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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary C Preventing Obesity in Mexican–American Children and Adolescents Frederick Trowbridge, Trowbridge & Associates, Inc., Atlanta, Georgia Fernando Mendoza, Stanford University School of Medicine Palo Alto, California INTRODUCTION Childhood obesity has become a worldwide concern because of its epidemic proportions and its growing link to type 2 diabetes and other chronic health conditions. Over the past two decades, there has been an increase in childhood and adolescent obesity to an unprecedented level. During the 1960s–1970s, the prevalence of obesity in children and adolescents in the United States was relatively stable at about 4–7 percent. However, during the 1980s the obesity prevalence doubled, with 11 percent of children and adolescents having body mass index (BMI) levels over the 95th percentile by the early 1990s (CDC, 2005b). In the latest National Health and Nutrition Examination Survey (NHANES) 2003–2004 (Ogden et al., 2006), childhood and adolescent obesity prevalence increased to 17 percent, which is triple the rate in NHANES I (1971–1974) and NHANES II (1976–1980) (Hedley et al., 2004). This dramatic increase in prevalence has driven childhood and adolescent obesity to a prominent position in the clinical and research arenas of child health. Moreover, as the links between obesity and its co-morbidities (e.g., type 2 diabetes, asthma, hypertension, sleep apnea, skeletal-muscular disorders, self-esteem and mental health disorders, and other chronic illnesses) have become more evident, the awareness of the long-term health effects of child and adolescent obesity has raised concerns at all levels of child health policy. Addressing the problem of obesity in Mexican–American children and adolescents will require consideration of the unique historical and demo-
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary graphic characteristics of Mexican Americans. Since the 1500s Mexican Americans have lived in what is now the southwestern United States and have maintained a continuing interchange of culture with Mexico. Today, Mexicans continue to immigrate to locations across the United States, and to maintain their cultural ties. Currently, one in five children in the United States lives in an immigrant family; they are either first- or second-generation children of immigrant parents (NRC/IOM, 1998). The country of origin for the largest proportion of these children is Mexico. In 2000, 39 percent of children in families new to the United States were Mexican—no other country contributes more than 4 percent (Hernandez, 2004). The substantial and ongoing interchange of people and culture between the United States and Mexico makes it clear that addressing childhood obesity in the Mexican–American community requires an approach that recognizes the common social, cultural, economic, and possibly genetic factors that contribute to childhood obesity in both Mexican–American and Mexican children and adolescents. At the same time, the influence of the substantially different social, cultural, and economic environment in which Mexican–Americans living in the United States find themselves, must also be taken into account. This paper reviews the prevalence and trends in obesity in Mexican–American children and youth and considers the multiple factors that may contribute to this growing health problem. The paper then provides an overview of current intervention strategies and programs and proposes actions that may offer the greatest potential for success in preventing and controlling the obesity epidemic. EXTENT AND CONSEQUENCES OF OBESITY IN MEXICAN– AMERICAN CHILDREN AND YOUTH Data from national surveys clearly demonstrate a high and increasing prevalence of childhood obesity in the United States (Ogden et al., 2002, 2006; Hedley et al., 2004). Obesity is particularly prevalent among Mexican–American children and youth. Moreover, Mexican–American children have a high prevalence of abdominal obesity, which may put them at elevated risk for type 2 diabetes and cardiovascular disease (CVD). High rates of obesity also may indicate that Mexican–American children and adolescents are more exposed to the negative impacts of obesity on their social and emotional health. Finally, since many Mexican–American children and youth depend on publicly funded health care programs such as Medicaid, the high prevalence of obesity will place increasing demands on health care providers serving Hispanic populations and thus will have significant implications for the funding needs of these programs.
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Measurement of Obesity in Children and Youth Body Mass Index (BMI) BMI is recommended widely as an appropriate measure of obesity in children older than 2 years of age (Daniels et al., 1997; Pietrobelli et al., 1998). This indicator is calculated easily from simple measurements of height and weight and is associated closely with indicators of cardiovascular disease (CVD) risk (Katzmarzyk et al., 2004). In addition, analysis of BMI data is facilitated by the availability of gender-specific reference data developed by the CDC for determining BMI-for-age percentiles (Kuczmarski et al., 2002). Reference curves based on an international data set derived from large, nationally representative surveys of child growth from six countries also are available (Cole et al., 2000). These reference curves are designed to merge smoothly with the BMI values for adults defining overweight as having a BMI between 25 to 29.9 kg/m2 and obese as having a BMI equal to or greater than 30 kg/m2. For consistency between the IOM report and this paper, obesity in children and youth is defined as having a BMI equal to or greater than age- and gender-specific 95th percentile of the BMI charts developed by the Centers for Disease Control and Prevention (CDC) in 2000. Being at-risk for obesity is defined as having a BMI between the age- and gender-specific 85th and 95th percentiles of the CDC BMI charts (IOM, 2005). However, BMI also has recognized limitations as an obesity indicator. The relationship of BMI to body fat in children varies in relation to age, maturational stage, gender, race, and fat distribution, so that a given BMI will not reflect an equivalent level of body fat for all individuals (Daniels et al., 1997). Despite these limitations, BMI remains a useful and practical indicator for clinical assessment and for characterizing obesity prevalence in population-based studies. Waist Circumference Waist circumference is a more specific indicator of abdominal fat, and it appears to perform at least as well as BMI in identifying children with a clustering of CVD risk factors (Katzmarzyk et al., 2004). Among the 4–17-year-old children and youth who were sampled in the NHANES III (1988– 1994), waist-to-height ratio actually performed better than BMI in identifying those with elevated CVD risk factors (Kahn et al., 2005). A 10-year cohort study beginning when children were 9 and 10 years old found that waist circumference and triglyceride level were significant predictors of the metabolic syndrome1 at ages 18 to 19 years. In this study, BMI was not a 1 The metabolic syndrome is diagnosed when an individual has at least three of five meta
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary significant predictor once waist circumference was included in the multivariate model (Morrison et al., 2005). The importance of abdominal obesity as a risk factor for CVD in adults was highlighted in a recent study that found that having an elevated waist-to-hip ratio was associated more strongly with myocardial infarction than having an elevated BMI (Yusuf et al., 2005). The population-attributable risk of myocardial infarction for the top two quintiles of waist-to-hip ratio was 24.3 percent versus only 7.7 percent for the top two quintiles of BMI. Descriptive data showing percentile distributions of waist circumference have been developed for 2–8-year-old African–American, European– American, and Mexican–American children based on data from NHANES III (Fernandez et al., 2004). In the same NHANES III data set, the waist circumference-to-height ratio did not vary significantly in relation to sex or age group, making it feasible to use a single set of cutoffs for classifying children of both sexes and all ages from 4 to 17 years (Kahn et al., 2005). The strong association of increased waist circumference with CVD risk factors and the availability of reference data support the use of waist circumference indicators, in addition to BMI, as valid and practical tools for assessing obesity and associated CVD risk in children and adolescents. However, additional research is needed to confirm the risks associated with abdominal obesity in different age, gender, and ethnic groups (especially Mexican and Mexican–American children and youth) and the usefulness of waist circumference as an indicator, alone or in combination with BMI, in identifying abdominal obesity in these different groups of children and adolescents. Obesity Prevalence and Trends Prevalence Since the late 1970s, there has been a dramatic increase in the prevalence of obesity among children and youth across all racial and ethnic groups in the United States. Data from national surveys indicate that the prevalence of obesity has more than doubled for children ages 2–5 years and adolescents ages 12–19 years, and obesity rates have more than tripled for children ages 6–11 years (Ogden et al., 2002). Prevalence estimates based on the National Longitudinal Survey of Youth data from 1986–1998 in children ages 4–12 years provide a similar picture of the increasing prevalence of obesity (Strauss and Pollack, 2001). bolic abnormalities: glucose intolerance, abdominal obesity, elevated triglyceride levels, low high-density lipoprotein levels, and high blood pressure.
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary An elevated prevalence of obesity is particularly evident for Mexican– American boys. In NHANES 2003–2004 (Ogden et al., 2006), Mexican– American boys ages 2–5 and 6–11 years had a higher prevalence of obesity than boys of any other race or ethnic group, while obesity prevalence for male adolescents was similar to other ethnic groups. (Figure C-1). In the 2003–2004 NHANES, Mexican–American girls ages 2–5 and 6–11 years had a prevalence of obesity that was less than that of African–American girls but greater than that of non-Hispanic White girls, while obesity prevalence for female Mexican–American adolescents was similar to non-Hispanic Whites (Figure C-2). Figure C-3 displays more data on obesity prevalence detailed by age group, gender, and ethnicity (Ogden et al., 2006). Additional research is needed to assess the underlying attitudes and diet and physical activity practices that may trigger these age, gender, and ethnic group differences. It is of interest to compare the prevalence of obesity in Mexican– American children and adolescents with their counterparts in Mexico. Data from the Mexican National Nutrition Survey (1999) (Rivera et al., 2001) and the Mexican National Health Survey (2000) (Olaiz et al., 2003) were analyzed using the same CDC reference criteria to define obesity (López Ridaura et al., 2006; del Rio-Navarro et al., 2004; Kuczmarski et al., 2002). Overall, results indicated that, except for the preschool age group, Mexican children had a lower prevalence of obesity than ethnically similar children in the United States surveyed in 1999–2000 (Ogden et al., 2006). Obesity prevalence in 2–5-year-old Mexican children was similar to their FIGURE C-1 Obesity prevalence in boys, NHANES 2003–2004. SOURCE: Ogden et al. (2006).
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary FIGURE C-2 Obesity prevalence in girls, NHANES 2003–2004. SOURCE: Ogden et al. (2006). Mexican–American counterparts. However, older Mexican children and adolescents had an obesity prevalence that was only half or one-third of the prevalence seen in Mexican–American children and adolescents (Table C-1 and Figure C-4). These results in children and adolescents from ethnically similar backgrounds suggest that environmental factors in the United States exert a significant influence on the growth and weight status of Mexican–American children and youth. Abdominal Obesity Prevalence Abdominal obesity appears to be a particular concern for Mexican adults, children, and youth. Data from the Mexican National Health Survey conducted in 2000 indicate a high prevalence of abdominal obesity in Mexican adults based on waist circumference measurements, with a reported prevalence of 46.3 percent in men (waist circumference ≥ 94 cm) and 81.4 percent in women (waist circumference ≥ 80 cm) (Sanchez-Castillo et al., 2005). Abdominal obesity was elevated even in women of normal weight, with co-morbidities relating better to waist circumference than to BMI. Moreover, the high prevalence of abdominal obesity in Mexican men and women was associated with a prevalence of diabetes and hypertension similar to or exceeding levels observed in the non-Hispanic White population in NHANES III (1988–1994).
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary FIGURE C-3 Percentage of U.S. children and adolescents who are obese or at risk for obesity, by age, gender, and ethnicity, 2003– 2004. SOURCE: Ogden et al. (2006).
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary TABLE C-1 Prevalence of Obesity in Non-Hispanic White, Mexican–American, and Mexican Children: 1999–2000 Age/ Gender Group NHANES 1999–2000 Non-Hispanic White NHANES 1999–2000a Mexican American Mexican National Nutrition Surveyb 1999 Mexican National Health Surveyc 2000 Boys 2–5 6.9 13.1 11.1 6–11 11.9 26.7 9.1 12–17 11.8 27.2 10.6 Girls 2–5 10.5 8.7 9.7 6–11 11.6 19.8 8.5 12–17 11.0 19.3 9.3 NOTE: Obesity is defined as greater than 95th percentile of BMI (Kuczmarski et al., 2002). aOgden et al. (2002). bRivera et al. (2002). cdel Rio-Navarro et al. (2004). Data represent average prevalence values for children 12 to 17 years.
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary FIGURE C-4 Prevalence of obesity in Mexican–American and Mexican children, 1999–2000. SOURCE: Rivera et al. (2002) and del Rio-Navarro et al. (2004). These observations of increased abdominal obesity in Mexican adults parallel the finding of increased abdominal girth in Mexican–American children and youth. In the NHANES III survey, 13.9 percent of Mexican– American children were classified as having a waist circumference-to-height ratio category that exceeded their BMI category, whereas only 7 percent of non-Hispanic Blacks and 9.48 percent of the overall sample were so classified (Kahn et al., 2005). A separate analysis of NHANES III data found that the smoothed 90th percentile of waist circumference for Mexican– American boys was consistently higher than that observed for either African–American boys or European–American boys. The 90th percentile for Mexican–American girls also was consistently higher than that of European–American girls at all ages and greater than that of African– American girls up to 9 years of age. Analysis of waist circumference data from the 1999–2000 NHANES survey also found a consistent pattern of higher mean waist circumference values for Mexican–American children (Ford et al., 2004) (Figure C-5). These findings of increased waist circumference suggest that Mexican– American children and youth, and particularly Mexican–American boys at all ages, may be at an increased risk of co-morbidities associated with abdominal obesity, including type 2 diabetes.
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary FIGURE C-5 Waist circumference (cm) of boys and girls 12–17 years old, by ethnic group. SOURCE: NHANES 1999–2000; Ford et al. (2004). Historical and Current Obesity Trends Obesity among Mexican–American children is not a new finding. A review of growth studies on Mexican–American children and youth during 1920–1980 (based primarily on immigrant and low-income Mexican Americans) showed a high prevalence of short stature and low weight that was indicative of undernutrition (Malina et al., 1986). However, by the 1970s and early 1980s, regional studies in this review indicated a higher-than-expected level of obesity among Mexican–American children and youth. This increased level of obesity was associated with a shorter stature as compared with non-Hispanic Whites, resulting in a short, plump physique. Data from NHANES I (1971–1974) demonstrated that differences in BMI between Mexican–American and non-Hispanic children and youth were related significantly to socioeconomic status (SES) (Mendoza and Castillo, 1986). Mexican–American children who had a lower SES had BMIs higher than their non-Hispanic counterparts, but this finding disappeared as SES increased. A combined analysis of NHANES I (1971–1974) and NHANES II (1976–1978) also found that stature was associated directly with SES and that poor children and youth were shorter (Martorell et al., 1988b). Overall, Mexican–American children and youth in this study
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary were shown to have a short, plump physique, and the data suggested they also had increased upper body fat (Martorell et al., 1988a). Height comparisons between Mexican–American children and non-Hispanic White children showed differences related to SES, although a similar association was not seen for Mexican–American adolescents. These observations suggest that short stature in lower SES Mexican–American children was likely to be related to less adequate nutrition early in life or even during the prenatal period. Since an SES effect was not seen in adolescents it may be that other factors, possibly genetic, are more influential after puberty. Data analysis from the Hispanic Health and Nutrition Examination Survey (HHANES) (1982–1984) indicated that Mexican–American children showed a higher-than-expected proportion of children above the 90th percentile for BMI between ages 6–11 years—with several year-groups showing twice the expected level—although adolescents showed more variability in the prevalence of obesity (Martorell et al., 1989). Further analyses of the HHANES showed that obesity was associated with increased centralized upper body adiposity and was not a result of having a different body proportion as compared with non-Hispanic Whites (Kaplowitz et al., 1989; Martorell et al., 1988a). In summary, data from HHANES confirmed findings from early studies, indicating that Mexican–American children had increased levels of obesity. The upward trend in obesity prevalence in Mexican–American children has continued in recent years. Between NHANES III (1988–1994) and NHANES (2003–2004), the prevalence of obesity in adolescent Mexican– American boys ages 12–19 years increased by 4.2 percent (Figure C-6). Among girls, the largest increases were noted in non-Hispanic White and African–American adolescents, although obesity also increased in Mexican–American girls (Figure C-7) (NCHS, 2004; Ogden et al., 2006). It is interesting to note that reported obesity prevalence in male Mexican– American adolescents 12–19 years old decreased from 27.2 percent in 1999– 2000 to 18.3 percent in 2003–2004, and in female adolescents from 19.3 percent in 1999–2000 to 14.1 percent in 2003–2004 (Ogden et al., 2006). The authors note that subgroup estimates by sex, age, and race/ethnicity are less precise than overall estimates due to smaller sample sizes, so that these prevalence estimates must be interpreted with caution. It is interesting to note that as obesity prevalence has increased over the last several decades, the linear growth of Mexican–American children and adolescents has shown relatively little change. Linear growth improved from the 1960s to 1980s when HHANES was conducted, suggesting that Mexican–American children and youth had not previously been achieving their full height potential (Martorell et al., 1989). Analysis of more recent data indicates that although weight-for-age and BMI percentiles of Mexican–American children increased between HHANES (1982–
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary achieve a reduction in the incidence and prevalence of obesity; improve dietary patterns to be consistent with dietary guidelines; meet physical activity guidelines; and achieve physical, psychological, and cognitive growth and development goals. However, more specific intermediate goals and recommendations that address the specific needs of Mexican–American children and youth must be defined. Achieving policy, environmental, and behavioral goals for obesity prevention for Mexican–American children and youth will require interventions at many levels, including television, print, and electronic media; schools; communities; and health care settings. To be successful, these efforts must be supported by ongoing research and monitoring and by effective advocacy. Some key issues to be addressed include the following: (a) the need for comprehensive, multifaceted interventions that can address dietary and physical activity behaviors; (b) greater insight into the feasibility of scaling up interventions to programs in large populations groups; and (c) an increased understanding of ways to sustain interventions after initial start-up funds are no longer available. Outlined below are a variety of potential actions that might be recommended and prioritized based on the discussions in the workshop. Media-Based Interventions Media-based interventions are appealing because of their potential to reach large target audiences and for their low cost. Given the high level of access that Mexican–American families have to television and radio as well as the growing access they have to the Internet, especially by older children and youth, these media channels are an increasingly important means of providing information and motivation for healthy lifestyle choices. Another appealing feature of media-based interventions is the ability of electronic content to be shared internationally, in particular between Mexico and the Mexican–American populations in the United States. At the same time, food and beverage advertising through the same media can promote consumption of high-calorie and low-nutrient food and beverages and can negatively influence dietary and physical activity behaviors, thus increasing the risk of obesity. Specific actions that support expanding the potential and reducing the negative impact of media-based messages are cited in the following list. Health Information in Television, Radio, and Print Media Establish policies and guidelines that define appropriate marketing of foods and beverages to children and youth in general and specifically to Mexican–American children and youth.
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Increase the number of new industry products and advertising messages that promote energy balance at a healthy weight and are targeted to Mexican–American consumers. Internet-Based Health Promotion Resources Develop culturally appropriate Web content that specifically targets Mexican–American children, youth, and parents. Develop Web content in Spanish, or adapt it from existing English language websites, to provide accurate and appealing health information and to offer tips and guidance in choosing healthy lifestyles. School-Based Interventions School environments provide an important influence on children’s behaviors and can foster healthful nutrition and physical activity or negatively influence these behaviors. Many of the interventions currently being implemented and evaluated are carried out in the school setting. Some key strategies for fostering health-promoting school environments include the following: Provide training for and support development of school wellness policies that promote healthful school nutrition and physical activity environments. Implement school food service and vending policies that encourage healthful dietary choices. Support the development and dissemination of language and culturally appropriate health education materials for Mexican–American children and youth. Support research to develop and evaluate school-based interventions that are sustainable and effective in promoting increased participation in healthful physical activity. Community-Based Interventions Community-based youth programs and policies that create environments where children, youth, and families can share physical activity are critical components of an obesity prevention strategy. Support expansion of community-based youth programs that serve Mexican–American children and youth. In neighborhoods with a high proportion of Hispanic families, support policies such as the expansion of park facilities, sidewalks, and bike paths that encourage safe physical activity.
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Provide training opportunities and materials to youth program staff to enhance their effectiveness. Give recognition for achievements in developing successful community-based programs that serve Mexican–American populations. Improve access to and affordability of fruits and vegetables for low-income Mexican–American populations. Encourage participation by Mexican–American families in federal food assistance programs that increase access to healthful foods. Implement policies that promote neighborhood safety, improved air quality, public transportation, and design conducive to healthy activity. Health Care Interventions Although many Mexican–American families lack adequate access, health care providers remain an important and trusted source of information and guidance. The impact of health care in motivating positive nutrition and physical activity behaviors can be enhanced by the following actions: Develop guidelines outlining best practices for health care providers to assist in counseling Mexican–American youth and families regarding healthful dietary and physical activity habits. Anticipatory guidance by health care providers should begin early and include information on maternal nutrition, breastfeeding, infant nutrition, and healthful diet and physical activity for children, youth, and families. Provide health promotion materials and information that is adapted to Hispanic language and culture. Encourage the development and evaluation of training courses and materials for health care professionals in the assessment and behavioral management of child obesity, particularly when caring for Mexican– American children and adolescents. Encourage collaboration between medical, public health, and school services to provide consistent and thus reinforcing health promotion messages and support for populations of Mexican–American children who are at high risk for childhood obesity, independent of insurance status or ability to pay. Research and Monitoring Expanded research and evaluation efforts are needed to provide the scientific underpinnings for obesity prevention efforts. Priority areas for research and opportunities for Mexico–U.S. collaborations are outlined below.
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Establish policies to support behavioral research that can assess the impact of television, radio, Internet, and print media messages on eating habits and physical activity in Mexican–American children and youth. Conduct research on the use of the Internet by Hispanic families and children, especially when they are seeking health-related information. Segment by age, gender, income, education, and location. Conduct research on the effectiveness of Web-based health promotion directed at Mexican–American children and youth. Support research on the effectiveness of school-based interventions for obesity prevention, particularly relating to the impact on Mexican– American children and youth. Conduct research on the availability, use, and effectiveness of community-based health promotion activities for improving dietary choices and physical activity in Hispanic, especially Mexican–American, children and youth. Support research to better understand the attitudes and perceptions of Mexican Americans about the health consequences of obesity and the link between obesity and dietary and physical activity habits. Support continued monitoring of obesity prevalence and related risk factors at the national level, particularly in high-risk populations such as Mexican Americans. Support and expand state and local surveys that provide insight into obesity status, attitudes, and dietary and physical activity behaviors, especially in populations at increased risk. Facilitate interdisciplinary research between medicine, public health, architecture, planning, food production economics, and communication to explore the ecological model of childhood obesity, particularly relying on scholars from ethnic study centers. Mexico–U.S. Collaboration Achievement of goals for intervention, monitoring, and research of child and adolescent obesity will be assisted greatly by establishing a framework in which Mexican and United States’ researchers, public health professionals, and policy makers can readily exchange ideas and information and can collaborate in future research and intervention efforts. Below are some specific steps that might be considered to foster such collaboration. Establish an ongoing mechanism for binational coordination to facilitate periodic meetings, e-mail newsletters, and other means of communication between Mexican and U.S. intervention program directors and researchers to exchange information on obesity prevention activities and research findings and to foster collaboration.
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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Establish a Mexico–United States scientific exchange program that provides opportunities for researchers in obesity prevention to share ideas and undertake joint research. Identify specific intervention strategies that could be implemented and evaluated in both countries, such as Use of a standardized health report card for tracking weight status and risk factors for obesity in children and youth, Use of waist circumference as a screening tool to identify children and youth at risk, Use of Internet-based resources (such as “todoenobesidad”) to provide health information and guidance, and Effectiveness of multicomponent school-based interventions to reduce behavioral and physiological risk factors, such as the Bienestar program. Develop a common framework for evaluating intervention effectiveness and provide opportunities, such as joint workshops, to review and learn from the experiences in each country. Provide awards that recognize significant research and programmatic accomplishments in obesity prevention relating to Mexican and Mexican– American children and youth. Provide training grants and fellowship support to encourage young researchers to enter the field of obesity prevention. Establish a Mexico–U.S. practice exchange that provides opportunities for public health, community organizations, advocates, policy makers, and others to share best practices, models, tools, and other information. Share and disseminate information on success stories in obesity prevention in both countries. Advocacy Learning from the experiences of other public health efforts, it is clear that success in obesity prevention will depend on the fostering of effective advocacy at many levels. As outlined in the Accelerating Policy on Nutrition report, the success of advocacy efforts will depend especially on accomplishing the following key objectives (Dorfman et al., 2005): Establish clear policy goals. Foster opportunities for dialog with a wide range of stakeholders to develop a common framework and terminology for describing the nature of the problem and the most effective means to achieve obesity prevention and to promote health. Seek political opportunities to advance the policy goals.
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