Education Policy Brief

Childhood Obesity and Nutrition Issues in the United States: An Update on School-based Policies and Practices

Terry Spradlin, Greta Gard, Vivian Huang, Beth Kopp, and Alanna Malik

VOLUME 10, NUMBER 1, SPRING 2012

2010, all states and Washington, D.C. had CONTENTS INTRODUCTION obesity rates in 2010 that far exceeded 15% (Robert Wood Johnson Foundation Introduction...... 1 Since the Center for Evaluation & Educa- [RWJF], 2009; U.S. Department of Health tion Policy’s (CEEP) policy brief, Child Obesity Trends and Costs...... 2 and Human Services, 2010). Obesity in Indiana: A Growing Public Pol- The Effects of Childhood Obesity...... 3 icy Concern, was published in 2005, rising America’s obesity problem has a signifi- obesity rates in the United States have con- cant impact on children and adolescents. A Decline in Physical Education...... 3 tinued to generate headlines and spark Since the 1960s, obesity rates in the U.S. extensive public discourse (Cline, Plucker, have more than quadrupled among children The School Food Environment ...... 4 & Spradlin, 2005). Obesity is not just a per- ages 6 to 11, more than tripled among ado- Federal and State Initiatives to sonal matter — it is also a public health lescents ages 12 to 19, and more than dou- Combat Childhood Obesity...... 6 epidemic that affects education achieve- bled among children ages 2 to 5 (Koplan, ment outcomes, economic productivity, Liverman, & Kraak, 2007). Today, nearly Wellness Policies...... 8 and state budgets. 23 million U.S. children and teens are either overweight or obese (see Figure 2) Major Findings for Indiana ...... 8 Within the last 20 years, obesity rates (Ogden, Carroll, & Flegal, 2008). Prevent- Policy Perspective among all groups in society — irrespective ing obesity during childhood is of critical U.S. Senator Richard Lugar...... 9 of age, sex, race, socioeconomic status, importance because habits formed during education level, or geographic region — childhood and adolescence usually persist Conclusions and have noticeably increased (Centers for Dis- into adulthood, making overweight chil- Recommendations ...... 11 ease Control and Prevention [CDC], 2009). dren and adolescents more likely to become Some health officials are now referring to Authors...... 12 overweight adults (Story, n.d.). childhood obesity as a pandemic. Accord- Acknowledgements...... 12 ing to the World Health Organization’s This Education Policy Brief will examine (WHO) most recent data, the United States the latest research and statistics regarding References ...... 12 has the sixth highest percentage of over- childhood obesity. In addition to providing weight adults compared to other countries an overview of current trends and effects of Web Resources...... 16 with available BMI (body mass index) data childhood obesity, this brief considers the (WHO, n.d.). Today, more than one third of reasons for the increase in obesity rates American adults (over 72 million people) among children, as well as the latest federal are considered obese (CDC, 2009). Within and state initiatives created to combat the past 50 years, the obesity rates for childhood obesity. In particular, the brief Americans have nearly tripled, growing highlights the significance of the Healthy, from 13.4% in 1960 to 35.1% in 2006. As Hunger-Free Kids Act of 2010, the “Let’s a result, there are currently more Ameri- Move” campaign, and recent soda tax ini- UPCOMING POLICY BRIEFS . . cans who are obese than are merely over- tiatives. The brief also considers local pol- weight (see Figure 1). icies addressing obesity, providing a summary of 41 wellness policies collected  The Evolution of Indiana’s School In 2008, 23 states saw a significant increase from school districts throughout Indiana. Accountability System in obesity, but not a single state had a sig- Finally, we offer conclusions and recom-  Trends in Virtual Learning in the U.S. nificant decrease. Although the U.S. mendations to schools and education lead-  Quantifying the Impact of Chronic Department of Health and Human Services ers, policymakers, and parents about how Absenteeism in Indiana’s K-12 Public (HHS) set a national goal under the to curb the obesity epidemic. Schools Healthy People initiative in 2000 to reduce adult obesity rates to 15% in every state by OBESITY TRENDS AND COSTS Figure 1. Age-adjusted prevalence of overweight, obesity, and extreme obese among U.S. adults aged 20-74 According to a 2011 report published by the Trust for America’s Health and the Robert Wood Johnson Foundation, Indiana has the 15th highest percentage of obese adults, an increase from its 16th place rank- ing in 2009. An alarming trend for Indiana is the percentage of obese and overweight children, now 27th in the nation and sur- passing four other states since 2009 (RWJF, 2011). In 2010, Indiana had a higher per- centage of overweight adults than any of its neighboring states (see Figure 3). Further- more, approximately 220,000 of 667,000 Indiana children ages 10-17 years (32.9%) are considered overweight or obese accord- ing to BMI-for-age standards (Childhood Obesity Action Network [COAN], n.d.).

Obesity is not just a disease that puts peo- ple at risk of further health concerns, it is also expensive. Obese people spend on Source: CDC, 2010c. average 42% more on health care than their healthy-weight counterparts (Finkelstein, Trogdon, Cohen, & Dietz, 2009). Accord- Figure 2. Prevalence of Obesity among U.S. Children and Adolescents Aged 2-19, for ing to researchers, the medical costs of obe- selected years 1963-1965 through 2007-2008 sity were estimated at approximately $78.5 billion nationwide in 1998, with roughly half of those expenses financed by Medi- care and Medicaid. In 2000, total costs reached $117 billion (CDC, 2009). By 2008, obesity-related health expenses had nearly doubled from the previous decade, reaching $147 billion a year, or nearly 10% of all yearly medical expenditures (Finkel- stein et al., 2009). Another researcher pre- dicts that in 2018, the U.S. will spend approximately $344 billion on health care costs attributable to obesity if the rates con- tinue to increase at their current levels (Thorpe, 2009). In Indiana, the 2008 health care spending on obesity-related illnesses amounted to $1.9 billion (Indiana State Department of Health, 2011).

The economic consequences of childhood obesity are extremely high. Nationally, the. direct costs for overweight or obese chil- Source: National Center for Health Statistics (2009). dren ages 6 to 19 totaled $14.1 billion * Data for first time period (1963-70) are from 1963-65 only for children ages 6-11 years and between 2002 and 2005 (Trasand & Chat- from 1966-70 only for adolescents ages 12-18 years. terjee, 2009). The costs included annual prescription drugs, emergency room visits, $1,429 (or 42%) more per year on medical and outpatient visits. It is estimated that the expenses, primarily for prescription drugs yearly average total health expenses for a to treat obesity-related illnesses, than child treated for obesity are more than someone who is of normal weight (Finkel- three times that of the average child stein et al., 2009). (Marder & Chang, 2006). Research shows that an adult who is obese spends about

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —2 Figure 3. Percentage of Overweight Adults in Indiana and Surrounding States. A DECLINE IN PHYSICAL EDUCATION

Numerous experts have indicated that physical activity in schools is vital for the well-being of children. It helps combat obe- sity and teaches habits that promote healthy lifestyles. Recent studies have demon- strated that integrating even a simple phys- ical activity such as walking into the curriculum improves children’s ability to pay attention in the classroom and results in better performance on academic achieve- ment tests (Hillman, 2009). Another study showed that adolescents who reported either participating in school activities, such as physical education and team sports, or playing sports with their parents were 20% more likely than their sedentary peers to earn an “A” in math or English (Nelson & Gordon-Larsen, 2006). Source: CDC, 2010b. Beyond academic achievement, studies suggest that physical activity directly ben- efits cognition. In one study, in which chil- healthy children and adolescents. Though dren jogged for about 30 minutes two to the reasons for absenteeism were not inves- THE EFFECTS OF CHILDHOOD four times per week, researchers measured tigated, the researchers pointed out that OBESITY a significant increase in activity in the pre- missed school days may subsequently lead frontal cortex, suggesting greater cognitive The consequences of excess weight are to poor school performance (Schwimmer, function. However, the cognitive gains both numerous and significant. Obesity is Burwinkle, & Varnie, 2003). associated with an increased risk of heart were only sustained while children main- disease, stroke, diabetes, some cancers, Children’s health and ability to learn in tained the jogging regimen (Harada, hypertension, osteoarthritis, gallbladder school are strongly correlated. Poor nutri- Okagawa, & Kubota, 2004). The cognitive disease, and disability. In children and ado- tional status has been proven to interfere gains from increased physical activity can lescents, being overweight increases the with cognitive function and is often associ- be seen in students of all ages and of varied risk of hypertension, high cholesterol, ated with low academic performance. The physical and cognitive abilities, including orthopedic disorders, sleep apnea, diabe- school environment can be a powerful cat- children with special needs and/or learning tes, low self-esteem, and becoming an alyst in decreasing the prevalence of obe- disabilities (Sibley & Etnier, 2003). Addi- overweight adult (National Center for sity and overweight youth. Schools tional benefits of physical activity include Health Statistics, 2009). Children treated offering a comprehensive approach to increased self-esteem, which may influ- for obesity are also at a higher risk for men- combating obesity are most effective. ence positive academic achievement and tal health and bone and joint disorders than Healthy school breakfast and lunch pro- better classroom behavior (Tremblay, are their non-obese peers (Marder & grams and ensuring physical education Inman, & Willms, 2000). (PE) as part of the curriculum have been Chang, 2006). Despite the demonstrated benefits of phys- shown to improve educational attainment ical activity, studies show that most youth In children, being obese or overweight has when employed collectively (Basch, do not meet physical activity guidelines, been conclusively linked to decreased 2010). Conversely, extraordinarily low which recommend an hour or more of attendance and academic achievement. A levels of physical activity among youth moderate-to-vigorous physical activity a recent CDC review of 50 studies deter- significantly increase the likelihood of day (CDC, 2003, 2008). Moreover, recent mined that physical activity increases stu- children becoming overweight and obese budgetary constraints and increasing pres- dents’ academic performance in areas such (Gordon-Larsen, Adair, Nelson, & Popkin, sure to improve standardized test scores in as grades and standardized test scores 2004; Kimm et al., 2001, 2002; Ogden, core subject areas have caused school offi- (CDC, 2010a). Another study concluded Carroll, & Flegal, 2006; Ogden, Flegal, cials to substantially reduce the time avail- that decreased academic achievement Carroll, & Johnson, 2002). Research fur- able for physical education. In some could be tied to the increased school absen- ther suggests that schools offering physical schools, PE programs have been com- teeism rate of obese children and adoles- education programs not only reduce obe- pletely eliminated (NASPE & AHA, cents. In the study, obese children and sity but also increase students’ attendance 2006). A 2007 study found that in a nation- adolescents missed a mean of 4.2 days of (Geier et al., 2007; Shore et al., 2008). school a year compared to a mean of 1.7 for ally representative survey of 349 school

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —3 districts, 62% of elementary schools and In November 2007, the USDA released the more than 20% of middle schools reported THE SCHOOL FOOD School Nutrition Dietary Assessment increased time for English/language arts ENVIRONMENT Study-III, which compared nutrients in (E/LA) and math since the 2001-02 school school lunches to the SMI standards. At the year (when No Child Left Behind was time of the study, only 21% of schools enacted). However, to accommodate for School Lunches served lunches that met the total fat stan- this increased time in E/LA and math, 44% dard, only 30% of schools served lunches of districts reported cutting time from one In 1946, the National School Lunch Pro- that met the saturated fat standard, only 6 to or more other subjects or activities such as gram (NSLP) was signed into law by Pres- 7% of schools served lunches that met all of social studies, science, art, music, physical ident Harry S. Truman with the goal of the SMI standards, and virtually no schools education, or recess at the elementary absorbing farm surpluses while simultane- serve lunches that met the sodium bench- level. The decrease was a 32% reduction ously guaranteeing a hot meal to all school- mark (Gordon et al., 2007). on average in the total instructional time age children. Over the past 60 years the devoted to these subjects since 2001-02 NSLP has helped combat childhood hun- More recently, a study released in 2009 by (McMurrer, 2007). ger and improve childhood nutrition, with the University of Michigan Cardiovascular more than 31 million children benefiting Center found that students who eat lunches Because there are no federal laws requiring from the program in Fiscal Year 2010 served by their schools are more likely to schools to offer physical education, many (United States Department of Agriculture be overweight or obese compared to chil- states have delegated responsibility for [USDA], n.d.). Recently, however, con- dren who bring their lunches from home. educational decisions regarding physical cerns have been raised about the program’s Not only were school-fed children more activity to the local school district or have ability to meet its original goal, especially than twice as likely to consume fatty meats imposed direct mandates. Currently, 43 as obesity has eclipsed malnutrition as the (25.8% versus 11.4%) and sugary drinks states mandate PE for elementary school central childhood nutrition problem. (36% versus 14.5%), but they also con- students, 40 states mandate PE for middle sumed fewer fruits and vegetables (16.3% students, and 46 states mandate PE for high versus 91.2%) (American College of Car- school students (NASPE, 2010). diology, 2010).

In Indiana, there is no state mandate for Though the U.S. Department of Agricul- physical education in elementary or middle ture provides $1 billion to the NSLP for school. Students are required to take PE as ...students who eat more than 180 different commodities, a part of a balanced curriculum, but there is lunches served by their including meats, cheeses, rice, pasta, pro- no year or grade specified. Although a man- schools are more likely to duce, and legumes, school districts nation- date for high school physical education be overweight or obese ally spent roughly 72% of the commodity exists as a graduation requirement, it does funds on meat and cheese items, which are compared to children who not specify the grade or the year of partici- both relatively high in fats and saturated pation in physical education during a stu- bring their lunches fats. In addition, more than 50% of com- dent’s high school tenure. In 2005, the from home. modity foods are sent to processors before Indiana Department of Education (IDOE) they are delivered to schools. Because pro- changed the number of credits awarded to cessing is not regulated for nutritional students for taking a physical education quality and often involves adding fat, course. Beginning with students who sugar, and sodium to the products (such as entered high school in fall 2006, students making chicken into chicken nuggets), received one credit each semester instead of Put in place in the mid-1990s, the USDA many of the “healthier” commodities one-half credit per semester. This change, School Meals Initiative for Healthy Chil- become foods of minimal nutritional value however, did not necessarily increase stu- dren (SMI) aimed to align school meals before reaching students (RWJF, 2008). dent participation in physical education with the Dietary Guidelines for Americans courses. In 2009, the IDOE made changes by increasing levels of whole grains, fresh allowing schools to award PE credits based fruit, and fresh vegetables, and reducing on a demonstration of proficiency against levels of fat, saturated fat, sodium, and Competitive Foods the Academic Standards for Physical Edu- sugar in school meals. SMI standards also Though school lunches are subject to fed- cation through student participation in “a required schools to offer meals that provide eral standards, competitive foods (foods variety of experiences, including those out- no more than 30% of total calories from fat and beverages sold outside of the USDA’s side of the classroom” (Zaring, 2009). In and less than 10% from saturated fat, while school meal program) have not faced the many states, including Indiana, these expe- providing adequate levels of target nutri- same oversight. Often sold in vending riences have included varsity sports, cheer- ents. The SMI is especially important since machines, snack bars, and à la carte lines in leading, and even band. research has shown that children are eating schools, competitive foods are a valued less fruit and consuming more beverages source of revenue for many schools. such as fruit drinks, sport drinks, and fruit Nationwide, nearly one in five elementary juice (Piernas & Popkin, 2010). schools, one third of all middle schools, and half of all high schools have a school store,

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —4 canteen, or snack bar where students can Signed into law in 2006, the bill (referred lunch at school also participate in the purchase food or beverages. Vending to as Public Law 54) was a positive step breakfast program (U.S. Department of machines were also present in 21% of ele- toward regulating the nutritional qualities Agriculture, 2010). mentary schools, 62% of middle schools, of competitive foods, but it is still very lim- and 86% of high schools (Larson & Story, ited in its effects, as only 50% of all com- In an attempt to address the barriers and 2010). Students who consumed competitive petitive foods are required to be “better increase participation in the SBP, various food items often reduced their school lunch choice” foods (see Table 1). schools in New York adopted the “Break- servings. Because the competitive foods fast After the Bell” program in its schools. sold are rarely nutritious, this can result in By incorporating the following alternative methods, New York schools were able to lower intakes of vitamins and minerals and The School Breakfast Program higher intakes of calories and fat (Story, give all students an opportunity to partici- Kaphingst, & French, 2006). Kubik et al. Originally begun as a pilot project in 1966 pate in the breakfast program: and made permanent by Congress in 1975, found that the greater the availability of à la • Grab and Go: A bagged, hand-held carte foods at lunch, the lower the daily the School Breakfast Program (SBP) funds breakfasts for students in public or private meal picked up in a high-traffic area intake of fruits and vegetables, and the such as a school lobby. This breakfast is higher the intake of daily total fat and satu- schools. All students are eligible to partici- pate, but as is the case with the National convenient for students to eat on the go rated fat. Similarly, the greater the avail- or in the classroom. ability of snack vending machines, the School Lunch Program, students who qual- lower the students’ intake of fruit (Kubik, ify under income guidelines receive break- • Breakfast on the Bus: A pre-bagged Lytle, Hannan, Pery, & Story, 2003). fast for free or at a reduced price (Nutrition meal provided to students when getting Consortium of New York State, n.d.). on the bus or served to students on the Though such studies highlight the impor- bus while waiting to enter the school. tance of restricting competitive foods in Studies have shown that eating a daily Students who have long bus rides are schools, federal regulations have only breakfast has many positive effects and is able to eat breakfast without being late restricted a small subset of competitive essential to the health and well-being of for class. foods in schools by prohibiting the sale of children. Children who eat breakfast at school are less hungry, less likely to be • Breakfast After First Period: Ideal for foods of minimal nutritional value high schools, breakfast service time is (FMNV) in the food service areas during tardy, and less likely to visit the school nurse. In addition, students who eat break- extended until after the first academic mealtimes. However, the Healthy, Hunger- class. This allows students to eat a Free Kids Act of 2010 (discussed fully on fast every morning also have improved nutrition and student achievement (Food snack or incorporate a morning meal page 6) provides the U.S. Department of into their routines. Agriculture (USDA) with the authority to Research and Action Center, 2010a). How- set new nutrition standards for all foods ever, barriers such as hectic morning • Universal Classroom Breakfast: All served in schools, including venting schedules, late bus schedules, not having students eat breakfast in the classroom machines. Because FMNVs have been enough time to eat before class begins, during morning announcements. Meals defined as foods providing less than 5% of pressure to arrive at class on time, and are delivered to the classroom and all the recommended intakes for eight key social stigmas prevent maximum participa- children eat, reducing the stigma that nutrients, only some competitive foods, tion in the SBP (Food Research and Action only low-income children eat breakfast like soda, gum, hard candies, and jelly Center, 2010a). As a result, despite the fact at school (Nutrition Consortium of New beans have been restricted. Other competi- that 86% of schools across the country York State, n.d.; Office of the First tive foods, such as candy bars, chips, and offer breakfast to their students, fewer than Lady, 2010). ice cream, have not been considered half of the low-income children who eat FMNVs and may be sold in the cafeteria during meal periods until the USDA issues guidelines or rules stating otherwise (U.S. General Accounting Office, 2004). Table 1. “Better Choice” Food and Beverages

Some states, including Indiana, have cre- “Better Choice” Beverages are: ated restrictions on the use of vending Fruit- or vegetable-based drinks that: machines and FMNVs. In 2007, a study • Contain at least 50% real fruit or vegetable juice; and conducted by the Center for Science in the • Do not contain additional caloric sweeteners. Public Interest (CSPI) found that only 12 states have “comprehensive school food “Better Choice” Foods Meet the Following Standards: and beverage nutrition standards that apply • No more than 30% of total calories from fat. to the whole campus and whole school day • No more than 10% of total calories from saturated and trans fat. at all grade levels” (CSPI, 2007). In Indi- ana, Senate Bill 111 was passed to require • No more than 35% of product weight from sugars that do not occur naturally in fruits, vegetables, or dairy products. that 50% of all competitive foods sold to students during the school day must qual- Source: Indiana Code §20-26-9-19 ify as “better choice” foods or beverages.

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —5 With the help of the Health and Human school activities, and co-curricular fit- FEDERAL AND STATE Services Department, the Department of ness programs; INITIATIVES TO COMBAT Education, the Housing and Urban Devel- • Educate administrators, educators, stu- CHILDHOOD OBESITY opment Department, the Federal Trade dents, and parents about the role of Commission, the Department of Agricul- sound nutrition and physical activity in In recent years, as awareness of the risks ture, and the White House, the First Lady academic achievement; and costs of obesity has increased, numer- and the task force noted that the agencies • Locate and secure national, state, and ous initiatives to combat childhood obesity and the White House reserve the right to local financial backing to provide sup- have been launched at both the state and use more extreme measures such as sub- port for the sustainability of school ini- federal levels. These programs seek to pre- poenas and new regulations in order to tiatives; and vent and treat obesity and to further achieve their goals (Office of the First improve the health of Americans. Lady, 2010). • Provide resources for schools to empower change. (Indiana Action for Healthy Kids, n.d.) “Let’s Move” Campaign Action for Healthy Kids In February of 2010, First Lady Michelle Billed as one of the nation’s leading non- Obama launched a “Let’s Move” public- profit organizations, Action for Healthy Healthy, Hunger-Free Kids Act awareness campaign against childhood Kids (AFHK) was founded in 2002 to part- of 2010 obesity. The campaign, which encom- ner with schools in fighting childhood obe- passes a wide range of initiatives aimed at sity and undernourishment by improving The Healthy, Hunger-Free Kids Act of ending childhood obesity within a genera- nutrition and increasing physical activity. 2010 commits an additional $4.5 billion to tion, defines success as returning the coun- The organization operates on both the fed- child nutrition programs over the next 10 try to a childhood obesity rate of 5%. Mrs. eral and state levels, providing expertise as years and directs the USDA to set new Obama, along with the White House Task well as programs and volunteers to schools nutrition standards for all foods served in Force on Childhood Obesity, released a and school districts in all 50 states (Action schools, from lunchrooms to vending 124-page report which outlined 70 recom- for Healthy Kids, 2009). machines. According to Senator Blanche mendations, including: Lincoln (D-AR), the Act will help over 30 In Indiana, the AFHK State Team’s (Indi- million children nationally who participate • Standardizing all labels on packaged ana Action for Healthy Kids) goal is to in the National School Lunch Program and foods; improve the health and educational perfor- more than 10 million children who partici- mance of children through better nutrition • Limiting the licensing of popular char- pate in the School Breakfast Program. In and physical activity in schools. In order to acters by restaurant chains to only general, the Bill will: meet this goal, the team has outlined the meals containing healthy foods; following objectives: • Allocate an additional $4.5 billion to • Encouraging women to breastfeed their fund school food programs over the children as an obesity preventive; • Award schools that are dedicated to next 10 years; teaching students life-long healthy hab- • Recommending that pediatricians not its and for making positive changes in • Enforce standards through a collabora- only monitor a child’s weight but also their school health environment with tive effort with food and beverage dis- his or her body mass index (BMI); the “Healthy Hoosier School Award.” tribution companies and public health • Getting more children enrolled in the Schools selected for this honor receive a officials; summer meals program, which pro- monetary award and recognition. In • Provide a 6% increase in reimburse- vides balanced meals when school is 2010-11, 113 Indiana elementary, mid- ments to schools for children in need of out of session; dle, and high schools received the free or low-cost lunches; • Making sure all children are physically Healthy Hoosier School Award (IDOE, • Fund the creation and promotion of active; 2011); farm-to-school programs and school • Increasing the availability of healthier • Improve school children’s eating habits gardens that would provide fresh pro- foods in schools; and by increasing access to nutritious foods duce for school lunches (Food Research and beverages on school grounds while and Action Center, 2010b); and • Eliminating “food deserts”— low- reducing access to high-calorie, low- • Automatically qualify an additional income communities that have limited nutrient options; access to quality, affordable, and nutri- 115,000 children in school meals pro- tious food options beyond the ubiqui- • Integrate nutrition education into the grams based on eligibility criteria from tous fast-food chains and corner stores. curriculum for all school children; Medicaid data. In addition, the committee also set out goals • Increase students’ physical activity The Act not only addresses the institutional to measure progress. For example, the com- through physical education courses; capacity of providing healthy school mittee aims to have children eating 75% of recess; and the integration of physical lunches, it also takes significant steps in the USDA recommended serving of fruits activity into academic classes, after- curbing the prevalence of childhood hun- by 2015, 85% by 2020, and 100% by 2030. ger. In particular, the Act will:

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —6 • Increase the provision of after-school or more an ounce. A report from the Tax feeding programs nationwide; Foundation notes that this could result in a • Lengthen the certification period of Soda Taxes tax of as much as 136% on some beverages (Drenkard, 2011). eligible children participating in the Sugar-sweetened beverages, such as soda, Special Supplemental Nutritional sweetened tea, or fruit punch, have consis- Opponents of the tax maintain that the Program for Women, Infants and tently been shown to be associated with a taxes are often too small to affect consump- Children (WIC) to one year; poor diet and to be one of the main causes tion, as a few recent studies found that • Authorize grants to maintain summer for the increasing rates of obesity and dia- higher soda taxes are very weakly associ- food program sponsors and breakfast betes. It is estimated that sugar-sweetened ated with adolescent and adult weight lev- programs; and beverages make up nearly 11% of chil- els (Brownell et al., 2009; Chriqui, Eidson, Bates, Kowalczyk, & Chaloupka, 2007). • Support research into the causes and dren’s total caloric consumption (Wang, Bleich, & Gortmaker, 2008). As a result, consequences of child hunger. Yet, advocates of soda taxes argue that some states have launched efforts to limit there are practical reasons why most states In addition, the Act seeks to establish sodas and other sweetened beverages in have implemented sales taxes on soft healthy eating options and rigorous nutri- schools. With the implementation of Public drinks. Carbonated soft drinks and sugar- tional standards in an effort to reduce the Law 54 (Senate Enrolled Act 111) in 2006, sweetened beverages are much more easily number of obese children by: Indiana became one of the first states in the defined than other categories of snack nation to do so. A 2011 study funded by the • Offering continued support to farm-to- items, which makes it easier to apply and National Institutes of Health and the Rob- school meal programs; charge such taxes. Furthermore, youth ert Wood Johnson Foundation demon- have increased their consumption of calo- • Increasing the availability of schools’ strates, however, that limits and bans on ries from sugar-sweetened beverages con- resources and training to improve meal sodas and sweetened beverages in schools tinuously since the 1970s. On average, quality; do not decrease students’ total daily con- more than 200 calories daily (or 10% of a • Working with childcare providers to sumption of such drinks, which are widely young person’s average daily energy establish healthy eating and lifestyle available to them outside of school (Taber, needs) come from sugar-sweetened bever- habits in young children; and 2011). As a result, some researchers have ages (Sturm, Powell, Chriqui, & Cha- backed initiatives such as soft drink taxes, • Involving parents, students, school offi- loupka, 2010). Although no studies have which target soda and sweetened beverage cials, and the general public in the found solid evidence that reduced con- consumption outside of school. establishment and periodic review of sumption of sodas leads to a lower BMI, school wellness policies. A policy brief by the Rudd Center for Food studies have shown that a reduction in the Although the Healthy, Hunger-Free Kids Policy and Obesity contends that a 10% consumption of sugar can lead to positive Act was designed to decrease hunger while increase in the price of soda would health consequences. Children who simultaneously improving nutrition among decrease consumption by 10% (Rudd Cen- reduced sugar intake by the equivalent of school-aged children, significant draw- ter for Food Policy and Obesity, 2009). A one can of soda per day improved their glu- backs exist. First, the Act is essentially 2010 survey found, however, that current cose and insulin levels, indicating a reduc- funded by cutting $2.2 billion of funds taxes are too low to make a visible impact tion in the risk of Type 2 diabetes, even from the Supplemental Nutrition Assis- on consumption (University of Chicago, without additional diet or exercise changes tance Program (SNAP). Best known for its 2010). Furthermore, in many cases, con- (Bremer, Auinger, & Byrd, 2009). Food Stamp Program, SNAP seeks to pro- sumers do not know they exist. In 2011, a Even if soda taxes do not significantly or vide hungry people, not just school chil- total of 37 states had imposed a sales tax on directly contribute to weight loss, support- dren, with increased access to affordable at least some soda purchases. In some of ers argue that soda taxes have an enormous food. According to researchers, passage of these states (including Indiana), the tax is revenue potential. A national tax of one cent the Act means that a family of four will simply a part of the sales tax that applies to per ounce on sugar-sweetened beverages lose nearly $60 a month in food stamp ben- food; in others, it is a separate or higher would generate at least $14.9 billion in the efits beginning in November of 2013 tax. In states like Michigan and Arizona, first year alone. This money could be spent (Fisher & Zaebest, 2010). soft drinks, like other foods, are not subject on measures aimed at reducing childhood to a sales tax. Currently, Indiana, which obesity or in ways that would counteract the Some opponents also argue that the Healthy, imposes a 7% sales tax on all soft drinks adverse impact of soft drinks on health. Hunger-Free Kids Act cedes too much sold, has one the of the highest soda taxes authority to the federal government. In par- in the nation, second only to California’s ticular, the Bill authorizes the Secretary of rate (see Table 2). Agriculture to establish nutritional standards for meals available at childcare agencies and In 2011, 19 states established or raised their schools. The Secretary of Agriculture, Tom soda tax rates. Of these, 11 had not taxed Vilsack, is now granted the authority to soda previously. This increase is signifi- decide what constitutes proper and nutri- cant. Moreover, many states have proposed tious meals for the nation’s youth. far more aggressive taxes. In 2011, 10 states proposed new soda taxes of one cent

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —7 WELLNESS POLICIES Table 2. Soda Taxes by State* The Child Nutrition and Reauthorization 2009 2011 Proposed Taxes Act of 2004 made it mandatory for all Alabama 0 4% school districts participating in the Arizona 0 40% National School Lunch Program or other Arkansas 0 2% 21¢/gal nutrition programs, such as the School Breakfast Program, to adopt and imple- California 6.25% 7.25% 1¢/oz. ment a wellness policy by the first day of Colorado 0 2.9% the 2006-07 school year. According to the Connecticut 6% 6% Act, district wellness policies were Florida 6% 6% required to include: Georgia 4%** 4% Hawaii 0 4% • Goals for nutrition education; Idaho 0 6.25% • Assurance that school meal nutrition Illinois 5.25% 6.25% 1¢/oz. guidelines meet the minimum federal Indiana 7% 7% school meal standards; Iowa 6% 6% • Guidelines for foods and beverages sold Kansas 0 6.3% or served outside of school meal pro- Kentucky 6% 6% grams; Maine 5% 5% • Goals for physical activity; Maryland 6% 6% • Plans for development, communication, Minnesota 6.5% 6.88% and promotion of the wellness policy; Mississippi 1%** 7% 2¢/oz. and Missouri 0 1.23% 2¢/oz. • Plans for implementation. Nebraska 5.5%** 5.5% New Jersey 7% 7% According to the Centers for Disease Con- New Mexico 5% 5.13% 5¢/oz. trol and Prevention (CDC), 2008 Indiana New York 4% 4% School Health Profiles indicate that among North Carolina 4.5% 5.75% middle schools and high schools in the state, North Dakota 5% 5% 93% of Indiana schools had a copy of their Ohio 5.5% 5.5% district’s wellness policy (CDC, n.d.). Oklahoma 0 4.5% Oregon 0 5¢/oz. Pennsylvania 6% 6% Rhode Island 7% 7% 1¢/oz. MAJOR FINDINGS FOR INDIANA South Carolina 6% 6% South Dakota 0 4% Using the School Wellness Policy Evalua- tion Tool developed by the Robert Wood Tennessee 0 5.5% 1¢/oz. Johnson Foundation, CEEP staff evaluated Texas 6.25% 6.25% 1¢/oz. 41 wellness policies received by e-mail Utah 0 1.75% 1% from various Indiana school districts. The Vermont 0 1¢/oz. results revealed that the quality of the poli- Virginia 25%* *** cies varied greatly. CEEP found that Washington 6.5% 6.5% although many were undeveloped and frag- West Virginia 3% 6% 1¢/16.9 oz. mented, 13 of the 41 policies (31.7%) Wisconsin 5% 5% received full points for fulfilling the federal Wyoming 4%** 4% requirements.

* Eight states (Alaska, Delaware, Louisiana, Massachusetts, Michigan, Nevada, and New Hampshire) have no existing or proposed soda taxes and are not included in the chart. ** Tax applies only to vending machine sales. *** Virginia has a progressive gross receipts tax on soda sales, with the tax amount depending on firm size.

Sources: Drenkard, 2011. (Continued on page 10)

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —8 Policy Perspective

THE ROLE OF SCHOOLS IN PROMOTING CHILDHOOD NUTRITION AND WELLNESS

U.S. Senator Richard Lugar

While we work to address hunger and food Our nation has maintained school nutrition This legislation also improves the Summer insecurity among nearly 20% of our programs since the 1940’s, in part as a mat- Food Service Program, which feeds more nation’s population, we also have to face ter of national security due to the effects of than 45,000 Indiana children in low- the fact that nearly one-third of our chil- childhood malnutrition among military- income areas during the summer months. dren are either overweight or obese. Rising aged recruits. While the situation regarding While this program has been in existence obesity rates imperil the health of millions food security for our population is different for more than four decades, I proposed sig- of Americans and reduce the number of today, the basic underlying issue remains nificant improvements after visiting a food young people who can serve in the military. the same. For many children from low- service site in New Albany, Indiana, and A report by Mission: Readiness entitled, income homes, school meals provide the finding low participation. I heard from “Ready, Willing, and Unable to Serve,” bulk of the nutrition they receive during the Indiana providers that governmental red highlights the serious situation our all-vol- day. These children have no choice with tape prevented many from participating. A unteer military finds itself in when trying regards to where or to which families they pilot program I authored in 1999 removed to enlist new recruits. Only one in four of are born. It is not their fault they lack the red tape and increased participation by today’s 17-24-year-olds are able to enlist, access to nutritious food. Hoosier children by 80%. This streamlined predominantly because of a lack of a high program has now been made permanent school diploma or obesity. While these programs provide nutritious throughout the United States. meals to more than 750,000 Hoosier chil- On December 13, 2010, the Healthy, Hun- dren each day, the Healthy, Hunger-Free In 2005, Senator Bingaman and I advanced ger-Free Kids Act of 2010, which extends Kids Act will also make great strides in an amendment to double funding for the and improves programs associated with the addressing obesity by improving the nutri- Team Nutrition program. Twenty-one health, wellbeing, and education of our tional quality of meals and expanding food states use this program to help combat nation’s children, was signed into law. As a access for our nation’s at-risk children. The childhood obesity, improve child nutrition, cosponsor of this legislation, I was pleased bill establishes a performance-based and promote physical activity in schools. that it passed without a single dissenting increase in reimbursements to schools that In addition, I have supported the Physical vote in the United States Senate. improve the nutritional quality of school Education for Progress Act to develop meals and updates rules currently in place school programs to promote daily physical that determine the types of foods sold in education and establish minimum weekly schools outside of the school meals pro- fitness requirements. gram. These rules include state and local recommendations but do not prohibit bake There are many innovative health and well- sales or snacks and refreshments sold at ness programs at schools, farms, and com- athletic events. Reductions in other federal munity organizations across the state. We spending priorities mean this bill does not must work together at the federal, state, add to the deficit. local, and individual levels to foster and support initiatives that promote individual and community health and wellness so that each child has a better chance to reach his or her potential.

U.S. Senator Richard Lugar Richard Lugar is U.S. Senator from Indiana. He is a member and former chairman of the Senate Agriculture, Nutrition, and Forestry Committee.

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —9 (Continued from page 8) reviewed by CEEP were vague. For exam- The Plan outlines six broad goals to increase ple, a goal for several wellness policies was Hoosiers’ access to healthy food and life- that “Physical activity and movement shall style options. Among the goals is a greater be integrated, when possible, across the emphasis on “increasing the capacity of Nutrition Education curricula and throughout the school day.” communities and settings within those (e.g., Of the 41 wellness policies reviewed, 30 As a result of the flexible wording of the schools, work sites, faith-based organiza- included goals for nutrition education. In federal requirement, 35 wellness policies tions, etc.) to develop and sustain environ- order to receive the full rating of “2,” dis- received a “2,” 1 policy received a “1,” and mental and policy support systems that trict policies must use strong language indi- 4 policies did not mention a physical activ- encourage healthy eating and active living.” cating that nutrition education was required. ity goal and received no points. Out of the 41 policies, 8 received a rating of Progress toward this goal will be measured “1” because the nutrition goals were either in a number of ways including: decreasing the percentage of high school students who implied or stated using weak language, such Development, Communication, as may, can, encourage, might, should, or are obese from 13% to 10% by 2020; try. Three policies did not include nutrition and Promotion increasing the percentage of high school education goals in their text. According to the federal requirement, par- students who meet the recommended ents, students, representatives of the school amounts of physical activity per day from food authority, the school board, school 41% to 55% by 2020, and increasing the percentage of mothers who breastfeed their School Meals administrators, and the public are required to be involved in the development of the babies from 71% to 75% by 2020. Of the 41 wellness policies, 33 clearly school wellness policy. In order for wellness Recognizing the importance of educational noted the district’s intent to meet all fed- policies to receive a maximum rating for institutions as agents in promoting healthy eral/USDA school meal regulations and this section, all six required groups must be living habits among children, the Plan sets standards for their reimbursable school mentioned in the policy. A total of 21 poli- 16 school objectives. Although the objec- meals. All meals served under the National cies successfully integrated these groups; 6 tives will not be discussed in detail here, it School Lunch Program must, under federal policies specified who was on the policy is important to note one single overarching law, meet nutrition guidelines based on the development team but did not represent all theme present within each objective: the goals of the Dietary Guidelines for Ameri- required groups; and 14 policies did not encouraging of collaboration and sharing cans. However, eight wellness policies had mention a policy development team at all. no mention of the district meeting federal/ of information in and among relevant USDA meal regulations. stakeholders, including the Indiana Depart- ment of Education, Indiana State Depart- Implementation and ment of Health, the Coordinated School Evaluation Health Advisory Council, school person- Competitive Foods and nel, parents, and school board members. Beverages In all, 20 districts designated the superinten- dent to ensure implementation and compli- A total of 31 of the wellness policies The Plan represents the most recent state- ance with the wellness policies, 7 districts wide effort to encourage healthy lifestyles addressed the sale of competitive foods and designated building principals, 4 districts beverages. Some policies noted that access and eating habits among Hoosiers. The sig- designated Wellness Committees, 1 district nificance of the plan lies in its clear-cut to foods of minimal nutritional value dis- designated its board of trustees, and 1 dis- pensed in vending machines was to be framework for state institutions, programs, trict designated a vague group (“the dis- and partners to tailor and implement. blocked or limited during the school day, trict”) with these responsibilities. In 7 while others simply required that all vend- policies there was no mention of plans for Indiana recently created the Division of ing machines carry only healthy foods and implementation and evaluation. Nutrition and Physical Activity (DNPA) to beverages. However, for a policy to receive combat the related problems of obesity, a “2,” the policy must include specific poor nutrition, and sedentary lifestyles. The nutrition guidelines selected by the district DNPA is tasked with collecting and evalu- for all foods available on campus during Other Indiana Policy Initiatives ating data related to nutrition and physical the school day. activity and with overseeing statewide ini- Indiana recently launched a Comprehen- tiatives regarding nutrition and physical sive Nutrition and Physical Activity Plan activity, including the development of a Physical Activity for 2010-20. The Plan builds on previous comprehensive state plan to prevent obe- state-level efforts such as Governor Mitch Because the federal requirement only calls sity and promote fitness and healthy eating. Daniels’ INShape Indiana health initiative, for a physical activity goal to be mentioned By consolidating these activities under the which was launched in 2005. This earlier in the wellness policy, policies can score DNPA, which will serve as a resource for initiative began with an online knowledge- well without mandating minimum amounts partners throughout the state, Indiana sharing forum and sought to translate of physical activity or outlining specific hopes to encourage coordination and coop- knowledge into action through six state- courses of action for meeting the goal. eration while preventing the duplication of wide summits and collaborations with edu- Many of the physical activity goals efforts among state agencies. cational institutions around the state.

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —10 field trips to farms and farmers’ mar- • Advocate against cutting spending CONCLUSIONS AND kets. For example, Arlington High for the Supplemental Nutrition RECOMMENDATIONS School in Indianapolis opened Dev- Assistance Program. ington Green Acres Farm to be main- Despite the attention focused on the issue tained by the students. • Increase the proportion of fresh fruits at both the state and federal level, the child- and vegetables purchased by the fed- hood obesity epidemic has worsened since • Ensure federal funds for school lunch eral government for use in the school the last CEEP policy brief on the subject or breakfast programs are reaching lunch program. These new food stan- (Cline, Plucker, & Spradlin, 2005). This the children most in need by encour- dards at schools should be supported trend is indicative of the need for renewed aging food service providers and by the Senate Agriculture Committee. efforts to promote healthy eating and exer- school administrators to improve food • Develop nutrition guidelines for pro- cise among school children. service accounts and eliminate waste- ful spending. cessors to align processed commodi- ties with the Dietary Guidelines for • Work with government officials, busi- Americans. Conclusion nesses, and community partners to increase the presence of fresh produce Indiana has lost ground nationally in the in supermarkets, farmers’ markets, fight to reduce the number of overweight Conclusion produce vendors, and community gar- and obese children. The negative outcomes dens in areas with limited consumer Research has consistently shown that phys- associated with childhood obesity are options and to address the relative ical activity both prevents children from numerous. For school children, obesity affordability of healthier food options being overweight or obese, and helps directly impacts student health and aca- compared to less healthy food improve their academic performance, demic performance. Furthermore, over- options. classroom behavior, and self-esteem. With weight and obese children also spend more the growing emphasis on improving the time and money on prescription drugs and For Parents: nation’s academic standards and wide- on outpatient and emergency room ser- spread school budget cuts, however, physi- vices. Although both the federal and state • Support a home environment that encourages healthy eating. There is a cal education is too often de-emphasized in governments have increased efforts to school curricula. As a result, students combat this problem, this issue must con- proven association between eating together as a family and both lower receive less time and fewer resources for tinue to be actively pursued in a collective exercise, a trend that limits their abilities to and dedicated manner. rates of obesity and healthier eating patterns (Neumark-Sztainer, Han- maintain a healthy weight. Despite the con- Recommendations nan, Story, Croll, & Perry, 2003). nection between physical fitness and aca- demic performance, the CDC’s 2006 For Schools and Education • Take an interest in and ask questions school health policies and programs study found that only 22% of states required Leaders: about the nutritional value of school meals. schools or school districts to measure or • Strengthen and enforce wellness pol- assess students’ height and weight or body icies. Currently, too many policies • Limit the amount of money given to mass index, and 73% of those states are fragmented and ineffective. children to spend on á la carte and required parent notification of the results vending machines items in schools. (Brener, Wheeler, Wolfe, Vernon-Smiley, • Limit students’ access to vending & Caldart-Olson, 2007). machines and competitive foods, For Members of Congress: especially during mealtimes. Educate • Make certain that children receive the Recommendations students and parents about the bene- full benefits of the proposed initia- fits of these changes. tives in the Healthy, Hunger-Free For Schools and Education Leaders: • Encourage participation in the School Kids Act of 2010. Breakfast Program, while ensuring • Encourage school administrators, • Promote physical activity for all grade that breakfast meals meet nutritional community members, and childcare levels, whether through recess or guidelines. agencies to discuss what effect the physical education classes. • Teach students to value healthy foods Healthy, Hunger-Free Kids Act of • Offer health services, which can play by cultivating a school garden, install- 2010 has had on their school or a central role in addressing obesity- ing a Farm-to-School program, or agency since implementation. related issues among students by pro- partnering with a locally supplied • Re-evaluate wellness policies written viding screenings, health information, food item program. Such initiatives under the 2004 Child Nutrition Reau- and referrals to students and their enable students to learn to plant and thorization Act to incorporate physi- families. Many overweight and obese grow their own produce, conduct cal activity, locally produced foods, youth lack health insurance and there- experiments, write nature-inspired and healthier school meal options for fore may not get regular medical care poetry, learn about nutrition, and take school-aged children. at physicians’ offices.

CHILDHOOD OBESITY AND NUTRITION ISSUES IN THE UNITED STATES: AN UPDATE ON SCHOOL-BASED POLICIES AND PRACTICES —11 • Require that all schools maintain and apply their local district’s wellness AUTHORS REFERENCES policy. Though all school districts were required to have a written form Terry Spradlin Action for Healthy Kids. (2009). “Let’s of their wellness policy under the ([email protected]) is the Director for Move” with Action for Healthy Kids. Child Nutrition and WIC Reauthori- Education Policy and HSSSE at the Center Retrieved from Action for Healthy Kids: zation Act of 2004, enforcement of for Evaluation & Education Policy. http://www.actionforhealthykids.org/ the legislation has been lax. resources/tools/lets-move-article.html Greta Gard For Parents: American College of Cardiology. (2010). ([email protected]) is Director of Proj- Children who eat school lunches more • Encourage daily physical activity. ect Implementation at the Center for Evalu- likely to be overweight. Retrieved May 26, ation & Education Policy. 2010, from http://www2.med.umich.edu/ • Limit the amount of time children prmc/media/newsroom/ spend watching television. Accord- Vivian Huang details.cfm?ID=1514 ing to a study done by Indiana Uni- ([email protected]) was an Undergrad- versity’s School of Health, Physical uate Research Assistant at the Center for Basch, C.E. (2010). Healthier students are Education, and Recreation, watching Evaluation & Education Policy during the better learners: A missing link in school more than two hours of television per 2009-10 academic year. reforms to close the achievement gap. day increases adolescents’ chances Equity Matters: Research Review, 6. of being overweight. This is because Beth Kopp Bremer, A.A., Auinger, P., & Byrd, R.S. children and adolescents are not only ([email protected]) was an Undergrad- (2009). Relationship between insulin resis- decreasing their energy expenditure uate Research Assistant at the Center for tance-associated metabolic parameters and by sitting idly in front of a television, Evaluation & Education Policy during the anthropometric measurements with sugar- but the study found that children are summer of 2009. sweetened beverage intake and physical often snacking while watching tele- activity levels in U.S. adolescents. Findings vision, increasing their calorie intake Alanna Malik from the 1999-2004 National Health and (Fleming-Moran & Thiagarajah, ([email protected]) was a Graduate Nutrition Examination Survey. Archives Research Assistant at the Center for Evalu- 2005). and Pediatric and Adolescent Medicine, ation & Education Policy during the 2010- 163(4), 328-35. • Where it can be done safely, encour- 11 academic year. Brener, N., Wheeler, L., Wolfe, L., Vernon- age walking or biking to school to Smiley, M., & Caldart-Olson, L. (2007). decrease the risk of obesity. Health services: Results from the School ACKNOWLEDGEMENTS Health Policies and Programs Study 2006. Journal of School Health, 77(8), 464-485. The authors would like to thank Stephen Hiller and Beth Young, of the Center for Brownell, K.D., Farley, T., Willett, W., Pop- Evaluation & Education Policy, for their kin, B.M., Chaloupka, F.J., Thompson, document review and edit suggestions; J.W., & Ludwig, D.S. (2009). The public Phyllis Lewis, Coordinator for Health Pro- health and economic benefits of taxing grams for the IDOE, and Rodney White- sugar-sweetened beverages. The New Eng- man, PhD student in Education Policy land Journal of Medicine, 361(16). Studies at Indiana University and a volun- Retrieved from http://content.nejm.org/cgi/ teer Graduate Research Assistant for CEEP. content/full/NEJMhpr0905723 Center for Science in the Public Interest (CSPI). (2007). State school foods report card 2007. Retrieved from http:// www.cspinet.org/ Centers for Disease Control and Prevention (CDC). (n.d.). The obesity epidemic and Indiana students. Retrieved December 10, 2010, from www.cdc.gov/HealthyYouth/ yrbs/pdf/obesity/in_obesity_combo.pdf Centers for Disease Control and Prevention (CDC). (2003). Physical activity levels among children aged 9-13 years - United States, 2002. Morbidity and Mortality Weekly Report, 52(33);785-788. Atlanta, GA: Author.

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Let’s Move: America’s Move to Raise a Healthier Generation of Kids http://www.letsmove.gov

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