Preventing Childhood Obesity

Health in the Balance

Committee on Prevention of Obesity in Children and Youth

Food and Nutrition Board

Board on Health Promotion and Disease Prevention

Jeffrey P. Koplan, Catharyn T. Liverman, Vivica I. Kraak, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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Preventing Childhood Obesity: Health in the Balance Preventing Childhood Obesity Health in the Balance Committee on Prevention of Obesity in Children and Youth Food and Nutrition Board Board on Health Promotion and Disease Prevention Jeffrey P. Koplan, Catharyn T. Liverman, Vivica I. Kraak, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Preventing Childhood Obesity: Health in the Balance THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The study was supported by Contract No. 200-2000-00629, T.O. #14 between the National Academy of Sciences and the Centers for Disease Control and Prevention; by Contract No. N01-OD-4-2139, T.O. #126 with the National Institutes of Health; and by Grant No. 047513 with The Robert Wood Johnson Foundation. The contracts were supported by funds from the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion; Centers for Disease Control and Prevention; National Institute of Diabetes and Digestive and Kidney Diseases; National Heart, Lung, and Blood Institute; National Institute of Child Health and Human Development; and the Division of Nutrition Research Coordination of the National Institutes of Health. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Prevention of Obesity in Children and Youth. Preventing childhood obesity : health in the balance / Committee on Prevention of Obesity in Children and Youth, Food and Nutrition Board, Board on Health Promotion and Disease Prevention ; Jeffrey P. Koplan, Catharyn T. Liverman, Vivica I. Kraak, editors. p. ; cm. Includes bibliographical references and index. ISBN 0-309-09196-9 (hardcover) — ISBN 0-309-09315-5 1. Obesity in children—United States—Prevention. 2. Child health services—United States. 3. Nutrition policy—United States. 4. Health promotion—United States. [DNLM: 1. Obesity—prevention & control—Adolescent. 2. Obesity—prevention & control—Child. 3. Health Policy—Adolescent. 4. Health Policy—Child. 5. Health Promotion—methods. 6. Social Environment. WD 210 I604p 2005] I. Koplan, Jeffrey. II. Liverman, Catharyn T. III. Kraak, Vivica I. IV. Institute of Medicine (U.S.). Board on Health Promotion and Disease Prevention. V. Title. RJ399.C6I575 2005 618.92’398—dc22 2004026241 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2005 by the National Academy of Sciences. All rights reserved. Illustration by Becky Heavner. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Preventing Childhood Obesity: Health in the Balance “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Preventing Childhood Obesity: Health in the Balance THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Preventing Childhood Obesity: Health in the Balance COMMITTEE ON PREVENTION OF OBESITY IN CHILDREN AND YOUTH JEFFREY P. KOPLAN (Chair), Woodruff Health Sciences Center, Emory University, Atlanta, GA DENNIS M. BIER, Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX LEANN L. BIRCH, Dpartment of Human Development and Family Studies, Pennsylvania State University, University Park ROSS C. BROWNSON, Department of Community Health, St. Louis University School of Public Health, MO JOHN CAWLEY, Department of Policy Analysis and Management, Cornell University, Ithaca, NY GEORGE R. FLORES, The California Endowment, San Francisco, CA SIMONE A. FRENCH, Division of Epidemiology, University of Minnesota, Minneapolis SUSAN L. HANDY, Department of Environmental Science and Policy, University of California, Davis ROBERT C. HORNIK, Annenberg School for Communication, University of Pennsylvania, Philadelphia DOUGLAS B. KAMEROW, Health, Social and Economics Research, RTI International, Washington, DC SHIRIKI K. KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia BARBARA J. MOORE, Shape Up America!, Washington, DC ARIE L. NETTLES, School of Education, University of Michigan, Ann Arbor RUSSELL R. PATE, Department of Exercise Science, University of South Carolina, Columbia JOHN C. PETERS, Food and Beverage Technology, Procter & Gamble Company, Cincinnati, OH THOMAS N. ROBINSON, Division of General Pediatrics and Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, CA CHARLES ROYER, Evans School of Public Affairs, University of Washington, Seattle SHIRLEY R. WATKINS, SR Watkins & Associates, Silver Spring, MD ROBERT C. WHITAKER, Mathematica Policy Research, Inc., Princeton, NJ

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Preventing Childhood Obesity: Health in the Balance Staff CATHARYN T. LIVERMAN, Study Director LINDA D. MEYERS, Director, Food and Nutrition Board ROSE MARIE MARTINEZ, Director, Board on Health Promotion and Disease Prevention VIVICA I. KRAAK, Senior Program Officer JANICE RICE OKITA, Senior Program Officer CARRIE SZLYK, Program Officer (through September 2003) TAZIMA A. DAVIS, Research Associate J. BERNADETTE MOORE, Science and Technology Policy Intern (through June 2003) ELISABETH RIMAUD, Financial Associate SHANNON L. RUDDY, Senior Program Assistant

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Preventing Childhood Obesity: Health in the Balance FOOD AND NUTRITION BOARD CATHERINE E. WOTEKI (Chair), Department of Food Science and Human Nutrition, Iowa State University, Ames ROBERT M. RUSSELL (Vice-Chair), U.S. Department of Agriculture Jean Mayer Human Nutrition Research Center on Aging, Tufts University, Boston, MA LARRY R. BEUCHAT, Center for Food Safety, University of Georgia, Griffin SUSAN FERENC, SAF* Risk, LC, Madison, WI NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver SHIRIKI K. KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia REYNALDO MARTORELL, Rollins School of Public Health, Emory University, Atlanta, GA LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, DC NICHOLAS J. SCHORK, Department of Psychiatry, Polymorphism Research Laboratory, University of California, San Diego JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison STEPHEN L. TAYLOR, Department of Food Science and Technology and Food Processing Center, University of Nebraska-Lincoln BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, Pennsylvania State University, University Park IOM Council Liaison DONNA E. SHALALA, University of Miami, Coral Gables, FL Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ELISABETH RIMAUD, Financial Associate

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Preventing Childhood Obesity: Health in the Balance BOARD ON HEALTH PROMOTION AND DISEASE PREVENTION JAMES W. CURRAN (Chair), Rollins School of Public Health, Emory University, Atlanta, GA RONALD BAYER, Joseph L. Mailman School of Public Health, Columbia University, New York, NY DAN G. BLAZER, Duke University Medical Center, Durham, NC HELEN B. DARLING, National Business Group on Health, Washington, DC STEPHEN B. FAWCETT, KU Work Group on Health Promotion and Community Development, University of Kansas, Lawrence JONATHAN FIELDING, Department of Health Services, Los Angeles County, CA LAWRENCE O. GOSTIN, School of Law, Georgetown University and Department of Public Health, Johns Hopkins University, Washington, DC ELLEN R. GRITZ, Department of Behavioral Science, University of Texas, Houston GEORGE J. ISHAM, HealthPartners, Minneapolis, MN MARK S. KAMLET, Department of Economics and Public Policy, Carnegie Mellon University, Pittsburgh, PA JOYCE SEIKO KOBAYASHI, Department of Psychiatry, University of Colorado Health Sciences Center and Acute Crisis Services Denver Health Medical Center ELENA O. NIGHTINGALE, Member Emerita, Institute of Medicine, Washington, DC ROXANNE PARROTT, Department of Communication Arts & Sciences, Pennsylvania State University, University Park THOMAS A. PEARSON, Department of Community and Preventive Medicine, University of Rochester, NY IRVING ROOTMAN, Faculty of Human and Social Development, University of Victoria, British Columbia, Canada DAVID J. TOLLERUD, School of Public Health and Information Sciences, University of Louisville, KY KATHLEEN E. TOOMEY, Division of Public Health, Georgia Department of Human Resources, Atlanta WILLIAM A. VEGA, University Behavioral HealthCare, Robert Wood Johnson Medical School, New Brunswick, NJ PATRICIA WAHL, School of Public Health and Community Medicine, University of Washington, Seattle LAUREN A. ZEISE, Reproductive and Cancer Hazard Assessment, Office of Environmental Health Hazard Assessment, Oakland, CA

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Preventing Childhood Obesity: Health in the Balance IOM Council Liaison JEFFREY P. KOPLAN, Woodruff Health Sciences Center, Emory University, Atlanta, GA Staff ROSE MARIE MARTINEZ, Director RITA A. GASKINS, Administrative Assistant

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Preventing Childhood Obesity: Health in the Balance Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: LINDA ADAIR, Carolina Population Center, University of North Carolina at Chapel Hill TOM BARANOWSKI, Children’s Nutrition Research Center, Baylor College of Medicine EDWARD N. BRANDT, College of Public Health, University of Oklahoma CUTBERTO GARZA, Division of Nutritional Sciences, Cornell University MICHAEL S. JELLINEK, Newton Wellesley Hospital, Newton Lower Falls, MA DAVID L. KATZ, Yale Prevention Research Center, Yale University CARINE LENDERS, Department of Pediatrics, Boston Medical Center

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Preventing Childhood Obesity: Health in the Balance AVIVA MUST, Department of Family Medicine and Community Health, Tufts University VIVIAN PILANT, Office of School Food Services and Nutrition, South Carolina Department of Education ALONZO PLOUGH, Department of Public Health-Seattle & King County, School of Public Health and Community Medicine, University of Washington ROSSI RAY-TAYLOR, Minority Student Achievement Network, Ann Arbor, MI JAMES F. SALLIS, San Diego State University, Active Living Research Program MARILYN D. SCHORIN, Yum! Brands, Inc. DONNA E. SHALALA, University of Miami MICHAEL D. SLATER, Department of Journalism and Technical Communication, Colorado State University SYLVIE STACHENKO, Centre for Chronic Disease Prevention and Control, Ottawa, Ontario ROLAND STURM, RAND Corporation BOYD SWINBURN, Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne MARGARITA S. TREUTH, Bloomberg School of Public Health, Johns Hopkins University LINDA VAN HORN, Feinberg School of Medicine, Northwestern University BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, Pennsylvania State University Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by ENRIQUETA C. BOND, Burroughs Wellcome Fund, and GORDON H. DEFRIESE, Department of Social Medicine, University of North Carolina at Chapel Hill. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preventing Childhood Obesity: Health in the Balance Preface In 2001, the U.S. Surgeon General issued the Call to Action to Prevent and Decrease Overweight and Obesity to stimulate the development of specific agendas and actions targeting this public health problem. In recognition of the need for greater attention directed to prevent childhood obesity, Congress, through the fiscal year 2002 Labor, Health and Human Services, Education Appropriations Act Conference Report, directed the Centers for Disease Control and Prevention (CDC) to request that the Institute of Medicine (IOM) develop an action plan targeted to the prevention of obesity in children and youth in the United States. In addition to CDC, this study was supported by the Department of Health and Human Services’ Office of Disease Prevention and Health Promotion (ODPHP); National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); the National Heart, Lung, and Blood Institute (NHLBI); the National Institute of Child Health and Human Development (NICHD); the Division of Nutrition Research Coordination of the National Institutes of Health; and The Robert Wood Johnson Foundation (RWJF). The charge to the IOM committee was to develop a prevention-focused action plan to decrease the prevalence of obesity in children and youth in the United States. The primary emphasis of the study’s task was on examining the behavioral and cultural factors, social constructs, and other broad environmental factors involved in childhood obesity and identifying promising approaches for prevention efforts. To address this charge, the IOM appointed a 19-member multidisciplinary committee with expertise in child health and development, obesity, nutrition, physical activity, economics,

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Preventing Childhood Obesity: Health in the Balance education, public policy, and public health. Six meetings were held during the 24-month study and a variety of sources informed the committee’s work. The committee obtained information through a literature review (Appendix C) and a commissioned paper discussing insights, strategies, and lessons learned from other public health issues and social change campaigns that might be relevant to the prevention of obesity in children and youth (Appendix D). The meetings included two workshops that were key elements of the committee’s information-gathering process (Appendix E). Held in June 2003, the first workshop focused on strategies for developing school-based policies to promote nutrition and physical activity in children and youth. The second workshop was organized in December 2003 and addressed marketing and media influences on preventing childhood obesity and issues related to family dynamics. Each workshop included public forum sessions, and the committee benefited from the breadth of issues raised by nonprofit organizations, professional associations, and individuals. Since the inception of this study, the committee recognized that it faced a broad task and a complex problem that has become an epidemic not only in the United States but also internationally. The committee appreciated the opportunity to develop an action plan on the prevention of obesity in children and youth and developed its recommendations to encompass the roles and responsibilities of numerous stakeholders and many sectors of society. Children are highly cherished in our society. The value we attach to our children is fundamentally connected to society’s responsibility to provide for their growth, development, and well-being. Extensive discussions will need to continue beyond this report so that shared understandings are reached and support is garnered for sustained societal and lifestyle changes that will reverse the obesity trends among our children and youth. Jeffrey P. Koplan, Chair Committee on Prevention of Obesity in Children and Youth

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Preventing Childhood Obesity: Health in the Balance Acknowledgments It was a privilege to chair this Institute of Medicine (IOM) committee whose members not only brought their breadth and depth of expertise to this important topic but were actively engaged in the committee’s work. This report represents the result of six meetings, two open sessions, numerous emails and phone conferences, and the extensive analysis and thoughtful writing contributed by the committee members who volunteered their time to work on this study. I thank each of the committee members for their dedication and perseverance in working through the diversity of issues in a truly interdisciplinary collaboration. The committee greatly benefited from the opportunity for discussion with the individuals who made presentations and attended the committee’s workshops and meetings, including: Neal Baer, Kelly Brownell, Harold Goldstein, Paula Hudson Collins, Mary Engle, Susan McHale, Alex Molnar, Eric Rosenthal, Mark Vallianatos, Jennifer Wilkins, and Judith Young, as well as all those who spoke during the open forums (Appendix E). This study was sponsored by the U.S. Department of Health and Human Services’ Centers for Disease Control and Prevention; Office of Disease Prevention and Health Promotion; National Heart, Lung, and Blood Institute; National Institute of Diabetes and Digestive and Kidney Diseases; National Institute of Child Health and Human Development; the Division of Nutrition Research Coordination of the National Institutes of Health; and The Robert Wood Johnson Foundation. The committee thanks Terry Bazzarre, William Dietz, Karen Donato, Gilman Grave, Van Hubbard,

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Preventing Childhood Obesity: Health in the Balance Woodie Kessel, Kathryn McMurry, Pamela Starke-Reed, Susan Yanovski, and their colleagues for their support and guidance on the committee’s task. This study was conducted in collaboration with the IOM Board on Health Promotion and Disease Prevention (HPDP), and we wish to thank both Rose Martinez, director of the HPDP Board, for her thoughtful interactions and discussions with the committee, and Carrie Szlyk, who was of great assistance in the early phases of this study. We appreciate the extensive analysis of lessons learned from other public health efforts and their relevance to preventing childhood obesity written by Michael Eriksen (Appendix D). Many thanks to Sally Ann Lederman and Lynn Parker for their technical review of sections of the report. Kathi Hanna’s work as a consultant, financial oversight by Elisabeth Rimaud, and the editing work of Steven Marcus, Laura Penny, and Tom Burroughs are also greatly appreciated. The work of Rebecca Klima-Hudson and Stephanie Deutsch is also most appreciated. The report has been enhanced by the artwork of Becky Heavner, and we thank her for these creative efforts. Last, but not least, I would like to thank the Food and Nutrition Board study staff, Linda Meyers, Cathy Liverman, Vivica Kraak, Janice Okita, Tazima Davis, and Shannon Ruddy, for their extraordinary competence, diligence, wisdom, and intellectual openness. Their in-depth knowledge of the subject matter, keen sense of policy and practice, and willingness to constantly work and revise to make this document as useful, thoughtful, and accurate as possible was invaluable in its creation. Preventing Childhood Obesity: Health in the Balance presents a set of recommendations that, when implemented together, will catalyze synergistic actions among families, communities, schools, and the public and private sectors to effectively prevent the large majority of children and youth in the United States from becoming obese. Although the committee members have diverse backgrounds, over the course of this study we have gained a deeper appreciation for the difficulty and complexity of the steps necessary to prevent obesity in our nation’s youth. We provide this guidance with the hope that it will benefit the health of our nation and future generations. Jeffrey P. Koplan, Chair Committee on Prevention of Obesity in Children and Youth

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Preventing Childhood Obesity: Health in the Balance Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   21      An Epidemic of Childhood Obesity,   21      Implications for Children and Society at Large,   22      Contexts for Action,   25      Public Health Precedents,   44      Summary,   47      References,   48 2   EXTENT AND CONSEQUENCES OF CHILDHOOD OBESITY   54      Prevalence and Time Trends,   54      Considering the Costs for Children and for Society,   65      Summary,   72      References,   73 3   DEVELOPING AN ACTION PLAN   79      Definitions and Terminology,   79      Framework for Action,   83      Obesity Prevention Goals,   86      Energy Balance,   90      Review of the Evidence,   107

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Preventing Childhood Obesity: Health in the Balance      Summary,   115      References,   115 4   A NATIONAL PUBLIC HEALTH PRIORITY   125      Leadership, Coordination, and Priority Setting,   129      State and Local Priorities,   131      Research and Evaluation,   134      Surveillance and Monitoring,   137      Nutrition and Physical Activity Programs,   141      Nutrition Assistance Programs,   142      Agricultural Policies,   144      Other Policy Considerations,   146      Recommendation,   147      References,   148 5   INDUSTRY, ADVERTISING, MEDIA, AND PUBLIC EDUCATION   153      Industry,   153      Nutrition Labeling,   166      Advertising, Marketing, and Media,   171      Media and Public Education,   177      References,   185 6   LOCAL COMMUNITIES   193      Mobilizing Communities,   194      Health Care,   221      References,   227 7   SCHOOLS   237      Food and Beverages in Schools,   238      Physical Activity,   253      Classroom Curricula,   261      Advertising in Schools,   265      School Health Services,   269      After-School Programs and Schools as Community Centers,   272      Evaluation of School Programs and Policies,   274      Recommendation,   276      References,   278 8   HOME   285      Promoting Healthful Eating Behaviors,   287      Promoting Physical Activity,   296      Decreasing Inactivity,   301

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Preventing Childhood Obesity: Health in the Balance      Parents as Role Models,   305      Raising Awareness of Weight as a Health Issue,   306      Recommendation,   308      References,   309 9   CONFRONTING THE CHILDHOOD OBESITY EPIDEMIC   319      Next Steps for Action and Research,   322     APPENDIXES     A   Acronyms   327 B   Glossary   331 C   Literature Review   339 D   Lessons Learned from Public Health Efforts and Their Relevance to Preventing Childhood Obesity   343 E   Workshop Programs   377 F   Biographical Sketches   383     INDEX   395

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