunate, yet common problems in healthcare, I found myself rededicated to the field. Only in medicine can I employ my unique skills and interests to their fullest potential. I do not yet have the qualifications necessary to completely treat patients, but I look forward to increasingly being able to heal patients, especially those whose healthcare is obstructed by language and other barriers.

Unobstructed language can be a powerful tool for positivity, which was made apparent when serving as a counselor at Camp Stevens, a summer camp for children whose parents have been affected by terminal illness. I experienced success in showing inexplicit support one day when I saw a camper sulking. When persuasion to join a Camp game failed, I just talked to him. I was surprised by how well this 9 year old and I connected. He eventually perked up, and joined a game of football. While happy to find success here, I cannot help but think of the effect I can have on future patients. Whether in giving a diagnosis, or assessing options with a patient, unspoken support is critical to effective medical practice, and is a facet I look forward to exploring more as a clinician.

While I have a fascination for languages, I am less interested in the tongues themselves as much as the connections they create. And while all languages can communicate compassion, medicine encapsulates the essence of compassion. Physicians have the unique ability and responsibility to both treat, and communicate support to their patients. Connecting to, and conveying support to others is my defining goal, both in learning new languages, and in working to become a great physician. While I continue studying new languages, medicine is the primary tongue I wish to master, as I focus my skills and passions on forging connections through healing.

At eight years old, I was certain that close run-ins with death were the stuff of movies—nothing more than an obstacle for a fictitious protagonist to overcome. She recovered within a few weeks of medical supervision, but this event planted in me an interest in the medical profession that has only continued to grow. Since then, I have nurtured and explored this interest in medicine throughout my undergraduate studies and extracurricular endeavors. As a student, I have devoted the majority of my time at UT Austin to understanding the biological, physical and chemical processes of the world we live in.

To satisfy my intellectual curiosity, I decided to apply the knowledge that I had mastered in the classroom by getting involved with research. At the Bio Sciences Lab, I used molecular biology, analytical chemistry and microbial genetics to help discover and characterize an important group of genes involved in the biosynthesis of vitamin B Like a detective, I uncovered clues with each set of experiments I conducted. Each clue slowly revealed how this group of genes function together to synthesize a molecule central to human metabolism.

In many ways, medicine is no different. When I shadowed Dr. In medicine, just like in research, a physician uses all of the tools at his or her disposal to uncover clues that will ultimately help diagnose and treat the patient. My experiences as an undergraduate researcher have continuously reaffirmed my desire to choose a career that is intellectually challenging and grounded in the sciences. Warren, an endocrinologist, I learned that being a physician means so much more than knowing the physiology of a certain disease state.

Being a physician means having a patient trust you to insert needles into their neck to biopsy a suspicious thyroid nodule. It means dealing with the frustrations of patient non-compliance and the exhaustive amount of paper work, which follows each patient encounter. But more than that, I learned that being a physician means having the privilege to build a relationship with that patient and the responsibility to leave that individual in better health than when they first entered your clinic. I look forward to one day building these sorts of relationship with patients of my own as I progress through my journey to become a physician. Although many of the experiences I had while shadowing physicians have been educational, motivational and at times even humbling, my most direct exposure to medicine has been through my volunteer work at St.

As a volunteer, what I did was important, but I wanted to do more for my community and I refused to wait until I was a physician to do so. Most of my students were Economics or Business majors who had never taken a Public Health course, so I saw this as an ideal opportunity to impress upon them the importance of this issue. From this teaching experience, I learned to take complex ideas about biology and public health and make them approachable and relevant to a group of individuals coming from many different backgrounds.

I am grateful for the opportunities I have had to volunteer and to learn from my professors, research mentors and the physicians who I have shadowed—but I am equally as grateful for the opportunities I have had to teach others. In choosing to become a physician, I have found a profession that seamlessly combines my unwavering curiosity for science and medicine with my passion to help others. Although I understand that the journey to becoming a physician is long and demanding, my experiences have assured me of my choice; I cannot imagine for myself a profession as personally gratifying and intellectually fulfilling as medicine.

As a bacterium that thrives in a pH of 2. Yet in the fall of , this microorganism was responsible for sparking a change of heart in a high school senior who had previously been determined to avoid pursuing a career in medicine. Years of empty lawn chairs at soccer matches and unattended music recitals had convinced me early on that medicine was simply not for me—that my physician parents had been afflicted with a predisposition for self-destructive altruism that had graciously skipped over me.

The story of Dr. Barry Marshall infecting his own body to prove that this bacterium caused gastric ulcers resonated with something deep inside of me. I considered this stirring example of self-sacrifice and was moved by the notion that Dr. Marshall must have experienced a profound pride in knowing his work had positively influenced the lives of others. I began my journey towards a career in medicine with hopes of experiencing such a sense of fulfillment. I have been fortunate enough to get a taste of this feeling in my time at Stanford. I can recall this warm, simple sense of shared happiness and achievement contrasting with the more ephemeral satisfaction that comes with individual accomplishments. It is my experiences in the hospital that have convinced me that I will find even greater contentment as a physician.

In my time shadowing Dr. Robert Martin in San Francisco, he continually insisted that there was no work more rewarding than caring for a fellow human being. I could see the sincerity behind his words when I observed how warmly he would pat his patients on the back at the end of an appointment. And I can still vividly recall the clarity I saw in his eyes when he told me the best part of his job — telling a patient that he does not have cancer. My time shadowing physicians has also allayed my high school concerns about being able to integrate medicine with my love of the humanities, particularly my fondness for analyzing literature, film, and poetry. I observed Dr. In addition to the human aspect of the field, I believe that a career in medicine would also allow me to indulge in my evolving passion for science.

My time in the lab has taught me how to be thorough and precise in my experimentation and thinking. Most importantly, my frustrations, setbacks, and successes have fostered both a profound appreciation for science and a hunger for a greater understanding of how life works. I saw this manifest itself in my leave term work at ahealth care information company when I stumbled upon an article on the gut microbiome being a potential treasure trove of cures for obesity, type 2 diabetes, and other metabolic diseases. At this moment, I recalled holding a colon in my hands in Dr. I found myself itching to contribute to our understanding of this incredibly promising and fascinating body system.

I am indebted to H. I know now that the price of missing out on a career medicine is greater than the personal sacrifices that inevitably come with such a demanding training process and line of work. My experiences at Stanford have convinced me that understanding the human body and taking care of people are my life callings. I am uncertain about whether I can convey this to my future children so that they may take a less circuitous route to understanding my choice of career, but I do know that my experiences have left me well prepared for the challenges that await me.

She had kind eyes and laugh lines that framed her smile; she reminded me of my grandmother. But after a few minutes, I noticed that her hands were trembling in her lap. It was my second summer shadowing Dr. Patel at the neurology clinic, so I already knew the motor coordination tests he was going to perform. The woman submitted to the tests reluctantly, as if she knew that she would fail. First, he asked her to balance a pen on the back of her hand, but it fell to the ground in a matter of seconds. When she attempted to hold a glass of water, the uncontrollable shaking expelled most of it.

Finally, she tried to write her name on a sheet of paper, but the pen jolted and skittered off the page. Ten minutes later, she balanced the same pen flawlessly and wrote her name without hesitation. In high school, I had my first real clinical experience shadowing a pediatrician, observing routine check-ups punctuated by the occasional ear infection or case of the flu. On one occasion, I watched as Dr. Debra used her stethoscope on an infant, when her expression changed completely. She motioned for me to come closer and gave me her stethoscope. As the pediatrician spoke to the parents, I could see the panic rise in their flushed faces as they realized the gravity of the situation. I desperately wanted to know what was going on so that I could be of some service. Instead, I just stood there, feeling useless.

I resolved to pursue a medical education in hopes of arming myself with the knowledge that would allow me to help the next time I found myself in a similar circumstance. As a neuroscience major in college, I became fascinated by how our nervous system connects to nearly every function in our bodies and how changes at the smallest level affect our overall behavior. Clocks, houses, and flowers were only half-composed, and the people who drew them could not comprehend what was wrong. From then on, I knew that I wanted to devote my life to understanding disorders like these.

My neuroscience courses were the first of my college classes where my excitement for the subject seemed to inform every aspect of my life outside the classroom. When I started shadowing a neurologist in college, I was thrilled to see how the science I learned about in lectures and textbooks was used to help patients on a daily basis. Shadowing Dr. The more time I spent at his clinic, the more motivated I was to dig deeper into the topics I learned about in class, which in turn gave me more knowledge to understand the cases I saw while I shadowed. My shadowing experiences in college were markedly different from my experiences in high school, because I now had the knowledge to fully appreciate the treatments being prescribed.

As the old woman who once struggled to hold a pen wrote her name for the first time in years, her whole family started tearing up. The woman had just undertaken a procedure known as deep brain stimulation, in which electrodes are placed at the thalamus and are connected to a device placed in the chest. Once activated post-operatively, the device sends electrical pulses to the thalamus, inhibiting the very signals that cause the tremor. It was medicine. The first hint of my interest in medicine came from seeing a mouse model of gallstones from my uncle as a year-old kid. Children and adolescents are more likely to engage in unhealthy eating behaviors when watching television ,, and are exposed to television advertisements promoting primarily restaurants and unhealthy food products , Increased television viewing among children and adolescents is associated with consuming more products such as fast food, soft drinks, and high-fat snacks ,,, and consuming fewer fruits and vegetables ,, Healthy People national health objectives include a comprehensive plan for health promotion and disease prevention in the United States.

Healthy People includes objectives related to physical activity and healthy eating among children and adolescents and in schools Appendix B Schools have direct contact with students for approximately 6 hours each day and for up to 13 critical years of their social, psychological, physical, and intellectual development The health of students is strongly linked to their academic success, and the academic success of students is strongly linked with their health. Therefore, helping students stay healthy is a fundamental part of the mission of schools School health programs and policies might be one of the most efficient means to prevent or reduce risk behaviors, prevent serious health problems among students, and help close the educational achievement gap , Schools offer an ideal setting for delivering health promotion strategies that provide opportunities for students to learn about and practice healthy behaviors.

Schools, across all regional, demographic, and income categories, share the responsibility with families and communities to provide students with healthy environments that foster regular opportunities for healthy eating and physical activity. Healthy eating and physical activity also play a significant role in students' academic performance. The importance of healthy eating, including eating breakfast, for the overall health and well-being of school-aged children cannot be understated. Most research on healthy eating and academic performance has focused on the negative effects of hunger and food insufficiency 62 and the importance of eating breakfast 65,, Recent reviews of breakfast and cognition in students 73,, report that eating a healthy breakfast might enhance cognitive function especially memory , increase attendance rates, reduce absenteeism, and improve psychosocial function and mood.

Certain improvements in academic performance such as improved math scores also were noted 65, A growing body of research focuses on the association between school-based physical activity, including physical education, and academic performance among school-aged children and adolescents. A comprehensive CDC literature review that included 50 studies synthesized the scientific literature on the association between school-based physical activity, including physical education, and academic performance, including indicators of cognitive skills and attitudes, academic behaviors e. The review identified a total of associations between school-based physical activity and academic performance. Therefore, the evidence suggests that 1 substantial evidence indicates that physical activity can help improve academic achievement, including grades and standardized test scores; 2 physical activity can affect cognitive skills and attitudes and academic behavior including enhanced concentration, attention, and improved classroom behavior ; and 3 increasing or maintaining time dedicated to physical education might help and does not appear to adversely affect academic performance Schools can promote the acquisition of lifelong healthy eating and physical activity behaviors through strategies that provide opportunities to practice and reinforce these behaviors.

School efforts to promote healthy eating and physical activity should be part of a coordinated school health framework, which provides an integrated set of planned, sequential, and school-affiliated strategies, activities, and services designed to promote the optimal physical, emotional, social, and educational development of students. A coordinated school health framework involves families and is based on school and community needs, resources, and standards. The framework is coordinated by a multidisciplinary team such as a school health council and is accountable to the school and community for program quality and effectiveness School personnel, students, families, community organizations and agencies, and businesses can collaborate to successfully implement the coordinated school health approach and develop, implement, and evaluate healthy eating and physical activity efforts.

Ideally, a coordinated school health framework integrates the efforts of eight components of the school environment that influence student health i. The following guidelines reflect the coordinated school health approach and include additional areas deemed to be important contributors to school health: policy development and implementation and professional development for program staff. This report includes nine general guidelines for school health programs to promote healthy eating and physical activity. Each guideline is followed by a series of strategies for implementing the general guidelines. Because each guideline is important to school health, there is no priority order.

Guidelines presented first focus on the importance of a coordinated approach for nutrition and physical activity policies and practices within a health-promoting school environment. Then, guidelines pertaining to nutrition services and physical education are provided, followed by guidelines for health education, health, mental health and social services, family and community involvement, staff wellness, and professional development for staff. Although the ultimate goal is to implement all guidelines recommended in this report, not every guideline and its corresponding strategies will be feasible for every school to implement. Because of resource limitations, some schools might need to implement the guidelines incrementally.

Therefore, the recommendation is for schools to identify which guidelines are feasible to implement, based on the top health needs and priorities of the school and available resources. Families, school personnel, health-care providers, businesses, the media, religious organizations, community organizations that serve children and adolescents, and the students themselves also should be systematically involved in implementing the guidelines to optimize a coordinated approach to healthy eating and regular physical activity among school-aged children and adolescents.

The guidelines in this report are not clinical guidelines; compliance is neither mandatory nor tracked by CDC. However, CDC monitors the status of student health behaviors and school health policies and practices nationwide through three surveillance systems. These systems provide information about the degree to which students are participating in healthy behaviors and schools are developing and implementing the policies and practices recommended in the guidelines. YRBSS includes a national, school-based survey conducted by CDC and state, territorial, tribal, and district surveys conducted by state, territorial, and local education and health agencies and tribal governments. YRBSS data are used to 1 measure progress toward achieving national health objectives for Healthy People and other program and policy indicators, 2 assess trends in priority health-risk behaviors among adolescents and young adults, and 3 evaluate the effect of broad school and community interventions at the national, state, and local levels.

In addition, state, territorial, and local agencies and nongovernmental organizations use YRBSS data to set and track progress toward meeting school health and health promotion program goals, support modification of school health curricula or other programs, support new legislation and policies that promote health, and seek funding and other support for new initiatives. SHPPS data are used to 1 identify the characteristics of each school health program component e.

The School Health Profiles i. State, local, and territorial education and health officials use Profiles data to 1 describe school health policies and practices and compare them across jurisdictions, 2 identify professional development needs, 3 plan and monitor programs, 4 support health-related policies and legislation, 5 seek funding, and 6 garner support for future surveys.

Results from the surveys are described throughout this report. Physical education, health education, and other teachers; school nutrition service staff members; school counselors; school nurses and other health, mental health, and social services staff members; community health-care providers; school administrators; student and parent groups; and community organizations should work together to maximize healthy eating and physical activity opportunities for students Box 1. Coordination of all these persons and groups facilitates greater communication, minimizes duplication of policy and program initiatives, and increases the pooling of resources for healthy eating and physical activity policies and practices Establish a school health council and designate a school health coordinator at the district level.

Each district should have a school health council to help ensure that schools implement developmentally appropriate and evidence-based health policies and practices. The school health council serves as a planning, advisory, and decision-making group for school health policies and programs. School health councils should include representatives from different segments of the school and community, including health and physical education teachers, nutrition service staff members, students, families, school administrators, school nurses and other health-care providers, social service professionals, and religious and civic leaders The school health council provides input on decisions about how to promote health-enhancing behaviors, including healthy eating and physical activity among students.

Some roles of school health councils include Each district also should designate a school health coordinator who manages and coordinates health-related policies and practices across the district, including those related to healthy eating and physical activity. This person serves as an active member of the district-level school health council and communicates the district school health council's decisions and actions to school-level health coordinators and teams, staff, students, and parents , A district school health coordinator also should. Establish a school health team and designate a school health coordinator at the school level. Each school should establish a school health team, representative of school and community groups, to work with the greater school community to identify and address the health needs of students, school administrators, parents, and school staff.

A school health team. Every school also should designate a school health coordinator to manage the school health policies, practices, activities, and resources, including those that address healthy eating and physical activity. School health coordinators might. An assessment of current school-based healthy eating and physical activity policies and practices is necessary to provide baseline information about strengths and weaknesses. An assessment can also identify how district-level policies are being implemented at the school level and in the development of community-specific strategies. An assessment enables the school health council, school health coordinator, parents, school administrators, and school board members to develop a data-based plan for improving student health.

Schools and school districts can refer to the School Health Index for a comprehensive list of policies and practices that promote healthy eating and physical activity in schools. The School Health Index guides schools through the development of an action plan to improve their school health policies and practices , Results from the School Health Index assessment and action plan can help schools determine where, what, and how to incorporate health promotion programs and policies into their overall school improvement plan.

Inclusion in the school improvement plan helps ensure that health is a regular item on agendas of district school board meetings and school-based management committees. Completing the School Health Index can lead to positive changes in the school health environment. For example, after completing the School Health Index, some schools have hired a physical education teacher for the first time, added healthier food choices to school meal programs, and incorporated structured fitness breaks into the school day An assessment might also involve collection of data on current eating and physical activity behaviors of students, community-based nutrition and physical activity programs, and student, staff, and parent needs School health policies are official statements from education agencies and other governing bodies e.

They identify what should be done, why it should be done, and who is responsible for doing it. School health policies can School health policies should comply with federal, state, and local laws and mandates. School health councils, teams, and coordinators can lead the development, implementation, and monitoring of policies , The Child Nutrition and WIC Reauthorization Act of required that each school district participating in the federally supported meal program establish a local school wellness policy for the first time by school year By , most school districts had a local wellness policy; however, the quality of policies varied across school districts.

In addition, many of the policies lacked plans for implementing and monitoring the status of the wellness policy The Healthy, Hunger-Free Kids Act of updated requirements for local school wellness policy to include, at a minimum,. The act also requires that the U. Department of Agriculture USDA , in conjunction with the CDC director, "prepare a report on the implementation, strength, and effectiveness of the local school wellness policies" States, districts, and schools should use a systematic approach when developing, implementing, and monitoring healthy eating and physical activity policies.

They can use the following strategies throughout the policy process. Identify and involve key stakeholders from the beginning of the policy process. One person, such as the school health coordinator at the district or school level, depending on the level at which the policy is to be implemented , should assume or be designated with overall responsibility for coordinating and implementing healthy eating and physical activity policies. This person also can help identify and involve key stakeholders, including the school health council or team. Key stakeholders in district- and school-level policy processes include students, families, school nutrition service staff, physical education teachers, health education teachers, school nurses, school principals and other administrators, staff from local health departments, health-care providers, and staff from local community organizations and businesses.

This group of stakeholders will contribute to the development, implementation, and monitoring of healthy eating and physical activity policies. Draft the policy language. Policy language should be specific, simple, clear, and accurate; avoid education, health, and legal jargon; and be easy for readers with diverse backgrounds to understand and apply. Policy language should be consistent with state, district, and school visions for student learning and health and other policies in the same jurisdiction. A written policy should describe Adopt, implement, and monitor healthy eating and physical activity policies. After the draft policy is completed, the process of adopting the policy begins , To ensure greater support for policy adoption, school health council members or other policy makers should be given time to share the draft policy with their partners and gather reactions.

Public hearings or other meetings that gather wider input from the school and community might be beneficial or required. Such hearings allow every interested person or organization to provide input on the policy. Policy adoption typically requires that the drafted policy be presented to the policy-making body e. The presentation should include background information about why the policy is needed e. Policies likely will require final approval by the school board, the district superintendent, or both. Implementation of policies should be a cooperative effort that includes the school health coordinator, school health council, and school staff members.

All school staff members and teachers, in particular, need sufficient time to implement the policy and make agreed-on changes in the school environment to support the policy Those responsible for implementation should be prepared to address challenges, such as perceptions that the policy is low priority, limited resources for full implementation, changes in school administrators and school staff members, and concerns such as lost revenue from certain food and beverage sales and resolving scheduling conflicts for use of physical activity facilities because of increasing numbers of physical activity programs Parental and community concerns might be mitigated by making incremental changes and ensuring that the media receive positive stories about the response to the policy.

Monitoring policy implementation allows school staff members to determine whether the policy yielded the expected results and which changes could be made to improve the results. Establishing policy is an important component of many of the nine guidelines. Following is a list of key healthy eating and physical activity policies that are described in the remaining guidelines:. Evaluation can be used to assess and improve policies and practices that promote increased physical activity and healthier eating among students and faculty members. All groups involved in and affected by school efforts to promote lifelong physical activity and healthy eating should have the opportunity to contribute to evaluation. Education agencies and schools should designate a person to take the lead on evaluation activities.

Schools may choose to enlist local universities, the health department, or the education department to assist with the evaluation of school policies and practices. Evaluation can serve various purposes, including 1 improving the content, support for, and implementation of physical activity and healthy eating policies and practices; 2 documenting changes in the school environment, physical education and health education curricula, physical activity and healthy eating services for students and school staff members, physical activity and dietary habits, and health outcomes such as blood pressure and blood glucose levels; 3 identifying strengths and weakness of policies and practices and making a plan for improvement; and 4 responding to new and changing needs of students and school staff members.

Although evaluations should not be used to audit or rank schools or penalize school staff members , , evaluations can be used to motivate schools to make changes and monitor school-level implementation of school district, state, and federal policies. Two fundamental types of evaluation are process and outcome. In process evaluation, educators collect and analyze data to determine who, what, when, where, and how much of program activities have been conducted.

Process evaluation is the foundation of evaluation because it specifies the activities involved in policies, programs, and practices, and whether they were implemented as intended. In addition, process evaluation allows education agency staff members to assess how well a policy, program, or practice has been implemented and what strengths and improvements are necessary. Outcome evaluation explores whether intended outcomes or specific changes occur as a direct result of policies, programs, or practices.

Outcomes might include changes at the school level e. Outcome evaluation can require a great deal of time, money, and expertise, and individual schools are unlikely to be able to conduct outcome evaluations on their own. A full-fledged outcome evaluation might be beyond the reach of most schools and is more likely the purview of state and local education agencies. However, some outcome-related questions can be answered using simple methods available to most schools. Outcome evaluation can focus on short- or long-term outcomes of policies, programs, or practices, including changes in practices at the school level or changes in student knowledge, attitudes, skills, behaviors, or health outcomes.

Conduct process evaluation of nutrition and physical activity policies and practices. Schools should conduct a process evaluation of their healthy eating and physical activity policies and practices. Process evaluation topics for schools might include the following:. Conduct outcome evaluation of healthy eating and physical activity policies, programs, and practices. In addition to the process evaluation topics, schools might evaluate changes that occurred after a policy, program, or practice was implemented. Outcome evaluation topics include the following:. The Physical Activity Evaluation Handbook illustrates the six steps of program evaluation in the framework with physical activity program examples Understanding Evaluation: The Way to Better Prevention Programs describes evaluation activities that school districts and community agencies can use to assess various programs State and local education agencies and schools can consult with evaluators at universities, school districts, or state departments of education and health to identify methods and materials for evaluating their efforts.

The physical surroundings and psychosocial climate of a school should encourage all students to make healthy eating choices and be physically active. The physical environment includes the entire school building and the area surrounding it; facilities for physical activity, physical education, and food preparation and consumption; availability of food and physical activity options; and conditions such as temperature, air quality, noise, lighting, and safety The psychosocial environment includes the social norms established by policies and practices that influence the physical activity and eating behaviors of students and staff members Developing and maintaining a supportive school environment can improve the sustainability of healthy eating and physical activity policies and practices that support healthy lifestyles ,, Box 2.

Provide adequate and safe spaces and facilities for healthy eating. School nutrition services should serve healthy food in an environment that allows students to pay attention to what they are eating and enjoy social aspects of dining , Students can enjoy meal time more when they feel relaxed and are able to socialize without feeling rushed. Actions to support safe and healthy eating include. Other food environment activities, such as school gardens, school salad bars, and farm-to-school programs, can enrich the eating and educational experience by providing quality produce and opportunities for hands-on multidisciplinary learning In , the National School Lunch Act was amended with a provision encouraging institutions participating in the school lunch and breakfast programs "to purchase unprocessed agricultural products, both locally grown and locally raised, to the maximum extent practicable and appropriate" In addition to integrating local agriculture products, such as fruits, vegetables, and eggs, into the school cafeteria, farm-to-school activities include hands-on education through school garden programs and field trips to local farms, classroom nutrition education, and alternative fundraising using local produce School garden programs have the potential to strengthen the healthy development of students through improved knowledge about fruits and vegetables ,, , increased preference for fruits and vegetables ,, , and increased consumption of fruits and vegetables ,,, Schools also should ensure that students have access to safe, free, and well-maintained drinking water fountains or dispensers during school meals, as required by the Healthy, Hunger-Free Kids Act , as well as throughout the school day This provides a healthy alternative to sugar-sweetened beverages and can help increase students' overall water consumption , Ensure that spaces and facilities for physical activity meet or exceed recommended safety standards.

All spaces and facilities for physical activity, including playing fields, playgrounds, gymnasiums, swimming pools, multipurpose rooms, cafeterias, and fitness centers, should be regularly inspected and maintained, hazardous conditions should be corrected immediately, and a comprehensive safety assessment should be done at least annually , Regular inspection and maintenance of indoor and outdoor play surfaces should ensure that environmental safety devices are provided and maintained, including , Develop, teach, implement, and enforce safety rules. Safe physical activity requires proper conditioning and use of appropriate equipment where needed.

Dangerous behaviors e. Explicit safety rules should be taught to and followed by students in physical education, extracurricular physical activity programs, and community sports and recreation programs ,, Adult supervisors should consistently reinforce safety rules, which should be posted in key locations. One person, such as the school health coordinator or lead physical education teacher, should be responsible for ensuring that safety measures are in place and updated as needed , ; however, minimizing physical activity--related injuries and illnesses among children and adolescents is the joint responsibility of teachers, administrators, coaches, athletic trainers, school nurses, other school and community personnel, parents, and students , Maintain high levels of supervision during structured and unstructured physical activity programs.

Trained staff members or volunteers, including coaches, teachers, parents, paraprofessionals, and community members, should supervise all physical activity programs. Staff members should be aware of the potential for physical activity--related injuries and illnesses among students so that the risks for and consequences of these injuries and illnesses can be minimized. To prevent injuries during structured physical activity schools can. Children and adolescents also could be provided with, and required to use, protective clothing and equipment appropriate for the type of physical activity and the environment Protective clothing and equipment includes footwear appropriate for the specific activity; helmets for bicycling; helmets, face masks, mouth guards, and protective pads for football and ice hockey; shin guards for soccer; knee pads for in-line skating; and reflective clothing for walking and running.

As a general recommendation, all protective equipment should 1 be in good condition; 2 be inspected and maintained frequently; 3 be replaced if worn, damaged, or outdated; 4 provide a good fit for the athlete; and 5 be appropriate for the sport and position. In addition, children and adolescents need to be trained to use equipment correctly; this is particularly true of helmets To prevent injuries during unstructured play time, schools should consider implementing training sessions for staff members focusing on observation techniques, behavior management, appropriate supervision, and emergency response procedures Additional information that schools might want to integrate into training sessions can be found in the Consumer Product Safety Commission Handbook for Public Playground Safety In general, playground supervisors should 1 repetitively teach children playground rules; 2 prevent, recognize, and stop children's dangerous and risky behavior; 3 help children to identify, acknowledge, and prevent their risky behavior; and 4 model appropriate safety behavior , When possible, schools can support those supervising unstructured physical activity by following the National Program for Playground Safety NPPS recommendations that the playground supervision ratio of teachers to students be equal to the indoor classroom ratio Increase community access to school physical activity facilities.

Schools should provide community access to physical activity facilities, such as gymnasiums, tracks, baseball and softball fields, basketball courts, outdoor play areas, and indoor fitness centers during the school day and out-of-school time ,, Establishing a formal policy or agreement, such as a joint use agreement, between schools and community organizations can help increase student, family, and community access to physical activity facilities and programs. A joint use agreement is a policy that allows two or more entities e. Joint use agreements provide details about the facilities to be shared, as well as scheduling, management, maintenance, and costs of the shared facilities.

Roles, responsibilities, and liability terms also are typically outlined within joint use agreements Access to these facilities can help to increase visibility of schools, provide community members a safe place for physical activity, and might increase partnerships with community-based physical activity programs , Frequently, schools have the facilities but lack the personnel to deliver extracurricular physical activity programs.

Community resources can expand existing school programs by providing program staff members as well as intramural and club activities on school grounds. For example, community agencies and organizations can use school facilities for after-school physical fitness programs for students, weight management programs for overweight or obese students, and sports and recreation programs for students with disabilities or chronic health conditions. Adopt marketing techniques to promote healthy dietary choices. Marketing techniques can be used to promote healthy foods and beverages among students.

The following techniques have been used in schools to increase the likelihood of students choosing healthier foods and beverages:. Use student rewards that support health. Student achievement or positive classroom behavior should only be rewarded with nonfood items or activities. The use of food as rewards, especially foods with little nutritional value, might increase the risk that children associate such foods with emotions, such as feelings of accomplishment , Providing food based on performance or behavior connects the experience of eating food to the student's perceptions and mood. Rewarding students with food during class also reinforces eating outside of meal or snack times. This practice can encourage students to eat treats even when they are not hungry and instill lifetime habits of rewarding or comforting themselves with unhealthy eating, resulting in overconsumption of foods high in added sugar and fat Although few studies have examined the effect of using food rewards on students' long-term eating habits, the IOM Nutrition Standards for Foods in Schools report determined that such use of foods in schools is inappropriate because this practice establishes an emotional connection between foods and accomplishments.

When an extrinsic reward system is used, rewards should be nonfood items or activities e. Do not use physical activity as punishment. Teachers, coaches, and other school and community personnel should not use physical activity as punishment or withhold opportunities for physical activity as a form of punishment. Using physical activity as a punishment e. Exclusion from physical education or recess for bad behavior in a classroom deprives students of physical activity experiences that benefit health and can contribute toward improved behavior in the classroom , Disciplining students for unacceptable behavior or academic performance by not allowing them to participate in recess or physical education prevents students from 1 accumulating valuable free-time physical activity and 2 learning essential physical activity knowledge and skills.

Schools can take numerous steps to help shape a health-promoting psychological environment. For example, they can adopt and enforce a universal bullying prevention program that addresses weight discrimination and teasing ,, , ensure that students of all sizes are encouraged to participate in a wide variety of physical activities , display posters or other visual materials that feature a diverse combination of students being active and eating healthy, and avoid practices that single out students on the basis of body size or shape Schools should avoid elimination games such as dodge ball, bombardment, and elimination tag that limit opportunities for all students to be active School health, mental health, and social services staff members can play a key role in helping to communicate and promote these practices.

The school nutrition policy should ensure a safe environment for students with chronic health conditions. The policy should cover all venues where foods and beverages are available, during the regular and extended school day, and all families and staff members should be informed of the policy Nutrition service staff members should be provided with information and support to assist students who are on nutrition programs or diets prescribed by their health-care provider. USDA provides guidance on accommodating children with special dietary needs, supported by the USDA nondiscrimination regulation , allowing for substitutions or modifications in the National School Meals Program for children whose disabilities restrict their diet as certified by a licensed physician

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