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1. Children’s Food Environment State Indicator Report [NAME] [ORGANIZATION] Using the Children’s Food Environment State Indicator Report, 2011 [Date] Information provided by: Division of Nutrition, Physical Activity & Obesity (DNPAO) National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention (CDC)

2. Presentation Outline • Background • Why we should worry about the obesity epidemic • How environment is connected to obesity • Development of report • Describe purpose of Children’s Food Environment State Indicator Report, 2011 • Present key components and data • Behavioral indicators • Policy and environmental indicators • Describe application of the [STATE] Action Guide

3. The Childhood Obesity Epidemic:Why We Should Worry • The proportion of American children who are obese has increased threefold since the early 1970’s • Obese children are more likely to become obese adults1,2 • The medical care costs of obesity among adults in the United States are staggering. In 2008 dollars, these costs totaled about $147 billion.3 1 The NS, Suchindran C, North KE, Popkin BM, Gordon-Larsen P. Association of adolescent obesity with risk of severe obesity in adulthood. JAMA. 2010 Nov 10;304(18):2042-7. 2 Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997 Sep 25;337(13):869-73. 3 Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood). 2009 Sep-Oct;28(5):w822-31.

4. How is Childhood Obesity Connected to the Environment? • Children are exposed to different environments in their daily lives that can influence the healthfulness of their food choices1. • Some Americans have less access to stores and markets that provide healthy, affordable foods especially in rural, minority and lower-income neighborhoods2. • Availability of sugar drinks and less healthy foods in middle and high schools varies widely across states3. • Children can be exposed to advertising for less healthy foods while watching television and even at school. These advertisements influence the food choices children make4. 1 Larson N, Story M. A review of environmental influences on food choices. Ann Behav Med. 2009 Dec;38 Suppl 1:S56-73. 2 Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009 Jan;36(1):74-81. 3. Brener ND, McManus T, Foti K, Shanklin SL, Hawkins J, Kann L, Speicher N. School Health Profiles 2008: Characteristics of Health Programs Among Secondary Schools. Atlanta: Centers for Disease Control and Prevention; 2009. 4. Harris JL, Pomeranz JL, Lobstein T, et al. A crisis in the marketplace: how food marketing contributes to childhood obesity and what can be done. Annu Rev Public Health 2009;30:211-25.

5. Why Focus on Food Environments? • We can support healthy food environments where children live, learn, and play by: • Reducing children’s access to less healthful food and beverage choices • Increasing access to more healthful food and beverage choices • Decreasing exposure to advertising of less healthy foods and beverages

6. Children’s Food Environment State Indicator Report Children’s Food Environment State Indicator Report, 2011 can be used: • As part of a state’s surveillance plan • To identify current successes and opportunities for growth in environmental and policy supports for making the food environment more healthful for children and adults • To provide data to inform change

7. Approaches for Improving the Food Environment • Socioecological (SE) Model • Physical environment • Home • Child care facilities • Schools • Communities • Macro-level environments • Policy actions • Food marketing/media Story, M., K. M. Kaphingst, et al. (2008). "Creating healthy food and eating environments: policy and environmental approaches." Annual Rev Public Health29: 253-72, Figure 1.

8. Children’s Food Environment State Indicator Report • Two categories of indicators • Behavioral indicators monitor status of sugar drinks, television viewing, television in the bedroom, and family meals • Policy and environmental indicators measure healthfulness of food environments across three settings: child care facilities, schools, and community • Indicators show where a state has been successful in improving the food environment and where more work may be needed

9. Children’s Food Environment State Indicator Report • [Insert state indicators, or data to augment Indicator Report information]

10. Development of Children’s Food Environment State Indicator Report Criteria for inclusion of an indicator included: • Promising area within the physical or macro-level environments of socioecological model for addressing child obesity • Data measurable and available for most states • Data from reputable source • Transparent methodology in obtaining information

11. Summary of Behavioral Indicators • Note: Change your state percentage! • Double-click on [STATE] and type your state name. • Right click on the plot area (white background), and select “edit data”. • Type your state name in the cell that says “State”. • Replace the "100"s in the state data with your actual state data. • Close out of the datasheet. The bar chart should now reflect your state data. • Delete this text box (but not the slide number box)!

12. Behavioral Indicators High School Student Soda Consumption and TV Viewing • Percentage of high school students who drank ≥1 sugar-sweetened soda per day • Percentage of high school students who watched television ≥3 hours per day • Source: 2009 Youth Risk Behavior Surveillance System (adolescents, grades 9–12)

13. Behavioral Indicators TV in the bedroom and Family Meals • Percentage of children ages 6-17 with television in their bedroom • Percentage of children ages 12-17 who do not eat meals with their families most days of the week • Source: 2009 Youth Risk Behavior Surveillance System (adolescents, grades 9–12)

14. Policy and Environmental Indicators Indicators across three different settings for improving the food environment: • The child care facility food environment • The school food environment • The community food environment

15. Child Care Food Environment • State Regulations Restrict Sugar Drinks in Child Care Centers and Family Child Care Homes • State Regulations Require Access to Drinking Water Throughout the Day in Child Care Centers and Family Child Care Homes • Reduce excess energy intake • Promote healthy choices such as water • State Regulations Limit Television and Video Time in Child Care Centers and Family Child Care Homes • Reduce influence of advertising of less healthy foods • Engage in active play and physical activity • Source: S. Benjamin, 2010. “Preventing Obesity In The Child Care Setting: Evaluating State Regulations.” http://cfm.mc.duke.edu/childcare

16. Child Care Food EnvironmentSugar Drinks and Water Access • State Regulations Restrict Sugar Drinks in Child Care Centers and Family Child Care Homes • Nationally: 2states have a state regulation restricting sugar drinks in child care centers and family child care homes • [STATE]: [Yes/No] • State Regulations Require Access to Drinking Water Throughout the Day in Child Care Centers and Family Child Care Homes • Nationally: 27states have regulations mandating access to drinking water in child care centers and family child care homes • [STATE]: [Yes/No] Source: S. Benjamin, 2010. “Preventing Obesity In The Child Care Setting: Evaluating State Regulations.” http://cfm.mc.duke.edu/childcare

17. Child Care Food EnvironmentTelevision • State Regulations Limit Television and Video Time in Child Care Centers and Family Child Care Homes • Nationally: 18 states have regulations limiting TV and video time in child care centers and family child care homes • [STATE]: [Yes/No] Source: S. Benjamin, 2010. “Preventing Obesity In The Child Care Setting: Evaluating State Regulations.” http://cfm.mc.duke.edu/childcare

18. School Food Environment • % Middle and High Schools that Offer Sugar Drinks as Competitive Foods • Includes sugar-sweetened sodas, fruit-flavored drinks, and sports drinks • % Middle and High Schools that Offer Less Healthy Foods as Competitive Foods • Includes candy, salty snacks, cookies, crackers, cakes, pastries, ice cream or frozen yogurt that is not low in fat, or water ices or frozen slushes that do not contain juice • % Middle and High Schools that Allow Advertising of Less Healthy Foods • Advertising in schools may impact children’s ability to make healthy food choices1 • Source: 2008 School Health Profiles survey of middle and high schools (Principal questionnaire). • 1 IOM (Institute of Medicine). 2005. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: The National Academies Press

19. School Food EnvironmentSugar Drinks • % Middle and High Schools That Offer Sugar Drinks as Competitive Foods • Nationally: 64% • Range across states: 17 – 80% • [STATE]: X% Source: 2008 School Health Profiles survey of middle and high schools

20. School Food EnvironmentLess Healthy Competitive Foods • % Middle and High Schools That Offer Less Healthy Foods as Competitive Foods • Nationally: 51% • Range across states: 22 – 83% • [STATE]: X% Source: 2008 School Health Profiles survey of middle and high schools

21. School Food EnvironmentAdvertising of Less Healthy Foods • % Middle and High Schools That Allow Advertising of Less Healthy Foods • Nationally: 49% • Range across states: 24 - 69% • [STATE]: X% Source: 2008 School Health Profiles survey of middle and high schools

22. Community Food Environment • Modified Retail Food Environment Index (mRFEI) Across Census Tracts within State • Measures the number of healthy and less healthy food retailers across census tracts in a state • Healthy Food Retailers = Supermarkets and Grocery Stores with 10 or more employees; Supercenters; Produce Stores • Less healthy Food Retailers = Convenience Stores; Fast Food Restaurants; Small Grocery Stores with 3 or fewer employees • Sources: Supermarkets, supercenters, and produce store data is derived from InfoUSA business database, 2009. Fast food retail data is from NavTeq database, 2009. Convenience store data is from Homeland Security Information Program database, 2008. • mRFEI is calculated for each census tract. mRFEI score presented for each state is the median score of census tract scores of that state. Grocery stores with 4 to 9 employees are not included in the mRFEI because it is difficult to make assumptions regarding the availability of healthy foods in these types of stores.

23. Community Food EnvironmentModified Retail Food Environment Index • Modified Retail Food Environment Index Across Census Tracts within State • Nationally: 10 • Range: 4 –16 • [STATE]: X Sources: Supermarkets, supercenters, and produce store data is derived from InfoUSA business database, 2009. Fast food retail data is from NavTeq database, 2009. Convenience store data is from Homeland Security Information Program database, 2008.

24. Community Food Environment • Modified Retail Food Environment Index Across Impoverished Census Tracts within State • Measures the number of healthy and less healthy food retailers across impoverished census tracts in a state • Impoverished = 20% or more of the residents below the poverty line • mRFEI calculated only for impoverished tracts • State score is median score of impoverished tracts in state • Sources: Supermarkets, supercenters, and produce store data is derived from InfoUSA business database, 2009. Fast food retail data is from NavTeq database, 2009. Convenience store data is from Homeland Security Information Program database, 2008. Poverty data from 2000 U.S. Census

25. Community Food Environment Modified Retail Food Environment Index - Impoverished • Modified Retail Food Environment Index Across Impoverished Census Tracts within State • Nationally: 7 • Range: 0 –14 • [STATE]: X% Sources: Supermarkets, supercenters, and produce store data is derived from InfoUSA business database, 2009. Fast food retail data is from NavTeq database, 2009. Convenience store data is from Homeland Security Information Program database, 2008.

26. Children’s Food Environment State Indicator Report Call to Action • Incorporate into state plan • Priority strategies • Surveillance • Advocate for improvement • Evaluate progress over time • Identify success stories • Broaden community support for obesity prevention • Strengthen policy action and support

27. Child Care Food Environment Potential Action Steps • Reduce or eliminate the availability of less healthy foods and sugar drinks and restrict screen time in child care settings. • Enact or revise licensing regulations • State standards for the Child and Adult Care Food Program • Quality Rating Improvement Systems • Encourage child care providers to conduct self-assessments of their centers or homes to identify improvements related to healthier foods and beverages. • Integrate nutrition and screen time best practices into provider training, certification and continuing education opportunities.

28. Child Care Food Environment Potential Action Steps • Provide technical assistance and resources to child care providers through a state network that includes: • Child Care Resource and Referral agencies • Cooperative Extension • Early Childhood Advisory Councils • Child Care Health Consultants • AAP State Chapter Child Care contact. • Increase access to healthier foods in child care with: • Farm to Preschool programs • Purchasing cooperatives • Gardening initiatives

29. Child Care Food Environment Resources for Action Preventing Obesity In The Child Care Setting: Evaluating State Regulations: http://cfm.mc.duke.edu/wysiwyg/downloads/State_Reports_Final.pdf Caring for Our Children: Preventing Childhood Obesity in Early Care and Education Programs (child care standards): http://nrckids.org/CFOC3/PDFVersion/preventing_obesity.pdf Food Research and Action Center: Child Care Food Program Wellness Tool Kit: http://frac.org/federal-foodnutrition-programs/child-and-adult-care-program/child-care-wellness-plans-and-policies/ National Child Care Information and Technical Assistance Center: Quality Rating & Improvement System Resource Guide: http://nccic.acf.hhs.gov/qrisresourceguide/ National Association of Child Care Resource & Referral Agencies: http://www.naccrra.org/ AAP Healthy Child Care America. http://healthychildcare.org/cccc.html

30. School Food Environment Potential Action Steps • Enroll elementary, middle, and high schools in USDA’s Team Nutrition program and apply for certification through the HealthierUS School Challenge. • Establish school wellness and nutrition policies to increase free drinking water access and eliminate the sale of sugar drinks on school grounds, including vending machines, concessions, and fundraisers. • Support school districts in implementing strong nutrition standards that restrict the availability of less healthy foods and sugar drinks.

31. School Food Environment Potential Action Steps • Revise food and beverage contracts so that only healthier food options are available to students • Collaborate with state and school district officials to redefine or eliminate beverage “pouring contracts” in schools

32. School Food Environment Resources for Action • USDA Team Nutrition and HealthierUS School Challenge website: http://teamnutrition.usda.gov/healthierUS/index.html • Making It Happen: School Nutrition Success Stories: http://www.cdc.gov/HealthyYouth/nutrition/Making-It-Happen/index.htm • Water in Schools website: http://www.waterinschools.org/ • CDC Fact Sheets about IOM Nutrition Standards for Foods in Schools: http://www.cdc.gov/HealthyYouth/nutrition/standards.htm • NPLAN: Model Healthy Beverage Vending Agreement: http://www.nplanonline.org/nplan/products/model-healthy-beverage-vending-agreement • CDC resource on Local Wellness Policy Tools & Resources for schools: http://www.cdc.gov/HealthyYouth/healthtopics/wellness.htm

33. Community Food Environment Potential Action Steps • Provide incentives for existing small food store owners in underserved areas to carry healthier, affordable food items • Create incentive programs to attract supermarkets and grocery stores to underserved neighborhoods • Target public transportation and public safety efforts to ensure community residents can access healthy food retailers easily and affordably.

34. Community Food Environment Potential Action Steps • Promote farmers’ markets, farm stands, mobile markets, and community gardens as venues for healthy foods. • Support restaurant programs that offer and promote healthier food options.

35. Community Food Environment Resources for Action NPLAN Creating a Healthy Food Zone Around Schools • http://www.nplanonline.org/nplan/products/creating-healthy-food-zone-around-schools PolicyLink Improving Access to Healthy Food: • http://www.policylink.org/site/c.lkIXLbMNJrE/b.5136643/k.1E5B/Improving_Access_to_Healthy_Food.htm The Food Trust: Our Projects: Community-Based Programs • http://www.thefoodtrust.org/index.php

36. Children’s Food Environment State Indicator Report Call to Action • [STATE] Resources • [Add applicable state resources here] • [STATE] Partners • [Add applicable state partners here] • Create awareness among… • [Add applicable groups]

37. Children’s Food Environment State Indicator Report Next Steps • Discussion of next steps • [Fill in points for discussion] 33

38. [STATE] Contact Information [NAME] [e-mail] [phone] • CDC Contact Information • foodenvironmentreport@cdc.gov • Technical assistance • Feedback and general questions Children’s Food Environment State Indicator Report http://www.cdc.gov/obesity Division of Nutrition, Physical Activity, and Obesity http://www.cdc.gov/nccdphp/dnpao/index.html