1. Childhood Obesity: The Way Forward Susan Dentzer Editor-in-Chief With thanks to the Robert Wood Johnson Foundation for its generous support

2. Childhood Obesity: Overview and National Trends William H. Dietz, MD, PhD Director Division of Nutrition, Physical Activity, and Obesity Centers for Disease Control and Prevention

3. Prevalence of Overweight Among Children and Adolescents Ages 6-19 Years Source: JAMA, April 5, 2006, Vol. 295, No. 13:1549 and Pediatrics 1998; 101:497

4. Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19 Years Ogden CL et al. JAMA 2008;299:2401

5. Changes in Obesity Prevalence by Race/ethnicity, Girls 2-19 Years Ogden CL et al. JAMA 2008;299:2401

6. Impact of Childhood Overweight (BMI > 95 th percentile) on Adult Obesity (BMI > 30) 25% obese adults were overweight children 4.9 BMI unit difference in severity Onset < 8y more severely obese as adults (BMI = 41.7 vs 34.0) 50% of adults with BMI > 40 were obese as children Freedman et al, Pediatrics 2001; 108: 712

7. Costs of Obesity – 1998 vs 2008 1998 2008 Total costs$78.5 B/y $147 B/y Medical costs 6.5% 9.1% Increased prevalence, not increased per capita costs, was the main driver of the increase in costs Finkelstein et al. Health Affairs 2009; 28:w822

8. Average Daily Energy Gap (kcal/day) Between 1988-94 and 1999-2002 Excess Weight Gained (Lb) Daily Energy Gap (kcal/day) All Teens10110 -165 Overweight Teens58 678 -1,017 Behavioral implications of 150 kcal: Replacing 1 can of soda (12 oz) with water (140 kcal) Reducing TV watching by an hour (167 kcal/day) 1 Walking 1.9 hours instead of sitting (for a 30-kg boy) Increasing PE from 1 to 3 times/week (240 kcal) Wang YC et al. Pediatrics 2006;118:e1721 Wiecha et al. 2006; Arch Pediatr Adolesc Med 160:436

9. National, State and Local Disparities in Childhood Obesity Findings from the 2007 National Survey of Children’s Health Christina Bethell, Lisa Simpson, Scott Stumbo, Adam Carle, Narengeral Gombojav

10. *2003 versus 2007 rates of obesity are significantly different (P<0.05) 20032007 Publicly Insured39.6%43.2%* Poor (< 100% FPL)39.8%44.8%* Hispanic37.7%41.0%* The Nation: 2003 vs. 2007

11. Within State Disparities ID=27.5 MN=23.1

12. Significantly lower than U.S. Lower than U.S., not significant Higher than U.S., not significant Significantly higher than U.S. Low: UT/MN: 23.1% High: MS: 44.4 Variation Across States Both Across and Within State Disparities Widened

13. AK=33.9 AZ=30.6 Within State Disparities

14. School EngagementMissed School Days Repeated a Grade b Statistically significant differences exist in estimated prevalence across child subgroups for this variable based on a chi square test and p<.01. Independent Impact on School Outcomes Higher Odds of Poorer School Outcomes for Overweight or Obese Children (Adjusted for Health Status, SES, etc.) Not Being Engaged in School 1.32 greater odds Missing 2 or more weeks of school in year 1.59 greater odds Repeated a grade in school 1.42 greater odds 31.0

15. While being publicly insured and not having access to a park or recreation center independently predicts overweight/obesity in children, most overweight or obese children are still privately insured and have neighborhood amenities A National Issue

16. How Much Should We Invest In Preventing Childhood Obesity? Leonardo Trasande, MD, MPP Mount Sinai School of Medicine

17. Background Policy makers generally agree that childhood obesity is a national problem and costly to our economy. However, it is not always clear whether enough is being spent to combat it. While continued research is needed to develop successful initiatives to prevent and treat obesity and overweight, estimating the economic benefits of successful intervention can permit policy makers to determine the level of investment in developing interventions that would be worth considering.

18. Methods This paper presented nine scenarios that assume three different degrees of reduction in obesity/overweight rates among children in three age groups. A mathematical model was then used to project lifetime health and economic gains. These data were then used to calculate the level of investment that would be cost-effective using widely accepted criteria in health care if it produced reductions in the number of obese or overweight children.

19. Results During childhood, U.S. children who were 12 years old in 2005 are estimated to incur $6.24 billion in attributable medical expenditures over their lifetime, and lose 2,102,522 Quality Adjusted Life Years will be lost as a result of being overweight or obese in adulthood. A one point reduction of obesity in this age group would save $260.4 million in medical expenditures and 102,749 Quality Adjusted Life Years. At a value of $50,000/Quality Adjusted Life Year, spending $2 billion a year would be cost-effective if it reduced obesity among twelve-year-olds by one percentage point.

20. Results Regardless of the degree of reduction in obesity/overweight and the age group in which the impact of prevention was studied, large investments no smaller than $103 million and potentially in the tens of billions of dollars, each year, would be warranted if it could produce small reductions in the number of children with this significant comorbidity.

21. Discussion In conveying the scope of the effort that should be undertaken, this analysis took a conservative approach, analyzing only direct medical expenditures in childhood and adulthood and Quality Adjusted Life Years lost as a result of obesity/overweight in childhood. This analysis suggests that even some costly interventions of uncertain efficacy and additional research to develop interventions may even be worth pursuit on a broad scale, if they actually produce success in reducing the number of overweight/obese children. As debate about health reform continues, this manuscript provides additional data to underscore the need to focus on child health and especially on prevention as a mechanism to improve health cost- effectively.

22. A Statewide Strategy To Battle Child Obesity in Delaware March 2010 Debbie I. Chang (dchang@nemours.org) Allison Gertel-Rosenberg Vonna L. Drayton Shana Schmidt Gwendoline B. Angalet www.nemours.org This research was funded, in part, by the Robert Wood Johnson Foundation

23. 360 o of Child Health Promotion: Impacting a Child Throughout the Day

24. Progress Results at the Population Level  Results from the 2008 DSCH, compared to the 2006 DSCH, suggest that the prevalence of overweight and obesity has leveled off for children ages 2 -17 years in Delaware –Overweight remained unchanged at 17%  Evidence indicates the prevalence of obesity and overweight has leveled off in all Delaware counties and within subpopulations  Disparities still remain among racial groups  Household awareness between 2006-2008 of the 5-2-1-Almost None campaign increased fourfold (5% to 19%)  When parents were aware of the 5-2-1-Almost None message, significantly more children engaged in: –1 hour of physical activity per day (26% versus 10% if parent not aware of campaign) –Moderate to vigorous physical activity for more than 20 minutes (33% versus 21% if parent not aware of campaign)

25. Progress Results - Child Care and School  Child care regulations adopted statewide in 2007 reflect NHPS’ 5-2-1-Almost None healthy lifestyle behaviors  81 % of child centers participating in NHPS’ learning collaborative made significant changes in healthy eating and physical activity practices  Schools were 4 times as likely to report implementation of the federally-mandated wellness policy if district policy included specific Nemours-recommended content and language  School changes include healthy vending, evidence-based physical fitness programs, fitness equipment, and activity breaks  Principles and staff identified the following facilitated implementation: –Technical assistance; Networking with other districts/schools; Support from other school administrators  Schools participating in fitness pilot of 150 minutes of physical activity per week: –Increased fitness level as measured by FITNESSGRAM® tests –Students 1.5 times more likely to achieve Healthy Fit Zone, an indicator of fitness

26. Progress Results in Primary Care  Primary Care providers receiving technical assistance from NHPS are more likely to provide children with appropriate screening, care, and treatment for overweight and obesity  Delaware Primary Care Quality Improvement Initiative 19 multidisciplinary primary care teams achieved high results: –98.2% of providers classified BMI or weight-for-length in 2009 (83% in 2007) –88.6% of providers provided counseling on healthy lifestyles in 2009 (72.7% in 2007) –88.1% of providers developed a care plan and family-management goals with obese/overweight patients who were ready to change in 2009 (74.2% in 2007)  Nemours’ providers: –Nemours’ provider classification of BMI during well child visits doubled, 49% (2007) to 94% (2008) –Nemours’ providers offer lifestyle counseling to 95% of all patients (almost double the national reported rate of 54.5%) –Health promotion was built into Nemours’ Electronic Medical Record (EMR)

27. Lessons Learned  Sustaining policy and practice changes –Policy and practice change, together, in multiple sectors is critical –Policy can drive practice and practice can drive policy –Community capacity is critical to sustainability and to promoting, supporting and implementing change  Create strong partnerships –Develop strong relationships with influential organizations –Clearly define roles among partners, understand partners’ reasons for involvement –Provide partners with data, tools and training to make recommended changes  Focus on maintaining strategy –Clearly defined program goals are critical to success –Focus on a limited set of priority areas and sectors to avoid dilution of effort and impact  Design an evaluation that works –Acknowledge the strengths and limitations of the evaluation –Outcome measures (BMI) should remain a focal point –Align evaluation efforts with strategy –Achieving outcomes takes time - establish intermediate milestones to help track progress –Focus on demonstrating broad association and linkages where possible

28. Childhood Obesity: The New Tobacco or…Childhood Obesity as a Social Movement: Lessons from Tobacco Jonathan D. Klein, MD, MPH American Academy of Pediatrics William C. Dietz, MD, PhD Centers for Disease Control and Prevention

30. Shared, personalized perception of a threat Common framing of the problem Grass roots commitment Social network focused on collective action Local nodes with dense social ties, linked to others with weak bridging ties (rapid diffusion) Organizational structure realignment Social Movements

31. Surveillance/data- led to recognition of the problem Early voices - scientists and advocates Industry deception and secondhand smoke harm to others became common frame - leading to changing social norms Uniting against common enemy - cigarette companies - lead to political will and policy changes Organized movement - realignment of framing Tobacco’s success

32. Surveillance/data- recognition as a pressing problem Early alarmed voices - scientists, advocates, funders No common frame - physical activity, eating, both Personal responsibility/choice Toxic food environment Industry role mixed No parallel to non-smokers rights movement Advocates are not coordinated (breastfeeding, social justice, local food, disease prevention, environment) Where Are We For Obesity?

33. Practice based interventions –Medical home –Access to levels of care –Family centered care Community and policy based interventions –Nutrition programs –Physical activity promotion –Physical environment –Sugar sweetened beverages –Food labeling and marketing What Can Clinicians Do?

34. Do we have the political will?

35. AAP pledges to: Body Mass Index (BMI %ile) Prescription for healthy, active living …and information about how to achieve healthy weight, and on the impact of eating and physical activity on health Overcoming obesity in this generation

36. Impact of Childhood Obesity On Employers M-J. Sepúlveda, MD FACP IBM Fellow & Vice President, Integrated Health Services IBM Corporation

37. The Framework Of Parent-Child Interactions Potentially Affecting Employers Parents promote obesity in children Obese children beget 1 of 4 obese adults Both incur high costs in health care Caregiving for physical and psychosocial needs consume adult time and energy from work Parent Health Child Health Health care costs Absenteeism, Presenteeism Future Workforce Parent Behavior Child Behavior Adult Health Employer Parent Performance Health care costs

38. The Direct Financial Impact on Employers Average claims costs for obese adults as well as obese children are nearly twice that of the non-obese Average claims cost of children with type II diabetes exceeds the average claims cost of adult type II diabetics Source: IBM, 2008 claims based on obesity diagnosis and costs $1,640 $10,789 $2,907$4,520 $8,844 $8,889 Non-obese Obese TII Diabetes Obese Non-obese Children (18 and under) Adults

39. Children’s Health Rebate 1- baseline inventory 2- set goals 3- track and report

40. What we’ve learned so far ….  Families engage, 11.7K earn rebate in 2008 – many add own goals… “Kids write what fruits and veggies they want” “No parents’ TV or computer between 6 & 9 PM” “Start with smaller portions and have kids ask for seconds” “Both parents in the pool during children’s swim lessons” “Adults watch portion sizes on desserts”  Families change behavior, some change is harder than others Source: IBM, 2008 Children’s Health Rebate Earners  Families value program, IBM Children eat healthy breakfast 5+days Children eat healthy dinner 5+days Family eats/prepares healthy meals together 5+ days Children get physical activity 5+days Family is physically active together 3+days Children have < 1hr entertainment screen time Adults have < 1hr entertainment screen time Children eat only healthy snacks on typical day Children eat 5+ fruits/veggies Percent of Participants (N=11,743) Beginning of Program End of program (12 weeks)

41. Motivating Employers to Act  Employer population data: prevalence rate, direct costs, +/- productivity costs  Benchmark data: community, competitor, best practices - Health care providers to diagnose and code - De-identified data sets: geographic trends from new government registries and costs from health plans  Evidenced based solutions from providers, insurers, non profits, government agencies Employer Opportunities to Act  Workforce policies: flexible work arrangements, access to health promotion programs  Health benefits coverage for overweight/obesity care and support services  Payment and demands for pediatric medical home services  Innovative collaborations with employer groups, health care provider organizations, public health agencies and communities

42. Specialized Care of Overweight Children in Community Health Centers Shikha Anand, MD, MPH

43. Components of High Quality Pediatric Obesity Treatment 1.Assessment of Medical Risk – labs, family history review, medical exam 2.Nutrition Assessment – junk food, sweetened beverages, fast food, fruits and vegetables 3.Activity Assessment – screen time and physical activity 4.Health Behavior Change - goals for lifestyle change set by patient 5.Monthly follow-up (recommended by the American Academy of Pediatrics)

44. Current Options for Obesity Treatment 1.Specialty Care in Hospital Clinics Pros: Includes nutrition, physical activity, medical assessment and health behavior change in a single visit Cons: Expensive, monthly visits outside of primary care office – inconvenient, difficult to coordinate with primary care clinic 2.Monthly Visits in Primary Care Pros: Convenient for families, cheaper than hospital-based care Cons: Provider not trained in obesity or health behavior change, obesity visits are difficult to schedule – take longer than usual primary care visits, other providers such as dieticians not included in visits - need to schedule additional visits to see other providers 3.Specialized Primary Care Combines expertise offered in specialty clinics with convenience and cost savings of primary care

45. Specialized Primary Care Treatment of Obesity 1.The Model Monthly multi-disciplinary clinic visits for overweight children Medical provider, dietician, case manager in a single visit Assess medical risk factors, nutrition, and activity Promote health behavior change Visits occur within the community health center where a child receives primary care 2.The Setting Eight community health centers in Massachusetts Urban and rural clinics, provide pediatric primary care Target poor and minority children 3.Early results 174 children with more than one clinic visit in first 14 months 50.0% decreased BMI, 100.0% set goals for lifestyle change (increased activity, decreased sweetened beverages, etc), 79.8% reported making such a change at a later visit

46. Implications for Future Practice 1.Improved effectiveness over current standard of obesity treatment in pediatric primary care 2.Increased efficiency by combining multiple providers in a single visit 3.Decreased cost compared to hospital-based clinics 4.Replication in eight diverse community health centers indicates that model is scalable 5.Specialized, multi-disciplinary primary care could be expanded to other common chronic conditions including ADHD and asthma

47. Acknowledgements 1.Bill Adams, MD and Barry Zuckerman MD 2.Healthy weight Clinic Teams: Holyoke, Greater Lawrence, Codman Square, Whittier Street, Greater New Bedford, Outer Cape, Lowell, and Bowdoin Street Community Health Centers 3.Healthy Weight Initiative Staff: Penny Marston and Deirdre Connor, MPA 4.Howard Bauchner, MD 5.Vijay Nayak, MD 6.Funding for this work provided by CAVU Foundation and Paul and Phyllis Fireman Foundation

48. Specialized Care of Overweight Children in Community Health Centers March 1, 2010 Page 01 Specialized Care of Overweight Children in Community Health Centers Shikha Anand, MD, MPH

49. Evidence-Based Components of High Quality Pediatric Obesity Treatment Specialized Care of Overweight Children in Community Health Centers March 1, 2010 Page 02 1.Assessment of Medical Risk – labs, family history review, medical exam 2.Comprehensive Nutrition Assessment – junk food, sweetened beverages, fast food, fruits and vegetables 3.Activity Assessment – screen time and physical activity 4.Health Behavior Change - goals set by patient for diet and activity changes, facilitated by provider with training in motivational interviewing 5.Monthly follow-up (recommended by the American Academy of Pediatrics)

50. Current Options for Medical Obesity Treatment 1.Specialty Care in Hospital Clinics Pros: Includes nutrition, physical activity, medical assessment and health behavior change in a single visit Cons: Expensive, monthly visits outside of primary care office – inconvenient, difficult to coordinate with primary care clinic 2.Monthly Visits in Primary Care Pros: Convenient for families, cheaper than hospital-based care Cons: Provider not trained in obesity or health behavior change, obesity visits are difficult to schedule – take longer than usual primary care visits, other providers such as dieticians not included in visits - need to schedule additional visits to see other providers 3.Specialized Primary Care Combines expertise offered in specialty clinics with convenience and cost savings of primary care Specialized Care of Overweight Children in Community Health Centers March 1, 2010 Page 03

51. Specialized Primary Care Treatment of Obesity 1.An Innovative Model Monthly multi-disciplinary clinic visits for overweight children Medical provider, dietician, case manager in a single visit Assess medical risk factors, nutrition, and activity Promote health behavior change 2.Delivery Within Underserved Communities Visits occur within the community health center where a child receives primary care Urban and rural clinics, provide pediatric primary care Target poor and minority children 3.Promising Early Results 174 children with more than one clinic visit in first 14 months 50.0% decreased BMI, 100.0% set goals for lifestyle change (increased activity, decreased sweetened beverages, etc), 79.8% reported making such a change at a later visit Exciting given the challenges of treating obesity in underserved youth Specialized Care of Overweight Children in Community Health Centers March 1, 2010 Page 04

52. Elements of our Community-Oriented Initiative Beyond the Model 1.Exciting Clinic-to-Clinic Collaboration Model pilot tested at a single clinic in 2006 and then spread to eight community health centers in Massachusetts in 2008 and 2009 Clinics have conference calls every month and face-to-face meetings twice every year Interactions serve as basis for quality improvement, problem-solving, and best- practice sharing throughout initiative Centralized technical assistance team provides support for these interactions as well as expert advice for clinics 2.Innovative Use of Health Information Technology Standardized clinical encounter form drives care quality at each community health center Web-based data collection system yields graphical analysis of health outcomes Quarterly review of data with clinics to drive improvement over time Specialized Care of Overweight Children in Community Health Centers March 1, 2010 Page 05

53. Implications for Future Practice 1.Improved effectiveness over current standard of obesity treatment in pediatric primary care 2.Increased efficiency by combining multiple providers in a single visit 3.Decreased cost compared to hospital-based clinics 3.Tie in to current patient-centered medical home movement occurring in community health centers nationwide 4.Replication in eight diverse community health centers indicates that model is scalable 5.Specialized, multi-disciplinary primary care could be expanded to other common chronic conditions including ADHD and asthma Specialized Care of Overweight Children in Community Health Centers March 1, 2010 Page 06

54. Acknowledgements 1.Bill Adams, MD and Barry Zuckerman MD 2.Healthy Weight Clinic Teams: Holyoke, Greater Lawrence, Codman Square, Whittier Street, Greater New Bedford, Outer Cape, Lowell, and Bowdoin Street Community Health Centers 3.CAVU Staff: Penny Marston and Deirdre Connor, MPA 4.Howard Bauchner, MD 5.Vijay Nayak, MD 6.Funding for this work provided by CAVU Foundation and Paul and Phyllis Fireman Foundation Specialized Care of Overweight Children in Community Health Centers March 1, 2010 Page 06

55. The Role of the Built Environment and Neighborhood Conditions in Childhood Obesity Gopal K. Singh, Ph.D. U.S. Department of Health & Human Services Health Resources & Services Administration Maternal and Child Health Bureau

56. Obesity Prevalence (%) by Neighborhood Built Environment Index, 2007 Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.

57. Prevalence (%) of Physical Inactivity and TV Viewing Time by Built Environment Index, Children Aged 10-17 Years, 2007 Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.

58. Excess Obesity Risk (Percent Higher Odds) Among Children Aged 10-17 From Unfavorable Neighborhood Built Environments, 2007 Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.

59. Excess Obesity Risk (Percent Higher Prevalence) Among Children in Unfavorable Neighborhood Social Conditions, 2007 Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.

60. Policy Solutions to the Grocery Gap Allison Karpyn Director of Research and Evaluation The Food Trust

61. Replicating Pennsylvania’s Fresh Food Financing Initiative

62. Identification of Areas of Need

63. Lessons Learned Adapt to Local Circumstances Maintain Focus Engage Diverse Sectors Include Industry Nurture Local Efforts Conduct More Research

64. Sodexo’s Commitment to Student Well-Being Roxanne E Moore MS, RD National Director of Wellness Sodexo Education

65. 65 Sodexo encourages student well-being  Sodexo was one of the first companies to join the MyPyramid Corporate Challenge to promote the USDA's dietary guidelines  Sodexo is the first foodservice company to formally adopt the snack and beverage guidelines from the Alliance for a Healthier Generation, a joint initiative of the American Heart Association and the William J. Clinton Foundation  As a participant in the National School Lunch Program and the School Breakfast Program, Sodexo culinary professionals create menus for school districts that meet or exceed all USDA nutritional guidelines for school meals

66. Sodexo educates students on good nutrition  Not only does Sodexo feed kids, but we also help to educate them ● Nutrition labeling ● A to Z Salad Bar ● Produce of the Month ● Kids Cooking ● School Gardens ● Los Kitos ● Age-appropriate nutrition education  Sodexo supports teachers with materials to aid with nutrition education lessons  Sodexo managers, chefs and dietitians work with parents, nurses, administrators, PTAs and district wellness committees to create nutrition programs that nourish and educate students

67. Sodexo partners with First Lady’s Let’s Move initiative  First Lady Michelle Obama is seeking the support of business leaders to end the epidemic of childhood obesity with the Let’s Move initiative  Sodexo is helping this fight by making nutritious school lunches affordable and accessible to all students and by focusing on nutrition education in the schools we serve  Sodexo’s support of HealthierUS School Challenge certification efforts is a great example of how we fight obesity on the local level

68. Sodexo helps schools get certified in the HealthierUS School Challenge  To earn HealthierUS School Challenge certification, school districts must meet a wide variety of guidelines that include menu planning, nutrition education and physical activity  Sodexo meets with clients to collaborate on the certification process, including the development of new programs, promotions and activities that help district’s meet the USDA requirements  Along with menu planning, Sodexo uses its many resources to assist clients with education and physical activity requirements

69. Sodexo fights to end childhood hunger  Research shows that poverty is a major contributor to childhood obesity  Sodexo School Services uses innovative programs to end hunger in the communities we serve  Breakfast in the Classroom programs bring delicious and nutritious meals directly to the students to ensure that they get the fuel they need to succeed in school  The Backpack Program provides nutritious weekend meals to students that might otherwise go without  Helping Hands Across America encouraged Sodexo employees to fight hunger locally and included a company-wide canned food drive

70. Agriculture Policy & Childhood Obesity A Food Systems and Public Health Commentary David Wallinga Director, Food and Health Program Institute for Agriculture and Trade Policy

71. Agriculture policy since 1974: “ Cheap food” Success as a cheap calorie policy Production-driven Export-driven Commodity subsidies not written into Farm Bill until 2002

72. Of 300 calorie excess, relative to 1985 (Putnam et al. 2002)  Added sweeteners account for 23 percent  Added fats account for 24%  Grains, mostly refined, account for 46 percent Linked to obesity promotion 400

73. Economic Research Service. Loss adjusted food availability [database on the Internet]. Washington (DC): U.S. Department of Agriculture; updated 2009 Feb [cited 10 Jan 2010]. Available from: http://www.ers.usda.gov/Data/FoodConsumption/ FoodGuideIndex.htm http://www.ers

74. Fresh fruits & veggies Total fruits & veggies Red meats Dairy Cereal & baked goods Sugars & sweets Fats & oils Soda pop Poultry Change in food prices, 1985 –2000, real $ Foods high in fats, sugars and calories are some of the least expensive, most inflation-resistant in the American food environment. Wallinga D. Today's food system: how healthy is it? J Hunger Environ Nutr 2009;4(3):251-81.

75. Near-term policy change A food systems analysis commensurate with the complexity of the health problems.A food systems analysis commensurate with the complexity of the health problems. Farmers as partners against childhood obesity.Farmers as partners against childhood obesity. Agriculture research to achieve synergies between growing healthier foods, with fewer fossil fuels, and with American farmers.Agriculture research to achieve synergies between growing healthier foods, with fewer fossil fuels, and with American farmers. A Healthy Food, Healthy Farm Bill

76. American spending on food, health relative to disposable income Figure 1, Wallinga D. Today's food system: how healthy is it? J Hunger Environ Nutr 2009;4(3):251-81.

77. Are “Competitive Foods” Sold at Schools Making Our Children Fat? Nicole Larson PhD, MPH, RD Mary Story PhD, RD

78. Competitive Foods in U.S. Schools: A Review of the Evidence Purpose: Conduct a comprehensive review of the research to : – Examine the availability and nutritional content of competitive foods in schools – Examine the impact of competitive foods on students’ dietary intake and students’ weight status Methods: Literature search of peer-reviewed studies from 1999-2009 Discuss policy implications

79. Competitive Foods and Dietary Intake 17 peer-reviewed studies – All 9 observational studies – 4 of 8 policy evaluations/interventions Students have better diets when unhealthy foods are not available at school Students may purchase & consume more healthful foods (e.g., fruits & vegetables) when they are available at school

80. Competitive Foods and Weight Status 6 peer-reviewed studies – All 3 observational studies – All 3 multi-component intervention studies Greater availability of unhealthy foods at school related to higher body fatness Limiting the availability of unhealthy foods at school was a component of successful interventions shown to reduce overweight

81. Schools and Competitive Foods: What do we know? Nutritionally poor foods are widely available in schools Findings from SNDA-III (2004-2005) Nationally, 1 or more sources of competitive foods were available in 73% of elementary schools, 97% of middle schools and 100% of high schools. Overall, 40% of students consumed 1 or more competitive foods on a typical school day and consumption increased with grade level. Healthy foods and beverages are increasingly available, but the most common items sold outside school meals are candy, sugary drinks, salty snacks and desserts. Bottom line: While schools have made improvements, more is needed.

82. What is the impact of competitive foods on child nutrition? Findings from SNDA-III Students who ate competitive foods/beverages at schools on average consumed 277 Kcal/day; two-thirds of these Kcal (177) were from low- nutrient, energy dense sources. The availability of snacks and drinks sold in schools are associated with higher student intakes of total calories, soft drinks, total fat and saturated fat intakes and lower intakes of fruits and vegetables and milk. The availability of junk foods in vending machines in or near the school cafeteria in middle schools was associated with higher than average body fatness. School food policies and practices that limited the availability of competitive beverages were associated with reduced consumption of calories from sweetened beverages schools. Students did not “make up” by drinking more outside of school.

83. Institute of Medicine’s Nutrition Standards for Foods in Schools (2007) Major conclusions: 1.Opportunities for competitive foods should be limited. The federal school nutrition programs should be the main source of nutrition at schools. 2.If competitive foods are available, they should consist of nutritious fruits, vegetables, whole grains, and nonfat or low-fat milk/dairy products, plain water, 100% juice (4-8 oz).

84. Competitive Foods: Our current situation Federally subsidized school meals are required by Congress and USDA to meet nutrition standards and comply with the Dietary Guidelines for Americans. Standards for competitive foods are 30 yr old and don’t address calories, fats, salt, and sugars. The USDA does not have authority to regulate foods or beverages sold outside the cafeteria or outside mealtimes.

85. Not Allowed Current competitive food standards don’t make sense Allowed Fruitades (with little juice) French fries Ice cream bars Candy bars Cookies Chips Snack cakes Doughnuts Seltzer water Caramel corn Popsicles (without fruit juice ) Jelly beans Chewing gum Lollipops Cotton candy Breath mints

86. Policy Recommendations: What is Needed? Update the national nutrition standards for competitive foods and beverages to bring them in line with the Dietary Guidelines and apply them to the whole campus for the entire school day. The new standards should: – Restrict the sale of sugar-sweetened beverages throughout the day in all schools. – Limit the availability of low-nutrient, energy-dense foods sold a la carte and in vending machines and fundraisers. – Promote children’s consumption of fruits, vegetables, whole grains and non-fat or low-fat dairy products.

87. Childhood Obesity: The Way Forward With thanks to the Robert Wood Johnson Foundation for its generous support