Childhood Obesity and Public Health in the United States. Natalie Stein MPH Capstone Project Spring 2010

Transcription

1 Childhood Obesity and Public Health in the United States Natalie Stein MPH Capstone Project Spring

2 Table of Contents Background... 3 Obesity in the United States... 3 Childhood obesity in the United States... 5 Monitoring childhood obesity... 5 Causes of childhood obesity... 7 Trends and patterns of childhood obesity Role of public health in childhood obesity Current public health efforts in childhood obesity: local, state, and national examples Local level public health and childhood obesity State level public health and childhood obesity National level public health and childhood obesity Components of a successful public health program for childhood obesity The current situation Bibliography

3 Background Obesity in the United States Obesity is a serious public health issue in the United States because of its high prevalence and overwhelming consequences. The National Institutes of Health (NIH) categorizes an individual s weight status using the body mass index (BMI), which is defined as an individual s weight in kg divided by the square of the height in cm 2. BMI classifications include normal weight (BMI 18.5 to 24.9), overweight (BMI 25 to 29.9), class I obesity (BMI 30 to 34.9), class II obesity (BMI 35 to 39.9), and class III, or extreme, obesity (BMI 40) (1998). Nearly two-thirds of all adult Americans are overweight, and about a third of Americans are obese (Mokdad, Ford et al. 2003). Furthermore, these conditions have risen at an alarming rate, with the prevalence of overweight increasing from 44 to 66 % among adults aged from 1960 to Similarly, the prevalence of obesity increased 13.3 to 32.1% during that same period (Flegal & Carroll). The health, psychosocial, and economic consequences of obesity are severe. An estimated 112,000 excess deaths in the United States are annually attributed to overweight and obesity (Flegal & Graubard, Excess deaths associated with underweight, overweight, and obesity, 2005), and the life expectancy of a severely obese adult (BMI 45) has been estimated to be 12 years shorter than that of an adult with a normal weight BMI of 24 (Fontaine & Redden, 2003). Health conditions linked to obesity include Type 2 diabetes (Hu, Manson et al. 2001), coronary heart disease (Willett & Manson, 1995), 3

4 hypertension (Brown & Higgins, 2000) (Mokdad & Ford, 2003), sleep apnea and other respiratory problems (Young, Palta et al. 1993), and osteoarthritis (Hochberg, Lethbridge-Cejku et al. 1995). Additionally, many cancers, including colon, breast, ovary, and prostate, are also linked to obesity, according to the National Cancer Institute. Psychosocial health risks of obesity include stigmatization and lower self-esteem (Stunkard and Wadden 1992). In addition to these health risks, obesity also presents significant challenges to the economy in both direct and indirect costs. The total costs of obesity estimated from 1994 NHANES data were $99 billion, with over 52% due to direct health care costs. Other costs are due to decreased productivity from early death and lost work days (Wolf & Colditz, 1998). One review found that on average, American workers over a BMI of 27 took an extra three days of sick leave per year compared to the sick days taken by workers with a BMI of less than 27; in Europe, the average difference in sick leave was ten days per person per year. As further evidence of the effect of obesity on the health of the work force, four separate interventional studies in this review each found that individuals who lost weight substantially decreased their sick leave days (Neovius & Johansson, 2008). Overweight and obesity are caused by many interacting factors, both genetic and environmental, that result in energy intake greater than energy expenditure over time. Approximately 25-40% of obesity may be attributable to genetics (Vogler & Sorensen, 1995), implying that other factors contribute to more than half of obesity. The obesogenic environment of modern society supports a positive energy balance through increased energy intake and decreased energy expenditure. Calorie-dense foods are 4

5 typically abundant, palatable, and promoted by the media and marketing, facilitating overconsumption. Similarly, daily physical activity is typically limited because of modern lifestyle factors such as desk jobs and driving, as well as a lack of regular exercise. Together, excess food intake and inadequate physical activity are the main lifestyle factors that contribute to obesity in the United States (James, 1995). This suggests that the most efficient interventions for preventing and treating overweight and obesity may be those interventions which focus on nutrition and physical activity patterns. Childhood obesity in the United States Monitoring childhood obesity Similar to adults in the United State, American children also have alarmingly high rates of risk of overweight and overweight. To determine these rates, the CDC monitors the nutritional status of babies, children, adolescents through age 20, and pregnant women, through the Pediatric and Pregnancy Nutrition Surveillance System (PedNSS) under the CDC (Prevention, 2010). Data are collected mainly from individuals or families during clinic visits while they are using public health services such as Women, Infants, and Children (WIC), Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program, and Title V Maternal and Child Health Program (MCH). The WIC program serves children up through age five (USDA, 2009). PedNSS reports two key growth indicators as an assessment of the status of childhood overweight in the United States. These are overweight, and risk of overweight, based on BMI-for-age comparisons to CDC reference growth charts from the year

6 (Prevention, 2000 Growth Charts, Centers for Disease Control and Prevention, 2000, 2000); CDC does not recognize a category of obese for children. Children are classified using a two-level system. Overweight is defined as having a BMI-for-age above the 95 th percentile on the growth charts. Children who are overweight are more likely to have components of metabolic syndrome, such as higher blood pressure and impaired glucose tolerance (Cambuli, et al., 2009), as well as psychosocial disadvantages such as low selfesteem and increased difficulty among their peers (Wille, et al., 2010). Beyond these immediate challenges, overweight in childhood is also linked to increased risk of later obesity and its associated chronic health problems. In addition to the overweight category of children greater than the 95 th percentile, the CDC has also identified children who fall between the 85 th and 95 th percentile as at risk for overweight. This classification helps to identify children who are at risk but may not be greater than the 95 th percentile, and, conversely, it acknowledges that children who are above the 85 th percentile may simply have grown faster than their peers of the same age. Therefore, some of the children within the category of at risk for overweight are at higher risk for developing into overweight adults, while other children in this category are actually early developers and are not at high risk (Whitaker, Wright, Pepe, Seidel, & Dietz, 1997). The National Health and Nutritional Examination Survey (NHANES), also conducted under the CDC, also uses the two-level classification system based on reference growth charts for weight for age. This survey classifies a BMI between the 85 th and 95 th percentile as overweight, and a BMI greater than the 95 th percentile as obese (Prevention, Childhood overweight and obesity, 2010). 6

7 Using the CDC s definitions for overweight and at risk for overweight, the PedNSS data estimate that 16.5% of children ages 2-5 are at risk for overweight, and 14.8% are overweight. This means that nearly six million children under age five are at risk for overweight or overweight (Ogden, Carroll, & & Flegal, 2008) an astounding number. Furthermore, the trend over the last several decades has been rapid increases in childhood overweight and obesity. According to NHANES data, rates of obesity among age 2-4 year olds more than doubled from 5% to 10.4% between the and surveys (Prevention, Childhood overweight and obesity, 2010). The prevalence and trends of obesity are especially alarming when considering the severe health implications of this situation. Although many of the detrimental effects of obesity are seen later in life, such as with the development of chronic diseases and the manifestations of their effects, the issue of childhood overweight is just as critical as adult overweight and obesity, if not more so. Individuals between two and five years old who are overweight or obese are more likely to develop into obese adults than individuals who are categorized in a normal weight range during these same years (Nader, 2006). In addition, these years are a time when children are developing lifestyle habits, such as those related to nutrition and physical activity, which may become lifelong patterns. Causes of childhood obesity The causes of obesity among children mirror the causes of overweight and obesity among adults. As with adults, the greatest contribution to the positive energy balance comes from lifestyle, factors such as nutrition and physical activity, which can be 7

8 modified by the environment or individual. Many dietary and exercise patterns among preschool children have been identified as being likely to affect dietary quality and obesity during these and later years. These findings can be used as guidelines for developing public health interventions to address childhood obesity. Energy balance: Food choices are a major influence in determining an individual s energy intake. The consumption of certain foods or beverages during the preschool years is associated with later development of obesity. For example, fried foods and fruit juice are both associated with later obesity, as well as with lower overall dietary quality (LaRowe, Moeller, & Adams, 2007). Conversely, consumption of healthful foods such as fruit and vegetables or whole grains is associated with a lower BMI later in childhood (Rolls, Plenary Lecture 1: Dietary strategies for the prevention and treatment of obesity., 2010). Factors such as marketing and the desire for convenient, appetizing foods can lead to children eating less nutritious foods (Harris, Schwartz, & Brownell, 2010). In addition to an excess of caloric intake, inadequate caloric expenditure is another contributor to chronic positive energy balance that leads to obesity. The overall amount of calories expended is sum of the calories used for basal metabolism (basal metabolic rate), calories used for food digestion and absorption (thermic effect of food), and calories required for physical activity. On average, the thermic effect of food accounts for about 10% of caloric needs, while basal metabolism and physical activity account for the remainder. Calories expended for physical activity are the most variable and controllable calories among the total needs, which is why interventions to increase 8

9 physical activity are likely to be the most successful approaches to increasing energy expenditure, moving energy balance away from the positive side, and decreasing obesity. Causes of positive energy balance: The United States has been described as obesogenic (Heber, 2010), a term used to describe how the built environment encourages a positive energy balance through increased energy intake and decreased energy expenditure. This happens through a combination of consuming too many calories in comparison to calories expended. Over the past several years, food intake and physical activity have been strongly influenced by modernization of society with developments such as drive-through and fast food restaurants, remote controls, and elevators all of which are examples of advancements that promote increased eating and decreased activity. Food intake patterns have been characterized by increased availability and desire for convenience. The traditional model for children might be three home cooked meals, eaten with the entire family present, per day. Typically these meals would be balanced, including a grain, some sort of protein, a vegetable, and a glass of milk. Now, family meals are much less common, and may consist of higher calorie, less nutritious convenience foods or restaurant foods (USDA, 2010). Many children have one or meals away from home, such as in a childcare setting. These institutional meals are not necessarily balanced and nutritious, and may consist of high calorie foods. This not only puts children at risk of excessive weight gain, but may also develop the desire for those foods, leading to lifelong struggles. In addition to family and child care setting meals, other factors within the food environment contribute to childhood obesity. The food supply is increasingly cheap and 9

10 abundant. Affordable, easily available, energy-dense foods are often low in nutrients, and since they are not very satiating compared to many nutrient dense foods, they are often overconsumed. This can lead to overconsumption and obesity (Miller M, Mangano, Dobmeier, Novacic, Rhyne J, & R.A., 2009). Furthermore, children are very impressionable, and are highly influenced by the messages they receive from their environment. Opportunities for eating are nearly everywhere, not just at the table at specified times. Food advertising is nearly ubiquitous, and it can lead children to desire certain foods. Children are especially susceptible to advertising, and marketing targeting children is extremely widespread in visible places such as television shows and grocery stores. Beside these factors contributing to increased caloric intake, multiple environmental factors contribute to decreased caloric expenditure compared to previous generations. Modern conveniences such as elevators or remote controls lead to less spontaneous activity than would occur if the child were to take the stairs or walk across the room to change the channel. Screen time, or the amount of time a child spends sitting in front of a screen such as a television, video game console, or computer, is as much as 90 minutes per day on average, with an additional 90 minutes in other sedentary activities (Taylor, Murdoch, Carter, Gerrard, Williams, & Taylor, 2009). Beyond the fact that screen time is sedentary time during which the child is not active, many screen occasions are associated with eating, and these snacks are often unhealthy (Feldman, Eisenberg, Neumark-Sztainer, & Story, 2007). 10

11 Trends and patterns of childhood obesity Some of the demographic patterns seen in childhood obesity parallel those of adulthood obesity, while others Some trends in childhood and adulthood obesity are include the high risk groups. A greater risk of obesity is associated with belonging to certain ethnic groups, and also with a lower socioeconomic status. Hispanic children aged 2 to 5 years are about 50% more likely to be obese than are non-hispanic white children, and Hispanic adults have about a 21% higher likelihood of obesity than non- Hispanic white adults (Centers for Disease Control and Prevention, 2010). For blacks, preschool aged children are less likely to be overweight than whites (12.6% prevalence versus 11.8%), but black adults are at the highest risk for obesity, with a 51% higher prevalence rate than non-hispanic whites (Centers for Disease Control and Prevention, 2010). These data imply the potential impact of targeting specific ethnic groups who may benefit most from interventions, and also these data show the importance of early interventions, such as in the preschool years, even before signs of obesity may be apparent. Perhaps the most influential factor in predicting obesity is socioeconomic status. Lower income households on a tight budget frequently experience food insecurity, and do are not always confident about the source of their next meal. Multiple studies have shown found positive associations between food insecurity and obesity (Wilde & Peterman, 2006) (Townsend, Peerson, Love, Acheterberg, & Murphy, 2001). Reasons for obesity include individual factors, as well as environmental factors. Individuals or members of households with low incomes may experience barriers to healthy eating 11

12 including lack of time, lack of money, and lack of knowledge. Convenient and cheap foods tend to be higher in calories and fat, and can contribute to obesity. Along with these individual factors, the surrounding environment can influence the development of obesity. Low-income neighborhoods, including many inner-city neighborhoods, are essentially food deserts characterized by a distinct lack of full-service affordable grocery stores. Instead, the cheapest and easiest options are convenience stores and fast food restaurants, which are often dense in low-income neighborhoods, and are associated with an increased risk of obesity (Li, Harmer, Cardinal, Bosworth, & Johnson-Shelton, 2009). In addition, physical activity is often discouraged within disadvantaged neighborhoods because of perceptions of danger (reference). Role of public health in childhood obesity These basic facts about childhood obesity suggest that public health interventions may be among the most powerful possible approaches to addressing the problem. First, childhood obesity is a widespread health problem throughout the nation, and public health tries to serve the greatest number of people in the most effective way possible. Next, public health is implicated because childhood obesity is a health disparity that affects different demographic groups at different rates. Another justification for the role of public health in childhood overweight and obesity is that many of the consequences of childhood obesity are delayed, such as an overweight BMI only after the preschool years, or long-term, such as the adulthood development of chronic diseases. Public health focuses on prevention rather than treatment. These three basic characteristics of the 12

13 childhood obesity crisis make it a perfect candidate to be the target of public health interventions (Schneider, 2006). 1. Public Health seeks to serve the greatest number of people with limited resources The role of public health in fighting childhood obesity is justified by the magnitude of the problem, since public health is responsible for serving the greatest number of people possible (Schneider, 2006). Public health initiatives typically compete with other public programs for a limited amount of funding. This means that resources devoted to public health are usually limited, and must be used in the most efficient way possible. Larger scale interventions in an entire entity or organization, such as those normally seen in public health, are likely to be more cost-effective than interventions at the individual level. Furthermore, public health interventions can impact the entire environment that affects food and exercise choices. 2. Public Health addresses health disparities Another justification for the role of public health in addressing childhood obesity is that childhood obesity is a health disparity because of the different risk rates between various demographic groups. Assurance is one of the three core functions of public health, which means that public health assumes responsibility for ensuring that health services in the community are available and accessible to everyone (Schneider, 2006). With carefully designed programs, public health interventions have the potential to help those who need it most, in particular the low-income groups who are at highest risk for obesity and related health problems. 13

14 3. Public Health is preventive Unlike clinical medicine, which often focuses on treatment for individuals, public health focuses on prevention. This is an especially important distinction when discussing childhood overweight and obesity, which is a problem that is more easily prevented than cured. In addition, obese adults were not always obese as preschool children (LaRowe, Moeller, & Adams, 2007), demonstrating that even children who are not currently overweight may still be at risk for overweight as older children or adults, and may benefit from preventive interventions such as those within the realm of public health. Current public health efforts in childhood obesity: local, state, and national examples Already, many public health programs have been implemented to help fight childhood obesity. These projects range from local level efforts to national level policies, and are at different stages in their implementation. These projects all target childhood obesity in some way. However, they may differ in nearly every aspect, including scale of intervention, target population, which causes of obesity are the focus, and the degree to which participation in the programs is compulsory or voluntary. Local health departments administer interventions at a community level, while state health departments can implement state-wide policies as well as direct funds for different purposes. At the federal level, legislation and regulations can impact policies and funding for multiple services nationwide. 14

15 Local level public health and childhood obesity A local health department is defined as the public health government entity at a local, level including a locally governed health department, state-created district, department serving a multicounty area, or any other arrangement with governmental authority and responsibility for public health functions at this local level (Mays, 2008). Because of the close proximity of local health departments to the geographic regions that they serve, local health departments are often the most visible entities within a community. They are the entity responsible for forming relationships with members of the community, and may form strategic partnerships with corporations or nongovernmental organizations to enhance efforts toward achieving public health objectives. Along with enforcing health policies and supporting research efforts, the local health department sponsors health promotion policies and carries out the day to day operations of public health projects. In addition, local health departments perform health education. The following project is an example of how a local public health department is planning to implement a project designed to combat childhood obesity. The Los Angeles County Department of Public Health (LACDPH) is a local public health department within California that serves all of Los Angeles County. Because of its large population of about 10 million people, the LACDPH is divided into six geographical regions known as service planning areas (SPA) (Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology, 2009). The motivation for this undertaking stemmed from recent actions to improve preschool nutrition in California. The only nutrition and physical activity requirements for licensure for LAC childcare centers are those mandated by the state of California, and 15

16 these guidelines are minimal (California). Childcare centers must adhere to specific nutritional standards in order to qualify for federal reimbursement through the USDA Child and Adult Care Food Program (CACFP). However, the CACFP guidelines are focused on meal patterns and not recent evidence-based standards (Title 7 - Agriculture; Subtitle B - Regulations of the Department of Agriculture; Chapter II - Food and Nutrition Service, Department of Agriculture; Subchapter A - child and nutrition food programs; Part Child and Adult Care Food Program, 2010) despite the American Dietetic Association s recommendation that child care settings be held to nutritional standards in agreement with dietary guidelines (American Dietetic Association, 2005) In fact, the decades-old recommendations were developed with the purpose of ensuring sufficient nutrition, rather than the more common current problem of overnutrition (Whaley, et al., 2008). In an attempt to address the issue of obesity in California childcare centers, the recent bill AB 627 (Brownley) (2009) proposed modest changes to state licensure requirements for child day care facilities. Suggestions for updated health and nutritional requirements included requiring vegetables and lower fat dairy products, limiting sugars, eliminating deep fat fried foods, and limiting child screen time throughout the day. However, the bill was ultimately vetoed, leaving California without improvements to its regulations. With over 100,000 children enrolled in childcare, LAC is severely impacted by the situation, and the LACDPH is working to address it in a new project to demonstrate the feasibility and importance of more stringent standards. This project includes initial assessment of child care centers nutrition and physical activity practices, distribution nutrition and physical activity recommendations aimed at reducing and preventing 16

17 childhood obesity, and a follow-up assessment to determine the effects of the recommendations. In addition, some childcare centers will receive additional support to help achieve the recommendations within their sites. The recommendations that participating child care centers will receive are developed from evidence-based recommendations by respected national associations, as well as current research studies. Recommendations and brief justifications are shown in the table. Recommendation Offer at least one whole grain serving at least three times per week. Offer at least one serving of non-potato vegetables at every lunch Brief Justifications Whole grains are a good source of fiber, and there is an inverse relationship between fiber intake and visceral adiposity (Davis et al, 2009). Only 22% of childcare centers in Los Angeles offer whole grains regularly (PHFE, WIC). The position statement of the American Dietetic Association (ADA) on Nutrition Guidance for Healthy Children recommends following the Dietary Guidelines, which include a recommendation to make half of the grains whole grains (ADA 2008). Children s vegetable consumption is below recommended amounts (Dennison, Rockwell, & Baker, 1998). Vegetables are a good source of fiber, and there is an 17

18 inverse relationship between fiber intake and visceral adiposity (Davis et al, 2009). A WIC report from Los Angeles County recommends that more non-potato vegetables be served at every lunch (Whaley, Gomez, et al, 2008). The ADA recommends that green and yellow Offer a serving of healthy fruits (not canned in syrup) every lunch. Avoid serving processed meats Avoid serving fried and prefried food choices. vegetables should be served every day, (ADA 2005), and that child care settings be held to nutritional standards in agreement with dietary guidelines (ADA position paper, 2005). Children s fruit consumption is below recommended amounts (Dennison, Rockwell, & Baker, 1998). Vegetables are a good source of fiber, and there is an inverse relationship between fiber intake and visceral adiposity (Davis et al, 2009). The ADA recommends that citrus fruits should be served every day (ADA 2005) Currently, 47% of LAC WIC offered higher fat meats (PHFE WIC) The American Cancer Society recommends avoiding consumption of processed meats (Kushi, et al., 2006) This can help decrease caloric intake because fried and pre-fried foods are relatively high in calories 18

19 (Kushi, et al., 2006). Fried foods are a source of trans fat, which may be linked to increased visceral adiposity (Stender, Dyerberg, & Astrup, 2007) Fried foods have high fat and trans fat contents, Offer only reduced or no fat milk choices. Avoid serving beverages with added sugar or artificial sweeteners which are associated with higher calorie dense foods and higher caloric intake. They should be avoided (Allen & Myers, 2006). Whole milk is a major source of saturated fat and cholesterol in preschoolers (Thompson & Dennison, 1994). The Institute of Medicine recommends low-fat or fat free milk for children aged 2 years and older (Koplan, Liverman, & Kreak, 2005). Early consumption of sugar sweetened beverages is associated with weight in childhood and adolescence (Fiorito, Marini, Francis, Smiciklas-Wright, & Birch, 2009). Consumption of sugar sweetened beverages between meals is associated with risk of overweight aged 2-5 y (Dubois, Farmer, Girard, & Peterson, 2007). Have drinking water freely Early consumption of sugar sweetened beverages is 19

20 available at meals. associated with weight in childhood and adolescence (Fiorito, Marini, Francis, Smiciklas-Wright, & Birch, 2009). The water must be available, attractive, and palatable Limit fruit or vegetable juice to no more than ½ cup per day (Patel, Bogart, Uyeda, Rabin, & Schuster, 2010). Liquid is not as satiating, per calorie, as solid foods such as whole fruits or vegetables (DiMeglio & Mattes, 2000). Juice intake is inversely associated with milk intake, which is already below recommended amounts (O'Connor, Yang, & Nicklas, 2006). Increased milk consumption is associated with an increased dietary quality according to the Healthy Eating Index (LaRowe, Moeller, & Adams, 2007). Fruit juice consumption in preschoolers is associated with obesity (Dennison, Rockwell, & Baker, Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity., 1997). Sipping juice throughout the day can cause cavities; it is better to limit juice consumption (Committee on Nutrition, 2001). Juice has no benefits over whole fruit (Committee on Nutrition, 2001). 20

21 The American Academy of Pediatrics recommends Promote family style serving (define family style) Include at least 60 minutes of physical activity time per day. Limit average amount of screen time (at a television, computer, or video game) to a maximum of 2 hours per day. that juice be limited to a single 4-6 oz serving per day of 100% juice or reconstituted juice (Committee on Nutrition, 2001). Children need to learn how to determine proper portion sizes, which are a key determinant of obesity (Kushi, et al., 2006). Physical activity burns calories, and the consensus is that at least an hour daily of exercise is best for health and childhood weight in school-aged children (Strong, et al., 2005). Amounts greater than 2 hours per day are associated with obesity (Robinson, 1999). This recommendation is consistent with the American Academy of Pediatrics recommendation. (American Academy of Pediatrics, 2001) The main part of this work is scheduled to begin in the second half of The target population is LAC s SPA-6, which is 63% Latino and 32% African American with 28% of households having incomes below 100% of the Federal Poverty Level. Correspondingly, an astounding 73% of adults in this area are overweight or obese compared to a national average of 61% and a LAC average of 59% (Los Angeles County 21

22 Department of Public Health, Office of Health Assessment and Epidemiology, 2009). Outcomes from this study are expected to demonstrate the effectiveness This project to improve nutrition and physical activity standards in childcare centers is a classic example of a public health intervention because addresses the three core public health functions of assessment, policy development, and assurance (Schneider, 2006). Each participating childcare center is assessed via environmental observation (EPAO), self assessment, and subjective questioning. In aggregate, these data are used to assess current practices and likely needs of the childcare centers. These data are also used to develop policy. In this case, the assessment results are expected to demonstrate that nutrition and physical activity practices in licensed childcare centers are suboptimal, but that they improve with the implementation of more rigid standards. This reasoning would be used to advocate for legislation to mandate healthier standards as a criterion for licensure. Finally, this project addresses the core function of assurance by seeking to improve circumstances in SPA-6, an underprivileged region of Los Angeles. Regions such as SPA-6 are most likely to need interventions to address childhood obesity. State level public health and childhood obesity At the state level, public health responsibilities resemble a mixture of local health department actions and wider scale planning. The structure of public health service organizations varies by state. Frequently, one organization may perform the majority of public health services, while sharing other duties with other organizations such as the state departments of transportation, agriculture, or housing (Mays, 2008). Public health 22

23 at the state level facilitates operations between the local and national levels, and may perform communication or organization roles. State public health associations assess need within the state to determine which regions are in greatest need of which resources. The state might compile data collected by local health departments and report it to federal agencies or use the information to plan public health projects. With the responsibility of distributing federal funds by administering or overseeing federal programs, the state has great potential to combat childhood obesity by implementing healthful nutrition and physical activity standards as a requirement for childcare licensure and reimbursement from federal programs. Although it is aimed at public elementary, middle, and high schools, the following public health policy demonstrates the enormous potential of the state to implement public health initiatives that could impact childhood obesity in preschools or childcare settings. The Texas Public School Nutrition Policy is an anti-obesity policy that first took effect in 2004, with the goal of encouraging nutrition and decreasing obesity (Andrade). The bill includes provisions to limit unhealthy foods and encourage healthy foods. The rules are formulated with different levels of stringency for elementary, middle, and high schools, with elementary schools being submitted to the toughest rules and high schools given more lax requirements. Compliance with the policy is required for schools to receive NSLP reimbursement, and rule violations are penalized with loss of compliance for that particular day. The code limits foods of minimal nutritive value (FMNV; includes foods such as soda water and chewing gum), carbonated beverages, candy, and competitive foods. In addition, the law restricts unhealthy practices such as on-site frying, limits the fat content of individual foods to 23g, and sets maximum portion sizes for various foods. 23

24 The law also promotes a healthy eating environment by setting guidelines for minimum time permitted to eat breakfast or lunch. One group attempted to determine the effects of implementing the Texas Public School Nutrition Policy shortly after its implementation (Mendoza, Watson, & Cullen, 2010). This group compared middle school lunches in participating schools from , before the policy, to lunches served under the new policy, in The study outcome measure was average energy density, since overconsumption of calories, ultimately leading to obesity, is more likely to occur with consumption of high energydense foods (Rolls, Roe, Beach, & Kris-Etherton, 2005). Analysis of schoolchildren s food reports revealed remarkable results, with the average energy density of solid foods decreasing from 2.80 kilocalories/g at baseline to 2.17 kilocalories/g after policy implementation. In addition, the overall average energy density of foods plus beverages decreased significantly from 1.38 kilocalories/g at baseline to 1.29 kilocalories/g after policy implementation. The results of this study show that the Texas Public School Nutrition Policy has important implications for childhood obesity prevention programs at all levels. The observed changes in energy density of served lunches after policy implementation are large enough to potentially prevent many cases of childhood obesity. The significant effects of this policy suggest the power of an organization-wide incentive-based policy focusing on improving nutrition. While the Texas Public School Nutrition Policy addresses elementary through high schools, analogous regulations and restrictions could be imposed on childcare settings, and results might be similar. For childcare settings, the 24

25 incentives could include not only reimbursement, as in NSLP schools in Texas, but also licensure. In addition, these successes are despite the presence of several weaknesses in the policy. For example, exemptions to the healthy food policies include numerous occasions such as school activities (e.g., band activities or field trips), as well as special events. Schools can serve FMNV if they are supplemented with simultaneous NSLP offerings, which effectively allows FMNV to be present very frequently. The law also permits high schools to be much less stringent than elementary schools, thus allowing less healthy foods in high schools. Other examples of places in which the law could be strengthened are with the specific criteria for which foods can be served; currently, nonfried potatoes are not limited, and the limit for any single food is 23 grams of fat per serving still a high amount. If these weaknesses were to be addressed, perhaps even greater results would be seen. National level public health and childhood obesity On a national level, public health activities largely consist of policy development and resource allocation (Mays, 2008). Public health operations on a national level are carried out both by governmental agencies. As with state level organization of public health, national public health affairs are addressed by multiple governmental agencies with varying amounts of involvement. These include the CDC, Food and Drug Administration (FDA), Environmental Protection Agency (EPA), USDA, and Department of Transportation (DOT). 25

26 While the federal government itself may rarely complete the ground operations associated with providing public health services at a community level, national policies and funding are still influential on local health behaviors. For example, the National School Lunch Program (NSLP), administered by the United States Department of Agriculture (USDA), provides free and reduced lunches to low-income schoolchildren throughout the nation (USDA, 2009). Ultimately, participating schools are reimbursed for the meals they serve, as long as the meals meet the criteria set by the USDA. This means that lunches must conform to the 1995 Dietary Guidelines, and provide one-third of the Recommended Dietary Allowances of protein, Vitamin A, Vitamin C, iron, calcium, and calories. In addition to receiving monetary reimbursement, participating schools also receive entitlement, or commodity, foods, which are foods that are in surplus from United States agriculture. (USDA, 2009). The NSLP is an example of a national program with far-reaching effects. Schools participating in NSLP are more likely to serve commodity foods than schools that do not participate. This holds true for milk, and schools participating in NSLP serve more milk and fewer calories from sugar sweetened beverages. The influence of national policy is not automatically positive, though; NSLP schools also serve more energy-dense foods than non-nslp schools, likely due to commodity foods like grains and oils (Briefel, Wilson, & Gleason, 2009). The strong potential of the federal government to influence local food intake necessitates careful planning during the development of programs to ensure that effects will be as desired. As an example of a national public health nutrition program, I will discuss the Head Start program. Head Start is a well-established federal program that addresses 26

27 childhood poverty. Unlike with the Texas Public School Nutrition Policy, nutrition is only a component of the program rather than the focus. The program was established in 1965 under the Head Start Act, and in 2007, served about a million low income (100% of the federal poverty level) and disabled children. The program promotes school readiness by enhancing the social and cognitive development of children through the provision of educational, health, nutritional, social and other services to enrolled children and families (DHHS, 2010). Head Start is overseen by the Administration for Children and Families within the Department of Health and Human Services, but the program is administered locally by individual preschools. It is difficult to assess the effects of Head Start s nutrition-related components, in part because of the long-term nature of the potential effects, and because these components are simultaneous with other Head Start intervention. The parts of Head Start related to nutrition include reimbursement for meals served at preschool that meet the CACFP criteria for adequate meals. In addition, the Office of the Head Start program provides to parents and educators supporting and educational materials, such as how to maximize resources in the Supplemental Food and Nutrition Assistance Program (formerly food stamps). While the Head Start program is generally recognized as successful in its mission to prepare disadvantaged children for entry to elementary schools (Currie & Thomas, 1995), long term effects are less certain, with non-attendees gaining on attendees as the school years pass (Barnett, 1993). From the perspective of nutrition, the Head Start may prevent undernutrition, but does not seem to prevent obesity (Harbaugh, Bounds, Kolbo, Molaison, & Zhang, 2009). This information emphasizes the 27

28 role of federal policies in childhood obesity, along with the importance of policies that have been carefully planned to meet specific objectives. Components of a successful public health program for childhood obesity Childhood obesity is unquestionably a significant threat to the current and future health of the population in the United States. Although a great deal of attention has been paid to the problem because of its magnitude, no program has yet resolved the crisis, demonstrating the need for further efforts. Childhood obesity is an ideal candidate for public health interventions because of its nationwide impact, its disparities in prevalence, and its potential for prevention. Given this, it is important to determine the necessary elements of a successful public health intervention to address childhood overweight. This section will discuss some of the important characteristics of a public health program that may be successful in decreasing childhood obesity. Funding is an essential component of any program, and finding adequate funding for public health can be especially challenging (Milstein, Homer, & Hirsch, 2010). To receive funds, public health advocates compete with advocates for other programs, and they must convince policy makers that their proposals are cost effective and worthy of allocations from an always tight budget. Programs should also have provisions for long term sustainability, including possibilities such as local funding sources through grants or other programs, corporate partnerships, or some sort of fundraising to support the program. For an initiative aimed at childhood obesity, advocates might point out the enormous cost of obesity in the United States, and estimate how much money could be saved by preventing obesity and its associated costs by investing smaller amounts of 28

29 money up front. In addition, a childhood obesity initiative might find corporations willing to support the initiative in exchange for positive publicity; for example, a children s cereal company might be willing to support an anti-obesity campaign in exchange for the privilege of advertising its positive efforts on cereal boxes. Another key element of a successful public health program is care at every stage. The plan should be developed only after careful background research into the scope and effects of the issue. A task force could be developed to perform background research and make recommendations to the government, who can pass legislation (O'Connell, 2005). The causes of the problem, in this case childhood overweight and obesity, should be carefully examined to enable development of solutions that address the ultimate causes and are therefore likely to be effective. In childhood obesity, causes might be a lack of regulation of nutrition in childcare settings; a proposed solution would be to implement legislation requiring certain nutrition and physical activity regulations. This should be accompanied by data to suggest that the solution would truly work; in this case, an advocate might point to the success of the Texas School Nutrition Policy in creating positive change, or to the fact that CACFP participants serve healthier meals than nonparticipants (Briefel, Wilson, & Gleason, 2009). Proposals should be carefully planned and have specific objectives with action plans designed to meet each objective. In addition, programs should include provisions for monitoring to determine efficacy and to consider whether aspects of the program should be changed as time passes. Another important aspect of a successful public health program is support from and participation of a variety of sources. The locals who are in charge of implementing the program must be able and willing to implement it. Any proposed regulations must be 29

30 accepted by childcare directors and must be feasible both financially and logistically. This could mean that certain foods must be subsidized, or that educational materials be distributed, or that support services be made available via a toll-free phone line. In addition, these local directors must feel that they have a stake in the new initiative, such as by being included in plan development and implementation, or by being financially rewarded or penalized for participation or infraction. Also, state level public health stakeholders should be motivated to support the initiative so that state policies can facilitate administration. This motivation could result from matching funds programs in which the federal government provides the state money for local distribution. Aside from childcare directors, the general community must be willing to support the initiative; to optimize results, parents must be willing to support healthier practices at the preschools. This could include serving healthy meals at home to supplement the healthier practices in childcare settings, or being willing to attend educational sessions. Program beneficiaries, in this case preschool children, must be in sufficient numbers to be able to display a public health impact. Finally, the environment must be conducive to the desired policy; if physical activity is to be required, neighborhoods must be safe enough for children to play in. These important characteristics of a successful public health intervention indicate that public health means are a potentially effective route for fighting childhood obesity by way of the childcare setting. A large proportion of the U.S. population aged 2-5 years attends childcare, and it is clear that even substandard regulation is better than no regulation (Briefel, Wilson, & Gleason, 2009). Weak existing guidelines suggest that public health interventions can be effective for change, and the ever-increasing concern 30

31 over obesity contributes to an atmosphere conducive to public health interventions in the area. In fact, recent legislation from the federal government could result in effective public health campaigns against childhood obesity. Two such possibilities come from the American Recovery and Reinvestment Act (111th Congress, 2009) and the Patient Protection and Affordable Health Care for America Act (Kaiser Family Foundation, 2010). Each of these has the potential to implement successful programs because they each include provisions for the development of anti-obesity programs. The current situation The American Recovery and Reinvestment Act, commonly known as the economic stimulus package, was signed into law in February of It includes over a billion dollars allocated for health prevention services (Centers for Disease Control and Prevention, 2010). These programs are to be executed within the Communities Putting Prevention to Work program, whose objectives are to: increase levels of physical activity; improve nutrition; decrease obesity rates; and decrease smoking prevalence, teen smoking initiation, and exposure to second-hand smoke (Centers for Disease Control and Prevention, 2010). This program is set to operate on four levels: the community level, the state level with a focus on environmental change, the state level with a focus on self management of chronic disease, and the federal level. The community program focuses on physical activity, nutrition, obesity prevention, and tobacco, and encourages partnerships between community and state health departments, as well as local bodies such as industry. The Department of Health and Human Services awards grants to 31

32 community health departments and organizations to carry out projects that are based on the legislation s objectives. Another major bill that may greatly impact childhood obesity among preschoolers is the Patient Protection and Affordable Health Care for America Act (111th Congress), signed into law in March, While much of the bill is focused on increasing access to health insurance coverage, certain aspects of the bill concentrate on public health prevention. The bill establishes a Prevention and Public Health Fund, and recommends the establishment of task forces to develop, update, and disseminate evidence-based recommendations (Kaiser Family Foundation, 2010); also, the legislation encourages coverage of preventive health services. Even more specific to childhood obesity, section 2535 requires the secretary to establish a community-based overweight and obesity prevention program (111th Congress). The ARRA and HB lay the groundwork for novel successful public health programs to be established for the prevention of childhood obesity. It is up to public health advocates to determine how to take advantage of the current opportunities and national attention in order to maximize efforts to decrease childhood obesity and improve the nation s health. Initiatives like this combined with national concern over obesity create the potential to bring about true positive change in the health of American children. 32