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Childhood Obesity: A Policy Statement of the Society of Behavioral Medicine

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) In 2003-2006, 16.3% of children and adolescents aged 2 through 19 years were at or above the 95th percentile and 31.9% were at or above the 85th percentile for age and sex based on the 2000 Centers for Disease Control (CDC) growth charts. (2) Ethnic differences exist, with almost 28% of non-Hispanic black and 20% of Mexican-American girls between the ages of 12-19 years at or above the 95th percentile, compared to 14.5% of non-Hispanic white girls. (2) In the US, "overweight" in children has generally been defined as a body mass index (BMI) at or above the 95th percentile for age and sex, based on the 2000 CDC growth charts. "At risk for overweight" has been defined as a BMI between the 85th and 95th percentiles. However, an expert committee convened by the American Medical Association, in collaboration with the Health Resources and Service Administration and the Centers for Disease Control and Prevention (CDC), recently recommended classifying children with a BMI at or above the 95th percentile as "obese " and those with a BMI between the 85th and 95th percentiles as "overweight." (3)

Figure 1. Percentage of Children and Adolescents Who Are Obesea, from the National Health and Nutrition Examination Survey (NHANES).

a Obesity is defined as a body mass index (BMI) for age and sex ≥ 95th percentile.

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

Findings. Schools provide an ideal setting to support prevention of obesity by promoting healthful eating and activity habits for over 53 million children. (5) 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. (5)

  • As of 2004-2005, the vast majority of high school students had access to soft drinks in the school environment both through vending machines (88%) and in the cafeteria at lunch (59%). Most students (67% in middle and 83% in high school) are also in schools that have a contract with a bottler. (6) However, in 2006 the beverage industry announced that it was voluntarily removing high-calorie soft drinks from all schools and also will limit the amount of other sugary beverages, such as fruit drinks, in school vending machines. (7)
  • In September, 2007, the second annual study on school nutrition wellness policies was released by the School Nutrition Association (SNA). Overall, findings suggest that healthier foods are available in schools, but offering more nutritious foods is more costly. (8)
  • Although there are guidelines for the amount of time children should spend in physical activity during the school day, only 4 percent of elementary schools, 8 percent of middle schools, and 2 percent of high schools offer daily physical education to students. (9, 10) Additionally, few states have standards for the amount of time students spend in physical education classes. (11)

Methods. Evidence suggests that good nutrition and regular physical activity have cognitive benefits for children. Therefore, school-based nutrition and physical activity programs can potentially lead to improved academic performance as well as a healthy lifestyle. (12, 13) 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 (14)

  • Hip-Hop to Health Jr. was a 14-week, developmentally appropriate curriculum designed for minority preschool children. (15) 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.
  • 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. (16) 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. (14) 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. (17)

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. (18) 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. Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiology of obesity. Gastroenterology. 2007;132:2087-102.
  2. Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003-2006. JAMA. 2008;299:2401-5.
  3. Barlow SE, Expert Committee. Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatr. 2007;120:S164-92.
  4. S. 2507. Child Nutrition and WIC Reauthorization Act of 2004. Sec. 204. Local Wellness Policy. 2004. Available from: http://www.schoolwellnesspolicies.org/resources/Section204LocalWellnessPolicies.pdf
  5. Story M, Kaphingst KM, French S. The role of schools in obesity prevention. Future of Children. Childhood Obesity. 2006;16:109-42.
  6. Johnston LD, Delva J, O'Malley PM. Soft drink availability, contracts, and revenues in American secondary schools. Am JPrev Med. 2007;33:S209-25.
  7. American Heart Association. Memo of understanding regarding school beverage policy. Alliance for a healthier generation. American Heart Association; 2008. Available from: http://www.schoolwellnesspolicies.org/resources/Section204LocalWellnessPolicies.pdf
  8. School Nutrition Association and School Nutrition Foundation. From cupcakes to carrots: local wellness policies one year later. School Nutrition Association and School Nutrition Foundation; 2007.
  9. Lee SM, Burgeson CR, Fulton JE, Spain CG. Physical education and physical activity: results from the School Health Policies and Programs Study 2006. J Sch Health. 2007;77:435-63.
  10. J Johnston LD, Delva J, O'Malley PM. Sports participation and physical education in American secondary schools: current levels and racial/ethnic and socioeconomic disparities. Am J Prev Med. 2007;33:S195-208.
  11. National Association for Sport and Physical Education and American Heart Association. The 2006 Shape of the Nation Report: status of physical education in the USA.
  12. 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.
  13. Parker L. The relationship between nutrition and learning: a school employee's guide to information and action. Washington, D.C.: National Education Association; 1989.
  14. Luepker RV, Perry CL, McKinlay SM, 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.
  15. 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.
  16. Gortmaker SL, Peterson K, Wiecha J, et al. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med. 1999;153:409-18.
  17. Hoelscher DM, Feldman HA, Johnson CC, et al. School-based health education programs can be maintained over time: results from the CATCH Institutionalization study. Prev Med. 2004;38:594-606.
  18. Institute of Medicine. Committee on Prevention of Obesity in Children and Youth. Food and Nutrition Board, Board on Health Promotion and Disease Prevention. In: Koplan JP, Liverman CT, Kraak VI, eds. Preventing Childhood Obesity: Health in the Balance. Washington, D.C.: National Academies Press; 2005.

Citation:
Fitzgibbon ML, Hayman LL, and Haire-Joshu D. Childhood obesity: can policy changes affect this epidemic? Society of Behavioral Medicine, July 2008. Available from: http://www.sbm.org/policy/childhood_obesity.asp

Approved by Health Policy Committee: date August 5, 2008
Approved by SBM Executive Committee: date August 20, 2008


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