Childhood Obesity:
The Way Forward
Susan Dentzer
Editor-in-Chief
With thanks to the Robert Wood Johnson
Foundation for its generous support
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
Prevalence of Overweight Among Children and Adolescents
Ages 6-19 Years
19
20
17
15 15
16
17
Percentage
15
11 11
10
Ages 6-11
Ages 12-19
7
5
5
6
6
4
5
0
19631970
19711974
19761980
19881994
19992000
20012002
20032004
Source: JAMA, April 5, 2006, Vol. 295, No. 13:1549 and Pediatrics 1998; 101:497
Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19
Years
Non-Hispanic White
Non-Hispanic Black
Mexican American
50
Percent
40
30
20
10
0
1999-2000
2001-2002
2003-2004
Ogden CL et al. JAMA 2008;299:2401
2005-2006
Changes in Obesity Prevalence by Race/ethnicity, Girls 2-19
Years
Non-Hispanic White
Non-Hispanic Black
Mexican American
50
Percent
40
30
20
10
0
1999-2000
2001-2002
2003-2004
Ogden CL et al. JAMA 2008;299:2401
2005-2006
Impact of Childhood Overweight
(BMI > 95th 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
Costs of Obesity – 1998 vs 2008
Total costs
Medical costs
1998
$78.5 B/y
6.5%
2008
$147 B/y
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
Average Daily Energy Gap (kcal/day) Between
1988-94 and 1999-2002
Excess Weight Gained
(Lb)
Daily Energy Gap
(kcal/day)
All Teens
10
110 -165
Overweight Teens
58
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
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
The Nation: 2003 vs. 2007
2003
2007
Combined Overweight/Obesity
Stable But Obesity Increased
Increase accounted for by selected subgroups
Publicly Insured
39.6%
35
Poor (< 100% FPL)
25Hispanic
39.8%
37.7%
30
20
15
15.7
15.3
14.8*
43.2%*
30.6
31.6
44.8%*
41.0%*
16.4
2003
2007
10
5
0
Overweight
Obesity
Overweight/Obesity
Combined
*2003 versus 2007 rates of obesity are significantly different (P<0.05)
Within State Disparities
State with the lowest overall rate
had the highest insurance
disparity
48.0
50
45
40
35
30
27.6
27.2
ID=27.5
MN=23.1
25
18.4
20
15
10
5
0
ID
Privately
Insured
ID
Publicly
Insured
MN
Privately
Insured
MN
Publicly
Insured
Variation Across States
Low: UT/MN: 23.1%
Both Across
and Within
State
Disparities
Widened
High: MS: 44.4
Significantly lower than U.S.
Lower than U.S., not significant
Higher than U.S., not significant
Significantly higher than U.S.
Within State Disparities
Lower Rate Does Not Mean Lower
Disparity
60.0
53.3
50.0
AK=33.9
40.0
AZ=30.6
32.0
27.6
30.0
20.0
14.1
10.0
0.0
AK
<100% FPL
AK
>400% FPL
AZ
<100% FPL
AZ
>400% FPL
Independent Impact on School Outcomes
45.0
40.0
38.2b
35.0
29.7
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Never/Rarely/
Sometimes Engaged
School Engagement
bStatistically
Higher Odds of Poorer School Outcomes for
43.8
Overweight or Obese Children
(Adjusted
for Health Status,
SES, etc.)
34.4
b
31.9
29.6
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
1-5 days
school
1.42 greater odds
11 or
more days
Missed School Days
41.5
31.0
No
Repeated a Grade
significant differences exist in estimated prevalence across child subgroups for this
variable based on a chi square test and p< .01.
A National Issue
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
100
90
80
70
9.0
100
Uninsured
50
Public
40
Private
20
10
0
57.8
Neighborhood
does not have park
or recreation
center
80
33.2
60
30
15.5
60
40
20
0
84.5
Neighborhood has
park and/ or
recreation center
How Much Should We Invest
In Preventing Childhood
Obesity?
Leonardo Trasande, MD, MPP
Mount Sinai School of Medicine
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.
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.
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.
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.
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 costeffectively.
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
360o of Child Health Promotion: Impacting
a Child Throughout the Day
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)
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
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)
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
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
Social Movements
• 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
Tobacco’s success
• 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
Where Are We For Obesity?
• 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)
What Can Clinicians Do?
• 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
Do we have the political will?
Scientific
Knowledge
Social
Strategies
Political
Will
Overcoming obesity in this generation
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
Impact of Childhood Obesity
On Employers
M-J. Sepúlveda, MD FACP
IBM Fellow & Vice President, Integrated Health Services
IBM Corporation
The Framework Of Parent-Child Interactions Potentially
Affecting Employers
Parent Behavior
Child Behavior
• 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
Health
care costs
Parent
Performance
Absenteeism,
Presenteeism
Employer
Adult
Health
Future Workforce
The Direct Financial Impact on Employers
Adults
• Average claims costs for
obese adults as well as
obese children are nearly
twice that of the nonobese
• Average claims cost of
children with type II
diabetes exceeds the
average claims cost of
adult type II diabetics
Children (18 and under)
$10,789
$8,889
$8,844
$4,520
Source: IBM, 2008 claims based on obesity diagnosis and costs
$2,907
$1,640
Children’s Health Rebate
1- baseline inventory
2- set goals
3- track and report
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
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
Beginning of Program
Children eat only healthy snacks on typical day
Children eat 5+ fruits/veggies
 Families value program, IBM
Source: IBM, 2008 Children’s Health Rebate Earners
End of program (12 weeks)
Percent of Participants (N=11,743)
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
Specialized Care of Overweight
Children in Community Health
Centers
Shikha Anand, MD, MPH
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)
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
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
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
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
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
Specialized Care of Overweight Children in Community Health Centers
March 1, 2010
Page 02
Evidence-Based Components of High Quality Pediatric
Obesity Treatment
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)
Specialized Care of Overweight Children in Community Health Centers
March 1, 2010
Page 03
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 04
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 05
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 bestpractice 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 06
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
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
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
Obesity Prevalence (%) by Neighborhood Built Environment Index, 2007
35
33
All Children Aged 10-17
30
Female Children Aged 10-11
26
25
20
20
20
19
17
15
15
15
10
Fewest neighborhood
amenities
2nd fewest
neighborhood
amenities
2nd most
neighborhood
amenities
Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.
Most neighborhood
amenities
Prevalence (%) of Physical Inactivity and TV Viewing Time by
Built Environment Index, Children Aged 10-17 Years, 2007
30
No Physical Activity
28
25
25
Watch TV > 2 hours/day
24
22
20
17
15
12
12
11
10
5
Fewest neighborhood
amenities
2nd fewest
neighborhood
amenities
2nd most
neighborhood
amenities
Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.
Most neighborhood
amenities
Excess Obesity Risk (Percent Higher Odds) Among Children Aged
10-17 From Unfavorable Neighborhood Built Environments, 2007
35
34
30
25
32
26
20
20
15
15
10
No access to library
No access to
No access to parks
No access to
Built Environment
or bookmobile
recreation or
Index (low vs high sidewalks or walking or playgrounds
community centers
paths
amenities)
Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.
Excess Obesity Risk (Percent Higher Prevalence) Among Children in
Unfavorable Neighborhood Social Conditions, 2007
100
93
All Children Aged 10-17
80
80
Female Children Aged 10-11
64
60
55
43
40
34
37
33
24
20
6
0
Social conditions
(least vs most
favorable)
Unsafe
neighborhood
Garbage/litter in
Poorly kept or
Vandalism (broken
streets or sidewalks rundown housing windows or graffiti)
Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.
Policy Solutions to the
Grocery Gap
Allison Karpyn
Director of Research and Evaluation
The Food Trust
Replicating Pennsylvania’s
Fresh Food Financing Initiative
Identification of Areas of Need
Lessons Learned
• Adapt to Local Circumstances
• Maintain Focus
• Engage Diverse Sectors
• Include Industry
• Nurture Local Efforts
• Conduct More Research
Sodexo’s Commitment to Student
Well-Being
Roxanne E Moore MS, RD
National Director of Wellness
Sodexo Education
Sodexo encourages student well-being

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

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

Sodexo was one of the first companies to join the MyPyramid Corporate
Challenge to promote the USDA's dietary guidelines
65
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
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
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
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
Agriculture Policy & Childhood Obesity
A Food Systems and Public Health Commentary
David Wallinga
Director, Food and Health Program Institute
for Agriculture and
Trade Policy
Agriculture policy since 1974: “Cheap food”
• Production-driven
• Export-driven
Success as a cheap calorie policy
Commodity subsidies not written into Farm Bill until 2002
Of 300
400 calorie excess, relative to 1985
 Added sweeteners account for 23 percent
 Added fats account for 24%
 Grains, mostly refined, account for 46 percent
(Putnam et al. 2002)
Linked to
obesity
promotion
Percent increase in calorie intake, 1970 to 2007
400
359
350
300
260
250
200
191
150
100
69
50
14
0
From corn flour,
meal, hominy,
starch
Added sugars
Corn sweeteners
Added fats and Salad and cooking
oils
oils
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
Foods high in fats, sugars and calories are some of the
least expensive, most inflation-resistant in the American
food environment.
40.0%
38.9%
Change in food prices, 1985 –2000, real $
Fresh fruits & veggies
30.0%
20.0%
20.4% Total fruits & veggies
11.5% Cereal & baked goods
10.0%
0.0%
-10.0%
-20.0%
-30.0%
-0.6%
-3.2%
-4.5%
-7.0%
-14.0%
-23.6%
Wallinga D. Today's food system: how healthy is it? J Hunger Environ Nutr 2009;4(3):251-81.
Near-term policy change
• A food systems analysis commensurate with the
complexity of the health problems.
• Farmers as partners against childhood obesity.
• Agriculture research to achieve synergies between
growing healthier foods, with fewer fossil fuels, and
with American farmers.
A Healthy Food, Healthy Farm Bill
American spending on food, health relative
to disposable income
30
25
Total health expenditures expressed as a percentage of
total disposable personal income
Total food expenditures relative to disposable personal
income
Percentage
20
15
10
0
1929
1931
1933
1935
1937
1939
1941
1943
1945
1947
1949
1951
1953
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
5
Figure 1 , Wallinga D. Today's food system: how healthy is it? J Hunger Environ Nutr 2009;4(3):251-81.
Are “Competitive Foods” Sold at
Schools Making Our Children Fat?
Nicole Larson PhD, MPH, RD
Mary Story PhD, RD
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
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
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
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.
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 lownutrient, 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.
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).
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.
Current competitive food standards
don’t make sense
Fruitades
Seltzer water
Caramel corn
Popsicles
(with little juice)
French fries
Ice cream bars
Candy bars
Cookies
Chips
Snack cakes
Doughnuts
(without fruit juice)
Jelly beans
Chewing gum
Lollipops
Cotton candy
Breath mints
Allowed
Not Allowed
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.
Childhood Obesity:
The Way Forward
With thanks to the
Robert Wood
Johnson
Foundation for its
generous support