for state of california erna wong, md pediatrician november 30, 2005 overweight children the role of...

FOR STATE OF CALIFORNIA

Erna Wong, MDPediatrician

November 30, 2005Overweight ChildrenThe Role of Health Care in Prevention & Treatment

FOR HEALTH PROFESSIONALS

The Role of Health Care in Prevention & TreatmentREGIONAL HEALTH EDUCATION

Today we will talk about...

The Epidemic of Overweight Children

Medical Office Visit Interventions

Weight Management Interventions

Environmental Changes and Physician Advocacy



By the end of this lecture participants will be able to…

Describe 3 overweight prevention strategies.

Diagnose overweight and at risk for overweight using BMI % for age.

Describe the weight goals for overweight children.

Give Brief Focused Advice.



About Kaiser Permanente (KP)

One of the nation’s oldest not-for-profit health care delivery systems and a leader in quality.

8.2 million members nationwide; 6.2 million in California.

KP has made a deep and longstanding commitment to healthy eating and active living in our communities with intensive interventions since 2001.



How serious is the problem of overweight children in California today?

1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm

No Opinion1%

Very Serious46%

Somewhat Serious46%

Not Serious7% Very Serious

Somewhat Serious

Not Serious

No Opinion



45

4

67

5

11 11

15.8 16.1

0

2

4

6

8

10

12

14

16

18

Per

cen

t

1963-70 1971-74 1976-80 1988-94 1999-02

6-11 Years 12-19 Years

Since 1963, the number of overweight children in the U.S. has tripled!

SOURCE: CDC/NCHS, NHES and NHANES

How many children are overweight?



Some children are more likely to be overweight.

% Overweight Kids & Teens in 2000% Overweight Kids & Teens in 2000 Teenagers

Black, Mexican American, American Indian, Alaskan Native

Children of overweight parents

10.18.4

11.1 11.8

19.5

23.7

12.7

23.6 23.4

0

5

10

15

20

25

2-5 Yr 6-11 Yr 12-19 Yr

White Non-Hispanic Black Non-Hispanic Mexican American

% O

verw

eigh

t

NHANES 1999-2000 JAMA 2002;288:1728-1732



Do overweight children grow up to be overweight adults?

The older the overweight child is, the more likely he/she will continue to be overweight as an adult.

8 out of 10 overweight teens will continue to be overweight as adults.

% Overweight Children% Overweight Children

who Become Obese Adultswho Become Obese Adults

10

35

50

80

0102030405060708090

100

Per

cen

tag

e

Preventive Medicine 1993; Vol. 22:pp. 167-177Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452



Source: Behavioral Risk Factor Surveil lance System, CDC.

19961991

2003

Obesity Trends* Among U.S. AdultsBRFSS, 1991, 1996, 2003

(* BMI 30, or about 30 lbs overweight for 5’4” person)

No Data <10% 10% – 14% 15% – 19% 20% – 24% ¡ 25%

How many adults are overweight?

“the average weight gain among subjects (20-40 years old) in the population is 1.8 to 2.0 pounds/year.”Science. 299:7;853-855 (2003)



What health problems are related to being overweight?

Type 2 diabetes Heart disease Hypertension Asthma Slipped capital femoral epiphysis Nonalcoholic steatohepatitis Polycystic ovary syndrome Sleep apnea Depression and low self-esteem

Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430



Metabolic Syndrome (1)

Criteria: TG>=110 mg/dL, HDL-C<=40 mg/dL, Waist Circ. >=90%, FBS>=110 mg/dL, BP>= 90% (3 of 5 criteria needed)

A predictor of Type 2 diabetes and premature coronary artery disease.

Prevalence = 28.7% among overweight adolescence.

The prevalence of metabolic syndrome increased with the severity of overweight and reached 50% in severely overweight children. (2)

1. Arch Pediatr Adolesc Med Vol. 157, Aug 2003 pp. 821-8272. N Engl J Med Vol. 350, June 2004 pp. 2362-2374

How many overweight children have metabolic syndrome?



“I think we’re looking at a first generation of children who may live less long than their parents as a result of the consequences of overweight and type 2 diabetes.”Francine Ratner Kaufman, MDHead, Division of Endocrinology & MetabolismChildren’s Hospital Los Angeles

The Epidemic of Overweight Children

www.discoveryhealthCME.com, N Engl J Med Vol. 352(11) March 2005, pp. 1138-1145



What are the costs of overweight and obesity?

Obesity-Associated Annual HospitalObesity-Associated Annual Hospital

Costs for Youths Aged 6 to 17 YearsCosts for Youths Aged 6 to 17 Years

35

127

0

20

40

60

80

100

120

140

Mil

lion

Dol

lars

1979-81 1997-99

3 FoldIncrease

Health care for obese adults costs 37% more than for people of normal weight, adding $732 to the annual medical bills of every American.

Treatment of illnesses related to obesity costs America $93 billion a year.

Health Affairs May 14, 2003; W3:219-226NIHCM Obesity in Young Children: Impact and Intervention Aug 2004



METABOLISMGENES

SESCULTURE

BEHAVIOR ENVIRONMENT

What are the causes of overweight and obesity?



What are the genetics of overweight and obesity?

Twin analysis indicates a heritability of fat mass of 40–70%

Adopted children have BMIs that correlate to those of their biological parents

Genetic Risk for Overweight One obese parent (3X increase) Two obese parents (13X increase) Early puberty

Behavioral Genetics, 1997, 27:325–351



What behaviors are related to children becoming overweight?

Not enough physical activity.

Too much TV & video games.

Not enough milk, dairy, fruits and vegetables.

Too many sweetened drinks (e.g., soda, juice drinks, sports drinks) and too much fast food.

Skipping meals and breakfast.

Position Paper - Prevention of Childhood Overweight What Should Be Done? Center for Weight and Health - U.C. Berkeley 10/02



Why is physical activity important?

3 out of 4 children in California fail to meet the minimum fitness standards in 5th, 7th and 9th grade.

Being in good shape… reduces the risk of being

overweight and heart disease

is related to better school performance

California Department of Education 12/10/02http://www.cde.ca.gov/news/releases2002/rel37.asp

Fitness and Academic PerformanceFitness and Academic Performance

2001 Grade 7 SAT 9 and Physical Fitness

0

10

20

30

40

50

60

70

1 2 3 4 5 6

Reading Math

Number of Fitness Standards Achieved

SA

T 9

Per

cen

tile



Why is TV harmful?

Children average 2-3 hours of TV viewing every day.

30-50% of children have a TV in their bedroom.

TV viewing is associated with... increased risk for being

overweight school problems aggressive behavior & drug use

Pediatrics Vol. 107 No. 2 February 2001 pp. 423-426



Are dairy products important?

Milk consumption in the U.S. has declined over the last 40 years.

Milk and calcium consumption has declined significantly for adolescent girls.

Drinking milk may reduce the risk of… becoming overweight developing osteoporosis

J Am Diet Assoc. 2003;103:1626-1631.



Are eating fruits and vegetables important?

In California, of 7th, 9th and 11th graders surveyed less than half reported eating fruits or vegetables at least once per day in the past week.

Eating 5 servings of fruits and vegetables every day can help reduce the risk of overweight.

Food Review. 2002;25:28-31.



Why are sweetened drinks harmful?

Teenagers drink an average of 20 ounces of soda every day.

Drinking more than 12 ounces a day of sweetened drinks is associated with…

an increased risk of being overweight

drinking less milk

an increased risk of cavities

J PEDIATRICS Vol. 142 June 2003, pp. 604-610BMJ. May 22, 2004;328:1237



What about eating out and fast food?

Eating out has increased from 16% to 27%.

Some fast food portion sizes have tripled from 1960 to 2000.

Fast food and eating out may be associated with an increased risk for overweight.

Int J Obes Relat Metab Disord. 2004;28:282-289.



What are the risks of skipping breakfast?

Eating breakfast by teens has declined by 20% over the last 20 years.

44% of teens said they skipped meals to lose weight.

Skipping breakfast is associated with… eating more later in the day and the risk of becoming overweight.

J Am Diet Assoc. Vol. 101, 2001, pp. 798-802



Small changes over time can make a big difference!

15 minutes of play

instead of watching TV

can prevent some

weight problems.



A Longitudinal Approach to Preventing Overweight

FetusFetus

Preventing:

• SGA

• LGA

InfantsInfants

Promoting:

• Breastfeeding ToddlersToddlers

Diagnosing:

• Early AdiposityRebound

ChildrenChildren

Increasing:

• Physical Activity

Decreasing:

• TV Viewing

• SweetenedBeverageConsumption

AdultsAdults

Increasing:

• Physical Activity

Decreasing:

• Portion Size

Encouraging:

• WeightMaintenanceThe Permanente Journal/ Summer 2003/ Volume 7 No. 3 pp. 6-7



Can overweight among children be prevented?

Breastfeed for the first year.

Wean from the bottle at 12 months of age.

Limit juice and other sweetened drinks to 4-6 ounces per day max.

Limit TV - none before 2 years, 1 hour or less over 2 years of age.

Avoid using food as a reward for good behavior.

J Pediatr Vol. 141 No. 6 December 2002 pp. 764-769JAMA Vol. 285 No. 19 May 2001 pp. 2461-2467



Primary Care

Interventions



Kaiser Permanente’s Approach to Preventing Overweight

MEDICAL OFFICE VISITINTERVENTIONS

BMI Screening Physician Counseling Patient Education Materials Referral and Follow-Up

WEIGHT MANAGEMENTINTERVENTIONS

Individual Counseling Group Programs Intensive Programs Internet Resources

ENVIRONMENTALCHANGES

School Programs Work Site Programs Community Programs Legislation & Partnerships



First Steps. . .First Steps. . .

Changing the Message Active bodies are healthy bodies Healthy bodies come in all shapes and sizes

Anticipatory guidance Breastfeeding promotion Improved nutrition Increased physical activity

Identification, Risk Stratification, and Early Intervention BMI Targeted evaluation and education



A Practical Approach to Overweight Children

Calculate BMI and Plot BMI% for Age Perform In-Depth Medical Assessment Determine Weight Goals Order Screening Lab Tests (if indicated) Provide Brief Focused Advice Arrange for Follow-Up Visit or Phone Call 1-4 Weeks

Proposed Treatment Approach to Overweight Children, Kaiser Permanente, © 2004

Well Child Care Visit

Follow-Up Visit or Phone Call Review Labs Discuss Treatment Options and Referrals Provide Brief Negotiation or Motivational Interviewing Arrange for Follow-Up as Necessary



Primary Care Interventions

Diagnosis of overweight using body mass index (BMI)% for age at well child care visits 2 years and older

In-depth medical assessment

Appropriate weight goals

Counseling - motivational interviewing

Referral and follow-up




BMI (English): [ weight (lb) / height (in) / height (in) ] x 703

BMI (metric): [ weight (kg) / height (cm) / height (cm) ] x 10,000

BMI Conversion Tables: http://www.cdc.gov/Web Calculator: http://www.cdc.gov/Palm Calculator and Growth Chart: http://www.pdacortex.com/BMI Calculator Wheel: http://www.trowbridge-associates.com/ $5

BMI = 28

BMI Does Not Measure Body Fat


How do you calculate body mass index (BMI)?



Why do we use BMI?

Consistent with adult standards and tracks childhood overweight into adulthood

BMI for age relates to health risks including cardiovascular disease, hypertension and type 2 diabetes

BMI measurement is recommended by the AAP at all well child care visits 2 years and older.


8Y

10Y



How is overweight diagnosed?

Indicators of Nutritional Status Overweight >= 95% for age At Risk of Overweight 85-94% for age Underweight < 5% for age

Early Adiposity Rebound Definition: Adiposity rebound is the point

when the BMI is the lowest for a child before it increases again

Experiencing early adiposity rebound (rebound before 5-6 years old) is a risk factor for subsequent adiposity in adulthood (1) and is associated with parental obesity (2)

8Y

10Y

(1) Pediatrics Vol. 101 No. 3 March 1998 pp. 462(2) Pediatrics Vol. 105 No. 5 May 2000 pp. 1115-1118

Early Adiposity Rebound (4Y)



Who should receive an in-depth medical assessment?



In-Depth Medical Assessment

HistoryDevelopmental delay (Genetic disorders)

Poor linear growth (Hypothyroidism, Cushing’s, Prader-Willi syndrome)

Headaches (Pseudotumor cerebri)

Nighttime breathing difficulty (Sleep apnea, hypoventilation syndrome)

Daytime somnolence (Sleep apnea, hypoventilation syndrome)

Abdominal pain (Gall bladder disease)

Hip or knee pain (Slipped capital femoral epiphysis)

Oligomenorrhea or amenorrhea (Polycystic ovary syndrome)

Family HistoryObesity HypertensionNIDDM DyslipidemiaCardiovascular disease Gall bladder disease

Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29



In-Depth Medical Assessment

Physical examinationHeight, weight, Blood pressure and BMITruncal obesity (Risk of cardiovascular disease; Cushing’s syndrome)

Dysmorphic features (Genetic disorders, including Prader–Willi syndrome)

Acanthosis nigricans (NIDDM, insulin resistance)

Hirsutism (Polycystic ovary syndrome; Cushing’s syndrome)

Violaceous striae (Cushing’s syndrome)

Optic disks (Pseudotumor cerebri)

Tonsils (Sleep apnea)

Abdominal tenderness (Gall bladder disease)

Undescended testicle (Prader-Willi syndrome)

Limited hip range of motion (Slipped capital femoral epiphysis)

Lower leg bowing (Blount’s disease)



In-Depth Medical Assessment - Laboratory Evaluation

Fasting lipid profile and insulin? (1)

Screening for diabetes if (2)…Age 10 or older with BMI >= 95% with 2 of the following:

Family History: type 2 diabetes in a 1st or 2nd degree relative Ethnic Group: Native American, African American, Hispanic, Asian/Pacific

Islander Signs of Insulin Resistance: acanthosis nigricans, hypertension, dyslipidemia,

polycystic ovary syndrome

Screening Tests for Diabetes and Diagnostic Criteria Fasting (8 hour) plasma glucose = 126 mg/dl Oral glucose tolerance test: 2-hour plasma glucose = 200 mg/dl Casual (random) plasma glucose = 200 mg/dl WITH symptoms of diabetes

ALT (SGPT) (1)

Other tests based on history and physical(1) Circulation 2005;111:1999-2012(2) Diabetes Care 2000a;23:381-9



What are the recommended weight goals?

Weight loss approx. 1 pound/month

Weight goal: BMI< 85%

Older Adolescents and Adults: 10% weight loss from baseline over 6 months



What should my child weigh?

Tell the parent what the weight would be for the BMI 85%.

Tell the parent that for children the focus is on making improvements in family lifestyles such as making better food choices and being more active not on weight or weight loss. Your health professional will follow your child’s height, weight and BMI and let you know how your family is doing.

Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29



The Role of Nurses, Health Educators, Physicians, etc.

All ChildrenGet up and play hardCut back on TV and video gamesEat 5 helpings of fruits and vegetables/dayCut down on sodas & juice drinks

ADVISE

IDENTIFYChildren at Risk or OverweightScreen with BMI starting at age 2 for all childrenFocus on key intervention ages

MOTIVATE Families at Risk to Make Changes Ask permission to discuss weightNegotiate areas of improvementAssess readiness to changeExplore ambivalenceOffer health education materials, referral and follow-up



Get More Energy! Poster

4 Key Messages

Readiness to Change Tool



Health Education Materials

Physicians who had

written nutrition

brochures in their exam

rooms were more likely

to discuss nutrition.

Preventive Medicine Vol. 38 No. 2 February 2004 pp. 198-202



EffectiveEffective

CommunicationCommunication

With FamiliesWith Families



Solutions for childhood nutrition problems mentioned in CA newspaper articles, 7/98–8/00 (N=88)

Personal behavior change 31%

No solution suggested 17%

Make better options available for school lunch 9%

Improve counseling by pediatricians 8%

Extend PE requirements in schools 7%

Improve nutrition education in schools6%

Add a “fat tax” to foods based on nutrient value 5%



What are more sensitive ways to address overweight?

Obesity

Ideal Weight

Personal Improvement

Focus on Weight

Diets or “Bad Foods”

Exercise

Overweight

Healthier Weight

Family Improvement

Focus on Lifestyle

Healthier Food Choices

Play or Activity

Effective Communication with Families, Kaiser Permanente, © 2004



Family Changes-Acknowledge Parental Perceptions and Barriers

May not perceive their obese children as overweight May define overweight as limited physical activity or being teased,

not by growth charts May attribute to being “big-boned” or “thick” May believe that nature not nurture determines weight May have trouble controlling children’s eating habits or use food to

shape child’s behavior May feel lack of control over child’s diet May themselves be dealing with weight issue




Family Changes-Parental Sensitivity

Parents should explain that children come in different shapes and sizes and that they love them whatever their size.

Parents should avoid saying “skinny,” “fat,” “obese” or teasing children about their weight.

Parents should address eating and activity as a family issue, not as the child’s “problem.”

Encouraging a Healthy Weight for Your Child, Kaiser Permanente, © 2003



Family Changes-Positive family attitudes

Having extra weight is no one’s fault.

There’s no such thing as good food or bad food.

Any activity is helpful, it doesn’t have to be “exercise.”

There is no ideal weight or body shape.

Body size is just one part of who a person is.




Family Changes-Parents Responsibilities

Purchase and offer healthy foods and portion sizes.

Limit fast food and eating out. Set limits on TV and video games.

Stick to them. Let child choose things to work on. Be a good role model with healthy

eating and physical activity. Regularly show affection.




Family Changes-Child’s Responsibilities

Eat as much or as little as they need among the food available.

Eat 3 meals a day with breakfast. Be active every day and have fun. Be responsible for TV and video

game limits. Be proud of things they do. Choose things to work on to be

healthier.




Starting the Conversation: Let’s Talk About Weight



What are the stages of change?

Prochaska & Di Clemente: Transtheoretical Model of Behavior Change

Action

Preparation

Contemplation

Relapse & Recycle

Maintenance

Pre-contemplation

Integrated Behavior



Change Talk

Self-motivating statements made by the patient: Recognition of an issue Hazards of not making a change Recent efforts to make a change Ideas and options for making a change Hope or confidence about making a change Specific intentions to make a change




Self Perception

People are more powerfully influenced by what they hear themselves say than by what someone else says to them

Encourage your patients to say the things that you usually tell them. Help your patients talk themselves into making a change.




Behavior Change Techniques

Lifestyle Advice – Well Child Visit < 1 minute Children not currently at risk for overweight

Brief Focused Advice – Well Child Visit < 3 minutes Children who are overweight or at risk for overweight

Brief Negotiation– Follow up Visit 10+ minutes: single or multiple sessions Children who are overweight or at risk for overweight




Lifestyle Advice

To stay healthy and energized:

Get up & play hard 30-60 minutes each day Limit TV/video games to <1 hour each day Eat five fruits and vegetables each day Limit juice and soda to < 1cup each day




Brief Focused Advice

Step #1: Engage the Patient / Parent Can we take a few minutes to discuss your health and weight? How do you feel about your health and weight?

Step #2: Share Information (optional) Your current weight puts you at risk for developing heart

disease and diabetes. What do you make of this? Some ideas for staying healthy include…. (see poster) What are your ideas for working toward a healthy weight?




Step #3: Make a Key Advice Statement I would strongly encourage you to…

Get up and play hard, 30-60 minutes a day. Cut back on TV & video games to 60 min/day. Eat 5 helpings of fruits of vegetables every day. Cut back on sodas & juice drinks to 1 small cup/day. Use patient ideas from step #2

Step #4: Arrange for Follow up Would you be interested in more information on ways to reach a

healthier weight? AND / OR Let’s set up an appointment in 1-4 weeks to talk about this further.

Brief Focused Advice




A counseling style that provides an effective and structured approach to behavior change counseling in brief clinical encounters

Based on behavior change theory and clinical research: Stages of Change Model, DiClemente and Prochaska, 1998 Motivational Interviewing, Miller and Rollnick, 1991

Brief Negotiation Steps Set the Stage Share Clinical Results Assess Readiness to Change Close Conversation/Transition to Referral

What is Brief Negotiation?




Motivate Families to Make Changes Using Brief Negotiation

Open the EncounterOpen the Encounter

Negotiate the AgendaNegotiate the Agenda

Assess ReadinessAssess Readiness Explore AmbivalenceExplore Ambivalence

Tailor the InterventionTailor the Intervention

Close the EncounterClose the Encounter




Open the Encounter

Ask Permission Would you be willing to discuss your weight for

the next few minutes? Ask an Open-Ended Question

How do you feel about your weight? What do you think about your weight? What have you tried so far to manage your

weight? Listen Summarize




Negotiate the Agenda

There are a number of ways to achieve

a healthy weight (refer to poster). They

include: Get up and play hard Cut back on TV and video

games Eat 5 helpings of fruits and

vegetables a day Cut down on soda and juice

Is there one of these you’d like to

discuss further today?

Or maybe you have another idea…




Assess Readiness to Change

5

ReadyNot Ready

2 3 410 8 9 1076

Straight question: “On a scale of 0-10, how ready

are you to think about [option chosen from poster] ?”

Backward question: “Why a 5 and not a 3?”

Forward question: “What would it take to move

you from a 5 to a 7?”



Explore Ambivalence

Ask a pair of questions to help the patient/parent explore pros and cons What are the things you like about ___? AND What are the things you don’t like about ___?

OR What are the advantages of keeping things the same? AND What are the advantages of making a change?

Summarize Did I get it all?




Tailor the Intervention

5

ReadyNot Ready

2 3 410 8 9 1076

Not Ready 0-3

Raise Awareness Advise & Encourage

Unsure 4-6

Evaluate Ambivalence

Ready 7-10

Strengthen Commitment & Facilitate Action



Close the Encounter

Summarize Show appreciation Offer advice, emphasize choice, express confidence Confirm next steps/referral



Health and Social Service Providers Responsibilities

Advise all children on the 4 key messages regardless of their shape or size.

Identify children at risk or overweight.

Motivate families at risk to make changes by assessing their readiness to change and identifying 1-2 key behaviors.

Provide educational materials. Provide follow up with at risk

families.




Tools for Primary Care Interventions

CDC Growth Charts BMI Wheel

Calculator Patient Education

Materials Exam Room Poster



Environmental

Changes and

Physician Advocacy



Are overweight children a personal or community issue?

No Opinion1%

Community Issue53%Personal Issue

30%

Both16%

1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm



What do Californians think the answer is?

Create more community recreational programs (96%).

Require schools to teach students about nutrition & physical activity (96%).

After-school athletic facilities open and available (93%).

Require PE in high school (92%). Require restaurants to post nutritional

information on menus (87%).1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm



Health Care and Prevention of Overweight Children

Medical office visit – BMI screening, counseling and referral

Environmental improvement at health care facilities and policy

Health professionals working with community collaborative and advocacy

Health care benefits

Social marketing



The Role of Health Care in Community Advocacy

Provide quality care to individual patients in regular practice.

Improve the system of care delivered by group/organization.

JAMA January 7, 2004 - Vol. 291, No. 1 pp. 94-98

Environmental change in local schools and communities to address tobacco, injury prevention, and obesity.

Public policy to address same issues.

Provide quality care to uninsured patients.

Improve insurance coverage, after-hours care and geographic distribution of services.



The Role of Health Care in Community Interventions

Leadership and Advocacy Subject matter expertise and credibility

Participation in community collaborative activities

Consultation on policy recommendations and interventions

Education and Social Marketing Presentations to government, school boards, teachers,

parents and students

Media interventions

Pediatrics Vol. 112 No. 4 October 2003, pp. e328-346Pediatrics Vol. 115 No. 4 April 2005, pp. 1142-1147



What is the AAP policy on soft drinks in schools?

Health Care should work to eliminate sweetened drinks in schools. This entails educating school authorities, patients, and patients’ parents about the health ramifications of soft drink consumption.

Health Care should advocate for the creation of a school nutrition advisory council comprising parents, community and school officials, food service representatives, physicians, school nurses, dietitians, dentists, and other health care professionals.

PEDIATRICS Vol. 113 No. 1 January 2004, pp. 152-154



What can schools do?

Salad bars and other low cost healthy meal options. Bans on soda contracts. More PE (at least 200 minutes every 10 school days). More fun PE, non-competitive activities. Walk to school events (www.cawalktoschool.com). Safe bicycle riding events. Teach children about healthy eating and physical

activity in school. Link activities – school, after-school and home.



What can communities do?

Make healthy foods available and affordable (e.g., farmers markets, community gardens).

Improve safety of and access to parks and other recreational areas.

Promote pedestrian and bicycle friendly zoning.

Design new communities to be more walkable.

Healthy messages on TV, radio and posters.



What resources are available for schools and communities?

The Children and Weight: What Schools and Communities Can Do About It Resource Kit http://www.cnr.berkeley.edu/cwh

CDC School Health Index http://www.cdc.gov/

California Project LEAN http://www.californiaprojectlean.org/

Guide to Community Preventive Services http://www.thecommunityguide.org

E. N. A. C. T. http://www.preventioninstitute.org/

for state of california erna wong, md pediatrician november 30, 2005 overweight children the role of...

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