November 2008 Issue
Combating Childhood Obesity: A Community Approach
By Joyce Green Pastors, RD, MS, CDE, and Barbara Yager, RD, Med
Today’s Dietitian
Vol. 10 No. 11 P. 8
Suggested CDR Learning Codes: 1070, 4000, 4010, 4020, 4090, 4150, 5070, 5190, 5370, 6040, 7200; Level 1
Childhood obesity is a serious health concern in the United States, and it is now the most prevalent chronic disorder in children.1 This article focuses on the development, organization, and primary accomplishments of a task force geared toward preventing childhood obesity based on our experience in Charlottesville, Va. It also reviews other national community-based efforts and their attempts to slow the rate of childhood obesity and concludes with a discussion of how dietitians’ training and education can help them initiate and lead community-based efforts to prevent childhood obesity.
Since 1980, the prevalence of overweight children (body mass index [BMI] equal to or greater than the 85th percentile) has nearly tripled among 2 to 5 year olds and youths aged 6 to 11 and more than tripled among adolescents aged 12 to 19. Even more alarming is the statistic that 5 million children of these age groups in the United States are obese (BMI equal to the 95th percentile).2 These data from the National Health and Nutrition Examination surveys (1976-1980 and 2003-2004) are summarized in Chart 1.
Children who are overweight are more likely to be overweight or obese as adults. Ethnic differences exist, as Hispanics, African Americans, and Native Americans—children and adults—have a greater prevalence of overweight and obesity than non-Hispanic whites.3 The rate of diabetes among youths has increased dramatically. In 1992, pediatric centers in the United States reported that 2% to 4% of their patients had type 2 diabetes; in 1999, this figure ranged from 8% to 45% and occurred mainly among youths of high-risk ethnicity.1
Genetics alone cannot account for the rising rates of overweight and obesity.4 Our current obesity epidemic suggests that environment may play a greater role than genetic influence.5 Behavior change in the areas of diet and physical activity has been successful to some degree on an individual basis, but for individual behaviors to be sustained, an environment that supports healthy choices is necessary.6 Looking at changes in the community environment to promote healthier eating, more physical activity, and less inactivity are emerging as more practical ways to address this issue.7 This is especially true for children who have little control over their environment and particularly in settings that promote an overabundance of energy-dense foods, limited sources of physical activity, and many sedentary options.8
Research has shown that the probability of being overweight or obese is significantly associated with the layout of the community in which an individual lives.9 People who live in communities with convenient, safe walking paths and easy access to fruits and vegetables may be more physically active and have healthier diets.10,11 Conversely, people who live in communities where crime rates are high, numerous alcohol outlets exist, and access to open space and fresh food is limited may have poor health.
A recent report by the Prevention Institute identified 11 case studies highlighting local environmental changes that would improve health in the high-risk communities previously described. Examples of community changes enacted include the following:
• bringing full-service grocery stores to areas that lack sufficient access;
• creating community gardens to foster healthy eating, physical activity, and social connections; and
• improving community walkability through major infrastructure changes in the built environment, such as improving sidewalks and crosswalks, providing local venues for physical activity, and building stores and businesses within safe walking or biking distance.11
There have been relatively few community-based childhood obesity interventions reported in the literature. The Pathways intervention, a randomized controlled trial conducted within Native American communities, involved 1,704 participants in 41 schools over six years. The project aimed to reduce body fat by promoting behavioral change and a holistic view of health among Native American children in third, fourth, and fifth grades.12 The Pathways project successfully reduced the energy density of foods children consumed by changing the school food environment.
There was no significant difference in the main outcome of the study—a change in percentage of body fat—but the study demonstrated other measurable benefits. Twenty-four dietary intake measures showed a significantly lower total daily energy intake (1,892 compared with 2,157 kilocalories per day) and percentage of energy from total fat (31.1% compared with 33.6%) in the intervention group than in the control group. The percentage of energy as fat shown in school lunches was 28.2% in the intervention schools compared with 32% in control schools. Self-reported physical activity was also higher for intervention schools than control schools. Also, knowledge of information in the Pathways curricula increased significantly in children involved in the intervention.
The study results of another reported project, Shape Up Somerville: Eat Smart. Play Hard., conducted in Somerville, Mass., suggest that children are more likely to maintain a healthy weight if they live in communities that nurture healthy habits.13 To determine how small, inexpensive environmental changes affect residents’ lifestyles, researchers from Tufts University developed the Shape Up program to reduce overweight among Somerville children by improving nutrition and increasing physical activity, for a net reduction of 125 kilocalories per day. Researchers helped schools increase their use of fresh foods and whole grains using funds provided by the grocery retailer Whole Foods and the Centers for Disease Control and Prevention (CDC). Students also attended in-class and after-school nutrition and fitness programs.
To encourage communitywide fitness, the city repainted crosswalks, installed bike racks at schools and on streets, and constructed a bike path. BMI scores remained relatively stable for the control groups but decreased for Somerville students, suggesting the children were getting close to achieving healthier weights.
In 2003, Arkansas passed Act 1220, which required the state’s public schools to annually report students’ BMI to parents and provide families with information about the importance of nutrition and physical activity, bar student access to food and beverage vending machines in elementary schools, create local school district-level advisory committees to raise awareness about physical activity and nutrition, and disclose food and beverage contract agreements. The act created a child health advisory committee to make recommendations to the state boards of education and health. Under this program, schools reduced the rate of increase in childhood obesity over a three-year period.14
The Coordinated Approach to Child Health (CATCH), a Texas-based program designed to prevent obesity by promoting physical activity and healthy eating habits, prevented an increase of overweight in low-income schools with predominantly Hispanic children. Eight El Paso elementary schools served as control or CATCH program sites, with 896 third-grade Hispanic children participating. The rate of increase of overweight was significantly less for girls (2%) in the CATCH program schools compared with the control schools (13%); in boys, there was a difference of 1% and 9% for CATCH program and control schools, respectively.15
The Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases is based on a cooperative agreement between the CDC’s Division of Nutrition, Physical Activity, and Obesity and 23 state health departments. The program was established in fiscal year 1999 to prevent and control obesity and other chronic diseases by supporting states in developing and implementing nutrition and physical activity interventions, particularly through population-based strategies (eg, balancing caloric intake and expenditure, increasing physical activity, increasing fruit and vegetable consumption, decreasing TV viewing time, increasing breast-feeding, reducing soft drink consumption, and decreasing portion size).
Twenty-one states are funded at the capacity-building level, and they are working to establish state infrastructure, plan obesity prevention and control efforts, identify data sources, collaborate and coordinate with partners, and begin to implement intervention. Seven other states are funded at the more advanced, basic implementation level. These states are implementing comprehensive nutrition and physical activity state plans to prevent and control obesity, provide training and technical assistance to communities, implement and evaluate nutrition and physical activity interventions, and evaluate the progress and impact of their state plan.16
Action for Healthy Kids (AFHK) was launched in 2002 at the Healthy Schools Summit and is a public-private partnership of more than 50 national organizations and government agencies representing education, health, fitness, and nutrition. AFHK teams, active in all 50 states, focus on changes in schools to improve nutrition and physical activity. AFHK teams across the country are working with school districts to develop school wellness policies, and the national Web site has developed a Web-based Wellness Policy Tool.
Think Globally, Act Locally
Childhood obesity impacts everyone, and working locally best remedies the problem. In our Charlottesville, Va., community, we developed a childhood obesity task force (COTF) to address the epidemic of childhood overweight and obesity in the city of Charlottesville and surrounding counties. It was convened in 1999 by the Thomas Jefferson Health District after BMI data collected on about 1,200 students aged 11 to 12 from the Albemarle County and Charlottesville City school systems showed BMI prevalence at or above the 95th percentile to be about 17%, a rate that continued to increase to 30% in 2007.
The COTF began with two local health department representatives (an RD and a health educator) meeting with both public officials and healthcare professionals to inform them about childhood overweight and obesity in the city’s public schools. They also met with the principals in the Charlottesville city schools and administrators at both the community and university hospitals. The resulting task force included school personnel, local pediatricians, dietitians and nurses who work in schools or fitness facilities or with an interest in children and obesity, and community agencies that work with children, including the Boys & Girls Club, Boy Scouts, Girl Scouts, and the city and county parks and recreation departments.
The primary purpose of bringing these key community leaders together was to share local data and explore whether there was alignment with these groups to address and solve the problem. One of the primary outcomes of the meeting was an agreement to work with four key areas: schools, healthcare professionals, community/public education, and media. Participants also decided that an important mission of the task force would be to act as an advocacy group for the community to foster healthy weight and overall fitness for children and their families. Specifically, this would include providing consultation, facilitation, training, and provision of funding and/or resources to schools and community agencies.
The following are some of the primary accomplishments in each of the COTF’s focus areas:
Schools
We were able to get a jump-start on working in schools through the assistance of one of our task force members, a local community hospital administrator who agreed to provide a “seed grant” ($6,000) for the local public school to apply for individual $1,000 grants to create a program promoting healthier eating and/or increased physical activity among school-age children. The COTF also organized a school summit for key personnel (principals, nurses, physical education/health teachers, guidance counselors, parent-teacher organization representatives, and school nutrition services directors) to share local data, announce funding for intervention projects, and brainstorm ways to use the funding. The summit accomplished the following:
• provided presentations about the COTF, including local data and intervention projects in schools and the community, to the city and county school boards, various parent/teacher organizations, and the local school health advisory boards;
• developed an educational resource called the Snack Food Guide Pyramid for schools to distribute to students and parents;
• converted two school divisions to nutrient-based menus to increase their ability to assess fat, calorie, fiber, sugar, and sodium content in menu offerings;
• established nutrition standards for offerings in a middle school snack bar;
• established wellness policies for all school divisions in the district and received consensus to use the governor’s scorecard as a means of evaluating the policies on an ongoing basis;
• developed a curriculum for training physical education teachers in two county school divisions about how to teach children key nutrition messages;
• standardized anthropometric data collected (third and fifth grades) from all school divisions;
• included school foodservice coordinators and physical education coordinators on the COTF;
• developed grant applications for public schools to apply for funding to develop projects that promote healthy eating and increased physical activity for school-age children;
• placed school menus with educational messages on school Web sites;
• piloted a color-coding system to ascertain which food choices students are making and how they’re making them;
• assisted with writing grants for two school divisions to successfully receive physical education grants of $150,000 and $350,000 for purchasing upgraded physical education equipment and improving physical education facilities;
• instituted a low-fat milk program by hosting milk taste-testing events and “milk mustache” campaigns using COTF volunteers; and
• developed a plan to remove all kitchen fryers from elementary schools.
Community/Public Education
The COTF achieved the following within the community:
• obtained grants to provide a bike and safe routes to school in the city, with the assistance of the community agency Alliance for Community Choice in Transportation;
• partnered with a local triathlon club to receive a percentage of proceeds from races in exchange for providing volunteers to assist on race days (This has netted the COTF $7,000 to $10,000 per year, which is then given back to community clubs and schools as individual grants of up to $1,000.);
• partnered with a local group called Local Motion on a social marketing campaign (with a Robert Wood Johnson Foundation grant) to advocate for “Let’s Get Moving” programs promoting physical activity to students;
• established a Web site (www.childhoodobesitytaskforce.org); and
• developed and printed a Youth Physical Activity Resource Guide for the district that lists 26 different kinds of physical activity and gives information for each activity, including contact information for each of our five localities. This resource is also available on the Web site.
Healthcare Professionals
Working with healthcare professionals, the COTF accomplished the following:
• started a monthly free clinic at a local pediatrician’s office to educate and manage overweight children and their families (With grant funding, this became the Children’s Fitness Clinic at the University of Virginia.);
• hosted Bill Dietz, MD, from the CDC to address the medical community on the scope of childhood obesity and Dan Kirschenbaum, PhD, to speak on treatment strategies for overweight youths and families, with particular emphasis on camp and residential services;
• shared local data with several medical groups and distributed best practices for testing for type 2 diabetes and high cholesterol levels in children (We have also shared handouts to use with families on topics such as healthy beverages, portion control, eating breakfast, how to dine out sensibly, the importance of family meals, and healthy recipes and menus.);
• developed and piloted a weekend Family Health and Fitness Camp for overweight children and their families at a local camp for special health needs, which we plan to offer on an annual basis through continued grant funding (In addition to the weekend camp, the families who attended also completed a 12-week follow-up program of cooking and dance classes. Monthly support group meetings and assigning a professional mentor to each of the families for regular communication and continued goal setting are also a part of the follow-up plan.); and
• mentored several medical residents, dietetic interns, and nursing students about important treatment aspects of childhood obesity, with particular emphasis on behavioral goals and use of a person-centered approach.
Media
The COTF partnered with the local cooperative extension agency, health department educators, and local dietitians from the university hospital to write weekly articles in the local newspapers on topics related to childhood obesity, healthy eating, and increased physical activity.
Overcoming Obstacles
Establishing any new initiative, especially a coalition or task force that needs funding, is a challenge. Some of the major obstacles the COTF has encountered include the following:
• Support from the community. Our first obstacle was getting the community and school administrations/school boards to acknowledge there was a problem and that they needed to provide support. Supplying them with weight and BMI data on 1,200 students in third through fifth grades helped us convince them.
• Participation from volunteer leaders in the community. The participation of committed physicians, dietitians, school nutrition services and physical education staff, school principals, and members of community agencies has given the task force credibility. A particular challenge is getting each of these members to volunteer their time to be actively involved in the task force’s working committees.
• Effective and ongoing task force leadership. Having two people from the local health department to initiate the development of the task force and who were committed to keeping the communication and work moving in a strategic manner was essential to our success. Continuing to groom new leadership is a challenge.
• Maintaining a funding stream. The COTF is a “pass through” organization for funding. The task force works to provide funding and resources to schools and other community agencies interested in helping to prevent and reduce overweight and obesity among children in the health district. Funding is necessary to sustain and promote continuity of new programs in schools and the community at large. It will be necessary to continue to apply for long-term grants, offered both locally, statewide, and nationally (eg, the Champions grant through the ADA Foundation and General Mills, the CATCH program, Robert Wood Johnson Foundation, and CDC state-based childhood obesity programs).
Specific funding needs in our community include a community coordinator to organize COTF projects (eg, Family Health and Fitness Camp), develop new initiatives, communicate with schools and community leaders, and promote the COTF’s work through the media. Also, the local schools need funding for an additional nutritionist to coordinate and provide education to promote healthy-eating messages to all schools within the health district. In addition, they need a physical activity coordinator to ensure physical activity is part of the wellness policy and coordinated into the curriculum to assist with the standards of learning.
The local community also needs funding to offer and improve access to physical activity resources for the lower socioeconomic groups that cannot afford memberships, don’t have adequate transportation, or lack the equipment necessary to increase their activity.
Clinical Application
Even though dietetics is a science-driven curriculum, in practice, a dietitian also needs to have behavior-change expertise and be knowledgeable about community resources to bring about population change, particularly with an issue such as childhood obesity.
But how do you start to change a population or community? There is no “right” place to start; rather, you begin with an environment with which you are familiar or to which you belong (eg, school if you have children, church if you are a member, a social or professional organization with which you are involved, your neighborhood).
The following basic community assessment, planning, and implementation process may be helpful as a guide to get started.
• Assessment: Gathering the data is certainly the starting place. We have collected height and weight data in city schools in our community. We surveyed schoolchildren to evaluate their juice and sweetened beverage consumption and determine their level of physical activity and inactivity and their amount of television/video game viewing per day. We also conducted an opinion survey of local pediatricians, family physicians, and internal medicine physicians to ascertain what they perceived to be the highest ranking issues for addressing childhood obesity in our community.
• Planning: It took the task force almost one year to evaluate the data and engage in discussion to determine the scope of the problem and become familiar with the built-in constraints that schools and communities have, primarily because of state and federal regulations. This process required the collective input of all community leaders to determine what projects have previously been or are currently being conducted, discuss their barriers and successes, and determine new initiatives.
• Implementation: To successfully implement new community initiatives, we’ve relied on funding, publicity and media attention, and a plan for evaluation.
Funding is always critical to the success of new projects, and it underscores the need to have the right partners at the table when you begin.
Promoting attention through publicity and media is of paramount importance for successful implementation of a project—for purposes of marketing, credibility or endorsement, continued funding, and sustainability. Our task force partnered with staff from our local extension service, healthcare professionals at our hospitals, and the health department to prepare weekly articles for our local papers on topics related to childhood obesity, healthy eating, and increased physical activity.
Developing a plan for evaluation is an area we have found challenging. Deciding what to evaluate and how to track outcomes requires expertise and funding, both of which are difficult for any volunteer organization. As a result of our school and community initiatives and preliminary review of the data, some of the questions that have been raised and that we think need additional investigation include the following:
• Do we know why some families can make successful lifestyle changes and why others fail? Is it so easily summed up in readiness to change? We have seen families who are very low on the readiness-to-change scale make the shift to healthier lifestyles based on our pilot weekend family camp experience.
• What is the age at which intervention is most effective for children and how might normal growth be affected?
• What is the role of family and other social networks or relationships in weight gain or loss?
A 2006 report compiled by the Institute of Medicine concluded that we have a greater chance of success in addressing the childhood obesity epidemic if public, private, and voluntary organizations combine and share respective resources to create a coordinated and sustained effort.17 The development of our community COTF is an example of this type of coordinated approach. The COTF’s accomplishments truly reflect the inclusiveness and diversity of its membership. Dietitians are especially well suited for bringing such diversity together and for bringing about community change.
— Joyce Green Pastors, RD, MS, CDE, is a diabetes nutrition specialist and an assistant professor of education in internal medicine at the University of Virginia School of Medicine in Charlottesville, where she has been employed for the past 26 years. She is a cochair of the Charlottesville Childhood Obesity Task Force.
— Barbara Yager, RD, MEd, is the director of the Women, Infants, and Children Program at the Thomas Jefferson Health District in Charlottesville, a locality of the Virginia Department of Health. She is a cochair of the Charlottesville Childhood Obesity Task Force.
©2008, Portions of this article originally appeared in the American Dietetic Association’s Diabetes Care and Education Dietetic Practice Group’s newsletter: On the Cutting Edge, Pastors JG, Yager B. 2008;29(4). They are used with permission.
CHART 1
Prevalence of Overweight (1976-1980 vs. 2003-2004)
Children aged 2 to 5 Increased from 5% to 13.9%
Children aged 6 to 11 Increased from 6.5% to 18.8%
Children aged 12 to 19 Increased from 5% to 17.4%
Learning Objectives
After completing this continuing education exercise, the student will be able to:
1. Explain which demographic groups have seen the most dramatic increase in overweight children in the past decade and discuss genetic, environmental, and physical factors impacting those groups.
2. List four ways that communities can improve a neighborhood’s physical environment to combat childhood obesity.
3. Discuss some of the obstacles of forming a community task force to combat childhood obesity and explain how the Charlottesville group is overcoming them.
4. Discuss some of the ways a community-based antiobesity effort can involve
public, private, and volunteer organizations.
5. Explain how the Charlottesville Childhood Obesity Task Force (COTF) involved public schools, local youth groups, and city government in its programs.
6. Explain how the Charlottesville COTF used nutrition educators in its program.
7. Explain the roles of local institutions in publicizing the task force’s campaign, activities, and programs.
8. List four obstacles to creating and maintaining an effective and ongoing community antiobesity effort.
9. List six active antichildhood obesity programs and discuss how they operate.
Examination
1. In the past 25 years, the percentage of overweight children has increased most dramatically in which age group?
a. 2 to 5 years old
b. 6 to 11 years old
c. 12 to 19 years old
d. All age groups have increased about the same percentage.
2. The United States is experiencing higher rates of increase of overweight children primarily due to:
a. genetic factors.
b. environmental settings that promote energy-dense foods, limited physical activity, and sedentary options.
c. physical factors such as unsafe neighborhoods and limited access to open spaces.
d. A combination of all of the above
3. Which of the following is NOT cited as a way to improve the physical environment impacting childhood obesity?
a. Bringing full-service grocery stores to neighborhoods
b. Creating community gardens
c. Improving sidewalks and street-crossing safety
d. Providing local venues for physical activity
e. Situating parking lots far from activity centers
4. What are some of the major obstacles in the development of a community task force?
a. Support and participation from community volunteers
b. Effective leadership
c. Maintaining funding
d. All of the above
5. What are the steps of the process for developing an effective community project?
a. Assess, plan, and implement
b. Gather data, solicit support, develop plan
c. Plan, intervene, evaluate
d. Plan, plan, plan
6. In Charlottesville, Va., the Childhood Obesity Task Force (COTF) began its efforts by:
a. informing public officials and healthcare professionals about local childhood obesity.
b. applying for a foundation grant to perform a study of the local school lunch program.
c. creating fact sheets for pediatricians.
d. analyzing neighborhoods for walkability.
e. protesting supermarkets that placed unhealthy foods in prominent displays.
7. As part of its effort, the Charlottesville COTF involved community organizations, including:
a. local labor unions.
b. military reserve and National Guard units.
c. benevolent, fraternal, and service groups such as the Elks, Lions, and Rotary.
d. Boy Scouts and Girl Scouts.
e. Little League and similar youth sports organizations.
8. As part of its school outreach efforts, the COTF:
a. developed a curriculum for training physical education teachers in nutrition.
b. promoted a “Teacher Weigh-in” to demonstrate that adult obesity results from childhood eating patterns.
c. lobbied legislators to investigate contracts with fast-food providers doing business with the schools.
d. offered cash prizes to the “biggest losers” among obese grade-school students.
e. organized a “March for Student Wellness.”
9. The COTF focused on snack foods by:
a. developing a Snack Food Guide Pyramid and establishing nutrition standards for offerings in school snack bars.
b. pressuring school-neighborhood convenience stores to stop selling candy.
c. offering classes in food label reading to parents, focusing on instruction in Spanish.
d. pressuring schools to increase the prices in snack food and beverage vending machines.
e. All of the above
10. To publicize their activities and programs, the COTF used:
a. newspaper articles and press releases prepared by the local extension service, hospitals, and the health department.
b. a coordinated media campaign designed by a local public relations firm, which worked pro bono.
c. preprinted brochures, provided by the Coordinated Approach to Child Health program and the USDA, distributed at schools.
d. a “Fat Fighters” telethon on a local TV station.
e. a mass e-mail and text message campaign targeted at children aged 10 and older.
References
1. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555
2. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Available at: http://www.cdc.gov/nchs/about/major/nhanes/datalink.htm. Accessed February 11, 2008.
3. Centers for Disease Control and Prevention. Prevalence of overweight among children and adolescents: United States, 2003-2004. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats
/overweight/overwght_child_03.htm. Accessed September 3, 2008.
4. Farooqi IS. Genetic and heredity aspects of childhood obesity. Best Prac Res Clin Endocrinol Metab. 2005;19(3):359-374.
5. Flegal KM, Odgen CL, Wei R, Kuczmarski RL, Johnson CL. Prevalence of overweight in US children: Comparison of US growth charts from the Centers for Disease Control and Prevention with other reference values for body mass index. Am J Clin Nutr. 2001:73(6):1086-1093.
6. Glanz K, Patterson RE, Kristal AR. Impact of work site health promotion on stages of dietary change: The Working Well Trial. Health Educ Behav. 1998;25:448-463.
7. French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Ann Rev Pub Health. 2001;22:309-335.
8. Ravussin E, Bouchard C. Human genomics and obesity: Finding appropriate drug targets. Eur J Pharmacol. 2000;410(2-3):131-145.
9. Ewing R, Schmid T, Killingsworth R, Zlot A, Raudenbush S. Relationship between urban sprawl and physical activity, obesity and morbidity. Am J Health Promot. 2003;18(1):47-57.
10. Drewnowski A. Obesity and the food environment: Dietary energy density and diet costs. Am J Prev Med. 2004;27(3):154-162.
11. Handy SL, Boarnet ME, Ewing R, Killingsworth RE. How the built environment affects physical activity: Views from urban planning. Am J Prev Med. 2002;23(2 Suppl):64-73.
12. Davis SM, Going SB, Helitzer DL, et al. Pathways: A culturally appropriate obesity-prevention program for American Indian schoolchildren. Am J Clin Nutr. 1999;69(4):796S-802S.
13. Economos CD, Hyatt RR, Goldberg JP, et al. A community intervention reduces BMI z-score in children: Shape Up Somerville first year results. Obesity. 2007;15(5):1325-1336.
14. Arkansas Center for Health Improvement. Third annual Arkansas assessment of childhood and adolescent obesity. August 16, 2006. Available at: http://www.achi.net/current_initiatives/BMI_Info/Docs/2006/
Results06/National_Rept_BMI2006_press_kit_background_material.pdf. Accessed February 11, 2008.
15. Coleman K, Tiller CL, Sanchez J, et al. Prevention of the epidemic increase in child risk of overweight in low-income schools: The El Paso coordinated approach to child health. Arch Ped Adol Med. 2005;159(3):217-224.
16. Centers for Disease Control and Prevention. Obesity and overweight: State-based programs. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/state_programs/about_us.htm. Accessed on February 11, 2008.
17. Institute of Medicine. Progress in Preventing Childhood Obesity: How Do We Measure Up? Washington, D.C.: National Academies Press; 2006. Available at: http://www.iom.edu/Object.File/Master/36/984/11722_reportbrief.pdf
