Preventing Childhood Obesity Health in the Balance (2005) / Chapter Skim
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3 Developing An Action Plan
3 Developing An Action Plan
Pages 79-124
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From page 79... ...
The critical elements of the action plan's development, described in this and subsequent chapters, were as follows: · Clarifying definitions related to key concepts · Developing a framework to guide the type and scope of data gathered · Articulating obesity prevention goals for children and youth · identifying criteria for conducting an in-depth review of the available evidence · Translating the findings from the best available evidence into specific recommendations that comprise an integrated action plan. DEFINITIONS AND TERMINOLOGY Childhood and Adolescent Obesity Body mass index (BMI)
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From page 80... ...
What constitutes "excess" is an amount of body fat (often expressed as a percentage of body mass) that is sufficient to cause adverse health consequences.
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From page 81... ...
Weight-for-length greater than the 95th percentile is used by CDC and the Special Supplemental Nutrition Program for Women, infants, and Children to define overweight for children in this age group. It is important that government agencies, researchers, health-care providers, insurers, and others agree on the same definition of childhood obesity.
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From page 82... ...
The committee concluded that the well-established concept of primary prevention was most amenable to its assigned task of developing a broad-based action plan that addresses the social, cultural, and environmental factors associated with childhood obesity. A primary prevention approach emphasizes efforts that can help the majority of children who are at a healthy weight to maintain that status and not become obese.
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From page 83... ...
FRAMEWORK FOR ACTION Using an ecological perspective, the committee developed a framework to depict the behavioral settings and leverage points that influence both sides of the energy balances equation—energy intake and energy expenditure. An ecological systems theory model postulates that changes in individual characteristics are affected not only by personal factors (e.g., age, gender, genetic profile)
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From page 84... ...
. These leverage points include the major sectors that affect the food system, opportunities for physical activity or sedentary behavior, and information and education regarding dietary behaviors and physical activity.
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From page 85... ...
culture. This framework, which emphasizes the need for obesity prevention efforts to leverage the interests and actions of a number of stakeholders working within and across multiple settings and sectors, guided the review of evidence and the development of recommendations in this report.
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From page 86... ...
. For individual children and youth, obesity prevention goals focus on maintaining energy balance (calories consumed versus calories expended)
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From page 87... ...
Examples include Increased number of children who safely walk and bike to school Improved access to and affordability of fruits and vegetables for low-income populations Increased availability and use of community recreational facilities Increased play and physical activity opportunities Increased number of new industry products and advertising messages that promote energy balance at a healthy weight Increased availability and affordability of healthful foods and beverages at supemmarkets, grocery stores, and fammers markets located within walking distance of the communities they se ve Changes in institutional and environmental policies that promote energy balance 87 mate aim of obesity prevention in children and youth, however, is to create, through directed social change, an environmental-behavioral synergy that promotes positive outcomes both at the population and individual levels Box 3-1 summarizes these long-term and intermediate goals, which will be discussed in greater detail throughout the report.
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From page 88... ...
Population weight goals for childhood obesity prevention should be stated in terms of changes in the mean BMI and in the shape of the entire BMI distribution Alternatively, goals can be stated in terms of decreasing the proportion of children or youth who exceed particular thresholds—e.g., 75th, 85th, 90th, 95th, or 97th percentiles of BMI for age and gender on the CDC BMI charts. In the absence of an appropriate evidence base, however, threshold goals are necessarily somewhat arbitrary and sacrifice substantial information about the rest of the distribution as well as substantial statistical power to detect differences between groups and over time (Robinson and Killen, 2001)
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From page 89... ...
The CDC BMI charts are mathematically smoothed curves of the pooled growth parameters of children and adolescents sampled in cross-sectional national health surveys conducted from 1963 to 1994. An analogy would be to consider the curves as compiled from a series of "snapshots" of large national samples made at different times over three decades.
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From page 90... ...
Strictly speaking, growing children, even those at a healdhy body weight, must be in a slightly positive energy balance to satisfy the additional energy needs of tissue deposition for normal growth. However, for the purpose of simplicity in this report, the committee uses the term "energy balance" in children to indicate m equality between energy intake and energy expenditure that supports normal growth widhout promoting excess weight gain.
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From page 91... ...
and dietary fiber, in addition to providing adequate energy to meet the needs of maintenance, growth, and development Although "energy intake = energy expenditure" looks like a fairly basic equation, in reality it is extraordinarily complex when considering the multitude of genetic, biological, psychological, sociocultural, and environmental factors that affect both sides of the energy balance equation and the interrelationships among these factors (Figure 3-2)
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From page 92... ...
SOURCE DHHS, 2001 b. serious health risks during childhood that can continue throughout adult life In the simplest terms, energy balance represents calories consumed versus calories expended, although as noted above, many individual variables can affect that balance The discretionary variables under an individual's control on a daily basis are dietary energy intake and the energy expended during physical activity.6 Daily energy intake is determined by the calorie content of the specific food and beverages consumed.
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From page 93... ...
The increasing prevalence of obesity among children and youth in the United States could be the result of an upward shift in energy intake, a downward shift in energy expenditure, or the occurrence of both trends concurrently (Hill and Peters, 1998; Harnack et al., 2000; Hill et al., 2003)
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From page 94... ...
Thus, the recent population lose in body weight reflects the interaction of genotypes that predispose individuals to obesity with detrimental behavioral and environmental factors. In animals, the evidence is strong for such gene-environment interactions affecting body weight and energy balance (Barsh et al., 2000)
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From page 95... ...
in the arcuate nucleus of the hypothalamus, which is home to two distinct populations of neurons with opposing actions one group that stimulates food intake and another that suppresses it (Elmquist and Flier, 2004)
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From page 96... ...
. Based on the Dietary Guidelines for Americans, the Healthy Eating 7The U.S Dietary Gridelines for Amc icans are correctly ruder revision and the sixth edirir~n will be released in 2005 The Food Gr ide Pyramid is an edr carir~nal tool that depicts qr aLrative dietary gr idance based on the principles of balance, proporhonaLty, and moderanon.
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From page 97... ...
Subsequent analyses of trends in energy intakes of children and youth have produced mixed findings (Enns et al., 2002; Nielsen et al., 2002; Sturm, 2005) , and much remains to be learned about the dietary factors that contribute to the obesity epidemic in these groups.
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From page 98... ...
Physical Activity Physical activity, which has been defined as "any bodily movement produced by skeletal muscles that results in energy expenditure" ( Caspersen et al., 1985) , is in many respects synonymous with childhood.
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From page 99... ...
Elevated plasma LDL and lowered HDL are risk factors for the development of coronary heart disease (CHD) and evidence indicates that atherosclerosis begins in childhood.
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From page 100... ...
Availability affects the range of possible individual choices, but personal choice is also mediated through a range of sociocultural variables that differ by age, gender, ethnicity, region, neighborhood characteristics, and socioeconomic status. This matrix of envrrontnental levels and types can also be developed to facilitate consideration of influences on obesity-related variables such as the availability of education and counseling and broader health promotion about weight gain prevention (physical environment)
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From page 103... ...
range view their bodies. There is also concern that obesity prevention efforts will lead to inappropriate weight concern, dieting preoccupation, or unhealthful weight control practices among children and youth.
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From page 104... ...
. When compared with food-insufficient households of higher income, low-income food-insufficient households had more obese children; however, food insufficiency by itself was not associated with self-reported measures of childhood obesity (Casey et al., 2001)
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From page 105... ...
Some types of leisure-time physical activity are theoretically available at low or no cost, but these options may be less available to children in low-income neighborhoods because of neighborhood safety concerns, lack of adult supervision, or limited community recreational or other resources. Addressing childhood obesity in these contexts will require attention to root causes, and attempts to mitigate the underlying social and environmental adversity will be needed (Travers, 1997)
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From page 106... ...
as well as high levels of obesity-related health problems. In addition, to the extent that a history of discrimination or marginalization based on race or ethnicity becomes intertwined with other sociocultural factors, a certain level of skepticism or distrust relative to mainstream information and initiatives, including health information, may influence the receptivity to obesity prevention messages—particularly when these messages seem to conflict with pre-existing attitudes and beliefs.
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From page 107... ...
. There is no single acceptable standard, however, for assessing the entire range of prevention interventions and programs (Kellam and Langevin, 2003)
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From page 108... ...
. However, efforts to apply its principles to identifying effective interventions for other areas of disease prevention and health promotion have met with varying degrees of success (Osaka Declaration, 2001; McQueen, 2002; WHO, 2003; Victora et al., 2004)
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From page 109... ...
Evidence obtained from well-designed controlled trials without randomization. Evidence obtained from well-designed cohort or case-controlled analytical studies, preferably from more than one center or research group.
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From page 110... ...
The endence standards are RCTs and outcome and process evaluations that use both quantitative and qualitative methods The focus is on the community Preventive dose rarely applies Difficult to scale up health promotion programs that reach the entire population Outcomes are to change social norms, envi onments, and the behavior of entire populations Interventions rarely take on social determinants external to the community
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From page 111... ...
. As childhood obesity is a serious public health problem calling for immediate reductions in obesity prevalence and an its health and social consequences, the committee strongly believed that actions should be based on the best available evidence—as opposed to waiting for the best possible evidence.
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From page 113... ...
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From page 114... ...
. · Given the significant shortage at present of experimental evidence to guide programs and policies, and the fact that many societal variables of interest have not been well addressed in controlled experimental studies as moderating or mediating factors, obesity prevention will require an evidence-based public health approach that continues to draw on RCTs, quasiexperiments, and observational studies as important sources of information (Victora et al., 2004)
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From page 115... ...
Relevant issues for setting obesity prevention goals for populations include concepts of optimum population BMI and healthy weight levels, potential effects on food intake and patterns of physical activity and inactivity, as well as attitudes and social norms related to food and eating, physical activity, inactivity, body size, and dietary restrictions. This chapter discusses a variety of influences on children's diets and physical activity patterns including genetic variation and biological considerations, and sociocultural and other environmental factors Using an ecological systems theory model and a primary prevention evidence-based public health approach, this report focuses on how changes in the individual child's behaviors are affected not only by individual factors but also through interactions with the larger social, cultural, and environmental contexts in which he or she lives (e.g., family, school, community, social and physical environments)
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From page 116... ...
2000. A study of body weight concerns and weight control ptachces of 4th and 7th g ade adolescents.
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From page 117... ...
1998. Use of the body mass index (BMI)
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From page 118... ...
1998. Meas~ement issoes telated to stodies of childhood obesity: Astessment of body composinon, body fat disttibmion, physical achvity, and food intake.
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From page 119... ...
J Am Med Assoc 282(16)
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From page 120... ...
2002. Va idity of body mass index compated with othet body-composinon teteening indexes fat the assessment of body fatness in childten and adoletcents.
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From page 121... ...
2002. The preteen on and treatment of childhood obesity.
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From page 122... ...
2003. Childhood obesity: A societal problem to solve.
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1997. Ideal body size be iefs and weight concetns of fo~th-gtade childten.
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