Prevention efforts were not only directed to families and communities but also to policy makers whose actions to establish social and environmental policy could support communities and families to be more physically active and consume healthier diets. Policy makers were exhorted to create more community-based obesity prevention and treatment programs for children and adults and provide demonstration grants to improve access to, and availability of, healthy affordable foods in inner cities. They also were advised to enact public policy to create and maintain safe and accessible sidewalks, walking and bicycle paths, and stairs.
In the community, schools offer ideal settings and multiple opportunities for preventing overweight and obesity by educating children about, and engaging them in, healthy eating and physical activity. To link the communication strategy to educate teachers, staff, and parents about the importance of school physical activity and nutrition programs to actions, schools can ensure that breakfast and lunch programs meet nutrition standards and provide food options that are low in fat, calories, and added sugars. Other ways to enact this communication strategy include offering healthy snacks in vending machines and school stores, and providing all students with quality daily physical education in order to cultivate the knowledge, attitudes, skills, behaviors, and confidence needed to be physically active for life.
Population-Based Prevention Programs Target Racial and Ethnic Minority Groups
Antronette K. Yancey and her colleagues reviewed studies of population-based interventions targeting communities composed primarily of members of racial and ethnic minorities. The investigators reported their findings in "Population-Based Interventions Engaging Communities of Color in Healthy Eating and Active Living: A Review" (Preventing Chronic Disease, vol. 1, no. 1, January 2004, http://www.cdc.gov/pcd/). They identified twenty-three interventions intended to promote healthy eating and active lifestyles aimed at African-American, Latino, American Indian, Alaska Native, Asian, Native Hawaiian or Other Pacific Islander populations that met specific study criteria and were implemented between 1972 and 2000.
Yancey and her colleagues described several initiatives instituted during the 1970s to early 1990s that produced modest but measurable improvement in diet. For example, one program promoted reducing cholesterol and saturated fat intake via mass and targeted print and electronic media in three semi-rural northern California towns with substantial Latino populations. Another intervention sought to engage African-American residents in public housing communities in Birmingham, Alabama, in group exercise programs. A third program cultivated regional coalitions of community-based organizations to develop fitness promotion activities such as walking clubs, cooking demonstrations and classes, aerobic exercise classes, walking trails, and health fairs.
The mid-1990s saw a partnership led by the California Department of Health Services to promote physical activity in nine ethnically underserved communities as part of the CDC-funded "ON THE MOVE! Initiative." In Richmond, Virginia, the expanded ON THE MOVE! Fitness Funatics project "ROCK! Richmond" offered free fitness instruction at community sites in underserved areas of the city. The program used ethnically relevant role models to counter community standards endorsing sedentary behavior and high-fat/low-fiber eating and to support persons choosing to live actively and make healthy food choices.
In 1999 and 2000 Spanish-language "1 percent or less" milk campaigns were launched in largely Latino communities by the California Adolescent Nutrition and Fitness Program. The campaign featured radio and print advertisements, point-of-purchase advertising, milk taste tests, community presentations, public relations, and a school-based program. After the six-week campaign, sales of 1 percent and fat-free milk rose 60 percent in one of the communities and a follow-up survey of retailers at six months found that 25 percent of this growth in 1 percent and fat-free milk sales persisted.
Other notable obesity prevention efforts included developing and implementing strategies to integrate physical activity and healthy food choices into routine work-site activities. Examples of such activities included incorporating planned activity breaks with music into lengthy meetings, offering healthy food choices at meetings and during breaks as well as at employee cafeterias, and hosting walking meetings.
NATIONAL INITIATIVE AIMS TO HELP AFRICAN-AMERICAN WOMEN MAINTAIN A HEALTHY WEIGHT.
The review by Yancey and her colleagues also described another obesity prevention intervention, "Sisters Together: Move More, Eat Better." The national program is an initiative of the Weight-Control Information Network of the National Institute of Diabetes and Digestive and Kidney Diseases (one of the institutes of the National Institutes of Health).
The program expanded upon the success of a pilot community-awareness program conducted in three innercity communities in Boston, Massachusetts, from 1995 to 1998. The pilot program disseminated the "Move More, Eat Better" message among African-American women aged eighteen to thirty-five via educational materials and such activities as walking groups, dance classes, and cooking demonstrations.
By 2001 the program had produced three educational brochures and had collaborated with national and local newspapers, magazines, radio stations, and consumer and professional organizations to continue to increase awareness about the health benefits of regular physical activity and healthy eating. Another "Sisters Together: Move More, Eat Better" activity produced a cable television show featuring local chefs who prepared healthy menu items available in their restaurants.
Federally Funded National Nutrition Education
Together, the Department of Health and Human Services and the Department of Agriculture (USDA) update Nutrition and Your Health: Dietary Guidelines for Americans every five years. First published in 1980, the guidelines serve as the basis for federal food and nutrition education programs. The fifth edition of the guidelines, published in 2000, advises Americans to:
TABLE 10.1
What counts as a serving?
| Bread, cereal, rice, and pasta group (grains group)—whole grain and refined |
| • 1 slice of bread |
| • About 1 cup of ready-to-eat cereal |
| • ½ cup of cooked cereal, rice, or pasta |
| Vegetable group |
| • 1 cup of raw leafy vegetables |
| • ½ cup of other vegetables cooked or raw |
| • ¾ cup of vegetable juice |
| Fruit group |
| • 1 medium apple, banana, orange, pear |
| • ½ cup of chopped, cooked, or canned fruit |
| • ¾ cup of fruit juice |
| Milk, yogurt, and cheese group (milk group)1 |
| • 1 cup of milk2 or yogurt2 |
| • 1 ½ ounces of natural cheese2 (such as Cheddar) |
| • 2 ounces of processed cheese2 (such as American) |
| Meat, poultry, fish, dry beans, eggs, and nuts group (meat and beans group) |
| • 2–3 ounces of cooked lean meat, poultry, or fish |
| • ½ cup of cooked dry beans3 or ½ cup of tofu counts as 1 ounce of lean meat |
| • 2 ½-ounce soyburger or 1 egg counts as 1 ounce of lean meat |
| • 2 tablespoons of peanut butter or ⅓ cup of nuts counts as 1 ounce of meat |
| Note: Many of the serving sizes given above are smaller than those on the Nutrition Facts Label. For example, 1 serving of cooked cereal, rice, or pasta is 1 cup for the label but only ½ cup for the Pyramid. |
| 1This includes lactose-free and lactose-reduced milk products. One cup of soy-based beverage with added calcium is an option for those who prefer a non-dairy source of calcium. |
| 2Choose fat-free or reduced-fat dairy products most often. |
| 3Dry beans, peas, and lentils can be counted as servings in either the meat and beans group or the vegetable group. As a vegetable, ½ cup of cooked dry beans counts as 1 serving. As a meat substitute, 1 cup of cooked, dry beans counts as 1 serving (2 ounces of meat). |
| SOURCE: "Box 8. What Counts as a Serving?" in Nutrition and Your Health: Dietary Guidelines for Americans, fifth edition, U.S. Department of Agriculture and U.S. Department of Health and Human Services, Washington, DC, 2000 [Online] http://www.health.gov/dietaryguidelines/dga2000/document/build.htm#pyramid [accessed February 17, 2004] |
- Aim for a healthy weight and encourage healthy weight in children.
- Engage in moderate physical activity for at least thirty minutes each day.
- Use the USDA Food Guide Pyramid to make food choices. (Figure 5.1 in Chapter 5 shows the current USDA Food Pyramid.)
- Practice portion control by paying close attention to serving sizes. (See Table 10.1 for sample serving sizes of the food groups included in the food guide pyramid.)
- Choose a diet that is low in saturated fat and cholesterol and moderate in total fat.
- Learn how to critically read nutrition facts labels. (See Figure 10.1.)
- Choose beverages and foods to moderate intake of sugars.
- Choose and prepare foods with less salt.
- If you drink alcoholic beverages, do so in moderation.
FIGURE 10.1
How to read a nutrition facts label
Revisiting and Revising the Food Pyramid
The current USDA dietary pyramid misses an enormous opportunity for improving the health of Americans. It's clear that we need to rebuild the pyramid from the ground up. Every American deserves it.—Walter Willett, the Fredrick John Stare Professor of Epidemiology and Nutrition in the Departments of Nutrition and Epidemiology, Harvard University School of Public Health, Eat, Drink, and Be Healthy (New York: Simon & Schuster, 2001)
Some public health professionals believe that the USDA Food Pyramid is flawed because its composition is unduly influenced by pressure from the food industry, whose members know that even subtle changes to the guidelines can affect a food manufacturer's sales. Further, these public health professionals assert that the guidelines should not be expected to represent objective scientific evidence since they are developed by the U.S. government agency responsible for agriculture, rather than health.
Nutrition experts at the Harvard School of Public Health developed an alternative to the USDA Food Pyramid they called the "Healthy Eating Pyramid." Based on scientific evidence about the links between diet and health, the alternative pyramid has as its base a foundation of daily exercise and weight control, instead of the bread, cereal, rice and pasta at the base of the USDA pyramid. (See Figure 10.2.) The peaks of the two pyramids are also quite different. The "Healthy Eating Pyramid" advises consumers to use red meat, butter, white rice, bread, potatoes, pasta, and sweets sparingly, whereas the USDA pyramid advises using fats, oils, and sweets sparingly. Both pyramids advise a varied diet; however, the alternative pyramid emphasizes a diet based on whole grain foods, plant oils such as olive, canola, soy, corn, sunflower, peanut, and other vegetable oils, and encourages most Americans to take a daily multivitamin.
There are other alternative pyramids to the USDA Food Guide Pyramid. The Oldways Preservation and Exchange Trust, a widely respected nonprofit "food issues think tank" offers four alternatives—Asian, Latin, Mediterranean, and vegetarian pyramids that, like the Harvard-designed pyramid, feature greater use of plant and vegetable oils and less consumption of meat than the USDA pyramid recommends.
In January 2004, members of the Dietary Guidelines Advisory Committee held their second meeting to discuss the sixth version of Nutrition and Your Health: Dietary Guidelines for Americans, slated for release in 2005. Among the issues the committee considered were a reassessment of the Food Guide Pyramid, the components of a healthy American diet, and energy balance. In preparation for the meeting, the thirteen committee members reviewed recent scientific research, including Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients) (Washington, DC: Institute of Medicine of the National Academies, 2002) and the 2003 World Health Organization (WHO) report on Diet, Nutrition and the Prevention of Chronic Diseases.
The Institute of Medicine report asserted that to meet daily energy and nutritional needs while minimizing risk for chronic disease, adults should get 45 percent to 65 percent of their calories from carbohydrates, 20 percent to 35 percent from fat, and 10 percent to 35 percent from protein. Earlier guidelines advised diets with 50 percent or more of carbohydrates and 30 percent or less of fat, with comparable protein-intake recommendations in previous and current guidelines. The guidelines for children are similar to those for adults, except that infants and younger children need a slightly higher proportion of fat—25 percent to 40 percent of their caloric intake. The report also emphasized balancing diet with physical activity, and recommended total daily calorie consumption for individuals based on height, weight, gender, and four different levels of physical activity. Its recommendation of an hour per day of physical activity was derived from studies of average daily energy expended by persons who maintain a healthy weight.
The WHO report, produced in partnership with the Food and Agriculture Organization, called upon a team of global experts to identify new recommendations for governments on diet and exercise to combat obesity and related chronic diseases. The report advised changing daily nutritional intake and increasing energy expenditure by:
- reducing consumption of foods high in saturated fat and sugar;
- sharply reducing the amount of salt in the diet;
- increasing the amount of fresh fruit and vegetables in the diet; and
- engaging in moderate-intensity physical activity for at least an hour a day.
The WHO report specifically recommended limiting fat to between 15 and 30 percent of total daily intake and saturated fats to less than 10 percent of this total. It suggested that between 55 and 75 percent of daily intake should be carbohydrates but that added sugars (refined or simple sugars as opposed to those naturally occurring in fruit and complex carbohydrates) should be limited to 10 percent or less. Protein should make up 10–15 percent of
TABLE 10.2
Average frequency of fruit and vegetable consumption per day, 1996–2000
| Year | Never or <1 a day | 1 to <3 a day | 3 to 5 a day | 5+ times a day |
| 1996 | 3.6 | 32.3 | 40.4 | 23.6 |
| 1998 | 3.5 | 33.1 | 39.6 | 23.8 |
| 2000 | 3.8 | 34.1 | 38.7 | 23.1 |
| SOURCE: "Table 1. Average Frequency of Fruit and Vegetable Consumption per Day: Nationwide Data, Years 1996–2000," in 5 A Day Consumption Statistics: Fruit and Vegetable Intake in the U.S., National Cancer Institute and Produce for Better Health Foundation, Washington, DC, 2004 [Online] http://www.5aday.com/html/research/consumptionstats.php [accessed February 17, 2004] | ||||
calorie intake and salt should be restricted to less than 5 grams a day (about one teaspoon). In a press release dated April 23, 2003, Dr. Gro Harlem Brundtland, Director-General of the WHO, said "Long-term progress will take time. We need to look decades ahead, and make a commitment now, to the health of our current and future generations throughout the globe. The work we are embarked upon could lead to one of the largest positive shifts in population health ever undertaken."
"5-a-Day for Better Health" Program
The "5-a-Day for Better Health" program is the nation's largest public–private nutrition education initiative. The program originated in the California Department of Health Services in 1988 and is jointly sponsored by the National Cancer Institute and the Produce for Better Health Foundation (PBH), a nonprofit consumer-education foundation representing the fruit and vegetable industry. In 2001 the national 5-a-Day partnership expanded to include other voluntary health organizations and produce associations. Along with the National Cancer Institute and PBH, the partnership now includes representatives from the USDA, CDC, American Cancer Society, Produce Marketing Association, United Fresh Fruit and Vegetable Association, National Alliance for Nutrition and Activity, and the Association of State and Territorial Directors of Health Promotion and Public Health Education.
The "5-a-Day for Better Health" program aims to increase fruit and vegetable consumption. Its objectives are "to increase public awareness of the importance of eating five or more servings of fruits and vegetables every day for better health, and to provide consumers with specific information about how to include more servings of fruits and vegetables into daily eating patterns." Data from the CDC revealed that in 1996, 1998, and 2000 less than one-quarter of Americans ate the recommended five servings per day of fruit and vegetables. (See Table 10.2.) A market research report performed by the NPD Group and published by PBH in October 2002 found that:
- Fruit and vegetable consumption is declining.
- Americans are eating only about four daily servings of fruits and vegetables, including French fries and potato chips. Excluding these high-fat processed potato products, Americans eat only about 3.6 servings of fruits and vegetables each day.
- Just one in five Americans meets the five-a-day minimum requirement for fruits and vegetables.
- Thirteen percent of American families, 22 percent of single persons, 27 percent of "empty nesters," (persons whose grown children no longer live at home) and 39 percent of older adults (persons age 65 and older) eat the minimum recommended five servings per day of fruits and vegetables.
- Nine out of ten teen girls (89 percent) and 96 percent of kids ages two to twelve do not eat five servings per day.
- Women (82 percent) are more likely than men (69 percent) to fall short of the five-serving minimum.
- Obesity levels are lowest among those who have high intakes of fruits and vegetables.
The "5-a-Day for Better Health" program provides customized, age-appropriate health education materials for children such as lesson plans and activity sheets. "There's a Rainbow on My Plate," is a comprehensive nutrition education curriculum that encourages kindergarten through sixth grade students to develop healthy eating habits. The curriculum was designed by PBH, Dole Food Company, Inc., and Crayola®, and in 2003 placed second in PROMO Magazine's 2003 National Pro Awards in the category of the Most Innovative Communication Strategy, which recognized the best promotions developed during 2002–2003. "There's a Rainbow on My Plate" debuted in March 2003 in 3,000 supermarkets and 12,000 elementary schools in the United States. Lessons featured information about fresh, dried, frozen, and canned fruits and vegetables and 100 percent fruit juices as well as the locations of these foods in the supermarket, and definitions of serving sizes. Participating schools received teacher's guides with lesson plans and activity sheets, coloring/activity books, packs of crayons, and take-home flyers for parents with Dole coupons.
Recent research reveals that active men should consume even more than the five servings of fruit and vegetables the program has promoted since its inception. In 2000 the "5-a-Day for Better Health" program launched "Men Shoot for 9" to encourage men to eat nine servings of fruits and vegetables every day. Table 10.3 shows that the recommended number of servings of fruits and vegetables also increased for children, teenage girls, and most women. Along with reducing risk for heart disease, high blood pressure, stroke, many cancers, and diabetes, diets rich in fruits and vegetables can help to prevent overweight and obesity. Fruits and vegetables are naturally low in calories and fat, and their high water and fiber content produce feelings of fullness and satiety. Combined with an active lifestyle and low-fat diet, eating greater amounts of fruits and vegetables and fewer high-calorie foods at meals can help control weight. The "Men Shoot for 9" program teaches men that they can feel full and consume fewer calories when they substitute vegetables for foods that contain more fat and calories.
IS NUTRITION EDUCATION WORKING TO IMPROVE AMERICANS' DIETS?
In August 2002 NPD Foodworld reported that the Healthy Eating Index (HEI), a measure developed in 1990 by the USDA to assess the health value of Americans' diets, was the lowest it had been since 1998. The HEI is a summary measure of overall diet quality. It captures the type and quantity of foods people eat and the degree to which diets comply with specific recommendations in the USDA Dietary Guidelines and the Food Guide Pyramid. The HEI assigns points for eating consistently within USDA guidelines. It assesses ten dietary components—grains, vegetables, fruits, milk, meat, total fat, total saturated fat, cholesterol, sodium, and a varied diet—on a scale of zero to ten. Individuals who eat grains, vegetables, fruits, milk, meat (including chicken and fish), as well as a variety of foods at or above the USDA recommended levels receive a maximum score of ten. A score of zero is assigned when the recommended amount of those components is not eaten. For fat, saturated fat, cholesterol, and sodium, a score of ten is awarded for eating the recommended amount or less. The highest possible score is a hundred, and a score of eighty or above is considered a healthy diet, scores between fifty-one and eighty show a need for dietary improvement, and scores below fifty indicate poor diets.
Still, some evidence indicates that Americans' eating habits were changing. In March 2003 the market research firm NPD Group reported that consumption of French fries had declined by 10 percent between December 2001 and December 2002. The following year, their report 18th Annual Eating Patterns in America (Port Washington, NY: NPD Group, 2003) found that during 2003 Americans consumed more fruits and vegetables than they had the year before and snacked less after dinner. Thirty-five percent of the population said they carefully planned nutritious meals—up from 32 percent in 2001. Americans also reported that they were exercising more. Sixty-six percent claimed they exercised strenuously at least once a week—compared to 62 percent in 2002. In addition to healthier eating habits, the NPD survey, which tracks body mass index (BMI) as well as diet and food choices, found that 55 percent of the population was overweight, compared to 56 percent in 2002. Although a 1 percent
TABLE 10.3
Recommended daily servings of fruits and vegetables for men, women, and children
| Vegetables | Fruits | Total | |
| Children ages 2 to 6 | 3 | 2 | 5 |
| Children over age 6, teenage girls, and most women | 4 | 3 | 7 |
| Teenage boys and most men | 5 | 4 | 9 |
| SOURCE: "Recommended Daily Servings of Fruits and Vegetables for Men, Women, and Children," in United States Department of Agriculture, Dietary Guidelines for Americans, Washington, DC, 2000 [Online] http://5aday.gov/9aday/serving/index.html [accessed February 17, 2004] | |||
decrease is not dramatic, the percent of overweight adults had been steadily increasing each year since 1998, when it was 50 percent.
In January 2004, the NPD Group released its first-ever study about Americans' snack food choices Snacking in America. The report found that such salty snacks as pretzels, chips, and tortilla chips account for about a quarter of the convenience foods Americans choose for snacks. Although children and teens snack on sugary treats such as candy, gum, chewy fruit snacks, and breath mints, which accounted for an additional 14 percent of snack food choices, some of the fastest growing snack foods among youth ages two to eighteen are healthier choices. Yogurt is the fastest growing snack food in terms of consumption frequency among children under thirteen years old. On average, children under thirteen ate yogurt eleven more times in the year ending June 2003 than they did three years earlier. Children ages two to seven ate yogurt as a snack nearly fourteen times more often in 2003 than they did in 1999, and children ages eight to twelve snacked on yogurt 8.5 times more in 2003 than five years earlier. Although children may be making some healthier choices when it comes to snacks, they also are snacking more frequently—in 2003 children and teens consumed about 22 more snacks per person per year than reported in 1999.
In What to Watch in 2004 Harry Balzer, vice-president of NPD Foodworld said he thought consumer demand for healthy options would predominate during 2004, with increasing interest in low-carbohydrate foods. He also asserted that purchase and consumption of fresh foods and fresh ingredients would increase and predicted that consumers would be searching for food choices that combined fresh, healthy ingredients with convenient preparation.
"Hearts N' Parks" Is a Model Community Prevention Program
The Surgeon General's report offered more than fifteen examples of prevention programs aimed at families and communities that are sponsored, developed, and administered by departments, offices, and agencies of the federal government. Some of the programs and initiatives are amplified by state, tribal, local, and private-sector partnerships.
One example of a federal prevention program is "Hearts N' Parks," a program supported by the National Heart, Lung, and Blood Institute and the National Recreation and Park Association. The program aimed "to reduce the growing trend of obesity and the risk of coronary heart disease in the United States by encouraging Americans of all ages to aim for a healthy weight, follow a heart-healthy eating plan, and engage in regular physical activity." "Hearts N' Parks" was introduced in 1999 in twelve North Carolina communities representing urban, suburban, and rural areas, and more than 2,000 people participated in the pilot program. It featured nutrition and fitness activities that could be easily integrated into existing education and recreation programs and adapted to meet the needs of persons of all ages. Along with activities, the program included consumer public health education materials about weight management, physical activity, high blood pressure, cholesterol, and heart disease. Educational materials aimed at specific audiences such as African Americans and Hispanics were also made available to participating communities.
The North Carolina pilot program involved rigorous evaluation measures to determine the effectiveness of the program. Participants completed pre- and post-test surveys to assess their knowledge about healthy eating and physical activity and to determine whether they had learned new physical activities and increased the time they spent in leisure-time physical activities. Figure 10.3 is the pre-test that was administered to assess the overall health status of adult program participants. Figure 10.4 assessed participants' pre-participation knowledge about health and nutrition and included questions about saturated fat, cholesterol, and high blood pressure. Figure 10.5 is the post-test used to evaluate the effectiveness of both the education component of the program and the adult participants' actions to lead healthier lives. The program also gathered demographic data about participants and tracked the numbers of participants that had translated their new-found knowledge into actions to improve their diets and become increasingly physically active.
Instead of long pre- and post-test questionnaires, youth who participated were asked to perform a "fitcheck" by calculating their "fit" and "sit" scores. The scores reflected how much time they spent performing physical activities such as walking to school, biking, or skateboarding versus time spent sitting in front of a television or computer or playing video games. (See Figure 10.6.) The post-test asked youth who participated in the program whether they had learned a new game or exercise, improved their skill in a specific sport or activity, and whether they would like to engage in any of these physical activities again. (See Figure 10.7.) Children's knowledge about nutrition and food choices was assessed using age-appropriate tests, since participants' ages ranged from four to seventeen. For example, the youngest children were shown pictures of various foods and asked which was better for their health.
The evaluation of the pilot "Hearts N' Parks" program, performed in 2000, considered it an overall success. The greatest progress was observed among children and teens, who demonstrated improvements in knowledge of healthy eating and intentions to improve their eating habits in the future. Overall, adult scores significantly improved for healthy eating habits. The evaluation also revealed that programs with approximately forty participants fared the best. The National Heart, Lung, and Blood Institute concluded that "Hearts N' Parks" "met its goals of improving heart-healthy knowledge and behavior among participants during the course of the program, implementing a process for conducting and evaluating the program, and providing professional development for site personnel."
On July 18, 2000, a second "Hearts N' Parks" pilot program was launched in the Washington, D.C., metropolitan area by the Arlington County Department of Parks, Recreation, and Community Resources. U.S. Surgeon General Dr. David Satcher, National Heart, Lung, and Blood Institute Director Dr. Claude Lenfant, National Recreation and Parks Association President-elect Alice Conkey, and Olympic figure skating champion Michael Weiss attended a kick-off event. Dr. Satcher observed that "Hearts N' Parks shows what the Federal government can accomplish with community and private sector support to improve the health of Americans from all ethnic and socioeconomic backgrounds."
In late 2001 "Hearts N' Parks" expanded to include fifty new centers in eleven states—Arizona, Florida, Georgia, Illinois, Indiana, Ohio, Maryland, Michigan, Missouri, New Mexico, and Nevada—throughout the country. The center sites agreed to make a three-year commitment to the program.
State Initiatives Funded by the Centers for Disease Control and Prevention
During fiscal year 2002, the CDC allocated $27.5 million to fund physical activity and nutrition programs to address obesity in twelve states. (See Figure 10.8.) During 2003, $34 million was used to expand these programs and to support research to increase physical activity and improve nutrition education in additional states and communities.
For fiscal year 2004, the CDC funded twenty state-level obesity prevention programs. The programs aim to build knowledge, skills, stronger intentions, and greater
FIGURE 10.3
Pre-test questions about your health
self-efficacy. They address the need for supportive environments that provide opportunities for healthy eating and more physical activity and that promote behavior change by emphasizing a balance of individual and environmental approaches for healthier lifestyles.
Three types of CDC funding are offered to support state-level prevention programs. Basic implementation funding is provided to enable the states to cultivate working partnerships with public agencies and private-sector organizations to establish public policies that support health promotion. Such efforts involve development and institution of systems changes, environmental interventions, and social marketing and communications efforts at the state and local levels. States may establish systematic community and environmental interventions in high-priority communities, targeting high-risk groups, and then share what is learned locally, throughout the state, and with other states. Capacity
FIGURE 10.4
Pre-test health and nutrition survey
building is funding to support the states to develop a state team, a state plan, partnerships, and a program designed to assess and reduce the burden and disparities in chronic diseases and associated risk factors, including the piloting of prevention and control interventions and delivery strategies. The CDC also funds community demonstration projects—local, innovative interventions that are rigorously evaluated to determine whether they should be implemented statewide or nationally.
Three states—Massachusetts, Pennsylvania, and Washington—received funds for basic prevention aims—developing and implementing prevention plans and strategies, and the balance received funds to continue or expand the capacity of existing prevention initiatives. The Massachusetts Partnership for Healthy Weight, a coalition of health, education, and public and private organizations, led a statewide initiative to reduce rates of overweight and obesity among Massachusetts residents. The coalition developed a five-year plan consisting of policy and system-wide approaches to increase healthy eating and physical activity. In 2003 Pennsylvania published a plan that will be coordinated by a statewide coalition that will focus on five areas—active community environments, health care,
FIGURE 10.4
Pre-test health and nutrition survey
action for healthy kids, advocacy, and research and evaluation. The Washington State Nutrition and Physical Activity Plan was completed in June 2003 and focused on:
- Creating and supporting active community environments
- Supporting breastfeeding-friendly work sites
- Instituting diabetes primary prevention projects and awareness campaigns
- Reducing sedentary activities in childcare settings
- Improving access to healthy foods
- Designing safe and active routes to school
Colorado Maintains a Culture of Fitness to Help Prevent Overweight and Obesity
For years Colorado has enjoyed the lowest obesity rate in the United States, with the CDC describing Denver as among the leanest cities in the nation. Colorado public health officials have credited the state's climate and emphasis on healthy, active lifestyles as antidotes to the obesity epidemic; however, it also is the state that has experienced the greatest increase in the obesity rate over the last decade, more than doubling between 1991 and 2002. (See Figure 10.9.)
Colorado public health officials were alarmed by this finding and have taken many actions to reinvigorate the state's "culture of fitness." Working together, the University of Colorado Health Sciences Center and CDC-funded Colorado Physical Activity and Nutrition Program developed a fitness walking program called "Colorado on the Move." This fitness intervention was piloted in 2002 in two communities, one with a large rural population and the other in an urban, largely African-American community. Program participants were given pedometers and encouraged to walk 2,000 steps a day more than they walked before the program. In 2004 "Colorado on the Move" made its national debut with twelve state affiliates and was renamed "America on the Move" to reflect its geographic expansion.
The Denver metropolitan area targeted work sites with a National Employee Health and Fitness Month, an annual event intended to promote individual behavioral change and heighten public awareness. Denver suburbs also took action to encourage physical activity by incorporating fitness concerns into land use, building, and zoning regulations. Decision-makers are asked to consider ways to ensure that new developments and planned communities offer ample opportunities for residents to walk. For example, Stapleton, the newly developed city just east of Denver, which will grow to 4,700 acres and approximately 30,000 residents by 2014, features parks and trails connecting banks, shopping centers, and restaurants.
Other fitness initiatives underway included such programs for children as "Walk to School Colorado," which aimed to increase physical activity through walk and bike to school programs. Among these were "Walk to School Day,"
FIGURE 10.5
Post-test health and nutrition survey
"Walking Wednesdays," "Walking School Bus," and "Bike Train." Statewide challenges, competitions, and incentives to increase physical activity are conducted at schools, in the community, and at work sites by Shape Up Across Colorado, a program funded by the state health department and conducted jointly by the Colorado Governor's Council for Physical Fitness and the American Heart Association.
The state is equally concerned about integrating effective nutrition education and offering healthy food choices that are as easily accessible as high-fat and high-calorie fast foods have been. In 2003 the Physicians' Committee for Responsible Medicine named Denver International Airport the best airport in the nation in terms of the percentage of its restaurants that offer healthy menu selections. (Founded in 1985, Physicians' Committee for Responsible Medicine is a nonprofit organization that promotes preventive medicine, conducts clinical research, and encourages higher standards for ethics and effectiveness in research.)
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