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Overweight Children The Role of Health Care in Prevention & Treatment . November 30, 2005. Erna Wong, MD Pediatrician. Today we will talk about. The Epidemic of Overweight Children Medical Office Visit Interventions Weight Management Interventions

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Overweight ChildrenThe Role of Health Care in Prevention & Treatment

November 30, 2005

Erna Wong, MD


Today we will talk about...

  • The Epidemic of Overweight Children

  • Medical Office Visit Interventions

  • Weight Management Interventions

  • Environmental Changes and Physician Advocacy

By the end of this lecture participants will be able to…

  • Describe 3 overweight prevention strategies.

  • Diagnose overweight and at risk for overweight using BMI % for age.

  • Describe the weight goals for overweight children.

  • Give Brief Focused Advice.

About Kaiser Permanente (KP)

  • One of the nation’s oldest not-for-profit health care delivery systems and a leader in quality.

  • 8.2 million members nationwide; 6.2 million in California.

  • KP has made a deep and longstanding commitment to healthy eating and active living in our communities with intensive interventions since 2001.

How serious is the problem of overweight children in California today?

  • Very Serious

  • Somewhat Serious

  • Not Serious

  • No Opinion

1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm

How many children are overweight?

Since 1963, the number of overweight children in the U.S. has tripled!


Some children are more likely to be overweight.

% Overweight Kids & Teens in 2000

  • Teenagers

  • Black, Mexican American, American Indian, Alaskan Native

  • Children of overweight parents

NHANES 1999-2000 JAMA 2002;288:1728-1732

Do overweight children grow up to be overweight adults?

  • The older the overweight child is, the more likely he/she will continue to be overweight as an adult.

  • 8 out of 10 overweight teens will continue to be overweight as adults.

Preventive Medicine 1993; Vol. 22:pp. 167-177

Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452

How many adults are overweight?

“the average weight gain among subjects (20-40 years old) in the population is 1.8 to 2.0 pounds/year.”

Science. 299:7;853-855 (2003)

What health problems are related to being overweight?

  • Type 2 diabetes

  • Heart disease

  • Hypertension

  • Asthma

  • Slipped capital femoral epiphysis

  • Nonalcoholic steatohepatitis

  • Polycystic ovary syndrome

  • Sleep apnea

  • Depression and low self-esteem

Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

How many overweight children have metabolic syndrome?

  • Metabolic Syndrome(1)

    • Criteria: TG>=110 mg/dL, HDL-C<=40 mg/dL, Waist Circ. >=90%, FBS>=110 mg/dL, BP>= 90% (3 of 5 criteria needed)

    • A predictor of Type 2 diabetes and premature coronary artery disease.

    • Prevalence = 28.7% among overweight adolescence.

  • The prevalence of metabolic syndrome increased with the severity of overweight and reached 50% in severely overweight children. (2)

1. Arch Pediatr Adolesc Med Vol. 157, Aug 2003 pp. 821-827

2. N Engl J Med Vol. 350, June 2004 pp. 2362-2374

The Epidemic of Overweight Children

“I think we’re looking at a first generation of children who may live less long than their parents as a result of the consequences of overweight and type 2 diabetes.”

Francine Ratner Kaufman, MD

Head, Division of Endocrinology & Metabolism

Children’s Hospital Los Angeles

www.discoveryhealthCME.com, N Engl J Med Vol. 352(11) March 2005, pp. 1138-1145

What are the costs of overweight and obesity?

  • Health care for obese adults costs 37% more than for people of normal weight, adding $732 to the annual medical bills of every American.

  • Treatment of illnesses related to obesity costs America $93 billion a year.

Health Affairs May 14, 2003; W3:219-226

NIHCM Obesity in Young Children: Impact and Intervention Aug 2004



What are the causes of overweight and obesity?





What are the genetics of overweight and obesity?

  • Twin analysis indicates a heritability of fat mass of 40–70%

  • Adopted children have BMIs that correlate to those of their biological parents

    Genetic Risk for Overweight

  • One obese parent (3X increase)

  • Two obese parents (13X increase)

  • Early puberty

Behavioral Genetics, 1997, 27:325–351

What behaviors are related to children becoming overweight?

  • Not enough physical activity.

  • Too much TV & video games.

  • Not enough milk, dairy, fruits and vegetables.

  • Too many sweetened drinks (e.g., soda, juice drinks, sports drinks) and too much fast food.

  • Skipping meals and breakfast.

Position Paper - Prevention of Childhood Overweight What Should Be Done? Center for Weight and Health - U.C. Berkeley 10/02

Why is physical activity important?

  • 3 out of 4 children in California fail to meet the minimum fitness standards in 5th, 7th and 9th grade.

  • Being in good shape…

    • reduces the risk of being overweight and heart disease

    • is related to better school performance

California Department of Education 12/10/02


Why is TV harmful?

  • Children average 2-3 hours of TV viewing every day.

  • 30-50% of children have a TV in their bedroom.

  • TV viewing is associated with...

    • increased risk for being overweight

    • school problems

    • aggressive behavior & drug use

Pediatrics Vol. 107 No. 2 February 2001 pp. 423-426

Are dairy products important?

  • Milk consumption in the U.S. has declined over the last 40 years.

  • Milk and calcium consumption has declined significantly for adolescent girls.

  • Drinking milk may reduce the risk of…

    • becoming overweight

    • developing osteoporosis

J Am Diet Assoc. 2003;103:1626-1631.

Are eating fruits and vegetables important?

  • In California, of 7th, 9th and 11th graders surveyed less than half reported eating fruits or vegetables at least once per day in the past week.

  • Eating 5 servings of fruits and vegetables every day can help reduce the risk of overweight.

Food Review. 2002;25:28-31.

Why are sweetened drinks harmful?

  • Teenagers drink an average of 20 ounces of soda every day.

  • Drinking more than 12 ounces a day of sweetened drinks is associated with…

    • an increased risk of being overweight

    • drinking less milk

    • an increased risk of cavities

J PEDIATRICS Vol. 142 June 2003, pp. 604-610

BMJ. May 22, 2004;328:1237

What about eating out and fast food?

  • Eating out has increased from 16% to 27%.

  • Some fast food portion sizes have tripled from 1960 to 2000.

  • Fast food and eating out may be associated with an increased risk for overweight.

  • Int J Obes Relat Metab Disord. 2004;28:282-289.

What are the risks of skipping breakfast?

  • Eating breakfast by teens has declined by 20% over the last 20 years.

  • 44% of teens said they skipped meals to lose weight.

  • Skipping breakfast is associated with…

    • eating more later in the day and

    • the risk of becoming overweight.

J Am Diet Assoc. Vol. 101, 2001, pp. 798-802

Small changes over time can make a big difference!

15 minutes of play instead of watching TV can prevent some weight problems.















Early Adiposity





Physical Activity



TV Viewing

Physical Activity




Portion Size




The Permanente Journal/ Summer 2003/ Volume 7 No. 3 pp. 6-7


A Longitudinal Approach to Preventing Overweight

Can overweight among children be prevented?

  • Breastfeed for the first year.

  • Wean from the bottle at 12 months of age.

  • Limit juice and other sweetened drinks to 4-6 ounces per day max.

  • Limit TV - none before 2 years, 1 hour or less over 2 years of age.

  • Avoid using food as a reward for good behavior.

J Pediatr Vol. 141 No. 6 December 2002 pp. 764-769

JAMA Vol. 285 No. 19 May 2001 pp. 2461-2467

Primary Care Interventions

Kaiser Permanente’s Approach to Preventing Overweight

First Steps. . .

  • Changing the Message

    • Active bodies are healthy bodies

    • Healthy bodies come in all shapes and sizes

  • Anticipatory guidance

    • Breastfeeding promotion

    • Improved nutrition

    • Increased physical activity

  • Identification, Risk Stratification, and Early Intervention

    • BMI

    • Targeted evaluation and education

A Practical Approach to Overweight Children

Well Child Care Visit

  • Calculate BMI and Plot BMI% for Age

  • Perform In-Depth Medical Assessment

  • Determine Weight Goals

  • Order Screening Lab Tests (if indicated)

  • Provide Brief Focused Advice

  • Arrange for Follow-Up Visit or Phone Call 1-4 Weeks

Follow-Up Visit or Phone Call

  • Review Labs

  • Discuss Treatment Options and Referrals

  • Provide Brief Negotiation or Motivational Interviewing

  • Arrange for Follow-Up as Necessary

Proposed Treatment Approach to Overweight Children, Kaiser Permanente, © 2004

Primary Care Interventions

  • Diagnosis of overweight using body mass index (BMI)% for age at well child care visits 2 years and older

  • In-depth medical assessment

  • Appropriate weight goals

  • Counseling - motivational interviewing

  • Referral and follow-up

Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

BMI = 28

BMI Does Not Measure Body Fat

How do you calculate body mass index (BMI)?

BMI (English):[ weight (lb) / height (in) / height (in) ] x 703

BMI (metric):[weight (kg) / height (cm) / height (cm) ]x 10,000

BMI Conversion Tables: http://www.cdc.gov/

Web Calculator: http://www.cdc.gov/

Palm Calculator and Growth Chart: http://www.pdacortex.com/

BMI Calculator Wheel: http://www.trowbridge-associates.com/ $5

Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

Why do we use BMI?

  • Consistent with adult standards and tracks childhood overweight into adulthood

  • BMI for age relates to health risks including cardiovascular disease, hypertension and type 2 diabetes

  • BMI measurement is recommended by the AAP at all well child care visits 2 years and older.

Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

How is overweight diagnosed?

  • Indicators of Nutritional Status

    • Overweight >= 95% for age

    • At Risk of Overweight 85-94% for age

    • Underweight < 5% for age

  • Early Adiposity Rebound

    • Definition: Adiposity rebound is the point when the BMI is the lowest for a child before it increases again

    • Experiencing early adiposity rebound (rebound before 5-6 years old) is a risk factor for subsequent adiposity in adulthood (1) and is associated with parental obesity (2)

Early Adiposity Rebound (4Y)

(1) Pediatrics Vol. 101 No. 3 March 1998 pp. 462

(2) Pediatrics Vol. 105 No. 5 May 2000 pp. 1115-1118

Who should receive an in-depth medical assessment?

In-Depth Medical Assessment


Developmental delay (Genetic disorders)

Poor linear growth (Hypothyroidism, Cushing’s, Prader-Willi syndrome)

Headaches (Pseudotumor cerebri)

Nighttime breathing difficulty (Sleep apnea, hypoventilation syndrome)

Daytime somnolence (Sleep apnea, hypoventilation syndrome)

Abdominal pain (Gall bladder disease)

Hip or knee pain (Slipped capital femoral epiphysis)

Oligomenorrhea or amenorrhea (Polycystic ovary syndrome)

Family History

Obesity Hypertension

NIDDM Dyslipidemia

Cardiovascular disease Gall bladder disease

Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29

In-Depth Medical Assessment

Physical examination

Height, weight, Blood pressure and BMI

Truncal obesity (Risk of cardiovascular disease; Cushing’s syndrome)

Dysmorphic features (Genetic disorders, including Prader–Willi syndrome)

Acanthosis nigricans (NIDDM, insulin resistance)

Hirsutism (Polycystic ovary syndrome; Cushing’s syndrome)

Violaceous striae (Cushing’s syndrome)

Optic disks (Pseudotumor cerebri)

Tonsils (Sleep apnea)

Abdominal tenderness (Gall bladder disease)

Undescended testicle (Prader-Willi syndrome)

Limited hip range of motion (Slipped capital femoral epiphysis)

Lower leg bowing (Blount’s disease)

In-Depth Medical Assessment - Laboratory Evaluation

  • Fasting lipid profile and insulin? (1)

  • Screening for diabetes if (2)…

  • Age 10 or older with BMI >= 95% with 2 of the following:

    • Family History: type 2 diabetes in a 1st or 2nd degree relative

    • Ethnic Group: Native American, African American, Hispanic, Asian/Pacific Islander

    • Signs of Insulin Resistance: acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome

  • Screening Tests for Diabetes and Diagnostic Criteria

    • Fasting (8 hour) plasma glucose = 126 mg/dl

    • Oral glucose tolerance test: 2-hour plasma glucose = 200 mg/dl

    • Casual (random) plasma glucose = 200 mg/dl WITH symptoms of diabetes

  • ALT (SGPT) (1)

  • Other tests based on history and physical

  • (1)Circulation 2005;111:1999-2012

    (2)Diabetes Care 2000a;23:381-9

    What are the recommended weight goals?

    Older Adolescents and Adults: 10% weight loss from baseline over 6 months

    What should my child weigh?

    • Tell the parent what the weight would be for the BMI 85%.

    • Tell the parent that for children the focus is on making improvements in family lifestyles such as making better food choices and being more active not on weight or weight loss. Your health professional will follow your child’s height, weight and BMI and let you know how your family is doing.

    Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29

    All Children

    Get up and play hard

    Cut back on TV and video games

    Eat 5 helpings of fruits and vegetables/day

    Cut down on sodas & juice drinks


    Children at Risk or Overweight

    Screen with BMI starting at age 2 for all children

    Focus on key intervention ages


    Families at Risk to Make Changes

    Ask permission to discuss weight

    Negotiate areas of improvement

    Assess readiness to change

    Explore ambivalence

    Offer health education materials, referral and follow-up


    The Role of Nurses, Health Educators, Physicians, etc.

    Get More Energy! Poster

    4 Key Messages

    Readiness to Change Tool

    Health Education Materials

    Physicians who had written nutrition brochures in their exam rooms were more likely to discuss nutrition.

    Preventive Medicine Vol. 38 No. 2 February 2004 pp. 198-202



    With Families

    Personal behavior change31%

    No solution suggested17%

    Make better options available for school lunch9%

    Improve counseling by pediatricians8%

    Extend PE requirements in schools7%

    Improve nutrition education in schools6%

    Add a “fat tax” to foods based on nutrient value5%

    Solutions for childhood nutrition problems mentioned in CA newspaper articles, 7/98–8/00 (N=88)

    What are more sensitive ways to address overweight?

    • Obesity

    • Ideal Weight

    • Personal Improvement

    • Focus on Weight

    • Diets or “Bad Foods”

    • Exercise

    • Overweight

    • Healthier Weight

    • Family Improvement

    • Focus on Lifestyle

    • Healthier Food Choices

    • Play or Activity

    Effective Communication with Families, Kaiser Permanente, © 2004

    Family Changes-Acknowledge Parental Perceptions and Barriers

    • May not perceive their obese children as overweight

    • May define overweight as limited physical activity or being teased, not by growth charts

    • May attribute to being “big-boned” or “thick”

    • May believe that nature not nurture determines weight

    • May have trouble controlling children’s eating habits or use food to shape child’s behavior

    • May feel lack of control over child’s diet

    • May themselves be dealing with weight issue

    Effective Communication with Families, Kaiser Permanente, © 2004

    Family Changes-Parental Sensitivity

    • Parents should explain that children come in different shapes and sizes and that they love them whatever their size.

    • Parents should avoid saying “skinny,” “fat,” “obese” or teasing children about their weight.

    • Parents should address eating and activity as a family issue, not as the child’s “problem.”

    Encouraging a Healthy Weight for Your Child, Kaiser Permanente, © 2003

    Family Changes-Positive family attitudes

    • Having extra weight is no one’s fault.

    • There’s no such thing as good food or bad food.

    • Any activity is helpful, it doesn’t have to be “exercise.”

    • There is no ideal weight or body shape.

    • Body size is just one part of who a person is.

    Encouraging a Healthy Weight for Your Child, Kaiser Permanente, © 2003

    Family Changes-Parents Responsibilities

    • Purchase and offer healthy foods and portion sizes.

    • Limit fast food and eating out.

    • Set limits on TV and video games. Stick to them.

    • Let child choose things to work on.

    • Be a good role model with healthy eating and physical activity.

    • Regularly show affection.

    Encouraging a Healthy Weight for Your Child, Kaiser Permanente, © 2003

    Family Changes-Child’s Responsibilities

    • Eat as much or as little as they need among the food available.

    • Eat 3 meals a day with breakfast.

    • Be active every day and have fun.

    • Be responsible for TV and video game limits.

    • Be proud of things they do.

    • Choose things to work on to be healthier.

    Encouraging a Healthy Weight for Your Child, Kaiser Permanente, © 2003

    Starting the Conversation:

    Let’s Talk About Weight

    Integrated Behavior




    Relapse &




    What are the stages of change?

    Prochaska & Di Clemente: Transtheoretical Model of Behavior Change

    Change Talk

    Self-motivating statements made by the patient:

    • Recognition of an issue

    • Hazards of not making a change

    • Recent efforts to make a change

    • Ideas and options for making a change

    • Hope or confidence about making a change

    • Specific intentions to make a change

    Effective Communication with Families, Kaiser Permanente, © 2004

    Self Perception

    People are more powerfully influenced by what they hear

    themselves say than by what someone else says to them

    Encourage your patients to say the things that you usually tell them. Help your patients talk themselves into making a change.

    Effective Communication with Families, Kaiser Permanente, © 2004

    Behavior Change Techniques

    • Lifestyle Advice – Well Child Visit

      • < 1 minute

      • Children not currently at risk for overweight

    • Brief Focused Advice – Well Child Visit

      • < 3 minutes

      • Children who are overweight or at risk for overweight

    • Brief Negotiation– Follow up Visit

      • 10+ minutes: single or multiple sessions

      • Children who are overweight or at risk for overweight

    Effective Communication with Families, Kaiser Permanente, © 2004

    Lifestyle Advice

    To stay healthy and energized:

    • Get up & play hard 30-60 minutes each day

    • Limit TV/video games to <1 hour each day

    • Eat five fruits and vegetables each day

    • Limit juice and soda to < 1cup each day

    Effective Communication with Families, Kaiser Permanente, © 2004

    Brief Focused Advice

    Step #1: Engage the Patient / Parent

    • Can we take a few minutes to discuss your health and weight?

    • How do you feel about your health and weight?

      Step #2: Share Information (optional)

    • Your current weight puts you at risk for developing heart disease and diabetes.

    • What do you make of this?

    • Some ideas for staying healthy include…. (see poster)

    • What are your ideas for working toward a healthy weight?

    Effective Communication with Families, Kaiser Permanente, © 2004

    Brief Focused Advice

    Step #3: Make a Key Advice Statement

    • I would strongly encourage you to…

      • Get up and play hard, 30-60 minutes a day.

      • Cut back on TV & video games to 60 min/day.

      • Eat 5 helpings of fruits of vegetables every day.

      • Cut back on sodas & juice drinks to 1 small cup/day.

      • Use patient ideas from step #2

        Step #4: Arrange for Follow up

    • Would you be interested in more information on ways to reach a healthier weight? AND / OR

    • Let’s set up an appointment in 1-4 weeks to talk about this further.

    Effective Communication with Families, Kaiser Permanente, © 2004

    What is Brief Negotiation?

    • A counseling style that provides an effective and structured approach to behavior change counseling in brief clinical encounters

    • Based on behavior change theory and clinical research:

      • Stages of Change Model, DiClemente and Prochaska, 1998

      • Motivational Interviewing, Miller and Rollnick, 1991

    • Brief Negotiation Steps

      • Set the Stage

      • Share Clinical Results

      • Assess Readiness to Change

      • Close Conversation/Transition to Referral

    Effective Communication with Families, Kaiser Permanente, © 2004

    Motivate Families to Make Changes Using Brief Negotiation

    Open the Encounter

    Negotiate the Agenda

    Assess Readiness

    Explore Ambivalence

    Tailor the Intervention

    Close the Encounter

    Effective Communication with Families, Kaiser Permanente, © 2004

    Open the Encounter

    • Ask Permission

      • Would you be willing to discuss your weight for the next few minutes?

    • Ask an Open-Ended Question

      • How do you feel about your weight?

      • What do you think about your weight?

      • What have you tried so far to manage your weight?

    • Listen

    • Summarize

    Effective Communication with Families, Kaiser Permanente, © 2004

    Negotiate the Agenda

    There are a number of ways to achieve

    a healthy weight (refer to poster). They


    • Get up and play hard

    • Cut back on TV and video games

    • Eat 5 helpings of fruits and vegetables a day

    • Cut down on soda and juice

      Is there one of these you’d like to

      discuss further today?

      Or maybe you have another idea…

    Effective Communication with Families, Kaiser Permanente, © 2004

    Assess Readiness to Change

    • Straight question:“On a scale of 0-10, how ready are you to think about[option chosen from poster]?”

    • Backward question:“Why a 5 and not a 3?”

    • Forward question:“What would it take to move you from a 5 to a 7?”

    Explore Ambivalence

    • Ask a pair of questions to help the patient/parent explore pros and cons

      • What are the things you like about ___?AND

      • What are the things you don’t like about ___?


      • What are the advantages of keeping things the same?AND

      • What are the advantages of making a change?

    • Summarize

    • Did I get it all?

    Effective Communication with Families, Kaiser Permanente, © 2004

    Tailor the Intervention

    Not Ready 0-3

    Raise Awareness Advise & Encourage

    Unsure 4-6

    Evaluate Ambivalence

    Ready 7-10

    Strengthen Commitment & Facilitate Action

    Close the Encounter

    • Summarize

    • Show appreciation

    • Offer advice, emphasize choice, express confidence

    • Confirm next steps/referral

    Health and Social Service Providers Responsibilities

    • Advise all children on the 4 key messages regardless of their shape or size.

    • Identify children at risk or overweight.

    • Motivate families at risk to make changes by assessing their readiness to change and identifying 1-2 key behaviors.

    • Provide educational materials.

    • Provide follow up with at risk families.

    Effective Communication with Families, Kaiser Permanente, © 2004

    Tools for Primary Care Interventions

    • CDC Growth Charts

    • BMI Wheel Calculator

    • Patient Education Materials

    • Exam Room Poster

    Environmental Changes and Physician Advocacy

    Are overweight children a personal or community issue?

    1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm

    What do Californians think the answer is?

    • Create more community recreational programs (96%).

    • Require schools to teach students about nutrition & physical activity (96%).

    • After-school athletic facilities open and available (93%).

    • Require PE in high school (92%).

    • Require restaurants to post nutritional information on menus (87%).

    1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm

    Health Care and Prevention of Overweight Children

    • Medical office visit – BMI screening, counseling and referral

    • Environmental improvement at health care facilities and policy

    • Health professionals working with community collaborative and advocacy

    • Health care benefits

    • Social marketing

    The Role of Health Care in Community Advocacy

    JAMA January 7, 2004 - Vol. 291, No. 1 pp. 94-98

    • Provide quality care to individual patients in regular practice.

    • Improve the system of care delivered by group/organization.

    • Provide quality care to uninsured patients.

    • Improve insurance coverage, after-hours care and geographic distribution of services.

    • Environmental change in local schools and communities to address tobacco, injury prevention, and obesity.

    • Public policy to address same issues.

    The Role of Health Care in Community Interventions

    • Leadership and Advocacy

      • Subject matter expertise and credibility

      • Participation in community collaborative activities

      • Consultation on policy recommendations and interventions

    • Education and Social Marketing

      • Presentations to government, school boards, teachers, parents and students

      • Media interventions

    Pediatrics Vol. 112 No. 4 October 2003, pp. e328-346

    Pediatrics Vol. 115 No. 4 April 2005, pp. 1142-1147

    What is the AAP policy on soft drinks in schools?

    • Health Care should work to eliminate sweetened drinks in schools. This entails educating school authorities, patients, and patients’ parents about the health ramifications of soft drink consumption.

    • Health Care should advocate for the creation of a school nutrition advisory council comprising parents, community and school officials, food service representatives, physicians, school nurses, dietitians, dentists, and other health care professionals.

    PEDIATRICS Vol. 113 No. 1 January 2004, pp. 152-154

    What can schools do?

    • Salad bars and other low cost healthy meal options.

    • Bans on soda contracts.

    • More PE (at least 200 minutes every 10 school days).

    • More fun PE, non-competitive activities.

    • Walk to school events (www.cawalktoschool.com).

    • Safe bicycle riding events.

    • Teach children about healthy eating and physical activity in school.

    • Link activities – school, after-school and home.

    What can communities do?

    • Make healthy foods available and affordable (e.g., farmers markets, community gardens).

    • Improve safety of and access to parks and other recreational areas.

    • Promote pedestrian and bicycle friendly zoning.

    • Design new communities to be more walkable.

    • Healthy messages on TV, radio and posters.

    What resources are available for schools and communities?

    • The Children and Weight: What Schools and Communities Can Do About It Resource Kit http://www.cnr.berkeley.edu/cwh

    • CDC School Health Index http://www.cdc.gov/

    • California Project LEAN http://www.californiaprojectlean.org/

    • Guide to Community Preventive Services http://www.thecommunityguide.org

    • E. N. A. C. T. http://www.preventioninstitute.org/

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