Childhood Obesity: Can Policy
Changes Affect this Epidemic?

Marian L. Fitzgibbon, PhD
Laura L. Hayman, PhD, RN, FAAN
Debra Haire-Joshu, PhD

Description of the issue. The health consequences of childhood obesity represent a significant public health challenge affecting children, parents, educators, health professionals, advocates, and policy makers. Since 1960, overweight prevalence rates among children and adolescents have increased more than threefold. ⁽¹⁾ Currently, about 17% of children and adolescents are overweight, and these rates are higher in minority populations. ⁽²⁾ If the epidemic is not reversed, obesity-related health problems and the associated costs will surpass those related to tobacco. ⁽³⁾

Figure 1. Percentage of Children and Adolescents Who Are Overweight*, from the National Health and Nutrition Examination Survey (NHANES). ^{(2, 4)}

*Overweight is defined as a body mass index (BMI) for age and sex = 95th percentile. For all years except 2003-2004, adolescents were also coded as overweight if their BMI was = 30 kg/m², even if it was below the 95th percentile.
†Age range is 12 to 19 for 2003-2004.

Policy Recommendations. An integrated and evidence-based school policy is essential to address the multiple causes of this epidemic. In the Child Nutrition and WIC Reauthorization Act of 2004, the U.S. Congress required all school districts with federally funded meal programs to develop and implement wellness policies by the start of the 2006-2007 school year. ⁽⁵⁾ This mandate requires that schools: set goals for nutrition education, physical activity and other school-based activities designed to promote student wellness; establish nutrition standards for all foods that are available on each school campus during the school day; monitor the implementation of the wellness policy; and involve a broad group of individuals in its development.

This act is a positive step. However, it misses a critical opportunity to ensure that schools incorporate policies that reflect the current evidence base. Also, it poses additional financial challenges for schools, since it is an unfunded mandate. Therefore, there is likely to be a wide variation in quality and implementation. It is critical that federal policy makers:

1. Require schools develop wellness policies that reflect evidence-based methods for promoting behavior change;
2. Provide additional funding to assure adequate implementation and rigorous evaluation of wellness policy initiatives as a critical step in the prevention of childhood obesity.

Findings. Schools provide an ideal setting to support prevention of obesity by promoting healthful eating and activity habits for over 53 million children. ⁽⁶⁾ However, schools are not evaluated on obesity rates, but on academic student outcomes required by federal mandates such as the No Child Left Behind Act of 2001. These unfunded requirements leave schools focusing on ways to finance school activities, which may come at the expense of child health outcomes. ^{(7, 8)}

• Many schools provide a setting for eating high-fat, high-sugar foods and beverages that can promote excessive weight gain. ⁽⁹⁾ Recently, over 71% of high schools had contracts with soft drink companies; 23% allowed promotion of candy, fast food, and soft drink products with coupons. Many of these products are sold in vending machines, and a recent study found that 58% of elementary schools, 84% of middle schools and 94% of high schools sell sweetened drinks. ⁽¹⁰⁾
• " Although there are guidelines for the amount of time children should spend in physical activity during the school day, only 8% of elementary and 6% of middle schools meet these recommendations, and physical education requirements decrease as the grade level increases. ⁽⁷⁾

Methods. Recent evidence suggests that good nutrition and regular physical activity also have cognitive benefits for children. Therefore, schools can provide a venue for improved academic performance as well as a healthy lifestyle. ^{(11, 12)} There is also evidence that school-based interventions can be effective in preventing excessive weight gain. However, to date, they have been less successful in reducing overweight. ⁽¹³⁾

• Hip-Hop to Health Jr. was a 14-week, developmentally appropriate curriculum designed for minority preschool children. In a randomized trial, a specially trained teacher visited each school three times weekly to teach the children about healthy eating and physical activity and lead a 20-minute vigorous physical activity session. Children in the schools receiving the Hip-Hop to Health Jr. program showed significantly smaller increases in body mass index (BMI) than children in the control schools at both 1-year and 2-year follow-up. ⁽¹⁴⁾
• Planet Health was a school-based intervention delivered in 10 metropolitan Boston schools that targeted 6 th-8th grade children, with the aims of increasing activity and fruit and vegetable consumption and decreasing television viewing and consumption of high-fat foods. ⁽¹⁵⁾ Results showed reduced obesity and increased fruit and vegetable consumption among girls in the intervention schools, as well as a reduction in television viewing among both boys and girls.
• " The Child and Adolescent Trial for Cardiovascular Health (CATCH) was a school-based intervention study designed to promote heart healthy behaviors (i.e., patterns of physical activity and nutrition) and reduce risk factors for heart disease in elementary school children. ⁽¹³⁾ Children in the CATCH/intervention schools showed significant improvements in dietary intake of total and saturated fat and increases in moderate-to-vigorous physical activity (MVPA). These changes in behavioral determinants of obesity and cardiovascular risk were sustained for 3 years (until 8th grade) without further intervention. ⁽¹⁶⁾

We must recognize that our current multi-level environment (e.g. media, industry, schools, home, community, government) encourages the development of childhood obesity, so change must occur on all levels. ⁽¹⁷⁾ Research suggests that it is possible to effect weight changes through school-based interventions; school wellness policies should also reflect this evidence base. Support for evaluation of efforts is needed to further establish what combination, duration, or intensity of activities (e.g., diet, sweetened beverage consumption, physical activity, physical inactivity, etc.), should be targeted by school-based programs to halt excessive childhood weight gain..

REFERENCES

1. Centers for Disease Control and Prevention. Quickstats: prevalence of overweight among children and teenagers, by age group and selected period, U.S., 1963-2002. MMWR Morb Mortal Wkly Rep. 2005;54:203.
2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004 JAMA. 2006;295:1549-55.
3. USDHHS. The Surgeon General's Call To Action To Prevent and Decrease Overweight and Obesity 2001. Washington, D.C.: USDHHS, PHS, Office of the Surgeon General; 2001. Report No.: 02NLM: WD 210 S9593 2001.
4. Freedman DS, Khan LK, Serdula MK, Ogden CL, Dietz WH. Racial and ethnic differences in secular trends for childhood BMI, weight, and height. Obes Res. 2006;14:301-8.
5. S. 2507. Child Nutrition and WIC Reauthorization Act of 2004. Sec. 204. Local Wellness Policy. 2004 [cited July 20, 2006]; Available from: http://www.schoolwellnesspolicies.org/resources/Section204LocalWellnessPolicies.pdf
6. 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;69:747S-54S.
7. Burgeson CR, Wechsler H, Brener ND, Young JC, Spain CG. Physical education and activity: results from the School Health Policies and Programs Study 2000. J Sch Health. 2001;71:279-93.
8. National Association for Sport and Physical Education. Shape of the Nation Report: Executive Summary. Reston, VA: National Association for Sport and Physical Education; 2001.
9. French SA, Story M, Fulkerson JA, Gerlach AF. Food environment in secondary schools: a la carte, vending machines, and food policies and practices. Am J Public Health. 2003;93:1161-7.
10. Wechsler H, Brener ND, Kuester S, Miller C. Food service and foods and beverages available at school: results from the School Health Policies and Programs Study 2000. J Sch Health. 2001;71:313-24.
11. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc. 2005;105:743-60.
12. Parker L. The Relationship between Nutrition and Learning: A School Employee's Guide to Information and Action. Washington: National Education Association; 1989.
13. Luepker RV, Perry CL, McKinlay SM, Nader PR, Parcel GS, Stone EJ, et al. Outcomes of a field trial to improve children's dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA. 1996;275:768-76.
14. Fitzgibbon ML, Stolley MR, Schiffer L, Van Horn L, KauferChristoffel K, Dyer A. Two year follow-up results for Hip-Hop to Health Jr.: a randomized controlled trial for overweight prevention in preschool minority children. J Pediatr. 2005;146:618-25.
15. Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, et al. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med. 1999;153:409-18.
16. Hoelscher DM, Feldman HA, Johnson CC, Lytle LA, Osganian SK, Parcel GS, et al. School-based health education programs can be maintained over time: results from the CATCH Institutionalization study. Prev Med. 2004;38:594-606.
17. Institute of Medicine (U.S.). Committee on Prevention of Obesity in Children and Youth, Food and Nutrition Board, Board on Health Promotion and Disease Prevention; Koplan JP, Liverman CT, Kraak VI, editors. Preventing Childhood Obesity: Health in the Balance. Washington, D.C.: National Academies Press; 2005.

Approved by Health Policy Committee: date October 10, 2006
Approved by SBM Executive Committee: date October 13, 2006

© Copyright 2007 Society of Behavioral Medicine. All Rights Reserved.

Society of Behavioral Medicine
555 East Wells St.
Suite 1100
Milwaukee, WI 53202-3823
Tel: 414-918-3156
Fax: 414-276-3349
For more information, please email us at info@sbm.org