Centers for Disease Control and Prevention

Indicator Definitions - School Health

Alcohol use among youth Category: Alcohol
Demographic Group:	Students in grades 9–12.
Numerator:	Students in grades 9–12 who report consumption of ≥1 drink of alcohol during the past 30 days.
Denominator:	Students in grades 9–12 who reported having a specific number of drinks of alcohol, including zero, during the past 30 days (excluding those who did not answer).
Measures of Frequency:	Biennial (odd years) prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Past 30 days.
Background:	In 2011, 39% of high school students reported drinking alcohol on at least one day during the past 30 days.¹ The prevalence of current drinking is similar for boys and girls, but increases by grade. In 2011, among U.S. high school students, 80% had consumed alcohol by the 12th grade, even though the sale of alcohol to persons under age 21 years has been illegal in all states since 1988.² Current drinking by youth is correlated with current drinking by adults in states. ³
Significance:	On average, alcohol is a factor in the deaths of approximately 4,300 youths in the United States per year, shortening their lives by an average of 60 years.⁴ Underage drinking cost the U.S. $24 billion in 2006.⁵ Studies have determined that delaying the age when drinking is initiated until age 21 years or later substantially reduces the risk of experiencing alcohol-related problems.⁶ Underage drinking is also strongly associated with injuries, violence, fetal alcohol spectrum disorders (FASDs), and risk of other acute and chronic health effects.^7,8
Limitations of Indicator:	The indicator does not convey the frequency of drinking or the specific amount of alcohol consumed. This indicator is available every other year.
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.¹ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective SA–13.1: Reduce the proportion of adolescents reporting use of alcohol or any illicit drugs during the past 30 days.
Related CDI Topic Area:	School Health

CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).
O’Malley PM, Wagenaar AC. Effects of minimum drinking age laws on alcohol use, related behaviors, and traffic crash involvement among American youth: 1976–1987. J Stud Alcohol 1991;52:478–491.
Nelson DE, Naimi TS, Brewer RD, Nelson HA. State alcohol-use estimates among youth and adults, 1993–2005. Am J Prev Med 2009;36:218–24.
Centers for Disease Control and Prevention. Alcohol-related disease impact (ARDI) application. Atlanta, GA: CDC; 2013: www.cdc.gov/ARDI.
Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med 2011;41(5):516-524.
Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: age at onset, duration, and severity. Pediatrics 2006;160:739–746.
Warren, K.R., Hewitt, B.G., & Thomas, J.D. (2011). Fetal Alcohol Spectrum Disorders. Alcohol Research & Health, Volume 34, Issue Number 1.
Bonnie RJ and O’Connell ME, editors. National Research Council and Institute of Medicine, Reducing Underage Drinking: A Collective Responsibility. Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press, 2004.

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Binge drinking prevalence among youth Category: Alcohol
Demographic Group:	Students in grades 9–12.
Numerator:	Students in grades 9–12 who report having ≥5 drinks of alcohol within a couple of hours on ≥1 day during the past 30 days.
Denominator:	Students in grades 9–12 who report having a specific number, including zero, of drinks of alcohol within a couple of hours on ≥1 day during the past 30 days (excluding those who did not answer).
Measures of Frequency:	Biennial (odd years) prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Past 30 days.
Background:	In 2011, 22% of high school students in the United States reported binge drinking during the past 30 days.¹ Binge drinking accounts for 90% of the alcohol consumed by youths², and about 2 in 3 high school students who drink report binge drinking³, usually on multiple occasions. In 2011, the prevalence of binge drinking among boys was 24% and 20% among girls.¹ The prevalence of binge drinking was higher among white (24%) and Hispanics (24%) students than black students (12%) ; prevalence increased with grade.1 Binge drinking by youth is correlated with binge drinking by adults in states.⁴
Significance:	Alcohol is a factor in the deaths of approximately 4,700 youths in the United States per year, shortening their lives by an average of 60 years.⁵ Underage drinking cost the U.S. $24 billion in 2006.⁶ Binge drinking is a risk factor for many health and social problems, including motor-vehicle crashes, violence, suicide, hypertension, acute myocardial infarction, sexually transmitted diseases, unintended pregnancy, fetal alcohol spectrum disorders (FASDs), and sudden infant death syndrome.^7,8
Limitations of Indicator:	The indicator does not convey the frequency of binge drinking or the specific amount of alcohol consumed. The definition of binge drinking used in the data source (YRBSS) is not gender-specific. This indicator is available every other year.
Data Resources:	Youth Risk Behavior Surveillance System. (YRBSS).
Limitations of Data Resources:	As with all self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.¹ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective SA–14.1: Reduce the proportion of students engaging in binge drinking during the past 2 weeks—High school seniors. Healthy People 2020 Objective SA–14.4: Reduce the proportion of persons engaging in binge drinking during the past month—Adolescents aged 12 to 17 years. CDC’s Prevention Status Report: Excessive Alcohol Use.⁹
Related CDI Topic Area:	School Health

CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).
Office of Juvenile Justice and Delinquency Prevention. Drinking in America: Myths, Realities, and Prevention Policy. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 2005.
CDC. Vital signs: binge drinking among high school students and adults—United States, 2009. MMWR 2010;59:1274–9.
Nelson DE, Naimi TS, Brewer RD, Nelson HA. State alcohol-use estimates among youth and adults, 1993–2005. Am J Prev Med 2009;36:218–24.
Centers for Disease Control and Prevention. Alcohol-related disease impact (ARDI) application. Atlanta, GA: CDC; 2013: www.cdc.gov/ARDI
Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med 2011;41(5):516-524.
National Institute of Alcohol Abuse and Alcoholism. Tenth special report to the U.S. Congress on alcohol and health. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; 2000.
Warren, K.R., Hewitt, B.G., & Thomas, J.D. (2011). Fetal Alcohol Spectrum Disorders. Alcohol Research & Health, Volume 34, Issue Number 1.
Centers for Disease Control and Prevention. Prevention Status Reports 2013: Excessive Alcohol Use. Atlanta, GA: US Department of Health and Human Services; 2014. http://www.cdc.gov/stltpublichealth/psr/alcohol/index.html

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Current cigarette smoking among youth Category: Tobacco
Demographic Group:	Students in grades 9-12
Numerator:	Respondents in grades 9-12 who report having smoked a cigarette on ≥1 of the previous 30 days
Denominator:	Students in grades 9–12 who reported information about smoking (excluding those who did not answer).
Measures of Frequency:	Biennial (odd years) prevalence and 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Previous 30 days
Background:	Tobacco use remains the leading preventable cause of death and disease in the United States, with more than 480,000 deaths occurring annually because of cigarette smoking and exposure to secondhand smoke.¹ Moreover, nearly 90% of adult smokers begin smoking by age 18 years.² As compared to nonsmokers, youth cigarette smokers are more likely to drink alcohol, use marijuana and cocaine, engage in risky sexual behaviors, engage in physical fighting, carry a weapon, and attempt suicide.² In 2011, 18.1% of students in grades 9-12 had smoked cigarettes on at least 1 day during the past 30 days.³
Significance:	Cigarette smoking increases risk of heart disease; chronic obstructive pulmonary disease; acute respiratory illness; stroke; and cancers of the lung, larynx, oral cavity, pharynx, pancreas, and cervix.⁴ If current tobacco use patterns persist, an estimated 6.4 million current child smokers will eventually die prematurely from a smoking-related disease.⁵
Limitations of Indicator:	There is presently no national middle school YRBSS; however, state and/or local data may be available in some areas. Also, some middle school surveys cover grades 7 and 8 only, and thus, data may not be consistent across jurisdictions.
Data Resources:	National data from the Youth Risk Behavior Surveillance System (YRBSS) are representative of all public and private school students in grades 6-8 in the 50 states and the District of Columbia. National YRBSS data are not the aggregate of the state YRBSS data; the National YRBSS uses a separate scientific sample of schools and students. For the national, state, territory, and local YRBSS samples, schools are selected with probability proportional to the size of student enrollment in grades 9-12 and then required classes of students (e.g., English classes) are randomly selected to participate. Within selected classes, all students are eligible to participate. See the Methodology of the Youth Risk Behavior Surveillance System for a more detailed description of sampling procedures.⁶
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁷ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective TU-2.1: Reduce use of tobacco products by adolescents (past month).
Related CDI Topic Area:	Alcohol; Cancer; Cardiovascular Disease; Chronic Obstructive Pulmonary Disease; School Health; Oral Health

CDC.U.S. Department of Health and Human Services. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
US Department of Health and Human Services. Preventing tobacco use among youth and young adults. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm.
CDC. Youth Risk Behavior Surveillance – United States, 2011. MMWR. 2012;61(4):1-162.
US Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC: 2010. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/2010/index.htm
CDC. Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC). Available at http://apps.nccd.cdc.gov/sammec/.
CDC. Youth Risk Behavior Surveillance System. Available at http://www.cdc.gov/mmwr/PDF/rr/rr5312.pdf.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Current smokeless tobacco use among youth Category: Tobacco
Demographic Group:	Students in grades 9-12
Numerator:	Respondents in grades 9-12 who report having used smokeless tobacco on ≥1 of the previous 30 days.
Denominator:	Students in grades 9-12 who reported information about smokeless tobacco use (excluding those who did not answer).
Measures of Frequency:	Biennial (odd years) prevalence and 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Previous 30 days
Background:	Tobacco use remains the leading preventable cause of death and disease in the United States, with more than 480,000 deaths occurring annually because of cigarette smoking and exposure to secondhand smoke.¹ In 2011, 7.7% of students in grades 9-12 had used smokeless tobacco (e.g., chewing tobacco, snuff, or dip) on at least 1 day during the past 30 days. ²
Significance:	Smoking and smokeless tobacco use are initiated and established primarily during adolescence.³ Smokeless tobacco use is not a safe alternative to smoking cigarettes, and can lead to nicotine addiction and several oral conditions, including halitosis, gingivitis, periodontitis, gingival recession, dental caries, oral pre-malignancies, and certain oral cancers.³
Limitations of Indicator:	There is presently no national middle school YRBSS; however, state and/or local data may be available in some areas. Also, some middle school surveys cover grades 7 and 8 only, and thus, data may not be consistent across jurisdictions.
Data Resources:	National data from the Youth Risk Behavior Surveillance System (YRBSS) are representative of all public and private school students in grades 6-8 in the 50 states and the District of Columbia. National YRBSS data are not the aggregate of the state YRBSS data; the National YRBSS uses a separate scientific sample of schools and students. For the national, state, territory, and local YRBSS samples, schools are selected with probability proportional to the size of student enrollment in grades 9-12 and then required classes of students (e.g., English classes) are randomly selected to participate. Within selected classes, all students are eligible to participate. See the Methodology of the Youth Risk Behavior Surveillance System for a more detailed description of sampling procedures.⁴
Limitations of Data Resources:	Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective TU-2.3: Reduce use of smokeless tobacco products by adolescents (past month).
Related CDI Topic Area:	Cancer; Oral Health, School Health

U.S. Department of Health and Human Services. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
CDC. Youth Risk Behavior Surveillance – United States, 2011. MMWR. 2012;61(4):1-162.
U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012.
CDC. Youth Risk Behavior Surveillance System. Available at http://www.cdc.gov/mmwr/PDF/rr/rr5312.pdf.

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Obesity among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9–12.
Numerator:	Students in grades 9–12 with a body mass index (BMI) at or above the sex- and age-specific 95th percentile from CDC Growth Charts: United States.¹
Denominator:	Students in grades 9–12 who answer height, weight, sex and age questions. YRBSS self-reported height and weight are edited for plausibility. Age- and sex-specific weight, height, and BMI cutpoints are used to exclude implausible values. Details can be found at ftp://ftp.cdc.gov/pub/data/YRBS/2011/YRBS_2011_National_User_Guide.pdf starting on page 3. Details on editing for plausibility start on page 5.
Measures of Frequency:	Biennial (odd years) prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Current.
Background:	In 2011, 13.0% of students in grades 9–12 were obese.² The prevalence of obesity among high school students has not changed significantly since 2003 based on self-reported data.² In 2011, the state-specific prevalence of obesity ranged from 7.3% to 17.0% based on self-reported YRBS data.²
Significance:	Obese children are more likely to have high blood pressure, high cholesterol, impaired glucose tolerance, asthma, joint problems, and other physical, social, and psychological problems.³ Obese children are more likely to become obese adults, which increases the risk for multiple chronic diseases in adulthood, including heart disease, stroke, hypertension, type 2 diabetes, osteoarthritis, and certain cancers.³
Limitations of Indicator:	Self-reported data underestimate obesity prevalence among adolescents.⁴
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁵ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-10: Reduce the proportion of children and adolescents who are considered obese. (NWS-10.4 is specific for adolescents aged 12–19 years.)
Related CDI Topic Area:	Asthma; Arthritis; Cancer; Cardiovascular Disease; Diabetes; School Health

Kuczmarksi RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Washington, DC: US Department of Health and Human Services, CDC, National Center for Health Statistics. Advance data; December 4, 2000 (revised). Publication no. 314. http://www.cdc.gov/nchs/data/ad/ad314.pdf
Centers for Disease Control and Prevention, Youth on line: high school YRBS. Atlanta, GA: U.S. Department of Health and Human Services. Available at http://apps.nccd.cdc.gov/youthonline/App/Default.aspx.
Centers for Disease Control and Prevention, Basics about childhood obesity. Atlanta, GA: U.S. Department of Health and Human Services. Available at http://www.cdc.gov/obesity/childhood/basics.html.
Sherry B, Jefferds ME, Grummer-Strawn LM. Accuracy of adolescent self-report of height and weight in assessing overweight status: a literature review. Arch Pediatr Adolesc Med. 2007 Dec;161(12):1154-61.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Overweight or obesity among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9–12.
Numerator:	Students in grades 9–12 with a body mass index (BMI) at or above the sex- and age-specific 85th percentile from CDC Growth Charts: United States.¹
Denominator:	Students in grades 9–12 who answer height, weight, sex and age questions. YRBSS self-reported height and weight are edited for plausibility. Age- and sex-specific weight, height, and BMI cutpoints are used to exclude implausible values. Details can be found at ftp://ftp.cdc.gov/pub/data/YRBS/2011/YRBS_2011_National_User_Guide.pdf starting on page 3. Details on editing for plausibility start on page 5.
Measures of Frequency:	Biennial (odd years) prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Current.
Background:	In 2011, 15.2% of students in grades 9–12 were overweight and 13.0% were obese based on self-reported data.² The prevalence of overweight and obesity among high school students has not changed significantly since 2003.² The state-specific prevalence of overweight ranged from 10.7% to 19.5%. The state-specific prevalence of obesity ranged from 7.3% to 17.0%.²
Significance:	Obese children are more likely to have high blood pressure, high cholesterol, impaired glucose tolerance, asthma, joint problems, and other physical, social, and psychological problems.³ Obese children are more likely to become obese adults, which increases the risk for multiple chronic diseases in adulthood, including heart disease, stroke, hypertension, type 2 diabetes, osteoarthritis, and certain cancers.³
Limitations of Indicator:	Self-reported data underestimate obesity prevalence among adolescents.⁴
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁵ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-10: Reduce the proportion of children and adolescents who are considered obese. (NWS-10.4 is specific for adolescents aged 12–19 years.)
Related CDI Topic Area:	Asthma; Arthritis; Cancer; Cardiovascular Disease; Diabetes; School Health

Kuczmarksi RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Washington, DC: US Department of Health and Human Services, CDC, National Center for Health Statistics. Advance data; December 4, 2000 (revised). Publication no. 314. http://www.cdc.gov/nchs/data/ad/ad314.pdf
Centers for Disease Control and Prevention, Youth on line: high school YRBS. Atlanta, GA: U.S. Department of Health and Human Services. Available at http://apps.nccd.cdc.gov/youthonline/App/Default.aspx.
Centers for Disease Control and Prevention, Basics about childhood obesity. Atlanta, GA: U.S. Department of Health and Human Services. Available at http://wwwdev.cdc.gov/obesity/childhood/basics.html.
Sherry B, Jefferds ME, Grummer-Strawn LM. Accuracy of adolescent self-report of height and weight in assessing overweight status: a literature review. Arch Pediatr Adolesc Med. 2007 Dec;161(12):1154-61.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Soda consumption among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9-12.
Numerator:	Students in grades 9–12 who report consuming 1 or more cans, bottles, or glasses of soda per day.
Denominator:	Students in grades 9–12 who report consuming any cans, bottles, or glasses of soda, including zero, per day (excluding unknowns and refusals).
Measures of Frequency:	Biennial (odd years) prevalence per day with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Past 7 days.
Background:	In 2011, 27.8% students in grades 9-12 drank one or more cans, bottles, or glasses of soda or pop per day.¹
Significance:	Sugar-sweetened beverage intake has been associated with obesity,² dental caries,³ type 2 diabetes,⁴ displacement of nutrient-rich foods (e.g., dairy),⁵ disruptive behaviors,^6,7 and poor mental health (e.g., psychological distress).⁸
Limitations of Indicator:	It does not include all sources of sugar-sweetened beverages.
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁹ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	None.
Related CDI Topic Area:	Diabetes; Oral Health; School Health

Eaton, D. K., et al. (2012). Youth risk behavior surveillance – United States, 2011. MMWR Surveill Summ 61(4): 1-162.
Malik, V. S., et al. (2013). Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr 98(4): 1084-1102.
Sohn W, Burt BA, Sowers MR. Carbonated soft drinks and dental caries in the primary dentition. J Dent Res. 2006;85(3):262-266.
Malik VS, Popkin BM, Bray GA, et al. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33(11):2477- 2483.
Frary CD, Johnson RK, Wang MQ. Children and adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. J Adolesc Health. 2004;34(1):56-63.
Park, S., et al. (2013). Problem behavior, victimization, and soda intake in high school students. Am J Health Behav 37(3): 414-421.
Lien L, Lien N, Heyerdahl S, et al. Consumption of soft drinks and hyperactivity, mental distress, and conduct problems among adolescents in Oslo, Norway. Am J Public Health. 2006;96(10):1815-1820.
Shi Z, Taylor AW, Wittert G, et al. Soft drink consumption and mental health problems among adults in Australia. Public Health Nutr. 2010;13(7):1073-1079.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Television viewing among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9-12.
Numerator:	Students in grades 9–12 who report watching television for 3 or more hours on an average school day.
Denominator:	Students in grades 9–12 who report watching television for any number of hours, including zero, on an average school day (excludes missing data).
Measures of Frequency:	Biennial (odd year) prevalence on an average school day with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Average school day.
Background:	In 2011, 32.4% of students in grades 9–12 watched television for 3 or more hours on an average school day.¹
Significance:	Excessive television viewing is associated with obesity.^2-4 Although data are inconsistent as to whether TV viewing reduces physical activity, there is evidence that TV viewing time is positively associated with reported intakes of high fat foods,⁵ and TV viewing during mealtime is associated with lower consumption of fruits and vegetables and higher consumption of salty snacks and soda⁶
Limitations of Indicator:	Indicator does not capture time spent with computers and hand-held devices; however, based on Kaiser Family Foundation data, of the 7.5 hours of screen time per day for 8-18 year-olds, 4.5 hours is TV viewing.⁷ Also, indicator intervals are not aligned with the American Academy of Pediatrics guidelines of 2 hours or less of screen time per day,^8-9 so survey results cannot be compared to them.
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.¹⁰ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective PA-8.2: Increase the proportion of children and adolescents aged 2 years through 12th grade who view television, videos, or play video games for no more than 2 hours a day.
Related CDI Topic Area:	Cardiovascular Disease; Diabetes; Nutrition, Physical Activity, and Weight Status

Centers for Disease Control and Prevention, Youth on line: high school YRBS. Atlanta, GA: U.S. Department of Health and Human Services. Available at http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?TT=&OUT=&SID=HS&QID=H80&LID=&YID=&LID2=&YID2=&
COL=&ROW1=&ROW2=&HT=&LCT=&FS=&FR=&FG=&FSL=&FRL=&FGL=&PV=&TST=&C1=&
C2=&QP=G&DP=&VA=CI&CS=Y&SYID=&EYID=&SC=&SO=
Dietz, W.H., Gortmaker, S.L. (1985). Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics, 75, 807–812.
Gortmaker S.L., Must A., Sobol A.M., Peterson K., Colditz G.A., & Dietz W.H. (1996) Television viewing as a cause of increasing obesity among children in the United States, 1986–1990. Archives of Pediatric & Adolescent Medicine, 150, 356–62.
Crespo C.J., Smith E., Troiano R.P., Bartlett S.J., Macera C.A., Andersen R. E. (2001). Television watching, energy intake, and obesity in U.S. children: results from the third National Health and Nutritional Examination Survey 1988-1994. Arch Pediatr Adolesc Med 155: 360-365.
Robinson TN, Killen JD. Ethnic and gender differences in the relationships between television viewing and obesity, physical activity and dietary fat intake. J Health Educ. 1995;26(SS2):91-98.
Coon KA, Goldberg J, Rogers BL, Tucker KL. Relationships between use of television during meals and children’s food consumption patterns. Pediatrics. 2001;107(1):E7.
Rideout VJ, Foehr UG, Roberts DF. Generation M2: Media in the Lives of 8- to 18-Year-Olds. Menlo Park, CA: Kaiser Family Foundation; 2010.
American Academy of Pediatrics. Children, adolescents, and television. Pediatrics. 2001;107(2):423-426.
American Academy of Pediatrics. Policy Statement—Children, Adolescents, Obesity and the Media. Pediatrics. 2011;128(1):201-208.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Computer use among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9–12.
Numerator:	Students in grades 9–12 who report playing video or computer games or using a computer for 3 or more hours/day on an average school day for something that was not school work.
Denominator:	Students in grades 9–12 who report playing video or computer games or using a computer for any number of hours, including zero, on an average school day for something that was not school work (excludes missing data).
Measures of Frequency:	Biennial (odd years) prevalence on an average school day with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Average school day.
Background:	In 2011, 31.1% of students in grades 9–12 played video or computer games or used a computer for 3 or more hours on an average school day.¹
Significance:	In 2011, the American Academy of Pediatrics updated a 2001 policy statement that recommended limiting total non-educational screen time (including television viewing) to no more than 2 hours per day.²
Limitations of Indicator:	Indicator does not capture time spent viewing TV or hand-held devices. However, based on Kaiser Family Foundation data, of the approximate 7.5 hours of screen time viewed per day by 8-18 year-olds, 2.75 hours is computer and video game time.³ Also, indicator intervals are not aligned with the American Academy of Pediatrics guidelines of 2 hours or less of screen time per day,^2,4 so survey results cannot be compared to them.
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁵ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective PA-8.3.3: Increase the proportion of adolescents in grades 9 through 12 who use a computer or play computer games outside of school (for non-school work) for no more than 2 hours a day.
Related CDI Topic Area:	Cardiovascular Disease; Diabetes; Nutrition, Physical Activity, and Weight Status

Centers for Disease Control and Prevention, Youth on line: high school YRBS. Atlanta, GA: U.S. Department of Health and Human Services. Available at http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?TT=&OUT=&SID=HS&QID=H80&LID=&YID=&LID2=&YID2=&COL=&ROW1=&ROW2=&HT=&LCT=&FS=
&FR=&FG=&FSL=&FRL=&FGL=&PV=&TST=&C1=&C2=&QP=G&DP=&VA=CI&CS=Y&SYID=&EYID=&SC=&SO=
American Academy of Pediatrics. Policy Statement—Children, Adolescents, Obesity and the Media. Pediatrics. 2011;128(1):201-208.
Rideout VJ, Foehr UG, Roberts DF. GENERATION M2: Media in the Lives of 8- to 18-Year-Olds. Menlo Park, CA: Kaiser Family Foundation; 2010.
American Academy of Pediatrics. Children, adolescents, and television. Pediatrics. 2001;107(2):423-426.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Healthy weight among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9–12.
Numerator:	Students in grades 9–12 with a body mass index (BMI) at the sex- and age-specific 5th percentile to less than the 85th percentile from CDC Growth Charts: United States.¹
Denominator:	Students in grades 9–12 who answer height, weight, sex and age questions. YRBSS self-reported height and weight are edited for plausibility. Age- and sex-specific weight, height, and BMI cutpoints are used to exclude implausible values. Details can be found at ftp://ftp.cdc.gov/pub/data/YRBS/2011/YRBS_2011_National_User_Guide.pdf starting on page 3. Details on editing for plausibility start on page 5.
Measures of Frequency:	Biennial (odd years) prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Current.
Background:	In 2011, 69% of high school students in the United States were healthy weight.²
Significance:	Being at healthy weight in adolescence is associated with lower risk of obesity during adulthood.³
Limitations of Indicator:	Self-reported data are associated with biased prevalence estimates for weight status.⁴
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁵ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-10: Reduce the proportion of children and adolescents who are considered obese (NWS-10.4 is specific for adolescents aged 12–19 years.)
Related CDI Topic Area:	School Health

Kuczmarksi RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Washington, DC: US Department of Health and Human Services, CDC, National Center for Health Statistics. Advance data; December 4, 2000 (revised). Publication no. 314. http://www.cdc.gov/nchs/data/ad/ad314.pdf
Analysis of data from: Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. Sep 25 1997;337(13):869-873.
Sherry B, Jefferds ME, Grummer-Strawn LM. Accuracy of adolescent self-report of height and weight in assessing overweight status: a literature review. Arch Pediatr Adolesc Med. 2007 Dec;161(12):1154-61.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Median daily frequency of fruit consumption among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9-12.
Numerator:	Number of total daily intake of fruit consumption (100% fruit juice and fruit)
Denominator:	All respondents for whom these data are available (excluding unknowns or refusals to provide responses to fruit consumption question).
Measures of Frequency:	Biennial median frequency with interquartile range; and by demographic characteristics when feasible.
Time Period of Case Definition:	Past 7 days
Background:	The Dietary Guidelines for Americans 2010 and Healthy People 2020 objectives call for Americans to increase their intake of fruits and vegetables.^1,2 Dietary intake recommendations for fruit intake are about 1.5-2 cup equivalents for girls 14-18 years of age and 2-2/12 cup equivalents for boys 14-18 years of age, depending on age and physical activity level.¹ In 2011, median daily intake of fruit among high school students was 1.0 times daily.³
Significance:	The Dietary Guidelines for Americans, 2010 recommends Americans eat more fruits and vegetables as part of a healthy diet, because they contribute important nutrients, can reduce the risk for many chronic diseases, and can also help with weight management.¹
Limitations of Indicator:	The indicator conveys the median frequency of fruit consumption among high school students surveyed. However, because it does not convey the cup equivalents of fruits consumed, it cannot be compared to Healthy People 2020 targets. Healthy People 2020 measures progress based on cup equivalents per 1000 kilocalories of intake. The Youth Risk Behavior Surveillance System (YRBSS) assesses frequency of fruit intake and therefore is not used to assess progress towards the specific Healthy People 2020 objectives for increased fruit consumption or national fruit intake recommendations based on cup equivalents. However, YRBSS data are used to track increased frequency of fruit consumption, a key recommendation of Dietary Guidelines for Americans.
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁴ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-14: Increase the contribution of fruits to the diets of the population aged 2 years and older.
Related CDI Topic Area:	School Health

U.S. Departments of Agriculture and Health and Human Services. Dietary Guidelines for Americans, 2010. 7th edition, Washington, DC: U.S. Government Printing Office, December 2010.
US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020. http://www.healthypeople.gov/.
Centers for Disease Control and Prevention. State Indicator Report on Fruits and Vegetables, 2013. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2013.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Median daily frequency of vegetable consumption among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9–12
Numerator:	Number of total daily intake of vegetable consumption (green salad, potatoes, carrots, and other vegetables)
Denominator:	All respondents for whom these data are available (excluding unknowns or refusals to provide responses to any of the vegetable consumption questions).
Measures of Frequency:	Biennial median frequency with interquartile range; and by demographic characteristics when feasible.
Time Period of Case Definition:	Past 7 days
Background:	The Dietary Guidelines for Americans 2010 and Healthy People 2020 objectives call for Americans to increase their intake of fruits and vegetables.^1,2 Dietary intake recommendations for vegetable intake are 2.5-3 cup equivalents daily for girls 14-18 years of age and 2.5 -4 cup equivalents daily for boys 14-18 years of age, depending on age and physical activity level.¹ In 2011, median daily intake of vegetables among high school students was 1.3 times per day.³
Significance:	The Dietary Guidelines for Americans, 2010 recommends Americans eat more fruits and vegetables as part of a healthy diet, because they contribute important nutrients, can reduce the risk for many chronic diseases, and can also help with weight management.¹
Limitations of Indicator:	The indicator conveys the median frequency of vegetable consumption among high school students surveyed. However, because it does not convey the cup equivalents of vegetables consumed, it cannot be compared to Healthy People 2020 targets. Healthy People 2020 measures progress based on cup equivalents per 1000 kilocalories of intake.²The Youth Risk Behavior Surveillance System (YRBSS) assesses frequency of vegetable intake and therefore is not used to assess progress towards the specific Healthy People 2020 objectives for increased vegetable consumption or national vegetable intake recommendations based on cup equivalents. However, YRBSS data are used to track increased frequency of vegetables consumption, a key recommendation of Dietary Guidelines for Americans.
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁴ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-15.1: Increase the contribution of total vegetables to the diets of the population aged 2 years and older.
Related CDI Topic Area:	School Health

U.S. Departments of Agriculture and Health and Human Services. Dietary Guidelines for Americans, 2010. 7th edition, Washington, DC: U.S. Government Printing Office, December 2010.
US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020. http://www.healthypeople.gov/.
Centers for Disease Control and Prevention. State Indicator Report on Fruits and Vegetables, 2013. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2013.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Participation in daily school physical education classes among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9–12.
Numerator:	Respondents who answered, “5 days”, to the following question: “In an average week in school when you go to school, how many days do you attend physical education (PE) classes?”
Denominator:	Students surveyed in grades 9–12. Respondents with missing data were excluded.
Measures of Frequency:	Biennial (odd years) prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	An average week in school.
Background:	Physical education is an effective strategy to increase physical activity among young people. In 2011, 31.5% of students went to physical education classes 5 days in an average week when they were in school (i.e., attended physical education classes daily).¹
Significance:	Among children and adolescents, physical activity can improve bone health, improve cardiorespiratory and muscular fitness, decrease levels of body fat, and reduce symptoms of depression.² Physical activity patterns established during adolescence might extend into adulthood and affect future chronic disease risk.³ The 2008 Physical Activity Guidelines for Americans states that children and adolescents should do 60 minutes (1 hour) or more of physical activity daily.³
Limitations of Indicator:	The indicator does not capture time spent in physical education class nor does it capture time spent physically active in class.
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁴ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective PA-4: Increase the proportion of the Nation’s public and private schools that require daily physical education for all students. Healthy People 2020 Objective PA-4.3: Increase the proportion of the Nation’s public and private senior high schools that require daily physical education for all students. Healthy People 2020 Objective PA-5: Increase the proportion of adolescents who participate in daily school physical education.
Related CDI Topic Area:	School Health

Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance – United States, 2011. MMWR Surveill Summ. 2012 Jun 8;61(4):1-162.
Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services;2008
U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services;2008.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Meeting aerobic physical activity guidelines among high school students Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Students in grades 9–12
Numerator:	Students in grades 9–12 that answered, “7 days”, to the following question: “During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spend in any kind of physical activity that increases your heart rate and makes you breathe hard some of the time.)”
Denominator:	Students in grades 9–12 who report doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day on 0 or more days during the 7 days before the survey.
Measures of Frequency:	Biennial (odd years) prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Past 7 days.
Background:	The 2008 Physical Activity Guidelines for Americans states that children and adolescents should do 60 minutes (1 hour) or more of physical activity daily.¹ In 2011, 28.7% of high school students had been physically active doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of least 60 minutes per day on each of the 7 days before the survey (i.e., physically active at least 60 minutes on all 7 days).²
Significance:	Among children and adolescents, physical activity can: improve bone health, improve cardiorespiratory and muscular fitness, decrease levels of body fat, and reduce symptoms of depression.³ Physical activity patterns established during adolescence might extend into adulthood and affect future chronic disease risk.
Limitations of Indicator:	The indicator may not be measuring the accurate amount of physical activity because the respondent must calculate each day’s activities and then consider this across the week. The indicator also does not capture the full guideline for children and adolescents which includes the following specifications: Aerobic: Most of the ≥60 minutes a day should be either moderate- or vigorous-intensity aerobic physical activity, and should include vigorous-intensity physical activity at least 3 days a week. Muscle-strengthening: As part of their ≥60 minutes of daily physical activity, children and adolescents should include muscle-strengthening physical activity on at least 3 days of the week. Bone-strengthening: As part of their ≥60 minutes of daily physical activity, children and adolescents should include bone-strengthening physical activity on at least 3 days of the week.
Data Resources:	Youth Risk Behavior Surveillance System (YRBSS).
Limitations of Data Resources:	As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youth who are attending school, and thus may not be representative of all persons in this age group.⁴ Results are not available from every state because some states do not participate in the YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data, and are therefore not included in the results.
Related Indicators or Recommendations:	Healthy People 2020 Objective PA-3: Increase the proportion of adolescents who meet current Federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity. Healthy People 2020 Objective PA-3.1: Increase the proportion of adolescents who meet current Federal physical activity guidelines for aerobic physical activity.
Related CDI Topic Area:	School Health

U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services;2008.
Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance – United States, 2011. MMWR Surveill Summ. 2012 Jun 8;61(4):1-162.
Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services;2008.
CDC. Youth Risk Behavior Surveillance—United States, 2011. MMWR 2012;61(No. SS-4).

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Dental visits among children and adolescents aged 1-17 years Category: Oral Health
Demographic Group:	Resident children and adolescents aged 1-17 years.
Numerator:	Children and adolescents aged 1-17 years with parent-reported dental visit for any kind of dental care, including check-ups, dental cleanings, x-rays, or filling cavities in the previous year.
Denominator:	Children and adolescents aged 1-17 years (excluding unknowns and refusals).
Measures of Frequency:	Prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Previous year.
Background:	According to the 2011/2012 National Survey of Children’s Health, 77.5% of children under 18 years of age reported having had at least one dental visit in the past year.¹
Significance:	Access to dental care is important to obtain prevention, education, and early identification and treatment of oral diseases.² The American Academy of Pediatric Dentistry, the American Academy of Pediatrics, the American Dental Association, and the American Association of Public Health Dentistry recommend establishing a dental home and the first dental visit by age 1 year. ^3-6 Referring a child for an oral health examination by a dentist who provides care for infants and young children 6 months after the first tooth erupts or by 12 months of age establishes the child’s dental home and provides an opportunity to implement preventive dental health habits that meet each child’s unique needs and keep the child free from dental or oral disease. Private and public funds are spent each year for emergency department visits due to oral health conditions and for providing restorations for the children that could have potentially been avoided with routine and optimal preventive and early dental care.^7,8
Limitations of Indicator:	Indicator does not validate types of dental care children actually received.
Data Resources:	National Survey of Children’s Health (NSCH).
Limitations of Data Resources:	NSCH is a parent-reported telephone survey, and subject to limitations such as recall bias and non-coverage bias. (Note: because NSCH is being redesigned, its mode and future periodicity is unknown at this time.)
Related Indicators or Recommendations:	Healthy People 2020 Objective OH-7: Increase the proportion of children, adolescents, and adults who used the oral health care system in the past 12 months (LHI).
Related CDI Topic Area:	School Health

National Survey of Children’s Health. NSCH 2011/2012. Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Available: www.childhealthdata.org. Accessed: March 4, 2014.
Institute of Medicine, National Research Council. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. 2011. Available at: http://www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx. Accessed: July 10, 2013.
American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Available from: http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf. Accessed: September 25, 2013.
Hale K. J., American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111(5 Pt 1):1113-1116.
American Dental Association. For the dental patient: baby’s first teeth. J Am Dent Assoc. 2002;133:255.
American Association of Public Health Dentistry. First oral health assessment policy. 2004. Available: http://aaphd.org/default.asp?page=FirstHealthPolicy.htm. Accessed: September 25, 2013.
Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining the cost-effectiveness of early dental visits. Pediatr Dent. 2006;28:102-5.
The Pew Center on the States. A costly dental destination – Hospital care means states pay dearly. 2012. Available: http://www.pewstates.org/uploadedFiles/PCS_Assets/2012/A%20Costly%20Dental%20Destination(1).pdf. Accessed: September 25, 2013.

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Preventive dental visits among children and adolescents aged 1-17 years Category: Oral Health
Demographic Group:	Resident children and adolescents aged 1-17 years.
Numerator:	Children and adolescents aged 1-17 years with parent-reported at least one preventive dental visit, including check-ups, or dental cleanings, in the previous year.
Denominator:	Children and adolescents aged 1-17 years (excluding unknowns and refusals).
Measures of Frequency:	Annual prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Previous year.
Background:	According to the 2011/2012 National Survey of Children’s Health, 77.2% of children aged 1-17 years reported having had at least one preventive dental visit in the past year.¹
Significance:	Studies have shown the benefits of regular and age-appropriate preventive dental visits; Children could avoid complex and expensive restorative and emergency dental treatment in later years, and these changes ultimately led to significant savings in dental expenditures.^2,3
Limitations of Indicator:	Indicator does not validate types of dental care children actually received.
Data Resources:	National Survey of Children’s Health (NSCH).
Limitations of Data Resources:	NSCH is a parent-reported telephone survey, and subject to limitations such as recall bias and non-coverage bias. (Note: because NSCH is being redesigned, its mode and future periodicity is unknown at this time.)

National Survey of Children’s Health. NSCH 2011/2012. Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Available: www.childhealthdata.org. Accessed: March 4, 2014.
Savage MF, Lee JY, Kotch JB, Vann WF. Early preventive dental visits: Effects on subsequent utilization and costs. Pediatrics 2004;114(4):e418-e423.
Ramos-Gomez FJ, Shepard DS. Cost-effectiveness model for the prevention of early childhood caries. J Calif Dent Assoc 1999;27(7):539-544.

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Presence of regulations pertaining to avoiding sugar in early care and education settings Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Children ages 0-5 years.
Numerator:	States with child care regulations serving children in child care ages 0-5 years that support avoiding sugar including concentrated sweets, such as candy, sodas, sweetened drinks, fruit nectars, and flavored milk. (Note: For states with separate regulations for large and small homes and centers, language in all sets of regulations should fully include national guidelines.)
Denominator:	50 States Note: The numerator and denominator above define the indicator for the United States data. Individual states will have a yes/no response to this indicator.
Measures of Frequency:	Percent of states with language that supports avoiding sugar including concentrated sweets, such as candy, sodas, sweetened drinks, fruit nectars, and flavored milk.
Time Period of Case Definition:	Current year.
Background:	In 2011, 20% of states had language in child care regulations that supported avoiding sugar including concentrated sweets, such as candy, sodas, sweetened drinks, fruit nectars, and flavored milk.¹
Significance:	Current research supports a diet based on a variety of nutrient dense foods which provide substantial amounts of essential nutrients.² To ensure that child care programs are offering a variety of foods the Caring for Our Children: National Health and Safety Performance Standards (3rd ed.) recommends that children should be offered items from each food group and avoid concentrated sweets such as candy, sodas, sweetened drinks, fruit nectars, and flavored milk.³
Limitations of Indicator:	Indicator does not capture compliance with regulation.
Data Resources:	Achieving a State of Healthy Weight: A National Assessment of Obesity Prevention Terminology in Child Care Regulations 2011.
Limitations of Data Resources:	There is much variability in the way states’ documents are organized and the language used within the states’ documents.
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-1: Increase the number of States with nutrition standards for foods and beverages provided to preschool-aged children in child care.
Related CDI Topic Area:	Diabetes; Oral Health; Reproductive Health

National Resource Center for Health and Safety in Child Care and Early Education. 2012. Achieving a state of healthy weight: 2011 update. Aurora, CO: University of Colorado Denver. Also available at http://nrckids.org
U.S. Departments of Agriculture and Health and Human Services. Dietary Guidelines for Americans, 2010. 7th edition, Washington, DC: U.S. Government Printing Office, December 2010.
American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. 2011. Caring for our children: National health and safety performance standards; Guidelines for early care and education programs. 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association. Also available at http://nrckids.org.

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Secondary schools that allow students to purchase soda or fruit drinks Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Secondary Schools
Numerator:	Number of secondary schools that allowed students to purchase soda pop or fruit drinks that are not 100% juice from vending machines or at the school store, canteen, or snack bar.
Denominator:	Number of secondary Schools
Measures of Frequency:	Percentage
Time Period of Case Definition:	2012
Background:	Many schools offer foods and beverages in after-school programs, school stores, snack bars, or canteens¹ and these foods sold in competition to school meals are often relatively low in nutrient density and relatively high in fat, added sugars and calories.² Competitive foods are widely available in many elementary schools, in most middle schools, and in almost all secondary schools.^1,3-5 Given that schools offer numerous and diverse opportunities for young people to learn and make consumption choices about healthful eating, schools should provide a consistent environment that is conducive to healthful eating behaviors.⁶ To help improve dietary behavior and reduce overweight among youths, schools should offer appealing and nutritious foods in school snack bars and vending machines and discourage sale of foods high in fat, sodium, and added sugars, and beverages and foods containing caffeine on school grounds.^7-11 Restricting the availability of high-calorie, energy dense foods in schools while increasing the availability of healthful foods might be an effective strategy for promoting more healthful choices among students at school.^6,12 In 2012, the percentage of secondary schools allowed students to purchase soda pop or fruit drinks at the school store, canteen, or snack bar ranged from 4.2% to 56.1% (median: 30.1%)¹³.
Significance:	Calorically sweetened beverage intake has been associated with dental caries and cardiovascular disease risk factors.^14–21These data are included in the CDC School Health Profiles summary report and were used as an indicator in the Children’s Food Environment Indicator Report.²²
Limitations of Indicator:	It does not include data on access outside of the school setting. As with any study that relies on self-report, it is possible that the data reflect some amount of over-reporting or underreporting and actual lack of knowledge.
Data Resources:	School Heath Profiles Principal Survey. Data are only available for those states with >70% response rate; data are weighted.
Limitations of Data Resources:	National data (other than median of state estimates) are not available. National data (other than median of state estimates) are not available. Data presented in this report apply only to secondary schools and are limited to school populations. As with all sample surveys, data might be subject to systematic error resulting from non-coverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-2.1: Increase the proportion of schools that do not sell or offer calorically-sweetened beverages to students.
Related CDI Topic Area:	Diabetes; Oral Health, School Health

O’Toole T, Anderson S, Miller C, Guthrie J. Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study. Journal of School Health 2007;77(8):500-521.
U.S. Department of Agriculture. Foods sold in competition with USDA school meal programs: a report to congress. Food and Nutrition Service, 2001. Available at: www.fns.usda.gov/cnd/lunch/_private/CompetitiveFoods/report_congress.htm. Accessed June 11, 2009.
Brener ND, Kann L, O’Toole TP, Wechsler H, Kimmons J. Competitive foods and beverages available for purchase in secondary schools – selected sites, United States, 2006. MMWR 2008;57(34):935-938.
U.S. Government Accountability Office. School meal programs: Competitive foods are widely available and generate substantial revenues. Report to Congressional Requesters GAO-05-563, 2005. Available at: www.gao.gov/new.items/d05563.pdf. Accessed June 12, 2009.
Fox MK, Gordon A, Nogales R, Wilson A. Availability and consumption of competitive foods in US public schools. Journal of the American Dietetic Association 2009a;109:S57-S66.
Food and Nutrition Board, Institute of Medicine, Committee on Prevention of Obesity of Children and Youth–Schools. In: JP Koplan, CT Liverman, VI Kraak, eds. Preventing Childhood Obesity: Health in the Balance. Washington, DC: National Academy Press, 2005, pp. 237–284.
Wechsler H, McKenna ML, Lee SM, Dietz WH. The role of schools in preventing childhood obesity. The State Education Standard 2004;5(2):4-12.
American Dietetic Association. Position of the American Dietetic Association: local support for nutrition integrity in schools. Journal of the American Dietetic Association 2010;110(8):1244-1254.(1):122-33.
Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: Institute of Medicine of the National Academies, 2007.
Fox MK, Dodd AH, Wilson A, Gleason PM. Association between school food environment and practices and body mass index of US public school children. Journal of the American Dietetic Association 2009b;109(2 suppl):S108–S17.
Briefel RR, Crepinsek MK, Cabili C, Wilson A, Gleason PM. School food environments and practices affect dietetic behaviors of US public school children. Journal of the American Dietetic Association 2009;109 (Suppl 1):S91–S107.
Story M, Nanney MS, and Schwartz MB. Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity. Milbank Quarterly 2009; 87(1):71-100.
Demissie Z, Brener ND, McManus T, Shanklin SL, Hawkins J, Kann L. School Health Profiles 2012: Characteristics of Health Programs Among Secondary Schools. Atlanta: Centers for Disease Control and Prevention; 2013.
Welsh JA, Sharma A, Abramson JL, Vaccarino V, Gillespie C, Vos MB. Caloric sweetener consumption and dyslipidemia among US adults. JAMA 2010;303:1490–7.
Welsh JA, Sharma A, Cunningham SA, Vos MB. Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents. Circulation 2011;123(3):249–57.
Marshall TA, Levy SM, Broffitt B, Warren JJ, Eichenberger-Gilmore JM, Burns TL, Stumbo PJ. Dental caries and beverage consumption in young children. Pediatrics 2003;112:e184–91.
Ismail AI, Burt BA, Eklund SA. The cariogenicity of soft drinks in the United States. J Am Dent Assoc 1984;109:241–5.
Heller KE, Burt BA, Eklund SA. Sugared soda consumption and dental caries in the United States. J Dent Res 2001;80:1949–53.
Malik VS, Hu FB. Sweeteners and risk of obesity and type 2 diabetes: the role of sugar-sweetened beverages. Curr Diab Rep (Epub ahead of print 31 January 2012).
Malik V, Popkin BM, Bray GA, Despres JP, Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation 2010;121:1356–64.
Kit B, Fakhouri TH, Park S, Nielson SJ, Ogen C. Trends in Sugar-sweetened beverage consumption among youth and adults in the united states: 1999-2010. Am J Clin Nutr. 2013;98:180-8.

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Secondary schools that allow students to purchase sports drinks Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Secondary Schools
Numerator:	Number of secondary schools that allow students to purchase sports drinks from vending machines or at the school store, canteen, or snack bar.
Denominator:	Number of secondary Schools
Measures of Frequency:	Percentage
Time Period of Case Definition:	2012
Background:	Many schools offer foods and beverages in after-school programs, school stores, snack bars, or canteens¹ and these foods sold in competition to school meals are often relatively low in nutrient density and relatively high in fat, added sugars and calories.² Competitive foods are widely available in many elementary schools, in most middle schools, and in almost all secondary schools.^1,3-5 Given that schools offer numerous and diverse opportunities for young people to learn and make consumption choices about healthful eating, schools should provide a consistent environment that is conducive to healthful eating behaviors.⁶ To help improve dietary behavior and reduce overweight among youths, schools should offer appealing and nutritious foods in school snack bars and vending machines and discourage sale of foods high in fat, sodium, and added sugars, and beverages and foods containing caffeine on school grounds.^7-11 Restricting the availability of high-calorie, energy dense foods in schools while increasing the availability of healthful foods might be an effective strategy for promoting more healthful choices among students at school.^6,12 In 2012, the percentage of secondary schools allowed students to purchase sports drinks at the school store, canteen, or snack bar ranged from 6.7% to 73.8% (median: 46.0%)¹³
Significance:	Calorically sweetened beverage intake has been associated with dental caries and cardiovascular disease risk factors ^14–21. These data are included in the CDC School Health Profiles summary report and were used as an indicator in the Children’s Food Environment Indicator Report ²².
Limitations of Indicator:	It does not include data on access outside of the school setting.
Data Resources:	School Heath Profiles Principal Survey. Data are only available for those states with >70% response rate; data are weighted.
Limitations of Data Resources:	National data (other than median of state estimates) are not available. National data (other than the median of state estimates) are not available. Data presented in this report apply only to secondary schools and are limited to the school populations. As with all sample surveys, data might be subject to systematic error resulting from non-coverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-2.1: Increase the proportion of schools that do not sell or offer calorically-sweetened beverages to students.
Related CDI Topic Area:	Diabetes; Oral Health, School Health

O’Toole T, Anderson S, Miller C, Guthrie J. Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study. Journal of School Health 2007;77(8):500-521.
U.S. Department of Agriculture. Foods sold in competition with USDA school meal programs: a report to congress. Food and Nutrition Service, 2001. Available at: www.fns.usda.gov/cnd/lunch/_private/CompetitiveFoods/report_congress.htm. Accessed June 11, 2009.
Brener ND, Kann L, O’Toole TP, Wechsler H, Kimmons J. Competitive foods and beverages available for purchase in secondary schools – selected sites, United States, 2006. MMWR 2008;57(34):935-938.
U.S. Government Accountability Office. School meal programs: Competitive foods are widely available and generate substantial revenues. Report to Congressional Requesters GAO-05-563, 2005. Available at: www.gao.gov/new.items/d05563.pdf. Accessed June 12, 2009.
Fox MK, Gordon A, Nogales R, Wilson A. Availability and consumption of competitive foods in US public schools. Journal of the American Dietetic Association 2009a;109:S57-S66.
Food and Nutrition Board, Institute of Medicine, Committee on Prevention of Obesity of Children and Youth–Schools. In: JP Koplan, CT Liverman, VI Kraak, eds. Preventing Childhood Obesity: Health in the Balance. Washington, DC: National Academy Press, 2005, pp. 237–284.
Wechsler H, McKenna ML, Lee SM, Dietz WH. The role of schools in preventing childhood obesity. The State Education Standard 2004;5(2):4-12.
American Dietetic Association. Position of the American Dietetic Association: local support for nutrition integrity in schools. Journal of the American Dietetic Association 2010;110(8):1244-1254.(1):122-33.
Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: Institute of Medicine of the National Academies, 2007.
Fox MK, Dodd AH, Wilson A, Gleason PM. Association between school food environment and practices and body mass index of US public school children. Journal of the American Dietetic Association 2009b;109(2 suppl):S108–S17.
Briefel RR, Crepinsek MK, Cabili C, Wilson A, Gleason PM. School food environments and practices affect dietetic behaviors of US public school children. Journal of the American Dietetic Association 2009;109 (Suppl 1):S91–S107.
Story M, Nanney MS, and Schwartz MB. Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity. Milbank Quarterly 2009; 87(1):71-100.
Demissie Z, Brener ND, McManus T, Shanklin SL, Hawkins J, Kann L. School Health Profiles 2012: Characteristics of Health Programs Among Secondary Schools. Atlanta: Centers for Disease Control and Prevention; 2013.
Welsh JA, Sharma A, Abramson JL, Vaccarino V, Gillespie C, Vos MB. Caloric sweetener consumption and dyslipidemia among US adults.
Welsh JA, Sharma A, Cunningham SA, Vos MB. Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents. Circulation 2011;123(3):249–57.
Marshall TA, Levy SM, Broffitt B, Warren JJ, Eichenberger-Gilmore JM, Burns TL, Stumbo PJ. Dental caries and beverage consumption in young children. Pediatrics 2003;112:e184–91.
Ismail AI, Burt BA, Eklund SA. The cariogenicity of soft drinks in the United States. J Am Dent Assoc 1984;109:241–5.
Heller KE, Burt BA, Eklund SA. Sugared soda consumption and dental caries in the United States. J Dent Res 2001;80:1949–53.
Malik VS, Hu FB. Sweeteners and risk of obesity and type 2 diabetes: the role of sugar-sweetened beverages. Curr Diab Rep (Epub ahead of print 31 January 2012).
Malik VS, Popkin BM, Bray GA, Despres JP, Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation 2010;121:1356–64.
Kit B, Fakhouri TH, Park S, Nielson SJ, Ogen C. Trends in Sugar-sweetened beverage consumption among youth and adults in the United States: 1999-2010. Am J Clin Nutr. 2013;98:180-8.

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Secondary schools that offer less healthy foods as competitive foods Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Secondary schools
Numerator:	Number of secondary schools that sell baked goods (e.g., cookies, crackers, cakes, pastries, or other baked goods), salty snacks, chocolate candy, other kinds of candy, soda pop or fruit drinks, and sports drinks in vending machines or at the school store, canteen, or snack bar.
Denominator:	Number of secondary Schools
Measures of Frequency:	Percentage
Time Period of Case Definition:	2012
Background:	Many schools offer foods and beverages in after-school programs, school stores, snack bars, or canteens¹ and these foods sold in competition to school meals are often relatively low in nutrient density and relatively high in fat, added sugars and calories.² Competitive foods are widely available in many elementary schools, in most middle schools, and in almost all secondary schools.^1,3-5 Given that schools offer numerous and diverse opportunities for young people to learn and make consumption choices about healthful eating, schools should provide a consistent environment that is conducive to healthful eating behaviors.⁶ To help improve dietary behavior and reduce overweight among youths, schools should offer appealing and nutritious foods in school snack bars and vending machines and discourage sale of foods high in fat, sodium, and added sugars, and beverages and foods containing caffeine on school grounds.^7-11 Because students’ food choices are influenced by the total food environment, the simple availability of healthful foods such as fruits and vegetables may not be sufficient to prompt the choice of fruits and vegetables when other high-fat or high-sugar foods are easily accessible.^12,13 However, offering a wider range of healthful foods can be an effective way to promote better food choices among high school students.¹⁴ Restricting access to snack foods is associated with higher frequency of fruit and vegetable consumption in elementary school aged children.¹⁵ Taken together, such findings suggest that restricting the availability of high-calorie, energy dense foods in schools while increasing the availability of healthful foods might be an effective strategy for promoting more healthful choices among students at school.^6,16 In 2012, the percentage of secondary schools that did not sell any of the following six items (baked goods, salty snacks, candy, soda pop or fruit drinks, or sports drinks) at the school store, canteen, or snack bar ranged from 12.9% to 88.9% (median: 42.7%)¹⁷.
Significance:	Most foods and beverages sold in school, outside of the school meals program, are high in sugar, fat, and calories, including high-fat salty snacks, high-fat baked goods, and high-calorie sugar-sweetened beverages, such as soft drinks, sport drinks, and fruit drinks. The School Health Profiles Survey includes this indicator in their annual reports.
Limitations of Indicator:	It does not include data on access outside of the school setting.
Data Resources:	School Heath Profiles Principal Survey. Data are only available for those states with >70% response rate; data are weighted.
Limitations of Data Resources:	National data (other than median of state estimates) are not available. National data (other than the median of state estimates) are not available. Data presented in this report apply only to secondary schools and are limited to the school populations. As with all sample surveys, data might be subject to systematic error resulting from non-coverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).
Related Indicators or Recommendations:	Healthy People 2020 Objective NWS-2: Increase the proportion of schools that offer nutritious food and beverages outside of school meals.
Related CDI Topic Area:	Cardiovascular Disease; Diabetes; Oral Health; School Health

O’Toole T, Anderson S, Miller C, Guthrie J. Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study. Journal of School Health 2007;77(8):500-521.
U.S. Department of Agriculture. Foods sold in competition with USDA school meal programs: a report to congress. Food and Nutrition Service, 2001. Available at: www.fns.usda.gov/cnd/lunch/_private/CompetitiveFoods/report_congress.htm. Accessed June 11, 2009.
Brener ND, Kann L, O’Toole TP, Wechsler H, Kimmons J. Competitive foods and beverages available for purchase in secondary schools – selected sites, United States, 2006. MMWR 2008;57(34):935-938.
U.S. Government Accountability Office. School meal programs: Competitive foods are widely available and generate substantial revenues. Report to Congressional Requesters GAO-05-563, 2005. Available at: www.gao.gov/new.items/d05563.pdf. Accessed June 12, 2009.
Fox MK, Gordon A, Nogales R, Wilson A. Availability and consumption of competitive foods in US public schools. Journal of the American Dietetic Association 2009a;109:S57-S66.
Food and Nutrition Board, Institute of Medicine, Committee on Prevention of Obesity of Children and Youth–Schools. In: JP Koplan, CT Liverman, VI Kraak, eds. Preventing Childhood Obesity: Health in the Balance. Washington, DC: National Academy Press, 2005, pp. 237–284.
Wechsler H, McKenna ML, Lee SM, Dietz WH. The role of schools in preventing childhood obesity. The State Education Standard 2004;5(2):4-12.
American Dietetic Association. Position of the American Dietetic Association: local support for nutrition integrity in schools. Journal of the American Dietetic Association 2010;110(8):1244-1254.(1):122-33.
Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: Institute of Medicine of the National Academies, 2007.
Fox MK, Dodd AH, Wilson A, Gleason PM. Association between school food environment and practices and body mass index of US public school children. Journal of the American Dietetic Association 2009b;109(2 suppl):S108–S17.
Briefel RR, Crepinsek MK, Cabili C, Wilson A, Gleason PM. School food environments and practices affect dietetic behaviors of US public school children. Journal of the American Dietetic Association 2009;109 (Suppl 1):S91–S107.
Cullen KW, Eagan J, Baranowski T, Owens E, deMoor C. Effect of a la carte and snack bar foods at school on children’s lunchtime intake of fruits and vegetables. Journal of the American Dietetic Association 2000;100:1482–1486.
Kubik MY, Lytle LA, Hannan PJ, Perry CL, Story M. The association of the school food environment with dietary behaviors of young adolescents. American Journal of Public Health 2003;93:1168–1173.
French SA, Story M, Fulkerson JA, Hannan P. An environmental intervention to promote lower fat food choices in secondary schools. Outcomes of the TACOS study. American Journal of Public Health 2004;94(9):1507-1512.
Gonzalez W, Jones SJ, Frongillo EA. Restricting snacks in US elementary schools is associated with higher frequency of fruit and vegetable consumption. Journal of Nutrition 2009;139:142-4.
Story, M, Nanney MS, and Schwartz MB. Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity. Milbank Quarterly 2009; 87(1):71-100.
Demissie Z, Brener ND, McManus T, Shanklin SL, Hawkins J, Kann L. School Health Profiles 2012: Characteristics of Health Programs Among Secondary Schools. Atlanta: Centers for Disease Control and Prevention; 2013.

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Tobacco-free schools Category: Tobacco
Demographic Group:	Secondary Schools
Numerator:	Number of secondary schools within the state that have a comprehensive tobacco-free school policy that prohibits tobacco use at all times by all persons, with no exceptions, on school property; in school vehicles and those used for school purposes; and at school sponsored events, both on and off school property.
Denominator:	Number of secondary schools
Measures of Frequency:	Percent
Time Period of Case Definition:	Survey year
Background:	These questions measure the extent to which schools develop, implement, and enforce a policy that creates a totally tobacco-free environment within the school experience for both young people and adults, as outlined in the CDC Guidelines for School Health Programs to Prevent Tobacco Use and Addiction.¹ The Pro-Children Act of 1994, reauthorized under the No Child Left Behind Act of 2001, prohibits smoking in facilities where federally funded educational, health, library, daycare, or child development services are provided to children under the age of 18.² During 2007–2008, approximately 88 million nonsmokers aged ≥3 years in the United States were exposed to secondhand smoke. Of these, 32 million were aged 3–19 years, reflecting the higher prevalence of exposure among children and youths.³
Significance:	Secondhand smoke exposure causes heart disease and lung cancer in nonsmoking adults and several health conditions in children.⁴ The U.S. Surgeon General has concluded that there is no safe level of secondhand smoke exposure and that only completely eliminating smoking in indoor spaces fully protects nonsmokers from secondhand smoke.⁴
Limitations of Indicator:	The data are based on the response of specific individuals in the sample schools throughout a given state, city, territory, or tribal government (e.g. administrator of principal) and are subject to the actual knowledge of the individual completing the survey.
Data Resources:	School Health Profiles Principal Survey. Data is only available for those states with >70% response rate; data are weighted.
Limitations of Data Resources:	National data (other than median of state estimates) are not available. Data presented in this report apply only to secondary schools and are limited to these school populations. As with all sample surveys, data might be subject to systematic error resulting from non-coverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).
Related Indicators or Recommendations:	Healthy People 2020 Objective TU-15: Increasing tobacco-free environments in schools, including all school facilities, property, vehicles, and school events.
Related CDI Topic Area:	School Health

CDC. Guidelines for school health programs to prevent tobacco use and addiction. MMWR 1994;43(RR-2):1–18.
US Department of Health and Human Services. Preventing tobacco use among youth and young adults. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm.
CDC. Vital Signs: Nonsmokers Exposure to Secondhand Smoke – United States, 1999-2008. MMWR 2010;59(35):1141-1146.
U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006.

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Secondary schools that allow community-sponsored use of physical activity facilities by youth outside of normal school hours Category: Nutrition, Physical Activity, and Weight Status
Demographic Group:	Secondary Schools
Numerator:	Number of secondary schools that had a, “yes”, response to the following question: “Does your school, either directly or through the school district, have a joint use agreement for shared use of school or community physical activity facilities?”
Denominator:	Number of secondary schools.
Measures of Frequency:	Percentage
Time Period of Case Definition:	Current year.
Background:	This question measures the extent to which schools and communities share physical activity facilities. School spaces and facilities should be available to young people before, during, and after the school day, on weekends, and during summer and other vacations. Access to these facilities increases visibility of schools, provides youth, their families, and community members a safe place for physical activity, and might increase partnerships with community-based physical activity programs. Community resources can expand existing school programs by providing program staff 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 children and adolescents, weight management programs for overweight or obese young people, and sports and recreation programs for young people with disabilities or chronic health conditions.^1-4 In 2012, the percentage of secondary schools that had a joint use agreement for shared of school or community physical activity facilities ranged from 40.9% to 86.6% (median: 65.2%)⁵.
Significance:	Among children and adolescents, physical activity can improve bone health, improve cardiorespiratory and muscular fitness, decrease levels of body fat, and reduce symptoms of depression.⁶ Physical activity patterns established during adolescence might extend into adulthood and protect against future chronic disease risk.⁶
Limitations of Indicator:	As with any study that relies on self-report, it is possible that the data reflect some amount of over-reporting or underreporting and actual lack of knowledge.
Data Resources:	School Health Profiles Principal Survey. Data are only available for those states with >70% response rate; data are weighted.
Limitations of Data Resources:	National data (other than median of state estimates) are not available. Data presented in this report apply only to secondary schools and are limited to the school populations. As with all sample surveys, data might be subject to systematic error resulting from non-coverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).
Related Indicators or Recommendations:	Healthy People 2020 Objective PA-10: Increase the proportion of the Nation’s public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours (that is, before and after the school day, on weekends, and during summer and other vacations).
Related CDI Topic Area:	School Health

CDC. School Health Guidelines to Promote Healthy Eating and Physical Activity. MMWR 2011;60(5):1-75.
Sallis JF, Conway TL, Prochaska JJ, et al. The association of school environments with youth physical activity. American Journal of Public Health 2001;1:618-20.
Evenson KR, McGinn AP. Availability of school physical activity facilities to the public in four U.S. communities. American Journal of Health Promotion 2004;18:243-50.
Choy LB, McGurk MD, Tamashiro R, Nett B, Maddock JE. Increasing access to places for physical activity through a joint use agreement: a case study in urban Honolulu. Preventing Chronic Disease 2008;5.
Demissie Z, Brener ND, McManus T, Shanklin SL, Hawkins J, Kann L. School Health Profiles 2012: Characteristics of Health Programs Among Secondary Schools. Atlanta: Centers for Disease Control and Prevention; 2013.
US Department of Health and Human Services. Physical activity guidelines for Americans, 2008. Washington, DC: US Department of Health and Human Services; 2008.

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Page last reviewed: May 11, 2017
Page last updated: May 11, 2017
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Chronic Disease Indicators

Indicator Definitions - School Health

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