Summary

Institute of Medicine Regional Symposium

Progress in Preventing Childhood Obesity: Focus on Schools

In collaboration with the Kansas Health Foundation Supported by The Robert Wood Johnson Foundation


June 27–28, 2005

Wichita Hyatt Regency Hotel

Wichita, Kansas


Obesity is now an epidemic among children and adolescents in the United States. Nationwide, roughly nine million children over six years of age are obese—with elevated risks of both health conditions, such as diabetes and hypertension, and poor quality of life, possibly throughout adulthood. In 2002, Congress charged the Institute of Medicine (IOM) with developing a prevention-focused action plan to decrease the number of obese children and youth in the United States. The resulting IOM report, Preventing Childhood Obesity: Health in the Balance, was released in September 2004 and identified promising approaches for obesity prevention efforts and a set of recommendations for a variety of stakeholders and sectors.

This year, with support from The Robert Wood Johnson Foundation (RWJF), the IOM is building on its previous work by initiating a new study to assess progress in childhood obesity prevention efforts. The IOM has appointed a 13 member multidisciplinary committee with expertise in child health, obesity, nutrition, physical activity, industry, community-based evaluation, public health, and public policy to conduct the study. In 2005, the IOM committee is organizing three regional meetings in the Midwest, South, and Western United States to galvanize obesity prevention efforts of local, state, and national decision-makers, community and school leaders, grassroots organizations, and industry including the food, beverage, restaurant, leisure, and entertainment industries. These three meetings will involve disseminating the findings and recommendations of the original IOM report and catalyzing dialogues that highlight best practices and identify assets and barriers to moving forward with obesity prevention efforts in each selected region.



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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium Summary Institute of Medicine Regional Symposium Progress in Preventing Childhood Obesity: Focus on Schools In collaboration with the Kansas Health Foundation Supported by The Robert Wood Johnson Foundation June 27–28, 2005 Wichita Hyatt Regency Hotel Wichita, Kansas Obesity is now an epidemic among children and adolescents in the United States. Nationwide, roughly nine million children over six years of age are obese—with elevated risks of both health conditions, such as diabetes and hypertension, and poor quality of life, possibly throughout adulthood. In 2002, Congress charged the Institute of Medicine (IOM) with developing a prevention-focused action plan to decrease the number of obese children and youth in the United States. The resulting IOM report, Preventing Childhood Obesity: Health in the Balance, was released in September 2004 and identified promising approaches for obesity prevention efforts and a set of recommendations for a variety of stakeholders and sectors. This year, with support from The Robert Wood Johnson Foundation (RWJF), the IOM is building on its previous work by initiating a new study to assess progress in childhood obesity prevention efforts. The IOM has appointed a 13 member multidisciplinary committee with expertise in child health, obesity, nutrition, physical activity, industry, community-based evaluation, public health, and public policy to conduct the study. In 2005, the IOM committee is organizing three regional meetings in the Midwest, South, and Western United States to galvanize obesity prevention efforts of local, state, and national decision-makers, community and school leaders, grassroots organizations, and industry including the food, beverage, restaurant, leisure, and entertainment industries. These three meetings will involve disseminating the findings and recommendations of the original IOM report and catalyzing dialogues that highlight best practices and identify assets and barriers to moving forward with obesity prevention efforts in each selected region.

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium In collaboration with the Kansas Health Foundation (KHF), the IOM held the study’s first regional symposium in Wichita, Kansas on June 27–28, 2005. This first symposium focused on the specific IOM report recommendations for schools and stakeholders in the school setting to explore how to create a healthy school environment (Box 1). The symposium was structured to include three plenary panels that focused on challenges and innovations for obesity prevention and school policies, school programs, and additional steps that can be taken by numerous stakeholders to overcome barriers to progress. Three break-out sessions focused on creating and strengthening linkages with other sectors to promote childhood obesity prevention including links between schools and home, community, and health care; links between schools and industry; and links between schools and the built environment (see program agenda). Overall, the symposium succeeded in providing a useful forum for stakeholders to explore viable strategies and exchange information about best practices and strategies for overcoming barriers through the plenary and break-out sessions. This brief summary highlights the recurring themes for accelerating change and moving forward with obesity prevention efforts that emerged from the symposium: forge strategic partnerships; empower local schools and communities; educate stakeholders; evaluate obesity prevention efforts; document the benefits of obesity prevention; innovate to address barriers; use a systems approach; and develop a long-term strategic plan. In collaboration with RWJF and KHF, approximately 90 individuals active in childhood obesity prevention efforts in the Midwest and who represented a range of stakeholder perspectives and innovative practices in the school setting—including teachers, students, principals, health educators, dietitians, food service providers, industry representatives, state government, and community leaders—were invited to participate in the symposium, and the discussion focused on exploring the barriers and opportunities for sustaining and evaluating these efforts. The findings of this summary, along with those of two other symposia, and a more detailed discussion of insights and regional examples will be incorporated in the committee’s final report that will be released in 2006. Forge Strategic Partnerships Much of the work in preventing childhood obesity currently takes place in a variety of environments—for instance, in a single school dis-

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium trict that decides to improve nutrition and promote physical activity, or a single government grant that promotes school health locally. To achieve broader and sustained progress, however, stakeholders and decision-makers from important arenas will all need to take the initiative by collaborating more closely with the common goal of promoting the health of students, and by forging partnerships among private industry, nonprofit organizations, health-care providers, state and local governments, and other active groups. One strategy for building a coalition is to identify and target the basic strengths, resources, and opportunities that varied participants can contribute. City planners, community developers, and school district officials all have a connection to childhood obesity and a responsibility to work together to address it. The challenge is to recognize their common interests and frame them in such a way that is compelling and can be used by each partner to leverage their special contribution. Empower Local Schools and Communities Every state, community, and school is contextually different. From student demographics to the existence or conditions of sidewalks, the social, cultural, and environmental factors that influence healthy lifestyles—and ultimately health status—are numerous and diverse. Because of this heterogeneity, there can be no “one size fits all” program. A variety of approaches that integrate efforts across many sectors is needed to prevent childhood obesity. Empowerment of communities and local school districts involves helping community members identify issues that are important and relevant to their lives, and enable them to develop strategies to address these issues. In particular, empowerment involves encouraging stakeholder participation, enhancing problem assessment capacities, developing local leadership, strengthening institutional structures, mobilizing resources, and enhancing stakeholder control and ownership for programs. Presentations at the Wichita symposium provided an indication that local school boards, principals, teachers, parents, and other community leaders are becoming empowered by recognizing the nuances and cultural circumstances of their particular communities and beginning to design and support activities to fit their community’s needs. Some local leaders are trying to enhance existing obesity prevention efforts in specific settings by supporting a range of obesity prevention efforts with the goal of the determining the best combination of improved

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium nutrition and physical activity measures for specific situations and groups of children and adolescents. Government and other initiatives should promote this kind of collaborative expansion and work to ensure evaluation efforts to build the evidence base that is needed to address this epidemic. Because decisions about school policies are largely made at the local level, there may be greater potential for local ownership of school-based changes relevant to obesity prevention and thus potentially greater opportunities for promoting and sustaining these changes. Build Stakeholder Support Empowering communities to change and creating ownership to ensure that these changes are implemented and sustained are tremendous challenges. When one Kansas school took many steps to fight obesity—by replacing traditional recess with structured physical activity, moving lunch into the classroom, encouraging teachers to eat the same lunch as students thereby serving as role models, and providing water bottles to students—skeptical parents initially resisted. Some did not believe that improved nutrition and regular physical activity could improve their children’s experience and academic performance in the classroom. Over time and with promising results from preliminary classroom evaluations, support for these changes grew substantially among parents, teachers, and the community. This school now serves as a model for other schools in the district to implement similar changes. From school boards to food and beverage vendors, a lack of awareness about the health-related risks of, and potential solutions for, obesity may hinder prevention efforts. Education of parents and other relevant stakeholders remains a central need to establish healthy eating and regular physical activity as a normal expectation in schools. Busy parents appreciate receiving clear, positive, and reinforcing messages that emphasize incremental changes they can make to improve the health of their children and adolescents. Industry can be a constructive partner for providing healthier product and packaging options and supporting educational initiatives and programs that promote energy balance. Partners working together to improve the school environment can serve as change agents to inspire changes at many different levels. Stories describing the intent and early findings from school-based efforts to increase physical activity and prevent obesity have been published regionally and across the country. The mass media can be an asset

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium in obesity prevention efforts in disseminating documented changes in schools and communities. Although raising awareness of the obesity problem is important function of the mass media, it also has great potential to move beyond the statistics and showcase solutions and concrete examples of individuals, families, schools, communities, and industry partners working toward successful change. The IOM report recommended that a long-term national multimedia and public relations campaign focused on obesity prevention in children and youth be developed and evaluated. In particular, the media should incorporate obesity issues into its content and reinforcing messages need to be provided in diverse media and effectively coordinated with other events and dissemination activities. However, a remaining challenge is to build on this media coverage and accelerate the pace and breadth of change. Evaluate Obesity Prevention Efforts As with other behavioral changes, it is difficult to assess the effectiveness of obesity prevention programs. Often, there is a need for combining efforts to promote a collective impact that cannot be detected by any single evaluation method. Evaluation also presents an additional cost to any prevention effort, and poses problems for schools with limited financial reserves and staff resources. Without evaluation, however, schools and communities cannot demonstrate that a given obesity prevention effort will work, and thus merit continued funding, time, or energy. Foundations, local and state government policy makers, community leaders, and others require evidence that obesity prevention efforts are effective so that they can be modified as needed, sustained, and disseminated. At the symposium, a range of evaluation approaches were discussed from formal evaluations conducted by academic institutions that were well-funded and were built in as components of the implementation process to grassroots efforts to evaluate innovative local programs that have only limited funding. The evaluation measures highlighted included intermediate outcomes such as increased time for scheduled physical activity or increased students’ consumption of fruits and vegetables. It is important to note that many obesity prevention interventions are in the early stages of development. Evaluators need to be realistic, assess incremental progress, and be comfortable with conducting both formative

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium evaluations as well as outcome evaluations in the ongoing response to childhood obesity. Document the Benefits of Obesity Prevention A healthier heart, physically fit body, and a higher energy level are among the known rewards of achieving energy balance at a healthy weight. School principals and teachers at the symposium anecdotally reported that physically fit students are also mentally fit students—with fewer discipline problems, improved classroom focus, and better scores on standardized tests. Although studies are beginning to examine these relationships, more empirical evidence is needed to assess the impact of improved diet and increased physical activity on academic performance and classroom management. If healthier students are, in fact, more attentive and academically successful students, then parents, principals, and policy makers alike may be more supportive of obesity prevention efforts. Innovate to Address Barriers Like other public health efforts, childhood obesity prevention faces several key barriers: funding, time, attitudes, a lack of both uniform guidelines and a shared vision. These barriers affect efforts across settings, from the home to schools and local programs. However, creativity, innovation, and persistence often can overcome these hurdles. A school obesity prevention plan budget could conceivably combine the funds from multiple organizations. One Kansas school district was surprised by the success of a newly installed vending machine that sold low-fat milk rather than soda. Some schools now incorporate structured physical activity into the daily academic (non-physical education) curriculum and others request that parents bring healthy food and beverage treats for classroom celebrations, replace food rewards with play dates and field trips, and encourage fundraising without using food. Additionally, creative educational approaches are being used such as introducing nutrition and physical activity into an integrated health, physical education, and math curriculum that satisfies health requirements, and the “body walk” tour that teaches children and youth about the relevance of food and physical activity to the healthy functioning of the human body. Advo-

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium cacy groups, too, have found solutions such as converting abandoned railroad trails to walkways, and creating walking school bus programs that drop off children a distance from schools and have adults safely escort them to promote daily physical activity before and after the school day. These examples demonstrate that recognized barriers, while remaining a challenge, need not stop efforts to improve the health of children and adolescents. Use a Systems Approach Individual interventions can help a group of children become healthier, but system-wide changes will reach many more with sustainable programs and are necessary to effect the social norm changes to stem the epidemic. Coordinated school health programs are a good example. By training and equipping schools across a state to improve the infrastructure that enhances the nutritional quality of food and beverage choices, improves the extent of physical activity in physical education classes, and encourages other health-related behaviors, these coordinated efforts reach a broad student population. School administrators can restructure the school day cost-effectively and show improved outcomes—both disciplinary and performance. School leaders seeking change should incorporate a systems approach with enough flexibility and adaptability to address the wide range of school populations and locales. Develop a Long-Term Strategic Plan As a public health crisis, childhood obesity can be overcome—but it will require a coordinated and sustained effort. Previous public health triumphs, from a drop in smoking rates to a measurable increase in the use of seat belts, demonstrate that prolonged concentrated efforts can eventually change social norms that promote healthy lifestyles in schools. Childhood obesity prevention will require a long-term response but changes are beginning as evidenced by the range of innovative programs and policy changes being implemented across the Midwest and other regions throughout the United States.

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium Agenda Institute of Medicine Regional Symposium Progress in Preventing Childhood Obesity: Focus on Schools In collaboration with the Kansas Health Foundation Supported by The Robert Wood Johnson Foundation June 27–28, 2005 Wichita Hyatt Regency Hotel Wichita, Kansas June 27, 2005 Opening Session Welcome Steve Coen, Kansas Health Foundation, Wichita Kathryn Thomas, The Robert Wood Johnson Foundation, Princeton, New Jersey Overview of the Meeting Goals and the Report, Preventing Childhood Obesity: Health in the Balance Jeffrey Koplan, Emory University and Institute of Medicine (IOM) Committee on Progress in Preventing Childhood Obesity, Atlanta, Georgia Perspectives on Childhood Obesity Policy Perspectives James Barnett, Kansas Senate, Emporia Health Perspectives James Early, University of Kansas, Wichita Kansas Teen Leadership for Physically Active Lifestyles Ann Sparke, Morris County Extension Service, Kansas Chynna Walters and Mary Byram, Council Grove High School, Kansas

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium Plenary Panel—Presentations and Discussion Obesity Prevention and School Policies: Challenges and Innovations Developing and evaluating state-, district- and school-based changes in school policy related to childhood obesity prevention Moderator: Eduardo Sanchez, Texas Department of State Health Services, Austin Kansas Coordinated School Health Program Jodi Mackey, Kansas State Department of Education, Topeka Paula Marmet, Kansas State Department of Health and Environment, Topeka School District Comprehensive School Wellness Policies Joan Pritchard, Goddard School District, Kansas Elementary School Policies Janine Kempker, Anthony Elementary School, Leavenworth, Kansas Ohio Physical Education and Food Service Policies Dianne Radigan, Children’s Hunger Alliance, Columbus, Ohio School District Food Service Policies Rosemary Dederichs, Minneapolis Public Schools Food Service, Minnesota School District Vending Machine Policies Carole Farthing, Independence, Kansas School Board Plenary Panel—Presentations and Discussion Obesity Prevention and School Programs: Challenges and Innovations Implementing and evaluating state-, district- and school-based programs aimed at childhood obesity prevention Moderator: Tom Robinson, Stanford University Prevention Research Center, Stanford, California Kansas Physical Dimensions and Physical Focus Merri Copeland, Friends University, Wichita Kansas

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium Arkansas School Initiatives Jim Raczynski, University of Arkansas for Medical Sciences, Little Rock Physical Activity Across the Curriculum Joseph Donnelly, University of Kansas, Lawrence Coordinated Approach to Child Health Steve Kelder, University of Texas Health Science Center at Houston Linking a Food-based Curriculum with the Elementary School Lunch Program Antonia Demas, Food Studies Institute, Trumansburg, New York Implementing Changes in Elementary School Curricula and Programs Sherrie Kisker, Platte County Health Department, Platte City Missouri Disa Rice and Carolyn Barry, Siegrest Elementary, Platte City, Missouri Obesity Prevention: Links with Other Sectors What efforts by other sectors of the community are relevant to school-based obesity prevention efforts? What are the barriers to change? What is needed to implement and sustain these changes? Breakout Session #1 Links Between Schools and Home, Community and Healthcare Facilitators: Marshall Kreuter, Georgia State University, Atlanta; Susan Foerster, California Department of Health Services, Sacramento Presentations followed by group discussion: Heather Duvall, Oklahoma Fit Kids Coalition, Oklahoma City Mary Ca Ralstin, Kansas PTA, Shawnee Mim Wilkey, Wichita YMCA, Health & Wellness Coalition, Kansas Jill Poole, Broken Arrow National Farm to School Program, Oklahoma LaVonta Williams, Wichita After School Program, Kansas Deborah Loman, National Association ofPediatric Nurse Practitioners, St. Louis, Missouri

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium Breakout Session #2 Links Between Schools and Industry Facilitators: John Peters, Procter & Gamble Company, Cincinnati, Ohio; Jeffrey Koplan, Emory University, Atlanta, Georgia Presentations followed by group discussion: Ann Hartley, Advance Food Company, Mooresville, North Carolina Barbara Jirka, Tyson Foods, Springdale, Arkansas Ellen Taaffe, PepsiCo, Chicago, Illinois Nancy Daigler, Kraft Foods, Northfield, Illinois Jane Byrnes-Bennett, Midwest Dairy Council, Wichita, Kansas Breakout Session #3 Links Between Schools and the Built Environment Facilitators: Russ Pate, University of South Carolina, Columbia; Ann Bullock, Health and Medical Division, Eastern Band of Cherokee Indians, North Carolina; Toni Yancey, UCLA School of Public Health Presentations followed by group discussion: Ian Thomas, PedNet, Columbia, Missouri Dan Grunig, Bicycle Colorado, Colorado Safe Routes to School, Denver Judy Johnston, Walkin’ Wichita, Kansas Dave Barber, Wichita-Sedgwick County Metropolitan Area Planning Department, Kansas Wess Galyon, Wichita Home Builders Association, Kansas Reception and Dinner Wichita Art Museum Dinner Speaker: Matt Longjohn, Consortium to Lower Obesity in Chicago Children, Illinois

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium Tuesday, June 28, 2005 Plenary Session Welcome Howard Rodenberg, Kansas State Health Director, Topeka Opening Remarks Vickie James, Healthy Kids Challenge, Dighton, Kansas Keystone Youth Policy Summit on Child and Adolescent Nutrition in America Larry Walker, Meagan Geuther, Steven Gohlke, Paige Ibanez, Academy of Science and Technology, Conroe, Texas Reports from Breakout Sessions Plenary Panel—Presentations and Discussion Preventing Childhood Obesity: What More Can Be Done? What are the barriers to further progress? What more can be done at the federal, state, community and private sector levels? Moderator: Doug Kamerow, RTI International, Washington, DC Federal Perspective Mary McKenna, Centers for Disease Control and Prevention, Atlanta, Georgia State Perspective Rod Bremby, Kansas Department of Health and Environment, Topeka Community Perspective Brenda Kumm, Mid-America Coalition on HealthCare/KCHealthyKids.org, Kansas City, Missouri Foundation Perspective Billie Hall, Sunflower Foundation, Topeka, Kansas Kathryn DeForest, Missouri Foundation for Health, St. Louis Industry Perspective Louise Finnerty, PepsiCo, Purchase, New York

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium Group Discussion Closing Session Summary and Next Steps Jeffrey Koplan, IOM Committee on Progress in Preventing Childhood Obesity

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Progress in Preventing Childhood Obesity: Focus on Schools - Brief Summary, Institute of Medicine Regional Symposium BOX 1 Schools Recommendations from the Institute of Medicine Schools should provide a consistent environment that is conducive to healthful eating behaviors and regular physical activity. To implement this recommendation: USDA, state and local authorities, and schools should: Develop and implement nutritional standards for all competitive foods and beverages sold or served in schools Ensure that all school meals meet the Dietary Guidelines for Americans Develop, implement, and evaluate pilot programs to extend school meal funding in schools with a large percentage of children at high risk of obesity. State and local education authorities and schools should: Ensure that all children and youth participate in a minimum of 30 minutes of moderate to vigorous physical activity during the school day Expand opportunities for physical activity through: physical education classes; intramural and interscholastic sports programs and other physical activity clubs, programs, and lessons; after-school use of school facilities; use of schools as community centers; and walking-and biking-to-school programs Enhance health curricula to devote adequate attention to nutrition, physical activity, reducing sedentary behaviors, and energy balance, and to include a behavioral skills focus Develop, implement, and enforce school policies to create schools that are advertising-free to the greatest possible extent Involve school health services in obesity prevention efforts Conduct annual assessments of each student’s weight, height, and gender- and age-specific BMI percentile and make this information available to parents Perform periodic assessments of each school’s policies and practices related to nutrition, physical activity, and obesity prevention. Federal and state departments of education and health and professional organizations should: Develop, implement, and evaluate pilot programs to explore innovative approaches to both staffing and teaching about wellness, healthful choices, nutrition, physical activity, and reducing sedentary behaviors. Innovative approaches to recruiting and training appropriate teachers are also needed. SOURCE: IOM (Institute of Medicine). 2005. Preventing Childhood Obesity: Health in the Balance. Washington, DC: The National Academies Press.