Childhood obesity in America

¶ … Prevention of Childhood Obesity in America

The work of Berkowitz and Borchard (2009) entitled: Advocating for the Prevention of Childhood Obesity: A Call to Action for Nursing" states that child obesity is a major public health problem as there are "multiple and interrelated factors associated with childhood overweight and obesity..." It is related by Berkowitz and Borchard (2009) that the Centers for Disease Control and Prevention (CDC) describe children "as being risk for overweight if they are above the 85th percentile body mass index (BMI) and defines childhood overweight as a BMI at or above the ex- and age-specific 95th percentile BMI cut points from the 2000 CDC Growth Charts." Health problems associated with childhood obesity include those of Type II diabetes, an increased risk for developing elevated cholesterol, asthma, joint problems, depression, and anxiety. Physical and psychosocial effects of moderate to severe overweight can include: hyperlipidemia, increased growth in puberty and then stunting, early onset of puberty in females, obstructive apnea, pancreatitis, gall bladder disease, hypertension, polycystic ovary syndrome, and long-term damage to the cardiovascular system. (Berkowitz and Borchard, 2009) the work of Myers and Vargas (2000) reports that a 20-year epidemiologic Bogalusa Heart Study "...identified that atherosclerosis, a major cause of heart disease in adults, has its origins in early childhood." (cited in Berkowitz and Borchard, 2009) Overweight or obese students are more like to experience "decreased scholastic performance and absenteeism...increased rates of sadness, loneliness, and nervousness as well as a greater likelihood to smoke and drink alcohol compared to obese children whose self-esteem increased or remained unchanged." (Berkowitz and Borchard, 2009) Factors that contribute to children being overweight or having obesity include those of race, ethnicity, parental knowledge and dietary habits" as well as environmental influences. (Berkowitz and Borchard, 2009)

II. Definition of Terms

BF - Body Fat

BMI - Body Mass Index

III. Obesity Defined

Childhood obesity is defined by Dehghan, Akhtar-Danesh and Merchant (2005) as "...an excess of Body Fat (BF)."

IV. Weight of Children in 1990 Versus 2000

The work of Dehghan, Akhtar-Danesh and Merchant (2005) relate the changes in the prevalence of overweight and obesity in the United States beginning in 1973 and running through 2000 in the following table labeled Figure 1 in this study.

Figure 1

Changes in the prevalence of overweight and obesity in some developed countries

Country/Year

Age/yr

Study (author)

Change in obesity

USA

1973 -- 1994

5 -- 24

Bogalusa [67]

Mean level increased 0.2 kg/yr, twofold increase in prevalence of obesity

1971 -- 1974

6 -- 19

NHANES I [68]

Relatively stable

1976 -- 1980

6 -- 19

NHANES II [68]

Relatively stable

1988 -- 1994

6 -- 19

NHANES III [68]

Doubled to 11%

1999 -- 2000

6 -- 19

NHANES IV [68]

Increased by 4%

Source: Dehghan, Akhtar-Danesh and Merchant (2005)

V. Obesity as a Medical Condition

The work of Dehghan, Akhtar-Danesh and Merchant (2005) state of childhood obesity that while "...the mechanism of obesity development is not fully understood, it is confirmed that obesity occurs when energy intake exceeds energy expenditure. There are multiple etiologies for this imbalance, hence, and the rising prevalence of obesity cannot be addressed by a single etiology." In addition, influencing the susceptibility of the child for obesity are genetic factors... However, environmental factors, lifestyle preferences, and cultural environment seem to play major roles in the rising prevalence of obesity worldwide. In a small number of cases, childhood obesity is due to genes such as leptin deficiency or medical causes such as hypothyroidism and growth hormone deficiency or side effects due to drugs (e.g. -- steroids). Most of the time, however, personal lifestyle choices and cultural environment significantly influence obesity."

VI. Prevention of Obesity Epidemic

The Office of Behavioral and Social Sciences Research: U.S. Department of Health & Human Services reports that a new National Collaborative on Childhood Obesity Research (NCCOR) was launched on February 19, 2009 to accelerate progress on reversing the epidemic of overweight and obesity among U.S. youth. The initiative brings together three of the nation's leading research funders -- the Centers for Disease Prevention and Control (CDC), the National Institutes of Health (NIH) and the Robert Wood Johnson Foundation (RWJF) -- to address the problem of childhood obesity in America. OBSSR is a founding member of NCCOR and provides both financial and program support." (Office of Behavioral and Social Sciences Research: U.S. Department of Health & Human Services, 2009)

The stated mission of the National Collaborative on Childhood Obesity Research (NCCOR) is to "...improve the efficiency, effectiveness and application of childhood obesity research and to halt -- and reverse -- the current childhood obesity trend through enhanced coordination and collaboration." (Office of Behavioral and Social Sciences Research: U.S. Department of Health & Human Services, 2009) NCCOR works toward reduction of childhood obesity in the U.S. through: (1) maximizing outcomes from research; (2) building the capacity for research and surveillance; (3) creating and supporting the mechanisms and infrastructure needed for research translation and dissemination; and (4) supporting evaluations. (Office of Behavioral and Social Sciences Research: U.S. Department of Health & Human Services, 2009)

The report entitled: "Local Government Actions to Prevent Childhood Obesity" published in September 2009 by the Institute of Medicine states that the "...Institute of Medicine (IOM) Committee on Childhood Obesity Prevention Actions for Local Governments was convened to identify promising ways to address this problem on what may well be the epidemic's frontlines." The Institute of Medicine report additionally states that local governments are not only experienced in promotion of children's health but as well local governments are "...are ideally positioned to promote behaviors that will help children and adolescents reach and maintain healthy weights." (2009) Promotion of healthy eating and activities of children will make a requirement that various government officials become involved in the healthy children initiative. Community involvement and evaluation are both stated as critical components in childhood obesity prevention efforts.

Promoting children's healthy eating and activity will require the involvement of an array of government officials, including mayors and commissioners or other leaders of counties, cities, or townships. Many departments, including those responsible for public health, public works, transportation, parks and recreation, public safety, planning, economic development and housing will also need to be involved. Adoption of policies and practices that are focused on raising children in good health and these factors within local communities "have an added opportunity to achieve health equity." (Institute of Medicine, 2009) the Institute of Medicine states that contributors to inequity in the well-being of some groups of people are factors such as "...poverty, poor housing, racial segregation, lack of access to quality education, and limited access to health care..." (2009)

The Institute of Medicine states that health eating is "...characterized as consuming the types and amounts of foods, nutrients, and calories recommended by the Dietary Guidelines for Americans, and adequate physical activity for children constitutes a total of 60 minutes per day." (2009) Nine healthy eating strategies along with six physical activity strategies have been recommended by the Institute of Medicine in the planning, implementing and refining of childhood obesity prevention efforts by local government officials. Also stated are 12 steps stated to have the most promise. The following is a list of the nine healthy eating strategies, six physical activity strategies and 12 steps toward these goals and strategies.

Goal 1 -- Improve Access to and Consumption of Healthy, Safe and Affordable Foods.

Strategy 1: Retail Outlets - Increase community access to healthy foods through supermarkets, grocery stores, and convenience/corner stores. (Institute of Medicine, 2009)

Action Steps: (1) Create incentive programs to attract supermarkets and grocery stores to underserved neighborhoods (e.g., tax credits, grant and loan programs, small business/economic development programs, and other economic incentives); (2) Realign bus routes or provide other transportation, such as mobile community vans or shuttles to ensure that residents can access supermarkets or grocery stores easily and affordably through public transportation; (3) Create incentive programs to enable current small food store owners in underserved areas to carry healthier, affordable food items (e.g., grants or loans to purchase refrigeration equipment to store fruits, vegetables, and fat-free/low-fat dairy; free publicity; a city awards program; or linkages to wholesale distributors); (4) Use zoning regulations to enable healthy food providers to locate in underserved neighborhoods (e.g., "as of right" and "conditional use permits; and (5) Enhance accessibility to grocery stores through public safety efforts, such as better outdoor lighting and police patrolling. (Institute of Medicine, 2009)

Strategy 2: Restaurants - Improve the availability and identification of healthful foods in restaurants. (Institute of Medicine, 2009)

Action Steps: (1) Require menu labeling in chain restaurants to provide consumers with calorie information on in-store menus and menu boards; (2) Encourage non-chain restaurants to provide consumers with calorie information on in-store menus and menu boards; (3) Offer incentives (e.g., recognition or endorsement) for restaurants that promote healthier options (for example, by increasing the offerings of healthier foods, serving age-appropriate portion sizes, or making the default standard options healthy -- i.e., apples or carrots instead of French fries, and non-fat milk instead of soda in "kids' meals"). (Institute of Medicine, 2009)

Strategy 3: Community Food Access - Promote efforts to provide fruits and vegetables in a variety of settings, such as farmers' markets, farm stands, mobile markets, community gardens, and youth-focused gardens. (Institute of Medicine, 2009)

Action Steps: (1) Encourage farmers markets to accept Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package vouchers and WIC Farmers Market Nutrition Program coupons; and encourage and make it possible for farmers markets to accept Supplemental Nutrition Assistance Program (or SNAP, formerly the Food Stamp Program) and WIC Program Electronic Benefit Transfer (EBT) cards by allocating funding for equipment that uses electronic methods of payment; (2) Improve funding for outreach, education, and transportation to encourage use of farmers markets and farm stands by residents of lower-income neighborhoods, and by WIC and SNAP recipients. Introduce or modify land use policies/zoning regulations to promote, expand, and protect potential sites for community gardens and farmers' markets, such as vacant city-owned land or unused parking lots (3) Develop community-based group activities (e.g., community kitchens) that link procurement of affordable, healthy food with improving skills in purchasing and preparing food. (Institute of Medicine, 2009)

Strategy 4 - Public Programs and Worksites - Ensure that publicly-run entities such as after-school programs, child-care facilities, recreation centers, and local government worksites implement policies and practices to promote healthy foods and beverages and reduce or eliminate the availability of calorie-dense, nutrient-poor foods. (Institute of Medicine, 2009)

Action Steps: (1) Mandate and implement strong nutrition standards for foods and beverages available in government-run or regulated after-school programs, recreation centers, parks, and child care facilities (which includes limiting access to calorie-dense, nutrient-poor foods); (2) Ensure that local government agencies that operate cafeterias and vending options have strong nutrition standards in place wherever foods and beverages are sold or available; (3) Provide incentives or subsidies to government run or regulated programs and localities that provide healthy foods at competitive prices and limit calorie-dense, nutrient poor foods (e.g., after-school programs that provide fruits or vegetables every day, and eliminate calorie-dense, nutrient poor foods in vending machines or as part of the program). (Institute of Medicine, 2009)

Strategy 5: Government Nutrition Programs - Increase participation in federal, state, and local government nutrition assistance programs (e.g., WIC, school breakfast and lunch, the Child and Adult Care Food Program [CACFP], the Afterschool Snacks Program, the Summer Food Service Program, SNAP). (Institute of Medicine, 2009)

Action Steps: (1) Put policies in place that require government-run and -regulated agencies responsible for administering nutrition assistance programs to collaborate across agencies and programs to increase enrollment and participation in these programs (i.e., WIC agencies should ensure that those who are eligible are also participating in SNAP, etc.); (2) Ensure that child care and after-school program licensing agencies encourage utilization of the nutrition assistance programs and increase nutrition program enrollment (CACFP, Afterschool Snack Program, and the Summer Food Service Program). (Institute of Medicine, 2009)

Strategy 6: Breastfeeding - Encourage breastfeeding and promote breastfeeding-friendly communities. (Institute of Medicine, 2009)

Action Steps: (1) Adopt practices in city and county hospitals that are consistent with the Baby-Friendly Hospital Initiative USA (United Nations Children's Fund/World Health Organization). This initiative promotes, protects, and supports breastfeeding through ten steps to successful breastfeeding for hospitals; (2) Permit breastfeeding in public places and rescind any laws or regulations that discourage or do not allow breastfeeding in public places and encourage the creation of lactation rooms in public places; (3) Develop incentive programs to encourage government agencies to ensure breastfeeding-friendly worksites, including providing lactation rooms; (4) Allocate funding to WIC clinics to acquire breast pumps to loan to participants. (Institute of Medicine, 2009)

Strategy 7: Drinking Water Access - Increase access to free, safe drinking water in public places to encourage water consumption instead of sugar-sweetened beverages. (Institute of Medicine, 2009)

Action Steps: (1) Require that plain water be available in local government-operated and administered outdoor areas and other public places and facilities; and (2) Adopt building codes to require access to and maintenance of fresh drinking water fountains (e.g., public restroom codes). (Institute of Medicine, 2009)

Goal 2: Reduction of Access to and Consumption of Calorie-Dense, Nutrient-Poor Foods.

Strategy 8: Policies and Ordinances - Implement fiscal policies and local ordinances to discourage the consumption of calorie-dense, nutrient-poor foods and beverages (e.g., taxes, incentives, land use and zoning regulations). (Institute of Medicine, 2009)

Action Steps: (1) Implement a tax strategy to discourage consumption of foods and beverages that have minimal nutritional value, such as sugar-sweetened beverages; (2) Adopt land use and zoning policies that restrict fast food establishments near school grounds and public playgrounds; (3) Implement local ordinances to restrict mobile vending of calorie-dense, nutrient-poor foods near schools and public playgrounds; (4) Implement zoning designed to limit the density of fast food establishments in residential communities (5) Eliminate advertising and marketing of calorie-dense, nutrient-poor foods and beverages near school grounds and public places frequently visited by youths; (6) Create incentive and recognition programs to encourage grocery stores and convenience stores to reduce point-of-sale marketing of calorie-dense, nutrient-poor foods (i.e., promote "candy-free" check out aisles and spaces). (Institute of Medicine, 2009)

Goal 3: Raise Awareness about the Importance of Healthy eating to prevent childhood obesity.

Strategy 9: Media and Social Marketing - Promote media and social marketing campaigns on healthy eating and childhood obesity prevention. (Institute of Medicine, 2009)

Action Steps: (1) Develop media campaigns, utilizing multiple channels (print, radio, internet, television, social networking, and other promotional materials) to promote healthy eating (and active living) using consistent messages; (2) Design a media campaign that establishes community access to healthy foods as a health equity issue and reframes obesity as a consequence of environmental inequities and not just the result of poor personal choices; (3) Develop counter-advertising media approaches against unhealthy products to reach youth as has been used in the tobacco and alcohol prevention fields. (Institute of Medicine, 2009)

Actions for Increasing Physical Activity

Goal 1: Encourage Physical Activity.

Strategy 1: Built Environment - Encourage walking and bicycling for transportation and recreation through improvements in the built environment. (Institute of Medicine, 2009)

Action Steps: (1) Adopt a pedestrian and bicycle master plan to develop a long-term vision for walking and bicycling in the community and guide implementation; (2) Plan, build, and maintain a network of sidewalks and street crossings that creates a safe and comfortable walking environment and that connects to schools, parks, and other destinations; (3) Plan, build, and retrofit streets so as to reduce vehicle speeds, accommodate bicyclists, and improve the walking environment; (4) Plan, build, and maintain a well-connected network of off-street trails and paths for pedestrians and bicyclists; (5) Increase destinations within walking and bicycling distance; (6) Collaborate with school districts and developers to build new schools in locations central to residential areas and away from heavily trafficked roads. (Institute of Medicine, 2009)

Strategy 2: Programs for Walking and Biking / Promote programs that support walking and bicycling for transportation and recreation. (Institute of Medicine, 2009)

Action Steps: (1) Adopt community policing strategies that improve safety and security of streets, especially in higher crime neighborhoods; (2) Collaborate with schools to develop and implement a Safe Routes to School program to increase the number of children safely walking and bicycling to schools; (3) Improve access to bicycles, helmets, and related equipment for lower-income families, for example, through subsidies or repair programs; (4) Promote increased transit use through reduced fares for children, families, and students, and improved service to schools, parks, recreation centers, and other family destinations; (5) Implement a traffic enforcement program to improve safety for pedestrians and bicyclists. (Institute of Medicine, 2009)

Strategy 3: Recreational Physical Activity - Promote other forms of recreational physical activity. (Institute of Medicine, 2009)

Action Steps: (1) Build and maintain parks and playgrounds that are safe and attractive for playing and in close proximity to residential areas; (2)( Adopt community policing strategies that improve safety and security for park use, especially in higher crime neighborhoods; (3) Improve access to public and private recreational facilities in communities with limited recreational options through reduced costs, increased operating hours, and development of culturally appropriate activities; (4) Create after-school activity programs, e.g., dance classes, city-sponsored sports, supervised play, and other publicly or privately supported active recreation; (4) Collaborate with school districts and other organizations to establish joint use of facilities agreements allowing playing fields, playgrounds, and recreation centers to be used by community residents when schools are closed; if necessary, adopt regulatory and legislative policies to address liability issues that might block implementation; (5) Create and promote youth athletic leagues and increase access to fields, with special emphasis on income and gender equity; (6) Build and provide incentives to build recreation centers in neighborhoods. (Institute of Medicine, 2009)