why are children overweight? · & consequences causes the causes of obesity in children are...
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Executive Summary 1
Overview of Obesity Prevalence, Causes & Consequences 3
Field Assessment Purpose and Methods 5
Field Assessment Findings I: The Obesity ProblemWhy are Children Overweight? 6What do Children Consume? 6How do Schools Contribute to the Problem? 7What Happens in Afterschool Programs? 9How does Culture Affect Diets? 11Are Foods Accessible and Available? 12Is Recreation Available for Children? 13What is the Impact of the Home Environment? 14
Field Assessment Findings II: How to Prevent ObesitySchool-Based Interventions 15Afterschool Interventions 17Parent Education 18Community-Based Interventions 19
Summary of Key Findings 20
Toward a Strategy for Obesity Prevention for Children in Rural America 22
References 24
Appendices 27
Contents
NHANES: National Health and Nutrition Examination Survey
BMI: Body Mass IndexAFDC: Aid to Families with
Dependent Children
WIC: Woman, Infants and Children
PE: Physical EducationAZ: ArizonaCA: CaliforniaGA: Georgia
KY: KentuckyMS: Mississippi
NM: New MexicoSC: South CarolinaTN: TennesseeWV: West Virginia
This report was funded with generous support from Mott’s, Inc.
Abbreviations
ExecutiveSummary
Executive SummaryThe prevalence of obesity is dramatically rising among children in theUnited States, particularly among minority populations. There aremultiple causes of childhood obesity, most of which are associated withpoor nutritional habits and inactivity. Obesity and overweight havebeen found to be difficult and expensive to treat and cure, thereforepreventing this condition in children will be the key to addressing thisnational epidemic. So far, however, there are few examples of effectiveobesity prevention programs especially among high risk isolated, ruralpopulations. This first, national assessment of the obesity problem andpotential opportunities for obesity-related interventions for children inrural, isolated America documents important findings.
The factors that contributed to obesity highlighted through thisqualitative research were:
• Rural children consumed large quantities of “junk food,” fast food,and fried food.
• Access to healthy food choices was limited in isolatedcommunities.
• Reliance on food stamps can create cycles of household foodinsufficiency which may prompt children to overeat during timesof plenty.
• Children had access to unhealthy food and drink choices atschool.
• Limited nutrition education was taught in school and childrenhad few opportunities to learn about nutrition in afterschoolsettings.
• Little or no physical education was provided in rural schools.• Rural communities had limited parks, recreational facilities, and
fitness centers.• Access to school facilities and recreational areas was a barrier to
providing physical activity for afterschool programs.• Most afterschool programs had indoor and/or outdoor areas for
physical activity, although few programs provided structuredactivities.
• Sedentary lifestyles, including excessive television viewing, playingvideo games, and using the computer were major reasons forinactivity.
• Limited parental involvement in how children spend free timeand a lack of role models for physical activity reduced activitylevels of children.
1
ExecutiveSummary
The potential areas for intervention mentioned by participants were to:• Improve availability and quality of physical education (PE) in
schools.• Modify the focus of PE from sports to lifelong fitness habits.• Develop nutrition education programs for children in school,
afterschool, as well as for parents and the community.• Improve infrastructure for physical activity such as playgrounds
and sports fields.• Increase access to school and community recreational facilities
for afterschool programs.• Develop community-based obesity prevention programs
delivering messages to children in schools, in afterschoolprograms, as well as among parents and in the community.
The information from this assessment, combined with State-levelefforts to address obesity and evidence-based approaches to obesityprevention, will set the stage for developing and implementing aprevention strategy for rural America.
2
Overview of ObesityPrevalence, Causes & Consequences
PrevalenceThe prevalence of obesity is rising dramatically among adults andchildren in all racial and ethnic groups in the United States. Accordingto the National Health and Nutrition Examination Survey (NHANES),31% of U.S. adults aged 20-74 years are obese (BMI) >30)1. Amongpreschool children in the United States, the prevalence of overweighthas doubled over the last two decades and is estimated to be over10%2. The prevalence has also doubled among youth aged 12 to 19years (from 6.1% to 15.5%). The most striking increase has beenamong children 6 to 11 years, where the rates of obesity have morethan tripled (5% to 15.3%).
Certain sub-groups, namely, Hispanic, non-Hispanic black and NativeAmerican populations are experiencing disproportionately higher ratesof obesity. Recent data revealed that 24% of Mexican-American andnon-Hispanic black children are overweight, compared toapproximately 15% of non-Hispanic white2. Among American Indianschool-age children, the prevalence of obesity is estimated to be over30%3, higher than any other group in the United States.4-6
Socio-economic status is also associated with obesity prevalence.Several studies have associated low socio-economic status with higherrates of obesity among children.7-10
Furthermore, children living in rural areas are disproportionatelyaffected by these higher rates of obesity (see Table 1 below). Over35% of middle school boys and girls from a Save the Children partnersite in Whitley County, Kentucky were obese.
3
State Population PrevalenceKentucky Children in grades 3 to 5 (n=54) One-third of rural children
were overweight11
West Virginia Fifth grade children in three 40% were overweight12
rural counties
West Virginia 5th grade children in 27% overweight13
14 rural counties (n=1338)
North Carolina Rural and urban The odds of being obese 3rd and 4th grade children were 50% higher for rural
children14
South Carolina 6th graders (n=352) in two rural 49% of the students were counties compared to national obese compared to national average; 75% African American students average of 21%15
Mississippi Children from middle school (n=205) 32% overweight16
Central New Mexico Rural American-Indian One third of the students fifth graders (n~2000) were overweight17
TTaabbllee 11:: Prevalence of Overweight among Rural Children in Save the Children regions.
Overview of ObesityPrevalence, Causes
& ConsequencesCausesThe causes of obesity in children are numerous and can mostly beattributed to environmental determinants including:
• Sedentary behaviors, television viewing, computer usage andsimilar behaviors that require limited movement.
• Poor nutritional choices and unhealthy eating habits includingover-consumption of high-calorie foods, eating when not hungry,eating while involved in other activities like watching TV or doinghomework.
• Familial factors, socio-economic status, food access, eating habitsand behaviors.
• Over-exposure to television and print advertisements of high-fat,high calorie foods.
• Lack of recreational facilities and/or opportunities for physicalactivity.
In addition, other environmental and cultural challenges to maintaininga healthy weight exist for children living in rural areas. For example,several studies have found that rural school-age children have a higherfat intake than their urban peers, especially among African-Americangirls.11,18,19 Also, limited resources and lack of access to places forexercise in rural communities make it more difficult for children to bephysically active.
ConsequencesPhysical, emotional, and social consequences are associated withchildhood obesity. Although some of the repercussions do not surfacefor several decades, even young children can suffer from serious healthproblems.20 The physical health effects are numerous, some of whichinclude hypertension, hypercholesterolimia, type 2 diabetes, andcardiovascular disease.20 Other health consequences includegallstones, hepatitis, and sleep apnea.20
Children and adolescents are also increasingly being diagnosed withtype 2 diabetes.21 A disproportionately higher rate of type 2 diabeteshas been found among American Indian,African-American and Hispanicyouth.22,23 The increasing prevalence of type 2 diabetes in children canmainly be attributed to the increase in childhood obesity. Thereforemany of the factors associated with developing type 2 diabetes arepotentially modifiable and preventable by controlling childhood obesity.22
Obese children often suffer emotional problems that range from lowself-esteem and negative body image to depression. Many overweightchildren also experience discrimination as they are often marginalizedfrom their peers, negatively stereotyped and teased. These social andemotional health issues can impact children over the short- and long-term.24
4
Field AssessmentPurpose and Methods
The overall purpose of the Nutrition and Physical Activity FieldAssessment was to gather and document information on: the extent ofthe obesity epidemic among children in our partner communities; thecurrent status of nutrition and physical activity activities including workdone by other organizations; and the potential opportunities forintervening in the area of nutrition and physical activity.
This assessment consisted of a series of in-depth interviews and focusgroups with over 45 participants in Appalachia (Kentucky and WestVirginia), the Southeastern area (South Carolina, Georgia, Mississippi,and Tennessee), and the Western area (Arizona, New Mexico, andCalifornia). The list of specific field sites included in this assessment isprovided in Appendix A. Data were collected from individuals affiliatedwith schools, community groups and healthcare facilities. Schoolpersonnel included in this assessment were Principals, Food servicemanagers, Physical Education (PE) teachers and classroom teachers.Assessment participants were Save the Children partners in bothschool and community-based afterschool programs including programdirectors, literacy specialists, physical activity coordinators, andvolunteers. Additional interviews were conducted with local andregional experts in the area of physical activity and nutrition includingnutritionists, epidemiologists, and medical doctors from variousregions. Extensive field notes were taken during the interviews as wellas tape recorded, when permissible, for accuracy in data collection.
All notes and tapes were transcribed into Word documents anddownloaded into a qualitative research program, NUD*IST, for dataanalyses. Textual data from the interviews were coded and analyzedbased on underlying themes in the data (e.g. physical activity barriers,dietary preferences).
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Field AssessmentFindings I:
The Obesity ProblemWhy are Children Overweight?Childhood obesity is multi-faceted, including individual, household, andcommunity factors. The overall consensus among participants wasthat children were becoming overweight because of “bad habits,”heredity, and environmental factors, such as poverty and lack ofaccess to facilities. One informant, who shared the same sentiment asmost of the participants, indicated that, “Kids are eating junk food andstaying at home watching TV or playing with an X-Box which are the majorreasons for obesity.” The poor eating and exercise habits of parentswere mentioned as a contributing factor to the ‘bad habits’ observedin children, even at an early age.
Other informants attributed the high rates of obesity in children tolack of physical activity. One teacher in California noted, “Since thehigh school removed PE (physical education) 2 years ago, I have seen anincrease in obesity among older kids.” Most of the informants werequick to say that childhood obesity, as well as adult obesity and healthfactors associated with obesity (e.g. diabetes, heart disease), weremajor problems in their communities. Few informants had estimatesof the extent of the obesity epidemic, but many have seen the effectsof it over recent years. The issues mentioned with respect to the risein childhood obesity, primarily included factors related to diet andactivity levels of children.
What do Children Consume?Barriers to eating healthy were multi-dimensional and numerousacross all of the regions. One of the major issues cited for the rise inchildhood obesity was the excessive consumption of “junk food”including chips, candy, cookies, and other high-fat and high-sugar foods.The most frequently cited food consumed by children across all of theregions was “Hot” Cheetos®, a spicy snack item that contains nearly 65%of its calories from fat. Children were also reported to consumeexcessive amounts of soda in all age groups across all regions. Anutritionist in Kentucky reported that children as young as 4 monthsof age are consuming “pop-in-a-bottle.” According to one informant,“Kids are ‘Popaholics’ and are drinking ‘Big gulps’ all day. They are drinking itin the morning for breakfast, then for lunch and dinner.” (AZ)
“Our moms are feeding
whole milk before kids are 1
year old. They are feeding
them pop in a bottle at 4
months old… That is why we
are seeing obesity rates
starting so early. I have seen
babies that are well above
the 90th percentile weight for
height. Babies and children
are taught to ignore their
body functions as far as being
full or hungry. We are
teaching our children to
ignore that and obesity rates
are starting even younger
than our school age kids and
it is very disheartening.” (KY)
6
Field AssessmentFindings I:The Obesity Problem
How do Schools Contribute to the Problem?Vending Machines. Vending machines in primary and middle schoolsprovided children with easy access to high-fat and high-sugar foods anddrinks. Some school personnel discussed attempts to reduce oreliminate children’s access to junk food during certain times of theschool day, such as during lunch; however, the majority of the schoolsin this assessment had vending machines available to children duringschool and afterschool hours. One of the major reasons mentionedfor maintaining vending machines was the revenue generated for theschool from the sale of items. In one school district, children had anestablished 10-minute “snack break” at 10 a.m. that consisted ofpurchasing “junk food” and soda from the vending machines.
Nearly all of the schools had vending machines with the exception ofone of the elementary schools visited in the Western region. ThePrincipal at this school did not want to have vending machines availablefor children because he “didn’t see the need for it in school”. Theabsence of vending machines eliminates the opportunity to purchasefood; however, many children bring chips, candy and soda to school.
School Lunches. Menus were collected from many of the schooldistricts and samples are in Appendix B. Food Service managersmentioned some of the challenges of following USDA guidelines whilealso finding ways to make the food appetizing to children. Theguidelines require schools to serve at least one serving of fruit andone of vegetable per day, which is less than the recommended intakeof fruits and vegetables recently published in the Dietary Guidelinesfor Americans, 2005.25 Most of the informants indicated that childrenalmost never consumed vegetables and infrequently consumed fruit.Children’s food preferences included: pizza, french fries, chickennuggets, hamburgers, corn dogs, and hot dogs. For breakfast, many ofthe kids preferred pancakes, donuts, or cinnamon rolls over otherhealthier choices like cereal, oatmeal or fruit. In addition, childrenbought food from vending machines or snack bars in lieu of the schoollunch provided.
Some schools were attempting to improve the selection of foods aswell as reduce food waste. One food service manager surveyedchildren about their food preferences. Based on her results sheeliminated certain items from the menu and added other foods thatwere more culturally acceptable in the region, such as Mexican andFilipino food. In addition, she replaced some of the typically high-fatitems with lower fat alternatives. “We serve the kids low-fat foods andthey don't even know it… like low-fat cheese, hot dogs made from turkey,corndogs made from turkey.” (CA)
“Kids get a 10-minute break
and they rush to the vending
machines to get snacks and
soda. Some of the kids get
fruit drinks but there is more
sugar in the fruit drinks than
the soda. Most kids eat candy
or chips during the break.
They cannot go outside
because by the time they
stand in line for their snack
they have no time to go
outside.” (KY)
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Field AssessmentFindings I:
The Obesity ProblemAccording to many informants, the pressure to increase academicscores has forced some school districts to reduce time allocated forrecess and lunch.
“Some kids only have 1/2 hour for lunch because they cut thelunch hour to make more time for academics. They don't havetime to eat because they have to wait in line for their food. Theyhave to ‘slam down’ food quickly. We see kids eating their food inthe lunch line or as they are walking up to dump their tray.” (CA)
Nutrition Education. Lack of nutrition education was cited as amajor reason for the inadequate knowledge of healthy eating amongchildren and families. Many of the schools had incorporated limitedhealth and nutrition education into their health or science curriculum.Most of the interviews with school staff revealed that they felt that thenutrition and health information taught in school was inadequate.Where nutrition education was available, most of the informants saidthat children learned about the food pyramid and food groups. Manyinformants stated that “No Child Left Behind” has forced schools whopreviously taught nutrition and health, to remove it from thecurriculum because it is not a required “knowledge set” for theacademic standardized exams.
Physical Activity. The majority of the regions had limited PEprograms at the elementary and middle school levels. Informantsattributed this to the “No Child Left Behind” legislation that mandatedschools to improve their academic standards. As a result, many of theinformants said that this legislation was the direct reason why theyhave eliminated PE in their school. Without adequate resources,including both financial and time, schools indicated that they were notable to continue with PE when “they are now focused on academicprogram improvement in school and PE gets short changed because thereare not enough minutes in a day.” (CA)
“Physical activity has not been a priority because of the ‘No Child Left Behind’ mandate that the schools are strugglingjust to meet what they were required to meet before that camedown.” (MS)
Several school districts had PE as part of their curriculum, however,they did not have a PE instructor. Providing physical education forschool children became the responsibility of the classroom teacher,when time permitted.
“A Typical meal at school wouldbe chicken nuggets and frenchfries that are all fried, or pizza.They are trying to improve thelunches, but they have to makeit palatable for the kids. Kidswill eat the chicken nuggets andthe pizza and the burgers andthe hot dogs. I have literallyseen children take their lunchesand dump it in the garbage andtake their snack ticket and go tothe snack bar. A lot of theschools have a snack bar so thatafter the kids have lunch theycan get cakes, cookies, candies,and ice cream… all stuff that ishigh in fat. Some schools thatdo provide it are trying tochange it or they tell their kidsto eat their lunch first and thekids just dump their traybecause nobody is monitoring it.And they take their snacktickets and get snacks and thatwould be their lunch.” (KY)
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Field AssessmentFindings I:The Obesity Problem
Other informants indicated that there were a lot of political reasonsassociated with reduction in physical activity for children.
“Let’s face it… when some of the new school buildings weredesigned and built the economic requirements and the politicalcomments that went into those funding of those school buildingswasn’t always conducive to physical activity for the children sothere is some barriers that… move down to the state level andthat funnels down into the local level which affects all theagencies that are trying to provide physical activity andnutrition.” (KY)
In schools that have PE programs, on average, one to two classes of PEwere offered per week. The typical PE activities were sports such asbasketball, volleyball, football, and t-ball. Other lifetime physicalactivities, such as walking, were not highlighted in most PE programs.One highly motivated teacher in Appalachia taught step aerobics to thechildren for PE and for children in the afterschool program. Anotherprogram in the Western Area used the SPARKa curriculum and “projectadventure” program to teach team building and problem solving skills.The physical education coordinator indicated that these curricula de-emphasize competitive sports and, instead focus on healthy lifestylesby incorporating hiking, running, and other fun games and activities into the program.
In addition to cuts in PE, many of the schools throughout the regionshave eliminated or reduced the time children have for recess.Reduction of recess time was cited as a necessary component toschools attempting to achieve higher academic standards. There is “norecess for kids. They have quiet time instead, but no scheduled recess unlessteacher decides to let them go outside.” (GA)
What Happens in Afterschool Programs?Snacks. Most of the afterschool program staff indicated that childrenreceived healthy snacks as part of the program. A few informantsmentioned that they were not able to give the children the most“healthy options” due to resource constraints and reliance on outsidedonations for food.
“There is no structuredphysical activity and theschool does not see theimportance of physicalactivity, even though the kidsare not getting it. Theteachers are committed toraising test scores and we aredoing it. It requires everyounce of energy for theteachers and we don’t havetime to do PE with the kidsbecause the kids only have a10-minute break… there is norecess except for one hour aweek which is considered PEtime. The school board isaware of the issues with thekids having no PE, but theyhave limited funds to raisetest scores so that is why PE,music, and art weredropped.” (KY)
9aSPARK (Sports Play and Active Recreation for Kids) is a nationally recognized program withdocumented research showing improved quality and quantity of physical activity in children.
Field AssessmentFindings I:
The Obesity Problem
“We provide meals that are available based on what is donatedor funded through USDA. Some of the food is healthy and someis not… we get a lot of cookies from Nabisco that are donated…many agencies are desperate for food ...” (CA)
Snacks provided in afterschool programs included: Rice Krispies®,Oreos®, sugar cookies, graham crackers, granola bars, crackers, wheatthins, chips, light popcorn, peanut butter and jelly sandwiches, crackersand cheese, flavored rice cakes, yogurt, celery, fruit, such as apples,flavored applesauce, apple juice, Gatorade®, Crystal Light®, Capri Sun®,and milk.
Nutrition Education. Several of the afterschool program staffindicated that they had incorporated nutrition lessons into theirliteracy program. One program in Appalachia utilized a child-friendlywebsite that allowed children to learn and explore various nutritiontopics. This provided children with nutrition information while alsoserving as an opportunity to use reading skills. Other programdirectors mentioned that they invite speakers, such as nutritionistsfrom local Extension offices, to teach children about the food pyramidand preparation of healthy snacks. Many of the afterschool programstaff indicated that they “do nutrition” every day, which involvesproviding a snack for the children, with limited or no nutritioneducation. Where there was more explicit nutrition education in theafterschool program it appeared to be limited to learning the basicfood groups and conducting cooking sessions with the children.
Physical Activity. Many of the afterschool partners had access toplaces for children to exercise. Several of the partners had indoorand/or outdoor areas where they can organize physical activities forchildren. However this varied considerably by site. In somecommunities, the afterschool center was the only place where childrenhad an outlet to be active.
“Kids need to be in organized things like sports or afterschoolprograms. If they are not in these programs they don’t get anyphysical activity because there is no gym or YMCA to stop by. Wedon’t have the resources or the transportation or the number ofthings it takes to make a group of kids want to come. We don’thave the draw we use to.” (WV)
“The schools provide us with
the afterschool snacks for our
program. It is always a
nutritious thing. Yesterday it
was a fruit roll-up and they
get a carton of low fat milk
or a thing of apple juice. The
day before it was a little
snack pack of pretzels,
popcorn, peanuts and
M&Ms… and some kind of a
cereal in there, like Chex
Mix. We asked the chief cook
to make them nutritious.”
(WV)
10
Field AssessmentFindings I:The Obesity Problem
Several afterschool programs throughout the regions had relativelyunstructured and organized physical activity. A partner in a remotelocation in the Western region had inadequate outdoor space forchildren to play. In contrast, a program visited in Whitley County,Kentucky, had structured, organized, and wide-ranging activities forchildren in the afterschool program. These included:Tae Kwon Doe,basketball, volleyball, aerobics, walking, and running (outdoor track).Each activity had a coach that guided and encouraged children throughthe various physical activities. This program was held at the middleschool, which allowed the children access to both indoor and outdoorrecreational facilities.
Although programs varied in the number, frequency, and intensity ofactivities, most of the partners provided some opportunity for childrento engage in outdoor play (weather permitting). This often involvedplaying on jungle gyms or basketball courts (where available), orengaging in group games such as Simon Says, Follow-the-Leader,Duck-Duck-Goose, etc. Several partners discussed their desire toincorporate team sports into their afterschool programs, but notedthat they had difficulty gaining access to facilities such as schools orrecreational facilities. “We were doing teams like basketball, softball, andsoccer, but it is hard to find a facility to do that, to practice. Even our CivicCenter, it’s like pulling teeth to get in there and use the space.” (KY)
How does Culture Affect Diets?Children’s food preferences for sweets, snacks, and soda were similaracross regions. Cultural and regional differences in food types,preferences, and availability of food did exist. Examples of typical mealsby region as reported by the informants are presented in Table 2.
11
Region Typical FoodsKentucky/West Virginia soup beans, corn bread, fried pork chops, fried chicken, and baloney
Western Native fry bread, tortillas, and fried potatoes American reservations
California – Rice and Beans, burritos, tacos, tamales, Mexican, or Filipino foods.Hispanic population
Southwest Region greens, yams, fried chicken, meatloaf, cornbread, mashed potatoes,and peas
TTaabbllee 22:: Typical foods consumed by region
Field AssessmentFindings I:
The Obesity Problem
Fried foods were common across all of the regions, especially the useof lard, ham hocks, and fat back for many local dishes. This wasreported on Native American reservations in the Western area as wellas among informants in the Appalachia and Southeast regions. Some ofthe informants indicated that it was culture and tradition that guidedpeople in their dietary patterns. “One of the biggest issues in our area isthe culture… the way they were taught to fry potatoes and eat friedchicken.” (SC)
Cultural factors were also mentioned as influential in families choosingto take their kids to fast food restaurants. “It is the immigrant culture ofacculturating by going to McDonald's, Burger King, eating junk food, cookies,and candy. When they go to McDonald's they buy cheap food and say weare Americans now.” (CA) Consumption of fast food by children wascommonly reported by informants in all regions of the United States.Most communities have fast food restaurants nearby or within 30minutes of their town. A large proportion of the families, throughoutall of the regions, frequented fast food restaurants, as reported byinformants.
Informants indicated that even when families in their community did nothave enough to eat; they would share whatever they had with others.
Are Foods Accessible and Available?Access to and availability of food, especially healthy food, in these rural,isolated communities affected family food choices. Many of the familiespurchased food in bulk, which often involved traveling long distances of30 minutes to 2 hours to a “decent” grocery store where they could“make their dollar stretch.” Informants indicated that the majority offamilies relied on some type of government assistance including foodstamps,AFDC,WIC, and commodity foods. In some cases, familiesused food pantries or other emergency food distribution programs intheir communities when their food supply ran out.
“When you go to someone’s
house, that’s how they welcome
you. It’s because they welcome
you with food because that’s all
they have to give you. But I
know and it still goes on today
that if you do home visits there
may not be anything else in that
house for the rest of the people
to eat, but if they offer you
something, you better take it
because they’re probably giving
you the last piece of bread or
whatever it is they have in their
house and the last cup of coffee
or tea. They’re giving it to you
because they respect and honor
you as a person who has come
to your house… and that still is
very prevalent in some areas of
the counties now, even today.
It’s just part of the culture.”
(KY) 12
Field AssessmentFindings I:The Obesity Problem
Food stamps, in particular, were mentioned as a factor in a monthlypattern of food availability and food scarcity that existed in many ruralhouseholds. Behavioral factors such as binge eating among childrenwere reported to occur at the beginning of the month (after thereceipt of food stamps) when there was a lot of food available in thehousehold. In addition, many families used other means to provide fortheir family when their food supply diminished toward the end of themonth. Some of these strategies included relying on family or friendsfor food, utilizing a food pantry, or using staples (e.g. flour to make frybread or tortillas, and potatoes) to make a meal for their family. Oneinformant stated that in her county there are “a lot of overweight peoplethat are undernourished… and they don't feel right.” (KY)
Lack of basic education was suggested as a reason why many familiesrun out of food stamps.
“They don’t know how to purchase healthy foods wisely and usetheir money dollar. A lot of our families are not able to budgetbuying foods, education-wise that is a big problem. The averagereading level in this area is about 5th grade so families have ahard time with that. Families have a hard time trying tounderstand how to make that dollar work for them.” (WV)
Is Recreation Available for Children?There were regional differences in terms of availability and accessibilityof places for children to be active. While some locations had parks,fitness centers, or recreational facilities, other communities had limitedplaces for physical activity. Although most of the schools hadplaygrounds or gyms, they were often inaccessible to children afterhours. One principal indicated that, “There is nothing available for thekids to do beyond the school playground and fields, but it gets locked atnight and on the weekends. Kids still find a way to squeeze through thegates so they can play.” (CA) Other barriers to physical activity in thecommunity were cost and transportation associated with participatingin recreational activities.
In several communities spaces for recreation and physical activity hadbecome dilapidated due to damage and neglect. “Many communityrecreation areas have been destroyed from vandalism, although most of
“Before the first of the
month the cupboards are
bare and families are eating
commodity foods.They use
all of the food stamps at the
beginning of the month
because they just ‘Shoot em’
… A lot of people buy food
in bulk, and packaged food,
or they use food stamps for
other things and do not have
food for the rest of the
month. When food is
purchased at the beginning
of the month, children would
‘Eat, eat, eat’.” (NM)
13
Field AssessmentFindings I:
The Obesity Problemthem still have a basketball court.” (AZ) In one very remote area in theWestern region, a community was able to raise revenue to build arecreation center. “We have a new recreation facility being built near theafterschool center that will have a weight room, a pool, a basketball court.This is being built with donations from the community.” (AZ) These newfacilities offer opportunities for community members, especiallychildren, to engage in physical activity in a safe environment.
What is the Impact of the Home Environment?Most of the children reportedly do not engage in physical activity whilethey are at home. According to nearly all of the informants, a sedentarylifestyle that included excessive time spent watching television, usingcomputers, and playing video games was the main reason children werenot active. An informant from the Southeastern area said, “Video games,like Nintendo and Play Station are a barrier to physical activity. Kids justwant to play games. Even the poorest of children have video games. Parentsuse television and video games as a ‘babysitter’.” (SC)
Lack of parental involvement was identified as a reason why childrenwere not very active while at home. Many of the communities had alarge proportion of single parent families and/or two parent homeswhere both parents work. Informants said that many of the childrenwere “latch-key” kids and did not have a parent who was at homewhen they arrived to encourage them to eat well or be physicallyactive. In addition, some parents did not feel it was safe for theirchildren to leave the house. “There are a lot of ‘latch key kids’ who stayhome alone. Parents don’t want their kids to go outside because they mightget hurt, so they just stay inside and watch TV.” (AZ) Physical activity athome may not be a priority or encouraged among some parents.
Several informants mentioned a lack of adult role models as a factor inthe inactivity of children. “Some of our educational role models are notthe role models they should be… yes meaning the teachers and the parents,the Principals.” (WV) In addition, “There are no role models for physicalfitness because adults are not active and obesity is the norm in thecommunity.” (AZ) Not seeing physical activity as a priority was alsocited as a factor in sedentary lifestyles. “Kids and families do not havegood habits, like exercising before school. We don’t make time for exerciseeven though we make time for everything else.” (KY)
“They assume their kids are
getting physical activity at
school, they’re getting
physical activity afterschool
and that’s good enough…
A lot of our parents work…
It’s easier from them to let
their kid go in, sit down at
the T.V. or the computer and
play games than it is to
actually deal with them.”
(KY)
14
Field AssessmentFindings II: How toPrevent Obesity
Overall, the majority of informants indicated that preventing obesitywould require collaboration of many different groups in all sectors ofthe community. One informant in West Virginia summed it up bystating that this effort “needs to involve schools, health professionals,private and public collaboration process for the survival and health ofchildren.” In addition, most of the informants indicated that it shouldbe a “comprehensive program that includes both physical activity andnutrition.”
The participants agreed that in order for a nutrition and physicalactivity program for children to be effective and sustainable, it must beappealing to children. A teacher in California said, “We need to changepeople's attitudes about health and make it fun and interesting.” Anotherinformant in Mississippi said, “If a program is fun kids will go.”
Schools-Based InterventionsPhysical Activity. Many of respondents felt that it was important tohave some type of physical activity at school. Several teachersindicated that children were more attentive after they had anopportunity to play outside. Several principals and school staffindicated that they would like to have more time for PE and/or initiatea structured PE program in their school. A few informants indicatedthat for a program to be successful, “You need a volunteer physical trainerthat likes working with kids and can be a role model for the kids.” (CA)Some informants suggested incorporating different activities that teachlifelong fitness habits, such as walking, dancing, yoga, martial arts,aerobics, weightlifting and using exercise machines. “We need to havean organized physical activity program which would include team orindividual sports, like Yoga, Karate,Tai kwon do, Judo… and a dance machineto get kids moving.” (MS)
Several schools had limited access to indoor and outdoor facilities forchildren to be active; therefore, many of the suggestions includedimproving the outdoor play areas. School officials indicated that theywould like to make structural improvements at their schools toimprove access to activities by children. Some of the suggestionsincluded improving the outdoor recreational areas, such as addingplayground equipment, building a walking track or trail, adding baseballand basketball courts. One informant suggested the followingenhancements to her school:
“We need a comprehensiveapproach that includes the schools,the health care professionals – bothprivate and public.We need acollaboration process where we canbring all the entities to the tablewhere they have common ground.And that common ground is survivaland the health of the children inthe population they are workingwith. And if there could be 3 or 4health care goals – physicalactivity, nutrition, dental – whateverit might be… if they could identifythose areas and do acomprehensive plan. And it has tobe community based… it has to bethe bringing together of the entitiesthat are the key players and do theprogram for the community thatyou are working with.And youtarget them… and you cover everybase… you have to make sure it’sgoing to be reinforced in everything – whether it’s in school,whether it’s in afterschool, whetherit’s in church, whether it’s in thedoctor’s office.” (WV)
15
Field AssessmentFindings II: How to
Prevent Obesity“We would like to improve the playground equipment and addthings like climbing equipment, parallel bars, forts, obstacle coursesfor kids, more swings, cement walls to play hard/hand ball. It wouldalso be great if we could add a weight lifting room that would alsohave exercise equipment machines made for kids.” (CA)
Nutrition. Few informants suggested improving school meals bychanging the breakfast and lunch options offered to children. Althoughthis may be a likely place to intervene, informants described theimportance of adhering to the USDA guidelines when developingmenus for children. Although many community members interviewedsuggested that schools remove vending machines and snack bars fromschools (or at least modify what is offered), a limited number of schoolpersonnel offered this as an option for supporting healthy eatingamong children. One informant in New Mexico thought that theyshould “change snack machines in schools to not allow soda and providemore juices and diet drinks.”
Many of the informants attributed the low rate of vegetable and fruitconsumption by children to a lack of knowledge of nutrition andsuggested developing nutrition education programs for their school. Itwas suggested by several informants that programs needed to becreative and led by a person who is knowledgeable about nutrition,such as a nutritionist. In one county in Kentucky, a nutritionist from thehealth department taught children about nutrition at various schoolsusing a “hands-on” approach.
The majority of the programs that were visited as part of thisassessment did not have ready access to a nutritionist within theircommunities. Some of the participants suggested that school districts,
“Hire a nutritionist for the schools to teach and train little kidsabout what parts of the body are geared towards food that theyeat. Like food for your heart, lungs and brain. Have thenutritionist go into the classrooms to teach because so many ofthe teachers are loaded down and there is no curriculum to teacha few things about nutrition.” (MS)
Another suggestion for school-based nutrition education programs,which would also be applicable in an afterschool setting, was the use ofpeers.
“I get the kids involvedbecause I find if they arebored, they are not going todo anything… When you dothat exercise stuff with them,they love that. I try to bringin every aspect of teaching,visual, because most peopledon’t remember what theyhear. What they see andwhat they do, they willremember better. So I try toget them seeing and doingthings, using the food modelsand things. I show them aserving size of pizza and theylook at you because they areamazed. You know it is oneslice, and they say they wouldeat 10 of those.” (KY)
16
Field AssessmentFindings II: How toPrevent Obesity
“Tutor kids and have kids teach the lesson so that they learnbetter. When they have to teach a lesson they ask morequestions and talk to kids in terms of what the studentsunderstand.” (CA)
Although there were few nutrition education programs available atmost of the schools, one middle school in Kentucky started a“nutrition fitness challenge” to help reduce overweight among children.
A food service manager in California offered her thoughts on nutritioneducation, “It is hard to stop kids from eating junk food but maybe you canteach them to eat “Hot” Cheetos® with a salad or with chicken to balanceout the bad with the good.”
Afterschool InterventionsPhysical Activity. Several afterschool program staff suggested havingexercise programs for kids that would include using exercise tapes(aerobics and Tae Bo), walking, hiking, martial arts, sports teams andusing the outdoor recreational areas. Many of the informantssuggested a more structured program where they would have staffavailable to teach the children various activities. One informant fromGeorgia said,
“We should have more staff to do activities… staff to work withkids in the afterschool program to provide safe activities forkids… They would be responsible for setting up the grounds foractivities, supervising the children, and scheduling different agegroups and different sports.” (GA)
Several program directors indicated that in order to increase physicalactivity among children, playgrounds and sports fields needed to beimproved or built. Informants indicated that improved access tofacilities in their community needs to be a priority. Suggestions weremade to collaborate with schools and community groups in order tohave access to gyms (that are not in use) as well as recreational areasthat are often off-limits at various times of the day or year. In addition,transportation was mentioned as a major barrier to childrenparticipating in afterschool programs and recreational activities.Suggestions were made by many of the informants to work with theschool districts to use or lease buses or have a ‘late bus’ service. Thiswould allow children an opportunity to participate in afterschoolactivities, even when they live in remote areas.
“We are going to start out
with nutrition classes then
physical activity on a daily
basis… work that into their
days… do 3-a-day and 5 a-
day (vegetable and fruit)
challenges.The kids that
actually complete the
program are going to get
incentives that are physical
activity and nutrition related
(bikes and stuff) or school
related.They (the school)
wants to do this because they
have such a problem with
high levels of overweight.”
(KY)
17
Field AssessmentFindings II: How to
Prevent ObesityNutrition. The major suggestion with respect to the nutritioninterventions was to incorporate more nutrition education into theafterschool program. One informant stated that they should, “Get booksand software on nutrition and food groups to combine with the literacyactivities.” (AZ) This was suggested by other informants as they felt thatthey had limited time to incorporate literacy activities and nutritioneducation into the time available afterschool. Several of the informantsthought that it would be important to “bring someone in”, such as anutritionist, to teach children about nutrition through activities such asby cooking with them or helping them to grow a garden.
Parent EducationMost of the partners highlighted the importance of including parents inthe effort to teach children about nutrition. Many ideas for programsincluded, but were not limited to, involving parents in the effort topromote healthy habits in their children. Some of the partners werepresently working with parents to educate them on nutrition relatedissues. Among the partners who had parenting programs, most of thesessions centered on preparing healthy meals.
Many informants shared the challenge of budget constraints and lack ofaccess to healthy foods in providing good nutrition for families andsuggested the need to teach parents how to “stretch their food dollar”and how to prepare healthy foods on a budget. “There should benutrition classes for parents to teach them how to have balanced diets. Theywould be pleased about the foods because we could show them that theycan stay within their budgets.” (NM)
Cultural aspects were also an important factor mentioned by severalinformants with respect to nutrition education for parents.Suggestions were made to have programs taught in one’s nativelanguage, such as Spanish or Navajo. In addition, some informantssuggested that nutrition messages be sensitive to cultural differences.One informant said, “Provide nutrition education for people about differentfoods because they may not culturally be used to eating foods like brusselsprouts.” (NM) In order for some families to participate, “They needpeople in the community who talk to them in their language and get themto buy into programs for kids. If families understand importance ofprograms… that will make a change.” (CA)
“We try to teach parents
about cooking, such as
making greens with smoked
turkey instead of ham hocks.
We teach families about
moderation… you can't eat
pizza, candy, and potato
chips every day. We try to
get parents to expose their
children to more vegetables
and fruits.” (GA)
18
Field AssessmentFindings II: How toPrevent Obesity
Many of the participants indicated that parenting classes should alsoemphasize the importance of motivating their children to be active.Some of the informants suggested finding ways to “Help parents putaway TV and video during the day light and have kids playing outside.” And“teach them how to play games and do things with kids to keep them awayfrom the TV.” (NM) Other informants felt that parents needed to bemotivated to spend more time doing things with their childrenbecause, “If you get parents motivated then kids will be motivated.” (KY)Several suggestions were made, such as a walking club for parents andchildren, group exercise (aerobics, dance) activities at communitycenters and special events at schools and in afterschool programs thatencouraged families to be active together.
Community-Based InterventionsThe major suggestion for a nutrition and physical activity program wasto make it a comprehensive community-based effort where messagesare delivered in schools, afterschool, among parents and in thecommunity. An informant in Appalachia mentioned a recent grant thatwas submitted to address child obesity as described in her own words,
“We want to train teens to be nutrition outreach workers, wherewe train them in nutrition, fitness, and child health. Each of theteens were going to identify kids in public housing that had aweight problem and teens were going to be a big brother, bigsister or a “fitness buddy” or “health buddy.” They were going towork one-on-one with the kids with a health workbook. We weregoing to have a nutrition class, with the nutritionist, orsomeone… to have a class once a week afterschool. Also, once amonth have a dinner where we would have the kids… workingwith someone from the Extension office… to plan a low costnutritious meal that the kids prepare and serve it to the parents.And that way we would give out recipes… and draw parents inbecause really it is the parents that have a lot to do with the kidsbehaviors.” (KY)
This program idea included several segments of the community, fromteen leaders, to local nutritionist, and to parents. Another program inCalifornia incorporated cultural aspects into health information byusing “telenovelas” (Spanish language soap operas). In addition, thisprogram brought the information directly to community members sotransportation would not be a barrier to participation.
“We did ‘nutrition on the go’which was a mobile truck thatwe sent to rural areas to do 2-3hour stations of nutritioneducation.This had 1 to 2 quicktips on nutrition-related topicslike the food pyramid, portionsizes, and health relatedinformation… We did diabetesinformation in the form of‘novellas’, child seat program,and taste tests. At the end ofthe stations were freeinformation… and families gotto take bags of fresh fruit andvegetables home with them. Alot of families were coming tothe program for theinformation, not just the food...They really wanted to eathealthy. All of this was donewith volunteers that weretrained within the localcommunities… they knewnutrition-related knowledge andpassed it on to friends andneighbors.” (CA)
19
Summary of Key Findings
This qualitative research yielded several important findings related tothe development of a programmatic strategy for obesity prevention inthese communities. The problem of obesity was evident in theassessment communities and key informants were well aware thatchildren were overweight as a result of factors related to bothnutrition and physical activity. The key informants had a wide range ofsuggestions for how to begin to tackle the obesity problem.
The Impact of Nutrition/Food Choices and Food Availability
• Consumption of “junk food” and fast food was the norm. It isstriking that across all four areas the most commonly reportedfood consumed by children was “Hot” Cheetos®.
• Children’s preference for other less healthy foods includedfrench fries, hot dogs, and donuts was a key barrier to alteringfood choices.
• Fried foods were common across all of the regions, despitecultural and regional differences.
• High-fat and high-sugar foods and drinks were available tochildren at schools through vending machines.
• Although required to follow USDA guidelines, school meals oftendid not provide adequate healthy alternatives for children.
• Afterschool programs did not consistently provide healthy snacksto children because of a lack of resources, lack of nutritionknowledge and the unavailability of healthy options.
• Access and availability of food, especially healthy food, was asignificant factor in these rural isolated communities.
• Poverty and dependence on food stamps can create a cycle offood plenty to food scarcity in these households; during times ofplenty children may overeat.
The Impact of Physical Activity Opportunities and Practices
• The majority of the schools had limited or no PE programs inschool; this was attributed to cuts made as a result of the “NoChild Left Behind” legislation.
• Many schools did not have PE instructors; classroom teacherswere often responsible for providing physical education.
• Typical PE activities were focused around sports such asbasketball, volleyball, football, and t-ball, whereas other lifetimefitness activities, such as walking, were not part of most PEprograms.
20
Summary of Key Findings
• Regional differences existed in the availability and accessibility ofplaces for children to be active; some locations had parks, fitnesscenters, or recreational facilities while other communities hadnone.
• Most afterschool programs provided low to moderate physicalactivity; few centers had structured, vigorous, regular physicalactivity for children.
• Access to school facilities and recreational centers were majorbarriers to providing physical activity in the afterschool setting.
• Rural children were inactive because the norm in these settingsis sedentary lifestyles including excessive time spent watchingtelevision, using computers and playing video games at home.
• A lack of physically active adult role models and little parentalinvolvement during children’s free time affected the inactivity ofchildren.
Potential Areas for Intervention• Making high-quality physical education available in schools was
seen as a key area for intervention.• Shifting the focus from sports to teaching lifelong fitness habits,
such as walking, dancing, yoga, martial arts, aerobics, weightliftingand using exercise machines was recommended.
• Nutrition education programs in school, afterschool, for parentsand in the community was a felt need expressed by mostinformants.
• Infrastructure for physical activity – sports fields and playgrounds– need improvement and expansion.
• Afterschool programs need access to facilities for recreation andphysical activity in the school and community.
• In general, key informants felt the need for a comprehensivecommunity-based effort at obesity prevention with consistentmessages delivered in schools, in afterschool programs, amongparents and in the community.
21
Toward a Strategyfor Childhood
Obesity Preventionin Rural America
Obesity and overweight have been found to be difficult and expensiveto treat and cure, therefore preventing this condition in children willbe the key to addressing this national epidemic. So far, however, thereare few examples of effective obesity prevention programs especiallyamong high risk isolated, rural populations. This first, nationalassessment of the obesity problem and potential opportunities forobesity-related interventions for children in rural, isolated Americadocuments important findings. This information, combined with State-level efforts to address obesity and evidence-based approaches toobesity prevention will set the stage for developing and implementing aprevention strategy for rural America.
State Legislation and InitiativesOver the last several years various states (including some of thoseincluded in this assessment) have passed legislation to combat thegrowing rates of childhood obesity. California, for example, is a leaderin terms of legislation passed to prohibit the sale of foods and drinksof low-nutritional value from vending machines in schools.27 Inaddition, California has implemented standards for nutrition educationand physical education in schools.27 Arkansas has mandated onehour/week of physical education with no less then 20 minutes ofphysical activity for grades Kindergarten through nine. See Appendix Cfor other obesity-related legislation passed by the states included inthis assessment.
Many states also have developed state-wide and local initiatives toprevent obesity and chronic diseases. For example, Coloradodeveloped a resource kit that encourages schools to implementprograms and policies that promote a healthy school environment.This kit provides action steps on how to create a positive environmentfrom the cafeteria to the classroom to impact a child’s eating andphysical activity behaviors.28 In West Virginia, an after-school program,Choosy Kids Club, provides elementary school children with anopportunity to learn healthy nutrition and physical activity decision-making skills.29 Appendix D lists other programs and initiatives by statethat focus on obesity prevention.
Evidence-Based Approaches to Obesity Prevention Researchers have attempted to identify the multi-dimensional causes ofobesity as well as effective solutions to combat the problem. A recentsystematic review examined nutrition and physical activity programsaimed at children to identify evidence-based approaches toprevention.30 Some of the key conclusions from this review and fromother research will contribute to the foundation of a strategy for
22
Toward a Strategyfor ChildhoodObesity Prevention inRural America
childhood obesity prevention in rural America. What we know so faris as follows:
• Programs to address physical activity should focus on aerobicactivity, rather than sports or skill development that is typicallytaught in physical education classes.
• PE teachers ensure more moderate to vigorous activity thanclassroom teachers.
• If classroom teachers are to play a role in physical education theywill need training and mentoring skills to learn how to maximizethe level of physical activity offered to children.
• Schools that provide concentrated physical activity programshave seen improvements in academic performance, despite havingreduced class time for academics to implement the physicalactivity program.31-34 A study conducted with children whoreceived a health related physical activity program (SPARK)26,found improvements in reading scores after 2 years of doublingtime for physical education.35
• Schools that successfully promote less video game and televisionuse appear to be highly effective in reducing physical inactivityand reducing obesity.36
• Research shows that successful nutrition interventions had atleast 10 sessions and were multi-faceted involving healthycafeteria choices, mass media campaigns, and parent involvement.
• Increasing knowledge in nutrition is insufficient; educationalmessages need to focus on changing actual behaviors rather thanimproving knowledge and/or attitudes.
• Interventions that target students, school cafeterias, after-schoolprograms, parents, and the community are more effective thanany intervention alone.
• Multi-faceted obesity prevention programs for primary schooland high school students that included components such asschool curricula, mass media, parent mailings, and healthycafeteria changes over at least 8 to 10 weeks show the mostpromise for altering food intake.
Conclusion Save the Children has worked for more than 70 years in partnershipwith schools and community-based organizations in these rural areashardest hit by the obesity crisis. This strong, long-term connectionputs Save the Children in an ideal position to help develop and adapteffective approaches to obesity prevention for these children. Bygaining perspective directly from the communities in which Save theChildren works, this Nutrition and Physical Activity Field Assessmenthas helped to further strengthen partnerships and collaborationsneeded to develop and implement a successful obesity preventionstrategy for children in rural America.23
1. Flegal KM, Carroll MD, Ogden CL, Johnson CL Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002; 288(14):1723-7.
2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002; 288(14):1728-32.
3. Caballero B, Clay T, Davis SM et al. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. Am J Clin Nutr. 2003; 78(5):1030-38.
4. Story M, Evans M, Fabsitz RR, Clay TE, Holy Rock B, Broussard B. The epidemic of obesity in American Indian communities and the need for childhood obesity-prevention programs.Am J Clin Nutr. 1999; 69(4):747S-754S.
5. Eisenmann JC, Katzmarzyk PT,Arnall DA, Kanuho V, Interpreter C, Malina RM. Growth and overweight of Navajo youth: secular changes from 1955 to 1997. Int J Obes Relat Metab Disord.2000; 24(2):211-8.
6. Sugarman JR,White LL, Gilbert TJ. Evidence for a secular change in obesity, height, and weight among Navajo Indian schoolchildren. Am J Clin Nutr. 1990; 52(6):960-6.
7. Strauss RS, Knight J. Influence of the home environment on the development of obesity in children. Pediatrics. 1999; 103(6):e85.
8. Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998.JAMA 2001;122;86(22):2845-8.
9. Goodman E.The role of socioeconomic status gradients in explaining differences in US adolescents' health. Am J Public Health. 1999; 89(10):1522-8.
10. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs.Am J Clin Nutr. 2004;79(1):6-16.
11. Crooks DL. Food consumption, activity, and overweight among elementary school children in an Appalachian Kentucky community.Am J Phys Anthropol. 2000; 112(2):159-70.
12. Neal WA, Demerath E, Gonzales E, Spangler E, Minor VE, Stollings R, Islam S. Coronary Artery Risk Detection in Appalachian Communities (CARDIAC): preliminary findings.W V Med J. 2001; 97(2):102-5.
13. Demerath E, Muratova V, Spangler E, Li J, Minor VE, Neal WA. School-based obesity screening in rural Appalachia. Prev Med. 2003; 37(6):553-60.
14. McMurray RG, Harrell JS, Bangdiwala SI, Deng S. Cardiovascular disease risk factors and obesity of rural and urban elementary school children. J Rural Health. 1999; 15(4):365-74.
15. Felton GM, Pate RR, Parsons MA,Ward DS, Saunders RP,Trost S, Dowda M. Health risk behaviors of rural sixth graders. Res Nurs Health. 1998; 21(6):475-85.
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17. Davis SM, Lambert LC. Body image and weight concerns among Southwestern American Indian preadolescent schoolchildren. Ethn Dis. 2000;10(2):184-94.
18. McMurray RG, Harrell JS, Bangdiwala SI, Deng S. Cardiovascular disease risk factors and obesity of rural and urban elementary school children. J Rural Health. 1999;15(4):365-74.
19. Kumanyika SK, Ewart CK. Theoretical and baseline considerations for diet and weight control of diabetes among blacks. Diabetes Care. 1990; 13(11):1154-62.
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21. Fagot-Campana A, Pettit DJ, Engelgau MM, Rios Burrows N, Geiss LS,Valdez R, et al.Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pedatr 2000;136:664-72.
22. Dabelea D, Hanson RL, Bennett PH, Roumain J, Knowler WC, Pettitt DJ. Increasing prevalence of Type II diabetes in American Indian children. Diabetologia. 1998; 41(8):904-10.
23. Goran MI, Ball GD, Cruz ML. Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescents. J Clin Endocrinol Metab. 2003; 88(4):1417-27.
24. Koplan JP, Liverman CT, Kraak VI. Preventing Childhood Obesity: Health in the Balance. Institute of Medicine. The National Academie Press. Washington, DC 2005.
25. Dietary Guidelines for Americans 2005. U.S. Department of Health and Human Services. U.S.Department of Agriculture (online) http://www.health.gov/dietaryguidelines/ (Accessed January 15, 2005).
26. SPARK. www.sparkpe.org/index.jsp. (Accessed February 25, 2005).
27. Wellever,A, Reichard A,Velasco,A. Obesity and Public Policy: Legislation Passed by States, 1999 to 2003. Kansas Health Institute,April 2004 (online).http://www.khi.org/Obesity/ObesityReport_Part1.pdf (accessed January 4, 2005).
28. Action for Healthy Kids (online) http://www.actionforhealthykids.org (Accessed January 27, 2005).
29. Choosy Kids Club.West Virginia Motor Development Center. West Virginia University (online) http://www.wvu.edu/~physed/mdc/about_choosy.htm (accessed January 27, 2005).
30. Thomas H, Cilisk D, Micucci,Wilson-Abra, Dobbins M. Effectiveness of Physical Activity Enhancement and Obesity Programs in Children and Youth. Public Health Research, Education & Development Program, 2004 (online) http://www.city.hamilton.on.ca/PHCS/EPHPP/Research/Summary/2004/HealthyWeightsFull2004.pdf (Accessed January 11, 1004).
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33. National Association of Sports and Physical Education (NASPE), Executive Summary,Shape of the Nation, 2001.
34. Shephard RJ. Curricular physical activity and academic performance. Pediatric Exercise Science 1997; 9:113-126.
35. Sallis JF, McKenzie TL, Kolody B, Lewis M, Marshall S, Rosengard P. Effects of health-related physical education on academic achievement: project SPARK Res Q Exerc Sport.1999; 70(2):127-34.
36. Campbell K,Waters E, O’Meara S, Kelly S, Summerbell CD. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews, 2002; CD001871.
27
Appendix AField Assessment
State City Site NameAZ Sells Pisinemo Learning CenterAZ San Carlos St. Charles Mission SchoolAZ San Carlos San Carlos Health Education DepartmentCA Visalia FoodLink Food PantryCA Earlimart Alila Elementary SchoolCA Terra Bella Terra Bella ElementaryGA Forsythe Community Improvement Coalition of Monroe CountyGA Hogansville West End CenterKY Hazard UK Center for Rural HealthKY Whitesburg Cowan Community CenterKY Pippa Passes Caney Creek Family Resource/Youth Services CenterKY Hindman Hindman Family Resource/Youth Services CenterKY Williamsburg Housing Authority of WilliamsburgKY Stearns Whitley City Middle SchoolKY Berea Berea CollegeMS Mound Bayou National Council of Negro WomenMS Mound Bayou Delta Health CenterMS Mound Bayou I.T. Montgomery Elementary SchoolNM Kirtland Kirtland Youth AssociationNM Crownpoint Crownpoint Department of YouthNM Crownpoint Crownpoint Community Wellness CenterNM Shiprock Indian Health ServicesNM Tierra Amarilla Chama Valley Independent School District #19SC Spartanburg Crescent Hill ApartmentsSC Spartanburg Community S.L.A.S.H. CenterSC Spartanburg Park Hill ElementaryTN Covington Children and Family ServicesWV Kermit ABLE Families
28
Appendix BCalifornia
29
Appendix BKentucky
30
Appendix BNew Mexico
31
Appendix BTennessee
32
Appendix CO
bes
ity-
rela
ted
Leg
isla
tio
n P
asse
d b
y “S
ave
the
Ch
ildre
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tes,
1999
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pted
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m W
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ver,
2004
)
Res
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tio
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um
ber
Year
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1999
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ge in
the
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uppo
rts
incr
ease
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ndin
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hool
and
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unity
-bas
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hysi
cal a
ctiv
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utri
tion
prog
ram
s,an
d fo
r pu
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edu
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n on
the
tre
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and
prev
entio
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obe
sity
.C
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Cal
ls fo
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embe
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prev
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.Enc
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and
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kpla
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lth a
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rs.
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2001
SCR
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“Cal
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CA
2002
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l Edu
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nd “
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ts M
onth
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t St
udy
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n Ph
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rgia
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Req
uest
s th
at t
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epar
tmen
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lth a
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ffect
of o
besi
ty in
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lts a
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Adv
isor
y C
omm
issi
ons
and
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ies
TN
2002
Cha
pter
658
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ates
the
Obe
sity
Stu
dy a
nd P
reve
ntio
n A
ct –
Dir
ects
Dep
artm
ent
of H
ealth
to
anal
yze
the
effe
ctiv
enes
s of
th
e Pu
b.A
cts
exis
ting
met
hods
of t
reat
men
ts a
nd p
reve
ntio
n of
obe
sity
and
to
expl
ore
alte
rnat
ive
met
hods
.of
200
2M
S20
01C
hapt
er 4
32C
reat
es t
he M
issi
ssip
pi C
ounc
il on
Obe
sity
Pre
vent
ion
and
Man
agem
ent
Stud
y;re
quir
es a
rep
ort
to le
gisl
atur
e.D
irec
ts t
he c
ounc
il to
stu
dy t
he fe
asib
ility
of t
ax in
cent
ives
for
wor
ksite
s th
at p
rom
ote
activ
ities
to
redu
ce
obes
ity in
wor
k fo
rce.
MS
2003
Cha
pter
484
Exte
nds
the
char
ter
for
the
Mis
siss
ippi
Cou
ncil
on O
besi
ty,P
reve
ntio
n an
d M
anag
emen
t to
July
1,2
006.
NM
20
03SJ
M 9
5C
reat
es a
tas
k fo
rce
to a
ddre
ss t
he g
row
ing
heal
th p
robl
ems
of y
oung
peo
ple,
incl
udin
g ob
esity
and
dia
bete
s an
d to
dev
elop
pro
pose
d le
gisl
atio
n.
Scho
ol F
ood
Pro
gram
s an
d P
olic
ies
AR
2003
Act
122
0C
reat
es t
he C
hild
Hea
lth A
dvis
ory
Com
mitt
ee t
o de
velo
p nu
triti
onal
and
phy
sica
l act
ivity
sta
ndar
ds,a
nd t
o m
ake
reco
mm
enda
tions
on
com
petit
ive
food
s so
ld t
hrou
gh v
endi
ng m
achi
nes.
Bans
ven
ding
mac
hine
s in
ele
men
tary
sch
ool
star
ting
in 2
003-
2004
sch
ool y
ear;
requ
ires
bod
y m
ass
inde
x sc
reen
ing
in s
choo
ls.
CA
2001
SB19
Proh
ibits
the
sal
e of
car
bona
ted
beve
rage
s in
ele
men
tary
and
mid
dle
scho
ols
and
plac
es n
utri
tion
stan
dard
s on
fo
ods
sold
to
stud
ents
at
brea
ks a
nd t
hrou
gh v
endi
ng m
achi
nes.
CA
2003
Cha
pter
458
Proh
ibits
sch
ool b
oard
s fr
om e
nter
ing
into
exc
lusi
ve o
r no
n-ex
clus
ive
cont
ract
s fo
r ad
vert
isin
g or
the
sal
e of
ca
rbon
ated
bev
erag
es u
nles
s a
polic
y is
ado
pted
aft
er a
pub
lic h
eari
ng.
CA
2003
Cha
pter
62
Dir
ects
sta
te a
genc
ies
and
the
Cal
iforn
ia s
choo
l foo
d se
rvic
e as
soci
atio
n to
dev
elop
sch
ool l
unch
men
u pl
ans
that
pr
ovid
e op
tiona
l veg
etar
ian
scho
ol lu
nche
s.C
A20
03C
hapt
er 4
15Se
ts n
utri
tiona
l sta
ndar
ds fo
r fo
od s
old
in a
nd p
rodu
ced
by p
ublic
sch
ools
.Pro
hibi
ts t
he s
ale
of c
arbo
nate
d be
v era
ges
in e
very
ele
men
tary
sch
ool c
ampu
s be
ginn
ing
2004
.Sal
es w
ould
cea
se in
mid
dle
scho
ols
2005
and
in
hig
h sc
hool
200
7.C
A20
03C
hapt
er 8
79En
cour
ages
sch
ools
and
chi
ld d
evel
opm
ent
prog
ram
s to
pro
vide
fres
h fr
uits
and
veg
etab
les
to s
tude
nts
on a
dai
ly b
asis
.
33
Appendix C
Res
olu
tio
n N
um
ber
Year
or
Sta
tute
S
tate
Pas
sed
Lo
cati
on
Des
crip
tio
n
Nut
riti
on E
duca
tion
CA
2002
CA
.Edu
catio
nR
equi
res
the
Dep
artm
ent
of E
duca
tion
to in
corp
orat
e nu
triti
on e
duca
tion
into
hea
lth c
urri
culu
m.
Cod
e 89
90
CA
2002
CA
.Edu
catio
n A
utho
rize
s nu
triti
on e
duca
tion
to b
e pr
ovid
ed a
s pa
rt o
f the
edu
catio
nal e
nric
hmen
t co
mpo
nent
of
Cod
e 84
82.3
an a
fter
sch
ool p
rogr
ams.
CA
20
03C
hapt
er 5
505
Spec
ifies
tha
t as
par
t of
a c
ompr
ehen
sive
hea
lth e
duca
tion
prog
ram
pup
ils m
ay r
ecei
ve in
stru
ctio
n on
pre
vent
ive
heal
th c
are
on t
opic
s su
ch a
s ob
esity
and
dia
bete
s.
Phy
sica
l Edu
cati
on a
nd P
hysi
cal A
ctiv
ity
of C
hild
ren
AZ
2001
Cha
pter
320
of
App
ropr
iate
s $1
50,0
00 o
ver
the
next
tw
o ye
ars
(FY
2001
-200
3) t
o fu
nd D
epar
tmen
t of
Hea
lth S
ervi
ces
the
Publ
ic A
cts
for
scho
ol-b
ased
pro
gram
s fo
r ch
ildre
n’s
phys
ical
fitn
ess
activ
ities
.of
200
1A
R
2001
AR
Sta
t Ann
M
anda
tes
K-9
pub
lic s
choo
ls t
o re
quir
e no
less
tha
n 1
hour
/wee
k of
PE
trai
ning
and
inst
ruct
ion
whi
ch in
clud
es n
o 6-
4-1
less
tha
n 20
min
utes
of p
hysi
cal a
ctiv
ity 3
tim
es a
wee
k.A
R20
01A
R S
tate
Ann
C
reat
es t
he “
Gre
at S
trid
es”
prog
ram
,whi
ch a
lloca
tes
fund
ing
for
rura
l com
mun
ities
to
esta
blis
h m
ile t
o w
alki
ng p
arks
.20
-8-3
02C
A20
01C
hapt
er 1
11Es
tabl
ishe
s C
A T
ask
Forc
e on
You
th a
nd W
orkp
lace
Wel
lnes
s to
pro
mot
e fit
ness
and
hea
lth in
sch
ools
and
wor
kpla
ces.
CA
2002
CA
.Edu
catio
n D
irec
ts t
he S
tate
Boa
rd o
f Edu
catio
n to
ado
pt m
odel
con
tent
sta
ndar
ds fo
r ph
ysic
al e
duca
tion
by 2
004.
Cod
e 60
605.
2C
A20
02C
A E
duca
tion
Req
uire
s th
e D
epar
tmen
t of
Edu
catio
n to
doc
umen
t th
e ac
tual
num
ber
of m
inut
es o
f ins
truc
tion
in p
hysi
cal
Cod
e 33
352
educ
atio
n pr
ovid
ed b
y ea
ch s
choo
l dis
tric
t to
det
erm
ine
com
plia
nce
with
the
law
.C
A
2003
Cha
p 93
Rec
ogni
zes
that
sch
ools
hav
e an
obl
igat
ion
to p
rovi
de p
hysi
cal e
duca
tion
to s
tude
nts
and
urge
s sc
hool
s to
co
mpl
y w
ith t
hose
obl
igat
ions
.C
A
2003
Cha
pter
459
Req
uire
s th
at t
rain
ing
of a
fter
sch
ool p
rogr
am s
taff
incl
udes
phy
sica
l fitn
ess
stan
dard
s.M
S20
02M
S C
ode
Ann
.R
ecom
men
ds g
uide
lines
to
scho
ol d
istr
icts
for
phys
ical
edu
catio
n an
d fit
ness
cla
sses
.Req
uire
s st
udy
of
37-1
3-13
4re
latio
nshi
p be
twee
n ph
ysic
al a
ctiv
ity a
nd c
lass
room
per
form
ance
.N
M19
99N
M S
tat.
Ann
A
llow
s m
oney
from
the
tob
acco
set
tlem
ent
fund
to
be a
ppro
pria
ted
for
publ
ic s
choo
l pro
gram
s in
clud
ing
6-4-
10ex
trac
urri
cula
r an
d af
ter-
scho
ol p
rogr
ams
desi
gned
to
invo
lve
stud
ents
in a
thle
tic a
ctiv
ities
.N
M20
02SJ
M 1
7R
eque
sts
that
the
Sta
te D
epar
tmen
t of
Pub
lic E
duca
tion
wor
k w
ith t
he D
epar
tmen
t of
Hea
lth a
nd o
ther
s to
de
velo
p st
rate
gies
to
help
tea
cher
s im
plem
ent
qual
ity p
hysi
cal e
duca
tion
curr
icul
a.N
M20
03C
hapt
er 1
48C
reat
es t
he “
Safe
Rou
tes
to S
choo
l:” p
rogr
am t
o in
crea
se a
nd m
ake
safe
r a
stud
ent’s
abi
lity
to w
alk
or r
ide
a bi
cycl
e to
sch
ool.
Oth
er O
besi
ty L
egis
lati
on
CA
2002
CA
Edu
catio
n R
equi
res
the
Dep
artm
ent
of E
duca
tion
to m
ake
com
petit
ion
gran
ts a
vaila
ble
for
scho
ol d
istr
icts
to
star
t or
C
ode
9000
expa
nd in
stru
ctio
nal s
choo
l gar
dens
and
sch
ool g
arde
n sa
lad
bars
with
a c
ompo
st p
rogr
am.
NM
1999
HB7
62
App
ropr
iate
s $1
00,0
00 fo
r SF
Y 2
000
for
publ
ic a
nd p
rofe
ssio
nal e
duca
tion
on t
he d
ange
rs o
f and
tre
atm
ents
(a
ppro
pria
tion)
for
obes
ity a
nd $
50,0
00 fo
r an
ti-ob
esity
dru
gs n
ot e
ligib
le fo
r re
imbu
rsem
ent
unde
r th
e M
edic
aid
prog
ram
for
low
-inco
me
pers
ons
in n
eed
of t
reat
men
t fo
r cr
itica
l or
chro
nic
obes
ity.
Sta
teIn
itia
tive
Des
crip
tio
nS
ou
rce
AR
Act
175
0:T
he G
reat
La
w r
equi
ring
tob
acco
set
tlem
ent
mon
ies
to b
e us
ed t
o pr
ovid
e gr
ants
N
atio
nal C
ente
r fo
r C
hron
icSt
ride
s G
rant
to r
ural
com
mun
ities
who
are
inte
rest
ed in
bui
ldin
g sa
fe,w
ell-l
it D
isea
se P
reve
ntio
n an
d H
ealth
yw
alki
ng p
arks
for
thei
r ci
tizen
s.Pr
omot
ion,
Ark
ansa
s C
ente
r fo
r H
ealth
Impr
ovem
ent
AR
Gov
erno
r's
Cou
ncil
A d
atab
ase
of p
rofe
ssio
nal p
erso
ns fr
om fi
tnes
s re
late
d oc
cupa
tions
suc
h as
N
atio
nal C
ente
r fo
r C
hron
icPr
ofes
sion
al D
atab
ase
coac
hes,
form
er a
thle
tes,
mot
ivat
iona
l spe
aker
s,an
d co
ache
s.D
isea
se P
reve
ntio
n an
d H
ealth
y Pr
omot
ion
AR
"Be
Act
ive
& C
are"
Aft
er-s
choo
l pro
gram
tha
t ta
rget
s 45
0 K
-5 s
tude
nts
at t
en d
iffer
ent
scho
ols
Act
ion
for
Hea
lthy
Kid
sth
roug
hout
the
Litt
le R
ock
Scho
ol D
istr
ict.
AR
The
Gre
at A
rkan
sas W
orko
utA
n an
nual
eve
nt in
volv
ing
over
600
3rd
an
d 4
th g
rade
rs r
epre
sent
ing
Nat
iona
l Cen
ter
for
Chr
onic
elem
enta
ry s
choo
ls a
cros
s th
e st
ate
with
phy
sica
l edu
catio
n pr
ogra
ms.
Dis
ease
Pre
vent
ion
and
Hea
lthy
Prom
otio
n
AR
Food
Mar
ketin
g an
d En
cour
ages
sta
te g
over
nmen
t an
d sc
hool
dis
tric
ts t
o de
sign
ate
scho
ols
Adv
ertis
ing
Dir
ecte
d at
as a
dver
tisin
g-fr
ee z
ones
;enc
oura
ges
colla
bora
tion
of t
he d
evel
opm
ent
of
Act
ion
for
Hea
lthy
Kid
sC
hild
ren
and
Ado
lesc
ents
:sc
hool
pol
icie
s th
at p
rom
ote
a he
alth
y ea
ting
envi
ronm
ent
and
guid
elin
es fo
r Im
plic
atio
ns fo
r O
verw
eigh
tre
spon
sibl
e ad
vert
isin
g.
AR
Act
122
0:BM
I Ini
tiativ
eM
ulti-
pron
ged
initi
ativ
e to
impr
ove
heal
th o
f Ark
ansa
s ch
ildre
nA
rkan
sas
Cen
ter
for
Hea
lth Im
prov
emen
t
AZ
Ari
zona
Hea
lthy
Scho
ol
Serv
es a
s a
guid
e to
est
ablis
hing
sta
ndar
ds fo
r a
heal
thy
scho
ol e
nvir
onm
ent
Envi
ronm
ent
Mod
el P
olic
ysu
ch a
s th
e fo
llow
ing:
30 m
inut
es o
f phy
sica
l edu
catio
n an
d re
cess
bef
ore
lunc
h in
ele
men
tary
sch
ools
;45
min
utes
of p
hysi
cal e
duca
tion
per
day
in m
iddl
e an
d
Act
ion
for
Hea
lthy
Kid
shi
ghsc
hool
s;en
cour
ages
sch
ools
to
offe
r br
eakf
ast
and
lunc
h op
tions
con
sist
ent
with
USD
A D
ieta
ry g
uide
lines
;and
,ade
quat
e sp
ace
and
time
for
scho
ol m
eals
.
CO
AFH
K H
ealth
y Sc
hool
s Su
mm
itT
he S
umm
it ou
tline
d th
e im
port
ance
of i
mpr
ovin
g nu
triti
on a
nd p
hysi
cal a
ctiv
ity
Act
ion
for
Hea
lthy
Kid
sin
Col
orad
o sc
hool
s.
CO
The
Col
orad
o Ph
ysic
al A
ctiv
ity
The
Kit
incl
udes
mat
eria
ls t
hat
enco
urag
e sc
hool
s to
impl
emen
t pr
ogra
ms
and
Act
ion
for
Hea
lthy
Kid
san
d N
utri
tion
Prog
ram
Sch
ool
polic
ies
that
pro
mot
e a
heal
thy
scho
ol e
nvir
onm
ent.
Site
Res
ourc
e K
it
GA
Geo
rgia
Coa
litio
n fo
r Ph
ysic
alA
col
labo
ratio
n of
pub
lic,p
riva
te,a
nd n
on-p
rofit
bus
ines
s or
gani
zatio
ns,a
nd
Geo
rgia
Coa
litio
n fo
r Ph
ysic
alA
ctiv
ity a
nd N
utri
tion
busi
ness
es w
hose
mis
sion
is t
o im
prov
e th
e he
alth
of G
eorg
ians
by
prom
otin
g A
ctiv
ity a
nd N
utri
tion
heal
thy
eatin
g an
d ph
ysic
al a
ctiv
ity.
GA
Geo
rgia
Obe
sity
Act
ion
A g
roup
of h
ealth
care
pro
fess
iona
ls t
hat
are
invo
lved
in e
duca
tion,
rese
arch
,G
eorg
ia D
epar
tmen
t of
Net
wor
k (O
AN
)an
d pr
ogra
m in
itiat
ives
in G
eorg
ia r
elat
ive
to c
hild
and
ado
lesc
ent
phys
ical
H
uman
Res
ourc
esac
tivity
,nut
ritio
n,an
d ov
erw
eigh
t.
34
Appendix D
Sta
teIn
itia
tive
Des
crip
tio
nS
ou
rce
KY
Phys
ical
Act
ivity
pilo
t pr
ogra
mT
he K
entu
cky
Stat
e Te
am is
col
labo
ratin
g w
ith t
he D
epar
tmen
t of
Edu
catio
n to
impl
emen
t a
pilo
t pr
ogra
m in
4 e
lem
enta
ry s
choo
ls t
hat
inco
rpor
ate
phys
ical
A
ctio
n fo
r H
ealth
y K
ids
activ
ity in
the
cla
ssro
om.
KY
Gro
win
g H
ealth
y K
ids
An
annu
al c
onfe
renc
e de
sign
ed t
o he
lp K
entu
cky
yout
h ac
hiev
e a
heal
thy
wei
ght.
Act
ion
for
Hea
lthy
Kid
s
KY
Blue
prin
t fo
r H
ealth
y K
ids
Ken
tuck
y C
hild
Now
and
the
Ken
tuck
y Sc
hool
-Bas
ed H
ealth
Cen
ter
Coa
litio
n K
entu
cky
Chi
ld N
ow!
have
form
ed a
par
tner
ship
to
impr
ove
the
heal
th o
f Ken
tuck
y ch
ildre
n.
KY
Twee
nsA
soc
ial m
arke
ting
inte
rven
tion
targ
etin
g ch
ange
s in
beh
avio
rs r
elat
ed t
o C
ente
r fo
r D
isea
se C
ontr
olnu
triti
on a
nd p
hysi
cal a
ctiv
ity a
mon
g ch
ildre
n be
twee
n th
e ag
es o
f 9 a
nd 1
3.
KY
The
Par
tner
ship
for
T
his
5 ye
ar C
DC
Obe
sity
gra
nts'
mis
sion
is a
coo
rdin
ated
effo
rt t
o re
duce
a
Fit
Ken
tuck
yan
d pr
even
t ob
esity
and
chr
onic
dis
ease
in K
entu
cky.
The
pla
n w
ill t
arge
t C
ente
r fo
r D
isea
se C
ontr
olbu
sine
sses
,com
mun
ities
,the
env
iron
men
t,he
alth
car
e an
d sc
hool
s.
MS
CD
C g
rant
Mis
siss
ippi
rec
eive
d gr
ants
to
fund
obe
sity
pre
vent
ion
prog
ram
s in
25
The
Ass
ocia
ted
Pres
s,A
pril
26,2
004
elem
enta
ry a
nd s
econ
dary
sch
ools
.
MS
Offi
ce o
f Hea
lthy
Scho
ols
The
Mis
siss
ippi
Dep
artm
ent
of E
duca
tion
is c
reat
ing
an
Offi
ce o
f Hea
lthy
Scho
ols
to a
ddre
ss h
ealth
and
edu
catio
n in
a
Mis
siss
ippi
Dep
artm
ent
of E
duca
tion
coor
dina
ted
appr
oach
.
MS
Del
ta N
utri
tion
Inte
rven
tion
Thi
s in
itiat
ive
is fo
cuse
d on
the
des
ign,
impl
emen
tatio
n,an
d ev
alua
tion
of
Mis
siss
ippi
Dep
artm
ent
of E
duca
tion:
Res
earc
h In
itiat
ive
nutr
ition
inte
rven
tion
rese
arch
str
ateg
ies
in 3
rur
al c
omm
uniti
es in
the
Low
er
Offi
ce o
f Chi
ld N
utri
tion
Mis
siss
ippi
Del
ta u
sing
a c
omm
unity
-bas
ed p
artic
ipat
ory
proc
ess.
MS
Del
ta H
ope
(Hea
lth O
ptio
ns
The
Coo
pera
tive
Exte
nsio
n Se
rvic
es a
t th
e LS
U A
gCen
ter,
the
Uni
vers
ity o
f fo
r Pe
ople
Thr
ough
Ext
ensi
on)
Ark
ansa
s an
d M
issi
ssip
pi S
tate
Uni
vers
ity a
re c
ondu
ctin
g an
edu
atio
nal i
nitia
tive
LSU
AgC
ente
rde
sign
ed t
o fig
ht c
hild
hood
obe
sity
in t
he r
egio
n.
Nat
iona
l C
arol
M.W
hite
Phy
sica
l G
rant
s ra
ngin
g fr
om $
50,0
00 t
o $7
20,0
00 a
re g
iven
to
purc
hase
equ
ipm
ent
Am
eric
an C
ounc
il fo
r Fi
tnes
s Ed
ucat
ion
Prog
ram
(PE
P)an
d tr
ain
teac
hers
.an
d N
utri
tion
NM
Hea
d to
Toe
Con
fere
nce
A n
etw
orki
ng e
vent
bro
ught
tog
ethe
r he
alth
pro
fess
iona
ls fr
om a
cros
s N
etw
orki
ng E
vent
New
Mex
ico
to s
hare
suc
cess
es,s
trat
egie
s,an
d ba
rrie
rs r
egar
ding
obe
sity
A
ctio
n fo
r H
ealth
y K
ids
prev
entio
n/re
duct
ion
prog
ram
s.
NM
Nav
igat
ing
Gui
de fo
r Te
ache
rs:
A g
uide
cre
ated
for
New
Mex
ico
scho
ol p
erso
nnel
pro
vide
s in
form
atio
n R
esou
rces
for
Scho
ol H
ealth
rela
ted
to s
tude
nt p
hysi
cal h
ealth
,men
tal,
and
emot
iona
l hea
lth,a
saf
e sc
hool
A
ctio
n fo
r H
ealth
y K
ids
envi
ronm
ent,
nutr
ition
,phy
sica
l act
ivity
,sta
ff w
elln
ess,
heal
th e
duca
tion,
and
pare
nt a
nd c
omm
unity
invo
lvem
ent.
NM
Coo
rdin
ated
App
roac
h to
T
his
NM
Dep
t of
Edu
catio
n fu
nded
pro
gram
incl
udes
nut
ritio
n cu
rric
ulum
,C
ente
r fo
r D
isea
se C
ontr
olC
hild
Hea
lth (
CAT
CH
)en
hanc
ed p
hysi
cal a
ctiv
ity,f
amily
invo
lvem
ent,
and
impr
oved
sch
ool n
utri
tion.
cont
.
35
Appendix D
36
Appendix DS
tate
Init
iati
veD
escr
ipti
on
So
urc
e
NM
Hea
lthie
r Sc
hool
s N
ew M
exic
oT
his
prog
ram
,fun
ded
by t
he N
ew M
exic
o D
epar
tmen
t of
Hea
lth a
dvoc
ates
fo
r th
e in
clus
ion
of t
he 8
com
pone
nts
of c
ompr
ehen
sive
sch
ool h
ealth
.T
his
Cen
ter
for
Dis
ease
Con
trol
grou
p pr
omot
es t
he u
se o
f the
Em
ergi
ng M
odel
of P
hysi
cal E
duca
tion,
emph
asiz
ing
life-
long
phy
sica
l act
ivity
,ind
ivid
ual p
ract
ice
and
skill
opp
ortu
nitie
s.
NV
Rec
ess
befo
re lu
nch
and
the
Thi
s pr
ogra
m fo
cuse
s on
impr
ovin
g ph
ysic
al a
ctiv
ity o
ppor
tuni
ties
and
A
ctio
n fo
r H
ealth
y K
ids
Brea
kfas
t Be
fore
Sch
ool P
rogr
amem
phas
izin
g th
e im
port
ance
of a
dequ
ate
time
and
sche
dule
for
scho
ol m
eals
.
SCSC
Par
tner
ship
for
Obe
sity
Fu
ture
effo
rts
incl
ude
part
neri
ng w
ith S
.C.H
ealth
y Sc
hool
s us
ing
Scho
ol
Cen
ter
for
Dis
ease
Con
trol
Prev
entio
n (S
CPO
P)H
ealth
inde
x an
d th
e im
plem
enta
tion
of a
nut
ritio
n ed
ucat
ion
curr
icul
um.
SCSC
PEA
P:T
he S
C P
hysi
cal
A p
rogr
am a
sses
smen
t to
hel
p im
prov
e th
e qu
ality
of P
.E.c
lass
es in
SC
.So
uth
Car
olin
a N
utri
tion
Educ
atio
n A
sses
smen
t Pr
ojec
tR
esea
rch
Con
sort
ium
SCR
eces
s Po
sitio
n St
atem
ent
The
invo
lvem
ent
of c
hild
ren
in d
aily,
unst
ruct
ured
phy
sica
l act
ivity
dur
ing
Sout
h C
arol
ina
Coa
litio
n fo
rsc
hool
hou
rs is
cri
tical
for
thei
r cu
rren
t an
d fu
ture
hea
lth.
Prom
otin
g Ph
ysic
al A
ctiv
ity
(htt
p://w
ww
.scc
ppa.
org/
advo
cacy
/r
eces
s.ht
ml)
SCD
.U.C
.K.-
Wal
king
- D
isco
ver
Prog
ram
tha
t en
cour
ages
tea
cher
s fr
om e
lem
enta
ry s
choo
ls t
o in
corp
orat
e So
uth
Car
olin
a N
utri
tion
and
Und
erst
and
Sout
h ph
ysic
al a
ctiv
ity in
to t
he s
choo
l wee
k.R
esea
rch
Con
sort
ium
Car
olin
a N
utri
tion
Res
earc
h
TN
Tenn
esse
e H
ealth
y W
eigh
t Lo
cal c
oalit
ions
to
impl
emen
t st
rate
gies
and
obj
ectiv
es a
imed
at
impr
ovin
g A
ctio
n fo
r H
ealth
y K
ids
Net
wor
k fo
r C
hild
ren
and
Yout
hhe
alth
of c
hild
ren
and
yout
h
TN
Coo
rdin
ated
Sch
ool
Prog
ram
is in
tend
ed t
o re
duce
tob
acco
use
and
add
ictio
n,im
prov
e ea
ting
Act
ion
for
Hea
lthy
Kid
spa
tter
ns,i
ncre
ase
phys
ical
act
ivity
,and
red
uce
obes
ity a
mon
g yo
uth.
Tenn
esse
e D
epar
tmen
t of
Edu
catio
n
TN
Tenn
esse
e N
utri
tion
and
Thi
s nu
triti
on e
duca
tion
prog
ram
is fo
r Te
nnes
see
fam
ilies
who
rec
eive
or
The
Uni
vers
ity o
fC
onsu
mer
Edu
catio
n ar
e el
igib
le fo
r Fo
od S
tam
ps.
The
goa
l is
to t
each
fam
ilies
how
to
choo
se a
nd
Tenn
esse
e Ex
tens
ion
Prog
ram
(T
NC
EP)
prep
are
nutr
ition
ally
ade
quat
e di
ets.
WV
Cho
osy
Kid
s C
lub
An
afte
rsch
ool p
rogr
am fo
r el
emen
tary
sch
ool c
hild
ren
from
a t
ri-c
ount
y ar
ea.
Thi
s pr
ogra
m fo
cuse
s on
Act
ive
lifes
tyle
s ba
sed
on h
ealth
y de
cisi
ons.
http
://w
ww
.bec
hoos
y.or
g
WV
“Suc
cess
Sha
red”
pro
ject
Thi
s st
ate
team
is w
orki
ng o
n a
pro
ject
tha
t ai
ms
to r
ecog
nize
and
rew
ard
the
acco
mpl
ishm
ents
of s
choo
ls m
akin
g po
sitiv
e su
stai
nabl
e ch
ange
s in
nut
ritio
n A
ctio
n fo
r H
ealth
y K
ids
and
phys
ical
act
ivity
.
WV
Rec
ipe
for
Succ
ess
Thi
s st
ate
team
dev
elop
ed R
ecip
e fo
r Su
cces
s,a
CD
-Rom
too
lkit
that
ass
ists
pr
inci
pals
in t
rain
ing
thei
r pe
ers
and
iden
tifyi
ng k
ey a
reas
of c
hang
e th
at m
odel
A
ctio
n fo
r H
ealth
y K
ids
heal
thfu
l eat
ing
and
prom
ote
phys
ical
act
ivity
in s
choo
ls.
cont
.
37
Photo Credits
Michael Bisceglie: Pages 1, 6, 7, 8, 9, 11, 12, 13, 16, 18, 21Susan Warner: Cover, pages 2, 3, 4, 5, 10, 14, 15, 17, 19, 20, 22, 23
54 Wilton Road • Wesport, Connecticut 06880www.savethechildren.org
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