Contents
Executive Summary
1
Overview of Obesity Prevalence, Causes & Consequences
3
Field Assessment Purpose and Methods
5
Field Assessment Findings I: The Obesity Problem
6
6
7
9
11
12
13
14
Why are Children Overweight?
What do Children Consume?
How do Schools Contribute to the Problem?
What Happens in Afterschool Programs?
How does Culture Affect Diets?
Are Foods Accessible and Available?
Is Recreation Available for Children?
What is the Impact of the Home Environment?
Field Assessment Findings II: How to Prevent Obesity
15
17
18
19
School-Based Interventions
Afterschool Interventions
Parent Education
Community-Based Interventions
Summary of Key Findings
20
Toward a Strategy for Obesity Prevention for Children in Rural America
22
References
24
Appendices
27
Abbreviations
NHANES: National Health and
Nutrition Examination
Survey
BMI: Body Mass Index
AFDC: Aid to Families with
Dependent Children
WIC: Woman, Infants
and Children
PE: Physical Education
AZ: Arizona
CA: California
GA: Georgia
KY:
MS:
NM:
SC:
TN:
WV:
Kentucky
Mississippi
New Mexico
South Carolina
Tennessee
West Virginia
This report was funded with generous support from Mott’s, Inc.
Executive
Summary
Executive Summary
The prevalence of obesity is dramatically rising among children in the
United States, particularly among minority populations. There are
multiple causes of childhood obesity, most of which are associated with
poor nutritional habits and inactivity. Obesity and overweight have
been found to be difficult and expensive to treat and cure, therefore
preventing this condition in children will be the key to addressing this
national epidemic. So far, however, there are few examples of effective
obesity prevention programs especially among high risk isolated, rural
populations. This first, national assessment of the obesity problem and
potential opportunities for obesity-related interventions for children in
rural, isolated America documents important findings.
The factors that contributed to obesity highlighted through this
qualitative research were:
• Rural children consumed large quantities of “junk food,” fast food,
and fried food.
• Access to healthy food choices was limited in isolated
communities.
• Reliance on food stamps can create cycles of household food
insufficiency which may prompt children to overeat during times
of plenty.
• Children had access to unhealthy food and drink choices at
school.
• Limited nutrition education was taught in school and children
had few opportunities to learn about nutrition in afterschool
settings.
• Little or no physical education was provided in rural schools.
• Rural communities had limited parks, recreational facilities, and
fitness centers.
• Access to school facilities and recreational areas was a barrier to
providing physical activity for afterschool programs.
• Most afterschool programs had indoor and/or outdoor areas for
physical activity, although few programs provided structured
activities.
• Sedentary lifestyles, including excessive television viewing, playing
video games, and using the computer were major reasons for
inactivity.
• Limited parental involvement in how children spend free time
and a lack of role models for physical activity reduced activity
levels of children.
1
Executive
Summary
The potential areas for intervention mentioned by participants were to:
• Improve availability and quality of physical education (PE) in
schools.
• Modify the focus of PE from sports to lifelong fitness habits.
• Develop nutrition education programs for children in school,
afterschool, as well as for parents and the community.
• Improve infrastructure for physical activity such as playgrounds
and sports fields.
• Increase access to school and community recreational facilities
for afterschool programs.
• Develop community-based obesity prevention programs
delivering messages to children in schools, in afterschool
programs, as well as among parents and in the community.
The information from this assessment, combined with State-level
efforts to address obesity and evidence-based approaches to obesity
prevention, will set the stage for developing and implementing a
prevention strategy for rural America.
2
Overview of Obesity
Prevalence, Causes
& Consequences
Prevalence
The prevalence of obesity is rising dramatically among adults and
children in all racial and ethnic groups in the United States. According
to the National Health and Nutrition Examination Survey (NHANES),
31% of U.S. adults aged 20-74 years are obese (BMI) >30)1. Among
preschool children in the United States, the prevalence of overweight
has doubled over the last two decades and is estimated to be over
10%2. The prevalence has also doubled among youth aged 12 to 19
years (from 6.1% to 15.5%). The most striking increase has been
among children 6 to 11 years, where the rates of obesity have more
than tripled (5% to 15.3%).
Certain sub-groups, namely, Hispanic, non-Hispanic black and Native
American populations are experiencing disproportionately higher rates
of obesity. Recent data revealed that 24% of Mexican-American and
non-Hispanic black children are overweight, compared to
approximately 15% of non-Hispanic white2. Among American Indian
school-age children, the prevalence of obesity is estimated to be over
30%3, higher than any other group in the United States.4-6
Socio-economic status is also associated with obesity prevalence.
Several studies have associated low socio-economic status with higher
rates of obesity among children.7-10
Furthermore, children living in rural areas are disproportionately
affected by these higher rates of obesity (see Table 1 below). Over
35% of middle school boys and girls from a Save the Children partner
site in Whitley County, Kentucky were obese.
Table 1: Prevalence of Overweight among Rural Children in Save the Children regions.
State
Children in grades 3 to 5 (n=54)
West Virginia
Fifth grade children in three
rural counties
5th grade children in
14 rural counties (n=1338)
Rural and urban
3rd and 4th grade children
West Virginia
North Carolina
South Carolina
Mississippi
Central New Mexico
3
Population
Kentucky
6th graders (n=352) in two rural
counties compared to national
average; 75% African American students
Children from middle school (n=205)
Rural American-Indian
fifth graders (n~2000)
Prevalence
One-third of rural children
were overweight11
40% were overweight12
27% overweight13
The odds of being obese
were 50% higher for rural
children14
49% of the students were
obese compared to national
average of 21%15
32% overweight16
One third of the students
were overweight17
Overview of Obesity
Prevalence, Causes
& Consequences
Causes
The causes of obesity in children are numerous and can mostly be
attributed to environmental determinants including:
• Sedentary behaviors, television viewing, computer usage and
similar behaviors that require limited movement.
• Poor nutritional choices and unhealthy eating habits including
over-consumption of high-calorie foods, eating when not hungry,
eating while involved in other activities like watching TV or doing
homework.
• Familial factors, socio-economic status, food access, eating habits
and behaviors.
• Over-exposure to television and print advertisements of high-fat,
high calorie foods.
• Lack of recreational facilities and/or opportunities for physical
activity.
In addition, other environmental and cultural challenges to maintaining
a healthy weight exist for children living in rural areas. For example,
several studies have found that rural school-age children have a higher
fat intake than their urban peers, especially among African-American
girls.11,18,19 Also, limited resources and lack of access to places for
exercise in rural communities make it more difficult for children to be
physically active.
Consequences
Physical, emotional, and social consequences are associated with
childhood obesity. Although some of the repercussions do not surface
for several decades, even young children can suffer from serious health
problems.20 The physical health effects are numerous, some of which
include hypertension, hypercholesterolimia, type 2 diabetes, and
cardiovascular disease.20 Other health consequences include
gallstones, hepatitis, and sleep apnea.20
Children and adolescents are also increasingly being diagnosed with
type 2 diabetes.21 A disproportionately higher rate of type 2 diabetes
has been found among American Indian,African-American and Hispanic
youth.22,23 The increasing prevalence of type 2 diabetes in children can
mainly be attributed to the increase in childhood obesity. Therefore
many of the factors associated with developing type 2 diabetes are
potentially modifiable and preventable by controlling childhood obesity.22
Obese children often suffer emotional problems that range from low
self-esteem and negative body image to depression. Many overweight
children also experience discrimination as they are often marginalized
from their peers, negatively stereotyped and teased. These social and
emotional health issues can impact children over the short- and longterm.24
4
Field Assessment
Purpose and
Methods
The overall purpose of the Nutrition and Physical Activity Field
Assessment was to gather and document information on: the extent of
the obesity epidemic among children in our partner communities; the
current status of nutrition and physical activity activities including work
done by other organizations; and the potential opportunities for
intervening in the area of nutrition and physical activity.
This assessment consisted of a series of in-depth interviews and focus
groups with over 45 participants in Appalachia (Kentucky and West
Virginia), the Southeastern area (South Carolina, Georgia, Mississippi,
and Tennessee), and the Western area (Arizona, New Mexico, and
California). The list of specific field sites included in this assessment is
provided in Appendix A. Data were collected from individuals affiliated
with schools, community groups and healthcare facilities. School
personnel included in this assessment were Principals, Food service
managers, Physical Education (PE) teachers and classroom teachers.
Assessment participants were Save the Children partners in both
school and community-based afterschool programs including program
directors, literacy specialists, physical activity coordinators, and
volunteers. Additional interviews were conducted with local and
regional experts in the area of physical activity and nutrition including
nutritionists, epidemiologists, and medical doctors from various
regions. Extensive field notes were taken during the interviews as well
as tape recorded, when permissible, for accuracy in data collection.
All notes and tapes were transcribed into Word documents and
downloaded into a qualitative research program, NUD*IST, for data
analyses. Textual data from the interviews were coded and analyzed
based on underlying themes in the data (e.g. physical activity barriers,
dietary preferences).
5
Field Assessment
Findings I:
The Obesity Problem
Why are Children Overweight?
Childhood obesity is multi-faceted, including individual, household, and
community factors. The overall consensus among participants was
that children were becoming overweight because of “bad habits,”
heredity, and environmental factors, such as poverty and lack of
access to facilities. One informant, who shared the same sentiment as
most of the participants, indicated that, “Kids are eating junk food and
staying at home watching TV or playing with an X-Box which are the major
reasons for obesity.” The poor eating and exercise habits of parents
were mentioned as a contributing factor to the ‘bad habits’ observed
in children, even at an early age.
Other informants attributed the high rates of obesity in children to
lack of physical activity. One teacher in California noted, “Since the
high school removed PE (physical education) 2 years ago, I have seen an
increase in obesity among older kids.” Most of the informants were
quick to say that childhood obesity, as well as adult obesity and health
factors associated with obesity (e.g. diabetes, heart disease), were
major problems in their communities. Few informants had estimates
of the extent of the obesity epidemic, but many have seen the effects
of it over recent years. The issues mentioned with respect to the rise
in childhood obesity, primarily included factors related to diet and
activity levels of children.
What do Children Consume?
Barriers to eating healthy were multi-dimensional and numerous
across all of the regions. One of the major issues cited for the rise in
childhood obesity was the excessive consumption of “junk food”
including chips, candy, cookies, and other high-fat and high-sugar foods.
The most frequently cited food consumed by children across all of the
regions was “Hot” Cheetos®, a spicy snack item that contains nearly 65%
of its calories from fat. Children were also reported to consume
excessive amounts of soda in all age groups across all regions. A
nutritionist in Kentucky reported that children as young as 4 months
of age are consuming “pop-in-a-bottle.” According to one informant,
“Kids are ‘Popaholics’ and are drinking ‘Big gulps’ all day. They are drinking it
in the morning for breakfast, then for lunch and dinner.” (AZ)
“Our moms are feeding
whole milk before kids are 1
year old. They are feeding
them pop in a bottle at 4
months old… That is why we
are seeing obesity rates
starting so early. I have seen
babies that are well above
the 90th percentile weight for
height. Babies and children
are taught to ignore their
body functions as far as being
full or hungry. We are
teaching our children to
ignore that and obesity rates
are starting even younger
than our school age kids and
it is very disheartening.” (KY)
6
Field Assessment
Findings I:
The Obesity Problem
How do Schools Contribute to the Problem?
Vending Machines. Vending machines in primary and middle schools
provided children with easy access to high-fat and high-sugar foods and
drinks. Some school personnel discussed attempts to reduce or
eliminate children’s access to junk food during certain times of the
school day, such as during lunch; however, the majority of the schools
in this assessment had vending machines available to children during
school and afterschool hours. One of the major reasons mentioned
for maintaining vending machines was the revenue generated for the
school from the sale of items. In one school district, children had an
established 10-minute “snack break” at 10 a.m. that consisted of
purchasing “junk food” and soda from the vending machines.
“Kids get a 10-minute break
Nearly all of the schools had vending machines with the exception of
one of the elementary schools visited in the Western region. The
Principal at this school did not want to have vending machines available
for children because he “didn’t see the need for it in school”. The
absence of vending machines eliminates the opportunity to purchase
food; however, many children bring chips, candy and soda to school.
and they rush to the vending
machines to get snacks and
soda. Some of the kids get
fruit drinks but there is more
sugar in the fruit drinks than
the soda. Most kids eat candy
or chips during the break.
They cannot go outside
because by the time they
stand in line for their snack
they have no time to go
outside.” (KY)
7
School Lunches. Menus were collected from many of the school
districts and samples are in Appendix B. Food Service managers
mentioned some of the challenges of following USDA guidelines while
also finding ways to make the food appetizing to children. The
guidelines require schools to serve at least one serving of fruit and
one of vegetable per day, which is less than the recommended intake
of fruits and vegetables recently published in the Dietary Guidelines
for Americans, 2005.25 Most of the informants indicated that children
almost never consumed vegetables and infrequently consumed fruit.
Children’s food preferences included: pizza, french fries, chicken
nuggets, hamburgers, corn dogs, and hot dogs. For breakfast, many of
the kids preferred pancakes, donuts, or cinnamon rolls over other
healthier choices like cereal, oatmeal or fruit. In addition, children
bought food from vending machines or snack bars in lieu of the school
lunch provided.
Some schools were attempting to improve the selection of foods as
well as reduce food waste. One food service manager surveyed
children about their food preferences. Based on her results she
eliminated certain items from the menu and added other foods that
were more culturally acceptable in the region, such as Mexican and
Filipino food. In addition, she replaced some of the typically high-fat
items with lower fat alternatives. “We serve the kids low-fat foods and
they don't even know it… like low-fat cheese, hot dogs made from turkey,
corndogs made from turkey.” (CA)
Field Assessment
Findings I:
The Obesity Problem
According to many informants, the pressure to increase academic
scores has forced some school districts to reduce time allocated for
recess and lunch.
“Some kids only have 1/2 hour for lunch because they cut the
lunch hour to make more time for academics. They don't have
time to eat because they have to wait in line for their food. They
have to ‘slam down’ food quickly. We see kids eating their food in
the lunch line or as they are walking up to dump their tray.” (CA)
Nutrition Education. Lack of nutrition education was cited as a
major reason for the inadequate knowledge of healthy eating among
children and families. Many of the schools had incorporated limited
health and nutrition education into their health or science curriculum.
Most of the interviews with school staff revealed that they felt that the
nutrition and health information taught in school was inadequate.
Where nutrition education was available, most of the informants said
that children learned about the food pyramid and food groups. Many
informants stated that “No Child Left Behind” has forced schools who
previously taught nutrition and health, to remove it from the
curriculum because it is not a required “knowledge set” for the
academic standardized exams.
Physical Activity. The majority of the regions had limited PE
programs at the elementary and middle school levels. Informants
attributed this to the “No Child Left Behind” legislation that mandated
schools to improve their academic standards. As a result, many of the
informants said that this legislation was the direct reason why they
have eliminated PE in their school. Without adequate resources,
including both financial and time, schools indicated that they were not
able to continue with PE when “they are now focused on academic
program improvement in school and PE gets short changed because there
are not enough minutes in a day.” (CA)
“Physical activity has not been a priority because of the
‘No Child Left Behind’ mandate that the schools are struggling
just to meet what they were required to meet before that came
down.” (MS)
Several school districts had PE as part of their curriculum, however,
they did not have a PE instructor. Providing physical education for
school children became the responsibility of the classroom teacher,
when time permitted.
“A Typical meal at school would
be chicken nuggets and french
fries that are all fried, or pizza.
They are trying to improve the
lunches, but they have to make
it palatable for the kids. Kids
will eat the chicken nuggets and
the pizza and the burgers and
the hot dogs. I have literally
seen children take their lunches
and dump it in the garbage and
take their snack ticket and go to
the snack bar. A lot of the
schools have a snack bar so that
after the kids have lunch they
can get cakes, cookies, candies,
and ice cream… all stuff that is
high in fat. Some schools that
do provide it are trying to
change it or they tell their kids
to eat their lunch first and the
kids just dump their tray
because nobody is monitoring it.
And they take their snack
tickets and get snacks and that
would be their lunch.” (KY)
8
Field Assessment
Findings I:
The Obesity Problem
Other informants indicated that there were a lot of political reasons
associated with reduction in physical activity for children.
“Let’s face it… when some of the new school buildings were
designed and built the economic requirements and the political
comments that went into those funding of those school buildings
wasn’t always conducive to physical activity for the children so
there is some barriers that… move down to the state level and
that funnels down into the local level which affects all the
agencies that are trying to provide physical activity and
nutrition.” (KY)
“There is no structured
physical activity and the
school does not see the
importance of physical
activity, even though the kids
are not getting it. The
teachers are committed to
raising test scores and we are
doing it. It requires every
ounce of energy for the
teachers and we don’t have
time to do PE with the kids
because the kids only have a
10-minute break… there is no
recess except for one hour a
week which is considered PE
time. The school board is
aware of the issues with the
kids having no PE, but they
have limited funds to raise
test scores so that is why PE,
music, and art were
dropped.” (KY)
9
In schools that have PE programs, on average, one to two classes of PE
were offered per week. The typical PE activities were sports such as
basketball, volleyball, football, and t-ball. Other lifetime physical
activities, such as walking, were not highlighted in most PE programs.
One highly motivated teacher in Appalachia taught step aerobics to the
children for PE and for children in the afterschool program. Another
program in the Western Area used the SPARKa curriculum and “project
adventure” program to teach team building and problem solving skills.
The physical education coordinator indicated that these curricula
de-emphasize competitive sports and, instead focus on healthy lifestyles
by incorporating hiking, running, and other fun games and activities
into the program.
In addition to cuts in PE, many of the schools throughout the regions
have eliminated or reduced the time children have for recess.
Reduction of recess time was cited as a necessary component to
schools attempting to achieve higher academic standards. There is “no
recess for kids. They have quiet time instead, but no scheduled recess unless
teacher decides to let them go outside.” (GA)
What Happens in Afterschool Programs?
Snacks. Most of the afterschool program staff indicated that children
received healthy snacks as part of the program. A few informants
mentioned that they were not able to give the children the most
“healthy options” due to resource constraints and reliance on outside
donations for food.
a
SPARK (Sports Play and Active Recreation for Kids) is a nationally recognized program with
documented research showing improved quality and quantity of physical activity in children.
Field Assessment
Findings I:
The Obesity Problem
“We provide meals that are available based on what is donated
or funded through USDA. Some of the food is healthy and some
is not… we get a lot of cookies from Nabisco that are donated…
many agencies are desperate for food ...” (CA)
Snacks provided in afterschool programs included: Rice Krispies®,
Oreos®, sugar cookies, graham crackers, granola bars, crackers, wheat
thins, chips, light popcorn, peanut butter and jelly sandwiches, crackers
and cheese, flavored rice cakes, yogurt, celery, fruit, such as apples,
flavored applesauce, apple juice, Gatorade®, Crystal Light®, Capri Sun®,
and milk.
Nutrition Education. Several of the afterschool program staff
indicated that they had incorporated nutrition lessons into their
literacy program. One program in Appalachia utilized a child-friendly
website that allowed children to learn and explore various nutrition
topics. This provided children with nutrition information while also
serving as an opportunity to use reading skills. Other program
directors mentioned that they invite speakers, such as nutritionists
from local Extension offices, to teach children about the food pyramid
and preparation of healthy snacks. Many of the afterschool program
staff indicated that they “do nutrition” every day, which involves
providing a snack for the children, with limited or no nutrition
education. Where there was more explicit nutrition education in the
afterschool program it appeared to be limited to learning the basic
food groups and conducting cooking sessions with the children.
Physical Activity. Many of the afterschool partners had access to
places for children to exercise. Several of the partners had indoor
and/or outdoor areas where they can organize physical activities for
children. However this varied considerably by site. In some
communities, the afterschool center was the only place where children
had an outlet to be active.
“Kids need to be in organized things like sports or afterschool
programs. If they are not in these programs they don’t get any
physical activity because there is no gym or YMCA to stop by. We
don’t have the resources or the transportation or the number of
things it takes to make a group of kids want to come. We don’t
have the draw we use to.” (WV)
“The schools provide us with
the afterschool snacks for our
program. It is always a
nutritious thing. Yesterday it
was a fruit roll-up and they
get a carton of low fat milk
or a thing of apple juice. The
day before it was a little
snack pack of pretzels,
popcorn, peanuts and
M&Ms… and some kind of a
cereal in there, like Chex
Mix. We asked the chief cook
to make them nutritious.”
(WV)
10
Field Assessment
Findings I:
The Obesity Problem
Several afterschool programs throughout the regions had relatively
unstructured and organized physical activity. A partner in a remote
location in the Western region had inadequate outdoor space for
children to play. In contrast, a program visited in Whitley County,
Kentucky, had structured, organized, and wide-ranging activities for
children in the afterschool program. These included:Tae Kwon Doe,
basketball, volleyball, aerobics, walking, and running (outdoor track).
Each activity had a coach that guided and encouraged children through
the various physical activities. This program was held at the middle
school, which allowed the children access to both indoor and outdoor
recreational facilities.
Although programs varied in the number, frequency, and intensity of
activities, most of the partners provided some opportunity for children
to engage in outdoor play (weather permitting). This often involved
playing on jungle gyms or basketball courts (where available), or
engaging in group games such as Simon Says, Follow-the-Leader,
Duck-Duck-Goose, etc. Several partners discussed their desire to
incorporate team sports into their afterschool programs, but noted
that they had difficulty gaining access to facilities such as schools or
recreational facilities. “We were doing teams like basketball, softball, and
soccer, but it is hard to find a facility to do that, to practice. Even our Civic
Center, it’s like pulling teeth to get in there and use the space.” (KY)
How does Culture Affect Diets?
Children’s food preferences for sweets, snacks, and soda were similar
across regions. Cultural and regional differences in food types,
preferences, and availability of food did exist. Examples of typical meals
by region as reported by the informants are presented in Table 2.
Table 2: Typical foods consumed by region
Region
11
Typical Foods
Kentucky/West Virginia
soup beans, corn bread, fried pork chops, fried chicken, and baloney
Western Native
American reservations
fry bread, tortillas, and fried potatoes
California –
Hispanic population
Rice and Beans, burritos, tacos, tamales, Mexican, or Filipino foods.
Southwest Region
greens, yams, fried chicken, meatloaf, cornbread, mashed potatoes,
and peas
Field Assessment
Findings I:
The Obesity Problem
Fried foods were common across all of the regions, especially the use
of lard, ham hocks, and fat back for many local dishes. This was
reported on Native American reservations in the Western area as well
as among informants in the Appalachia and Southeast regions. Some of
the informants indicated that it was culture and tradition that guided
people in their dietary patterns. “One of the biggest issues in our area is
the culture… the way they were taught to fry potatoes and eat fried
chicken.” (SC)
Cultural factors were also mentioned as influential in families choosing
to take their kids to fast food restaurants. “It is the immigrant culture of
acculturating by going to McDonald's, Burger King, eating junk food, cookies,
and candy. When they go to McDonald's they buy cheap food and say we
are Americans now.” (CA) Consumption of fast food by children was
commonly reported by informants in all regions of the United States.
Most communities have fast food restaurants nearby or within 30
minutes of their town. A large proportion of the families, throughout
all of the regions, frequented fast food restaurants, as reported by
informants.
Informants indicated that even when families in their community did not
have enough to eat; they would share whatever they had with others.
“When you go to someone’s
house, that’s how they welcome
you. It’s because they welcome
you with food because that’s all
they have to give you. But I
know and it still goes on today
that if you do home visits there
Are Foods Accessible and Available?
Access to and availability of food, especially healthy food, in these rural,
isolated communities affected family food choices. Many of the families
purchased food in bulk, which often involved traveling long distances of
30 minutes to 2 hours to a “decent” grocery store where they could
“make their dollar stretch.” Informants indicated that the majority of
families relied on some type of government assistance including food
stamps, AFDC,WIC, and commodity foods. In some cases, families
used food pantries or other emergency food distribution programs in
their communities when their food supply ran out.
may not be anything else in that
house for the rest of the people
to eat, but if they offer you
something, you better take it
because they’re probably giving
you the last piece of bread or
whatever it is they have in their
house and the last cup of coffee
or tea. They’re giving it to you
because they respect and honor
you as a person who has come
to your house… and that still is
very prevalent in some areas of
the counties now, even today.
It’s just part of the culture.”
(KY)
12
Field Assessment
Findings I:
The Obesity Problem
Food stamps, in particular, were mentioned as a factor in a monthly
pattern of food availability and food scarcity that existed in many rural
households. Behavioral factors such as binge eating among children
were reported to occur at the beginning of the month (after the
receipt of food stamps) when there was a lot of food available in the
household. In addition, many families used other means to provide for
their family when their food supply diminished toward the end of the
month. Some of these strategies included relying on family or friends
for food, utilizing a food pantry, or using staples (e.g. flour to make fry
bread or tortillas, and potatoes) to make a meal for their family. One
informant stated that in her county there are “a lot of overweight people
that are undernourished… and they don't feel right.” (KY)
Lack of basic education was suggested as a reason why many families
run out of food stamps.
“Before the first of the
month the cupboards are
bare and families are eating
commodity foods.They use
all of the food stamps at the
beginning of the month
because they just ‘Shoot em’
… A lot of people buy food
in bulk, and packaged food,
or they use food stamps for
other things and do not have
food for the rest of the
month. When food is
purchased at the beginning
of the month, children would
‘Eat, eat, eat’.” (NM)
13
“They don’t know how to purchase healthy foods wisely and use
their money dollar. A lot of our families are not able to budget
buying foods, education-wise that is a big problem. The average
reading level in this area is about 5th grade so families have a
hard time with that. Families have a hard time trying to
understand how to make that dollar work for them.” (WV)
Is Recreation Available for Children?
There were regional differences in terms of availability and accessibility
of places for children to be active. While some locations had parks,
fitness centers, or recreational facilities, other communities had limited
places for physical activity. Although most of the schools had
playgrounds or gyms, they were often inaccessible to children after
hours. One principal indicated that, “There is nothing available for the
kids to do beyond the school playground and fields, but it gets locked at
night and on the weekends. Kids still find a way to squeeze through the
gates so they can play.” (CA) Other barriers to physical activity in the
community were cost and transportation associated with participating
in recreational activities.
In several communities spaces for recreation and physical activity had
become dilapidated due to damage and neglect. “Many community
recreation areas have been destroyed from vandalism, although most of
Field Assessment
Findings I:
The Obesity Problem
them still have a basketball court.” (AZ) In one very remote area in the
Western region, a community was able to raise revenue to build a
recreation center. “We have a new recreation facility being built near the
afterschool center that will have a weight room, a pool, a basketball court.
This is being built with donations from the community.” (AZ) These new
facilities offer opportunities for community members, especially
children, to engage in physical activity in a safe environment.
What is the Impact of the Home Environment?
Most of the children reportedly do not engage in physical activity while
they are at home. According to nearly all of the informants, a sedentary
lifestyle that included excessive time spent watching television, using
computers, and playing video games was the main reason children were
not active. An informant from the Southeastern area said, “Video games,
like Nintendo and Play Station are a barrier to physical activity. Kids just
want to play games. Even the poorest of children have video games. Parents
use television and video games as a ‘babysitter’.” (SC)
Lack of parental involvement was identified as a reason why children
were not very active while at home. Many of the communities had a
large proportion of single parent families and/or two parent homes
where both parents work. Informants said that many of the children
were “latch-key” kids and did not have a parent who was at home
when they arrived to encourage them to eat well or be physically
active. In addition, some parents did not feel it was safe for their
children to leave the house. “There are a lot of ‘latch key kids’ who stay
home alone. Parents don’t want their kids to go outside because they might
get hurt, so they just stay inside and watch TV.” (AZ) Physical activity at
home may not be a priority or encouraged among some parents.
Several informants mentioned a lack of adult role models as a factor in
the inactivity of children. “Some of our educational role models are not
the role models they should be… yes meaning the teachers and the parents,
the Principals.” (WV) In addition, “There are no role models for physical
fitness because adults are not active and obesity is the norm in the
community.” (AZ) Not seeing physical activity as a priority was also
cited as a factor in sedentary lifestyles. “Kids and families do not have
good habits, like exercising before school. We don’t make time for exercise
even though we make time for everything else.” (KY)
“They assume their kids are
getting physical activity at
school, they’re getting
physical activity afterschool
and that’s good enough…
A lot of our parents work…
It’s easier from them to let
their kid go in, sit down at
the T.V. or the computer and
play games than it is to
actually deal with them.”
(KY)
14
Field Assessment
Findings II: How to
Prevent Obesity
Overall, the majority of informants indicated that preventing obesity
would require collaboration of many different groups in all sectors of
the community. One informant in West Virginia summed it up by
stating that this effort “needs to involve schools, health professionals,
private and public collaboration process for the survival and health of
children.” In addition, most of the informants indicated that it should
be a “comprehensive program that includes both physical activity and
nutrition.”
The participants agreed that in order for a nutrition and physical
activity program for children to be effective and sustainable, it must be
appealing to children. A teacher in California said, “We need to change
people's attitudes about health and make it fun and interesting.” Another
informant in Mississippi said, “If a program is fun kids will go.”
“We need a comprehensive
approach that includes the schools,
the health care professionals – both
private and public.We need a
collaboration process where we can
bring all the entities to the table
where they have common ground.
And that common ground is survival
and the health of the children in
the population they are working
with. And if there could be 3 or 4
health care goals – physical
activity, nutrition, dental – whatever
it might be… if they could identify
those areas and do a
comprehensive plan. And it has to
be community based… it has to be
the bringing together of the entities
that are the key players and do the
program for the community that
you are working with. And you
target them… and you cover every
base… you have to make sure it’s
going to be reinforced in every
thing – whether it’s in school,
whether it’s in afterschool, whether
it’s in church, whether it’s in the
doctor’s office.” (WV)
15
Schools-Based Interventions
Physical Activity. Many of respondents felt that it was important to
have some type of physical activity at school. Several teachers
indicated that children were more attentive after they had an
opportunity to play outside. Several principals and school staff
indicated that they would like to have more time for PE and/or initiate
a structured PE program in their school. A few informants indicated
that for a program to be successful, “You need a volunteer physical trainer
that likes working with kids and can be a role model for the kids.” (CA)
Some informants suggested incorporating different activities that teach
lifelong fitness habits, such as walking, dancing, yoga, martial arts,
aerobics, weightlifting and using exercise machines. “We need to have
an organized physical activity program which would include team or
individual sports, like Yoga, Karate,Tai kwon do, Judo… and a dance machine
to get kids moving.” (MS)
Several schools had limited access to indoor and outdoor facilities for
children to be active; therefore, many of the suggestions included
improving the outdoor play areas. School officials indicated that they
would like to make structural improvements at their schools to
improve access to activities by children. Some of the suggestions
included improving the outdoor recreational areas, such as adding
playground equipment, building a walking track or trail, adding baseball
and basketball courts. One informant suggested the following
enhancements to her school:
Field Assessment
Findings II: How to
Prevent Obesity
“We would like to improve the playground equipment and add
things like climbing equipment, parallel bars, forts, obstacle courses
for kids, more swings, cement walls to play hard/hand ball. It would
also be great if we could add a weight lifting room that would also
have exercise equipment machines made for kids.” (CA)
Nutrition. Few informants suggested improving school meals by
changing the breakfast and lunch options offered to children. Although
this may be a likely place to intervene, informants described the
importance of adhering to the USDA guidelines when developing
menus for children. Although many community members interviewed
suggested that schools remove vending machines and snack bars from
schools (or at least modify what is offered), a limited number of school
personnel offered this as an option for supporting healthy eating
among children. One informant in New Mexico thought that they
should “change snack machines in schools to not allow soda and provide
more juices and diet drinks.”
Many of the informants attributed the low rate of vegetable and fruit
consumption by children to a lack of knowledge of nutrition and
suggested developing nutrition education programs for their school. It
was suggested by several informants that programs needed to be
creative and led by a person who is knowledgeable about nutrition,
such as a nutritionist. In one county in Kentucky, a nutritionist from the
health department taught children about nutrition at various schools
using a “hands-on” approach.
The majority of the programs that were visited as part of this
assessment did not have ready access to a nutritionist within their
communities. Some of the participants suggested that school districts,
“Hire a nutritionist for the schools to teach and train little kids
about what parts of the body are geared towards food that they
eat. Like food for your heart, lungs and brain. Have the
nutritionist go into the classrooms to teach because so many of
the teachers are loaded down and there is no curriculum to teach
a few things about nutrition.” (MS)
Another suggestion for school-based nutrition education programs,
which would also be applicable in an afterschool setting, was the use of
peers.
“I get the kids involved
because I find if they are
bored, they are not going to
do anything… When you do
that exercise stuff with them,
they love that. I try to bring
in every aspect of teaching,
visual, because most people
don’t remember what they
hear. What they see and
what they do, they will
remember better. So I try to
get them seeing and doing
things, using the food models
and things. I show them a
serving size of pizza and they
look at you because they are
amazed. You know it is one
slice, and they say they would
eat 10 of those.” (KY)
16
Field Assessment
Findings II: How to
Prevent Obesity
“Tutor kids and have kids teach the lesson so that they learn
better. When they have to teach a lesson they ask more
questions and talk to kids in terms of what the students
understand.” (CA)
Although there were few nutrition education programs available at
most of the schools, one middle school in Kentucky started a
“nutrition fitness challenge” to help reduce overweight among children.
A food service manager in California offered her thoughts on nutrition
education, “It is hard to stop kids from eating junk food but maybe you can
teach them to eat “Hot” Cheetos® with a salad or with chicken to balance
out the bad with the good.”
Afterschool Interventions
“We are going to start out
with nutrition classes then
physical activity on a daily
basis… work that into their
days… do 3-a-day and 5 aday (vegetable and fruit)
challenges.The kids that
Physical Activity. Several afterschool program staff suggested having
exercise programs for kids that would include using exercise tapes
(aerobics and Tae Bo), walking, hiking, martial arts, sports teams and
using the outdoor recreational areas. Many of the informants
suggested a more structured program where they would have staff
available to teach the children various activities. One informant from
Georgia said,
“We should have more staff to do activities… staff to work with
kids in the afterschool program to provide safe activities for
kids… They would be responsible for setting up the grounds for
activities, supervising the children, and scheduling different age
groups and different sports.” (GA)
actually complete the
program are going to get
incentives that are physical
activity and nutrition related
(bikes and stuff) or school
related.They (the school)
wants to do this because they
have such a problem with
high levels of overweight.”
(KY)
17
Several program directors indicated that in order to increase physical
activity among children, playgrounds and sports fields needed to be
improved or built. Informants indicated that improved access to
facilities in their community needs to be a priority. Suggestions were
made to collaborate with schools and community groups in order to
have access to gyms (that are not in use) as well as recreational areas
that are often off-limits at various times of the day or year. In addition,
transportation was mentioned as a major barrier to children
participating in afterschool programs and recreational activities.
Suggestions were made by many of the informants to work with the
school districts to use or lease buses or have a ‘late bus’ service. This
would allow children an opportunity to participate in afterschool
activities, even when they live in remote areas.
Field Assessment
Findings II: How to
Prevent Obesity
Nutrition. The major suggestion with respect to the nutrition
interventions was to incorporate more nutrition education into the
afterschool program. One informant stated that they should, “Get books
and software on nutrition and food groups to combine with the literacy
activities.” (AZ) This was suggested by other informants as they felt that
they had limited time to incorporate literacy activities and nutrition
education into the time available afterschool. Several of the informants
thought that it would be important to “bring someone in”, such as a
nutritionist, to teach children about nutrition through activities such as
by cooking with them or helping them to grow a garden.
Parent Education
Most of the partners highlighted the importance of including parents in
the effort to teach children about nutrition. Many ideas for programs
included, but were not limited to, involving parents in the effort to
promote healthy habits in their children. Some of the partners were
presently working with parents to educate them on nutrition related
issues. Among the partners who had parenting programs, most of the
sessions centered on preparing healthy meals.
“We try to teach parents
about cooking, such as
Many informants shared the challenge of budget constraints and lack of
access to healthy foods in providing good nutrition for families and
suggested the need to teach parents how to “stretch their food dollar”
and how to prepare healthy foods on a budget. “There should be
nutrition classes for parents to teach them how to have balanced diets. They
would be pleased about the foods because we could show them that they
can stay within their budgets.” (NM)
making greens with smoked
Cultural aspects were also an important factor mentioned by several
informants with respect to nutrition education for parents.
Suggestions were made to have programs taught in one’s native
language, such as Spanish or Navajo. In addition, some informants
suggested that nutrition messages be sensitive to cultural differences.
One informant said, “Provide nutrition education for people about different
foods because they may not culturally be used to eating foods like brussel
sprouts.” (NM) In order for some families to participate, “They need
people in the community who talk to them in their language and get them
to buy into programs for kids. If families understand importance of
programs… that will make a change.” (CA)
chips every day. We try to
turkey instead of ham hocks.
We teach families about
moderation… you can't eat
pizza, candy, and potato
get parents to expose their
children to more vegetables
and fruits.” (GA)
18
Field Assessment
Findings II: How to
Prevent Obesity
Many of the participants indicated that parenting classes should also
emphasize the importance of motivating their children to be active.
Some of the informants suggested finding ways to “Help parents put
away TV and video during the day light and have kids playing outside.” And
“teach them how to play games and do things with kids to keep them away
from the TV.” (NM) Other informants felt that parents needed to be
motivated to spend more time doing things with their children
because, “If you get parents motivated then kids will be motivated.” (KY)
Several suggestions were made, such as a walking club for parents and
children, group exercise (aerobics, dance) activities at community
centers and special events at schools and in afterschool programs that
encouraged families to be active together.
Community-Based Interventions
“We did ‘nutrition on the go’
which was a mobile truck that
we sent to rural areas to do 2-3
hour stations of nutrition
education.This had 1 to 2 quick
tips on nutrition-related topics
like the food pyramid, portion
sizes, and health related
information… We did diabetes
information in the form of
‘novellas’, child seat program,
and taste tests. At the end of
the stations were free
information… and families got
to take bags of fresh fruit and
vegetables home with them. A
lot of families were coming to
the program for the
information, not just the food...
They really wanted to eat
healthy. All of this was done
with volunteers that were
trained within the local
communities… they knew
nutrition-related knowledge and
passed it on to friends and
neighbors.” (CA)
19
The major suggestion for a nutrition and physical activity program was
to make it a comprehensive community-based effort where messages
are delivered in schools, afterschool, among parents and in the
community. An informant in Appalachia mentioned a recent grant that
was submitted to address child obesity as described in her own words,
“We want to train teens to be nutrition outreach workers, where
we train them in nutrition, fitness, and child health. Each of the
teens were going to identify kids in public housing that had a
weight problem and teens were going to be a big brother, big
sister or a “fitness buddy” or “health buddy.” They were going to
work one-on-one with the kids with a health workbook. We were
going to have a nutrition class, with the nutritionist, or
someone… to have a class once a week afterschool. Also, once a
month have a dinner where we would have the kids… working
with someone from the Extension office… to plan a low cost
nutritious meal that the kids prepare and serve it to the parents.
And that way we would give out recipes… and draw parents in
because really it is the parents that have a lot to do with the kids
behaviors.” (KY)
This program idea included several segments of the community, from
teen leaders, to local nutritionist, and to parents. Another program in
California incorporated cultural aspects into health information by
using “telenovelas” (Spanish language soap operas). In addition, this
program brought the information directly to community members so
transportation would not be a barrier to participation.
Summary of
Key Findings
This qualitative research yielded several important findings related to
the development of a programmatic strategy for obesity prevention in
these communities. The problem of obesity was evident in the
assessment communities and key informants were well aware that
children were overweight as a result of factors related to both
nutrition and physical activity. The key informants had a wide range of
suggestions for how to begin to tackle the obesity problem.
The Impact of Nutrition/Food Choices
and Food Availability
• Consumption of “junk food” and fast food was the norm. It is
striking that across all four areas the most commonly reported
food consumed by children was “Hot” Cheetos®.
• Children’s preference for other less healthy foods included
french fries, hot dogs, and donuts was a key barrier to altering
food choices.
• Fried foods were common across all of the regions, despite
cultural and regional differences.
• High-fat and high-sugar foods and drinks were available to
children at schools through vending machines.
• Although required to follow USDA guidelines, school meals often
did not provide adequate healthy alternatives for children.
• Afterschool programs did not consistently provide healthy snacks
to children because of a lack of resources, lack of nutrition
knowledge and the unavailability of healthy options.
• Access and availability of food, especially healthy food, was a
significant factor in these rural isolated communities.
• Poverty and dependence on food stamps can create a cycle of
food plenty to food scarcity in these households; during times of
plenty children may overeat.
The Impact of Physical Activity
Opportunities and Practices
• The majority of the schools had limited or no PE programs in
school; this was attributed to cuts made as a result of the “No
Child Left Behind” legislation.
• Many schools did not have PE instructors; classroom teachers
were often responsible for providing physical education.
• Typical PE activities were focused around sports such as
basketball, volleyball, football, and t-ball, whereas other lifetime
fitness activities, such as walking, were not part of most PE
programs.
20
Summary of
Key Findings
• Regional differences existed in the availability and accessibility of
places for children to be active; some locations had parks, fitness
centers, or recreational facilities while other communities had
none.
• Most afterschool programs provided low to moderate physical
activity; few centers had structured, vigorous, regular physical
activity for children.
• Access to school facilities and recreational centers were major
barriers to providing physical activity in the afterschool setting.
• Rural children were inactive because the norm in these settings
is sedentary lifestyles including excessive time spent watching
television, using computers and playing video games at home.
• A lack of physically active adult role models and little parental
involvement during children’s free time affected the inactivity of
children.
Potential Areas for Intervention
• Making high-quality physical education available in schools was
seen as a key area for intervention.
• Shifting the focus from sports to teaching lifelong fitness habits,
such as walking, dancing, yoga, martial arts, aerobics, weightlifting
and using exercise machines was recommended.
• Nutrition education programs in school, afterschool, for parents
and in the community was a felt need expressed by most
informants.
• Infrastructure for physical activity – sports fields and playgrounds
– need improvement and expansion.
• Afterschool programs need access to facilities for recreation and
physical activity in the school and community.
• In general, key informants felt the need for a comprehensive
community-based effort at obesity prevention with consistent
messages delivered in schools, in afterschool programs, among
parents and in the community.
21
Toward a Strategy
for Childhood
Obesity Prevention
in Rural America
Obesity and overweight have been found to be difficult and expensive
to treat and cure, therefore preventing this condition in children will
be the key to addressing this national epidemic. So far, however, there
are few examples of effective obesity prevention programs especially
among high risk isolated, rural populations. This first, national
assessment of the obesity problem and potential opportunities for
obesity-related interventions for children in rural, isolated America
documents important findings. This information, combined with Statelevel efforts to address obesity and evidence-based approaches to
obesity prevention will set the stage for developing and implementing a
prevention strategy for rural America.
State Legislation and Initiatives
Over the last several years various states (including some of those
included in this assessment) have passed legislation to combat the
growing rates of childhood obesity. California, for example, is a leader
in terms of legislation passed to prohibit the sale of foods and drinks
of low-nutritional value from vending machines in schools.27 In
addition, California has implemented standards for nutrition education
and physical education in schools.27 Arkansas has mandated one
hour/week of physical education with no less then 20 minutes of
physical activity for grades Kindergarten through nine. See Appendix C
for other obesity-related legislation passed by the states included in
this assessment.
Many states also have developed state-wide and local initiatives to
prevent obesity and chronic diseases. For example, Colorado
developed a resource kit that encourages schools to implement
programs and policies that promote a healthy school environment.
This kit provides action steps on how to create a positive environment
from the cafeteria to the classroom to impact a child’s eating and
physical activity behaviors.28 In West Virginia, an after-school program,
Choosy Kids Club, provides elementary school children with an
opportunity to learn healthy nutrition and physical activity decisionmaking skills.29 Appendix D lists other programs and initiatives by state
that focus on obesity prevention.
Evidence-Based Approaches to Obesity Prevention
Researchers have attempted to identify the multi-dimensional causes of
obesity as well as effective solutions to combat the problem. A recent
systematic review examined nutrition and physical activity programs
aimed at children to identify evidence-based approaches to
prevention.30 Some of the key conclusions from this review and from
other research will contribute to the foundation of a strategy for
22
Toward a Strategy
for Childhood
Obesity Prevention in
Rural America
childhood obesity prevention in rural America. What we know so far
is as follows:
• Programs to address physical activity should focus on aerobic
activity, rather than sports or skill development that is typically
taught in physical education classes.
• PE teachers ensure more moderate to vigorous activity than
classroom teachers.
• If classroom teachers are to play a role in physical education they
will need training and mentoring skills to learn how to maximize
the level of physical activity offered to children.
• Schools that provide concentrated physical activity programs
have seen improvements in academic performance, despite having
reduced class time for academics to implement the physical
activity program.31-34 A study conducted with children who
received a health related physical activity program (SPARK)26,
found improvements in reading scores after 2 years of doubling
time for physical education.35
• Schools that successfully promote less video game and television
use appear to be highly effective in reducing physical inactivity
and reducing obesity.36
• Research shows that successful nutrition interventions had at
least 10 sessions and were multi-faceted involving healthy
cafeteria choices, mass media campaigns, and parent involvement.
• Increasing knowledge in nutrition is insufficient; educational
messages need to focus on changing actual behaviors rather than
improving knowledge and/or attitudes.
• Interventions that target students, school cafeterias, after-school
programs, parents, and the community are more effective than
any intervention alone.
• Multi-faceted obesity prevention programs for primary school
and high school students that included components such as
school curricula, mass media, parent mailings, and healthy
cafeteria changes over at least 8 to 10 weeks show the most
promise for altering food intake.
Conclusion
23
Save the Children has worked for more than 70 years in partnership
with schools and community-based organizations in these rural areas
hardest hit by the obesity crisis. This strong, long-term connection
puts Save the Children in an ideal position to help develop and adapt
effective approaches to obesity prevention for these children. By
gaining perspective directly from the communities in which Save the
Children works, this Nutrition and Physical Activity Field Assessment
has helped to further strengthen partnerships and collaborations
needed to develop and implement a successful obesity prevention
strategy for children in rural America.
References
1. Flegal KM, Carroll MD, Ogden CL, Johnson CL Prevalence and trends in obesity among
US adults, 1999-2000. JAMA. 2002; 288(14):1723-7.
2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among
US children and adolescents, 1999-2000. JAMA. 2002; 288(14):1728-32.
3. Caballero B, Clay T, Davis SM et al. Pathways: a school-based, randomized controlled trial for the
prevention of obesity in American Indian schoolchildren. Am J Clin Nutr. 2003; 78(5):1030-38.
4. Story M, Evans M, Fabsitz RR, Clay TE, Holy Rock B, Broussard B. The epidemic of obesity in
American Indian communities and the need for childhood obesity-prevention programs.
Am J Clin Nutr. 1999; 69(4):747S-754S.
5. Eisenmann JC, Katzmarzyk PT, Arnall DA, Kanuho V, Interpreter C, Malina RM. Growth and
overweight of Navajo youth: secular changes from 1955 to 1997. Int J Obes Relat Metab Disord.
2000; 24(2):211-8.
6. Sugarman JR,White LL, Gilbert TJ. Evidence for a secular change in obesity, height, and weight
among Navajo Indian schoolchildren. Am J Clin Nutr. 1990; 52(6):960-6.
7. Strauss RS, Knight J. Influence of the home environment on the development of obesity in
children. Pediatrics. 1999; 103(6):e85.
8. Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998.
JAMA 2001;122;86(22):2845-8.
9. Goodman E.The role of socioeconomic status gradients in explaining differences in US
adolescents' health. Am J Public Health. 1999; 89(10):1522-8.
10. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs.
Am J Clin Nutr. 2004;79(1):6-16.
11. Crooks DL. Food consumption, activity, and overweight among elementary school children in an
Appalachian Kentucky community. Am J Phys Anthropol. 2000; 112(2):159-70.
12. Neal WA, Demerath E, Gonzales E, Spangler E, Minor VE, Stollings R, Islam S. Coronary Artery
Risk Detection in Appalachian Communities (CARDIAC): preliminary findings.
W V Med J. 2001; 97(2):102-5.
13. Demerath E, Muratova V, Spangler E, Li J, Minor VE, Neal WA. School-based obesity screening in
rural Appalachia. Prev Med. 2003; 37(6):553-60.
14. McMurray RG, Harrell JS, Bangdiwala SI, Deng S. Cardiovascular disease risk factors and obesity
of rural and urban elementary school children. J Rural Health. 1999; 15(4):365-74.
15. Felton GM, Pate RR, Parsons MA,Ward DS, Saunders RP,Trost S, Dowda M. Health risk
behaviors of rural sixth graders. Res Nurs Health. 1998; 21(6):475-85.
24
References
16. Davy BM, Harrell K, Stewart J, King DS. Body weight status, dietary habits, and physical activity
levels of middle school-aged children in rural Mississippi. South Med J. 2004; 97(6):571-7.
17. Davis SM, Lambert LC. Body image and weight concerns among Southwestern American Indian
preadolescent schoolchildren. Ethn Dis. 2000;10(2):184-94.
18. McMurray RG, Harrell JS, Bangdiwala SI, Deng S. Cardiovascular disease risk factors and obesity
of rural and urban elementary school children. J Rural Health. 1999;15(4):365-74.
19. Kumanyika SK, Ewart CK. Theoretical and baseline considerations for diet and weight control of
diabetes among blacks. Diabetes Care. 1990; 13(11):1154-62.
20. Must A, Strauss RS.Risks and consequences of childhood and adolescent obesity.
Int J Obes Relat Metab Disord. 1999; 23 Suppl 2:S2-11.
21. Fagot-Campana A, Pettit DJ, Engelgau MM, Rios Burrows N, Geiss LS,Valdez R, et al.Type 2
diabetes among North American children and adolescents: an epidemiologic review and a public
health perspective. J Pedatr 2000;136:664-72.
22. Dabelea D, Hanson RL, Bennett PH, Roumain J, Knowler WC, Pettitt DJ. Increasing prevalence of
Type II diabetes in American Indian children. Diabetologia. 1998; 41(8):904-10.
23. Goran MI, Ball GD, Cruz ML. Obesity and risk of type 2 diabetes and cardiovascular disease in
children and adolescents. J Clin Endocrinol Metab. 2003; 88(4):1417-27.
24. Koplan JP, Liverman CT, Kraak VI. Preventing Childhood Obesity: Health in the Balance. Institute
of Medicine. The National Academie Press. Washington, DC 2005.
25. Dietary Guidelines for Americans 2005. U.S. Department of Health and Human Services. U.S.
Department of Agriculture (online) http://www.health.gov/dietaryguidelines/
(Accessed January 15, 2005).
26. SPARK. www.sparkpe.org/index.jsp. (Accessed February 25, 2005).
27. Wellever, A, Reichard A,Velasco, A. Obesity and Public Policy: Legislation Passed by States, 1999
to 2003. Kansas Health Institute, April 2004 (online).
http://www.khi.org/Obesity/ObesityReport_Part1.pdf (accessed January 4, 2005).
28. Action for Healthy Kids (online) http://www.actionforhealthykids.org
(Accessed January 27, 2005).
29. Choosy Kids Club.West Virginia Motor Development Center. West Virginia University (online)
http://www.wvu.edu/~physed/mdc/about_choosy.htm (accessed January 27, 2005).
25
30. Thomas H, Cilisk D, Micucci,Wilson-Abra, Dobbins M. Effectiveness of Physical Activity
Enhancement and Obesity Programs in Children and Youth. Public Health Research, Education &
Development Program, 2004 (online) http://www.city.hamilton.on.ca/PHCS/EPHPP/
Research/Summary/2004/HealthyWeightsFull2004.pdf (Accessed January 11, 1004).
References
31. Symons, CW. Bridging Student Health Risks and Academic Achievement through Comprehensive
School Health Programs. Journal of School Health 1997; 224.
32. President’s Council on Physical Fitness and Sports. Physical activity promotion and school
physical education. Physical Activity and Fitness Research Digest, 1999.
33. National Association of Sports and Physical Education (NASPE), Executive Summary,
Shape of the Nation, 2001.
34. Shephard RJ. Curricular physical activity and academic performance. Pediatric Exercise Science
1997; 9:113-126.
35. Sallis JF, McKenzie TL, Kolody B, Lewis M, Marshall S, Rosengard P. Effects of health-related
physical education on academic achievement: project SPARK Res Q Exerc Sport.
1999; 70(2):127-34.
36. Campbell K,Waters E, O’Meara S, Kelly S, Summerbell CD. Interventions for preventing obesity
in children. Cochrane Database of Systematic Reviews, 2002; CD001871.
26
Appendix A
Field Assessment
State
AZ
AZ
AZ
CA
CA
CA
GA
GA
KY
KY
KY
KY
KY
KY
KY
MS
MS
MS
NM
NM
NM
NM
NM
SC
SC
SC
TN
WV
27
City
Sells
San Carlos
San Carlos
Visalia
Earlimart
Terra Bella
Forsythe
Hogansville
Hazard
Whitesburg
Pippa Passes
Hindman
Williamsburg
Stearns
Berea
Mound Bayou
Mound Bayou
Mound Bayou
Kirtland
Crownpoint
Crownpoint
Shiprock
Tierra Amarilla
Spartanburg
Spartanburg
Spartanburg
Covington
Kermit
Site Name
Pisinemo Learning Center
St. Charles Mission School
San Carlos Health Education Department
FoodLink Food Pantry
Alila Elementary School
Terra Bella Elementary
Community Improvement Coalition of Monroe County
West End Center
UK Center for Rural Health
Cowan Community Center
Caney Creek Family Resource/Youth Services Center
Hindman Family Resource/Youth Services Center
Housing Authority of Williamsburg
Whitley City Middle School
Berea College
National Council of Negro Women
Delta Health Center
I.T. Montgomery Elementary School
Kirtland Youth Association
Crownpoint Department of Youth
Crownpoint Community Wellness Center
Indian Health Services
Chama Valley Independent School District #19
Crescent Hill Apartments
Community S.L.A.S.H. Center
Park Hill Elementary
Children and Family Services
ABLE Families
Appendix B
California
28
Appendix B
Kentucky
29
Appendix B
New Mexico
30
Appendix B
Tennessee
31
Resolution Number
or Statute
Location
Description
2003
2003
2001
2002
2001
1999
CO
CO
CA
CA
GA
SC
SCR 5
ACR 194
SR252
SCR252
SJR03-005
SJR03-004
SCR8
2001
2003
2003
MS
MS
NM
Chapter 484
SJM 95
Chapter 658 of
the Pub. Acts
of 2002
Chapter 432
2003
2003
2003
CA
CA
CA
2003
2001
CA
CA
2003
AR
Chapter 879
Chapter 415
Chapter 62
Chapter 458
SB19
Act 1220
School Food Programs and Policies
2002
TN
Advisory Commissions and Studies
1999
AR
Creates the Child Health Advisory Committee to develop nutritional and physical activity standards, and to make
recommendations on competitive foods sold through vending machines. Bans vending machines in elementary school
starting in 2003-2004 school year; requires body mass index screening in schools.
Prohibits the sale of carbonated beverages in elementary and middle schools and places nutrition standards on
foods sold to students at breaks and through vending machines.
Prohibits school boards from entering into exclusive or non-exclusive contracts for advertising or the sale of
carbonated beverages unless a policy is adopted after a public hearing.
Directs state agencies and the California school food service association to develop school lunch menu plans that
provide optional vegetarian school lunches.
Sets nutritional standards for food sold in and produced by public schools. Prohibits the sale of carbonated
beverages in every elementary school campus beginning 2004. Sales would cease in middle schools 2005 and
in high school 2007.
Encourages schools and child development programs to provide fresh fruits and vegetables to students on a daily basis.
Creates the Mississippi Council on Obesity Prevention and Management Study; requires a report to legislature.
Directs the council to study the feasibility of tax incentives for worksites that promote activities to reduce
obesity in work force.
Extends the charter for the Mississippi Council on Obesity, Prevention and Management to July 1, 2006.
Creates a task force to address the growing health problems of young people, including obesity and diabetes and
to develop proposed legislation.
Creates the Obesity Study and Prevention Act – Directs Department of Health to analyze the effectiveness of
existing methods of treatments and prevention of obesity and to explore alternative methods.
Recommends obesity treatment coverage in the Medicaid program; supports increased funding for school and
community-based physical activity and nutrition programs, and for public education on the treatment and
prevention of obesity.
Calls for members of General Assembly to participate in “Colorado on the Move.”
Encourages the people of Colorado to value their personal health by making lifestyle changes to prevent
onset of chronic disease. Encourages schools to combat obesity by promoting a healthy diet and exercise.
Encourages workplaces to participate in shaping health and well-being of workers.
Proclaims “California Fitness Day.”
Proclaims “Physical Education and Sports Week” and “Physical Fitness and Sports Month.”
Creates the Joint Study Committee on Physical Activity in Georgia schools.
Requests that the Department of Health and Environmental Control study the effect of obesity in adults and children.
Commemorative or Advisory Resolutions
State
Year
Passed
Obesity-related Legislation Passed by “Save the Children” States, 1999 - 2003 (Adapted from Wellever, 2004)
Appendix C
32
33
2002
2003
CA
CA
CA. Education
Code 8990
CA. Education
Code 8482.3
Chapter 5505
Authorizes nutrition education to be provided as part of the educational enrichment component of
an after school programs.
Specifies that as part of a comprehensive health education program pupils may receive instruction on preventive
health care on topics such as obesity and diabetes.
Requires the Department of Education to incorporate nutrition education into health curriculum.
Resolution Number
or Statute
Location
Description
2001
2001
2001
2002
2002
2003
2003
2002
1999
2002
2003
AR
AR
CA
CA
CA
CA
CA
MS
NM
NM
NM
Chapter 148
Chapter 459
MS Code Ann.
37-13-134
NM Stat. Ann
6-4-10
SJM 17
Chapter 320 of
the Public Acts
of 2001
AR Stat Ann
6-4-1
AR State Ann
20-8-302
Chapter 111
CA. Education
Code 60605.2
CA Education
Code 33352
Chap 93
2002
1999
CA
NM
CA Education
Code 9000
HB762
(appropriation)
Other Obesity Legislation
2001
AZ
Requires the Department of Education to make competition grants available for school districts to start or
expand instructional school gardens and school garden salad bars with a compost program.
Appropriates $100,000 for SFY 2000 for public and professional education on the dangers of and treatments
for obesity and $50,000 for anti-obesity drugs not eligible for reimbursement under the Medicaid program for
low-income persons in need of treatment for critical or chronic obesity.
Requires the Department of Education to document the actual number of minutes of instruction in physical
education provided by each school district to determine compliance with the law.
Recognizes that schools have an obligation to provide physical education to students and urges schools to
comply with those obligations.
Requires that training of after school program staff includes physical fitness standards.
Recommends guidelines to school districts for physical education and fitness classes. Requires study of
relationship between physical activity and classroom performance.
Allows money from the tobacco settlement fund to be appropriated for public school programs including
extracurricular and after-school programs designed to involve students in athletic activities.
Requests that the State Department of Public Education work with the Department of Health and others to
develop strategies to help teachers implement quality physical education curricula.
Creates the “Safe Routes to School:” program to increase and make safer a student’s ability to walk or ride a
bicycle to school.
Establishes CA Task Force on Youth and Workplace Wellness to promote fitness and health in schools and workplaces.
Directs the State Board of Education to adopt model content standards for physical education by 2004.
Mandates K-9 public schools to require no less than 1 hour/week of PE training and instruction which includes no
less than 20 minutes of physical activity 3 times a week.
Creates the “Great Strides” program, which allocates funding for rural communities to establish mile to walking parks.
Appropriates $150,000 over the next two years (FY2001-2003) to fund Department of Health Services
for school-based programs for children’s physical fitness activities.
Physical Education and Physical Activity of Children
2002
CA
Nutrition Education
State
Year
Passed
Appendix C
Action for Healthy Kids
Georgia Coalition for Physical
Activity and Nutrition
The Summit outlined the importance of improving nutrition and physical activity
in Colorado schools.
The Kit includes materials that encourage schools to implement programs and
policies that promote a healthy school environment.
A collaboration of public, private, and non-profit business organizations, and
businesses whose mission is to improve the health of Georgians by promoting
healthy eating and physical activity.
Governor's Council
Professional Database
"Be Active & Care"
The Great Arkansas Workout
Food Marketing and
Advertising Directed at
Children and Adolescents:
Implications for Overweight
Act 1220: BMI Initiative
Arizona Healthy School
Environment Model Policy
AFHK Healthy Schools Summit
The Colorado Physical Activity
and Nutrition Program School
Site Resource Kit
Georgia Coalition for Physical
Activity and Nutrition
Georgia Obesity Action
Network (OAN)
AR
AR
AR
AR
AZ
CO
CO
GA
GA
A group of healthcare professionals that are involved in education, research,
and program initiatives in Georgia relative to child and adolescent physical
activity, nutrition, and overweight.
Serves as a guide to establishing standards for a healthy school environment
such as the following: 30 minutes of physical education and recess before lunch
in elementary schools; 45 minutes of physical education per day in middle and
highschools; encourages schools to offer breakfast and lunch options consistent
with USDA Dietary guidelines; and, adequate space and time for school meals.
Multi-pronged initiative to improve health of Arkansas children
Encourages state government and school districts to designate schools
as advertising-free zones; encourages collaboration of the development of
school policies that promote a healthy eating environment and guidelines for
responsible advertising.
An annual event involving over 600 3rd and 4th graders representing
elementary schools across the state with physical education programs.
After-school program that targets 450 K-5 students at ten different schools
throughout the Little Rock School District.
A database of professional persons from fitness related occupations such as
coaches, former athletes, motivational speakers, and coaches.
Georgia Department of
Human Resources
Action for Healthy Kids
Action for Healthy Kids
Arkansas Center for
Health Improvement
Action for Healthy Kids
National Center for Chronic
Disease Prevention
and Healthy Promotion
Action for Healthy Kids
National Center for Chronic
Disease Prevention
and Healthy Promotion
National Center for Chronic
Disease Prevention and Healthy
Promotion, Arkansas Center for
Health Improvement
AR
Law requiring tobacco settlement monies to be used to provide grants
to rural communities who are interested in building safe, well-lit
walking parks for their citizens.
Act 1750:The Great
Strides Grant
Source
AR
Description
Initiative
State
Appendix D
34
35
American Council for Fitness
and Nutrition
Action for Healthy Kids
Grants ranging from $50,000 to $720,000 are given to purchase equipment
and train teachers.
A networking event brought together health professionals from across
New Mexico to share successes, strategies, and barriers regarding obesity
prevention/reduction programs.
Growing Healthy Kids
Blueprint for Healthy Kids
Tweens
The Partnership for
a Fit Kentucky
CDC grant
Office of Healthy Schools
Delta Nutrition Intervention
Research Initiative
Delta Hope (Health Options
for People Through Extension)
Carol M.White Physical
Education Program (PEP)
Head to Toe Conference
Networking Event
Navigating Guide for Teachers:
Resources for School Health
Coordinated Approach to
Child Health (CATCH)
KY
KY
KY
MS
MS
MS
MS
National
NM
NM
NM
This NM Dept of Education funded program includes nutrition curriculum,
enhanced physical activity, family involvement, and improved school nutrition.
A guide created for New Mexico school personnel provides information
related to student physical health, mental, and emotional health, a safe school
environment, nutrition, physical activity, staff wellness, health education, and
parent and community involvement.
The Cooperative Extension Services at the LSU AgCenter, the University of
Arkansas and Mississippi State University are conducting an eduational initiative
designed to fight childhood obesity in the region.
This initiative is focused on the design, implementation, and evaluation of
nutrition intervention research strategies in 3 rural communities in the Lower
Mississippi Delta using a community-based participatory process.
The Mississippi Department of Education is creating an
Office of Healthy Schools to address health and education in a
coordinated approach.
Mississippi received grants to fund obesity prevention programs in 25
elementary and secondary schools.
This 5 year CDC Obesity grants' mission is a coordinated effort to reduce
and prevent obesity and chronic disease in Kentucky.The plan will target
businesses, communities, the environment, health care and schools.
A social marketing intervention targeting changes in behaviors related to
nutrition and physical activity among children between the ages of 9 and 13.
Kentucky Child Now and the Kentucky School-Based Health Center Coalition
have formed a partnership to improve the health of Kentucky children.
An annual conference designed to help Kentucky youth achieve a healthy weight.
cont.
Center for Disease Control
Action for Healthy Kids
LSU AgCenter
Mississippi Department of Education:
Office of Child Nutrition
Mississippi Department of Education
The Associated Press, April 26, 2004
Center for Disease Control
Center for Disease Control
Kentucky Child Now!
Action for Healthy Kids
Action for Healthy Kids
KY
The Kentucky State Team is collaborating with the Department of Education
to implement a pilot program in 4 elementary schools that incorporate physical
activity in the classroom.
Physical Activity pilot program
Source
KY
Description
Initiative
State
Appendix D
Recess before lunch and the
This program focuses on improving physical activity opportunities and
Breakfast Before School Program emphasizing the importance of adequate time and schedule for school meals.
SC Partnership for Obesity
Prevention (SCPOP)
SCPEAP:The SC Physical
Education Assessment Project
Recess Position Statement
D.U.C.K. - Walking - Discover
and Understand South
Carolina Nutrition Research
Tennessee Healthy Weight
Local coalitions to implement strategies and objectives aimed at improving
Network for Children and Youth health of children and youth
Coordinated School
Action for Healthy Kids
Tennessee Nutrition and
Consumer Education
Program (TNCEP)
Choosy Kids Club
“Success Shared” project
Recipe for Success
NV
SC
SC
SC
SC
TN
TN
TN
WV
WV
WV
This state team developed Recipe for Success, a CD-Rom toolkit that assists
principals in training their peers and identifying key areas of change that model
healthful eating and promote physical activity in schools.
This state team is working on a project that aims to recognize and reward the
accomplishments of schools making positive sustainable changes in nutrition
and physical activity.
An afterschool program for elementary school children from a tri-county area.
This program focuses on Active lifestyles based on healthy decisions.
This nutrition education program is for Tennessee families who receive or
are eligible for Food Stamps. The goal is to teach families how to choose and
prepare nutritionally adequate diets.
Program is intended to reduce tobacco use and addiction, improve eating
patterns, increase physical activity, and reduce obesity among youth.
Program that encourages teachers from elementary schools to incorporate
physical activity into the school week.
The involvement of children in daily, unstructured physical activity during
school hours is critical for their current and future health.
A program assessment to help improve the quality of P.E. classes in SC.
Future efforts include partnering with S.C. Healthy Schools using School
Health index and the implementation of a nutrition education curriculum.
This program, funded by the New Mexico Department of Health advocates
for the inclusion of the 8 components of comprehensive school health. This
group promotes the use of the Emerging Model of Physical Education,
emphasizing life-long physical activity, individual practice and skill opportunities.
Healthier Schools New Mexico
NM
Description
Initiative
State
cont.
Action for Healthy Kids
Action for Healthy Kids
http://www.bechoosy.org
The University of
Tennessee Extension
Tennessee Department of Education
Action for Healthy Kids
South Carolina Nutrition
Research Consortium
South Carolina Coalition for
Promoting Physical Activity
(http://www.sccppa.org/advocacy
/recess.html)
South Carolina Nutrition
Research Consortium
Center for Disease Control
Action for Healthy Kids
Center for Disease Control
Source
Appendix D
36
Photo Credits
Michael Bisceglie: Pages 1, 6, 7, 8, 9, 11, 12, 13, 16, 18, 21
Susan Warner:
Cover, pages 2, 3, 4, 5, 10, 14, 15, 17, 19, 20, 22, 23
37
54 Wilton Road • Wesport, Connecticut 06880
www.savethechildren.org