The State ISSUE REPORT of Obesity: Better Policies for a Healthier America 2016 SEPTEMBER 2016 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and healthcare. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more infor- mation, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook. TFAH would like to thank RWJF for their generous support of this report. TFAH BOARD OF DIRECTORS Gail C. Christopher, DN Arthur Garson, Jr., MD, MPH President of the Board, TFAH Director, Health Policy Institute Vice President for Policy and Texas Medical Center Senior Advisor John Gates, JD WK Kellogg Foundation Founder, Operator and Manager Cynthia M. Harris, PhD, DABT Nashoba Brook Bakery Vice President of the Board, TFAH Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA Director and Professor Executive Director Institute of Public Health, Florida A&M University Hogg Foundation for Mental Health at the Theodore Spencer University of Texas at Austin Secretary of the Board, TFAH Tom Mason Senior Advocate, Climate Center President Natural Resources Defense Council Alliance for a Healthier Minnesota Robert T. Harris, MD C. Kent McGuire, PhD Treasurer of the Board, TFAH President and CEO Medical Director Southern Education Foundation North Carolina Medicaid Support Services CSC, Inc. Eduardo Sanchez, MD, MPH Chief Medical Officer for Prevention David Fleming, MD American Heart Association Vice President PATH REPORT AUTHORS Laura M. Segal, MA Alejandra Martín, MPH Director of Public Affairs Health Policy Research Manager Trust for America’s Health Trust for America’s Health Jack Rayburn, MPH Senior Government Relations Manager Trust for America’s Health 2 TFAH • RWJF • StateofObesity.org The State of TABLE OF CONTENTS Table of Contents What Is The State Of Obesity In America? . . 5 l E xample Initiative: Texas Ten Step Star Achiever Breastfeeding Learning Obesity: Introduction . . . . . . . . . . . . . . . . . . . . . . . . 7 l S Collaborative . . . . . . . . . . . . . . . . . . . 53 upporting At-Risk Children – Early Identification Obesity Policy and Follow-Up Support Systems . . . . . . . . . 54 SECTION 1: Adult Obesity Trends . . . . . . . 13 2015 Behavioral Risk Factor Survey Adult l E xample Initiative: Nurse-Family series Partnership . . . . . . . . . . . . . . . . . . . . . 55 Obesity Rates . . . . . . . . . . . . . . . . . . . . . . 14 Racial and Ethnic Inequities and Obesity . . 21 B. School-Based Policies and Programs . . . 56 l A merican Indian/Alaska Native State Data . . 23 l O verview: Nutrition and Physical Activity in School-Aged Children and Teens . . . . . . . . 57 l H igh School Students Dietary Behaviors and SECTION 2: Childhood Obesity Trends . . . . 24 Physical Activity (YRBS data) . . . . . . . . . . 59 Overview: Children and the Importance of Maintaining a Healthy Weight . . . . . . . . . . . 25 l C hild Nutrition Reauthorization in 2016 – and School Meal and Snack Programs . . . . . . 66 l O besity and Adverse Childhood Experiences (ACEs) and Toxic Stress . . . . . . . . . . . . . . 26 l I mplementation of the Elementary and Secondary Components of ESSA, 2015 . . 71 WIC Preschoolers (Supplemental Nutrition l L ocal School Wellness Policies . . . . . . . . . 74 Program for Women Infants and Children Participant and Program Characteristics data) .27 l E xamples of School-Based Programs: Children’s Aid Society-Community Schools, Children Ages 10 to 17 (National Survey of HealthMPowers and Healthy Out-of-School Children’s Health data) . . . . . . . . . . . . . . . 29 Time Coalition (HOST) . . . . . . . . . . . . . . . 76 High School Students (Youth Risk Behavior l C DC School Health Cooperative Agreements Surveillance data) . . . . . . . . . . . . . . . . . . . 30 and National Goals and Guidance . . . . . . . 78 l N ew Models for School-Based Health and Food-Insecure Children . . . . . . . . . . . . . . . .32 Social Services . . . . . . . . . . . . . . . . . . . . 78 Prenatal and Maternal Health . . . . . . . . . . 35 l S tate Policy Reviews: . . . . . . . . . . . . . . . . 79 l W omen Enrolled in WIC and were Obese l W ater Availability . . . . . . . . . . . . . . . . . 79 Prepregnancy–1994, 2004 and 2014 . . . . 36 l reakfast Policies . . . . . . . . . . . . . . . . 80 B l Breastfeeding . . . . . . . . . . . . . . . . . . . . . 37 l Farm-to-School . . . . . . . . . . . . . . . . . . . 81 l ero-Exemption School Nutrition Policies 82 Z SECTION 3: High-Impact Policy Opportunities 38 l ut-of-School and School Celebration O A. Early Childhood Policies and Programs . . 38 Nutrition Policies . . . . . . . . . . . . . . . . . 82 l O verview: Nutrition and Physical Activity in l P hysical Education Requirements . . . . . 83 Infants, Toddlers and Young Children . . . . . 40 l P hysical Activity Requirements . . . . . . . . 84 l C hild and Adult Care Food Programs (CACFP) l S afe Routes to School Programs . . . . . . 84 – 2016 Standards . . . . . . . . . . . . . . . . . . 41 l S hared-Use Policies . . . . . . . . . . . . . . . 86 l I mplementation of the 2014 Reauthorization of the Child Care and Development Block l H ealth Assessments . . . . . . . . . . . . . . 87 Grant (CCDBG) . . . . . . . . . . . . . . . . . . . . 42 C. Community-Based Policies and l S tate Requirements for Child Care Programs . . . . . . . . . . . . . . . . . . . . . 88 Settings . . . . . . . . . . . . . . . . . . . . . . 43 l O verview: U.S. Eating Habits, Physical l E xamples of Early Child Care Initiatives: Let’s Activity, Built Environment, Health, Food Move, Young Star . . . . . . . . . . . . . . . . . . 46 Deserts and Food Marketing . . . . . . . . . . 89 l H ead Start – Performance Standards . . . . 47 l C DC Support for Obesity, Nutrition and l I mplementation of the Early Education Physical Activity Programs . . . . . . . . . . . . 92 Components of Every Student Succeeds Act l M arketplace Incentives to Improve Healthy (ESSA) of 2015 . . . . . . . . . . . . . . . . . . . 48 Food Availability in More Communities: l C DC’s Early Childhood Initiatives – Technical Healthy Food Financing Initiatives (HFFI) and Assistance, School Health Grants, National Early New Market Tax Credits (NMTC) . . . . . . . . 94 SEPTEMBER 2016 Care and Education Learning Collaborative . . 49 l I mplementation of Restaurant Menu Labeling l W IC – Continued Emphasis on Nutrition and Requirements . . . . . . . . . . . . . . . . . . . . . 97 Breastfeeding Support . . . . . . . . . . . . . . . 50 l R evised Nutrition Facts Label Information . . 97 l A dditional Measures to Increase l R evised Dietary Guidelines for Americans . . 98 Breastfeeding Support –Insurance, Medical l oD’s Operation Live Well (OLW) and Healthy D Practices and Workplace Policies . . . . . . . 51 Base Initiative (HBI) . . . . . . . . . . . . . . . . 99 l S ome Key Breastfeeding Laws in States: Birth l S tate Policy Reviews: . . . . . . . . . . . . . . . 100 Facilities Support, Workplace and Jury Duty, Public Indecency Exemption and Support in l C omplete Streets and Transportation Child Care Facilities . . . . . . . . . . . . . . . . . 51 Alternative Programs . . . . . . . . . . . . . 100 Table of Contents (continued) l N utrition Assistance and Education Programs . . . . . . . . . . . . . . . . . . . . . 102 l H ospitals Supporting Local Health Improvement Efforts: Including through l S tate Government Workplace and Facilities Nonprofit Community Benefit Programs . . 117 Nutrition Standards . . . . . . . . . . . . . . 105 l R eview of Community Benefit and Childhood l O verview: Sugar-Sweetened Beverages – Obesity Efforts by the Catholic Health Consumption and Impact . . . . . . . . . . 106 Association of the United States . . . . . 118 l L ocal and State Taxing Policies . . . . . . 107 SECTION 4: State Of Obesity Policy D. Health, Healthcare and Obesity . . . . . . 108 Recommmendations . . . . . . . . . . . . . . . . 120 l verview: Major Obesity-Related Health O A. Invest in Obesity Prevention . . . . . . . . . 120 Concerns . . . . . . . . . . . . . . . . . . . . . . . 109 B. Early Childhood Policies and Programs . . 120 l O verview: Obesity and Healthcare Costs . 111 C. School-Based Policies and Programs . . . 120 l H ealthcare Coverage . . . . . . . . . . . . . . . 112 D. Community-Based Policies and Programs 121 l tatus of Medicaid Fee-for-Service S E. Health, Healthcare and Obesity . . . . . . . 121 Treatment and Obesity Interventions . . 113 l H ealthcare – Screening and Encouraging APPENDIX: Methodology For Behavioral Healthy Practices and Connecting to Risk Factor Surveillance System For Obesity, Supportive Services . . . . . . . . . . . . . . . 114 Physical Activity And Fruit And Vegetable Consumption Rates . . . . . . . . . . . . . . . . . 122 l E xamples of Centers for Medicare and Medicaid (CMS) Obesity Prevention Pilots and Programs . . . . . . . . . . . . . . . . . . . . 115 MAPS AND TABLES State Maps: Adult Rates, 2015 . . . . . . . . 13 State Table: Voices for Healthy Kids and Nemours State Map: State Requires Physical Education Policy Scan on ECE Obesity Prevention . . . . . . 44 for Elementary, Middle and High Schools . . 83 State Table: Obesity and Overweight Rates and Related Health Indicators in the States . . . 14 State Map: Breastfeeding Support in Birth State Map: State Requires a Minimum Time to Facilities . . . . . . . . . . . . . . . . . . . . . . . . 51 Participate in Physical Education . . . . . . . . 83 State Maps: Past Obesity Trends among U.S. Adults . . . . . . . . . . . . . . . . . . . . . . . . . 17 State Maps: State Breastfeeding Laws . . 52 State Map: State Requires Minimum Amount of Time for Physical Activity per Day/Week . . 84 State Maps: Obesity Rates for Baby Boomers, State Map and Table: Percent of High School Seniors and Young Adults, 2015 . . . . . . . 18 Students who did not Eat Fruit or Drink 100 State Map: State had Statutes or Regulations Percent Fruit Juices . . . . . . . . . . . . . . . . 59 on Safe Routes to School . . . . . . . . . . . . . . 84 State Table: Obesity Rates by Age and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . 21 State Map and Table: Percent of High School State Map: Percent Obligated State-Controlled Students Who Did Not Eat Vegetables . . . 60 TAP Funds for SRTS Projects . . . . . . . . . . . 85 State Map: Percent of Children Ages 2 to 4 Enrolled in WIC Classified as Obese . . . . 27 State Map and Table: Percent of High School State Map: State has Shared-Use Students Who Drank a Can of Soda . . . . . 61 Agreements . . . . . . . . . . . . . . . . . . . . . . 86 State Map: Children Enrolled in WIC, Differences in Obesity Rates between 2008 and 2012 . 28 State Map and Table: Percent of High School State Map: State Requires BMI Screening or Students Who Did Not Eat Breakfast . . . . 62 Weight-Related Assessments . . . . . . . . . . 87 State Map: Percent of Children Classified as Obese PedNSS 2011 . . . . . . . . . . . . . . 28 State Map and Table: Percent of High School State Map: Percent of Adults Who are Students Who Were Not Active all Week . . 63 Inactive . . . . . . . . . . . . . . . . . . . . . . . . . . 90 State Map: Percent of Children Ages 10 to 17 Classified as Obese, 2011 NSCH . . . . . . . . 29 State Map and Table: Percent of High School State Map: Healthy Food Financing Initiative: Students Who Played Games or Used a Grants Distributed from 2011 to 2015 . . . 95 State Map and Table: Percentage of High Computer Three or More Hours per Day . . 64 School Students Classified as Obese . . . 30 State Map: Complete Street Policies and State Map and Table: Percent of School Intent for Action by State . . . . . . . . . . . . 101 State Map: Percent of Women Classified as Districts Participating in Farm-to-School . . 81 Obese Prepregnancy, 2011 . . . . . . . . . . . . 35 State Map: Percent Sales Tax on Regular State Map and Table: Percent of Total Budget Soda in Food Stores by State . . . . . . . . 107 State Maps: Percent of Women Enrolled in WIC School District Spent on Local Food . . . . . 81 and Classified as Obese Prepregnancy–1994, State Map: Percent of Adults with 2004 and 2014 . . . . . . . . . . . . . . . . . . . . 36 State Map: State Fundraising Exemption Diabetes . . . . . . . . . . . . . . . . . . . . . . . . 109 Policies . . . . . . . . . . . . . . . . . . . . . . . . . 82 State Map: Percent of Infants Exclusively State Map: Percent of Adults with Breastfeeding at 6 Months, 2012 Births . 37 Hypertension . . . . . . . . . . . . . . . . . . . . 110 4 TFAH • RWJF • StateofObesity.org FO REWO R D The State of OPENING LETTER State of Obesity: BETTER POLICIES FOR A HEALTHIER AMERICA Obesity: WHAT IS THE STATE OF OBESITY IN AMERICA? Obesity Policy The following is a letter from Risa series Lavizzo-Mourey, MD, MBA, president and CEO of the Robert Wood Johnson Foundation (RWJF), and Richard Hamburg, Interim President and CEO Trust for America’s Health (TFAH) The Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) believe that all adults should have access to affordable, healthy foods and beverages and the opportunity to live healthy, active lives.. We also believe all children in the United States—no matter who they are or where they live—should have the chance to grow up at a healthy weight. Since this report was first issued more than a decade ago, we’ve seen progress toward achieving this vision. Take, for example, CentraCare Health, l A nd between 2008 and 2015, the obesity a nonprofit healthcare system in central rate among 12-year-olds in St. Cloud Minnesota that, in the early 2000s, set out to dropped from 17 percent to 13 percent, a help children in the region reach a healthy 24 percent relative decline. weight. With support from Stearns County Stories like this illustrate the progress we Public Health and a grant from Minnesota’s have seen in recent years. The obesity rate Statewide Health Improvement Program, is declining among our nation’s youngest CentraCare Health brought together children and has held steady among older a coalition of medical professionals, children and teens for ten years but is still policymakers, educators and other local increasing among younger teens. In addition organizations committed to making healthy to St. Cloud, a number of cities, counties and foods and physical activity a regular part of states, Cherokee County, South Carolina, children’s lives. The result? Seminole County, Florida, Southern California, l N ew, safer routes to school. Philadelphia, Colorado, and New Mexico, have reported declines in their childhood obesity l G rocery stores and local schools SEPTEMBER 2016 rates in the last year alone, joining a list of adopted a nutrition scoring system many others from coast to coast. to make it easier for families to make healthy choices. Growth in adult rates have slowed over time. We used to see dozens of states reporting l S chool districts updated their increases in their adult obesity rates each year. wellness policies This year, just two did. But rates overall are littleny / Shutterstock.com still far too high. Twenty-five states have adult ages and put the finishing touches on new l M ississippi enacted a bill setting snack obesity rates over 30 percent, putting millions menu labeling requirements that cover chain nutrition standards that goes beyond of people at increased risk for heart disease, restaurants and other food retail establish- Smart Snacks requirements; cancer and diabetes. Rates are even higher ments. These changes will provide important l V irginia enacted a bill setting minimum among Black, Latino and Native American nutrition information to consumers when time requirements for physical activity in families, as well as families living in poverty. they shop at the grocery store or go out to elementary schools; and, eat. With more information, families will be Fortunately, we have also seen significant able to make healthier choices. l L os Angeles approved requirements for all progress on the policy front this year farmers’ markets to accept SNAP Electronic that will benefit millions of families and l Th anks to the enactment of the landmark Benefit Transfer (EBT) cards. neighborhoods across America: Every Student Succeeds Act (ESSA), physical education is included for the first This year’s report has a renewed focus on l Th e U.S. Department of Agriculture time among the “well-rounded” subjects what states already are doing to help all (USDA) issued updated nutrition eligible for federal funding for schools children grow up at a healthy weight, and standards for the foods and beverages with a high percentage of students from has implications for leaders across sectors. served in the Child and Adult Care Food lower-income families. Program (CACFP). More than four million This progress makes us hopeful about the young children from low-income families, These changes will take time to be fully future. We need that hope. Because there’s as well as more than 120,000 adults, will implemented, but we are confident that they still no question that obesity is a bigger benefit from the updated standards. will ultimately result in healthier schools and threat to our health and our country now communities for families across the country. than it was when we were children. l Th e U.S. Department of Agriculture also released updated requirements for local States and cities are continuing to show a lot This year’s State of Obesity report is an urgent school wellness policies that will ensure of forward momentum too. Some examples call to action for government, industry, any food or beverage marketed in schools over the past year include: healthcare, foundations, schools, child care and meets Smart Snacks nutrition standards. families around the country to redouble efforts l O hio enacted a budget that includes to provide a brighter, healthier future for our l Th e U.S. Food and Drug Administration $2 million in seed capital to create a children. Together we can build an inclusive issued final updates to the Nutrition Facts Healthy Food Financing Initiative (HFFI), Culture of Health in this country and ensure panel found on packaged foods and bever- which will be a flexible grant and loan fund; that all children and families live healthy lives. 6 TFAH • RWJF • StateofObesity.org I N TRO DUCT IO N The State of INTRODUCTION Introduction Obesity: After decades of increasing, the national childhood obesity rate has leveled off and the rise in obesity among adults is beginning Obesity Policy to slow. This is progress, but rates are alarmingly higher than series they were a generation ago as demonstrated by this report, which looks at data over the past 25 years.  Obesity remains one of the biggest threats rates of obese 6- to 11-year-olds more to the health of our children and our than doubling (from 7 percent to country, putting millions of Americans 17.5 percent) and rates of obese teens at increased risk for a range of chronic (ages 12 to 19) quadrupling from 5 diseases and contributing to more than percent to 20.5 percent.3, 4 [NHANES, $147 billion to $210 billion dollars in 2011-2014 data] preventable healthcare spending.1 l O besity rates have also become much Some of the most concerning trends higher starting in earlier ages — 8.9 include: percent of 2- to 5-year-olds are now obese, and approximately 2 percent For children and youth: are extremely obese.5 [NHANES, 2011- Nationally, childhood obesity rates have 2014 data] remained stable for the past decade — at around 17 percent [ages 2 to 19, National l A mong high school students, out of Health and Nutrition Examination Survey 37 states, obesity rates exceeded 15 (NHANES), 2011-2014 data].2 Rates are percent in 11 states and no state had declining among 2- to 5-year-olds, stable a rate below 10 percent.6 [Youth Risk among 6- to 11-year-olds, and increasing Behavior Survey (YRBS), 2015 data] among 12- to 19-year-olds. l N early 2 percent of young children (ages l S ince 1980, the childhood obesity rates 2 to 5) are extremely obese, 5.6 percent (ages 2 to 19) have tripled — with the of 6- to 11-year olds are extremely obese Trends in obesity prevalence among youth aged 2–19 years: United States, 1999–2000 through 2013–2014 20 Youth1,2 17.1 16.8 16.9 16.9 17.2 15.4 15.4 Percent SEPTEMBER 2016 13.9 10 0 1999–2000 2001–2002 2003–2004 2005–2006 2007–2008 2009–2010 2011–2012 2013–2014 Survey years 1 Significant increasing linear trend from 1999–2000 through 2013–2014. 2 Test for linear trend for 2003–2004 through 2013–2014 not significant (p >0.05). SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey. Prevalence of obesity among youth aged 2–19 years, by sex and race and Hispanic origin: United States, 2011–2014 30 Non-Hispanic White Non-Hispanic Black Non-Hispanic Asian Hispanic 25 21.9 1,2 22.4 1,2,4 21.4 1,2 1 20.7 20 1,2 19.5 18.4 1,2 Percent 1 14.7 1 15.1 15 14.3 3 11.8 10 8.6 5.3 5 0 All Males Females 1 Significantly different from non-Hispanic Asian persons. 2 Significantly different from non-Hispanic White persons. 3 Significantly different from females of the same race and Hispanic origin. 4 Significantly different from non-Hispanic Black persons. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2014. and 7.8 percent of 12- to 19-year-olds l 0.7 percent of Black females and 2 l n addition, there are also significant I are extremely obese (body mass index 18.4 percent of Black males are obese; inequities in rates of extreme obesity (BMI) at or above 120 percent of the l 5.1 percent of White females and 1 (body-mass-index) at or above 120 sex-specific 95th percentile on the CDC 14.3 percent of White males are percent of the sex-specific 95th BMI-for-age growth charts).7 [NHANES, obese; and percentile on the Centers for Disease 2011-2014 data] Control and Prevention (CDC) BMI- l .3 percent of Asian females and 5 for-age growth charts.10 [NHANES, l here are also significant racial and T 11.8 percent of Asian males are obese. 2011-2014 data] ethnic inequities. Rates are higher l mong A preschoolers (ages 2 to 5), among Latino (21.9 percent) and Latinos are three times as likely (15.6 l lmost 9 percent of Black, 7.6 percent A Black (19.5 percent) children than percent) and Blacks are twice as likely of Latino, 4.4 percent of White and among White (14.7 percent) and Asian (10.4 percent) to be obese as Whites 1.3 percent of Asian children are (8.6 percent) children (ages 2 to 19) (5.2 percent) and Asians (5.0 percent). extremely obese (ages 2 to 19). — and the rates are higher starting l mong A American Indian/Alaska Native l mong preschoolers (ages 2 to 5), A at earlier ages and increase faster.8 children, 25 percent of 2- to 5-year-olds, Latinos (7.6 percent) and Blacks [NHANES, 2011-2014 data] 31 percent of 6- to 11-year-olds and 31 (8.6 percent) are almost twice as l 1.4 2 percent of Latina females and 22.4 percent of 12- to 19-year-olds are obese.9 likely to be extremely obese as percent of Latino males are obese; Whites (4.4 percent). [Indian Health Service, 2008 data] 8 TFAH • RWJF • StateofObesity.org Obesity and Overweight Rates for Children Ages 2 to 19, NHANES 40 38.9% 35.2% 35 30 28.5% 25 21.9% 19.5% 19.5% 20 14.7% 15 10 8.6% 8.6% 7.6% 4.4% 5 1.3% 0 Asian Black Latino White ■ Extremely Obese (2011-2014) ■ Obese (2011-2014) ■ Obese and Overweight Combined (2011-2012) Note: The Centers for Disease Control and Prevention uses the term Hispanic in analysis. § = non-Hispanic; Extreme obesity in children = BMI at or above 120% of the 95th percentile on BMI-for-age growth charts. Obesity and Overweight Rates for Cildren Ages 2 to 19, NHANES by Gender and Race11 50 BOYS GIRLS 40.7% 40 37.0% 36.1% 34.4% 31.6% 32.0% 30 29.2% 27.8% 25.1% 22.4% 20.7% 21.4% 20 18.4% 17.1% 16.9% 15.1% 14.3% 13.7% 11.8% 10 8.9% 8.4% 8.0% 7.3% 5.9% 5.3% 5.7% 5.0% 3.9% 2.2% 0.4% 0 All Asian§ Black§ Latino White§ All Asian§ Black§ Latino White§ ■ Extremely Obese (2011-2014) ■ Obese (2011-2014) ■ Obese and Overweight Combined (2011-2012) Note: The Centers for Disease Control and Prevention uses the term Hispanic in analysis. § = non-Hispanic. TFAH • RWJF • StateofObesity.org 9 For adults: l W omen are also almost twice as likely l B lack women (16.8 percent) are l O besity rates exceeded 35 percent (9.9 percent) to be extremely obese twice as likely to be extremely obese in four states, 30 percent in 25 states compared to men (5.5 percent); as White women (9.7 percent).17 and are above 20 percent in all states. l I n addition, rates are the highest l A nd there are income and/or The lowest rate was 20.2 percent in among middle-age adults (41 education inequities: Colorado. [Behavioral Risk Factor percent for 40- to 59-year-olds), l N early 33 percent of adults who Surveillance Survey, 2015] compared to 34.3 percent of 20- to did not graduate high school were 39-year-olds and 38.5 percent of l I n 1985, no state had an adult obese compared with 21.5 percent of adults ages 60 and older. obesity rate higher than 15 percent; those who graduated from college or in 1991, no state was over 20 percent; l T here are significant racial and ethnic technical college. [2008-2010 data] in 2000, no state was over 25 percent; inequities [NHANES, 2013-2014 data]: l M ore than 33 percent of adults who and, in 2006, only Mississippi and l O besity rates are higher among earn less than $15,000 per year are West Virginia were above 31 percent. Blacks (48.4 percent) and Latinos obese compared with 24.6 percent l N ationally, nearly 38 percent of adults (42.6 percent) than among Whites of those who earned at least $50,000 are obese.14 [NHANES, 2013-2014 data] (36.4 percent) and Asian Americans per year.18 [2008-2010 data] (12.6 percent).15 l N early 8 percent of adults are l A pproximately one in four young adults extremely obese (BMI greater than l T he inequities are highest among — ages 17 to 24 — are too overweight or equal to 40.0); women: Blacks have a rate of 57.2 to join the military. Being overweight percent, Latinos of 46.9 percent, or obese is the leading medical reason l O besity rates are higher among women Whites of 38.2 percent and Asians of why young adults cannot enlist.19, 20 (40.4 percent) compared to men (35.0 12.4 percent. For men, Latinos have And, the military spends more than percent). Between 2005 and 2014, the a rate of 37.9 percent, Blacks of 38.0 $1.5 billion on healthcare costs and on difference in obesity among women percent and Whites of 34.7 percent.16 recruiting replacements for those who was 5.1 percent higher among women and 1.7 percent higher among men. are too unfit to serve. 2015 ADULT OBESITY RATES WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO n <25% KS MO WV DE KY VA MD DC n >25% & <30% CA OK TN NC n >30% & <35% NM AR AZ SC n >35% MS AL GA TX LA Territory Obesity Rate Guam 31.6 Puerto Rico 29.5 FL AK (Note: BRFSS methodological changes were HI made in 2011. Estimates should not be com- pared to those prior to 2010)28 10 TFAH • RWJF • StateofObesity.org Obesity and Overweight Rates for Adults, National Health and Nutrition Examination Survey, 2013 to 201421 (with Native American/Alaska Native Rates per 2014 National Health Interview Survey22) 60 57.2% BOTH GENDERS MEN WOMEN 50 48.4% 46.9% 42.6% 42.3% 40 38.0% 37.9% 38.2% 36.4% 34.7% 30 20 16.8% 12.6% 12.4% 12.6% 12.4% 10 9.7% 7.6% 8.7% 7.1% 7.2% 5.6% Unknown 5.4% N/A N/A N/A 0 Asian§ Black§ Latino American White§ Asian§ Black§ Latino White§ Asian§ Black§ Latino White§ Indian/ Alaska Native§ ■ Obese ■ Extremely Obese Note: The Centers for Disease Control and Prevention uses the term Hispanic in analysis. § = non-Hispanic; N/A data only included 2 participants. Reversing the epidemic — and ensuring essential. While personal responsibility that all children have the opportunity is an important consideration in obesity to grow up at a healthy weight — will prevention, the choices families and require intensifying our investments in youth make are impacted by where the most effective programs and policies. they live, learn, work and play. In many neighborhoods, healthy foods are Evidence about what’s working to help scarce and more expensive, while cheap curb the epidemic is growing and some processed foods are widely available key lessons have emerged. and heavily marketed. Finding safe, First, prevention should be a top priority, accessible places to be physically active especially among young children and can be a challenge for many. pregnant women. It is easier and Third, it is essential to target more more effective to prevent unhealthy intense efforts in areas where there are weight gain than it is to reverse it later. the greatest challenges. Obesity rates Strategies that focus on helping every are highest among racial and ethnic child maintain a healthy weight are minorities, people who live in low- critical. By giving children a healthy income communities and those living in start, they will be on a much better the South. These populations are more trajectory for lifelong health as they age. likely to have limited access to healthy Second, making healthy choices an options and progress in addressing the easier part of people’s daily lives is inequities has been limited. TFAH • RWJF • StateofObesity.org 11 Experts have identified a range of policies community health needs assessments and CDC’s overall budget and equals around and programs that can help make healthy are considering providing community 5 percent of the budget for the National eating and physical activity part of the benefit funds aimed at improving Institutes of Health (NIH).27 In addition, daily routine, including improving school residents’ health. New healthcare many federal, state and local prevention nutrition, complete streets initiatives, models, such as Accountable Health initiatives either narrowly address a access to open space, incentives for Organizations (AHOs), Patient-Centered particular concern or shift to a new focus healthy food purchases, food labeling and Medical Homes (PCMH) and prevention or approach after a short time period. limits on advertising to children. initiatives focused on improving the This report is an urgent call to action. health of Medicaid populations are also Many of the most successful approaches engaging communities and investing There are more effective ways to use for preventing obesity focus on resources into obesity and other available federal, state and local public matching the specific needs and prevention programs. health funds to prevent obesity and leveraging the existing resources within improve health. New strategies are a local community. These place-based Research also shows a strong return needed to secure other funding sources approaches ensure that people who on investment for community-based and engage diverse partners in support live in the community are invested prevention programs. CDC, The New of the most promising approaches for in making a difference in their own York Academy of Medicine (NYAM) and helping all Americans eat healthier cities and towns. For example, a other experts have identified a range and be more active. Success will place-based approach may involve of programs that have proved effective require individuals, families, schools, creating local partnership networks that in reducing obesity and obesity-related communities, businesses, government and involve leaders from the public health, disease levels by 5 percent or — in every other sector of American society healthcare, education, philanthropic, some cases — more.23, 24, 25   The analysis to play a role in building an inclusive social service, transportation and showed that investment of $10 per Culture of Health, in which every person housing sectors. Those partners work person per year in proven community- has an equal opportunity to live the together to determine key priorities for based programs to increase physical healthiest life they can. that community; identify local assets, activity, improve nutrition and prevent resources and potential funding sources; smoking and other tobacco use could In this report, TFAH and RWJF examine: and evaluate the most effective strategies save the country more than $16 billion Section 1: Adult Obesity Trends for achieving the shared goal. annually within five years — a return of $5.60 for every $1.26 Section 2: Childhood Obesity Trends A growing number of mechanisms support place-based approaches. This Yet the current investment in prevention Section 3: High-Impact Policy strategy brings together partners from programs represents a small fraction Opportunities healthcare, public health and boards of this level and there is a significant A. Early Childhood Policies and of health, social services, community challenge in bringing these efforts to Programs groups, local governments and private scale across the country. For instance, B. School Aged Children and Teen businesses to focus on shared interests the federal budget only includes $50 Policies and Programs and goals and combine resources to million annually to promote nutrition, achieve a stronger collective impact. physical activity and obesity prevention C. Community Policies and Programs For instance, healthy food financing programs at CDC, which are distributed D. Healthcare and Health Policies initiatives help increase the availability through small targeted grants across the and Programs of accessible, affordable foods in many country. CDC’s total chronic disease Section 4: Recommendations communities. Nonprofit hospitals have prevention funding is only $1.17 billion a new focus on conducting regular a year, which is less than one-quarter of 12 TFAH • RWJF • StateofObesity.org SECTI O N 1: The State of SECTION 1: ADULT OBESITY TRENDS Adult Obesity Trends Obesity: Twenty-five states have adult obesity rates above 30 percent, 43 states have rates above 25 percent, and every state is above 20 percent. Rates & Trends In 1985, no state had an adult obesity (see discussion in rates and rankings rate higher than 15 percent; in 1991, no methodology for more details on the state was over 20 percent; in 2000, no differences). Between 2011 and 2012, state was over 25 percent; and, in 2006, only one state had an increase. Between only Mississippi and West Virginia were 2012 and 2013, six states had increases. above 30 percent. Between 2014 and 2015, two states had increases and four decreases..28 Since 2005, there has been some evidence that the rate of increase has been slowing In 2010, the U.S. Department of Health across the states. In 2005, every state but and Human Services (HHS) set a one experienced an increase in obesity national goal to reduce the adult obesity rates from the previous year; from 2007 rate from 33.9 percent to 30.5 percent to 2008, rates increased in 37 states; from by 2020, which would be a 10 percent 2009 to 2010, rates increased in 28 states; decrease.29 Healthy People 2020 also set and, from 2010 to 2011, rates increased a goal of increasing the percentage of in 16 states (in 2011, CDC changed people at a healthy weight from 30.8 methodologies for the Behavioral percent to 33.9 percent by 2020. As of Risk Factor Surveillance System), 2014, 17 states fell short of that goal.30 2015 ADULT OBESITY RATES WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD CA DC OK TN NC NM AR AZ SC MS AL GA TX LA SEPTEMBER 2016 FL AK n <25% HI n >25% & <30% n >30% & <35% n >35% (Note: BRFSS methodological changes were Territory Obesity Rate made in 2011. Estimates should not be com- Guam 31.6 pared to those prior to 2010)28 Puerto Rico 29.5 CHART ON OBESITY AND OVERWEIGHT RATES ADULTS Obesity Overweight & Obesity Diabetes Physical Inactivity Hypertension (BRFSS 2015 Data) (BRFSS 2015 Data) (BRFSS 2015 Data) (BRFSS 2015 Data) (BRFSS 2015 Data) Percent of Percent of Adults Precent of Percent of Obese Percent of Adults Overweight and Who are Physically Adults Who have States Adults Ranking Ranking with Diabetes Ranking Ranking Ranking Obese Adults Inactive Hyptertension (95% C.I.) (95% C.I.) (95% C.I.) (95% C.I.) (95% C.I.) Alabama 35.6 (+/-1.5) 2 68.7 (+/-1.5) 6 13.5 (+/-0.9) 3 31.9 (+/-1.5)* 5 40.4 (+/-1.5) 3 Alaska 29.8 (+/-2.4) 26 67.2 (+/-2.6) 10 7.6 (+/-1.4) 48 22.0 (+/-2.4) 41 27.5 (+/-2.2) 48 Arizona 28.4 (+/-1.6) 34 65.3 (+/-1.7) 28 10.1 (+/-0.8) 24 24.7 (+/-1.5)* 32 30.8 (+/-1.4) 27 Arkansas 34.5 (+/-2.3) 6 69.5 (+/-2.3) 3 12.6 (+/-1.3) 7 34.2 (+/-2.3)* 2 39.3 (+/-2.2) 4 California 24.2 (+/-1.0) 47 60.3 (+/-1.2) 44 10.0 (+/-0.7) 25 20.0 (+/-1.0)** 47 28.5 (+/-1.0) 46 Colorado 20.2 (+/-1.1) 51 56.6 (+/-1.4) 50 6.8 (+/-0.5) 51 17.9 (+/-1.1)* 51 25.7 (+/-1.1) 50 Connecticut 25.3 (+/-1.2) 42 61.6 (+/-1.3) 42 9.3 (+/-0.7) 31 23.5 (+/-1.2)* 35 30.4 (+/-1.1) 30 Delaware 29.7 (+/-2.1) 28 66.8 (+/-2.2) 14 11.5 (+/-1.2) 10 29.4 (+/-2.1)* 10 34.5 (+/-2.0) 12 D.C. 22.1 (+/-2.5) 50 54.4 (+/-3.4) 51 8.5 (+/-1.3) 39 19.4 (+/-2.5) 48 29.4 (+/-2.5) 41 Florida 26.8 (+/-1.3) 35 64.1 (+/-1.4) 35 11.3 (+/-0.8) 15 26.2 (+/-1.4)* 24 33.5 (+/-1.3) 16 Georgia 30.7 (+/-1.9) 19 65.5 (+/-2.0) 26 11.3 (+/-1.0) 15 27.3 (+/-1.9)* 15 36.2 (+/-1.8) 9 Hawaii 22.7 (+/-1.4) 49 57.0 (+/-1.7) 49 8.5 (+/-0.8) 39 22.5 (+/-1.4)* 38 32.0 (+/-1.5) 23 Idaho 28.6 (+/-1.8) 33 65.2 (+/-2.0) 29 8.1 (+/-0.8) 45 21.2 (+/-1.6)* 45 31.2 (+/-1.7) 25 Illinois 30.8 (+/-1.6) 18 66.2 (+/-1.7) 20 9.9 (+/-0.9) 26 24.8 (+/-1.5) 30 30.8 (+/-1.5) 27 Indiana 31.3 (+/-1.8) 15 66.5 (+/-1.9) 16 11.4 (+/-1.1) 13 29.4 (+/-1.8)* 10 32.4 (+/-1.6) 21 Iowa 32.1 (+/-1.6) 12 66.7 (+/-1.7) 15 8.8 (+/-0.8) 36 26.3 (+/-1.5)* 23 30.6 (+/-1.4) 29 Kansas 34.2 (+/-0.8)* 7 68.0 (+/-0.8)* 9 9.7 (+/-0.4) 29 26.5 (+/-0.7)* 21 31.6 (+/-0.7) 24 Kentucky 34.6 (+/-1.7)* 5 67.2 (+/-1.8) 10 13.4 (+/-1.1) 4 32.5 (+/-1.7) 4 39.0 (+/-1.6) 6 Louisiana 36.2 (+/-1.9) 1 69.2 (+/-1.9) 4 12.7 (+/-1.1)* 5 31.9 (+/-1.8)* 5 39.3 (+/-1.8) 4 Maine 30.0 (+/-1.4) 24 66.5 (+/-1.5)* 16 9.9 (+/-0.8) 26 24.8 (+/-1.3)* 30 34.1 (+/-1.3) 14 Maryland 28.9 (+/-1.7) 31 65.0 (+/-1.9) 30 10.3 (+/-0.9) 22 24.1 (+/-1.6)* 34 32.5 (+/-1.6) 19 Massachusetts 24.3 (+/-1.3) 46 59.7 (+/-1.5) 46 8.9 (+/-0.8) 35 26.5 (+/-1.4)* 21 29.6 (+/-1.2) 38 Michigan 31.2 (+/-1.3) 16 66.2 (+/-1.3) 20 10.7 (+/-0.8) 18 25.5 (+/-1.2) 27 33.1 (+/-1.2) 18 Minnesota 26.1 (+/-0.9)** 39 62.8 (+/-1.0) 39 7.6 (+/-0.4) 48 21.8 (+/-0.8)* 42 26.3 (+/-0.8) 49 Mississippi 35.6 (+/-1.9) 2 70.1 (+/-1.8) 2 14.7 (+/-1.2)* 1 36.8 (+/-1.8)* 1 42.4 (+/-1.8) 2 Missouri 32.4 (+/-1.6) 10 66.3 (+/-1.7) 19 11.5 (+/-0.9) 10 27.0 (+/-1.5) 17 34.1 (+/-1.5) 14 Montana 23.6 (+/-1.6)** 48 61.0 (+/-1.9) 43 7.9 (+/-0.9) 47 22.5 (+/-1.5)* 38 29.1 (+/-1.5) 45 Nebraska 31.4 (+/-1.1) 14 67.0 (+/-1.2) 12 8.8 (+/-0.6) 36 25.3 (+/-1.0)* 28 29.9 (+/-1.0) 34 Nevada 26.7 (+/-2.7) 36 64.7 (+/-2.9) 31 9.7 (+/-1.5) 29 24.7 (+/-2.6) 32 28.3 (+/-2.4) 47 New Hampshire 26.3 (+/-1.5) 38 63.6 (+/-1.8) 37 8.1 (+/-0.7) 45 22.6 (+/-1.5)* 36 29.2 (+/-1.4) 44 New Jersey 25.6 (+/-1.3) 41 63.4 (+/-1.5) 38 9.0 (+/-0.7) 33 27.2 (+/-1.4)* 16 30.9 (+/-1.3) 26 New Mexico 28.8 (+/-1.8) 32 64.5 (+/-1.9) 32 11.5 (+/-1.1) 10 22.6 (+/-1.6) 36 30.0 (+/-1.5) 33 New York 25.0 (+/-1.1)** 44 59.5 (+/-1.3) 48 9.8 (+/-0.7) 28 29.3 (+/-1.2)* 12 29.3 (+/-1.0) 43 North Carolina 30.1 (+/-1.4) 22 65.8 (+/-1.5) 25 10.7 (+/-0.8) 18 26.2 (+/-1.3)* 24 35.2 (+/-1.4) 11 North Dakota 31.0 (+/-1.8) 17 67.0 (+/-1.9) 12 8.7 (+/-0.9) 38 26.8 (+/-1.7)* 19 30.4 (+/-1.6) 30 Ohio 29.8 (+/-1.4)** 26 66.5 (+/-1.5) 16 11.0 (+/-0.8) 17 27.0 (+/-1.4)* 17 34.3 (+/-1.4) 13 Oklahoma 33.9 (+/-1.7) 8 68.9 (+/-1.7) 5 11.7 (+/-0.9) 9 33.2 (+/-1.7)* 3 36.2 (+/-1.6) 9 Oregon 30.1 (+/-1.7) 22 64.5 (+/-1.7)* 32 10.7 (+/-1.0)* 18 18.8 (+/-1.5)* 50 30.1 (+/-1.5) 32 Pennsylvania 30.0 (+/-1.6) 24 66.2 (+/-1.7) 20 10.4 (+/-1.0) 21 27.8 (+/-1.6)* 14 32.5 (+/-1.6) 19 Rhode Island 26.0 (+/-1.7) 40 62.6 (+/-1.9) 40 9.0 (+/-0.9) 33 28.1 (+/-1.8)* 13 32.4 (+/-1.6) 21 South Carolina 31.7 (+/-1.2) 13 66.2 (+/-1.3) 20 11.8 (+/-0.7) 8 26.7 (+/-1.2) 20 37.8 (+/-1.2) 8 South Dakota 30.4 (+/-1.9) 21 64.5 (+/-2.1) 32 9.3 (+/-1.0) 31 21.5 (+/-1.7) 44 29.9 (+/-1.7) 34 Tennessee 33.8 (+/-1.9) 9 68.7 (+/-2.0) 6 12.7 (+/-1.1) 5 30.4 (+/-1.9)* 8 38.5 (+/-1.8) 7 Texas 32.4 (+/-1.5) 10 68.7 (+/-1.5) 6 11.4 (+/-0.9) 13 29.5 (+/-1.5) 9 29.5 (+/-1.3) 40 Utah 24.5 (+/-1.0) 45 59.6 (+/-1.2) 47 7.0 (+/-0.5) 50 20.3 (+/-1.0)* 46 23.6 (+/-0.9) 51 Vermont 25.1 (+/-1.4) 43 59.9 (+/-1.7) 45 8.2 (+/-0.8) 44 22.2 (+/-1.4)* 40 29.4 (+/-1.4) 41 Virginia 29.2 (+/-1.4) 29 64.1 (+/-1.5) 35 10.3 (+/-0.8) 22 25.1 (+/-1.3) 29 33.2 (+/-1.3) 17 Washington 26.4 (+/-1.0) 37 62.5 (+/-1.1) 41 8.4 (+/-0.5) 41 19.0 (+/-0.9) 49 29.7 (+/-0.9) 37 West Virginia 35.6 (+/-1.5) 2 71.1 (+/-1.4) 1 14.5 (+/-1.0) 2 30.8 (+/-1.4)* 7 42.7 (+/-1.5) 1 Wisconsin 30.7 (+/-1.7) 19 66.0 (+/-1.8) 24 8.4 (+/-0.9) 41 21.6 (+/-1.5) 43 29.6 (+/-1.5) 38 Wyoming 29.0 (+/-2.0) 30 65.4 (+/-2.2) 27 8.4 (+/-0.9) 41 26.2 (+/-1.9)* 24 29.9 (+/-1.8) 34 Note: For ranking, 1 = Highest rate and 51=Lowest rate; Red and * indicates a statistically significant increase and green and ** indicates a statistically significant decrease; CI = Confidence Intervals. Source: Behavior Risk Factor Surveillance System (BRFSS), CDC. 14 TFAH • RWJF • StateofObesity.org AND RELATED HEALTH INDICATORS IN THE STATES CHILDREN AND ADOLESCENTS Young Children Food Insecurity Ages 2 to 4: Children and Teenagers Ages 6 to 17: Obesity and Children and Teenagers Ages 6 to 17: Obesity and Physical (USDA 2013- Obesity (WIC PC Physical Activity (NSCH 2011 Data) Activity (NSCH 2011 Data) 2015 Data) 2012 Data) Percent of Obese Percent of Obese Percent of Children Percentage of Percentage of Percentage of High School Percent of Low-Income Ranking Participating in Vigorous Obese High(95% School Overweight High Students Who Were Households with States Children Ages Children Ages 2-4 10-17 (95% C.I.) Physical Activity per Day Students School Students Physically Active At Least Food Insecurity, (95% C.I.) (Ages 6-17) Conf Interval) (95% Conf Interval) 60 Minutes on All 7 Days Average Alabama 15.6 (+/- 0.4) 18.6 (+/- 3.9) 11 32.7 17.1 (+/- 2.7) 15.8 (+/- 2.7) 24.8 (+/- 2.4) 17.6* Alaska 20.6 (+/- 0.9) 14.0 (+/- 3.3) 32 32.9 12.4 (+/- 2.1) 13.7 (+/- 2.6) 20.9 (+/- 2.8) 13.3 Arizona 14.9 (+/- 0.3) 19.8 (+/- 4.6) 7 26.4 10.7 (+/- 2.7) 12.7 (+/- 1.9) 21.7 (+/- 2.5) 14.9 Arkansas 14.6 (+/- 0.4) 20.0 (+/- 4.2) 6 31.6 17.8 (+/- 2.2) 15.9 (+/- 2.5) 27.5 (+/- 3.0) 19.2* California 17.6 (+/- 0.1) 15.1 (+/- 4.1) 21 25.2 N/A N/A N/A 12.6** Colorado 8.9 (+/- 0.3) 10.9 (+/- 3.6) 47 28.3 N/A N/A N/A 12.1** Connecticut 16.6 (+/- 0.5) 15.0 (+/- 3.2) 23 25.8 12.3 (+/- 2.3) 13.9 (+/- 1.6) 26.0 (+/- 3.2) 13.1 Delaware 16.9 (+/- 0.8) 16.9 (+/- 4.1) 16 26.5 14.2 (+/- 1.4) 16.3 (+/- 1.7) 23.7 (+/- 2.0) 11.9** D.C. 14.4 (+/- 1.0) 21.4 (+/- 5.5) 3 26.8 N/A N/A N/A 13.2 Florida 13.7 (+/- 0.2) 13.4 (+/- 3.3) 38 31.5 11.6 (+/- 1.2) 14.7 (+/- 1.2) 25.3 (+/- 1.4) 12.7** Georgia 13.4 (+/- 0.3) 16.5 (+/- 3.8) 17 30.6 12.7 (+/- 1.7) 17.1 (+/- 2.1) 24.7 (+/- 2.2) 14.9 Hawaii 10.2 (+/- 0.5) 11.5 (+/- 2.6) 44 28.7 13.4 (+/- 1.9) 14.9 (+/- 2.0) 22.0 (+/- 1.5) 9.7** Idaho 11.8 (+/- 0.5) 10.6 (+/- 3.4) 49 25.5 9.6 (+/- 1.5) 15.7 (+/- 1.3) 27.9 (+/- 2.7) 13.8 Illinois 15.9 (+/- 0.2) 19.3 (+/- 3.9) 9 23.5 11.5 (+/- 1.8) 14.4 (+/- 1.7) 25.4 (+/- 2.3) 11.1** Indiana 14.7 (+/- 0.3) 14.3 (+/- 3.7) 28 28.6 N/A N/A N/A 14.8 Iowa 15.1 (+/- 0.4) 13.6 (+/- 3.2) 35 31.2 N/A N/A N/A 10.6** Kansas 13.1 (+/- 0.4) 14.2 (+/- 3.6) 31 28.2 12.6 (+/- 2.1) 16.3 (+/- 1.8) 38.3 (+/- 2.3) 14.6 Kentucky 13.5 (+/- 0.4) 19.7 (+/- 3.9) 8 32.3 18.0 (+/- 2.5) 15.4 (+/- 2.1) 22.5 (+/- 2.6) 17.6* Louisiana 13.8 (+/- 0.4) 21.1 (+/- 4.0) 4 31.1 13.5 (+/- 2.7) 16.4 (+/- 1.9) N/A 18.4* Maine 14.9 (+/- 0.7) 12.5 (+/- 3.0) 42 32.0 11.6 (+/- 1.6) 14.2 (+/- 0.9) 22.3 (+/- 1.6) 15.8* Maryland 16.2 (+/- 0.4) 15.1 (+/- 3.7) 21 24.4 11.0 (+/- 0.4) 14.8 (+/- 0.4) 21.6 (+/- 0.6) 10.7** Massachusetts 16.9 (+/- 0.4) 14.5 (+/- 3.5) 25 25.5 10.2 (+/- 1.8) 12.9 (+/- 1.7) 23.0 (+/- 2.3) 9.7** Michigan 13.9 (+/- 0.2) 14.8 (+/- 3.6) 24 27.7 13.0 (+/- 1.8) 15.5 (+/- 1.3) 26.7 (+/- 2.8) 14.9 Minnesota 12.2 (+/- 0.3) 14.0 (+/- 3.7) 32 28.7 N/A N/A N/A 9.9** Mississippi 14.8 (+/- 0.4) 21.7 (+/- 4.4) 1 27.7 15.4 (+/- 2.4) 13.2 (+/- 2.6) 25.9 (+/- 3.5) 20.8* Missouri 13.5 (+/- 0.3) 13.5 (+/- 3.0) 36 33.7 14.9 (+/- 2.8) 15.5 (+/- 2.3) 27.2 (+/- 2.6) 15.2 Montana 11.3 (+/- 0.7) 14.3 (+/- 3.4) 28 32.4 9.4 (+/- 1.1) 12.9 (+/- 1.2) 27.7 (+/- 1.7) 12.2 Nebraska 17.2 (+/- 0.6) 13.8 (+/- 3.1) 34 31.3 12.7 (+/- 2.0) 13.8 (+/- 1.6) 32.3 (+/- 2.6) 14.8 Nevada 12.9 (+/- 0.4) 18.6 (+/- 4.2) 11 22.4 11.4 (+/- 2.0) 14.6 (+/- 2.5) 24.0 (+/- 2.6) 14.2 New Hampshire 14.8 (+/- 0.9) 15.5 (+/- 3.6) 19 28.1 11.2 (+/- 1.7) 13.8 (+/- 1.6) 22.9 (+/- 2.3) 10.1** New Jersey 16.8 (+/- 0.3) 10.0 (+/- 2.9) 50 25.3 8.7 (+/- 2.2) 14.0 (+/- 2.2) 27.6 (+/- 3.7) 11.1** New Mexico 13.5 (+/- 0.5) 14.4 (+/- 3.7) 27 29.6 12.6 (+/- 2.4) 15.0 (+/- 1.8) 31.1 (+/- 2.4) 14.4 New York 15.1 (+/- 0.2 14.5 (+/- 3.2) 25 24.6 10.6 (+/- 1.1) 13.8 (+/- 1.1) 25.7 (+/- 3.3) 14.1 North Carolina 13.5 (+/- 0.3) 16.1 (+/- 4.0) 18 31.6 12.5 (+/- 1.9) 15.2 (+/- 2.2) 25.9 (+/- 2.6) 15.9* North Dakota 14.0 (+/- 1.) 15.4 (+/- 3.8) 20 30.4 13.5 (+/- 1.8) 15.1 (+/- 1.8) 24.7 (+/- 2.5) 8.5** Ohio 13.0 (+/- 0.2) 17.4 (+/- 3.7) 14 28.5 13.0 (+/- 2.4) 15.9 (+/- 2.0) 25.9 (+/- 3.7) 16.1* Oklahoma 15.0 (+/- 0.4) 17.4 (+/- 3.6) 14 34.9 11.8 (+/- 2.0) 15.3 (+/- 2.4) 38.5 (+/- 3.4) 15.5* Oregon 15.9 (+/- 0.4) 9.9 (+/- 2.8) 51 28.5 N/A N/A N/A 16.1* Pennsylvania 13.1 (+/- 0.3) 13.5 (+/- 3.5) 36 27.0 N/A N/A N/A 12.4** Rhode Island 16.7 (+/- 0.8) 13.2 (+/- 3.3) 41 25.2 10.7 (+/- 1.3) 16.2 (+/- 2.5) 23.2 (+/- 3.8) 11.8** South Carolina 12.6 (+/- 0.3) 21.5 (+/- 4.1) 2 30.3 13.9 (+/- 2.5) 16.8 (+/- 2.1) 23.8 (+/- 3.0) 13.2 South Dakota 14.8 (+/- 0.8) 13.4 (+/- 3.3) 38 30.2 11.9 (+/- 2.3) 13.2 (+/- 1.6) 27.7 (+/- 2.5) 11.5** Tennessee 15.3 (+/- 0.3) 20.5 (+/- 4.2) 5 34.5 16.9 (+/- 1.9) 15.4 (+/- 2.3) 25.4 (+/- 3.1) 15.1* Texas 15.9 (+/- 0.1) 19.1 (+/- 4.5) 10 29.0 15.7 (+/- 1.9) 15.6 (+/- 1.6) 30.0 (+/- 2.4) 15.4* Utah 8.7 (+/- 0.4) 11.6 (+/- 3.3) 43 18.1 6.4 (+/- 1.9) 11.0 (+/- 2.2) 19.7 (+/- 2.7) 11.9** Vermont 13.7 (+/- 0.9) 11.3 (+/- 2.7) 45 33.3 13.2 (+/- 2.1) 15.8 (+/- 1.0) 25.4 (+/- 1.9) 11.4** Virginia 20.1 (+/- 0.4) 14.3 (+/- 3.6) 28 26.1 12.0 (+/- 1.3) 14.7 (+/- 1.4) 23.8 (+/- 1.6) 9.8** Washington 14.3 (+/- 0.3) 11.0 (+/- 3.1) 46 28.5 N/A N/A N/A 12.9 West Virginia 14.1 (+/- 0.6) 18.5 (+/- 3.4) 13 34.1 15.6 (+/- 2.3) 15.5 (+/- 2.0) 31.0 (+/- 2.4) 15.0 Wisconsin 15.2 (+/- 0.3) 13.4 (+/- 3.1) 38 28.3 11.6 (+/- 2.1) 13.0 (+/- 1.2) 24.0 (+/- 2.3) 11.3** Wyoming 10.6 (+/- 0.9) 10.7 (+/- 4.2) 48 30.2 10.7 (+/- 1.4) 12.8 (+/- 1.2) 28.2 (+/- 2.0) 13.2 Source: USDA, Women, Note: For ranking, 1 = Highest rate and 51 = Lowest rate. Note: Previous YRBS reports used the term “overweight” to describe youth with a BMI at Source: Calculated by USDA, Infants, and Children Source: National Survey of Children’s Health (NSCH), 2011 data. or above the 95th percentile for age and sex and “at risk for overweight” for those with a Economic Research Service Participant and Program BMI at or above the 85th percentile, but below the 95th percentile. However, this report using data from the Current Characteristics ( uses the terms “obese” and “overweight” based on the 2007 recommendations from the Population Survey Food Security WIC PC), 2012. Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Supplement, Red and * Overweight and Obesity convened by the American Medical Association. Source: Youth Risk indicate state rate is statistically Behavior Survey (YRBS) 2015, CDC. YRBS data are collected every 2 years. Percentages are significanlty higher than the as reported on the CDC website and can be found at: http://www.cdc.gov/HealthyYouth/ national average of 13.7. Green yrbs/index.htm. and ** indicates state rate is statistically significantly lowere than the national rate. TFAH • RWJF • StateofObesity.org 15 STATES WITH THE HIGHEST OBESITY RATES STATES WITH THE LOWEST OBESITY RATES (BRFSS 2015 DATA) (BRFSS 2015 DATA) Percentage of Adult Obesity Percentage of Adult Obesity Rank State Rank State (95% C.I.) (95% C.I.) 1 Louisiana 36.2 (+/-1.9) 51 Colorado 20.2 (+/-1.1) 2 Alabama 35.6 (+/-1.5) 50 D.C. 22.1 (+/-2.5) 2 Mississippi 35.6 (+/-1.9) 49 Hawaii 22.7 (+/-1.4) 2 West Virginia 35.6 (+/-1.5) 48 Montana 23.6 (+/-1.6) 5 Kentucky 34.6 (+/-1.7) 47 California 24.2 (+/-1.0) 6 Arkansas 34.5 (+/-2.3) 46 Massachusetts 24.3 (+/-1.3) 7 Kansas 34.2 (+/-0.8) 45 Utah 24.5 (+/-1.0) 8 Oklahoma 33.9 (+/-1.7) 44 New York 25.0 (+/-1.1) 9 Tennessee 33.8 (+/-1.9) 43 Vermont 25.1 (+/-1.4) 10 Missouri 32.4 (+/-1.6) 42 Connecticut 25.3 (+/-1.2) 10 Texas 32.4 (+/-1.5) Note: For rankings, 51 = Lowest rate of obesity. C.I. = Confidence Intervals. Note: For rankings, 1 = Highest rate of obesity. C.I. = Confidence Intervals. cdrin / Shutterstock.com 16 TFAH • RWJF • StateofObesity.org 1991 PAST OBESITY TRENDS* AMONG U.S. ADULTS WA MT ND BRFSS: 1991, 1993 to 1995, 1998 to 2000, and MN VT ME 2005 to 2007 Combined Data SD WI OR ID WY IA MI NY NH MA (*BMI >30, or about 30lbs overweight for 5’4” person) NE PA RI IL IN OH CT NV UT CO NJ Interactive maps and timelines for all years are available KS MO WV DE MD CA KY VA DC at stateofobesity.org OK TN NC NM AR AZ SC MS AL GA TX LA 1993–1995 Combined Data FL AK WA MT ND HI MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD CA DC OK TN NC NM AR AZ SC MS AL GA TX LA FL AK HI 1998 to 2000 Combined Data WA ND MT MN VT SD WI ME n No Data n >20% <25% OR ID WY MI NY NH MA n <10% n >25% <30% IA NE IL IN OH PA CT RI n >10% & <15% n >30% NV UT NJ CO KS MO WV DE n >15% & <20% KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA 2005 to 2007 Combined Data FL AK WA ND MT HI MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC Note: BRFSS methodological changes were made in 2011. NM AR AZ Estimates should not be compared to those prior to 2010. SC MS AL GA Source: CDC, BRFSS TX LA FL AK HI TFAH • RWJF • StateofObesity.org 17 Obesity Rates for Young Adults (18- to 25-year-olds) BRFSS 2015 WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK AR TN NC Obesity Rates for Baby Boomers (45-to 64-year-olds) BRFSS 2015 AZ NM SC MS AL GA WA ND TX LA MT MN VT ME SD WI OR ID NH FL WY MI NY AK IA MA NE HI PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA FL AK HI Obesity Rates for Seniors (65-+ year-olds) BRFSS 2015 WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD CA DC n <15% n >25% <30% n >40% <45% OK TN NC AZ NM AR SC n >15% & <20% n >30% <35% n Data not available MS AL GA TX LA n >20% & <25% n >35% <40% FL AK HI 50 20 and over 20–39 40–59 60 and over Prevalence of obesity among adults 44.6 aged 20 and over, by sex and age: 41.0 40.4 United States, 2013–2014 40 39.4 37.7 38.5 37.2 37.5 37.0 34.3 35.0 31.6 30 Percent 20 NOTES: Totals were age-adjusted by the direct method to the 2000 U.S. census population using the age groups 10 20–39, 40–59, and 60 and over. Crude estimates are 37.9% for all, 35.2% for men, and 40.5% for women. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2013–2014. 0 All Men Women 18 TFAH • RWJF • StateofObesity.org RATES AND RANKINGS METHODOLOGY ADULT OBESITY DATA SETS National Health and Nutrition Evaluation Survey (NHANES) National data – based on weight and height measurements 2013-14 (bi-annual) Behavioral Risk Factor Surveillance System (BRFSS) National and state data – based on state level phone surveys 2015 (annual) The state obesity analysis in State of Obesity compares data from The data are based on telephone surveys by state health the Behavioral Risk Factor Surveillance System. departments, with assistance from CDC. BRFSS is the largest ongoing telephone health survey in the People self-report their weight and height, which are used to world. It is a state-based system of health surveys established calculate BMI. A number of studies have shown that rates by CDC in 1984. BRFSS completes more than 400,000 adult of overweight and obesity are probably higher than shown by interviews each year. For most states, BRFSS is the only source the data because people tend to underreport their weight and of population-based health behavior data about chronic disease exaggerate their height.32 prevalence and behavioral risk factors. BRFSS made two changes in methodology for its dataset BRFSS surveys a sample of adults in each state to get information starting in 2011 to make the data more representative of the on health risks and behaviors, health practices for preventing total population. The changes included making survey calls to disease and healthcare access mostly linked to chronic disease and cell phone numbers and adopting a new weighting method: 33 injury. The sample is representative of the population of each state. l T he first change is including and then growing the number of Washington, D.C., is included in the rankings because CDC interview calls made to cell phone numbers. Estimates today provides funds to the city to conduct a survey in an equivalent way are that three in 10 U.S. households have only cell phones. to the states. l T he second is a statistical measurement change, which involves the way the data are weighted to better match the Racial and Ethnic Populations — Limited Data demographics of the population in the state. The total sample size for BRFSS in states is often 600 to The new methodology means the BRFSS data will better 800 people. represent lower-income and racial and ethnic minorities, as well as populations with lower levels of formal education. Although Many states do not have large enough populations of Asian/ generalizing is difficult because of these variables, it is likely that Pacific Islanders and American Indian/Alaska Natives — and the changes in methods will result in somewhat higher estimates in some states even of Blacks and Latinos — to be reflected for the occurrence of behaviors that are more common among within the survey findings. younger adults and certain racial and ethnic groups. Increased funds to expand the sample sizes for each state would The change in methodology does not allow for direct comparisons provide an opportunity to collect more meaningful information to data collected prior to 2011. about different racial and ethnic groups in each state. More information on the methodology is available in Appendix A. TFAH • RWJF • StateofObesity.org 19 Obesity is defined as an excessively of the same age and sex; childhood high amount of body fat or adipose obesity is defined as a BMI at or above tissue in relation to lean body mass. 34,35 the 95th percentile for children of the Overweight refers to increased body same age and sex; and severe childhood weight in relation to height, which is then obesity is defined as a BMI greater than compared to a standard of acceptable 120 percent of 95th percentile for children weight. 36 Body mass index is a common of the same age and sex. CDC makes measure expressing the relationship (or growth charts available to plot BMI for ratio) of weight to height. The equation is: children and adolescents (ages 2 to 20) BMI = ( Weight in pounds (Height in inches) x (Height in inches) ) x 703 Note: In the metric system, BMI is kg / height2 (the 703 is the conversion needed when using pounds and inches.) Adults with a BMI of 25 to 29.9 are to determine percentile at http://www. considered overweight, while individuals cdc.gov/healthyweight/assessing/bmi/ with a BMI of 30 or more are considered childrens_bmi/about_childrens_bmi.html. obese. Adults with a BMI of 35 or higher BMI is considered an important measure and an obesity-related condition (e.g., for understanding population trends. For diabetes) and adults with a BMI of 40 or individuals, it is one of many factors that higher are considered severely obese. should be considered in evaluating healthy For children, overweight is defined as a weight, along with waist size, body fat BMI at or above the 85th percentile and composition, waist circumference, blood lower than the 95th percentile for children pressure, cholesterol level and blood sugar.37 20 TFAH • RWJF • StateofObesity.org RACIAL AND ETHNIC INEQUITIES AND OBESITY OBESITY RATES BY AGE AND ETHNICITY Obesity Rates by Age — BRFSS 2015 Obesity Rates by Ethnicity — BRFSS 2015 Obesity Among Obesity Among 18-24 Year Olds 25-44 Year Olds 45-64 Year Olds 65+ Year Olds Obesity Among Blacks Latinos Whites Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank 2015 (95% C.I.) 2015 (95% C.I.) 2015 (95% C.I.) 2015 (95% C.I.) 2015 (95% C.I.) 2015 (95% C.I.) 2015 (95% C.I.) Alabama 25.1b 3 38.1b 2 40.4 (+/-2.3) 5 30.2 (+/-2.4) 13 43.2 (+/-1.9) 2 27.6 (+/-7.8) 40 31.1 (+/-1.0) 11 Alaska 19.2b 18 31.3 (+/-4.5) 20 30.7 (+/-3.4) 41 34.7 (+/-5.3) 1 40.5 (+/-9.1) 14 28.3 (+/-6.4) 34 27.7 (+/-1.3) 29 Arizona 17.5 24 31.4 (+/-3.2) 19 32.7 (+/-2.4) 30 24.2 (+/-2.0) 45 34.2 (+/-6.1) 37 35.5 (+/-2.9) 8 24.4 (+/-1.1) 43 Arkansas 20.7 11 36.8 (+/-4.8) 5 40.5 (+/-3.6) 3 29.8 (+/-3.0) 15 43.9 (+/-3.6) 1 36.9 (+/-7.2) 3 33.2 (+/-1.4) 2 California 13.6 (+/-2.3) 36 26.2 (+/-1.8) 38 26.9 (+/-1.8) 49 22.8 (+/-2.2) 48 32.8 (+/-3.1) 39 31.3 (+/-1.3) 23 22.2 (+/-0.8) 48 Colorado 11.2b 43 19.8b 50 24.1 (+/-1.7) 51 20.0 (+/-1.7) 50 27.7 (+/-3.8) 45 28.3 (+/-1.7) 34 19.1 (+/-0.6) 49 Connecticut 11.2 (+/-3.5) 43 26.2 (+/-2.4) 38 29.2 (+/-1.8) 45 25.5 (+/-1.9) 41 35.5 (+/-3.1) 29 30.3 (+/-2.7) 29 24.0 (+/-0.9) 44 Delaware 18.2b 19 29.9 (+/-4.4) 29 34.8 (+/-3.3) 25 27.9 (+/-2.9) 29 36.6 (+/-3.0) 23 35.3 (+/-4.9) 10 29.4 (+/-1.3) 20 D.C. N/A N/A 16.0 (+/-3.9) 51 31.0 (+/-4.2) 38 29.7 (+/-3.9) 16 35.2 (+/-2.2) 34 18.5 (+/-6.0) 51 9.9 (+/-1.4) 51 Florida 16.5 (+/-4.2) 28 25.7 (+/-2.8) 42 32.1 (+/-2.3) 34 25.8 (+/-1.9) 40 35.3 (+/-2.4) 33 26.5 (+/-1.9) 44 25.2 (+/-0.8) 39 Georgia 16.0b 31 30.8b 22 36.9 (+/-2.9) 15 29.7b 16 37.8 (+/-2.0) 19 27.1 (+/-4.4) 42 28.0 (+/-1.1) 26 Hawaii 14.1 b 34 26.4b 37 25.2 (+/-2.2) 50 17.9 (+/-2.3) 51 33.6 (+/-10.7) 38 31.8 (+/-3.2) 18 17.9 (+/-1.4) 50 Idaho 15.5 b 32 30.1 (+/-3.5) 27 33.3 (+/-2.9) 28 27.3 (+/-2.7) 32 N/A N/A 36.3 (+/-4.6) 6 28.1 (+/-1.1) 24 Illinois 17.1b 25 30.3 (+/-3.2) 24 36.1 (+/-2.6) 19 31.3 (+/-2.8) 5 40.7 (+/-3.3) 13 36.0 (+/-3.5) 7 28.3 (+/-1.1) 22 Indiana 22.6b 4 29.6 (+/-3.5) 31 37.4 (+/-2.7) 11 29.5b 19 41.5 (+/-3.6) 10 31.4 (+/-4.2) 21 31.3 (+/-0.9) 9 Iowa 17.8b 21 35.1 (+/-3.4) 10 35.9 (+/-2.4) 20 31.1 (+/-2.5) 7 35.4 (+/-6.9) 30 34.0 (+/-4.2) 12 31.6 (+/-0.9) 6 Kansas 22.1 (+/-2.5) 8 36.9b 4 38.9 (+/-1.3) 8 30.5 (+/-1.2) 11 42.7 (+/-2.8) 5 35.4 (+/-2.1) 9 31.0 (+/-0.5) 12 Kentucky 17.8b 21 36.8 (+/-3.6) 5 40.5 (+/-2.6) 3 31.2b 6 42.7 (+/-4.2) 5 24.3 (+/-7.2) 49 32.9 (+/-0.9) 3 Louisiana 29.0b 2 35.9 (+/-3.6) 8 40.7 (+/-3.0) 2 33.6b 2 42.5 (+/-2.2) 7 29.9 (+/-6.9) 30 31.9 (+/-1.2) 5 Maine 22.5b 5 30.2 (+/-3.0) 26 32.7 (+/-2.1) 30 29.0 (+/-2.1) 23 35.9 (+/-12.7) 26 25.3 (+/-7.6) 47 29.2 (+/-0.8) 21 Maryland 10.3 (+/-4.4) 48 29.4 (+/-3.7) 32 34.4 (+/-2.6) 26 29.4 (+/-2.6) 20 38.0 (+/-1.9) 18 25.1 (+/-4.1) 48 26.7 (+/-1.0) 33 Massachusetts 10.6b 47 23.0 (+/-2.4) 48 29.9b 42 25.2 (+/-2.7) 42 35.9 (+/-3.5) 26 32.4 (+/-2.6) 16 23.0 (+/-0.7) 46 Michigan 16.3b 29 33.9b 11 35.1 (+/-2.0) 23 30.0b 14 37.6 (+/-2.4) 20 36.9 (+/-4.8) 3 30.2 (+/-0.8) 15 Minnesota 13.1 b 38 24.6 (+/-1.7) 46 30.9 (+/-1.4) 40 28.5 (+/-1.6) 26 29.9 (+/-3.5) 42 31.2 (+/-3.9) 24 26.5 (+/-0.6) 35 Mississippi 32.8b 1 38.4b 1 36.8 (+/-2.7) 16 30.8 (+/-2.6) 9 43.2 (+/-1.9) 2 25.4 (+/-10.2) 46 31.5 (+/-1.3) 7 Missouri 21.4b 10 33.7 (+/-3.3) 12 37.0 (+/-2.5) 14 29.4 (+/-2.3) 20 38.4 (+/-3.5) 17 31.5 (+/-6.9) 19 30.4 (+/-1.0) 14 Montana 12.9b 40 23.0 (+/-3.3) 48 28.3 (+/-2.5) 47 23.2 (+/-2.4) 47 N/A N/A 26.8 (+/-6.2) 43 23.8 (+/-0.9) 45 Nebraska 15.1b 33 31.6b 18 37.4b 11 32.0b 3 36.3 (+/-4.4) 25 30.8 (+/-3.0) 26 30.0 (+/-0.6) 16 Nevada N/A N/A 28.0 (+/-5.0) 34 32.7 (+/-4.8) 30 23.9 (+/-4.7) 46 34.5 (+/-5.9) 35 30.5 (+/-3.7) 28 26.3 (+/-1.6) 37 New Hampshire 19.9b 17 24.4b 47 28.9 (+/-2.1) 46 27.8 (+/-2.2) 30 27.6 (+/-11.5) 46 27.8 (+/-8.3) 38 27.3 (+/-0.9) 31 New Jersey 10.7b 46 25.7 (+/-2.6) 42 29.7 (+/-2.1) 44 26.9 (+/-2.6) 35 36.6 (+/-2.2) 23 28.8 (+/-2.0) 32 25.6 (+/-0.9) 38 New Mexico 21.7b 9 33.6 (+/-3.6) 13 31.2 (+/-2.6) 36 22.3 (+/-2.6) 49 37.5 (+/-8.0) 21 31.2 (+/-1.6) 24 22.8 (+/-1.1) 47 New York 12.7 (+/-3.0) 42 24.7 (+/-2.1) 45 29.9 (+/-1.7) 42 24.9 (+/-1.8) 43 32.3 (+/-2.3) 40 30.6 (+/-2.1) 27 24.9 (+/-0.9) 40 North Carolina 20.1b 16 30.1 (+/-2.8) 27 35.7 (+/-2.3) 21 26.7 (+/-2.6) 37 39.9 (+/-1.9) 15 28.1 (+/-3.0) 36 27.2 (+/-0.9) 32 North Dakota 16.7 (+/-5.0) 26 31.8 (+/-3.5) 15 37.1 (+/-2.7) 13 30.9 (+/-2.8) 8 20.0 (+/-9.1) 47 35.1 (+/-9.0) 11 31.3 (+/-1.0) 9 Ohio 17.8b 21 27.9 (+/-2.8) 35 36.3 (+/-2.2) 18 29.0 (+/-2.1) 23 37.1 (+/-2.9) 22 26.3 (+/-5.2) 45 30.5 (+/-0.8) 13 Oklahoma 22.5b 5 35.3 (+/-3.3) 9 40.4 (+/-2.5) 5 28.1 (+/-2.1) 28 35.4 (+/-3.4) 30 33.9 (+/-3.8) 13 32.5 (+/-0.9) 4 Oregon 20.3 (+/-5.7) 14 31.2 (+/-3.4) 21 33.1 (+/-2.7) 29 28.9 (+/-2.6) 25 29.4 (+/-10.0) 43 31.4 (+/-4.5) 21 28.1 (+/-1.0) 24 Pennsylvania 12.8b 41 30.3 (+/-3.3) 24 35.5 (+/-2.7) 22 30.8 (+/-2.9) 9 35.7 (+/-2.9) 28 39.1 (+/-5.1) 2 29.5 (+/-0.8) 19 Rhode Island 10.8b 45 27.7b 36 31.4 (+/-2.6) 35 24.4 (+/-2.4) 44 34.5 (+/-4.8) 35 28.9 (+/-3.3) 31 26.4 (+/-1.0) 36 South Carolina 20.3 b 14 33.4b 14 36.5 (+/-1.9) 17 28.5 (+/-1.9) 26 42.2 (+/-1.5) 8 32.1 (+/-5.0) 17 28.3 (+/-0.8) 22 South Dakota 16.1b 30 30.7b 23 38.0 (+/-3.2) 10 26.5 (+/-2.8) 38 N/A N/A 28.8 (+/-9.8) 32 29.6 (+/-1.1) 18 Tennessee 18.1b 20 37.7 (+/-4.0) 3 39.4 (+/-3.1) 7 27.7 (+/-2.6) 31 43.0 (+/-3.3) 4 27.6 (+/-8.8) 40 31.5 (+/-1.2) 7 Texas 22.4b 7 31.7 (+/-2.6) 17 38.6 (+/-2.6) 9 29.7 (+/-2.6) 16 41.5 (+/-3.1) 10 36.9 (+/-1.6) 3 27.9 (+/-1.0) 28 Utah 10.2b 49 25.0 (+/-1.7) 44 31.1 (+/-1.9) 37 26.2 (+/-2.2) 39 30.9 (+/-8.3) 41 27.7 (+/-2.1) 39 24.5 (+/-0.6) 42 Vermont 13.0b 39 25.8b 41 27.9b 48 26.9b 35 29.0 (+/-13.0) 44 22.4 (+/-8.1) 50 24.8 (+/-0.8) 41 Virginia 16.7b 26 29.2b 33 34.1 (+/-2.2) 27 29.3b 22 39.2 (+/-2.1) 16 27.9 (+/-3.7) 37 26.7 (+/-0.8) 33 Washington 13.6 b 36 26.0b 40 31.0b 38 27.2b 34 35.4 (+/-4.7) 30 31.5 (+/-2.9) 19 27.7 (+/-0.7) 29 West Virginia 20.7 (+/-4.6) 11 36.8 (+/-3.0) 5 43.2 (+/-2.4) 1 30.3 (+/-2.5) 12 41.5 (+/-5.8) 10 40.2 (+/-9.4) 1 35.2 (+/-0.9) 1 Wisconsin 14.1b 34 31.8b 15 35.1 (+/-2.7) 23 31.8b 4 41.6 (+/-6.3) 9 33.4 (+/-6.1) 14 29.8 (+/-1.0) 17 Wyoming 20.4 (+/-7.5) 13 29.9 (+/-4.0) 29 32.5 (+/-3.0) 33 27.3 (+/-2.6) 32 N/A N/A 33.4 (+/-5.2) 14 28.0 (+/-1.1) 26 Note: For ranking, 1 = Highest rate and 51 = Lowest rate; b = confidence intervals could not be calculated; C.I. = Confidence Intervals. Source: Behavior Risk Factor Surveillance (BRFSS), CDC TFAH • RWJF • StateofObesity.org 21 Obesity rates are higher among adult insecurity; and more targeted marketing Blacks (48.4 percent), Latinos (42.6 of less nutritious foods.42, 43 percent) and American Indian/Alaska l E liminating health inequalities could Natives (42.3 percent) than among reduce medical expenditures by $54 Whites (36.4 percent) and Asian billion to $61 billion per year, and Americans (12.6 percent).38, 39 recover $13 billion annually because l T he disparities are highest among of work missed due to illness and women: Blacks have an obesity rate about $250 billion per year due to of 57.2 percent, Latinos of 46.9 premature deaths, according to a percent, Whites of 38.2 percent and study of data from 2003 to 2006.44 Asians of 12.4 percent. Black women l D ifferences in rates among Latinos, are twice as likely to be severely Blacks and Whites for a set of obese as White women.40 preventable diseases (diabetes, heart l F or men, Blacks have an obesity rate of disease, high blood pressure, renal 38.0 percent, Latinos of 37.9 percent disease and stroke — many of which and Whites of 34.7 percent.41 are often related to obesity) cost the healthcare system $23.9 billion Many neighborhoods with higher rates of annually, according to an Urban racial and ethnic minorities experience Institute analysis.45 Based on current less access to affordable, healthy food trends, by 2050, this is expected to options; limited access to safe places to more than double to $50 billion a year. be physically active; higher rates of food Obesity and Overweight Rates for for Adults, National Health and Nutrition Examination Survey, 2013 201446 (with Obesity and Overweight Rates Adults, National Health and Nutrition Examination Survey, 2013 to to 201421 (with Native American/Alaska Native Rates per 2014 National Health Interview Survey22) American Indian/Alaska Native Rates per 2014 National Health Interview Survey47) 60 57.2% BOTH GENDERS MEN WOMEN 50 48.4% 46.9% 42.6% 42.3% 40 38.0% 37.9% 38.2% 36.4% 34.7% 30 20 16.8% 12.6% 12.4% 12.6% 12.4% 10 9.7% 7.6% 8.7% 7.1% 7.2% 5.6% Unknown 5.4% N/A N/A N/A 0 Asian§ Black§ Latino American White§ Asian§ Black§ Latino White§ Asian§ Black§ Latino White§ Indian/ Alaska Native§ ■ Obese ■ Extremely Obese Note: The Centers for Disease Control and Prevention uses the term Hispanic in analysis. § = non-Hispanic; N/A data only included 2 participants. 22 TFAH • RWJF • StateofObesity.org AMERICAN INDIAN/ALASKA NATIVE STATE DATA According to an analysis by the Kaiser Family Foundation (KFF) of 2014 BRFSS Rates of American Indian/Alaska Native Adults Who Were Overweight and Obese, 2014 BRFSS surveys in states with reportable data for American Indian/Alaska Native WA populations, 14 of the 24 states MT ND ME VT analyzed had adult overweight and OR MN ID NH SD WI NY MA obesity rates above 70 percent. Ohio WY MI CT RI had the highest adult rate at 93.9 NE IA PA NJ NV OH DE percent, and North Carolina had the CA UT IL IN MD CO WV VA lowest at 60.9 percent.48 KS MO DC KY NC AZ OK TN States with the Highest Reported NM AR SC Overweight and Obesity Rates for MS AL GA American Indian/Alaska Native TX LA Adults FL Percent of AK Rank State Adults Obese HI and Overweight < 70% 70% to < 75% 75% to < 80% 1 Ohio 93.9% ≥ 80% N /A 2 Maryland 84.8% 3 New Mexico 79.5% Source: Kaiser Family Foundation 4 Arizona 77.5% 5 Oklahoma 76.4% Overweight and Obesity Rates for American Indian/Alaska Native Adults 6 Kansas 75.7% 2014 BRFSS Data 7 North Dakota 75.2% Wyoming Wisconsin Source: Kaiser Family Foundation Washington Note: Confidence intervals were not reported. Utah Texas South Dakota States with the Lowest Reported South Carolina Overweight and Obesity Rates for Oklahoma Ohio American Indian/Alaska Native North Dakota Natives North Carolina New Mexico States Percent of Nebraska Rank State Adults Obese Montana and Overweight Minnesota Maryland 24 North Carolina 60.9% Maine 23 South Carolina 63.7% Kentucky Kansas 22 Colorado 64.1% Indiana Colorado 21 Washington 64.2% Arizona 20 Kentucky 64.3% Alaska Alabama 19 Utah 66.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 18 Alaska 67.9% Percent Rates Source: Kaiser Family Foundation Note: Confidence intervals were not reported. Source: Kaiser Family Foundation TFAH • RWJF • StateofObesity.org 23 S EC T I ON 2 : The State of SECTION 2: CHILDHOOD OBESITY TRENDS Childhood Obesity Trends Obesity: Childhood obesity rates have remained at around 17 percent for Obesity Policy the past decade.49 Series The federal government has several major studies that track national trends sources that track different obesity as well as different childhood obesity rates, including a National Health and rates in U.S. states. Nutrition Evaluation Survey, and three Trends in obesity prevalence among youth aged 2–19 years: United States, 1999–2000 through 2013–2014 20 Youth1,2 17.1 16.8 16.9 16.9 17.2 15.4 15.4 Percent 13.9 10 0 1999–2000 2001–2002 2003–2004 2005–2006 2007–2008 2009–2010 2011–2012 2013–2014 Survey years 1 Significant increasing linear trend from 1999–2000 through 2013–2014. 2 Test for linear trend for 2003–2004 through 2013–2014 not significant (p >0.05). SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey. CHILDHOOD OBESITY DATA SETS National data – based National Health and Nutrition on weight and height 2-19 year olds 2013-14 (bi-annual) Evaluation Survey (NHANES) measurements Supplemental Nutrition Program National and state Low-income 2012 for children, for Women, Children and Infants data – based on 2-5 year olds 2014 for mothers Participant and Program weight and height and mothers Characteristics (WIC PC) measurements enrolled in WIC (bi-annual) National and state 2011 (periodically, National Survey of Children’s trends– based on 10-17 year around every four Health (NSCH) phone survey of olds parents years) State data – based Youth Risk Behavior Survey High school on weight and height 2015 (bi-annual) (YRBS) students measurements SEPTEMBER 2016 CHILDREN AND THE IMPORTANCE OF MAINTAINING A HEALTHY WEIGHT Good nutrition and physical activity are particularly important for infants, toddlers and young children who need an adequate intake of key nutrients while their brains and bodies are rapidly developing. The foundations for lifelong, healthy eating and physical activity begin in these formative years. A child’s health is even impacted by the mother’s underlying health before and during pregnancy — where a mother’s obesity and diabetes puts the child at increased risk for a range of health concerns. l C hildren who are overweight or obese are more likely to be obese as adults. Being overweight or obese can put children at a higher risk for health problems such as heart disease, that are $19,000 higher compared to a health — particularly among children from hypertension, type 2 diabetes, stroke, healthy-weight 10-year-old who maintains low-income families: cancer, asthma and osteoarthritis — a normal weight throughout life. 54 l C hildren who grow up in low-income during childhood and as they age.50, 51 l A child who is obese for two families and neighborhoods are at l P reventing obesity early can impact consecutive years has a $194 higher higher risk for obesity and related a child’s lifetime trajectory. A study outpatient visit expenditure, a $114 health problems.58, 59 of more than 7,700 children found higher prescription drug expenditure l M ore than 15 million children (20.9 that a third of the children who were and a $12 higher emergency room percent) experience food insecurity overweight in kindergarten were obese expenditure compared to a normal/ annually — where their family has by eighth grade. When the children underweight child during the same two limited access to adequate food and entered kindergarten, 12.4 percent years, based on a Medical Expenditure nutrition due to cost, proximity and/or were obese and another 14.9 percent Panel Survey (2002-2005).55  other reasons.60, 61 were overweight; in eighth grade, 20.8 l T he average total annual health cost for l N early half of infants and toddlers under percent were obese and 17 percent were a child treated for obesity under private 3-years-old live in low-income families; 24 overweight. Overweight 5-year-olds were insurance is $3,743, while the average percent live in poverty; and 6.6 percent more than four times as likely as healthy- health cost for all children covered by of the U.S. population lives in deep pov- weight children to become obese.52 private insurance is $1,108.56 erty.62, 63 (Low-income is defined as two Obesity is associated with higher healthcare l H ospitalizations of children and youths times the federal poverty level (FPL); pov- needs and costs among children: with a diagnosis of obesity nearly erty is below FPL; deep poverty is earning doubled between 1999 and 2005, while less than $6,000 per year or raising a l O verweight and obesity in childhood is total costs for children and youths with child on less than $7,600 per year.) associated with $14.1 billion in additional obesity-related hospitalizations increased prescription drug, emergency room l S eventy percent of Black, 66 percent from $125.9 million in 2001 to $237.6 and outpatient visit healthcare costs of Native American, 64 percent of million in 2005 (in 2005 dollars).57 annually.53 An obese 10-year-old child Latino and 34 percent of White who continues to gain weight throughout Focusing on nutrition and physical activity children under the age of three live in adulthood has lifetime medical costs early can help improve a child’s future low-income families. TFAH • RWJF • StateofObesity.org 25 OBESITY AND ADVERSE CHILDHOOD EXPERIENCES (ACES) AND TOXIC STRESS Stress and trauma in childhood can harm and alter a child’s creases with a child’s age, except for economic hardship, which body and brain. Adverse childhood experiences, adverse is reported relatively equally for children of all ages. family experiences and toxic stress can dramatically increase Children with four or more ACEs had a 220 percent greater risk a child’s likelihood of becoming obese and for developing many of heart disease than children experiencing no ACEs. They had a obesity-related illnesses. 240 percent greater risk of stroke, and 160 percent greater risk of Adverse Family Experiences diabetes. An ACE score of 6 or more could lower life expectancy l A round one-third (30.5 percent) of children experienced two or by two decades.73 Adults who were abused as children have more adverse family experiences, including 1) divorce or sep- higher incidences of heart disease, chronic lung disease, cancer aration; 2) death; 3) incarceration of a parent or guardian; 4) and liver disease; and are more likely to be smokers or obese.74,75 living with anyone who was mentally ill, suicidal or severely de- Research also shows that support from caring adults and pressed; 5) living with anyone who had an alcohol or drug prob- protective systems can help buttress or reduce the negative lem; 6) witnessing any violence in the household; 7) being the effects that toxic stress, ACEs and other adverse family expe- victim of violence or witnessing violence in the neighborhood; riences can have on a child. Programs and services that help 8) suffering racial discrimination; and 9) having a caregiver who give parents and caregivers additional resources, skills and often found it hard to get by on the family’s income. 64, 65 support can help them in turn provide safe, stable and nurtur- l Y outh ages 10 to 17 who have experienced two or more adverse ing environments for their children.76 family experiences have an 80 percent higher chance of obesity than children who do not experience such events, according to Death an analysis of the 2011–2012 National Survey of Children’s Health (NSCH).66 The strongest association between adverse Early Death family experiences and obesity was among White children, and Disease, there was no reported association among Black children. Disability and Social Problems Scientific Toxic Stress Adoption of gaps Health-risk Behaviors Toxic stress occurs when children experience not just one trau- Social, Emotional, and matic event but rather are exposed to repeated and ongoing Cognitive Impairment traumas, such as physical, sexual or emotional abuse, chronic Disrupted Neurodevelopment neglect, caregiver substance abuse or mental illness, repeated exposure to violence in the home or in their neighborhood and/ Adverse Childhood Experiences Conception or the accumulated burden and stress of family economic hard- Mechanisms by Which Adverse Childhod Experiences ship.67 More than half of U.S. public school students live in pov- Influence Health and Well-being Throughout the Lifespan erty, which can contribute to toxic stress as well as to obesity.68, 69 Source: Centers for Disease Control and Prevention Adverse Childhood Experiences More than half of children experience an adverse event during ACE-Related Odds of Having a Physical Helath Condition childhood — and many experience multiple co-occurring adverse Health Condition 0 ACEs 1 ACEs 2 ACEs 3 ACEs 4+ ACEs Arthritis 100% 130% 145% 155% 236% events.70, 71 The most commonly reported ACEs were physical Asthma 100% 115% 118% 160% 231% abuse (28.3 percent), substance abuse in the household (26.9 Cancer 100% 112% 101% 111% 157% percent), sexual abuse (24.7 percent for girls and 16 percent for COPD 100% 120% 161% 220% 399% Diabetes 100% 128% 132% 115% 201% boys) and parent divorce or separation (23.3 percent).72 More Heart Attack 100% 148% 144% 287% 232% than one-quarter (27 percent) of children experience at least two HeartDisease 100% 123% 149% 250% 285% Kidney Disease 100% 83% 164% 179% 263% ACEs, 14 percent experience three and 7 percent experience Stroke 100% 114% 117% 180% 281% four or more. The more ACEs experienced, the higher likelihood Vision 100% 167% 181% 199% 354% for increased negative outcomes. The prevalence of ACEs in- Source: Iowa Aces 360 26 TFAH • RWJF • StateofObesity.org Percent of Children Ages 2 to 4 Enrolled in WIC Classified as Obese 2012 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA <10% ≥10% to <15% TX LA ≥15% to <20% ≥20% to <25% FL AK HI Note: Obesity rates for Guam = 10.0 percent, Puerto Rico = 15.7 percent and Virgin Islands = 12.9 percent. Source: USDA, Food and Nutrition Service l IC PRESCHOOLERS: W to 14 percent. During that time, Approximately 14 percent of children rates significantly decreased for 25 (ages 2 to 5) enrolled in WIC were states (Arizona, California, Colorado, obese [2014 WIC Participant and Florida, Georgia, Kentucky, Louisiana, Program Characteristic (PC) national Maine, Massachusetts, Michigan, data, 2012 state-level data, measured Minnesota, Mississippi, Missouri, weight and height of participants].77 Montana, Nevada, New Hampshire, New Jersey, New York, North l R ates ranged from highs of 20.6 Carolina, South Carolina, South percent in Alaska and 20.1 percent Dakota, Texas, Utah, Washington and in Virginia to lows of 8.9 percent in Wisconsin); and rates significantly Colorado and 8.7 percent in Utah, in increased for seven states (Alabama, 2012. The rates exceed 15 percent Arkansas, Nebraska, Ohio, Oregon, in 18 states.78 The obesity rate for Pennsylvania and Tennessee). Puerto Puerto Rico was 15.7 percent, the Rico was the only U.S. territory that Virgin Islands was 12.9 percent and had a significant decrease. Guam was 10.0 percent. n I n 2007, USDA published interim l R acial and ethnic differences are nutritional changes to the WIC significant: 16.6 percent of American program, updating standards Indian/Alaska Natives, 16.1 percent to align closely to the National of Latinos, 15.5 percent of Native Academies of Medicine (NAM, Hawaiian/Pacific, 14 percent of formerly the Institute of Medicine) Whites, 11.2 percent of Blacks and 10.1 and the Dietary Guidelines for percent of Asians were obese, in 2014. Americans—which had been the l B etween 2008 and 2012, obesity rates first major change in more than 30 decreased from almost 15 percent years. Changes expanded access to TFAH • RWJF • StateofObesity.org 27 healthy fruits and vegetables; whole Children Enrolled in WIC, Significant Increase and Decrease in Obesity Rates grains; and low-fat dairy for women, between 2008 and 2012 by State infants and children; and gave states and local WIC programs more WA flexibility to meet the national and MT ND ME VT cultural needs of WIC participants.79 OR MN NH ID SD WI The final rules were published in NY MA WY MI CT RI March of 2014. IA PA NJ NV NE OH DE UT IL IN l T he WIC program is one of the CA CO MD WV KS MO VA DC longest running nutrition support KY programs in the country. It provides NC AZ TN OK NM AR SC nutrition support to low-income preg- GA Increase nant, postpartum and breastfeeding MS AL Decrease TX LA No Change women, infants and children up to age 5 who are at risk for inadequate FL AK nutrition.80 WIC participation in HI states ranged from a low of 0.12 per- cent in Wyoming to a high of 16.5 Note: Puerto Rico had a significant decrease. Source: USDA, Food and Nutrition Service percent in California, in 2014.81 SIGNS OF PROGRESS AMONG LOW-INCOME PRESCHOOLERS From 1998 to 2011, the Pediatric [data from children in the WIC; In 1999, the obesity rate for these Nutrition Surveillance System Early Periodic Screening, Diagnosis children was 12.7 percent. It peaked at (PedNSS) tracked obesity rates among and Treatment (EPSDT); and Title V 15.2 percent in 2003 and dropped to low-income children ages 2 to 5 Maternal and Child Health programs]. 14.7 percent in 2011.82, 83, 84 Between 2008 and 2011, obesity rates decreased significantly in 18 states and in the U.S. PedNSS Rates as of 2011 86 Virgin Islands and only increased in three states (out of 43 states).85 WA MT ME Not all states, or federally funded ND VT OR MN clinics within states, participated in ID NH SD WI NY MA PedNSS, which limited the data set. WY MI CT RI IA PA NJ The last PedNSS data was collected NV NE OH DE in 2011. The WIC Participant and UT IL IN CA MD CO WV KS MO VA DC Program Characteristic continues to KY NC collect height and weight information AZ TN OK — along with age and sex and other NM AR SC MS AL GA No Data participant characteristics– and is <10% TX LA ≥10% to <15% conducted biennially in April by USDA in ≥15% all 50 states, Washington, D.C. and U.S. FL AK territories (American Samoa, Guam, the HI Northern Marina Islands, Puerto Rico and the Virgin Islands). Interactive maps and timelines for 1998-2011 are available at stateofobesity.org. The data for PedNSS is based on actual measurements rather than self-reported data. 28 TFAH • RWJF • StateofObesity.org l HILDREN AGES 10 to 17: Nearly C Percentage of Children Ages 10 to 17 Classified as Obese by State, 2011 National one-third (31.3 percent) of children Survey on Children’s Health ages 10 to 17 are overweight or obese [2011-2012, National Survey of WA Children’s Health, phone surveys of MT ND ME VT parents in each state].87, 88 OR MN NH ID SD WI NY MA l R ates ranged from a low of 9.9 WY MI CT RI IA PA NJ percent in Oregon to a high of 21.7 NV NE OH DE IL IN percent in Mississippi. CA UT CO MD WV KS MO VA DC KY l S even out of 10 states with the NC TN highest rates are in the South. The AZ NM OK AR SC obesity rate in the South (41.8 GA <10% MS AL percent) was nearly three times ≥10% to <15% TX LA ≥15% to <20% the rate in the Northeast (14.6 ≥20% to <25% FL percent). Rates in the Midwestern AK HI states were 22.2 percent and 21.5 percent in the West. l R ates exceeded 15 percent in An interactive map and timeline of these data are available at stateofobesity.org 19 states and were 20 percent or Source: National Survey on Children’s Health, 2011 above in four states. TFAH • RWJF • StateofObesity.org 29 l igh School Students: 13.9 percent H l I n 2015, obesity rates ranged from a of high school students are obese, low of 10.3 percent in Montana to a and an additional 16.0 percent high of 18.9 percent in Mississippi. are overweight [2015, Youth Risk l O besity rates exceeded 15 percent in Behavior Surveillance System, 37 states eleven states, were between 10 and participating, self-reported data].89 15 percent in 26 states and no states were below 10 percent. PERCENTAGE OF HIGH SCHOOL STUDENTS WHO WERE OBESE—SELECTED U.S. STATES YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM, 201590 An interactive map and timeline of these among Latinos, 15.9 percent among data are available at stateofobesity.org American Indian/Alaska Natives and 12.4 percent among Whites. Nationally, self-reported obesity among high school students has increased by l A mong females: Blacks have a rate of 31.1 percent, from 10.6 percent in 1999 15.2 percent, Latinas of 13.3 percent to 13.9 percent in 2015.91 and Whites of 9.1 percent. l R ates are higher among males (16.8 l A mong males: Latinos have a rate of percent) than females (10.8 percent). 19.4 percent, Blacks of 18.2 percent and Whites of 15.6 percent. l R ates vary by race/ethnicity: 16.8 percent among Blacks, 16.4 percent Percentage of High School Students Classified as Obese by State, 2015 YRBS WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA No Data ≥10% to <15% TX LA ≥15% to <20% FL AK HI Note: U.S. Territories: Guam = 20.4 percent, Northern Mariana Islands = 16.0 percent, Palau = 14.1 percent, and Puerto Rico = 11.1 percent; data not available for Colorado, District of Columbia, Georgia, Iowa, Kansas, Louisiana, Minnesota, New Jersey, Ohio, Oregon, Texas, Utah, Washington and Wisconsin. Source: CDC, Youth Risk Behavior Surveillance System 30 TFAH • RWJF • StateofObesity.org Obesity Rates for High School Students by Race/Ethnicity and Gender, YRBS 1999 to 2015 1999 2001 2003 2005 2007 2009 2011 2013 2015 TOTAL 10.6% 10.5% 12.0% 13% 12.8% 11.8% 13% 13.7% 13.9% BY RACE/ETHNICITY American Indian/ Alaskan Native§ N/A 17.2% 17.5% 13% 19.5% 8.2% 17.5% 9.10% 15.9% Asian§ 3.6% 6.7% 6.8% 5.4% 7.2% 7.2% 9.8% 5.6% 5.5% Black § 12.3% 16.0% 16.1% 15.9% 18.3% 15.0% 18.2% 15.7% 16.8% Latino 13.2% 15.1% 16.2% 16.7% 16.3% 14.9% 14.1% 15.2% 16.4% Native Hawaiian/ Other Pacific Islander § 12.5% 7.5% N/A N/A N/A 20.1% 21.4% 7.5% N/A White§ 10.0% 8.8% 10.3% 11.7% 10.6% 10.2% 11.5% 13.1% 12.4% Multiple Race§ 11.2% 9.2% 9.6% 13.5% 13.5% 13.4% 13.6% 15.2% 17.5% BY GENDER Female 7.4% 6.9% 8.1% 9.9% 9.4% 8.1% 9.8% 10.9% 10.8% Male 13.7% 14.2% 15.7% 15.9% 16.2% 15.2% 16.1% 16.6% 16.8% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic Obesity Rates for High School Students by Race/Ethnicity and Gender, YRBS 1999 to 2015 1999 2001 2003 2005 2007 2009 2011 2013 2015 ASIAN § Female 0.7% 2.7% 1.9% 1.3% 2.3% 3.5% 5.3% 2.1% 1.9% Male 5.9% 10.8% 11.1% 8.8% 11.4% 10.9% 13.8% 9.9% 8.3% BLACK§ Female 12.3% 14.6% 13.9% 16.0% 17.6% 12.5% 18.6% 16.7% 15.2% Male 12.3% 17.5% 18.2% 15.8% 18.9% 17.5% 17.7% 14.8% 18.2% LATINO Female 9.2% 8.8% 11.3% 11.9% 12.4% 10.8% 8.6% 11.4% 13.3% Male 17.3% 21.4% 21.2% 21.2% 20.2% 18.8% 19.2% 19.0% 19.4% WHITE§ Female 6.1% 5.3% 6.3% 8.2% 6.7% 6.1% 7.7% 9.7% 9.1% Male 13.5% 12.4% 13.9% 15.1% 14.5% 13.7% 15.0% 16.5% 15.6% MULTIPLE RACE Female 7.7% 6.7% 2.6% 11.6% 8.2% 10.3% 12.5% 14.4% 14.3% Male 16.0% 12.3% 16.6% 15.4% 20.2% 17.3% 14.8% 16.1% 21.1% Note: Breakdowns not available for American Indian/Native American and Native Hawaiian/Other Pacific Islanders – less than 100 respondents for each of the subgroups. § = non-Hispanic. TFAH • RWJF • StateofObesity.org 31 FOOD-INSECURE CHILDREN More than 15 million U.S. children live or skip meals sometimes due to lack a high of 20.8 percent in Mississippi. in “food-insecure” households — having of funds — which can contribute to Very low food security—when one or limited access to adequate food and increased risk for obesity. In addition, more members of a household reduces nutrition due to cost, proximity and/or stress, anxiety and less access to safe, their food intake or disrupts their eating other resources.92 Low income individuals convenient places for physical activity can patterns because of insufficient money are at increased risk for both food contribute to increased risk for obesity. and other food resources—range from insecurity and obesity. Lower-income 2.9 percent in North Dakota to 7.9 in Food insecurity is particularly concentrated individuals often have more limited access Mississippi.97 According to a review in different areas around the country — in to affordable, healthier food options — by the U.S. Department of Agriculture, 321 counties, the average food insecurity living in neighborhoods with fewer grocery food insecurity in states varies by, and rate is 23 percent, while in the other stores with less healthy options — and depends on, household factors, such 2,821 counties, the average rate is 15 that have more available less expensive as income, employment and household percent.96 Fifty percent of the high food- food options, such as processed or fast structure (i.e. single parents), as well insecurity counties are in rural areas, 26 foods, are of lower nutritional value and as state-level characteristics, such as percent are metropolitan and 90 percent are calorie-dense with added sugar and/ average wages, cost of housing, levels of are in the South. or fats. 93, 94, 95 In addition, some families participation in food assistance programs have cycles of food deprivation and Rates of child food insecurity range from (including summer meal programs for overindulgence — where they restrict a low of 8.5 percent in North Dakota to children) and tax policies.98 Child Food Insecurity in The United States Source: Feeding America 32 TFAH • RWJF • StateofObesity.org l L ow-income Americans (at/under 100 U.S. Households with Children by Food Security Status of Adults and Children, 2014 percent of the FPL) spend a larger Food insecurity among adults only in percentage of their income on food households with children – 9.8% (16.1 percent) but spend less in real dollar amounts ($35 per person Low food security Food-insecure among children – per week) than do higher-income households – 8.3% Food-insecure, 19.2% Americans (13.2 percent; $50 per children Very low person per week).99, 100 food security and adults – among 9.4% l A pproximately 25 percent of Black and children – 1.1% Latino families experience food-insecurity Food-secure households compared to 11 percent of White 80.8% households.101 Black and Latino families have earned $1 for every $2 earned by Source: Calculated by ERS using data from the December 2014 Current Population Survey Food White families for the past 30 years. 102 Security Supplement l N early 60 percent of counties where Native American/Alaska Natives make up the majority population have the highest food-insecurity rates in the nation. Among all 3,142 Native American/Alaska Native counties, Food Insecurity Rate those living in Apache County, Arizona (at 42 percent) and Wade Hampton, Alaska (at 40 percent) have the highest child food-insecurity in the nation, approximately double the national rate of 20.9 percent.103, 104 l B lack and Latino families spend around $10 per person per week less on food ($40 to $44) compared with White families ($50).105 ZIP codes with the highest concentration of Blacks have about half the number of chain supermarkets as ZIP codes with the highest concentration of Whites, and ZIP codes with the highest concentrations of Latinos have only one- third as many.106 Many of these same neighborhoods also are struggling with high rates of obesity and unemployment and depressed economies. l A mong counties where American Share of American Indian and Alaska Natives Indian/Alaska Natives are the majority population, the average meal price was Sources: Feeding America Community Survey 2010–14 Note: American Indian and Alaska Natives are those who indicate American Indian and Alaska Native alone and no Hispanic ethnicity $3.18, and went as high as $4.14, TFAH • RWJF • StateofObesity.org 33 compared with the average meal across l F amilies in predominantly minority all U.S. counties of $2.82. Those and low-income neighborhoods have same counties are also grappling with limited access to supermarkets and high levels of poverty (at 32 percent) fresh produce.  Greater accessibility and unemployment (at 10.8 percent). 107 to supermarkets is consistently linked to lower rates of overweight and More than 29 million Americans live obesity.109 Studies have found that in “food deserts,” meaning they do there is less access to supermarkets not have a supermarket or supercenter and nutritious, fresh foods in many within a mile of their home if they live urban and lower-income neighborhoods in an urban area, or within 10 miles of and less healthy items are also often their home if they live in a rural area, more heavily marketed at the point-of- making it challenging to access healthy, purchase through product placement in affordable food.108 these stores.110, 111 Female-headed households with children consistently have higher rates of food insecurity than other households with children Food insecure 45 Female head, no spouse Male head, no spouse 40 With children under age 6 Married-couple families 35 30 P ercent of households with children 25 20 15 10 5 G reat R ecession 0 Dec '07 J une '09 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: USDA, Economic Research Service 34 TFAH • RWJF • StateofObesity.org PRENATAL AND MATERNAL HEALTH Percent of Women Classified as Obese Prepregnancy by State, 2011 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA No Data ≥15% to <20% TX LA ≥20% to <25% ≥25% to <30% FL AK HI Note: Puerto Rico = 20.5 percent Source: CDC, National Vital Statistics Reports, U.S. Birth Certificate Nearly one in four (23.4 percent) women mother.112 More than 6 percent (approxi- are obese before becoming pregnant — mately one in 16) of pregnant women have which can increase the risk for a wide range or develop diabetes during pregnancy — of health complications for the baby and the known as gestational diabetes.113 TFAH • RWJF • StateofObesity.org 35 WOMEN ENROLLED IN WIC AND WERE OBESE PREPREGNANCY 1994, 2004 AND 2014 Percent of Women Enrolled in WIC and Classified as Obese Percent of Women Enrolled in WIC and Classified as Obese Prepregnancy by State, 1994 Prepregnancy by State, 2004 WA WA MT ND ME MT ND ME VT VT OR MN OR MN ID NH ID NH SD WI NY MA SD WI NY MA WY MI WY MI CT RI CT RI NE IA PA NJ NE IA PA NJ NV NV UT IL IN OH DE UT IL IN OH DE CA MD CA MD CO WV VA CO WV VA KS MO DC KS MO DC KY KY NC NC AZ OK TN AZ OK TN NM AR SC NM AR SC MS AL GA MS AL GA TX LA TX LA FL FL AK AK HI HI No Data ≥1% to <5% ≥5% to <10% ≥10% to <15% No Data ≥1% to <5% ≥5% to <10% ≥10% to <15% ≥15% to <20% ≥20% to <25% ≥25% to <30% ≥30% to <35% ≥15% to <20% ≥20% to <25% ≥25% to <30% ≥30% to <35% ≥35% to <40% ≥40% ≥35% to <40% ≥40% Note: American Samoa = 36.3 percent, Guam = 28.0 percent, Puerto Rico Note: The Virgin Islands = 21.7 percent. = 20.3 and the Virgin Islands = 32.4 percent. Source: USDA, Food and Nutrition Services Source: USDA, Food and Nutrition Services Percent of Women Enrolled in WIC and Classified as Obese The rate of women who were obese before becoming pregnant and Prepregnancy by State, 2014 participating in the WIC program has dramatically increased over the WA past 20 years, increasing 86 percent from 19.2 percent in 1994 to MT ND ME OR MN VT almost 36 percent in 2014.114, 115 In 1994, the rates ranged from a ID NH WY SD WI NY MA low of 1 percent in Iowa to a high of 24.7 percent in Vermont. MI CT RI NE IA PA NJ NV UT IL IN OH DE By 2004, 28.8 percent of women who were enrolled in the WIC CA MD CO WV VA KS MO KY DC program were obese prior to becoming pregnant.116 Rates ranged NC AZ OK TN from a low of 21.1 percent in Rhode Island to a high of 34.3 in NM AR SC MS AL GA Alabama. Nineteen states and Washington D.C. had more than TX LA a 20 percent increase of women being obese, with five states AK FL having more than a 45 percent increase. [19 states out of 31 and HI Washington, D.C. reported data in 1994 and 2004.] And by 2014, the percent of women who were obese doubled No Data ≥1% to <5% ≥5% to <10% ≥10% to <15% ≥15% to <20% ≥20% to <25% ≥25% to <30% ≥30% to <35% in 13 states and Washington, D.C. 117 Iowa had the greatest ≥35% to <40% ≥40% increase from 1 percent in 1994 to 40.8 percent in 2014, fol- Note: America Samoa = 26.9 percent, Guam = 36.6 percent and the lowed by Illinois, which increased by more than seven times, Virgin Islands = 30.2 percent. from 5 percent in 1994 to 35.9 percent in 2014. [19 states out Source: USDA, Food and Nutrition Services of 44 and Washington D.C. reported data in 1994 and 2014.] 36 TFAH • RWJF • StateofObesity.org Maternal health — including obesity, poor nutrition and type 2 mortality rate (6.0 per 1,000 live births, 2013) is almost twice as diabetes — can increase risk for miscarriages, birth defects, high as some comparable countries — the average infant mortal- slow fetal growth, prematurity and low birth weight babies. ity in comparable countries is 3.5 per 1,000 live births.123 The Poor maternal nutrition can also lead to increased risk for ab- United States ranks 24th among developed countries.124 normal brain development, developmental delays, diabetes, hy- Good prenatal healthcare is important to help reduce risks and pertension, heart disease, obesity and lower IQ in babies.118, 119 complications. Many experts, however, now believe that much of l O ne in nine children in the United States is born prematurely prenatal care, which usually begins during the first three months of (before 37 weeks of gestation or 3 weeks early). Premature pregnancy, comes too late to prevent many serious maternal and births cost the country $26.2 billion annually, or $51,600 per childhood health problems. Even the first few weeks after concep- baby, in direct medical and lifetime added costs.120, 121 tion are critical for healthy fetal development. Medical professionals recommend an increased focus on regular well-care and preventive l O n average, there were approximately 23,400 infant deaths per healthcare for women throughout childbearing age, including screen- year in the United States over the past decade.122 The U.S. infant ing for risk of obesity and related chronic health conditions. BREASTFEEDING HEALTH BENEFITS OF BREASTFEEDING The American Academy of Pediatrics (AAP) recommends breast- feeding as a natural source of nutrition that “provides the healthi- There are mixed findings on the potential relationship be- est start for an infant.” The NAM and AAP recommend that babies tween breastfeeding and obesity among infants.128, 129, 130 be breastfed exclusively for about the first 6 months and should However, there are a number of identified health benefits continue breastfeeding through the first year of life. 125, 126, 127 for breastmilk as the “first food.” In addition, there are weight-related benefits that have been identified for mothers who breastfeed.131, 132 Women who exclusively breastfeed Percent of Infants Exclusively Breastfeeding at Six Months for at least three months loose up to 3.2 pounds more com- by State, 2013 Births pared to women who do not breastfeed or breastfeed non WA exclusively one-year postpartum, and are more likely to return MT ND ME OR MN VT to the same or lower BMI as prepregnancy.133 ID NH SD WI NY MA WY MI CT RI l I nfants: Lower risk of ear and gastrointestinal infections, nec- NE IA PA NJ NV IL IN OH DE rotizing enterocolitis (a gastrointestinal disease), diabetes and CA UT MD CO WV VA KS MO KY DC obesity.134 Some research suggests it may also reduce risk TN NC for asthma and allergies, childhood leukemia and sudden in- AZ OK NM AR SC fant death syndrome (SIDS).135, 136, 137, 138 Some research has MS AL GA TX LA found children who are breastfed longer are more likely to have FL better developed language skills, verbal and nonverbal intelli- AK HI gence during childhood, greater upward social mobility, higher neurological development and lower stress markers.139, 140 <10% ≥15% to <20% ≥25% to <30% ≥10% to <15% ≥20% to <25% ≥30% l M others: Lower risk of breast and ovarian cancer, type 2 diabetes and postpartum depression. It has been shown Note: Puerto Rico = 20.1 percent. to help mothers bond with the child and mothers who nurse Source: CDC, Division of Nutrition, Physical Activity and Nutrition miss less work.141, 142 l E conomic: Families can save on cost of formula. In addi- Only around half (51.8 percent) of infants are breastfeeding at tion, around $2.2 billion could be saved in annual medical 6 months — with rates of exclusive breastfeeding rates ranging costs if breastfeeding recommendations were met.143 from 9.3 percent in Mississippi to 33.8 percent in Montana.144 TFAH • RWJF • StateofObesity.org 37 S EC T I ON 3 : The State of SECTION 3: HIGH-IMPACT POLICY OPPORTUNITIES High-Impact Policy Opportunities Obesity: Currently, millions of Americans are not getting adequate or Obesity Policy recommended levels of quality nutrition or physical activity. Series The health and social risks are every day. Research particularly supports particularly acute for children. strategies that target young children— Unhealthy weight, poor nutrition and practicing healthy habits at a young age insufficient physical activity increases makes it more likely that those habits will a child’s risk for physical, mental, continue into adulthood. behavioral, emotional, learning and In this section, TFAH and RWJF review a dental problems — including making it range of recent policy trends, changes and hard to perform basic tasks and regulate opportunities that build on lessons learned their social-emotional behavior.145 and leverage promising approaches to A range of strategies can make it easier promote a healthy weight in all children for Americans to make healthier choices and healthy lives for all adults. A. EARLY CHILDHOOD POLICIES AND PROGRAMS It is easier and more effective to prevent children both at home and in child overweight and obesity during early care settings. Many of these efforts childhood than reverse trends later in focus on providing support via families, life. Starting in early childhood pays the neighborhoods, healthcare services and biggest dividends; by promoting good child care programs. nutrition and physical activity from the A recent research review of early start, children will be more likely to childhood obesity prevention efforts enter kindergarten at a healthy weight in the first 1,000 days of life conducted and maintain healthy habits for life. by Healthy Eating Research found Rates of overweight and obesity are that efforts focusing on multiple risk highest among children from low-income factors and delivered at multiple levels families and racial and ethnic inequities (individual, family and community) persist as they age. These trends are often through various sectors (healthcare, related to limited access to affordable, industry and policy) may help reduce nutritious food and lack of safe, the risk of childhood obesity.146, 147 convenient places to be physically active. Researchers concluded that “the challenge now is to be innovative in There are a number of federal policies the creation of population-level obesity and programs aimed specifically at SEPTEMBER 2016 prevention interventions that are cost- improving nutrition, activity and effective and sustainable.”148 health for infants, toddlers and young Key policies highlighted in this section include: l C hild and Adult Care Food Program l C DC’s Early Childhood Initiatives — (CACFP) Technical Assistance, School Health Grants and National Early Care and l I mplementation of the 2014 Education Learning Collaborative Reauthorization of the Child Care and Development Block Grant (CCDBG) l W IC — Continued Emphasis on Nutrition and Breastfeeding Support l S tate Obesity-Related Child Care Licensing and Standards Trends l A dditional Measures to Increase Breastfeeding Support — Through l H ead Start — Performance Standards Insurance, Medical Practices and l I mplementation of the Early Workplace Policies Education Components of Every Student Succeeds Act (ESSA) of 2015 Budgets for Some Key Federal Child Care and Enacted Budget Obesity-Related Programs FY 2016 Child and Adult Care Food Program (USDA) $3.340 billion149 Child Care and Development Block Grant $2.761 billion150 Head Start $9.168 billion151 WIC (USDA) $6.35 billion152 Note: For some of these programs, only a portion of the funding goes toward obesity-related activities (i.e., nutrition, physical activity). TFAH • RWJF • StateofObesity.org 39 NUTRITION AND PHYSICAL ACTIVITY IN INFANTS, TODDLERS AND YOUNG CHILDREN Currently, significant number of infants, l L imit Screen Time: The NAM also toddlers and preschoolers do not meet recommends that parents and the Dietary Guidelines for Americans caregivers limit young children’s or AAP recommendations for a healthy screen time, since it promotes diet or sufficient physical activity. 153 sedentary behavior and takes away Chronic poor nutrition (from food of from time that could be spent in more poor nutritional value and/or hunger) physical activities.157, 158 NAM also and insufficient activity impairs physical recommends keeping children active development, as well as the cognitive throughout the day and ensuring development of zero- to 3-year-olds — a adequate sleep each night. AAP the , time of rapid brain growth, changing the American Public Health Association fundamental neurological architecture of (APHA) and the National Resource the brain and central nervous system. Council for Health and Safety in In addition, malnourished children have Child Care and Early Education lower academic achievement and more recommends no more than 30 social and behavioral problems.154 minutes of screen time per week for children in child care and early l M eeting Recommended Activity education settings for education or Levels: According to Shape America, physical activity use only.159 each day, toddlers (2- to 3-year-olds) should get at least 30 minutes of l R ecommended Nutrition: Around structured physical activity (adult-led); one-third of toddlers and preschoolers at least 60 minutes unstructured (ages 2 to 4) do not eat any fruits physical activity (free play); and not be or vegetables in a given day, and inactive for more than one hour at a only one-third meet the daily time (except for sleeping). 155 Active recommendation of one cup of fruit children have lifelong health benefits and 1 cup of vegetables for children of stronger muscles and bones, leaner ages 2 to 3 and one to one-and- bodies by controlling body fat, lower one-half cups for children ages 4 risk of high blood pressure or high to 8. French fries are the most blood cholesterol levels and are less eaten vegetable by toddlers and likely to become overweight or obese preschoolers.160, 161 and to develop type 2 diabetes. 156 l N o Sugar-Sweetened Beverages: l S afe and Accessible Places to be The AAP recommends pediatric Active: Unsafe conditions and neigh- practice should aim to remove all borhoods and limited knowledge sugar-sweetened beverages from among parents and caregivers about children’s diets, “because there is recommended types and amount of no evidence for the health benefits activity at each stage of development of sugar-sweetened beverages,” can contribute to young children not which currently make up 8 percent of being sufficiently active. children’s total daily calories.162, 163 40 TFAH • RWJF • StateofObesity.org Child and Adult Care Food Program — 2016 Standards More than half of American children under the age of 6 regularly spend a significant amount of time in child care settings.164 And, more than 11 million children under age 6 spend an average of 30 hours in non-parental child care settings, with children of working parents spending almost 40 hours a week in child care sites.165 CACFP provides nutritious meals and The updated standards build on a snacks to more than four million children 2011 requirement that child care sites each day in Head Start/Early Head Start, participating in CACFP make drinking child care centers and home- and family- water available throughout the day and based day care centers.166, 167 In April serve only low-fat or non-fat milk to 2016, USDA released updated nutrition children ages 2 and older. standards for food and beverages served The program provides child care through CACFP, as part of a requirement operators with specific meal patterns of the Healthy, Hunger-Free Kids and portion sizes, and provides sample (HHFK) Act of 2010 to better align with menus and meal planning training the most current nutrition science and to child care providers. Studies show the Dietary Guidelines for Americans. that child care programs participating The standards include more whole in CACFP serve meals that are more grains; a greater variety of vegetables nutritious — including higher amounts and fruits; less added sugars and solid of key nutrients and fewer servings of fats; healthy beverages, including low- fats and sweets — than those served fat and fat-free milk; and support for by child care programs that do not breastfeeding. The requirements were participate in CACFP.168 designed to be “significant, achievable and cost-neutral.” This was the first major Many child care providers face revision to CACFP’s meals since 1968. challenges in implementing the new Implementation is required by October 1, standards.169 For instance, many 2017. The new standards have the added providers — particularly small, benefit of being more closely aligned with individual-owned providers — have recently-updated nutrition standards for limited food budgets and preparation the School Breakfast Program and the facilities and/or lack sufficient National School Lunch Program. nutrition training.170, 171 TFAH • RWJF • StateofObesity.org 41 Implementation of the 2014 Reauthorization of the Child Care and Development Block Grant CCDBG, the primary federal funding Healthy Child Care, Healthy Communities l ncouraging healthy relationships E stream for child care assistance for — an initiative of Child Care Aware of with food and physical activity: Early low-income families, was reauthorized America supported by a grant from RWJF learning and development guidelines in 2014 and included a set of stronger — is providing technical assistance to six should support eating competency requirements to; 1) protect the states around implementation of CCDBG, as the preferred social-emotional- health and safety of children in care including policies and toolkits for support behavioral intervention in response through more consistent standards and creating healthier child care environments to promoting healthy relationships monitoring of standards; 2) improve via their state plans, which were required with food. Guidelines should support the quality of care, including increased by March 2016 with compliance required family-style meals and socialization supports for child care providers; and 3) by September 30, 2016. States continue to during meal-times, which helps build enable families to easily access child care have the opportunity to update practices emotional, gross and fine motor assistance to support stable, continuous to align with recommendations beyond development — as well as promoting care that is better coordinated with their formal plans. Some key areas of opportunities for children’s active other programs and resources.172, 173 emphasis include:174 play every day; and The law provides some new l mplementing best practice standards I l rofessional development, education P opportunities for states, localities and for nutrition, physical activity and and training for providers: Caregivers child care providers to better promote health — and maintaining continuous and staff should receive ongoing nutrition, activity and health education quality improvement: There should be continuing education and professional for families. States must provide written policies to support infant/child development opportunities in health, information on public-facing websites nutrition, screen time, physical activity nutrition and physical activity standards; about eligibility for the Supplemental and breastfeeding, ongoing provider including support for breastfeeding. Nutrition Assistance Program (SNAP) training and consistent parent and care- A review of CCDBG by the Center for and CACFP; research and best practices giver communication around common Law and Social Policy (CLASP) and on healthy eating and physical activity; healthy eating and active play messaging. the National Women’s Law Center and may include information about Policies should be aligned with (NWLC) identified a key challenge: a training requirements for child care established evidence and research. large number of new requirements were staff. States must also use a portion Best practice information should be added for states but funding was not of their funding (7 percent in fiscal disseminated to provide clear, consistent, significantly increased to implement the year (FY) 2016-2017; 8 percent in FY age-appropriate guidance to parents changes. Discretionary CCDBG funding 2018-2019; and 9 percent in 2020) and caregivers through multiple (starting at a base of $2.44 billion in to support at least one of 10 defined mediums — supporting positive meal- FY 2015) was increased by 16 percent activities. Activities include: training time experiences and inclusive feeding over six years and mandatory funding and professional development of the consideration for children with special remained flat at $2.92 billion annually.175 child care workforce using scientifically- needs. Best practices should be The FY 2016 budget allocation for based, age appropriate strategies to aligned as well as possible with CCDBG was $2.76 billion.176 According promote development of a young child; Quality Rating and Improvement to their assessment, the funding is not training on children’s learning and Systems (QRIS) standards; sufficient for raising health and safety nutritional and physical activity needs; l eferrals and integration with R standards, increasing quality of care and and supporting efforts to develop high- healthcare, health and other social maintaining core support for child care quality health, mental health, nutrition, services: There should be systems in assistance to low-income families. The physical activity and development place to refer children and families to actual discretionary funding level must be standards. CCDBG reauthorizes the other local health and social service allocated by Congress annually. States are Child Care and Development Funds programs, including nutrition and also required to contribute matching and (CCDF) for states, and each state has breastfeeding programs as needed; maintenance-of-effort (MOE) funding. created a plan for FY 2016 to FY 2018. 42 TFAH • RWJF • StateofObesity.org STATE REQUIREMENTS FOR CHILD CARE SETTINGS States can set licensing and/or other requirements for child care providers to operate in the state — including setting standards related to obesity, nutrition and physical activity. In addition, 41 states and Washington, D.C. have adopted QRIS Standards to help improve the availability of quality child care. QRIS Standards provide a frame- work for improving child care by making program quality comparable across the field, creating and aligning program stan- dards with early learning and child care practitioner standards, developing and aligning infrastructure to support quality improvement and assessing achievement ical activity and screen time (between including a mix of moderate and vigorous along a continuum.177 States’ systems July 2015 and November 15)—HEPA physical activities that promote bone differ significantly in their level of funding standards support QRIS standards in and muscle strengthening. Play will take support and implementation status.178, 179 promoting quality child care settings. 181 place daily outdoors whenever possible. In addition, different states have different Twenty-one types of child care settings, l S creen Time: Eliminate screen time for requirements for how QRIS and licensing varying by state, were reviewed including: children under two years of age. For chil- requirements can work together. In some Child Care Centers and Child Care Fam- dren over two, screen time is limited to states, for instance, licensing works as a ily Centers for infants to 13-year-olds; less than 30 minutes per day for children first step of the QRIS process or is a pre- school-age child care for 5-years-old in half-day programs and less than one requisite for participating in QRIS. and older; Day Care Homes for children hour per day for those in full-day programs. Two organizations, Nemours and Voices under the age of 12; and Day Care Cen- l F ood: Serve fruits or vegetables at every for Healthy Kids (VFHK), have conducted ters for children under the age of 18. meal and snack. Children serve them- reviews of Early Childhood Education stan- The review found that for afterschool selves (family-style). No partially hydro- dards related to obesity. The chart on programs, only Alaska had requirements genated oils (trans fat), fried or pre-fried pages 44-45 reflects the findings of differ- for outdoor activities when possible, for foods. Serve whole grains when grains ent state requirements. promoting a mixture of types of physical are served. Serve foods free of sugar as activity and limits on screen time. l N emours — a pediatric care organiza- one of the first three ingredients or less tion, committed to the health of children HEPA standards include: 182 than eight grams of added sugar. in Delaware, New Jersey, Pennsylvania l R ole modeling: Staff model healthy l B everages: Offer water at the table and Florida, as well as research, educa- eating and active living. during every meal and accessible at all tion and advocacy — conducted a scan l F amily engagement: Engage times. Serve only water and plain, low- of obesity prevention standards in state parents/caregivers using informational fat (one percent) or non-fat milk. licensing requirements and QRIS sys- materials and/or activities focused on l I nfant Feeding: Adults who work with in- tems, as of March 2016.180 healthy eating and physical activity a fants and their families should promote l I n addition, the Public Health Law Cen- minimum of once a quarter. and support exclusive breastfeeding for ter conducted a review of the Y-USA’s l P hysical Activity: Ensure that children six months and continuation of breast- Healthy Eating and Physical Activity engage in at least 30 minutes of feeding in conjunction with complemen- (HEPA) standards with state child care physical activity for half-day programs tary foods for one year or more. licensing laws and regulations for phys- and 60 minutes for full-day programs, TFAH • RWJF • StateofObesity.org 43 AHA VOICES FOR HEALTHY KIDS STATE POLICY REVIEW ON OBESITY PREVENTION: EARLY CHILDHOOD EDUCATION Early Childhood Education (Ages 0 to 5) Physical Activity (PA) Screen Time (ST) Child and Adult Defined PA: State Mixture of Screen Time Defined: Screen Time Screen Time Limits for Care Food Program defines PA as Activities: State Infant Varied Infant Tummy State defines Limits for Children Under the Age (CACFP): State moderate or requires mixture Outdoor PA: Activity: State Time: State screen-time to Children Under of Two: State limits has licensing vigorous for at of moderate and State requires requires indoor requires daily include T.V., movies, the Age of Two: screen time to 1 laws linked to least: 60 mins/day vigorous actives, active play and outdoor tummy time cell phones, video State eliminates hour/day for full-day CACFP that for full-day and 30 including bone- outdoors activities for infants less games, computer, screen time for programs and 30 automatically mins/day for part- and muscle- whenever under adult than 6 months and other digital children under mins/day for part-day State* update day programs strengthening possible supervision of age devices the age of two programs Alabama √C,F √C,F √C,F √C,F Alaska √A Arizona √C √C √C √C √C Arkansas √D,F √C √C √C √C √C California √C Colorado √C √C √C,F √C,F √C,F √F √C √C Connecticut √D √C √C Delaware √C,F √C,F √F √F D.C. √V N/A N/A N/A N/A N/A N/A N/A N/A Florida √C,F √C √C √C √C Georgia √L √C √C √C √C √C √C Hawaii √D,G,F √C,F Idaho √C Illinois √F √F √F Indiana √C,F √C,F √C,F Iowa √D,V √C Kansas √C √C Kentucky √C,F Louisiana √A √C √C Maine √C √C √C Maryland √D,G,F √C √C √C √C √C Massachusetts Michigan √C,F √C √C Minnesota √D √C Mississippi Missouri √C,F √C,F Montana √D,F Nebraska √C,F √C,F Nevada New Hampshire New Jersey √D,F √C,F √C,F √C,F √C,F New Mexico √D,F √C,F √C,F √C,F New York √D North Carolina √D,F √C,F √C,F √C,F √C √C,F √C,F √C,F √C,F North Dakota √C,F Ohio √C √C Oklahoma √C,F √C Oregon √C √C √C Pennsylvania √D Rhode Island √D,F √C √C √C √C √C √C √C South Carolina √D √C South Dakota Tennessee √C,F √C,F √C,F Texas √C,F √C,F √C,F √C Utah √D,F √C,F √C Vermont √C,F √C,F Virginia √C √C √C √C √C Washington √F √C,F √C,F √C,F West Virginia √D √C √C √C,F √F √C,F √C √C √C Wisconsin √D,F √F √F √F √F Wyoming √C,F Total States 20 States + D.C. 8 States 23 States 32 States 27 States 13 States 10 States 12 States 7 States Note: *Applies to Child Care Centers or Child Care Family Care Homes only. √ = State has a law, statute or both. A = All Child Care Facilities;C = Child Care Centers D = Child Day Care Centers; G = Child Care Group Homes; F = Child Care Family Homes; L = Child Learning Centers; V = Child Development Centers; N/A = Data was not collected for D.C. 44 TFAH • RWJF • StateofObesity.org NEMOURS STATE POLICY REVIEW ON OBESITY PREVENTION: EARLY CHILDHOOD EDCUATION State Early Childhood Education (ECE) Licensing Regulations/Quality Rating and Improvement System (QRIS) Standards to Prevent Obesity (Ages 0 to 5) Private Breastfeeding Nutritional USDA Space: State Screen Time: State Standards: State Breastfeeding: State has regulations Physical Activity: has regulations Drinking Water: State has regulations Healthy Eating: State has regulations requiring licensed State has requiring licensed has regulations requiring licensed CACFP: State has regulations requiring licensed ECE programs to regulations ECE programs that requiring licensed ECE programs has regulations requiring licensed ECE programs have a private requiring licensed either prohibit ECE programs to to provide food requiring licensed ECE programs to to allow/ space available ECE programs to screen time for make drinking (meals and ECE programs to have healthy eating encourage onsite for mothers to have time for daily children under age water available to snacks) that meet meet CACFP for State* policies breastfeeding breastfeed infants physical activity 2 or sets limits children USDA standards” meals and snacks Alabama √L √L √L √L √L √L Alaska √ L √ L √ L √ L √L Arizona √L √L √L √L √L Arkansas √L,Q √L √L,Q √L √L √L California √L √L √L √L Colorado √L,Q √L,Q Connecticut √L √L √L Delaware √ L,Q √ L √ L,Q √ L √L D.C. √L √L √L √ L √L Florida √ L √ L √ L √ L √L Georgia √L,Q √L √L,Q √L √L √L Hawaii √ L √ L √ L √L Idaho √Q √Q Illinois √L √L √L √L Indiana √L,Q √L √L,Q √L,Q √L Iowa √ L,Q √ L √L √L Kansas √L √L √L Kentucky √L √L √L √L Louisiana √L √L √L √L Maine √ L √ L,Q √ L √ L Maryland √L,Q √L,Q √Q √L √L √Q Massachusetts √ L,Q √ L,Q √ L √L Michigan √L,Q √L √L,Q √L √L √L √Q Minnesota √ L,Q √ L,Q √ L √L Mississippi √L √L √L √L √L √L √L Missouri √ L √ L √ L Montana √L,Q √L,Q √L √L √Q Nebraska √ L,Q √ Q √ L,Q √ Q √L √Q Nevada √L,Q √L,Q √L,Q √L √Q New Hampshire √L √L √L New Jersey √L,Q √Q √L,Q √L √L √L New Mexico √ L,Q √ L,Q √ L,Q √ L √L New York √L,Q √L,Q √L,Q √L,Q √L √L,Q North Carolina √L √L √L √L √L √L √L North Dakota √L,Q √L √L,Q √L √L Ohio √ L √ L √ L √ L √L Oklahoma √L √L,Q √Q √L Oregon √L,Q √L,Q √L,Q √L Pennsylvania √L,Q √L,Q √L Rhode Island √L √L,Q √L √L South Carolina √L,Q √L,Q √L,Q √L √L,Q South Dakota √ L √ L Tennessee √L √L √L √L √L Texas √ L,Q √ L √ L √ L √L √L Utah √L,Q √Q √Q √L,Q √Q √Q √L Vermont √ L √ L √ L √ L √ L Virginia √L √L √L √L √L Washington √ L,Q √ L,Q West Virginia √L √L √L √L √L Wisconsin √ L,Q √ L,Q √ L √ L Wyoming √L √ L Total States 50 States + D.C. 22 States + D.C. 4 States + D.C. 50 States + D.C. 28 States 43 States 26 States + D.C. 5 States Note: *Applies to Child Care Centers or Child Care Family Care Homes only. √ = State has either licensing regulations, QRIS Stanadards or both. L= licensing regulations; Q = QRIS Standards TFAH • RWJF • StateofObesity.org 45 EXAMPLES OF EARLY CHILD CARE INITIATIVES Lets’ Move! Child Care183 Let’s Move! Child Care encourages child care and early 4) everages: give water during meals and throughout the B education providers to meet a basic set of best practices in day and avoid sugary drinks. For children two years and five goal areas: older, serve low- or non-fat milk and four to six ounces maximum of 100 percent juice a day; and 1) hysical activity: provide one to two hours of physical P activity throughout the day, including outside play 5) nfant feeding: provide breast milk to infants of mothers I when possible; who wish to breastfeed, welcome mothers to nurse mid- day and support parents’ decisions with infant feeding. 2) creen time: none for children under age 2 and for S those 2 years and older, limit screen time to 30 minutes The Department of Defense, General Services Administration, per week during child care and no more than one to two Bright Horizons, Knowledge Universe, the Learning Care hours per day at home; Group, New Horizons, YMCA, the Boys and Girls Clubs of America and others have made commitments to the Partnership 3) ood: serve fruits or vegetables at every meal, eat F for a Healthier America to meet the Let’s Move! Child Care meals family-style whenever possible and avoid serving standards that are aligned with the initiative’s goals.184 fried foods; YoungStar185 YoungStar — a quality rating and improvement system of rating out of five). Programs eligible for certification must Wisconsin’s Department of Children and Families — seeks be CACFP participants, provide three months of menus to improve the care children receive by creating incentives that have been reviewed by a nutrition professional and/or to encourage providers to make child care healthier and receive a good score on the Early Childhood Environment educating parents or caregivers on how best to select Rating Scale. Providers can earn additional points by providers. scheduling at least 60 minutes of physical activity each day.186 YoungStar engages with parents, preschools, home-based YoungStar has also partnered with Wisconsin Shares — programs, learning centers and others to ensure children are the state’s child care subsidy program. Through the cared for in places that are healthy and safe. The program partnership, Wisconsin Shares reimbursements are tied to measures the quality of care and rates providers yearly. The YoungStar quality ratings. Partly because of this partnership, organization then provides detailed information to the nearly 75 percent of children in the Wisconsin Shares public. For the providers, YoungStar offers tools and training program attend quality child care centers. to improve care and sets standards for quality of care. YoungStar has rated nearly 4,000 providers that care for To ensure children are engaging in healthy activities, about 44,000 children. In total, more than 700 providers YoungStar requires all providers to serve nutritious foods caring for more than 32,000 children have received three (if the provider wants to have at minimum a three star stars, certifying they serve healthy foods.187 46 TFAH • RWJF • StateofObesity.org Head Start — Performance Standards More than 1.1 million children from low-income families are enrolled in Head Start and Early Head Start programs. More than 80 percent of participants are 3- to 5-year-olds, 38 percent are Latino and 28 percent are Black.188 The programs have a number of requirements for participating providers, including health; nutrition; education; social services; and parental engagement. To support the nutritional needs of enrolled children, Head Start and Early Head Start programs participate in either CACFP or the federal School Meal Programs. For the first time in 40 years, Head Start is revising program standards. Final standards — intended to improve quality, including increased focus on supporting health and well-being — are expected in 2016.189 In 2015, HHS also released a new version of an early learning framework, Head Start Early Learning Outcome Framework (HSELOF), incorporating More than 80 percent of Head Start participants are 3- to 5-year- recent developmental research to olds, 38 percent are Latino and 28 percent are Black. create stimulating and foundational learning experiences and to support better health among young children.190 services — and there are opportunities HSELOF covers five domains: to increase coordination and case approaches to learning; social and management for children and families. emotional development; language and Around 90 percent of children enrolled literacy; cognition; and perceptional, in Head Start are also enrolled in motor and physical development.191 Medicaid, Children’s Health Insurance The framework includes nutrition and Program (CHIP) or state-funded health physical activity, including support for insurance; 97 percent have a medical physical development milestones like home; 91 percent have a dental care balance and coordination, and for home provider; and 97 percent have developing healthy eating habits and recommended immunizations.193 relationships with food.192 Twelve percent of Head Start enrollees A number of Head Start and Early Head are children with disabilities (special Start programs are making concerted plans under Individuals with Disabilities efforts to ensure enrolled children have Education Act (IDEA)), compared to access to and are referred to healthcare 6 percent of all preschool aged children. TFAH • RWJF • StateofObesity.org 47 Implementation of the Early Education Components of Every Student Succeeds Act of 2015 ESSA, the primary law supporting need communities, and will be jointly federal early and secondary education administered by the Department of programs, was reauthorized in Education (Ed) and HHS.195, 196 December 2015 and includes a number l E xplicitly allowing for the use of Title I of provisions that increase options funds (federal grants directed through and flexibility that could support early states to local school districts and childhood education, health and well- public schools with high percentages being.194 Provisions of the law focus on of children from low-income families) the importance of good health (which to help support early education includes nutrition, relationships to programs and encourage planning for food, physical activity and overall well- transition from pre-Kindergarten (pre- being) for young children to thrive and K) programs to elementary schools. be ready for school, and at the same In the past, states and localities have time to reduce the risk for obesity and used only a small portion of Title I associated health problems. Some key money to support early education. early education and health components of ESSA include: l U se of Title II funds for professional education support to provide l C ompetitive Preschool Development programs and activities to meet the Grants — authorized at $250 million needs of young children; to develop annually (for FY 2017 to FY 2020) the skills of principals, teachers or — to provide assistance to states other school leaders; to measure for strategic planning, building whether efforts are progressing; and to partnerships with Head Start providers help address the child’s transition to and other child care/early education elementary school. related organizations and improving parental choice among existing early l E stablishment of Full-Service education options. States may use Community Schools and Promise funds to support school readiness Neighborhoods support “pipeline” of “low-income and disadvantaged” services as a continuum of children and improve transitions to coordinated care for children from the kindergarten K-12 system. Efforts birth through entry into school can include health-related efforts, and success through graduation — social-emotional learning and overall including early childhood services well-being. The program replaces that improve school readiness as the current Preschool Development well as physical and social emotional Grant program, which focused on development. building preschool programs in high- 48 TFAH • RWJF • StateofObesity.org CDC’s Early Child Education Initiatives — Technical Assistance, School Health Grants and National Early Care and Education Learning Collaborative CDC’s Division of Nutrition, Physical Activity and Obesity (DNPAO) supports a number of obesity prevention initiatives designed to embed obesity prevention standards, and implementation support for these standards, into components of state and local early care and education (ECE) systems.197 The agency provides funding, training and technical assistance to a variety of state and community agencies and other organizations to implement obesity prevention efforts targeting ECE settings. The agency developed a framework and technical assistance materials for obesity prevention in ECE settings; convenes experts and disseminates best practices and research; and provides cooperative agreement grant funding to all 50 states and Washington, D.C. to promote school health and prevent and control diabetes, heart disease, obesity and associated risk factors. This funding requires all grantees to promote physical activity in the ECE setting from experts, share tools and receive In addition, in October 2012, CDC training to assist in improving policies launched a five-year cooperative and practices, and participating states agreement with Nemours — a nonprofit work on strengthening support for children’s health organization and obesity prevention in their ECE systems healthcare provider network (to using CDC’s Spectrum of Opportunities conclude in 2017) — to partner with framework as a guide. More than 1,500 states to implement ECE learning programs (child care, Head Start, pre-Ks collaboratives to improve nutrition, and family child care) have participated, breastfeeding, physical activity and serving more than 146,000 children in screen time policies and practices 11 states (Alabama, Arizona, California, at both the state and ECE provider Florida, Indiana, Kansas, Kentucky, levels.198 ECE providers in participating Missouri, New Jersey, Virginia and states exchange ideas with peers, learn Washington.)199 TFAH • RWJF • StateofObesity.org 49 WIC — Continued Emphasis on Nutrition and Breastfeeding Support More than half (52 percent) of all infants in the United States participate in WIC. WIC provides benefits — direct food assistance as well as counseling and education support — to around 8 million low-income individuals, including around 2 million pregnant and post-partum women, 2 million infants and 4 million children under the age of 5.200 Researchers have identified that revised nutrition standards and options that went into effect in the WIC program in 2009 and increases in breastfeeding contributed to a decline in obesity rates among WIC-enrolled preschoolers between 2008 and 2011.201 WIC clinics in all 50 states, Washington, D.C, and U.S. territories provide nutritious food, nutrition education, Source: National WIC Association breastfeeding promotion and support young children. It has helped to reduce Congress is currently considering Child and referrals to other health and the chances of low birthweight babies Nutrition Reauthorization bills, which social services to participants at no by 29 percent and very low birthweight include reauthorization of WIC. The charge.202 More than 40 states and all babies by 50 percent; increased Senate Agriculture Committee and U.S. territories participate in the WIC breastfeeding initiation and duration; the House Education and Workforce Farmers’ Market Nutrition Program to and reduced maternal obesity at the Committee approved separate make fresh produce and other foods onset of future pregnancies. Children reauthorization of Improving Child more easily available to enrollees.203 whose mothers participated in the Nutrition Integrity Act bills in 2016.209, 210 Participants also have access to a program prenatally had improved The Senate version includes a provision to number of resources, such as health vocabulary scores, and children who expand WIC eligibility for children from screenings, nutrition counseling and participated in WIC after the first year of 5-years-old to 6-years-old, and emphasizes breastfeeding supplies and counseling, life experienced significantly improved development of an Electronic Benefit immunization screenings and referrals memory. For every dollar spent on WIC Transfer system to be in place by 2020. and substance abuse referrals.204 pregnant women, up to $4.21 is saved in The House version also modifies the EBT Breastfeeding promotion and services Medicaid spending.205, 206, 207 system and would authorize USDA to are also top WIC priorities. conduct pilot projects to test alternative WIC appropriations were $6.35 billion WIC has shown positive results certification, food delivery procedures in FY 2016, which the President’s budget in promoting healthy weight and and service delivery methods. has requested again for FY 2017.208 nutritionally-balanced diets among 50 TFAH • RWJF • StateofObesity.org Additional Measures to Increase Breastfeeding Support — Through Insurance and Medical Practices and Workplace Policies According to the NAM, without the benefit own policies for breastfeeding support. break time for an employee to express of outside advice or resources, mothers are A review by CMS found that: 16 states breast milk for her nursing child for 1 less likely to start breastfeeding or may stop and Washington, D.C. provide lactation year after the child’s birth each time earlier than recommended.211 counseling for new mothers to provide such employee has a need to express support and education; at least 29 states the milk.” 214 State laws may provide The Affordable Care Act (ACA) requires and Washington, D.C. provide some form additional protections for employees. private insurers and Medicaid expansion of breastfeeding education; 38 states and A location must be made available states to provide coverage of breastfeeding Washington, D.C. provide support for that is a functional space — shielded support, supplies, counseling — defined breastfeeding pumps and 15 states and from view, free from intrusions from as comprehensive lactation support and Washington, D.C. provided support for co-workers and the public and is not counseling by a trained provider during other breastfeeding supplies.213 a bathroom. Employers with fewer pregnancy and/or in the postpartum than 50 employees are not subject to period — and costs for renting The ACA also amended the Fair Labor the requirement if compliance would breastfeeding equipment.212 Traditional Standards Act (FLSA) to require impose an undue hardship. state Medicaid programs can set their employers to provide “reasonable SOME KEY BREASTFEEDING LAWS IN STATES Breastfeeding Support in Birth Facilities—State Averages CDC’s Prevention Status Reports examined the extent to which hospitals, birth cen- State Averages, Maternal Practices in Infant Nutrition and Care Score, 2015 ters and other birth facilities in the state WA implemented evidence-based strategies MT ME ND to support breastfeeding in the categories MN VT OR NH of: 1) labor and delivery; 2) breastfeeding ID SD WI NY MA assistance; 3) mother-newborn contact; 4) WY MI CT RI IA PA NJ newborn feeding practices; 5) breastfeeding NV NE OH IL IN DE support after discharge; 6) nurse/birth atten- CA UT MD CO WV KS MO VA DC dant breastfeeding training and education; KY NC and 7) structural and organizational factors TN AZ OK NM AR SC related to breastfeeding.215 MS AL GA <70 ≥70 to <80 Twenty-five states and Washington D.C. TX LA ≥80 received an average score of 80 or higher FL (green) out of 100 (higher score representing AK HI more birth facilities that support breastfeeding); 23 states received a score of 70 to 79 (yellow); and two states scored 70 or lower (red). The national average score Note: Puerto Rico = 69. was 79. The data were obtained from CDC’s Source: CDC National Survey of Maternal Practices in Infant Nutrition and Care (mPINC). TFAH • RWJF • StateofObesity.org 51 Workplace and Jury Duty: Twenty-seven State Breastfeeding Laws: Workplace and Jury Duty states and Washington, D.C. have additional laws relating to breastfeeding WA MT§ ME in the workplace, and 17 states exempt ND VT OR MN breastfeeding mothers from jury duty or ID § NH SD§ WI NY MA allow for postponement of service.216 WY MI§ RI CT§ NE§ IA§ PA NJ NV OH DE UT§ IL§ IN CA § MD CO WV KS§ MO§ VA§ DC KY§ NC AZ TN OK§ NM AR SC MS § AL GA TX LA FL § AK HI State has laws relating to breastfeeding in the workplace State does not have laws relating to breastfeeding in the workplace § State exempts breastfeeding mothers from jury duty or allow jury service to be postponed Source: National Conference of State Legislatures Exempt from Public Indecency and State Breastfeeding Laws: Public Indecency and Child Care Facilities Support in Child Care Facilities: While 49 states and Washington, D.C. have laws WA MT§ ME that specifically allow women to breastfeed ND VT§ OR MN in any public or private location, only 29 ID NH SD WI NY MA states and Washington, D.C. exempt WY MI RI CT breastfeeding from public indecency NV NE IA PA NJ OH DE§ laws.217 Seven states and Washington, UT§ IL IN CA§ MD CO WV D.C. have regulations that support onsite KS MO VA DC KY breastfeeding in child care facilities. 218 NC§ AZ§ TN OK§ NM AR SC MS§ AL GA TX§ LA FL § AK HI State exempts breastfeeding from public indecency laws State does not exempt breastfeeding from public indecency laws § State child care regulation supports breastfeeding in child care facilities Source: National Conference of State Legislatures 52 TFAH • RWJF • StateofObesity.org EXAMPLE INITIATIVE: Texas Ten Step Star Achiever Breastfeeding Learning Collaborative219 The Texas Women, Infants and Children 3. nform all pregnant women about I program partnered with the National the benefits and management of Institute for Children’s Health Quality breastfeeding. (NICHQ) and the Texas Department of 4. elp mothers initiate breastfeeding H State Health Services (DSHS) to create within one hour of birth. a quality improvement project to help facilities increase exclusive breastfeeding 5. Show mothers how to breastfeed at day two after birth. The collaborative and how to maintain lactation, addresses disparities by connecting even if they are separated from community partners to resources that their infants. help them support breastfeeding. The 6. ive infants no food or drink other G 20 participating hospitals and birthing than breast-milk, unless medically facilities will use quality improvement indicated. techniques in which teams work with each other and with national breastfeeding and 7. ractice rooming in — allow mothers P quality improvement experts to increase and infants to remain together 24 rates of breastfeeding.  The project hours a day. aligns with the UNICEF/World Health 8. ncourage breastfeeding on demand. E Organization Ten Steps to Successful Breastfeeding, which are: 9. ive no pacifiers or artificial nipples G to breastfeeding infants. 1. Have a written breastfeeding policy that is routinely communicated to all 10. oster the establishment of F healthcare staff. breastfeeding support groups and refer mothers to them on discharge 2. Train all healthcare staff in the skills from the hospital or birth center. necessary to implement this policy. TFAH • RWJF • StateofObesity.org 53 Supporting At-Risk Children — Early Identification and Follow-Up Support Systems The healthcare system and related support this type of care, such as fees for social services provide important coordinated care from patient-centered opportunities for early identification medical/health homes or reductions and support for children who are at risk in recurring hospital admittances or for becoming obese. Early identification emergency room visits. Models such of concerns and interventions during as PCMH, Medicaid Home Health young childhood help families demonstration programs, hospital understand positive nutrition and initiatives to reduce emergency-room activity practices — as well as how to use, smaller practice resource pooling identify risks, such as ACEs and toxic and others are providing options to stress concerns — and connect children pay for and support care coordination and their families to services to help approaches. Expanded use of prevent, delay or mitigate the negative Electronic Health Records (EHRs) — impact these factors can have on healthy including integrating EHRs with other child development.220 (See additional social service tracking systems — also information about obesity, ACEs and helps identify concerns and track toxic stress on page 26.) connection with ongoing use of care. Every child is supposed to be screened In addition, home visiting programs by their pediatrician for regular are an effective evidence-based strategy developmental milestones — including for targeting help to children at risk weight and height — as well as for for a range of concerns that increase other risks relating to the home the likelihood of obesity and a range and neighborhood environment. of other physical, behavioral and Increasingly AAP and other experts mental health concerns. The ACA have developed screening tools to expanded home visiting programs identify toxic stress, trauma or adverse by creating The Maternal, Infant experiences. Once concerns are and Early Childhood Home Visiting identified, building a regularized Program to respond to the needs of coordinated care and case worker children and families in communities system — both through the health at risk.221 States conduct community system and across other social services needs assessments to determine the — can help ensure children and their specific characteristics of their at-risk families receive the care and services populations, such as disproportionately they need. Providing specific referrals high rates of teen parents, first-time to services and programs in a local mothers, low-income parents and community as well as follow up case children exhibiting developmental management ensures patients access concerns. The most effective home and use the services. New health visiting programs are integrated with reform payment systems and incentives other programs and supports.222 provide increased opportunities to 54 TFAH • RWJF • StateofObesity.org EXAMPLE INITIATIVE: Nurse-Family Partnership223 Nurse-Family Partnership (NFP) works ment in Medicaid and SNAP a 9 percent , with young, low-income, first-time preg- reduction in Medicaid costs and an 11 nant women who are not ready to take percent reduction in SNAP costs in the care of a child by, first, establishing a 10 years following birth. A 2005 RAND trusted relationship with a public health analysis found a net benefit to society nurse, who meets with the mother of $34,148 (in 2003 dollars) per high- from pregnancy until the baby turns er-risk family served, totaling a return two years old. For more than 35 years, of $5.70 for every dollar invested.224 A NFP which is supported by RWJF, has , 2012 study found long-term benefits of enrolled mothers early in their pregnan- almost $23,000 per participant.225, 226 cies and helped public health nurses The program has demonstrated the abil- continuously conduct home visits over ity to reduce child abuse and neglect, a two-and-a-half year period. The home arrests among children, emergency visits are important because they con- room visits for accidents and poisonings nect first-time mothers with the care and and behavior and intellectual problems support they need to ensure a healthy among children. Participants demon- pregnancy. The model has been shown strated improved health behaviors after to have significant benefits. For in- birth, including uptake in recommended stance, when Medicaid pays for NFP ser- nutrients in daily diets and higher vices, the federal government gets a 54 levels of initiating breastfeeding.227 percent return on its investment. NFP Nurse-Family Partnership programs cur- services have resulted in lower enroll- rently operate in 43 states. Monetary Benefits to Society Increased participant income (net of welfare loss) Reduction in tangible Lower-risk $7,271 crime losses families $9,151 Savings to government Cost Higher-risk $7,271 families $41,419 $0 10,000 20,000 30,000 40,000 50,000 Net present value dollars per child 2003 Source: 2005 RAND Corporation Study TFAH • RWJF • StateofObesity.org 55 B. SCHOOL-BASED POLICIES AND PROGRAMS Studies show that school-based programs can help prevent and reduce obesity.228 Children and teens spend a significant portion of their time at school and in before- and after-school programs. They often eat as many as two meals and several snacks in these settings. For many children, the only reliable meals they have are at school and a significant number of students consume up to half of their total daily calories at school.229, 230 The federal government can set national that support families and the larger goals, recommendations and nutrition community where children live and play. standards that are tied to schools’ Key policies highlighted in this section participation in federally-supported include: programs or compliance with grant requirements for other federal programs. l C hild Nutrition Reauthorization in 2016 For other policies, including physical — and School Meal and Snack Programs education and activity and wellness l I mplementation of the Elementary and programs, the more than 14,000 school Secondary School Components of the districts in the country have primary Every Student Succeeds Act of 2015 jurisdiction — or “local control.” States l L ocal School Wellness Policies often try to create incentives for school l C DC School Health Cooperative districts to follow compliance rules to Agreements and National Goals and qualify for state funding. Guidance Over the past decade, school-based l N ew Models for School-Based Health efforts have focused on improving the and Social Services nutritional quality of food available in l S tate Policy Review: Water schools; improving the duration and Availability, Breakfast Policies, Farm- quality of physical education; increasing to-School, Zero-Exemption School opportunities for physical activity before, Nutrition Policies, Out of School and during and after school; and building School Celebration Nutrition Policies, evidence-based wellness programs. Physical Education Requirements, School-based programs are most Physical Activity Requirements, Safe effective when they are coordinated and Routes to School Programs, Shared- connected to strategies and programs Use Policies and Health Assessments Budgets for Some Key Federal School-Based Enacted Budget Obesity-Related Programs FY 2016 National School Lunch Program (USDA) $ 12.528 billion231 School Breakfast Program (USDA) $ 4.339 billion232 Title IV, U.S. Department of Education $24.198 billion233 Farm-to School Program (USDA) $ 9.1 million234 Safe Routes to School (Department of Transportation) $ 143.0 million235 Division of Adolescent and School Health (CDC) $33 million236 Note: For some of these programs, only a portion of the funding goes toward obesity-related activities (i.e., nutrition, physical activity). 56 TFAH • RWJF • StateofObesity.org NUTRITION AND PHYSICAL ACTIVITY IN SCHOOL-AGED CHILDREN AND TEENS Proper nutrition improves healthy growth, l dolescents with metabolic syndrome A rates of absenteeism and tardiness brain capacity, cognitive capabilities and — a composite of obesity components and less focus in the classroom.245 academic performance in school-age — have significantly lower overall intel- l egular physical activity helps R children. 237 Conversely, an unhealthy ligence scores, including in math and maintain a healthy weight; builds diet, too much food of low nutritional spelling, and have lower mental flexi- healthy bones and muscles; value and/or insufficient food decreases bility and attention spans than adoles- decreases the likelihood of obesity academic performance and limits the cents without metabolic syndrome.242 and disease risk factors such as high brain’s ability to perform properly. l hildren who are more physically active C blood pressure, high cholesterol and l S chool Achievement: A range of and have a lower BMI have better aca- type 2 diabetes; reduces anxiety and studies have demonstrated the demic scores. 243 Increasing extracurric- depression; and promotes positive importance of healthy nutrition and ular activity has been shown to improve mental health.246, 247, 248 sufficient physical activity for better classroom behavior and self-esteem, l ccording to a CDC review of 50 A school performance and behavior. lower dropout rates and indirectly im- studies on academic performance and Children who are overweight or obese prove academic achievement.244 physical activity, there is substantial are more likely to have lower academic l tudents who do not eat breakfast; S evidence that physical activity can achievement than non-overweight or do not eat enough fruits, vegetables help improve academic achievement, non-obese children.238, 239, 240 and dairy products; and are hungry including grades and standardized test l hildren who are persistently over- C due to insufficient food intake or have scores; and physical activity can have weight or obese are likely to score deficiencies in nutrients — Vitamins A, an impact on cognitive skills, attitudes poorer academically in math than their B6, B12, C, folate, iron and zinc — are and academic behavior (including healthy-weight peers. 241 Poor scores more likely to have decreased cogni- enhanced concentration, attention and were seen as early as the first grade. tive performance, lower grades, higher improved classroom behavior).249, 250 TFAH • RWJF • StateofObesity.org 57 l S chool Nutrition and Physical Activity school programs not only increase Policies Can Have a Positive Impact: A consumption of fruits and vegetables, number of studies have examined how but change eating habits, leading changes in nutrition and activity policies students to choose healthier options and practices can help improve health at lunch. A recent health impact and promote healthier choices and assessment examining Oregon’s farm- better learning. to-school reimbursement law found that the law would create and maintain l chool breakfast programs can S jobs for Oregonians, increase student help improve attendance rates and participation in the school meals decrease tardiness; and, among program, improve household food undernourished children, can improve security and strengthen connections academic performance and cognitive within Oregon’s food economy.265 functioning.251 School breakfast participation is also associated with l ell-structured physical education W lower obesity and overweight rates programs can result in more active among students.252, 253 children.266 In addition, providing short activity breaks during the school l tudents in states with strong laws S day can increase physical activity in Percent of Kindergarteners Living restricting the sale of unhealthy snack students and improve some measures Within One Mile of School Who Walk or foods and beverages in school gained of health, such as muscle strength, Bike to School less weight over a three-year period endurance and flexibility.267 than those living in states with no such policies.254 l ationwide, millions of children and N adolescents participate in after- 89% 35% l hildren eat less of their lunch, C school programs. Integrating physical consume more fat, take in fewer movement into the daily routine of nutrients and gain weight when schools such programs can lead to increased sell unhealthy snacks and drinks outside 1969 2009 physical activity among youths.268 of regular meals.255, 256, 257, 258, 259, 260, 261 l hen young people have access to school W l lementary schools are less likely to E recreational facilities outside of school sell candy, ice cream, sugary drinks, hours, they tend to be more active.269 cookies, cakes and other unhealthy snacks when states or school districts l y 2009, only 35 percent of B have policies that limit the sale of kindergarteners who lived within one mile such items. 262 of school walked or biked to school even once a week; in 1969, 89 percent regularly l 2012 health impact assessment A did.270 An analysis by Bridging the Gap found that schools serving healthier found that laws requiring sidewalks, snacks and drinks generally increased crossing guards and traffic safety their total food service revenues.263 measures increase the number of children l arm-to-school programs have F walking or biking to school; and that shown results in improving students’ certain laws, such as busing requirements nutritional intake. 264 A study by for particularly short distances, decrease researchers at the University of biking and walking rates.271 California, Davis found that farm-to- 58 TFAH • RWJF • StateofObesity.org HIGH SCHOOL STUDENTS DIETARY BEHAVIORS AND PHYSICAL ACTIVITY—SELECTED U.S. STATES, YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM 2015272 An interactive map and timeline of these data are available at stateofobesity.org KEY YRBS NUTRITION, ACTIVITY AND Percent of High School Students Who Did Not Eat Fruit or Drink 100 Percent Fruit Juices (During the Seven Days SCREEN TIME FINDINGS Before the Survey), YRBS 2015 l O nly 5.2 percent of high school students report not eating WA fruit or drinking 100 percent fruit juice, and only 6.8 percent MT ND ME VT report not eating vegetables. OR MN ID NH SD WI NY MA l A round one in five (20.4 percent) of students drink one WY MI CT RI NV NE IA PA NJ or more can, bottle or glass of soda per day — which is UT IL IN OH DE CA CO WV VA MD a 39.6 percent drop from rates in 2007 (33.8 percent). KS MO DC KY NC Thirteen percent drink two or more soda servings a day AZ OK TN NM AR SC and 7.1 percent drink three or more. The question did not GA MS AL include energy or other added-sugar drinks. TX LA l 1 3.8 percent of students do not eat breakfast regularly. FL AK HI l 7 2.9 percent of students do not engage in at least 60 minutes of physical activity on all seven days of the week. No Data ≥1% to <5% ≥5% to <10% ≥10% to <15% l 4 1.7 percent of students play video or computer games three or more hours a day — an 88.7 percent increase Note: U.S. Territories: Guam = 8.6 percent, Northern Mariana Islands = 5.0 percent, Palau = 11.6 percent and Puerto Rico = 10.2 percent. from 2003 (22.1 percent). Television viewing has dropped Source: CDC, Youth Risk Behavior Surveillance System by 35.5 percent — from 38.2 percent to 24.7 percent. HIGH SCHOOL STUDENTS WHO DID NOT EAT FRUIT OR DRINK 100 PERCENT FRUIT JUICE (SEVEN DAYS BEFORE THE SURVEY) BY RACE/ETHNICITY AND GENDER, YRBS 1999-2015 1999 2001 2003 2005 2007 2009 2011 2013 2015 TOTAL 5.4% 6.1% 6.1% 5.8% 5.8% 5.1% 4.8% 5.0% 5.2% BY RACE/ETHNICITY American Indian/Alaska Native§ N/A 7.3% 10.6% 14.9% 5.4% 10.0% 4.6% 13.7% 4.1% Asian§ 3.5% 6.4% 2.9% 2.6% 4.1% 3.7% 5.3% 2.9% 2.8% Black § 5.6% 6.4% 8.0% 7.9% 6.7% 7.0% 6.5% 6.9% 6.9% Latino 4.2% 4.7% 6.4% 4.5% 5.1% 4.9% 4.5% 4.1% 4.9% Native Hawaiian/Other Pacific Islander § 4.5% 10.0% N/A N/A 5.4% 5.5% 7.5% 4.8% N/A White§ 6.0% 6.0% 5.6% 5.6% 5.9% 4.8% 4.5% 4.9% 4.9% Multiple Race§ 2.2% 8.4% 8.1% 5.1% 5.4% 4.3% 3.7% 3.4% 7.3% BY GENDER Female 5.1% 5.5% 5.2% 5.5% 5.1% 4.3% 4.3% 4.0% 4.3% Male 5.8% 6.6% 7.0% 6.0% 6.4% 5.8% 5.3% 6.1% 5.9% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic. Source: CDC, Youth Risk Behavior Surveillance System TFAH • RWJF • StateofObesity.org 59 Percent of High School Students Who Did Not Eat Vegetables (During the Seven Days Before the Survey), YRBS 2015 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA No Data TX LA ≥1% to <5% ≥5% to <10% FL AK ≥10% to <15% HI Note: U.S. Territories: Guam = 9.1 percent, Northern Mariana Islands = 6.1 percent, Palau = 8.1 per- cent and Puerto Rico = 15.5 percent. Source: CDC, Youth Risk Behavior Surveillance System HIGH SCHOOL STUDENTS WHO DID NOT EAT VEGETABLES (SEVEN DAYS BEFORE THE SURVEY) BY RACE/ETHNICITY AND GENDER, YRBS 1999-2015 1999 2001 2003 2005 2007 2009 2011 2013 2015 TOTAL 4.2% 4.6% 5.2% 6.0% 5.9% 6.0% 5.7% 6.6% 6.7% BY RACE/ETHNICITY American Indian/Alaska Native§ N/A 5.4% 6.2% 9.6% 4.6% 5.3% 5.8% 8.6% 4.2% Asian§ 1.4% 3.7% 3.3% 3.0% 3.6% 2.9% 5.0% 2.3% 4.8% Black § 8.4% 9.4% 11.2% 11.1% 11.5% 12.7% 9.9% 11.3% 10.9% Latino 6.9% 7.6% 7.1% 8.5% 9.1% 8.6% 8.2% 9.3% 8.5% Native Hawaiian/Other Pacific Islander § 10.7% N/A N/A N/A N/A 4.3% 7.3% 9.8% N/A White§ 3.0% 3.2% 3.3% 4.2% 3.9% 3.6% 4.0% 4.5% 4.9% Multiple Race§ 2.6% 5.8% 8.0% 4.9% 3.3% 6.8% 4.7% 5.1% 9.0% BY GENDER Female 3.5% 4.1% 4.6% 5.1% 5.2% 4.9% 4.5% 5.7% 5.6% Male 4.8% 5.1% 5.9% 6.7% 6.6% 6.9% 6.9% 7.5% 7.7% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic Source: CDC, Youth Risk Behavior Surveillance System 60 TFAH • RWJF • StateofObesity.org Percent of High School Students Who Drank a Can, Bottle or Glass of Soda One or Drinking one or more can of soda More Times per Day (During the Seven Days Before the Survey), YRBS 2015 per day decreased 39.6 percent WA from 2007 (at 33.8 percent) to MT ME ND OR MN VT 2015 (at 20.4 percent). ID NH SD WI NY MA WY MI CT RI NV NE IA PA NJ In 2015, 13 percent of students drank OH DE UT IL IN two or more cans, bottles or glasses of CA MD CO WV KS MO VA DC soda or pop a day, and 7.1 percent drank KY NC three or more. These questions did not AZ TN OK NM AR SC include/account for energy drinks or wa- MS AL GA ters with added sugars. No Data TX LA ≥10% to <15% ≥15% to <20% FL AK ≥20% to <25% HI ≥25% to <30% ≥30% to <35% Note: U.S. Territories: Guam = 16.7 percent, Northern Mariana Islands = 21.7, Palau = 29.3 percent and Puerto Rico = 30.2 percent. Source: CDC, Youth Risk Behavior Surveillance System HIGH SCHOOL STUDENTS WHO DRANK A CAN OF SODA ONE OR MORE TIMES PER DAY (SEVEN DAYS BEFORE THE SURVEY) BY RACE/ETHNICITY AND GENDER, YRBS 2007-2015 2007 2009 2011 2013 2015 TOTAL 33.8% 29.2% 27.8% 27.0% 20.4% BY RACE/ETHNICITY American Indian/Alaska Native§ 37.7% 32.5% 35.8% 33.8% 21.8% Asian§ 18.5% 16.3% 17.6% 12.2% 8.9% Black § 37.6% 33.7% 28.0% 30.2% 22.7% Latino 33.4% 28.1% 27.0% 22.6% 21.7% Native Hawaiian/Other Pacific Islander § 34.6% 31.4% 23.8% 20.2% N/A White§ 34.0% 29.0% 28.8% 29.0% 19.7% Multiple Race§ 29.6% 28.6% 23.2% 24.5% 24.0% BY GENDER Female 29.0% 23.3% 24.0% 24.0% 16.4% Male 38.6% 34.6% 31.4% 29.9% 24.3% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic Source: CDC, Youth Risk Behavior Surveillance System TFAH • RWJF • StateofObesity.org 61 Percent of High School Students Who Did Not Eat Breakfast (During the Seven Days Before the Survey), YRBS 2015 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA No Data TX LA ≥10% to <15% ≥15% to <20% FL AK ≥20% to <25% HI Note: U.S. Territories: Guam = 16.5 percent, Northern Mariana Islands = 8.3 percent, Palau = 18.5 percent and Puerto Rico = 17.5 percent. Source: CDC, Youth Risk Behavior Surveillance System HIGH SCHOOL STUDENTS WHO DID NOT EAT BREAKFAST (SEVEN DAYS BEFORE THE SURVEY) BY RACE/ETHNICITY AND GENDER, YRBS 2011-2015 2011 2013 2015 TOTAL 13.1% 13.7% 13.8% BY RACE/ETHNICITY American Indian/Alaska Native§ 13.0% 18.6% 14.3% Asian§ 16.0% 12.8% 11.4% Black § 16.1% 16.0% 18.0% Latino 14.4% 17.4% 14.7% Native Hawaiian/Other Pacific Islander§ N/A 21.6% N/A White§ 12.0% 11.5% 12.0% Multiple Race§ 12.8% 12.6% 18.2% BY GENDER Female 13.9% 13.8% 14.2% Male 12.3% 13.5% 13.3% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic Source: CDC, Youth Risk Behavior Surveillance System 62 TFAH • RWJF • StateofObesity.org Percent of High School Students Who Were Not Active all Seven Days of the Week (During the Seven Days Before the Survey), YRBS 2015 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA No Data TX LA ≥65% to <70% ≥70% to <75% FL AK ≥75% to <80% HI ≥80% Note: U.S. Territories: Guam = 76.5 percent, Northern Mariana Islands = 72.6 percent, Palau = 75.0 percent and Puerto Rico = 81.7 percent. Source: CDC, Youth Risk Behavior Surveillance System HIGH SCHOOL STUDENTS WHO WERE NOT PHYSICALLY ACTIVE ALL SEVEN DAYS OF THE WEEK (SEVEN DAYS BEFORE THE SURVEY) BY RACE/ETHNICITY AND GENDER, YRBS 2011-2015 2011 2013 2015 TOTAL 71.3% 72.9% 72.9% BY RACE/ETHNICITY American Indian/Alaska Native§ 70.9% 70.0% 60.8% Asian§ 80.2% 78.2% 83.5% Black § 74.0% 73.7% 75.8% Latino 73.5% 74.5% 75.4% Native Hawaiian/Other Pacific Islander§ 72.4% 72.5% N/A White§ 69.6% 71.8% 71.0% Multiple Race§ 68.1% 72.2% 69.6% BY GENDER Female 81.5% 82.3% 82.3% Male 61.7% 63.4% 64.0% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic Source: CDC, Youth Risk Behavior Surveillance System TFAH • RWJF • StateofObesity.org 63 Percent of High School Students Who Played Video, Computer Games or Used a Computer Three or More Hours per Day (for Something Besides School Work), YRBS 2015 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA No Data TX LA ≥30% to <35% ≥35% to <40% FL AK ≥40% to <45% HI ≥45% to <50% Note: U.S. Territories: Guam = 47.2 percent, Northern Mariana Islands = 50.3 percent, Palau = 22.4 percent and Puerto Rico = 37.4 percent. Source: CDC, Youth Risk Behavior Surveillance System HIGH SCHOOL STUDENTS WHO PLAYED VIDEO OR COMPUTER GAMES OR USED A COMPUTER THREE OR MORE HOURS PER DAY (FOR SOMETHING BESIDES SCHOOL WORK ON AN AVERAGE SCHOOL DAY) BY RACE/ETHNICITY AND GENDER, YRBS 2003-2015 2003 2005 2007 2009 2011 2013 2015 TOTAL 22.1% 21.1% 24.9% 24.9% 31.1% 41.3% 41.7% BY RACE/ETHNICITY American Indian/Alaska Native§ 30.7% 22.7% 20.8% 28.5% 30.0% 46.1% 35.9% Asian§ 26.6% 32.7% 35.4% 39.9% 42.1% 51.5% 45.6% Black § 26.2% 25.2% 30.5% 30.4% 38.1% 49.1% 44.6% Latino 21.4% 19.8% 26.3% 25.7% 32.4% 43.4% 46.2% Native Hawaiian/Other Pacific Islander§ N/A N/A 29.0% 30.8% 29.0% 51.4% N/A White§ 20.5% 19.6% 22.6% 22.1% 28.1% 37.4% 38.6% Multiple Race§ 26.9% 27.4% 22.6% 29.2% 33.3% 46.3% 46.9% BY GENDER Female 16.5% 14.8% 20.6% 21.2% 26.6% 40.4% 42.8% Male 27.3% 27.4% 29.1% 28.3% 35.3% 42.3% 40.6% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic Source: CDC, Youth Risk Behavior Surveillance System 64 TFAH • RWJF • StateofObesity.org Percent of High School Students Who Watched Three or More Hours per Day of Watching three or more hours Television (on an Average School Day), YRBS 2015 of television per day (on an WA average school day) decreased MT ME ND OR MN VT 42.3 percent from 1999 (at ID NH SD WI NY MA WY MI 42.8 percent) to 2015 (at CT RI IA PA NJ NV NE OH DE 24.7 percent). UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA No Data TX LA ≥15% to <20% ≥20% to <25% FL AK ≥25% to <30% HI ≥30% to <35% U.S. Territories: Guam = 23.6 percent, Northern Mariana Islands = 23.7 percent, Palau = 28.1 per- cent and Puerto Rico = 29.2 percent. Source: CDC, Youth Risk Behavior Surveillance System HIGH SCHOOL STUDENTS WHO WATCHED THREE OR MORE HOURS PER DAY OF TELEVISION (ON AN AVERAGE SCHOOL DAY) BY RACE/ETHNICITY AND GENDER, YRBS 1999-2015 1999 2001 2003 2005 2007 2009 2011 2013 2015 TOTAL 42.8% 38.3% 38.2% 37.2% 35.4% 32.8% 32.4% 32.5% 24.7% BY RACE/ETHNICITY American Indian/Alaska Native§ N/A 48.5% 38.8% 42.0% 33.5% 31.3% 36.0% 42.3% 30.4% Asian§ 38.1% 30.8% 35.4% 29.2% 25.6% 23.8% 26.1% 24.5% 14.5% Black § 73.7% 68.9% 67.2% 64.1% 62.7% 55.5% 54.6% 53.7% 39.2% Latino 52.2% 47.8% 45.9% 45.8% 43.0% 41.9% 37.8% 37.8% 28.2% Native Hawaiian/Other Pacific Islander § 49.3% 46.8% N/A N/A 35.8% 40.1% 30.3% 35.1% N/A White§ 34.2% 31.0% 29.3% 29.2% 27.2% 24.8% 25.6% 25.0% 20.0% Multiple Race§ 41.2% 40.6% 46.2% 40.0% 37.5% 34.6% 33.5% 38.3% 27.9% BY GENDER Female 41.0% 35.0% 37.0% 36.3% 33.2% 32.1% 31.6% 32.2% 24.4% Male 44.5% 41.8% 39.3% 38.0% 37.5% 33.5% 33.3% 32.8% 25.0% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic Source: CDC, Youth Risk Behavior Surveillance System TFAH • RWJF • StateofObesity.org 65 DISPARITIES IN SCHOOL FOODS AND MILK OFFERED IN ELEMENTARY SCHOOLS While, overall, the proportion of healthy food options in schools has increased significantly and unhealthy items have de- creased from 2006-2007 to 2013-2014, majority-Black and -Latino schools and schools with lower-income students were less likely to have as many healthy offer- ings, such as fresh fruit and salads.273 Child Nutrition Reauthorization in 2016 — and School Meal and Snack Programs Nearly 31 million children participate in the National School Lunch Program PERCENT OF LOW INCOME STUDENTS IN U.S. PUBLIC SCHOOLS 2013 — with around 21.5 million receiving National Average: 51% free or reduced-cost meals. Around WA 45% 14 million participate in the school MT ND VT 36% ME 43% 42% 30% breakfast program — with around 12 OR MN 38% 49% NH 27% million receiving free or reduced-cost ID 47% SD 40% WI 41% NY 48% MA 37% WY MI RI 46% breakfasts. 274, 275, 276 38% IA 47% PA CT 36% NE 40% 40% NJ 37% NV 44% OH More than half (51 percent) of public 51% UT 59% CO IL 50% IN 49% 39% DE 51% WV MD 43% CA school students are from low-income 55% 42% KS 48% MO 45% KY 52% VA 39% 55% families; 25 years ago, less than 32 NC 53% OK TN 58% percent of public school students were AZ 50% NM 61% AR SC 68% 61% 58% Percent of Students from low-income families. 277 MS AL 58% GA 60% 0.0 - 38 71% LA 38 - 42 The 2010 Healthy, Hunger-Free Kid TX 60% 65% 42 - 47 AK Act required USDA to align nutrition 40% FL 59% 47 - 50 standards for school meals and snacks 51 and above HI with the most recent Dietary Guidelines 51% for Americans — which went into effect for school meals in 2012 and for school Data Source: U.S. Department of Education, National Center for Education Statistics, Common Core of Data snacks in 2014. The nutrition standards include more whole grains, low-fat dairy, 66 TFAH • RWJF • StateofObesity.org fruits, vegetables and lean protein and limits on fat, added sugar and salt.278, 279 Schools snacks include any foods and drinks outside of breakfast and lunch in vending machines, school stores, bake sales and à la carte items.280 More than 98.5 percent of schools reported meeting the revised school meal nutrition requirements, as of December 2015.281 Studies found that students consumed more fruit, threw away less of their entrees and vegetables (lowering the amount of wasted food) and consumed the same amount of milk via school meals in 2014 under the updated standards as they did in 2012.282 A review of school meals in Washington state before and after the Percentage of Eligible Districts Adopting the Community Eligibility Provision revised standard implementation found Take-Up for School Year 2015-2016 the nutritional quality of foods chosen by students increased by 29 percent and calorie content per gram decreased by 13 percent, and participation in the program was not impacted.283 In addition, more than 17,000 schools are participating in the Community Eligibility Provision (CEP) of the act, which allows schools in high-poverty areas to serve free meals to all students at their school — benefiting about 8.5 million students.284, 285 The provision helps reduce labor, processing and paperwork costs — families no longer have to complete applications and schools do not have to verify a family’s status — and reduced stigma in CEP schools helps improve meal uptake Source: Center on Budget and Policy Priorities and Food Research & Action Center which can improve overall nutrition. Schools can also qualify for higher states and Washington, D.C. — 82 percent the buying power of DoD’s food “severe need” reimbursement rates if of FFVP schools serve produce 3 to 5 procurement and distribution system;287 40 percent or more of their lunches are times per week;286 2) the Department of 3) the USDA’s Special Milk Program free or reduced-price meals. Defense (DoD) Fresh Fruit and Vegetable (SMP), which provides assistance to Additional school nutrition programs Program, which provides schools with around 3,600 schools, 570 summer camps include: 1) the Fresh Fruit and Vegetable more than $120 million worth of produce and 480 child care institutions that do Program (FFVP), which operates in all 50 — through the efficiencies and leveraging not participate in other federal nutrition TFAH • RWJF • StateofObesity.org 67 Percentage of Ditricts Participating in Farm to School Activities Source: USDA programs to provide low-fat or non-fat Senate released their version of the milk to children;288 and 4) USDA’s Farm- Improving Child Nutrition Integrity to-School program, which awards up to Act of 2016 in January, and the House $5 million in competitive grants annually. released its version in April.295, 296 The Nationally, an analysis by USDA found Senate version includes a number of that more than 4,300 of the nation’s changes to the 2010 law. Some key 13,133 public school districts changes include: simplifying eligibility are participating in Farm-to-School and some administrative requirements programs benefiting more than 23 for child care providers to participate million students.289 in CACFP; expanding access to the Summer Food Service Program to In addition, nearly 3.2 million children include organizations beyond schools; participate in USDA’s Summer Food introducing EBT options where available Service Program or School-Sponsored and piloting a third meal in six states; Summer Programs.290 This only covers maintaining most of the school meal about one in seven children eligible for and snack nutrition standards from 2010 free and reduced-price school meals while reducing school meal whole grain during the school year. In nine states, standards to 80 percent and postponing fewer than one in 10 students from low- the sodium reduction requirement for income families receive summer meals.291 two years; doubling the Farm-to-School Children are more vulnerable to rapid grants (to $10 million); and redesigning BMI gains and food insecurity during the verification process for family school the summer because they do not have meal eligibility applications (schools access to school meal programs.292, 293, 294 implementing community eligibility In 2016, Congress is considering the programs would be exempt).297, 298, 299 A Child Nutrition Reauthorization. The bi-partisan statement from the Senate Agriculture Committee said the intent 68 TFAH • RWJF • StateofObesity.org Source: USDA TFAH • RWJF • StateofObesity.org 69 of the school meal sections of the bill requirement and reducing the whole was to provide “flexibility to school food grain requirement; expanding the operators while preserving the intent to foods that can be sold à la carte; provide our nation’s schoolchildren with and exempting foods sold as part of healthful meals, leading to improved school fundraisers from nutrition academic performance and healthy standards. It also would eliminate Paid eating habits.”300 Lunch Equity requirements, a pilot demonstration project in four states The House version also includes a for expanding summer meals to allow number of proposed changes to the for-profit businesses to provide meals 2010 law, including: changing the in underserved areas, increase school community eligibility threshold from 40 breakfast reimbursement rate by 2 percent of a school’s students eligible Source: USDA cents and reduce some administrative for free or reduced-cost lunches to 60 requirements for CACFP child care percent; putting increased school meal centers and expand eligibility to application verification requirements in schools operated by the Bureau of place; postponing the sodium nutrition Indian Affairs.301, 302, 303 School Meal Program Eligibility, as of 2015304 Household Income: Household Income: Free Lunch Eligible Reduced Lunch Eligible 130 percent of FPL 185 percent of FPL Household size: 2 $20,709 $29,471 Household size: 4 $31,525 $44,863 Source: Department of Agriculture, Food and Nutrition Service IMPLEMENTING SCHOOL NUTRITION IMPROVEMENTS IN MASSACHUSETTS A review of Massachusetts schools an increase in the second year making implementing nutrition standards for both up for a loss in the first year.305 The school meals and snacks found that review also found a 15 percent increase overall food service revenue was steady in school lunch participation among after two years of implementation, with students eligible for reduce-priced meals. 70 TFAH • RWJF • StateofObesity.org Implementation of the Elementary and Secondary School Components of the Every Student Succeeds Act of 2015 ESSA includes increased emphasis on the helps support nutrition and physical workforce readiness; 6) community- health and overall well-being of children activity — and must spend 20 percent based support for students who are and school settings as being integral of its grant on safe and healthy school either living in the community or who to student success and achievement. activities, 20 percent on well-rounded have attended schools serviced by the It includes a range of opportunities education activities and the remaining pipeline; 7) social, health, nutrition and options to help support a safe 60 percent can be spent on all three and mental health services and and healthy school and student priority areas (with a 15 percent cap for supports; and 8) crime prevention and improvements — but gives flexibility to spending on technology equipment). rehabilitation programs for youth.312 states and localities for what they choose School districts receiving less than From 2010 to 2016, $270 million to focus on and prioritize.306, 307, 308, 309 $30,000 must use the funds in at least in Promise Neighborhood grants one of three categories listed earlier. supported efforts that focused on l T he law significantly changes the approach to federally-supported school health and safety programs. It creates ESSA authorizes $1.65 billion for Title IV annually, although a Student Support and Academic Enrichment Grants program (Title Congress is not obligated to appropriate the full amount. The IV) — as a block grant that can be President’s FY 2017 proposed budget allocates $500 million to this used for activities in three areas, including: 1) supporting safe and program. The total FY 2016 funding for the programs consolidated healthy students (such as, health and into this new block grant was $275 million.311 physical education, comprehensive school mental health or drug and violence prevention); 2) supporting l T itle IV also authorizes a Promise improvements for 50 distressed school effective use of technology; and/or 3) Neighborhoods program — which can districts and 700 schools.313 The providing students with a well-rounded support elementary and secondary President’s FY 2017 budget requested education (for example, arts, civics and schools as well as early education $129 million which would support 15 career counseling).310 It eliminates efforts. The program supports local Promise Neighborhood grants.314 and consolidates 49 previously existing service organizations or nonprofits to l T here are also provisions to support grant programs, including the Carol partner with local schools or districts a Full-Service Community Schools M. White Physical Education Program — to provide “pipeline services” from Program (the President’s FY 2017 (PEP). PEP had been the only birth to post-secondary education budget request is at $10 million) to federal funding stream for physical and/or career attainment, which support local school districts to partner education programs to help states and can include: 1) high-quality early with community-based organizations, community organizations implement childhood education programs; nonprofit organizations or other comprehensive physical fitness and 2) high-quality school and out-of- public or private entities to provide nutrition programs, but was limited to school programs and strategies; 3) comprehensive and coordinated around $44 million a year. transitions from elementary school to academic, social and health services for Title IV funds will be allocated to middle school, from middle school students and family members to support states and districts based on the Title to high school and from high school improved educational outcomes for I formula. Any district receiving an into and through postsecondary children in neighborhoods with high allocation above $30,000 must conduct education and into the workforce; 4) rates of obesity, poverty, academic a needs assessment — which could family and community engagement failure and involvement of community include how the school environment and support; 5) postsecondary and members in the justice system. TFAH • RWJF • StateofObesity.org 71 l T he law allows increased flexibility in wellness priorities, providing for three academic indicators (by 2017). the use of a portion of Title I additional school health professionals Many of the example indicators can money (funds designated for or educators and staff training to help support health — such as chronic socioeconomically disadvantaged support improving health. Title I, Part absenteeism (an “early warning” system or lower performing schools and A of ESSA is authorized for $15 billion to identify children who miss significant students) to support school wide in FY 2017 and $16.2 billion by 2020. amounts of school and may be at-risk for priorities. And, also allows for schools States can set aside up to 7 percent of a range of health and social concerns with the flexibility to be able to choose these funds for school improvement and to connect them to services) and how portions of their Title II efforts. The President’s FY 2017 budget school climate (such as supporting a professional development money is requests $15.4 billion for Title I.315 healthy campus environment or social- allocated to support educators’ and emotional development). For instance, l S tate education agencies must also staff professional development and Connecticut’s accountability indicators develop state accountability systems training priorities. These can include include physical fitness and chronic — which must include at least one support for promoting health and absenteeism.316 non-academic indicator along with Source: Family League of Baltimore 72 TFAH • RWJF • StateofObesity.org CHILDREN’S AID SOCIETY COMMUNITY SCHOOLS317 The Children’s Aid Society (CAS) oper- signing and implementing community ates more than 20 community schools school strategy. Programs are tailored in New York City in partnership with the to the unique needs and strengths of New York City Department of Education individual communities. Evaluations and other community resources. The have shown positive results in academic model aims to combine the best ed- gain, better student and teacher atten- ucational practices with the delivery dance, school readiness and parent of an array of social, health, child and engagement. A social return on invest- youth development services while also ment study, conducted by the Finance emphasizing community and parental Project, showed a return on investment involvement. CAS, through its National of $10.30 for every $1 invested at the Center for Community Schools, offers elementary level and $14.80 for every training, consultation, planning tools $1 invested at the middle school level. and guidance on all aspects of de- UNITED WAY COMMUNITY SCHOOLS Source: United Way of America TFAH • RWJF • StateofObesity.org 73 Local School Wellness Policies The Child Nutrition Act of 2004 required food/beverages during school hours.321 every school district participating in the The Local School Wellness Policy final National School Lunch Program and rule, released in July 2016, requires that School Breakfast Program to develop any food or beverage that is marketed on and implement a local wellness plan, and school campuses during the school day the Healthy, Hunger-Free Kids Act of meet the Smart Snacks standards. As of 2010 strengthened those requirements. 2014, 11 states and Washington, D.C. have In 2014, USDA issued a proposed rule additional policies addressing marketing to update local school wellness policy of unhealthy foods in schools (Alabama, standards, including proposing requiring Alaska, Connecticut, Iowa, Maine, that schools only allow the marketing of Mississippi, Montana, Nevada, Oklahoma, foods and beverages that meet the Smart Oregon and West Virginia). 322 Snacks in Schools nutrition standards, School district plans are required to ensuring policies meet minimum include: standards to support an environment that promotes nutrition and student health l G oals for nutrition promotion and and requiring transparency to the public education, physical activity and other about the policies and implementation.318 school-based activities that promote An interim final rule was issued during student wellness. the 2014-2015 school year. The final rule, l N utrition guidelines for all foods issued in July 2016, aligns the nutritional available on each school campus during quality of snacks sold to children during the school day to promote student the school day with the same science- health and reduce childhood obesity. based improvements made to school l P articipation by parents, students, breakfasts and lunches and gives states representatives of the school the flexibility to allow limited exemptions food authority, teachers of to school-sponsored fundraisers during physical education, school health the school day.319 professionals, the school board, school Wellness policies can lead to changes in administrators and the general public promoting improved health, nutrition to participate in the development, and physical activity in schools. For implementation and update of the instance, while schools currently have wellness policy. the ability to limit food marketing l I nforming and updating the public during the school day, as of 2013, only (including parents, students and 20 percent of public school districts others in the community) about the had wellness policies that addressed content and implementation of the food marketing, and only half of those local school wellness policy. districts specifically prohibit unhealthy l P eriodically measuring which schools food and beverage marketing.320 Food are in compliance with the local and beverages are marketed to students wellness policy, the extent to which the in some schools via signs, scoreboards, local education agency’s local wellness posters, branded fundraisers, corporate policy compares to model local school incentive programs, scholarships and wellness policies, the progress made in education materials. Seventy percent of attaining the goals of the local wellness elementary and middle school students policy and making this assessment are exposed to poor quality, high caloric available to the public. 74 TFAH • RWJF • StateofObesity.org A 2016 report by Bridging the Gap (48.5 of 100) but have become stagnant analyzed a range of ninety-five wellness since the 2008-2009 school year and policies and scored them based on remain weak (17.7 of 100). Class comprehensiveness (all items covered parties (1 percent) and fundraisers (17 for a given topic were addressed) percent) remain the least regulated and strength (strong policies had and the level of regulation varies from requirements and specified an elementary schools (21.7 of 100) to implementation plan or strategy), middle school (16.4 of 100) to high scoring a total of 100 points for each school (14.7 of 100); individual category.323 Almost all l E ighty-eight percent of districts have school districts nationwide (95 percent) physical activity goals and physical have adopted wellness policies from Percent of School Percent of School education provisions in their wellness Districts with Strong Districts Providing 2006-2007 to 2013-2014 and all policy policies, however only 3 percent of Provisions for Free Adequate Time to categories have significantly improved districts have physical education Water at Meals Eat Meals in comprehensiveness and strength requirements for all school levels, over the last eight years, yet policies vary less than 10 percent of districts greatly on how widely and stringently offer physical activity opportunities they are implemented. Overall, 14% 11% before/after school and 44 percent nutrition education policies were the offer physical activity for every grade most comprehensive (scoring 55.5 of level. Very few schools meet physical 100) and strongest (scoring 36.4 of 100) education and physical activity and unhealthy food marketing and national standards; healthy food promotion policies were one of the least comprehensive (scoring l S taff wellness and modeling continues 26.5 of 100) and weakest (scoring 10.4 of to be under-addressed, being one of 100). Further analysis found that since the least comprehensive (29.9 of 100) the beginning of school year 2013-2014: and weakest (14.5 of 100) provisions, with only one-quarter of districts having l A lmost all districts (93 percent) had nu- policies making staff role models for tritional goals, however schools continue healthy behaviors, 11 percent having to lack the curriculum (67 percent) and staff wellness programs and 8 percent the latest techniques for teaching nutri- having physical activity opportunities; tion education (90 percent); l T he percent of districts restricting l E ight-six percent of districts have unhealthy food marketing or implemented school meal plans that promoting healthy food choices met federal nutrition standards since remains relatively low, with only 14 the 2006-2007 school year, however percent of districts having strong policies have begun to level off in what restricted marketing of unhealthy is addressed and at what strength (e.g., food and 7 percent promoting healthy only 14 percent of school districts have choices on campus; and strong provisions for free drinking water at meals and only 11 percent l L ess than half of districts (49 have adequate time to eat meals); percent) have ongoing health advisory committees for evaluating and l T he scope of competitive foods and implementing wellness policies. beverages provisions are comprehensive TFAH • RWJF • StateofObesity.org 75 EXAMPLES OF SCHOOL-BASED PROGRAMS HealthMPowers324 HealthMPowers, which offers compre- conducted to help demonstrate the link hensive school wellness programs between health and academic achieve- throughout Georgia, was founded by two ment and further reinforce healthy steps parents and community leaders, Andy that can be taken in the home. Isakson and Mary Johnson, who wanted Since 2003, HealthMPowers has reached to promote healthy behaviors and envi- more than 260 schools and more than ronments by improving health education 200,000 students, school staff and and empowering students, school staff families. During the 2014–2015 school and families. year, HealthMPowers provided more HealthMPowers implements a three- than 45,000 students in 86 SNAP-Ed year, school-wide intervention that trains sponsored schools and early child care teachers and parents and provides di- centers with training, evaluation and re- rect services and resource materials to sources. According to HealthMPowers, support healthy school environments. the increased learning and focus resulted in healthier school environments and im- HealthMPowers evaluates each proved student behaviors and outcomes: school’s current health programs and almost 90 percent of participating stu- policies and selects appropriate re- dents improved in their health knowledge sources — programs, curricula and and behaviors, nearly 70 percent im- other teaching tools — to improve proved in their Progressive Aerobic Cardio- each school’s unique health needs. A vascular Endurance Run (PACER) and 80 “School Health Council” is created to percent either maintained or lowered their establish and execute an action plan to BMI over the course of the year.325 improve health education. In tandem with the school wellness plan, HealthM- HealthMPowers also helped increase Powers provides development sessions the number of students who partici- and encourages the creation of well- pated in school based physical activ- ness programs to help teachers and ity and extracurricular physical activity staff model healthy behaviors. at least 5 days per week, improved the consumption of fruits and de- To reach the home, “Family Newslet- creased screen time.326 According to ters” with age-appropriate information their most recent annual report, each on health issues are paired with ac- school moved from the unhealthy zone tivities families can use to reinforce at baseline into the healthy target zone healthy lessons learned at school. by the end of the year. Additionally, seminars for families are 76 TFAH • RWJF • StateofObesity.org EXAMPLES OF SCHOOL-BASED PROGRAMS Healthy Out-of-School Time Coalition327 In January 2009, the National Insti- These standards have been adopted by tute on Out-of-School Time (NIOST) at a wide range of coalition members, such the Wellesley Centers for Women at as the National AfterSchool Association, Wellesley College, the University of the YMCA of the USA, the Council on Massachusetts Boston (UMB) and Accreditation, the National Recreation the YMCA of the USA collaborated to and Park Association, the Boys & Girls found the Healthy Out-of-School Time Clubs of America and the Alliance for a Coalition (HOST). Healthier Generation, and disseminated to tens of thousands of out-of-school In 2010-2011, HOST created evi- time professionals and supporters. dence-based, healthy eating and physi- cal activity standards to foster positive Voices for Healthy Kids and other orga- nutrition and physical activity outcomes nizations are working to develop recog- for children in grades K-12 attending nition and accreditation programs and before school, afterschool, holiday and standards for HEPA to help expand their summer programs. HEPA implementation. Source: After School Alliance TFAH • RWJF • StateofObesity.org 77 CDC School Health Cooperative Agreements and National Goals and Guidance Every state and Washington, D.C. receives practices, programs and assessment tools State Public Health Actions to Prevent and and conducts surveys and other studies to Physical Control Diabetes, Heart Disease, Obesity Education monitor the status of students’ health and and Associated Risk Factors and Promote Physical Physical policies.329, 330 The agency has collaborated Activity Before School Health (DP13-1305) cooperative Activity During and After with SHAPE America (Society of Health School agreement funding via CDC. These School and Physical Educators) and other funds help support school, workplace, partners to develop the Comprehensive early childhood and community-based Staff Family and School Physical Activity Program, a multi- 60 Community programs to promote healthier school Involvement Engagement component approach where districts and MINUTES environments, nutrition, physical schools provide opportunities for children education and physical activity. Thirty-two and teens to achieve the nationally- COMPREHENSIVE SCHOOL states receive enhanced funding.328 PHYSICAL ACTIVITY PROGRAM recommended goal of at least 60 minutes of physical activity per day, most of which CDC also provides states, localities and Source: CDC should be moderate or vigorous in schools with guidance on evidence-based intensity. 331, 332, 333 New Models for School-Based Health and Social Services A range of new models are emerging nurses, but also expanding to develop In December 2014, CMS issued a to better address the health and social approaches that can help ensure clarification of a longstanding rule that service needs of students as an integral students who are not receiving sufficient permits schools to be reimbursed for part of helping them be successful in care through the traditional health health services provided to students school, which can help provide support system can access the care they need. who are covered by Medicaid.335 This to students to address health issues provides an important opportunity to These range from full on-site school related to obesity and risk for obesity have support for expanding the delivery based health centers (SBHCs) to mobile — including nutrition counseling and of health services through schools. health centers to strong partnerships with education — or for managing health local community health centers (CHCs) The stronger connection between problems associated with nutrition and/ to designated case managers. There health services and education can also or activity. In addition, they can help are also a range of potential payment help support connecting students and connect students and their families with models — for instance, in California, their families to additional care and other medical and support services — there are more than 230 SBHCs serving social services. For instance, a case ranging from nutrition assistance to nearly a quarter million children, which worker system can ensure that students broader social service support, which are financed through a variety of sources, are receiving follow up care — such can help increase access to healthy foods including reimbursement from public as appointments and services with and opportunities to be physically active. insurance programs and private health specialists or therapists — or that the Often school health programs have plans; local, state and federal grants; students and their families are being centered on school nurses to respond philanthropic foundations; and in-kind connected with other forms of support, to acute needs. A number of efforts contributions from school districts and such as supportive housing or food focus on increasing support for school other partners.334 assistance programs. 78 TFAH • RWJF • StateofObesity.org STATE SCHOOL NUTRITION, PHYSICAL ACTIVITY AND HEALTH EDUCATION POLICY TRENDS l Water Availability Under federal law, schools are required There are also concerns about the quality schools using a local public water supplier to provide easily accessible, clean water and safety of the free water that is avail- (e.g., municipal water system) to regularly to students at no cost. According to a able in many schools. test the water because the public water review by Bridging the Gap, more than supplier is required to regularly test the In 2014, the CDC released the Water Ac- 10 percent of middle and high schools water to ensure that it meets federal and cess in Schools Toolkit to help schools and nearly 15 percent of elementary state drinking water standards for con- meet federal requirements for making drink- schools did not meet the drinking water taminants, including bacteria and certain ing water available during mealtimes and requirements during the 2011-2012 chemicals.342 However, even if the water across school campuses.340 Included in the school year.336 And, one in four mid- meets federal and state standards, water tool kit is a needs assessment checklist dle and high school students attend a pipes and plumbing fixtures in the schools that guide schools through the process of school where water-quality issues are can affect the quality of the water. An evaluating current policies and practices affecting drinking fountains. analysis of California schools by Commu- related to drinking water, developing and pri- nity Water Center, for example, found that Most children are not drinking the rec- oritizing action plans to increase access to 24 percent of the 6,974 schools were im- ommended amount of water during the drinking water and evaluating changes. pacted by unsafe drinking water between school day.337 Children who drink more An analysis by USA Today of U.S. Envi- 2003 and 2014.343 The most common water consume less sugar and other bev- ronmental Protection Agency (EPA) data contaminants included lead, copper, bacte- erages. While many schools have water showed that about 350 schools and ria, arsenic, pesticide DBCP nitrates, and , fountains available, students may not day-care centers failed around 470 lead disinfectant by-products. make use of them due to limited avail- tests between 2012 and 2015.341 The ability, cleanliness or time-use barriers. The Flint, Michigan contaminated water cri- federal government only requires schools For instance, availability of cups or water sis has brought increased attention to con- with their own water systems — about 10 bottles can help encourage greater water cerns about unsafe water. And a number percent of schools (8,225 facilities) — to consumption, but few schools provide of school systems around the country have test for lead. Federal law does not require them to students. 339 increased testing and reporting on school water safety. For instance, 10 schools HOW MANY SCHOOLS MET FEDERAL DRINKING WATER REQUIREMENTS, tested in Oregon, four out of 28 schools 2011-2012 SCHOOL YEAR tested in Boston and 30 out of 67 schools Elementary Schools Middle Schools High Schools in Newark, New Jersey have reported high Fountains only 64.1% 61.9% 60.6% lead levels in drinking water.344, 345, 346 Dispensers only 13.3% 14.9% 11.9% Some groups are exploring mechanisms Fountains and dispensers 7.5% 9.3% 16.6% and funding to support cost-effective test- Other combinations 1.4% 1.4% 0.3% ing and remediation strategies for regular Did not meet requirement 13.6% 12.6% 10.6% testing of water in schools.347, 348 Source: Bridging the Gap TFAH • RWJF • StateofObesity.org 79 l Breakfast Policies A number of states have adopted policies Breakfast in the Classroom or Grab N’ to allow for more inclusive and flexible Go options.349 breakfast programs in schools, such A number of states require schools to serve as offering Breakfast in the Classroom, free Breakfast After the Bell if they have Breakfast After the Bell and/or Grab N’ high rates of students qualifying for free Go or Second Chance Breakfasts, which and reduced meals, including Colorado (70 can provide additional opportunities for percent or more); Nevada (70 percent or students to receive breakfast without hav- more); New Mexico (all elementary schools ing to arrive early for school and/or helps to provide breakfast before or after begin- lessen the possible sense of stigma of ning of instructional day); Texas (80 percent being associated with participating in the or more); and West Virginia (mandates ex- free and reduced lunch program. panding innovative breakfast delivery mod- Washington, D.C. requires that all public els such as Grab N’ Go or Second Chance schools and public charter schools offer Breakfasts).350, 351, 352 A number of states free breakfast to all students. The have enacted legislation to recommend flex- program offered in elementary schools ible breakfast delivery programs (such as where more than 40 percent of stu- Illinois and New Jersey) and/or increased dents qualify for free or reduced-price funding for programs (such as Arkansas, meals is Breakfast in the Classroom, Maryland and Virginia) without mandating while middle and high schools that requirements. In addition, a number of meet this threshold must offer any inno- local school districts are requiring or sup- vative breakfast service model, such as porting innovative breakfast programs. 80 TFAH • RWJF • StateofObesity.org l Farm-to-School Farm-to-School programs are estimated farmers, ranchers, fishermen and food pro- According to a review conducted by the Na- to serve more than 42 percent of schools cessors and manufacturers — a 105 percent tional Farm to School Network, 40 states and and 23.6 million children.353 In addition, increase over the $386 million purchased in Washington, D.C. enacted Farm-to-School more than 7,000 schools report having the 2011-2012 school year. 354 Schools that legislation between 2002 and 2014.355 school gardens. buy local food drive the local economy; for However, many of these programs cover only every dollar spent locally, another $0.40 to select students or schools in these states In 2013-2014, school districts reported pur- $1.60 of economic activity is generated. rather than all students or schools. chasing nearly $800 million in local food from State Farm to School Legislation: 2002-2014 LACKING F2S LEGISLATION Never proposed or enacted LACKING F2S LEGISLATION Task forces, councils, working groups, pilot programs or other support LOCAL PURCHASING PREFERENCE LAWS Requiring or encouraging state agencies, including schools, to purchase food locally UNFUNDED F2S PROGRAM Farm to preschool, farm to school or school garden programs FUNDED F2S PROGRAM Through appropriations, grants or reimbursement FUNDED F2S COORDINATOR POSITION State employee dedicated to coordinating state farm Source: National Farm-to-School Network to school efforts Percent of School Districts Participating in Farm-to-School Percent of Total Budget School District Spent on Local Activities by State, 2013-2014 Food by State, 2013-2014 WA WA MT ND ME MT ND ME VT VT OR MN OR MN ID NH ID NH SD WI NY MA SD WI NY MA WY MI WY MI CT RI CT RI NE IA PA NJ NE IA PA NJ NV NV UT IL IN OH DE UT IL IN OH DE CA MD CA MD CO WV VA CO WV VA KS MO DC KS MO DC KY KY NC NC AZ OK TN AZ TN NM OK AR SC NM AR SC MS AL GA MS AL GA TX LA TX LA FL FL AK AK HI HI ≥20% to <30% ≥30% to <40% ≥40% to <50% ≥50% to <60% <10% ≥10% to <20% ≥20% to <30% ≥30% ≥60% to <70% ≥70% to <80% ≥80% to <90% ≥90% Source: USDA Source: USDA TFAH • RWJF • StateofObesity.org 81 l Z ero-Exemption School Nutrition Policies A review by the Institute for Health Re- with the USDA’s Smart Snacks nutrition search and Policy at the University of standards: Alaska, California, Connecti- Chicago found that, as of March 2016, cut, Delaware, Hawaii, Iowa, Kentucky, 20 states and Washington, D.C. have Louisiana, Maryland, Minnesota, Missis- adopted zero-exemption policies for foods sippi, Montana, Nevada, New Hampshire, sold on school campuses during the New Jersey, New York, North Carolina, Or- school day — meaning all foods sold, egon, Rhode Island, Washington.356 even for fundraising efforts, must comply State Fundraising Exemption Policies, as of March 2016 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA TX LA FL AK HI State with zero-exemption policies State with exemption policies Source: National Wellness Policy Study l Out-of-School Time and School Celebration Nutrition Policies A review by Voices for Healthy Kids of also included standards for programs and competitive food policies found that, in events beyond school hours and/or for the fall of 2014, seven states and Wash- school celebrations (Hawaii, Maine, Mis- ington, D.C. had standards for competitive sissippi, Oregon, Rhode Island, Washing- snacks that align with USDA’s Smart ton and West Virginia).357 Snack in Schools nutrition standards and 82 TFAH • RWJF • StateofObesity.org l Physical Education State Requires Physical Education for Elementary, Middle and High Schools Every state has physical education re- WA quirements for students. However, these MT ME ND requirements are often limited or not VT OR MN ID NH enforced, and many programs are inade- SD WI NY MA WY MI quate. National guidelines recommend CT RI 358 NE IA PA NJ at least one hour of moderate to intense NV OH DE UT IL IN daily physical activity for children. To help CA MD CO WV KS MO VA DC meet these guidelines, the American Heart KY NC Association (AHA) and SHAPE America AZ OK TN NM AR SC recommend that states require elementary MS AL GA students receive 150 minutes per week TX LA and middle and high school students re- ceive 225 minutes per week of instructional FL AK physical education. HI A 2016 review by Voices for Healthy Kids State has requirements for elementary, middle and high schools State has requirements for elementary and middle schools and SHAPE America found that physical State has requirements for elementary and high schools education policies for elementary, middle State has requirements for middle and high schools Source: Shape America and State has requirements for elementary, middle or high schools and high schools vary significantly.359 AHA Voices for Healthy Kids State has no requirements l T hirty-eight states and Washington, D.C. require elementary school students to take physical education; State Requires Physical Education for Elementary, Middle and High Schools l T hirty-six states and Washington, D.C. WA§ require physical education for middle MT ND ME§ VT§ school students; and OR* MN ID NH§ SD WI§ NY MA l F orty-three states and Washington, WY MI § CT§RI D.C. require physical education for high NE IA PA§ NJ§ NV OH§ DE§ IL IN school students. CA§ UT MD CO§ WV§ KS MO VA§ DC§ KY l H owever, only 18 states and Washing- NC§ ton, D.C. set a minimum amount of time AZ TN§ § OK NM AR SC§ that elementary students must partic- GA § MS§ AL§ ipate in physical education; 14 states TX§ LA and Washington, D.C. set amounts for FL§ middle schools; and 6 set amounts for AK high schools; HI l O nly Oregon and Washington, D.C. meet the national recommendations for weekly State has minimum time requirements for elementary, middle and high schools time in physical education at both ele- State has minimum time requirements for elementary and middle schools mentary and middle schools; and State has minimum time requirements for elementary and high schools State has minimum time requirements for elementary, middle or high schools State has no minimum requirements l T wenty-seven states and Washington, D.C. § State has student assessment in physical education or of physical fitness require a student assessment in physical * State met national recommendations for weekly time in physical education education or of student physical fitness. Source: Shape America and AHA Voices for Healthy Kids TFAH • RWJF • StateofObesity.org 83 l Physical Activity State Requires Minimum Amount of Time for Physical Activity Per Day/Week Many states have started enacting laws WA requiring schools to provide a certain num- MT ME ND ber of minutes and/or a specified difficulty VT OR MN ID NH§ level of physical activity.360, 361 SD WI NY MA WY MI § CT§RI l E ighteen states specifically require NE IA PA§ NJ NV OH§ DE§ schools to provide physical activity. CA UT IL IN§ MD CO WV§ KS MO§ VA§ DC l E ight states have elementary school KY NC§ requirements; six states have both AZ OK TN NM AR SC elementary and middle school require- MS AL GA ments; and four states have require- TX LA ments at all three school levels. FL AK l T en states require elementary schools § HI to offer recesses on a daily basis for a certain number of minutes or total num- ber of minutes per week. The amount of State has requirements for elementary, middle and high schools time dedicated to recesses may or may State has requirements for elementary and middle schools not be added towards the minutes of State has requirements for elementary schools only State has no minimum requirements required physical activity. § State has a daily recess requirement for elementary schools with a minimum time Sources: Education Commission of the States and Shape America and AHA Voices for Healthy Kids l Safe Routes to School (SRTS) State had Statutes or Regulations on Safe Routes to School, as of August 2014 Every state and Washington, D.C. WA*§ participates in some form of SRTS MT ME ND program to promote walking and biking to VT § OR MN ID NH and from school. However, the programs SD WI NY§ MA WY MI vary significantly in their activities, CT RI NE IA PA NJ implementation and funding. And, some NV OH DE§ UT IL IN states have initiatives without official laws CA§ MD CO* WV KS MO VA DC* or statutory requirements. KY NC AZ TN OK SRTS supports improving sidewalks, NM§ AR SC bike paths and safe street crossings; MS AL GA reducing speeds in schools zones and TX LA LA neighborhoods; addressing distracted FL AK driving; and educating people about HI§ pedestrian and bike safety. It includes a range of partners, such as educators, parents, students, government officials, State with SRTS Statute(s) and Regulation(s) city planners, business and community State with only SRTS Statute(s) or Regulation(s) leaders and health officials. Early studies State with no SRTS Statute(s) or Regulation(s) § State requires establishment and administration of SRTS of SRTS have shown a positive effect on * State requires an advisory committee physically active travel among children Source: Public Health Law Center 84 TFAH • RWJF • StateofObesity.org and a reduction in crashes involving Secretary and the Secretary of Health pedestrians.362, 363, 364 and Human Services, the Administrator of Transportation for Highways, the While many states have SRTS policies Administrator of Transportation for Mass and programs, a review by Pubic Health Transit and the Commissioner of Public Law Center, found that only 16 states Health to coordinate and cooperatively and Washington D.C. have laws/rules adopt best practices to expand services strengthening their commitment and offered for SRTS programs. And, Vermont requirement on establishing, developing is the only state that requires the traffic and implementing programs.365 Only committee to consider setting maximum seven states require the establishment highway speed limits near schools based and administration of SRTS programs on data collected from SRTS programs. and two states require the appointment of an advisory committee to develop a A review by the SRTS National SRTS plan (Colorado and Washington). Partnership and the YMCA of the USA Colorado is the only state that requires found that only six states (California, their Department of Transportation (DOT) Colorado, Florida, Hawaii, Minnesota to notify schools and make information and Washington) had dedicated funds about safe-use of public streets and for SRTS and only five states (Florida, premises available to students. And, Nebraska, Oregon, Rhode Island and only Massachusetts has a healthy Washington) specifically obligated more transportation compact established than 60 percent of federal transportation within the DOT that requires the funds to support SRTS projects.366 Percent Obligated State-Controlled Transportation Alternatives Program (TAP) In many states, SRTS is targeted Funds for Safe Routes to School Projects by State to traditionally underserved school communities. As of 2014, 69 percent WA of schools receiving SRTS awards are MT ME ND OR MN VT classified as Title I schools, or as NH ID SD WI NY MA having a high percentage of students WY MI from low-income families. Forty-seven CT RI NE IA PA NJ NV OH percent of SRTS schools enroll students IL IN DE CA UT MD who are eligible to receive free and CO WV KS MO VA DC KY reduced-price meals.367 NC AZ TN OK NM AR SC MS AL GA TX LA LA FL AK HI 1% to 15% 16% to 30% 31% to 45% 46% to 60% >60% State obligated no TAP funds Source: Safe Routes to School National Partnership TFAH • RWJF • StateofObesity.org 85 l Shared-use Agreements State has Shared-use Agreements Thirty-six states and Washington, D.C. WA§ have laws supporting shared-use of MT ME ND school facilities, opening school play- VT § OR MN ID NH grounds and fields for recreational use SD WI NY§ MA WY MI to the community outside of school CT RI NE IA PA NJ hours. Most of the laws recommend NV OH DE§ UT IL IN but do not require schools to implement CA§ MD CO§ WV KS MO VA DC* shared-use practices. 368 KY NC AZ TN OK Many communities do not have enough NM§ AR SC safe and accessible places for people MS AL GA to be physically active, indoors and out. TX LA LA Schools often have gymnasiums, play- FL AK grounds, tracks and fields, but they are § HI not accessible to the community when not in use by the school. Many schools keep State with Shared-use Agreements their facilities closed during non-school State with no Shared-use Agreements hours for fear of liability in the event of an injury, vandalism and the cost of main- Source: Safe Routes to School National Partnership tenance and security. Some states and communities have laws encouraging or requiring schools to make facilities avail- facilities to the local community.370 Pro- co’s Recreation and Park Services receives able for use by the community through grams are mostly funded by private-public $300,000 per year for a patrol officer to shared- or joint-use agreements. 369 These money, and are maintained and developed open, close and inspect schools and partic- agreements allow school districts, local through the collaborative work of the cit- ipating schools receive $350,000 per year governments and community-based orga- ies’ departments of education and parks to use for PTA and community activities. nizations to overcome common concerns, and recreation services. l N ew York City’s Schoolyards to Play- costs and responsibilities that come l A s of 2016, 80 schools in San Francisco grounds initiative has opened 220 along with opening school property to the have voluntarily opened up their play- schools, from after school hours until public during non-school hours. grounds on the weekend, which has led dusk during the week and from 8 a.m. to Shared-use programs in San Francisco, to a decrease in school vandalism and dusk on the weekends and holidays. Par- California and New York City, for exam- littering, and an increase in community and ticipating schools receive $50,000 a year ple, show the benefits of opening school local business engagement. San Francis- for associated labor and maintenance. 86 TFAH • RWJF • StateofObesity.org l Health Assessments Twenty-nine states and Washington, D.C. §49452.7, replaced individual BMI report- have laws that require BMI screening or ing, California Education Code §49452.6. weight-related assessments other than BMI and other health assessments are BMI.371, 372, 373, 374, 375 intended to help schools and communi- l N ineteen states have BMI screening ties assess rates of childhood obesity, requirements: Alabama, Arkansas, Cali- educate parents and students and fornia*, Florida, Illinois, Kentucky, Maine, evaluate obesity prevention and control Mississippi, Missouri, Nebraska, New programs.376 AAP recommends that BMI Mexico, New York, North Carolina, Ohio, be calculated and plotted annually for all Oklahoma, Pennsylvania, Tennessee, youth as part of normal health supervision Vermont and West Virginia. within the child’s medical home, and the NAM recommends annual school-based l T en states and Washington, D.C. have BMI screenings.377, 378 CDC has identified other weight-related screening require- safeguards for schools that conduct BMI ments: Connecticut, Delaware, Georgia, screenings to ensure they focus on pro- Iowa, Louisiana, Massachusetts, Nevada, moting health and wellness for children.379 New Jersey, South Carolina and Texas. CDC Safeguards for BMI measurement l A s of July 2010, statewide distribution programs are available at: http://www. of diabetes risk information to school cdc.gov/healthyyouth/obesity/BMI/BMI_ children, California Education Code measurement_schools.htm State Requires BMI Screening or Weight-Related Assessments WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA TX LA LA FL AK HI State requires BMI screening State requires weight-related assessments other than BMI State does not require BMI screening/weight-related assessments Sources: Linchey J and Madsen KA, 2010; Obesity in Mississippi, 2013; Ruggieri DG and Bass SB, 2014; Shape America and AHA Voices for Healthy Kids, 2016; and State School Health Policy Database, 2014 TFAH • RWJF • StateofObesity.org 87 C. COMMUNITY-BASED POLICIES AND PROGRAMS Many Americans only have a doctor’s appointment once or twice a year. The rest of the year they are often on their own to try to follow their doctor’s advice in their daily lives. A growing body of evidence shows that Americans cannot achieve health goals — including eating healthier, increasing physical activity and managing obesity and related health problems — without support in their neighborhoods, workplaces and schools.380 “Health professionals are adept at places to be physically active can make l I mplementation of Restaurant Menu treating a vast range of diseases, injuries it easier to make healthy choices. Labeling Requirements and other medical conditions. But Federal, state and local governments l R evised Nutrition Facts Label their training and healthcare delivery can support a range of strategies and Information incentives do not emphasize addressing programs that can help prevent obesity the root causes of health problems that around the country. l R evised Dietary Guidelines for occur outside of the healthcare system Americans Key policies highlighted in this section — factors such as education, access include: l D oD’s Operation Live Well (OLW) to healthy food, job opportunities, and Healthy Base Initiative (HBI) safe housing, environment and toxic l C DC Support for Obesity, Nutrition stress — that fundamentally shape how and Physical Activity Programs l S tate Policy Review: Complete long or well people live,” according Streets and Transportation Alternative l M arketplace Incentives to Improve to a report by the RWJF Commission Programs, Nutrition Assistance Healthy Food Availability in More to Build a Healthier America.381 and Education Programs, State Communities: Healthy Food According to CDC, a majority of Government Workplace and Facilities Financing Initiatives (HFFI) and New chronic diseases, including many cases Nutrition Standards and Local and Market Tax Credits (NMTC) of obesity-related illnesses like type State Taxing Policies 2 diabetes and heart disease, could be prevented through lifestyle and Budgets for Some Key Federal Community-Based Enacted Budget FY environmental changes. A short list of Obesity-Related Programs 2016 key risk factors, including obesity, high Division of Nutrition, Physical Activity and Obesity (CDC) $50 million blood pressure, physical inactivity and Chronic Disease Programs at CDC $1.2 billion diets low in fruits and vegetables and Healthy Food Financing Initiative $22 million383 high in saturated fats, have a major $7 billion384 (2015-2016 New Market Tax Credits impact on overall risk for a range of combined funding) health problems.382 Transportation Alternative Programs $835 million385 SNAP (USDA) $80.849 billion386 A range of policies supporting the SNAP-Ed (USDA) $408 billion availability of accessible, affordable Note: For some of these programs, only a portion of the funding goes toward obesity-related healthy foods and safe, convenient activities (i.e., nutrition, physical activity). 88 TFAH • RWJF • StateofObesity.org U.S. EATING HABITS PORTION DISTORTION The typical American diet exceeds population consumed at least 567 20 Years Ago Today recommendations for high-density energy calories from SSBs on any given day Bagel foods (foods that are high in calories, — equivalent to more than four 12-oz saturated fat, sodium and added sugars), cans of soda.397 Although Americans and does not have enough low-density are consuming less SSBs — an average energy foods (foods that are low in of 155 calories per day, which is equal calories and fat and high in calcium, fiber, to one can of soda, SSBs still make up 140 calories 350 calories water and other vital minerals). 387, 388, 389 nearly 8 percent of children’s and 9 per- 3 inches (diam.) 6 inches (diam.) cent of adult’s (20- to 39-year-olds) total Coffee Low-income families have less access to daily calories (NHANES data analysis, many healthy, affordable foods — both 1999-2010).398 While the most com- due to cost and logistics. While the monly consumed SSB is soda, there has typical American family spends $50 per also been a rise in non-traditional SSBs person per week on food, low-income consumption — fruit drinks, sweetened With whole milk Mocha, steamed whole families spend $35 per person per week & sugar milk & mocha syrup bottled water, sports drinks and energy and spend a relatively higher proportion of 45 calories 350 calories drinks — and adolescent sports drink 8 ounces 16 ounces their total income on food.390 and energy drink consumption has tri- Muffin According to USDA and CDC, Americans pled, from 4 percent to 12 percent. 399 eat more than the daily recommended l D ietary Fat: Americans consume an calories, sodium, saturated fats, refined average of 640 calories worth of added grains and added sugars, while consuming fats per person per day.400 210 calories 500 calories too few whole grains, fruits, vegetables, 1.5 ounces 4 ounces low-fat or fat-free dairy, lean meats and l F ruits and Vegetables: 37.7 percent of seafood and oils that are healthy. 391 adults and 36 percent of adolescents eat Cheeseburger fruit less than once a day and 22.6 per- l C alories: On average, Americans con- cent and 37.7 percent of adolescents eat sume nearly 460 more calories a day vegetables less than one time a day.401 than in 1970 (2,568 calories in 2010 333 calories 590 calories compared to 2,109 in 1970).392 l R estaurants, Fast Food and Prepared Foods: Americans consume around Pizza l P ortion Distortion: Portions sizes have one-third of their calories — and spend grown significantly over time — with nearly half (48 percent) of their food restaurant portion sizes doubling or tri- budget ($709.2 billion annually) — eat- pling over the past 20 years.393, 394 ing out.402, 403 Food eaten outside the 500 calories 850 calories l S ugar: Americans consume nearly three home often can be higher in fat and Popcorn times the recommended amount of sodium. Consumers routinely underes- sugar; added sugar consumption has in- timate calories and fat when eating out, creased by 14 percent since 1970.395, 396 and children eat nearly double the num- ber of calories when they eat out versus l S ugar-Sweetened Beverages (SSBs): eating at home.404, 405, 406, 407, 408 270 calories 630 calories In 2005-2008, five percent of the U.S. 5 cups 11 cups Source: National Heart, Lung, and Blood Institute TFAH • RWJF • StateofObesity.org 89 Physical Activity and Health Percent of Adults Who are Physically Inactive, BRFSS 2015 l E ighty percent of American adults do not WA meet the government’s national physical MT ME ND activity recommendations for aerobic VT OR MN ID NH and muscle strengthening. 409 Around 45 SD WI NY MA WY MI percent of adults are not sufficiently ac- CT RI NE IA PA NJ tive to achieve health benefits.410 There NV OH DE UT IL IN are also benefits to being physically CA MD CO WV KS MO VA DC active, including decreased risk of mor- KY NC tality and metabolic syndrome.411 AZ OK TN NM AR SC l A round $117 billion in healthcare costs are MS AL GA associated with inadequate physical activ- TX LA ity. 412 Adults who are inactive pay $1,437 FL AK more per year in healthcare costs than HI physically active adults.413 Studies have also found the more inactive the mother, the more inactive the child, and the more physically active the mother, the more phys- 10% to <15% ≥20% to <25% ≥30% to <35% ≥40% to <45% ≥15% to <20% ≥25% to <30% ≥35% to <40% ically active the child early in life.414 Source: CDC, BRFSS Mississippi had the highest reported percentage of inactivity among adults at 36.8 percent. Built Environment and Health Research has shown that children and on three million people living in 8,777 reation centers have a 20 percent to families are more active when they live in urban-Canadian neighborhoods found 45 percent greater risk of becoming neighborhoods that have sidewalks, parks, an association between the walkability overweight.419, 420, 421 In general, states bicycle lanes and safe streets. 415 of a neighborhood and rates of obesity, with the highest levels of bicycling and overweight and diabetes. 418 The 12- walking have the lowest levels of obesity, l A ccording to the National Academy of year study found that those living in high blood pressure and diabetes, and Sciences (NAS), a healthy built environ- the most walkable neighborhoods had have the greatest percentage of adults ment — which includes having safe, more than 10 percent lower overweight who meet the recommended 30-plus accessible places to walk, bike or en- and obesity rates compared to those minutes a day of physical activity.422 gage in other physical activity — “can who lived in the least walkable areas. facilitate… physical activity. The built en- l N ational and local community studies Overweight and obese rates increased vironment can be structured in ways that show that access to public parks, public by more than 9 percent among individ- give[s] people more…opportunities and pools and green space is much lower in uals living in the least walkable neigh- choices to be physically active.”416 neighborhoods largely occupied by racial borhoods. Additionally, diabetes was and ethnic minorities, and are related l R esidents of walkable communities are significantly lower among individuals to higher obesity and lower physical twice as likely to meet physical activity living in the most walkable neighbor- activity rates.423, 424 For example, only guidelines as those who do not live in hoods compared to those living in the one-third of Latinos live within walking walkable neighborhoods.417 least walkable ones. distance of a park compared to almost l A recent study published in the Journal l C hildren in neighborhoods that lack half of all Whites.425 of the American Medical Association access to parks, playgrounds and rec- 90 TFAH • RWJF • StateofObesity.org Food Deserts l N early 30 million Americans — around 9 access to supermarkets and fresh pro- percent of the nation’s population — live duce. Greater accessibility to supermar- in food deserts — which means they do kets is consistently linked to lower rates not have a supermarket or supercenter of overweight and obesity.427 Studies within a mile of their home if they live have found that there is less access to in an urban area, or within 10 miles of supermarkets and nutritious, fresh foods their home if they live in a rural area — in many urban and lower-income neigh- Nearly 30 million making it challenging to access healthy, borhoods and unhealthier items are also Americans don’t have access to a affordable food.426 often more heavily marketed at the point- supermarket within a mile of their home if of-purchase through product placement in they live in urban areas, or within 10 miles if l F amilies in predominantly minority and they live in rural areas. stores in low-income neighborhoods.428, 429 low-income neighborhoods have limited Food Marketing Nearly $2 billion is spent annually to ers viewed almost one fast food ad on market foods and beverages to children Spanish-language TV every day in 2013, a and adolescents in the United States. A 16 percent increase from 2010.433 In addi- report from the NAM concluded that food tion, low-income Latino neighborhoods have advertising affects children’s food choices, up to nine times the density of outdoor ad- food purchase requests, diets and vertising for fast food and sugary drinks as health.430 Food marketing is more preva- high-income White neighborhoods,434 and lent in Black and Latino neighborhoods. Latino children are more likely to attend a school that is close to fast-food restaurants l B lack children see twice as many calo- and convenience stores.435, 436 ries advertised in fast food commercials as White children.431 The products most frequently marketed to Blacks are high-calorie, low-nutrition foods and beverages. Billboards and other forms of outdoor advertisements, which often promote foods of low nutritional value, are 13 times denser in predominantly Black neighborhoods than they are in White neighborhoods.432 l L atinos are a major target audience for food marketers, particularly due to their population growth and relative spending power. Studies have found that 84 percent of youth-targeted food advertising on Span- ish-language TV promotes food of low nu- tritional value. Between 2010 and 2013, fast food restaurants increased their overall advertising expenditures on Spanish-lan- guage TV by 8 percent. Latino preschool- TFAH • RWJF • StateofObesity.org 91 CDC Support for Obesity, Nutrition and Physical Activity Programs CDC supports a range of obesity programs focused on some obesity-related l S upports cross-cutting approaches to prevention programs in communities illnesses, such as diabetes, heart disease prevent risk factors that contribute around the country. The National and stroke. The United States spends an to chronic diseases. Center for Chronic Disease Prevention estimated $190 billion annually on obesity- l C reated a National Center for and Health Promotion (NCCDPHP) related illness costs, which is around Chronic Disease Prevention and — including the Division of Nutrition, 20 percent of all medical spending.438 Promotion initiative across four Physical Activity and Obesity — is Childhood obesity is responsible for $14.1 divisions — Division of Heart the lead center working on obesity billion in direct medical costs. Diseases and Stroke Prevention; prevention and control, and it works Division of Diabetes Translation; A large majority of NCCDPHP’s budget in partnership with the School Health Division of Nutrition, Physical goes to state and community grant pro- Branch of the Division of Population Activity and Obesity; and Division grams, based on the availability of funds. Health, Division of Heart Disease and of Population Health — aimed Some key obesity-related grants include: Stroke, Division of Diabetes Translation at efficiently implementing and Division of Community Health.437 l S tate Public Health Actions to Prevent cross-cutting strategies that In addition, the National Center for and Control Diabetes, Heart Disease, address risk factors for a range of Environmental Health (NCEH) also Obesity and Related Risk Factors and chronic diseases and increasing studies the relationship between the Promote School Health (“1305” awards) coordination to improve the built environment (such as community l P rovides $101.2 million to enhance impact of preventing obesity, planning and transportation) and key chronic disease prevention diabetes, heart disease and other health issues like obesity. programs in states. related conditions. DNPAO received $50 million in appropriations in FY 2016 to track and analyze obesity, nutrition and physical activity trends at national, state and CDC Division of Nutrition, Physical Activity, and Obesity Fiscal Year 2007 to Fiscal Year 2016 local levels, and study and promote best practices for effective strategies and $50 programs. It provides around $17 million $49.92 a year to states for obesity prevention $44.30 $44.99 $10.00 $10.00 activities. DNPAO also works on a series $42.19 $38 $40.59 $35.00 of obesity prevention priority initiatives, $35.00 including breastfeeding, early child care $34.19 $34.00 (Dollars in millions) $8.82 education and a “high-obesity” program $25 that provides $7.5 million in competitive $32.23 grants to communities where adult obesity rates are above 40 percent. As new $13 priority initiatives have been introduced, $12.58 there has not been a corresponding increase in funds; consequently money $0 $2.50 available for core activities has decreased 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 by around $10 million (16 percent). Fiscal Year ■ Discretionary Funding ■ Prevention and Public Health Fund Total federal funding for all CDC chronic disease prevention activities is approximately $1.2 billion. This includes 92 TFAH • RWJF • StateofObesity.org Chronic Disease Funding — Fiscal Year 2003 to Fiscal Year 2016* $1,500 $1,125 $59 $301 $411 $244 $457 $452 $339 (Millions) $750 $790 $818 $900 $834 $825 $834 $882 $905 $774 $756 $740 $719 $747 $838 $375 $0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Fiscal Year ■ Funding from the Prevention and Public Health Fund ■ Chronic Disease Discretionary level (Without the PPHF) *FY 2010-2016 values are supplemented by the Prevention and Public Health Fund l S tate and Local Public Health Actions l $ 51 million supports 49 grants for to Prevent Obesity, Diabetes, and Heart culturally-tailored, evidence-based Disease and Stroke (“1422” awards) strategies to reduce health inequities l A four-year project to create at the community level. community strategies to promote l M illion Hearts Campaign health and integrate with l $ 4 million supports a national healthcare systems. initiative aimed at preventing 1 million l $ 70 million was given to 17 states heart attacks and strokes by 2017. and four large cities. l G ood Health and Wellness in Indian l P artnership to Improve Community Country Health (PICH) l $ 14 million supports 23 grants to l A three-year initiative supporting prevent and manage heart disease, evidence-based strategies to diabetes and associated risk factors improve the health of communities in American Indian tribes and and reduce the prevalence of Alaska Native villages. chronic diseases by addressing tobacco use and obesity. l P reventive Health and Health Services Block Grant l I n 2014, $49.3 million was awarded to 39 communities ($30.9 million to 13 l P rovides every state with flexible large cities and urban counties; $14.2 support to address what they million to 20 small cities and counties; determine to be their most and $4.2 million to six American important health needs. Indian tribes). The third and final l B lock grant funds have doubled year of this cooperative agreement will from $80 million in FY 2013 to begin September 30, 2016. $160 million in FYs 2014, 2015 and 2016 under the Public Health and l R acial and Ethnic Approaches to Prevention Fund (Prevention Fund). Community Health (REACH) TFAH • RWJF • StateofObesity.org 93 Marketplace Incentives to Improve Healthy Food Availability in More Communities: Healthy Food Financing Initiatives and New Market Tax Credits (NMTC) USDA, HHS and the Department of options, including by providing Treasury (Treasury) have developed incentives and programs to encourage a number of initiatives to support more grocery and food stores to locate increased access to healthier food in low-income communities. HEALTHY FOOD ACCESS Having local, accessible stores with a table consumption, and for every addi- quality selection of healthy foods helps tional supermarket in a tract, produce make healthier choices easier: consumption rises 32 percent. Among Whites, each additional supermarket l S upermarkets and supercenters pro- corresponds with an 11 percent in- vide the most reliable access to a vari- crease in produce consumption.441 ety of healthy, high-quality products at the lowest cost, and shoppers gener- l A dults with no supermarkets within ally prefer these stores to smaller gro- a mile of their homes are 25 percent cery stores and convenience stores. 439 to 46 percent less likely to have a healthy diet than those with the most l A dults living in neighborhoods with su- supermarkets near their homes.442 permarkets and/or grocery stores have the lowest rates of obesity (21 percent), l N ew and improved grocery stores can and those living in neighborhoods with catalyze commercial revitalization in no supermarkets and access to only a community. An analysis of the eco- convenience stores and/or smaller nomic impacts of five new stores that grocery stores have the highest rates of opened with Fresh Food Financing Ini- obesity (32 percent to 40 percent).440 tiative assistance found that, for four of the stores, total employment sur- l B lacks living in a census tract with a rounding the supermarket increased at supermarket are more likely to meet a faster rate than citywide trends.443 dietary guidelines for fruits and vege- Healthy Food Financing Initiatives USDA, authorized at $125 million. are public-private partnerships which USDA supports loans, grants, promotion use grants and loans to support the and other public and private investment financing of supermarkets, farmers’ programs designed to create healthy markets, food hubs, urban farms and food options in food deserts across the other healthy food retail options. country. The initiative provides financial The federal government has funded and technical assistance to eligible fresh, HFFI grants through HHS, USDA and healthy food retailers for the purposes Treasury since 2011.444, 445 of market planning and promotion efforts, as well as infrastructure and The Farm Bill of 2014 established a operational improvements designed to permanent federal HFFI program at 94 TFAH • RWJF • StateofObesity.org stimulate demand among low-income consumers for healthy foods and to Healthy Food Financing Initiative: Grants Distributed from 2011 to 2015 by State increase the availability and accessibility WA of locally and regionally produced foods MT ME ND in underserved areas.  VT OR MN ID NH SD WI HHS awards competitive grants NY MA WY MI CT RI to Community Development IA PA NJ NV NE Corporations to support projects that UT IL IN OH DE CA MD help finance grocery stores, farmers CO WV KS MO VA DC KY markets and other sources of fresh, NC TN nutritious foods. As of 2015, the AZ NM OK AR SC Community Economic Development GA MS AL (CED)-HHFI programs have awarded TX LA more than $44.5 million in grants FL to help support the dual goal of AK improving access to healthy food HI while helping to create jobs and business opportunities in low-income State with grants State with no grants communities. Source: HHS, Office of Community Services Through Treasury, the Community Development Financial Institutions (CDFI) Fund provides flexible financial assistance and specialized training and also developed more than 1.12 Local Food, Local Places is a federal and technical assistance to CDFIs (to million square feet of space for farming initiative that provides technical support support investments in low-income activities, food distribution centers and and expertise to rural communities communities) that invest in businesses other non-retail healthy food projects. to develop comprehensive strategies that provide healthy food options. and strengthen local food systems Treasury also administers the New Since 2011, the federal CDFI Fund and economies.451 Six federal agency Markets Tax Credit Program, which has awarded $90 million via 44 HFFI partners — USDA, EPA, DOT, CDC, encourages investments in low- financial assistance awards in 29 states. Appalachian Regional Commission and income communities by allowing These funds have leveraged more than Delta Regional Authority — selected individual and corporate investors $1 billion in grants, loans, federal tax 26 regions in 14 states — Alabama, to receive a tax credit against their incentives and investments to finance Arizona, Arkansas, California, Kentucky, federal income tax in exchange for projects to eliminate food deserts.446 Louisiana, Maine, Mississippi, Missouri, making equity investments in financial HFFI-projects have created or retained New York, North Carolina, Oklahoma, intermediaries called Community 2,500 jobs. Ohio and Pennsylvania — to develop Development Entities (CDEs).448, 449 specific projects and implement action In the first two rounds of HFFI, 23 Since the NMTC program was created plans to promote local foods and CDFIs received awards over a three- in 2000, it has distributed more than businesses, create permanent grocery year period and made 99 loans totaling $40 billion in federal tax credits. The stores and revitalize communities and $43.5 million to 114 healthy food NMTC program helped finance 49 underused land.452 The intent is for projects in low-income, low-access food supermarket and grocery store projects communities to be able to diversify deserts.447 These loans created more between 2003 and 2010 that improved their local economies, while building than 899,000 square feet of new space healthy food access in low-income sustainable communities and expanding for 64 retail outlets ranging from small communities for more than 345,000 accessibility to healthy foods. green grocers to large supermarkets, people, including 197,000 children.450 TFAH • RWJF • StateofObesity.org 95 THE MICHIGAN GOOD FOOD FUND453 Source: The Food Trust, PolicyLink and Reinvestment Fund In 2015, the Michigan Good Food Fund underserved areas by providing loans and further financial support from the W.K. Kel- (MGFF) — a statewide public-private business assistance to support projects logg Foundation, the Kresge Foundation, healthy food financing program — was across the state’s food value chain, includ- and the Max M. & Marjorie S. Fisher Foun- launched to increase access to healthy ing production, processing, aggregation, dation. MGFF partners are implementing food, spur economic development and cre- distribution and retail projects. Other core the program with a focus on promoting ate jobs. Managed by Capital Impact Part- partners of the fund include Fair Food equitable access to food jobs, business ners (CIP), a nonprofit CDFI that has been Network and the Michigan State University ownership, and flexible capital; sustain- overseeing a California FreshWorks fund Center for Regional Food Systems. The able environmental practices; and locally since 2011, MGFF will expand access MDFF is supported with a $3 million fed- grown and regionally produced foods.  to healthy food for Michigan residents in eral grant from the federal HFFI as well as ILLINOIS FRESH FOOD FUND454 Source: The Food Trust, PolicyLink and Reinvestment Fund In 2007, the Illinois Food Marketing Task the 10 policy recommendations put forth efforts to improve nutrition education. Force, convened by Voices for Illinois by the Task Force.  The program is modeled after Children, the Illinois Retail Merchants the Pennsylvania Fresh Food Financing Governor Pat Quinn announced the launch Association, the Illinois Food Retailers Initiative, the New York Healthy Food and of the new fund in 2012. The state is Association, and The Food Trust, met to Healthy Communities Fund and similar working with IFF, a CDFI, to administer the develop recommendations to overcome programs across the country. This new program and provide initial funding for the barriers to supermarket and other program will bring more grocery stores the initiative in the form of a $10-million fresh food retail access that plagues many that sell fresh produce to underserved grant. An additional $3 million in funding communities throughout the state.  This communities across Illinois, which has been secured by IFF through the effort gave way to the Illinois Fresh Food improves health and wellness while federal Healthy Food Financing Initiative.  (IFF) Fund, a statewide grocery financing also stimulating local economies and program designed to increase access to In addition to healthy food retail, creating jobs. For more information, go healthy foods in underserved communities the program supports community to the Illinois Fresh Food Fund, http:// in Illinois. This new program was one of engagement programs, including www.iff.org/. ADDITIONAL EXAMPLES OF FOOD FUNDS: l T he California FreshWorks Fund has or low-interest loans to supermarkets supermarkets and other fresh food out- raised $272 million to bring grocery and other fresh food retailers.456, 457 lets in 78 urban and rural areas serving stores, fresh produce markets and other 500,000 residents.458 FFFI has also l T he Circle Foods store — the first healthy food retail stores to communi- created or retained 4,860 jobs in under- Black owned grocery store in New Or- ties that do not have them. 455 served neighborhoods. Home values leans, which was originally opened in near new grocery stores have increased l I n New Orleans, the City Council priori- 1939 and was destroyed by Hurricane from 4 percent to 7 percent, and local tized healthy food retail as a rebuilding Katrina — reopened in 2014 with the tax revenues also have increased.459 strategy after Hurricane Katrina, creating help of such assistance. the Fresh Food Retailer Initiative to pro- l T he Pennsylvania Fresh Food Financing vide direct financial assistance to retail Initiative (FFFI), since 2004, has financed businesses by awarding forgivable and/ 96 TFAH • RWJF • StateofObesity.org Implementation of Restaurant Menu Labeling Requirements In April 2016, FDA published final mandated by the ACA and will take consistent manner” so that consumers can guidance to accompany menu labeling effect in May 2017. see it clearly before purchasing items. requirements.460 All chain restaurants Other nutrition information — such Some market research has shown (with 20 or more locations) and similar as calories from fat, total fat, saturated that menu labeling may impact the food establishments — including fat, trans fat, cholesterol, sodium, total decisions of some segments of the bakeries, grocery stores, convenience carbohydrates, fiber, sugars and protein population more than others; for stores and coffee chains — will be — will be required to be made available in instance, it may have a greater effect required to clearly post the calorie writing upon consumer request. Vending on women than men, on higher-calorie count for each standard item on machines will be required to post nutrition items and among certain types of their menus. The requirements were information in a “direct, accessible, and restaurant chains. Revised Nutrition Facts Label Information In May 2016, FDA published a final rule establishing changes to the Nutrition and Supplement Facts Label.461 The new nutrition label, Nutrition Facts scheduled to take effect on most 8 servings per container Serving size 2/3 cup (55g) products in 2018, will include visual Amount per serving Calories 230 information for consumers alongside % Daily Value* Total Fat 8g 10% Saturated Fat 1g 5% changes, including: Trans Fat 0g Cholesterol 0mg 0% Sodium 160mg 7% Total Carbohydrate 37g 13% C hanges in serving sizes as determined Dietary Fiber 4g 14% l Total Sugars 12g Includes 10g Added Sugars 20% via separate FDA rulemaking based on Protein 3g Vitamin D 2mcg 10% changes in how much people tend to Calcium 260mg Iron 8mg 20% 45% Potassium 235mg 6% eat certain foods at one time; * The % Daily Value (DV) tells you how much a nutrient in a serving of food contributes to a daily diet. 2,000 calories a day is used for general nutrition advice. l A requirement that products list added sugar in grams and as a percent daily value, that shows what percent of the daily recommended maximum Source: FDA of added sugar is provided by one type, and adjusting the serving/ serving of the product; portions to full package labeling or l C hanges in the specific vitamins and dual size labeling (portion versus minerals required based on changes entire package) to better match what in dietary recommendations and people may be consuming. Source: FDA trends; and The final rule represents the first l A dditional changes to make it comprehensive update to the nutrition easier to read, such as larger font label in over two decades. TFAH • RWJF • StateofObesity.org 97 Revised Dietary Guidelines for Americans In 2015, HHS and USDA jointly released the 8th edition of the Dietary Guidelines for Americans (DGA).462 Guidelines are revised every 5 years to reflect the latest assessments of nutrition science. The 2015-2020 edition emphasizes the idea that Americans should shift food choices toward more nutrient-dense foods and beverages in place of less healthy choices. Most federal food programs are required by law to have nutrition standards that meet the DGA, including CACFP, National School Lunch Program, School Breakfast Program, Smart Snacks and WIC. The 2020 version will include the first guidelines for children under the age of 2. The guidelines also highlight the importance of all sectors play in helping Americans meet healthy eating and physical activity recommendations. Source: Health.gov Source: USDA Source: Health.gov 98 TFAH • RWJF • StateofObesity.org DoD’s Operation Live Well (OLW) and Healthy Base Initiative (HBI) Nearly one in three young men and The initiative includes demonstration women are ineligible to serve in the projects such as the Healthy Base Initiative armed forces due to being overweight (HBI), which is being implemented at or obese.463 In 2011, more than 12 14 DoD sites worldwide. Action plans for percent of active duty service members HBI are based on assessments completed were obese, a 61 percent increase from at the selected installations. HBI aims to 2002. Obese service members are identify best-practice efforts in reducing more likely to be injured compared obesity and tobacco use, while improving to healthy weight members. Unfit fitness, readiness and resilience. In a or overweight service members are survey of more than 600 employees at one dismissed, costing more money to of the HBI sites (the Defense Logistics screen and train replacements. Agency (DLA)), 93 percent of employees said the initiative is helping change their DoD’s Operation Live Well is a strategic behaviors, including eating habits and approach to create more ready, resilient physical activity, while 83 percent used and healthier armed forces and military the farmers’ market(s) and 65 percent communities.464 OLW brings together participated in the stairwells program.465 the resources and capabilities of local military communities, including There is also continued support for the commanders; health and medical DoD school systems to launch initiatives experts; commissaries and dining to serve healthier meals to children. facilities; education resources; places For example, Fort Campbell Army Base of worship; and morale, welfare and is a Department of Defense Education recreation programs. Activity school district of nine schools with 4,700 students that participates in OLW is DoD’s long-term initiative to the National School Lunch Program.466 improve the health and wellness of the With the help of registered dieticians, more than 10 million members of the schools developed and implemented U.S. defense community, including nutrition goals, launched farm-to-school service members and their families, programs and trained food service retirees and DoD civilians. workers on nutrition standards. Glynnis Jones / Shutterstock.com TFAH • RWJF • StateofObesity.org 99 STATE OBESITY PREVENTION RELATED POLICIES Complete Streets and Transportation Alternatives Program Across the country, more than 900 re- 24 policy and funding indicators for Com- gional and local communities, including plete Streets and Active Transportation; 32 states, Washington, D.C. and Puerto Safe Routes to School and Active Trans- Rico, have adopted Complete Streets portation Funding; Active Neighborhoods policies.467 Complete Streets policies and Schools; and State Physical Activity incorporate safe and convenient walking Planning. This includes reviewing state and bicycling into transportation planning; policies and funding and states’ use of improve conditions and opportunities for federal support from DOT’s Transportation walking and bicycling; and provide safe Alternatives Program and other sources of and convenient facilities for these modes support. The highest average scores were of transportation. in the Western and Mid-Atlantic states and lowest in the South and Mountain West In a 2016 report, Making Strides: State states. California (161 out of 200 points) Report Cards on Support for Walking, Bi- and Washington (158 points) ranked the cycling and Active Kids and Communities, highest; North Dakota (46 points) and the SRTS National Partnership and the Oklahoma (40 points) ranked the lowest.468 YMCA of the USA assessed a range of State Support of Walking, Bicycling, and Physical Activity for Children and Adults as of 2016. WA MT ND ME MI OR VT MN ID NH SD WI NY MA WY MI CT RI IA PA NE NV NJ OH MD UT IL IN DE CA CO WV VA DC KS MO KY NC TN AZ OK NM AR SC AL GA MS TX LA FL AK HI LACING UP 0 - 50 POINTS M A K I N G S T R I D ES 101 - 150 POINTS WARMING UP 51 - 100 POINTS BUILDING SPEED 151 - 200 POINTS Source: Safe Routes to School National Partnership 100 TFAH • RWJF • StateofObesity.org Among the Making Strides indicators, state Complete Street Policies and Intent for Action by State Complete Streets policies varied significantly. WA l T hirteen states and Washington, D.C. MT ME ND included mandatory requirements for VT OR MN ID NH clear actions that demonstrate the state’s SD WI NY MA WY MI intent to meet a range of needs — to CT RI NE IA PA NJ improve “active living” options balanced NV OH DE UT IL IN CA MD with ongoing other transportation and CO WV KS MO VA DC KY community development needs, such NC as by making walking, biking and public AZ OK TN NM AR SC transportation options more available MS AL GA and convenient while also addressing car TX LA community concerns; FL l E leven states had mandatory requirements AK HI but did not have clear action or intent; l E ight states did not have mandatory requirements; and State has adopted a Complete Street Policy and has mandatory requirements with clear l E ighteen states had not adopted a policy.469 action and intent State has adopted a Complete Street Policy and has mandatory requirements,but no clear Local governments can implement action or intent State has adopted a Complete Street Policy, but does not have any requirements strategies to promote physical activity such State has not adopted a Complete Street Policy as zoning to support parks and recreation Source: Safe Routes to School National Partnership facilities and trails, green spaces, sidewalks and housing and retail development. TFAH • RWJF • StateofObesity.org 101 Nutrition Assistance and Education Programs More than 15 percent of Americans (46 often make free processing equipment million) are enrolled in the Supplemental available to merchants, and/or through Nutrition Assistance Program, with nearly manual vouchers. 70 percent of recipients in families All 50 states, Washington, D.C. and with children.471, 472 Young children and U.S. territories participate in SNAP-Ed, mothers with SNAP benefits are less a grant program that provides resources likely to be overweight or in poor or fair to states to manage evidence-based health.473, 474, 475 nutrition education programs and policy, In addition to providing funds to help environmental and systems changes to families buy food, SNAP programs support help SNAP participants have access to, a number of strategies to foster healthy understand the importance of and select food choices. healthy foods with their SNAP benefits and to be physically active. More than More than 3,000 farmers’ markets $408 million was allocated in FY 2016 across the country accept SNAP benefit for state SNAP-Ed programs.476 payments — EBTs SNAP programs Virginia Cooperative Extension OHIO STATE UNIVERSITY EXTENSION Every $1 spent on quality nutrition education saves SNAP-ED WORKS SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM EDUCATION Every $1 spent on nutrition education saves as much as $10 in long-term health as much as $10 care costs Supplemental Nutrition Assistance Program Education in long-term healthcare costs. THE CHALLENGE THE CHALLENGE Obesity costs more than 31% of OHIO CHILDREN 65% of OHIO ADULTS are 75% of adults & youth in Ohio do not 1 in 6 adolescents of Ohio 318,150 Virginians 29.8% of Virginia children 64% of Virginia adults are $3.3 billion ages 10-17, are overweight or obese overweight or obese eat FRUITS AND VEGETABLES at least one time daily FAMILIES WITH CHILDREN face hunger/food insecurity 1in 7 people face food insecurity are overweight or obese* overweight or obese** dollars each year in Virginia THE SNAP-ED SOLUTION THE SNAP-ED SOLUTION TEACH SNAP families SUPPORT how to buy and prepare TEACH families how to buy farmers markets to establish INTRODUCE school kids to new fruits and healthy foods and prepare healthy foods Electronic Benefits Transfer vegetables through workshops, classes, and school gardens HELP low-income families HELP families stretch tight budgets (EBT) and matching programs stretch tight budgets and buy and buy nutritious options for SNAP participants healthy options CREATE a culture of health THE RESULTS THE RESULTS 85% of families buy and prepare MORE HEALTHY FOODS INCREASED USE OF REACHING SNAP MYPLATE PARTICIPANTS SNAP-Ed FEWER FAMILIES go hungry 61% of SNAP-Ed participants reported using MyPlate to make 57% of Ohio SNAP-Ed adult participants reported using SNAP Works for Virginians Nutritious foods BECOME AFFORDABLE AND food choices for a healthier life style ACCESSIBLE, such as at Farmers Markets SNAP-ED FAMILIES WITH INCREASED FOOD SECURITY More Farmers Markets with SNAP EBT STRENGTHEN LOCAL ECONOMIES WORKS CHILDREN LEARN FROM SNAP-ED More than 1/3 of SNAP-Ed participants say they were less In 2015,Virginia SNAP-Ed reached 81,987 limited resource children and 24,210 adults throughout the commonwealth. FOR 59% of SNAP-Ed participants food insecure after completing an are adults ages 18-59, many with *Source: Child and Adolescent Health Measurement Initiative. http://www.childhealthdata.org/home. 2011 National Survey of Children’s Health, Data Resource Center for Child and Adolescent Health website. Accessed June 2013. OHIOANS children in the household Ohio SNAP-Ed program **Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. BRFSS Prevalence & Trends Data [online]. 2015. [accessed Jan 12, 2016]. (http://www.cdc.gov/brfss/brfssprevalence). IMPACT ON YOUTH For further information and resources go to INCREASED SNAP-Ed youth participants www.movemore.ext.vt.edu CONSUMPTION OF reported eating more foods from Funded by the USDA Food and Nutrition Service and Virginia Department of Social Services. HEALTHIER FOODS MyPlate food groups; choosing FY14 SNAP-ED reached 44,322 adult Nearly half of SNAP-Ed healthy snacks more often; eating Virginia Cooperative Extension programs and employment are open to all, regardless of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, genetic information, veteran status, or any other basis protected by law. An equal and 74,324 youth participants participants regularly consume a breakfast more often and being opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia variety of fruits & vegetables more physically active. State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; M. Ray McKinnie, Interim Administrator, 1890 Extension Program, Virginia State University, Petersburg. VT/0116/HNFE-343NP COLLEGE OF EDUCATION AND HUMAN ECOLOGY COLLEGE OF FOOD, AGRICULTURAL, AND ENVIRONMENTAL SCIENCES Source: Virginia Cooperative Extension Source: Ohio State University Extension 102 TFAH • RWJF • StateofObesity.org WHOLESOME WAVE DOUBLE VALUE COUPON PROGRAM477 Wholesome Wave, a 501(c)(3) nonprofit dedicated to making Wave received a $31.5 million federal Food Insecurity Nutrition healthy, locally and regionally grown food affordable to all, Incentive (FINI) grant to help expand its network.478 launched the Double Value Coupon Program (DVCP) in 2008. l I n 2013, federal nutrition benefits and private sector DVCP The program provides customers with a monetary incentive to incentives accounted for $2.45 million in sales at farmers’ spend federal nutrition benefits at participating farmers’ mar- markets.479 kets. The program encompasses a network of more than 110 nutrition incentive programs operated at around 730 farmers’ l C ommunities also see an increase in economic activity. The markets in at least 40 states and Washington, D.C. The incen- $2.45 million spent at local farmers’ markets creates a sig- tive matches the amount spent and can be used to purchase nificant ripple effect. In addition to the dollars spent at mar- healthy, fresh, locally grown fruits and vegetables. kets, almost one-third of DVCP consumers said they planned to spend an average of nearly $30 at nearby businesses on The program reaches more than 150,000 participants and their market day, for a total of more than $1 million. families. Wholesome Wave collaborates with underserved com- munities, nonprofits, farmers, farmers’ markets, healthcare pro- l W holesome Wave’s 2012 Diet and Behavior Shopping Study viders and government entities to form networks that improve indicated 90 percent of DVCP consumers increased or greatly health, increase fruit and vegetable consumption and generate increased their consumption of fresh fruit and vegetables, a revenue for small and mid-sized farms. In 2015, Wholesome behavior change that hopefully continues year-round. SEEDS OF HOPE480 Seeds of Hope, a ministry of the Episcopal Diocese of Through Seeds of Hope-sponsored workshops and nutrition ed- Los Angeles that began in 2014, works with communities, ucation, more congregations and their communities are eating congregations and schools to create gardens and orchards out healthier. In total, Seeds of Hope has started community-gardens of unused land to provide healthy foods to those in need. and farms for more than 30 organizations, which in turn increases access to healthy foods among low-income community residents.  The program started with a simple idea: many churches and communities have lots of land and there are also a lot of For instance, in Echo Park in Los Angeles, the Cathedral of St. people that need access to healthy foods. The goal was to Paul worked with Seeds of Hope to turn an empty lot into a parish transform available lands into food-producers. Eight staffers, garden. At the St. Andrew’s Church in Fullerton, parishioner and funded by grants—including from SNAP-Ed—help develop or landscape architect, Mark Rios, designed a garden for free using expand gardens and provide health and nutrition classes. land and donated boats, which parishioners and Cal State Fullerton agriculture students tend to and the harvest, is donated to local Staff provide practical and technical support to help create and food banks. At St. Luke’s Church in Long Beach, which is located sustain gardens and can offer and marshal resources—raw ma- in a food desert and does not have much land, they created rolling terials (plants/trees) and volunteer crews—to aid in planting, gardens on beds of wheels, so they could be mobile to help the tending, harvesting, packing and delivering food. plants flourish but also move them out of the way when needed. The initiative seeks to create and sustain gardens and healthy Seeds of Hope helped bring knowledge, materials and interns to nutrition programs throughout the diocese and further promote help with the project. In the first few months of the project, St. physical activity. By coordinating a diocese-wide approach and Luke’s grew enough Swiss chard and red lettuce to supplement increasing food production and distribution, Seeds of Hope a biweekly meal plan for the homeless and has helped engage benefits the hungry and undernourished.   parishioners in larger exercise and nutrition classes. TFAH • RWJF • StateofObesity.org 103 DINE FOR LIFE481 Dine for Life (DINE), created by the cooking classes and nutritionists to Durham County (North Carolina) help form Wellness Committees and Department of Public Health and provide support for students, families supported by SNAP-Ed and local funding, and staff. The healthy shopping initiative, is a school- and community-based DINE Healthy Environments Program, nutrition education program that works works with corner stores, grocery stores, with SNAP-eligible families and children farmers’ markets and other mobile to help foster healthy behaviors. markets to increase access to healthy foods — to make healthier, affordable DINE provides nutrition education in foods more available and accepting elementary and middle schools, in “double bucks” for SNAP benefits and child care settings and through healthy Farmers Market Nutrition Program (FMNP) shopping initiatives. The program “coupons” to WIC participants. provides curriculum lessons based on the dietary guidelines and MyPlate, GARDEN KITCHEN­ 482 Garden Kitchen, a partnership The program hosts interactive classes between the City of South Tucson, intended to motivate families to cook Pima County, the University of Arizona healthy meals. In addition, Garden Kitchen College of Agriculture and Life Science provides detailed resources and how-to’s and the Pima County Cooperative for growing your own food, including in- Extension, started as a nutrition depth PDFs that provide information on education program. gardening across the seasons in Arizona. But it quickly grew into a community Lastly, Garden Kitchen hosts family- program that incorporates food friendly physical activity and healthy demonstrations, gardening classes, eating events on the first Saturday of physical activity events and provides every month along with many other numerous resources to help community events. In addition, Garden communities and families get active Kitchen has created an EPIC (Encourage- and eat healthy. Known as a “seed- Practice-Inspire-Change) Activities Blog to to-table” nutrition education program, get kids moving. The blog contains how- Garden Kitchen gives families to’s related to pedometer challenges, information on how to make healthy how to be active with chalk, scavenger meals last on a budget. hunts, dance, yoga and other activities. 104 TFAH • RWJF • StateofObesity.org State Government Workplace and Facilities — Nutrition Standards State governments can establish policies regulations to support healthy food standards for food sold or provided and serve as a role model by setting procurement (Connecticut, Delaware, to state employees through vending nutrition standards for food that is sold Kentucky, New York and Oklahoma), only machines, cafeterias and at meetings or in government office buildings and other one state (Washington) and Washington, events, but it only applies to executive state-run facilities. D.C. require specific nutritional agencies and executive properties. standards for all three procurement As an indicator in their Prevention Status Colorado, Connecticut, Iowa and Missouri levels and no state currently met all of Reports, CDC reviewed nutrition standards have rules requiring state funded AHA VFHK’s bottom lines. that states set for food and beverages sold nutrition services for meals provided to on properties or facilities owned, leased Some states have nutritional food the elderly to meet “daily Recommended or operated by the state executive branch standards relating to a specific state Dietary Allowance (RDA) set by the Food (addressing fruits, vegetables, whole agency/department or population in and Nutrition Board of the National grains, water, added sugars, sodium, trans a specific setting. Mississippi, for Research Council of the National fat, saturated fat and calories/portion example, has a statute covering vending Academy of Science”; Kentucky has a sizes.)483 Only the state of Washington and machines and food services facilities that rule for snack meals served in residential Washington, D.C. provided and referenced recommends purchasing healthy food child care facilities to meet USDA’s quantifiable nutrition standards and applied choices for snack bars, vending machines nutritional guidelines; and Arkansas, them to two or more food service venues and state-run cafeterias located in state California, New Jersey and Texas have on state executive branch property (green buildings, but does not require any specific rules requiring meals served at juvenile rating); only two states (California and nutritional standards. Washington state, detention facilities to meet the USDA’s Tennessee) met the standard for a single on the other hand, has required nutritional dietary requirements. food service venue (yellow rating); and 47 states received a red rating for not achieving the standards. Nutrition Standards Policy for Foods and Beverages Sold on State Executive Branch Property, as of February 2016 51 The Public Health Law Center, on behalf of 2 2 the Voices for Healthy Kids, reviewed state Rating State’s nutrition standards policy for Number of States** policies (statues, regulations, executive 2013 data not Sale of foods and beverages comparable to Green Provided or referenced quantified nutrition orders) that set nutritional standards for 2015 data because standards AND applied to two or more food service venues on state executive branch property state-level food and beverage procurement of changes in the Yellow Provided or referenced quantified nutrition policy/practice 47 standards AND applied to a single food service for 1) vending machines on state property, indicator or rating venue on state executive branch property Red Did not provide or reference quantified nutrition scale 2) agency food service facilities, and standards, did not apply to state executive branch property, OR no policy existed 3) state institutional feeding programs. Procurement policies were also compared with AHA VFHK’s bottom line policies. 0 2015 (N = 51) The review found that only five states Source: CDC, Prevention Status Report have the authority to implement TFAH • RWJF • StateofObesity.org 105 SUGAR-SWEETENED BEVERAGES: CONSUMPTION AND IMPACT l S ugar-Sweetened Beverage Consumption: According to the 2013 BRFSS from 23 states and Washington, D.C., 30 percent of adults drank SSBs at least once a day.485 Younger adults, males, Blacks and adults who have lower education and are unemployed were more likely to drink one or more SSBs per day. U.S. soda consumption has declined from 10.2 billion cases in 2004 (at its peak) to 8.7 billion cases in 2015.486 Other SSBs, such as fruit drinks, energy drinks and waters with added sugars, have experienced some increases. According to studies through the mid-2000s, 90 percent of children ages 6 to 11 drank at least one SSB daily, and they were the top calorie source for teens.487, 488 Children are estimated to consume 155 calories per day — 8 percent of their total daily energy intake — from SSBs. Although among preschoolers (ages 2 to 5), SSBs make up only 5 percent of their daily energy intake, the percent of daily energy intake from SSBs increases as children get older, doubling among teenagers to 10 percent of daily energy intake.489 [NHANES 1999-2010]. In the past ten years, among children ages 2 to 19 there has been a significant decrease of total calories from beverages — including SSBs, whole milk, fruits juices with added sugars and fruit flavored drinks — from 24.4 percent energy in 2001-2002 to 21.1 percent energy in 2009-2010.490 And, among preschoolers (ages 2 to 5), total caloric intake from beverages fell by 77 calories per day (from 432 calories per day in 2003-2004 to 355 calories per day in 2011-2012).491 Source: American Heart Association [NHANES 1999-2012] Preschoolers are drinking significantly less whole fat milk (from 166 calories per day in 2003-2004 adults and children and is also a major contributor to obesity to 124 calories per day in 2011-2012) and less SSBs (from and type 2 diabetes.492, 493 A recent study found that children 154 calories per day in 2003-2004 to 97 calories per day who consumed a large amount of SSBs (at least five servings in 2011-2012) and drinking more reduced fat milk (from 18 per week) were almost 3.5 times more likely to be obese than calories per day in 2003-2004 to 31 calories per day in 2011- those who never or almost never consumed sugar-sweetened 2012) and more low/no-calorie beverages (from 22 calories beverages.494 Adults who drink a soda or more per day are per day in 2003-2004 to 35 calories per day in 2011-2012). 27 percent more likely to be overweight than those who do not drink sodas, regardless of income or ethnicity. They also l I ncreased Health Risks Related to Sugar-Sweetened have a 26 percent higher risk for developing type 2 diabetes Beverage Consumption: A number of studies have found that and a 20 percent higher risk for a heart attack.495, 496, 497 regular consumption of SSBs contributes to weight gain in 106 TFAH • RWJF • StateofObesity.org Local and State Taxing Policies Percent Sales Tax on Regular Soda in Food Stores by State, as of January 2014 States and localities have the right to WA determine tax policies to meet their MT ME ND local interests. For instance, reviews by VT OR MN Bridging the Gap found that: ID NH SD WI NY MA WY MI As of 2014, 34 states and Washington, CT RI NE IA PA NJ NV D.C. charge a sales tax on soda sold at OH DE UT IL IN CA MD food stores: Alabama, Arkansas, California, CO WV KS MO VA DC Colorado, Connecticut, Florida, Hawaii, Idaho, KY NC Illinois, Indiana, Iowa, Kansas, Kentucky, AZ OK TN NM AR SC Maine, Maryland, Minnesota, Mississippi, MS AL GA No Sales Tax Missouri, New Jersey, New York, North 1% to <5% TX LA 5% to <10% Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South FL AK Dakota, Tennessee, Texas, Utah, Virginia, HI Washington, West Virginia and Wisconsin.498 More than 30 communities have also pro- Source: Bridging the Gap posed specific excise taxes on soda and other SSBs. In 2014, Berkeley, California became the first city to pass such a tax, A number of studies have shown that rela- per 12 ounces were instituted, it would with voters approving a penny-per-ounce tax tive prices of foods and beverages can lead generate $1.5 billion a year, and the Con- on soda and other SSBs such as sports to changes in how much people consume gressional Budget Office estimated that drinks and sweet teas, with proceeds to be them.505, 506, 507 Several studies have es- a federal excise tax of three cents per 12 used for nutrition and physical activity initia- timated that a 10 percent increase in the ounces of SSBs would have generated an tives.499, 500 The Berkeley soda tax fund has price of SSBs (including soft drinks and estimated $24 billion in revenue between already allocated $1.5 million to programs juices) could reduce consumption by 8 per- 2009 and 2013.512, 513 aiming to reduce consumption of sodas cent to 11 percent.508, 509, 510 As of 2012, An SSB tax of one-peso-a-liter in Mexico and other SSBs, including $637,5000 to the sales tax rate for every state that sub- has raised more than $2 billion since it school districts for cooking, gardening and jects soda to the tax is 7 percent or below, was passed in 2014, and consumption nutrition programs; $637,5000 to commu- and it is 5 percent or lower in 14 states.511 dropped by six percent among the general nity-based agencies; and $225,000 to the Researchers at Yale University estimated population and 9 percent among low-in- city Public Health Division to coordinate, that, if a national soda tax of a penny come households.514 evaluate and report on the programs.501 In June 2016, Philadelphia was the next city to approve a tax on soda and other SSBs, PHILADELPHIA SUGAR-SWEETENED BEVERAGE TAX IN 2016 1.5 cents-per-ounce.502 Funding will be used to boost pre-K education programs. In June 2016, the Philadelphia City sweeteners. It goes into effect in January Council approved a 1.5 cent-per-ounce tax 2017 and is expected to raise around In November 2016, there will be a number on sugar-sweetened and diet beverages $91 million annually. Opponents of the of soda/SSB ballot tax initiatives. For instance, three cities in California are pro- to support universal pre-K and community measure expressed concern about loss posing a one-cent tax — San Francisco’s schools and renovations of neighborhood of jobs to bottlers, distributors and other soda tax will fund programs to reduce parks, recreation centers and libraries. workers and a regressive impact on low- consumption of SSBs and Oakland’s and The Council also adopted a tax credit for income families.515, 516 According to the Albany’s soda tax intends to fund health pro- businesses that sell healthy beverages. Wall Street Journal, the beverage industry grams.503 And, Boulder, Colorado is propos- The tax includes regular sodas, diet has spent more than $100 million since ing a two-cent-tax per ounce directed to fund sodas, sports drinks, energy drinks and 2009 to defeat similar initiatives in more programs aimed at improving and promoting other nonalcoholic beverages with added than two dozen cities and states.517 healthy nutrition and physical activity.504 TFAH • RWJF • StateofObesity.org 107 D. HEALTH, HEALTHCARE AND OBESITY Access to affordable, quality healthcare is important for maintaining good health. Doctors and other healthcare providers can provide guidance around nutrition and physical activity for patients, screen patients who are at risk for or who have developed obesity or obesity-related illnesses and provide counseling and support for ongoing care. New models are also emerging to encour- l H ealthcare Coverage age and incentivize increased connection l H ealthcare — Screening and between doctor’s care and support and Encouraging Healthy Practices and services for people’s daily lives. Connecting to Supportive Services Key policies highlighted in this section l H ospitals Supporting Local Health include: Improvement Efforts: Including through Nonprofit Community Benefit Programs 108 TFAH • RWJF • StateofObesity.org MAJOR OBESITY-RELATED HEALTH CONCERNS l T YPE 2 DIABETES: Mississippi has the PERCENTAGE OF ADULTS WITH DIABETES BY STATE, 2015 BRFSS highest rate of diabetes at 14.7 percent. An interactive map and timeline of these data are available at stateofobesity.org 10 of the 12 states with the highest type 2 diabetes rates are in the South. WA MT ND MN VT ME l D iabetes rates have nearly doubled in OR SD WI ID NH the past 20 years — from 5.5 percent WY IA MI NY MA NE (1994) to 9.3 percent in 2012. 518, 519 IN OH PA CT RI IL NV UT NJ CO KS MO WV DE l M ore than 29 million American adults KY VA MD DC CA have diabetes and another 86 million TN NC OK AR have prediabetes.520 The CDC projects AZ NM SC that one-in-three adults could have MS AL GA TX LA diabetes by 2050.521 l M ore than one-quarter of seniors AK FL (ages 65 and older) have diabetes HI (25.9 percent or 11 million seniors). l D iabetes is the seventh leading n >5% & <10% n >10% & <15% cause of death in the United States, accounting for around $245 billion in medical costs and lost productivity each year.522 Average medical l D iabetes rates are higher among Amer- Rates of Diagnosed Diabetes expenditures are around 2.3 times ican Indians/Alaska Natives (15.9 American Indians/ percent), Blacks (13.2 percent) and 15.9% higher among people with diagnosed Alaskan Natives diabetes than what expenditures would Latinos (12.8 percent) than Asians (9.0 non-Hispanic Blacks 13.2% be absent diabetes. percent) and Whites (7.6 percent).526 l A mong Asian-Americans, rates are 12.0 Hispanics 12.8% l M ore than 80 percent of people with diabetes are overweight or obese. percent for Asian Indians, 11.3 percent Asian Americans 9.0% for Filipinos, 4.4 percent for Chinese l A pproximately 208,000 children and and 8.8 percent for other Asians. non-Hispanic Whites 7.6% young adults (ages 2 to 20) have l A mong Latinos, rates are 14.8 percent 0% 5% 10% 15% 20% diabetes and two million teens (ages 12 to 19) have prediabetes.523, 524 Rates for Puerto Ricans, 13.9 percent for Source: American Diabetes Association, 2012 data of type 2 diabetes among children and Mexican-Americans, 9.3 percent for youth (ages 0 to 19) have increased by Cuban-Americans and 8.5 percent for more than 30 percent since 2001. 525 Central- and South-Americans. TFAH • RWJF • StateofObesity.org 109 l H EART DISEASE AND PERCENTAGE OF ADULTS WITH HYPERTENSION, 2015 BRFSS HYPERTENSION: The 10 states with An interactive map and timeline of these data are available at stateofobesity.org the highest rates of hypertension are in the South. West Virginia has the WA ND MT highest rate at 42.7 percent. MN VT ME SD WI OR l O ne in four Americans has some form ID WY MI NY NH IA MA of cardiovascular disease. Heart NE PA RI IL IN OH CT disease is the leading cause of death NV UT CO NJ KS MO WV DE in the United States — responsible for KY VA MD DC CA one in three deaths.527, 528 OK TN NC NM AR AZ SC l A t least one out of every five teens MS AL GA TX LA has abnormally high cholesterol, a major risk factor for heart disease; FL among obese teens, 43 percent have AK abnormally high cholesterol.529 HI l O ne in three adults has high blood pressure, a leading cause of n <25% n >25% to <30% n >30% to <35% n >35% to <40% n >40% to <45% stroke.530 Approximately 30 percent of hypertension cases may be attributable to obesity, and the figure l C ANCER: Up to 40 percent of some l A RTHRITIS: Almost 70 percent of indi- may be as high as 60 percent in men forms of cancers are attributable to viduals diagnosed with arthritis are over- under age 45.531 obesity. 535 Approximately 20 percent of weight or obese.538 l P eople who are overweight are more cancer deaths in women and 15 percent likely to have high blood pressure, high of cancer deaths in men are attributable l N ON-ALCOHOLIC FATTY LIVER levels of blood fats and high LDL (bad to overweight and obesity. 536 DISEASE: Up to 25 percent of adults cholesterol), which are all risk factors have nonalcoholic fatty liver disease l A recent review published in the for heart disease and stroke.532 (NFLD), which can lead to liver damage Journal of the American Medical (cirrhosis) or the need for transplants.539 l D eaths from heart disease and stroke Association found that adults who are almost twice as high among exercised the most decreased their l K IDNEY DISEASE: An estimated 24.2 Blacks as among Whites. risk of having 13 types of cancer — 42 percent of kidney disease cases among percent less risk of esophageal cancer; l L atinos are more likely to suffer a men and 33.9 percent of cases among 20 percent or more less risk of liver, stroke than are other ethnic groups. women are related to being overweight lung, kidney, stomach, endometrial Specifically, Mexican Americans or obese.540 or myeloid leukemia cancer; and 10 are 43 percent more likely to have percent to 17 percent less risk of a stroke — the leading cause of l A LZHEIMER’S/DEMENTIA: Both myeloma, colon, head and neck, rectal, disability and the third-leading cause overweight and obesity at midlife bladder or breast cancer.537 Overall, of death — than Whites.534 independently increase the risk of adults who exercised more lowered dementia, Alzheimer’s disease and their risk of total cancers by 7 percent vascular dementia.541, 542 compared to those who exercised less. 110 TFAH • RWJF • StateofObesity.org l M ENTAL HEALTH: Studies have shown conditions.546 , 547, 548 One study of an association between anxiety and women ages 40 to 65 found that one- obesity. 543, 544, 545 The direction of the quarter of obese women had moderate association can seem to be related to to severe depression — with rates 4 both cause and effect. Obese adults times greater than non-obese and non- are more likely to have depression, overweight women.549 anxiety and other mental health HEALTHCARE COSTS Difference in Direct Healthcare Costs for a Morbidly Obese adult Comapred with a Obesity is one of the biggest drivers As a person’s BMI increases, so do the Healthy-weight Adult of preventable chronic diseases and number of sick days, medical claims and healthcare costs in the United States. healthcare costs.554 For instance: Reducing obesity, improving nutrition l O bese adults spend 42 percent more on and increasing physical activity can help lower costs through fewer doctor’s direct healthcare costs than adults who 81% are at a healthy weight.555 Higher office visits, tests, prescription drugs, sick days, emergency room visits and l P er capita healthcare costs for severely admissions to the hospital and lower the or morbidly obese adults (BMI >40) are risk for a wide range of diseases. 81 percent higher than for healthy weight adults.556 In 2000, around $11 billion Healthy-weight Morbidly Obese Currently, estimates for these costs was spent on medical expenditures for range from $147 billion to nearly $210 morbidly obese U.S. adults. billion per year.550 In addition, obesity is associated with job absenteeism, costing l M oderately obese (BMI between 30 and Difference in Emergency Room Costs for approximately $4.3 billion annually 551 35) individuals are more than twice as Patients Presenting With Chest Pains and with lower productivity while at work, likely as healthy weight individuals to be Compared with a Healthy-weight Patient costing employers $506 per obese prescribed prescription pharmaceuticals worker per year.552 to manage medical conditions.557 Medicaid and Medicare pay for more l C osts for patients presenting at emer- 41% than half of the nation’s obesity-related gency rooms with chest pains are 41 per- 22% 28% Higher healthcare costs.553 Eleven percent of cent higher for severely obese patients, Higher Higher U.S. adult Medicaid expenditures are 28 percent higher for obese patients and spent on treating obesity-related medical 22 percent higher for overweight patients Overweight Obese Severly Obese conditions. than for healthy-weight patients.558 TFAH • RWJF • StateofObesity.org 111 Healthcare Coverage Most private healthcare plans, Medicaid linked public health and healthcare.560 expansion plans and Medicare are The second round of CORD funding required to cover a set of evidence-based (CORD 2.0; 2016-2018) will look preventive healthcare services, including more closely at developing healthcare no-cost screening and counseling for delivery models that meet the USPSTF obesity. In particular, clinical services recommendations. HRSA also supports that meet United States Preventive programs such as the Maternal and Services Task Force (USPSTF) Grade B Child Health Block Grant, which recommendations, or higher, are required increases the access, participation and to be covered at no additional cost. quality of health services for children, particularly low-income children Some emerging healthcare models — like enrolled in Medicaid, and promotes Patient-Centered Medical Homes and healthy behavior as part of daily life. Accountable Care Organizations (ACOs) — groups of healthcare providers who Traditional Medicaid states can set their bear risk and prioritize coordinated care own policies for coverage for preventive and quality to achieve improved health obesity services for adults. CMS provides for their patients and reduce costs — are a one percentage point increase in the increasingly incentivized to focus on federal medical assistance percentage preventing obesity and related illnesses to (FMAP) incentive for Medicaid states help keep the pool of patients they cover to provide coverage of adult preventive healthier.559 This may include providing services recommended with an “A” more doctor care and counseling for or “B” rating by the U.S. Preventive nutrition, physical activity and obesity, but Services Task Force — including also greater efforts to connect patients with obesity screening and counseling — community-based programs and support. to Americans enrolled in traditional Medicaid programs with no patient All state Medicaid and Children’s Health cost. Eight states have submitted Insurance Programs are required to applications to CMS to implement this cover basic screening and services for enhanced match option. Adults covered children. This requirement is relevant through states participating in Medicaid to childhood obesity from a policy expansion or who are insured through perspective since the USPSTF assigns a healthcare exchanges are eligible for grade B recommendation to assessing “Preventive and Wellness Services and BMI and referring those children with Chronic Disease Management” coverage obesity to receive moderate to high — including obesity screening and intensity counseling — 26-75 hours of counseling — with no co-payments. comprehensive weight management contact time in a 6 month period. While Medicare covers preventive Efforts are currently underway to services for seniors, a 2014 analysis determine how best to operationalize by the STOP Obesity Alliance found these recommendations for low- that less than 1 percent of Medicare income children and their families, enrollees — 120,000 — have as in the Childhood Obesity Research participated in obesity counseling since Demonstration (CORD) Project. The it became available in 2011.561 Around initial CORD project (2011-2015) sought 30 percent of seniors — more than 15 to test multi-sectoral and multi-level million Medicare enrollees — are obese approaches to childhood obesity that and would be eligible for the benefit. 112 TFAH • RWJF • StateofObesity.org STATUS OF MEDICAID FEE-FOR-SERVICE TREATMENT OF OBESITY INTERVENTIONS A 2016 review of obesity-related fee-for-service coverage by state Medicaid programs conducted by the George Washington University and the STOP Obesity Alliance found that:562 l P revention*: Eight states cover all obesity-related disease management obesity-related preventive care services CPT codes. Thirty-four states cover no — via established medical fee billing obesity-related disease management called Current Procedural Terminology CPT codes. (CPT) codes. Twenty-one states and l B ehavioral Consultation*: Sixteen Washington, D.C. cover one or more states cover all obesity-related behavioral obesity-related preventive care CPT consultation CPT codes. Fifteen states codes. Nineteen states cover no and Washington, D.C. cover one or more obesity-related preventive care CPT obesity-related behavioral consult CPT codes and/or assert that obesity-related codes. Seventeen states cover no obesi- preventive care services are explicitly ty-related behavioral consult CPT codes. excluded in respective provider manuals. l Pharmaceuticals*: Thirteen states cover l N utrition*: 18 states and Washington, obesity drugs. Of these, eight states D.C. cover all obesity-related nutritional have limited coverage (covers only lipase consult CPT codes. Twelve states cover inhibitors) or require weight-loss bench- one or more obesity-related nutritional marks be met for continued coverage. consult CPT codes. Eighteen states Thirty-six states explicitly exclude all obe- cover no obesity-related nutritional sity drug coverage, with one state — Ver- consult CPT codes. Provider manuals mont — expressly citing safety concerns indicated that while six states — Con- as justification for non-coverage. necticut, Minnesota, New Mexico, South Dakota, Utah and West Virginia — may l B ariatric Surgery: Forty-eight states utilize nutrition CPT codes, they are not and Washington, D.C. cover bariatric sur- reimbursable for treating obesity. Pro- gery. Of these states, 36 require prior vider manuals also indicated that four authorization and 37 require criteria states — Georgia, Michigan, Nebraska beyond BMI to determine eligibility. Two and Vermont — do not utilize nutrition states — Montana and Mississippi– ex- CPT codes but do reimburse for nutri- plicitly exclude bariatric surgery. tional counseling. *Note: In some cases, coverage for Iowa, l D isease Management*: Three states Kansas and/or Washington, D.C. was unde- cover all obesity-related disease man- termined. Coverage for Tennessee was not agement CPT codes. Eleven states and assessed as the state’s Medicaid popula- Washington, D.C. cover one or more tion is entirely managed care. TFAH • RWJF • StateofObesity.org 113 Healthcare — Screening and Encouraging Healthy Practices and Connecting to Supportive Services A number of healthcare providers that can be redeemed for fresh access to healthy food and build a and hospital systems have developed fruits and vegetables at participating healthier food system, beginning programs and policies to help support retailers. Prescriptions must be refilled with the food procured and served healthy nutrition and physical activity at monthly clinic visits, where new by hospitals. Changes made by inside and beyond the doctor’s office goals for healthy eating are set.567 hospitals include purchasing healthier — including by connecting patients More than 10,000 people have received beverages, increasing access to public to available supportive services. Some FVRx prescriptions in rural and urban drinking water, reducing meat options, examples include: areas across 12 states, generating purchasing meats raised without over $500,000 in fruit and vegetable antibiotics and purchasing local l creening Patients for Food Insecurity S sales.568 During a four-month FVRx and sustainably-grown produce.573 and Linking to WIC and SNAP program in New York City, 80 percent Hundreds of hospitals and Food With one in seven Americans of patients reported the program Service Contractors have signed onto experiencing food insecurity — substantially increased how many fruits a Healthy Food in Health Care Pledge including 15 million children — and vegetables their family eats, and 40 demonstrating their commitment to doctors can play a role in helping percent decreased their BMI.569 these and other strategies to provide screen children and adults for food local, nutritious and sustainable food.574 Prescribing physical activity — by insecurity and help connect them to suggesting the recommended amount food assistance resources, including l sing Electronic Health Records to U of exercise and referring patients to federal nutrition programs like the Track Obesity Trends and Target certified trainers or exercise classes SNAP, WIC and school lunch and Prevention Strategies and Support as needed — has also been shown to breakfast programs.563, 564, 565 help increase activity levels. In a pilot EHRs include timely, geographically program at four Kaiser Northern specific and clinically valid health The American Academy of Pediatrics California centers, a physical activity information — such as height, weight has released a policy statement prescription program was associated and other indicators of obesity — that supporting the role of pediatricians with weight loss in overweight patients can be used to better understand in promoting food security for all and improved blood sugar control for obesity trends and other health children, through screening and diabetes patients.570 conditions in communities and within connecting patients to resources as well patient pools. EHR data is more as by promoting policies that support l ealthy Food in Hospitals and H accurate and specific than information access to adequate healthy food.566 Healthcare Settings — Policies collected via other methods like for Procurement, Cafeterias and surveys, where data are self-reported l ruit, Vegetable and Physical Activity F Vending Machines and often lack detailed geographic “Prescriptions” information.575,576 Giving patients prescriptions to spend The healthcare sector spends $12 on fruits and vegetables or physical billion annually on food and beverages. For example, San Diego County activity can help provide patients with Changes in foodservice policies — what developed a healthy weight information and encouragement to foods they purchase and make available surveillance system to collect height support healthy nutrition and increase to patients, staff and visitors — provides and weight data from EHRs, which physical activity. healthier options and helps model provided accurate body mass index healthy choices.571,572 values to track the progress of local For instance, the national Fruit efforts to reduce obesity and to inform and Vegetable Prescription (FVRx) A national program, Healthy Food future efforts.577 Program includes a clinical visit to in Health Care Pledge, helps the set nutrition goals and collect health healthcare system use its purchasing indicators, along with prescriptions power and expertise to increase 114 TFAH • RWJF • StateofObesity.org EXAMPLES OF CMS OBESITY PREVENTION PILOTS AND PROGRAMS l C hildhood Obesity Performance training, using electronic medical re- Improvement Projects: States im- cords, improving care coordination and plementing a Medicaid managed care developing educational materials and program are mandated by the federal community resource lists. Community government to require health plans to health workers provided patient educa- complete performance improvement tion (including parenting practices and projects (PIPs).578 Thirteen states recipe planning) and helped link families reported a combined total of 26 to community resources such as phys- PIPs that targeted childhood obesity ical activity options at local parks and in 2014-2015. While specific inter- YMCAs and referrals to WIC offices. ventions of each PIP varied across l eventy-five schools and 60 early care S states and managed care organiza- and education centers participated tions (MCOs), most of the programs through evidence-based programs, such included improving BMI percentile as CATCH, SPARK, Eat Well Keep Mov- documentation, nutrition counseling ing and Planet Health. Grantees worked and physical activity counseling. For with school administrators, staff and instance, since 2008, all three MCOs other stakeholders, such as wellness in Georgia have operated improvement committees and champions, to pro- projects focused on reducing childhood mote healthy eating and physical activ- obesity. The projects aim to improve ity throughout the school day. These performance on weight assessment included improvements in school poli- and counseling measures, including cies, systems and environments identi- increasing BMI percentile documenta- fied in CDC’s School Health Guidelines tion, nutrition counseling and physical as well as engaging children through activity counseling for members ages media and social marketing campaigns 3 to 17. The MCOs focused on raising to promote healthy behaviors. provider awareness of conducting and documenting weight assessment, coun- l nterventions in the six communities in I seling activities and face-to-face visits the program included activities, such with health promotion coordinators. as working with restaurants to provide healthier children’s menu options and l C hildhood Obesity Research efforts in local parks and recreation Demonstration Project: An centers to increase children’s active evaluation report is expected in 2016 participation in park programs. This of a Childhood Obesity Research included helping families connect with Demonstration, a four-year project ongoing community childhood obesity led by CDC targeted to children ages prevention efforts and bolstering the 2 to 12 in a set of communities with work of community coalitions. high numbers of children eligible l rograms were used to support families P for Medicaid or CHIP to integrate with children who are overweight or pediatric care with community obese — including through referrals to prevention efforts.579 behavioral therapists, registered dieti- l ifteen healthcare centers partici- F cians, nurses, doctors, community health pated — including through provider workers or group education sessions. TFAH • RWJF • StateofObesity.org 115 EXAMPLES OF CMS OBESITY PREVENTION PILOTS AND PROGRAMS l N ational Diabetes Prevention Program (DPP): CDC leads the National NATIONAL WORKING DIABETES Diabetes Prevention Program, an TOGETHER evidence-based program for preventing TO PREVENT TYPE 2 DIABETES type 2 diabetes. More than 625 PREVENT I O N organizations offer the program PROGRAM nationally.580 The year-long program helps participants combine medical THE GROWING THREAT OF PREDIABETES care with health educator coaches Prediabetes is ident ed when your blood sugar level is higher than normal but not high en ough yet to be diagnosed as type 2 diabetes and group counseling sessions to 86 support lifestyle changes, such as MILLION Without weight loss eating healthier, incorporating physical adults have and moderate activity into their daily lives, adherence prediabetes physical activity to medications and improving problem- solving and coping skills. Sessions are 15–30% of people with 5 prediabetes will weekly for six months and then monthly 9 10 develop type 2 diabetes Y E ARS for six months. Evidence shows DDP OUT people with prediabetes within 5 years OF don’t know they have it has cut participants’ risk for developing type 2 diabetes by 58 percent. REDUCING THE IMPACT OF DIABETES CMS supports a DPP-demonstration program among 10,000 Medicare bene- Congress authorized CDC to establish the NATIONAL DIABETES ficiaries with prediabetes. The National PREVENTION PROGRAM (National DPP)—a public-private initiative to o er evidence-based, cost e ective interventions in Council of Young Men’s Christian Asso- communities across the United States to prevent type 2 diabetes ciations of the United States of America (YMCA USA), local YMCA affiliates and the Diabetes Prevention and Control It brings together: Alliance (a subsidiary of United Health HEALTH CARE ORGANIZATIONS Research shows Group) are working in 17 communities in EMPLOYERS FAITH-BASED structured lifestyle eight states (Arizona, Delaware, Florida, PRIVATE INSURERS ORGANIZATIONS interventions can GOVERNMENT cut the risk of Indiana, Minnesota, New York, Ohio and COMMUNITY AGENCIES ORGANIZATIONS type 2 diabetes in Texas) to examine the effectiveness of the program on improving health and re- HA LF ducing healthcare costs. The demonstra- to achieve a greater impact on reducing type 2 diabetes tion program runs through 2016. Source: CDC 116 TFAH • RWJF • StateofObesity.org Hospitals Supporting Local Health Improvement Efforts: Including through Nonprofit Community Benefit Programs Seventy percent of nonprofit hospitals community and to strategically work report that obesity is a top health together and help leverage resources priority in the communities they toward common objectives. serve.581 In addition, 58 percent report In many areas, community benefit nutrition and physical activity, 44 investments are an important source percent report diabetes and 57 percent of funding for community health report heart disease and hypertension improvement efforts. In addition, the as top concerns. [The survey included percentage of resources devoted to members of the American Association community-based health improvement of Medical Colleges] programs, services and initiatives is Nonprofit hospitals are required expected to increase, as hospitals are to conduct community health evaluating newly required community needs assessments in coordination health needs assessments and the with local partners and develop an number of uninsured and underinsured implementation strategy to address patients continues to drop. pressing issues in their communities. l H istorically, the majority of community All nonprofit hospitals in the United benefit spending (85 percent in 2009 States (around 2,900 or 60 percent of and up to 92 percent in 2011) has hospitals) are required to maintain been used to support direct patient community benefit programs to care, such as charity care or to cover help improve the health of the uncompensated costs.584, 585 However, communities they serve and to qualify uncompensated care has decreased for exemption from federal income as the number of insured patients has taxes. These hospitals reported increased — dropping by $7.4 billion spending $62.4 billion on community from 2013 to 2014 alone. An in-depth benefit, as of 2011.582, 583 analysis in Health Affairs found that on a national basis, nonprofit hospitals These programs provide opportunities devoted on average 9.7 percent of for hospitals to partner with state their operating expenditures to and local health departments, community benefits (up from 7.5 local employers and businesses and percent in 2009), but the amount community groups to increase their varied widely among hospitals.586 understanding of the needs of their TFAH • RWJF • StateofObesity.org 117 REVIEW OF COMMUNITY BENEFIT AND CHILDHOOD OBESITY EFFORTS BY THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES587 In the review of 203 member organiza- Meal program that includes low-calorie l School-Based Programs tions’ community health needs assess- and low-fat food options. Collaboration with schools primarily revolved ments, more than half listed childhood around improving schools’ wellness policies, St. Francis Hospital (in Evanston, Illinois), obesity as a need or sub-need, and 75 of organizing school health teams, encourag- a member of Presence Health, hopes to these hospitals included childhood obesity ing schools not to use food as a reward or increase fruit and vegetable consumption in their implementation strategies. incentive, hosting nutrition- and physical by holding taste-testing events in the com- The Catholic Health Association evaluated munity and demonstrating how to adapt activity-based camps, promoting physical how 54 hospital members planned to pre- ethnic recipes to make them healthier. activity during recess and lunch breaks, of- vent, manage and treat childhood obesity These events supplement other hospital fering school-based obesity screenings and in their communities. The 54 implemen- outreach efforts, such as nutritional edu- facilitating coordination among clinical nutri- tation strategies represented 26 states cation for children and families; partner- tionists, teachers and athletic trainers. and 20 system affiliations. Twenty-three ships with farmers’ markets; and helping St. Mary’s Regional Medical Center in hospitals ran their own, independent enhance community gardens. Lewiston, Maine, a Covenant Health facil- programs; others collaborated with or ity, has partnered with a local elementary supported outside programs or coalitions l Physical Fitness Programs school to establish a cooking club, imple- to address childhood obesity. Most strat- Programs intended to improve physical ment cafeteria menu changes and create egies concentrated on improving nutrition, activity centered on providing physical ac- a youth gardener program that fosters improving physical activity, working with tivity education, offering fitness programs leadership and agricultural skills. schools and creating public awareness in community settings and improving ac- and education campaigns. Providence St. Vincent Medical Center in cess to formal physical activity programs Portland, Oregon, has extended its ser- in the community. l Nutrition Programs vices beyond the typical nine-month school St. Francis Medical Center (in Trenton, year to offer a summer food program so Improvements in nutrition focused on in- New Jersey) is helping to re-establish students have access to adequate nutri- creasing access to healthy foods through collaboration among public departments tion and exercise while school is out. community gardens, farmers’ market(s), and agencies including Trenton Police food banks and vendors that accept SNAP Department, City of Trenton Recreation l Public Awareness benefits; advocating for healthier corner Department and schools to ensure that Hospitals’ public awareness campaigns stores, supermarkets and vending ma- public parks and community centers are bear witness to the complexity of childhood chines; increasing nutritional education; regularly available for physical fitness obesity as an issue. Some campaigns plan providing nutritional counseling; and offer- activities. This Trinity Health facility also to take a broad approach, such as trying to ing cooking classes. is working to expand security at parks, increase awareness about the importance St. Mary’s Hospital (in Waterbury, Con- recreational facilities and in corridors to of physical activity and nutrition education. necticut) stood out in the area of nutri- and from schools to increase access to Other hospitals plan to employ more spe- tional improvement. Currently, the facility activity outlets. cific campaigns, targeting such topics as offers inpatient and outpatient nutritional resources for accessible and affordable St. John Medical Center (in Longview, counseling; funds the Early Childhood healthy food, the dangers of high-calorie Washington), a PeaceHealth facility, has Obesity Prevention program to collect beverages, reducing screen time for chil- implemented a plan to integrate exercise data on childhood obesity and develop dren or promoting hospital-run programs. promotion and nutritional counseling into interventions; and provides lunch and Hospitals reported that these sources of standard primary and preventative care. snacks to impoverished children through information will be posted in outdoor adver- a state grant. In the hospital, St. Mary’s tising space and public buildings or dissem- food service supplier offers a Mindful inated through popular media. 118 TFAH • RWJF • StateofObesity.org l Other Efforts populations. For example, Daughters of A few hospitals employed strategies Charity St. Francis Medical Center (in Lyn- based on less conventional efforts, includ- wood, California) reported, “Because the ing policy and advocacy initiatives. For ex- traditional Latino cultural values prioritize the ample, various hospitals plan to advocate well-being of the family over the well-being of for the formation of food policy councils the individual, the [Vida Sana/Healthy Life in the community, the development of Community Wellness] Program focuses on workplace and school wellness policies, the participation of the entire family,” and and the adoption of policies that promote therefore offers family health screenings and healthy eating, active living and improved regular fitness activities that accommodate access to healthy food options. individuals of all ages. St. Joseph Health (in Petaluma, California) Similarly, Bon Secours Mary Immaculate galvanized community-level support for its Hospital (in Newport News, Virginia) im- advocacy agenda related to healthy food plemented the Let’s Get Real program, and physical activity. The hospital’s “neigh- designed to address the specific needs borhood care” staff engaged low-income of the African-American community. The residents in activities targeting environmen- program encompasses a “Cookin’ Light” tal and policy changes through leadership class that teaches parents how to reduce training, community education, outreach, the amounts of sodium and fat in their and relationship building with local officials. meals, and a “Tree of Life” class that ed- ucates participants on the associations Some implementation strategies targeting between family culture, heredity and car- childhood obesity included breast-feeding diovascular disease. initiatives involving prenatal education on breast-feeding and child development, or Avera St. Mary’s Hospital (in Pierre, South attempts to increase breast-feeding sup- Dakota) is partnering with the local De- port in work, hospital and public settings. partment of Parks and Recreation and other groups to develop family trails com- l Family Involvement plete with various “learning structures” to encourage walking and playing, as well as A few recurring patterns appeared within to restore bike trails in the community. the spectrum of hospital-run and hospi- tal-sponsored programs. Many hospitals l Comprehensive Programs organized educational programming geared at children and their families, too. Chil- A few hospital-run programs were multi- dren and parents take part in sessions faceted and attempted to target childhood on healthy eating plans, physical fitness, obesity from various angles. SSM Health weight management, medical education Cardinal Glennon Children’s Hospital (in and stress reduction, and they receive be- St. Louis) organizes a “Head to Toe” pro- havioral tools, as well. At Ascension Health gram twice a year for children with a pedi- Mount St. Mary’s Hospital and Health Cen- atrician’s written recommendation to join ter in Lewiston, New York, parents receive in. The comprehensive program involves homework assignments and all family mem- an exercise specialist, registered dietician, bers are offered weigh-in opportunities. social worker and health promotion pro- fessionals who offer participating children Some hospitals pointed to the importance 12 intensive group sessions on nutrition, of family-based programming among minority physical activity and emotional health. TFAH • RWJF • StateofObesity.org 119 S EC T I ON 4 : The State of SECTION 4: RECOMMENDATIONS State of Obesity Policy Obesity: Recommendations Obesity Policy A. Invest in Obesity Prevention assessments and include physical activity and screen time related Series l C enters for Disease Control & Prevention: Providing adequate performance standards. funding for the CDC’s National l C hild and Adult Care Food Program: Center for Chronic Disease Prevention Participants in CACFP — including child and Health Promotion/Division care centers, day care homes, afterschool of Nutrition, Physical Activity, and care centers, adult day care centers Obesity would permit CDC to increase and emergency shelters — should be support to additional state and local provided with the resources necessary for health departments to carry out full, timely implementation of updated interventions focused specifically on nutrition standards. improving nutrition and promoting physical activity. C. School-Based Policies and Programs l P revention and Public Health Fund: l C hild Nutrition Act: The Prevention and Public Health l B uilding on progress made over the Fund should be fully allocated to last two years, schools should continue support evidence-based and innovative implementation of the final “Smart approaches to improving the public Snacks” rule that updates nutrition health system and reducing disease standards for snack foods and rates. Future increases to the Prevention beverages served and sold in schools. Fund should be directed toward l T he USDA and state education innovative public health programs, not departments should encourage all used to supplant the CDC budget. eligible schools to participate in the Community Eligibility Provision, B. Early Child Policies and Programs under which schools in high-poverty l E very Student Succeeds Act: The areas may serve free school meals to Department of Education should all students. release guidance to support the l S chools should comply as quickly as use of Title I funding for quality possible with a provision in USDA’s early childhood education services final rule updating local school that encourage healthier meals, wellness policy guidelines that all opportunities for physical activity, foods marketed in schools meet limiting screen time and connecting Smart Snacks nutrition standards. families to community resources promoting overall health and wellness. l E very Student Succeeds Act: States SEPTEMBER 2016 and localities should prioritize l H ead Start: HHS should issue final evidence-based programs that enhance performance standards that ensure regular physical education and meals and snacks meet USDA’s physical activity opportunities through requirements for the National School the school day (Title I), and apply Lunch Program, the School Breakfast for physical education grants under Program or the Child and Adult Care the Student Support and Academic Feeding Program, include nutrition Enrichment Grants program (Title IV). and physical activity in community l F ederal, state and local policymakers l S tates and localities should pursue should identify opportunities to strategies—including tax credits, further integrate education and health zoning incentives, grants, low-interest so that indicators of student health are loans and public-private partnerships— included in education accountability to increase access to healthy, affordable measures. Needs assessments should foods in communities. be supported to identify the best evidence-based strategies that match a E. Health, Healthcare and Obesity local community’s issues and concerns l A ll public and private health plans and leverage existing resources. should cover the full range of obesity prevention, treatment and D. Community-Based Policies and management services, including Programs nutritional counseling, medications l M enu labeling: Chain restaurants and behavioral health consultation. and similar food retail establishments l M edicare should encourage eligible covered under the FDA’s menu beneficiaries to enroll in obesity labeling regulations should, to the counseling, a covered benefit, and extent possible, provide required evaluate its use and effectiveness. information to consumers in advance of the final May 2017 implementation l H ealth plans and health systems date, and FDA should develop and should seek innovative solutions implement a strategy for enforcement, for linking clinical treatment and public awareness and education. counseling services with public health strategies to help people develop and l S tate and municipal governments maintain healthy diets and physically should prioritize health in transportation active lifestyles. planning, including by using the limited available Transportation Alternative l H eight and weight data from Program funds to help communities electronic health records should be ensure that all residents have access to used more routinely for child and walking, biking, transit and other forms adult obesity surveillance and the of active transportation that promote targeting and evaluation of clinical physical activity. and public health interventions. TFAH • RWJF • StateofObesity.org 121 The State of APPENDIX APPENDIX : Methodology for Behavioral Obesity: Risk Factor Surveillance System for Obesity Policy Obesity, Physical Activity and Fruit and Vegetable Consumption Rates Series Methodology for Obesity and Other Rates Using BRFSS 2015 Data ANNUAL DATA ethnicity — researchers report results Data for this analysis was obtained from for Whites, Blacks and Latinos — and the Behavioral Risk Factor Surveillance gender. Another variable, ‘overweight’ System dataset (publicly available on the was created to capture the percentage of web at www.cdc.gov/brfss). The data adults in a given state who were either were reviewed and analyzed for TFAH overweight or obese. An overweight and RWJF by Sarah Ketchen Lipson, adult was defined as one with a BMI PhD, Research Assistant Professor, greater than or equal to 25 but less than University of Michigan Medical School, 30. For the physical inactivity variable, Department of Pediatrics, Child Health a binary indicator equal to one was Evaluation and Research Unit. created for adults who reported not engaging in physical activity or exercise BRFSS is an annual cross-sectional during the previous thirty days other survey designed to measure behavioral than their regular job. For diabetes, risk factors in the adult population researchers created a binary variable (18 years of age or older) living in equal to one if the respondent reported households. Data are collected from ever being told by a doctor that he/she a random sample of adults (one per had diabetes. Researchers excluded household) through a telephone all cases of gestational and borderline survey. The BRFSS currently includes diabetes as well as all cases where the data from 50 states, the District of individual was either unsure, or refused Columbia, Puerto Rico, Guam and the to answer. Virgin Islands. To calculate prevalence rates for Variables of interest included BMI, hypertension, researchers created a physical inactivity, diabetes, hypertension dummy variable equal to one if the and consumption of fruits and respondent answered “Yes” to the vegetables five or more times a day. BMI following question: “Have you ever been was calculated by dividing self-reported told by a doctor, nurse or other health weight in kilograms by the square of self- professional that you have high blood reported height in meters. The variable pressure?” This definition excludes ‘obesity’ is the percentage of all adults in respondents classified as borderline SEPTEMBER 2016 a given state who were classified as obese hypertensive and women who reported (where obesity is defined as BMI greater being diagnosed with hypertension than or equal to 30). Researchers also while pregnant. provide results broken down by race/ Endnotes 1 awley J and Meyerhoefer C. The medical C 14 legal KM, Kruszon-Moran D, Carroll MD, F 25 enter for Training and Research Trans- C care costs of obesity: an instrumental vari- et al. Trends in obesity among adults in lation. Who We Are. In Center TRT, 2013. ables approach. Journal of Health Economics, the United States, 2005 to 2014. JAMA, http://centertrt.org/ (accessed June 2015). 31(1): 219-230, 2012; And Finkelstein, 315(21): 284-2291, 2016. http://jama. 26 Trust for America’s Health. Prevention for Trogdon, Cohen, et al. Annual medical jamanetwork.com/article.aspx?arti- a Healthier America: Investments in Disease spending attributable to obesity. Health cleid=2526639 (accessed June 2016). Prevention Yield Significant Savings, Strong Affairs, 38(5): w822-w831, 2009. 15 Flegal KM, et al., 2284-2291, 2016. Communities. Washington, DC: Trust for 2 Ogden CL, et al., No. 219, 2015. America’s Health, 2009. 16 Flegal KM, et al., 2284-2291, 2016. 3 hildhood Obesity Facts. In Centers for C 27 About the Center. Budget. In Centers 17 Flegal KM, et al., 2284-2291, 2016. Disease Control and Prevention, 2015. http:// for Disease Control and Prevention, 2015. www.cdc.gov/healthyschools/obesity/facts. 18 rust for America’s Health and Robert T http://www.cdc.gov/chronicdisease/ htm (accessed May 2016). Wood Johnson Foundation. F as in Fat: about/budget.htm#modalIdString_ How Obesity Threatens America’s Future — tblHeadCtr (accessed April 2016). 4 gden CL, et al. Prevalence of obesity O 2011. Washington, D.C.: Trust for Ameri- among adults and youth: United States, 28 Census regions of the United States. ca’s Health, 2011. http://www.tfah.org/ 2011-2014. NCHS Data Brief, No. 219, 2015. Northeast: CT, ME, MA, NH, NJ, NY, PA, report/88/ (accessed July 2012). Based http://www.cdc.gov/nchs/data/data- RI, VT; Midwest: IL, IN, IA, KS, MI, MN, on data using the previous BRFSS meth- briefs/db219.htm (accessed April 2016). MO, NE, ND, OH, SD, WI; South: AL, AR, odology in use from 2008-2010. DE, DC, FL, GA, KY, LA, MD, MS, NC, 5 gden CL, Carroll MD, Lawman HG, et al. O 19 ission: Readiness. Still Too Fat to Fight. M OK, SC, VA, TN, TX, VA, WV; West: AK, Trends in obesity prevalence among chil- Washington, D.C.: Mission: Readiness, AZ, CA, CO, HI, ID, MT, NM, NV, OR, dren and adolescents in the United States, 2012. http://missionreadiness.s3.ama- UT, WA, WY. 1988-1994 through 2013-2014. JAMA, zonaws.com/wp-content/uploads/Still- 315(21): 2292-2299, 2016. 29 Healthy People 2020. Nutrition and Too-Fat-To-Fight-Report.pdf (accessed Weight Status. In HealthyPeople.gov, 2015. 6 ann L, McManus T, Harris WA, et al., K June 2015). http://www.healthypeople.gov/2020/top- Youth Risk Behaviors Surveillance—United 20 ission: Readiness. Retreat is Not An Option M icsobjectives2020/objectiveslist.aspx?topi- States, 2015. MMWR, 65(SS6): 1-174, 2016. for Kansas. Healthier School Meals Protect Our cId=29 (accessed June 2013). 7 gden CL, Carroll MD, Lawman HG, et al. O Children and Our Country. Washington, 30 BRFSS Prevalence and Trends Data, Trends in obesity prevalence among chil- D.C.: Mission: Readiness, 2014. http:// Overweight and Obesity (BMI). In Centers dren and adolescents in the United States, missionreadiness.s3.amazonaws.com/ for Disease Control and Prevention, 2016. 1988-1994 through 2013-2014. JAMA, wp-content/uploads/MR-NAT-Retreat- http://www.cdc.gov/brfss/brfsspreva- 315(21): 2292-2299, 2016. jama.jamanet- Not-an-Option2.pdf (accessed May 2016). lence/index.html (accessed May 2016). work.com/article.aspx?articleid=2526638 21 gden CL, Carroll MD, Lawman HG, et O 31 Pregnant women were included in cal- 8 gden CL, Carroll MD, Lawman HG, et al. O al. Trends in obesity prevalence among culations of BMI prior to 2011 and the Trends in obesity prevalence among chil- children and adolescents in the United height standards also changed in that dren and adolescents in the United States, States, 1988-1994 through 2013-2014. year.  Users can see that the calculated 1988-1994 through 2013-2014. JAMA, JAMA, 315(21): 2292-2299, 2016. variables changed from _BMI4 to _BMI5 315(21): 2292-2299, 2016. 22 ables of Summary Health Statistics: Na- T (and _BMI4CAT and _BMI5CAT).  They 9 ndian Health Service. Healthy Weight for I tional Health Survey, 2014. Table A-15. In can also see that the variable for height Life. A Vision for Healthy Weight Across the CDC, National Centers for Health Statistics, used in the calculations changed in that Lifespan of American Indians and Alaska 2016. http://www.cdc.gov/nchs/nhis/ year.   Data users are cautioned against Natives, Actions for Communities, Individuals, shs/tables.htm (accessed July 2016). trending before and after 2011. Docu- and Families. Rockville, MD: U.S. Depart- mentation on the changes can be found 23 he New York Academy of Medicine. A T ment of Health and Human Services, 2011. on the BRFSS website in the calculated Compendium of Proven Community-Based Pre- https://www.ihs.gov/healthyweight/in- variable reports for the respective years.  vention Programs. New York, NY: The New cludes/themes/newihstheme/display_ob- York Academy of Medicine, 2013. http:// 32 Merrill RM and Richardson JS. Validity jects/documents/HW4L_Communities.pdf www.tfah.org/report/110/ (accessed of self-reported height, weight, and Body (accessed May 2015). April 2016). Mass Index: findings from the National 10 Ogden CL, et al., 2292-2299, 2016. Health and Nutrition Examination Sur- 24 hat is the Community Guide? In The W vey, 2001-2006. Preventing Chronic Disease, 11 Ogden CL, et al., 2292-2296, 2016. Guide to Community Preventive Services, 6(4): A121, 2009. http://www.cdc.gov/ 2016. http://www.thecommunityguide. 12 Ogden CL, et al., 2292-2296, 2016. pcd/issues/2009/oct/08_0229.htm (ac- org/ (accessed May 2015). cessed March 2010). 13 Ogden CL, et al., 806-814, 2014. TFAH • RWJF • StateofObesity.org 123 33 Description of BRFSS and changes in 45 aidmann T. Estimating the Cost of Racial W 57 Trasande L, Liu Y, Fryer G, et al. Effects methodology provided by CDC. and Ethnic Health Disparities. Washington, of childhood obesity on hospital care and D.C.: The Urban Institute, 2009. http:// costs, 1999–2005. Health Affairs, 28(4): 34 Stunkard AJ and Wadden TA. Obesity: The- www.urban.org/research/publication/es- w751–w760, 2009. ory and Therapy. Second Ed. New York, NY: timating-cost-racial-and-ethnic-health-dis- Raven Press, 1993. 58 Lees K. “Children in Poor Neighbor- parities hoods at Great Risk of Obesity.” Science 35 National Research Council. Diet and 46 legel, K.M., Kruszon-Moran D., Car- F World Report June 20, 2014. http:// Health: Implications for Reducing Chronic roll M., et al. Trends in obesity among www.scienceworldreport.com/arti- Disease Risk. Washington, D.C.: National adults in the United States, 2005 to 2014. cles/15584/20140620/children-in-poor- Academy Press, 1989. JAMA. 315(2): 2284-2291, 2016. http:// neighborhoods-at-greater-risk-of-obesity. 36 National Research Council, 1989. jama.jamanetwork.com/article.aspx?arti- htm (accessed October 2014). cleid=2526639 37 Parker-Pope T. “Watch Your Girth”. The 59 Centers for Disease Control and Pre- New York Times May 13, 2008. http:// 47 ables of Summary Health Statistics: Na- T vention. Obesity among low-income, query.nytimes.com/gst/fullpage. tional Health Survey, 2014. Table A-15. In preschool-aged children — United States, html?res=9A0DE7D7153CF930A- CDC, National Centers for Health Statistics, 2008–2011. Morbidity and Mortality Weekly 25756C0A96E9C8B63 (accessed May 2016. http://www.cdc.gov/nchs/nhis/ Report, 62(31): 629-634, 2013. http://www. 2016). shs/tables.htm (accessed July 2016). cdc.gov/mmwr/preview/mmwrhtml/ mm6231a4.htm?s_cid=mm6231a4_w (ac- 38 Flegal KM, et al., 2284-2291, 2016. http:// 48 http://kff.org/other/state-indicator/ cessed October 2014). jama.jamanetwork.com/article.aspx?arti- adult-overweightobesity-rate-by-re/ cleid=2526639 (accessed June 2016). 60 Feeding America. Map the Meal Gap. 49 gden CL, et al. Prevalence of obesity O Chicago, IL: Feeding America, 2016. 39 Tables of Summary Health Statistics: Na- among adults and youth: United States, http://www.feedingamerica.org/ tional Health Survey, 2014. Table A-15, 2011-2014. NCHS Data Brief, No. 219, hunger-in-america/our-research/map- 2016. 2015. http://www.cdc.gov/nchs/data/da- the-meal-gap/2014/map-the-meal-gap- tabriefs/db219.htm (accessed April 2016). 40 Flegel, K.M., Kruszon-Moran D., Car- 2014-exec-summ.pdf (accessed May roll M., et al. Trends in obesity among 50 reedman DS, et al. The relation of child- F 2016). adults in the United States, 2005 to 2014. hood BMI to adult adiposity: The Bogalusa 61 Child Food Insecurity in the United JAMA. 315(2): 2284-2291, 2016. http:// Heart Study. Pediatrics, 115(1): 22-27, 2005. States. In Feeding America, 2016. http:// jama.jamanetwork.com/article.aspx?arti- 51 he Writing Group for the SEARCH for T map.feedingamerica.org/county/2014/ cleid=2526639 Diabetes in Youth Study, et al. Incidence child (accessed May 2016). 41 Flegel, K.M., Kruszon-Moran D., Car- of diabetes in youth in the United States. 62 Jiang Y, Ekono M, and Skinner C. Basic roll M., et al. Trends in obesity among JAMA, 297(24): 2716-2724, 2007. Facts About Low-Income Children: Children adults in the United States, 2005 to 2014. 52 unningham SA, Kramer MR, Narayan V. C Under 3 Years, 2014. New York, NY: Na- JAMA. 315(2): 2284-2291, 2016. http:// Incidence of childhood obesity in the United tional Center for Children in Poverty, jama.jamanetwork.com/article.aspx?arti- States. N England J of Med, 370: 403-411, 2014. 2014. http://www.nccp.org/publications/ cleid=2526639 pub_1148.html (accessed May 2016). 53 rasande L and Chatterjee S. The impact T 42 Profiles of Latino Health: A Closer Look of obesity on health service utilization and 63 Understanding Poverty. In Urban Institute. at Latino Child Nutrition. Issue 1: Food costs in childhood. Obesity, 17(9):1749– http://www.urban.org/features/under- Insecurity within the Latino Commu- 1754, 2009. standing-poverty (accessed May 2016). nity. In National Council of La Raza, 2015. http://www.nclr.org/Assets/uploads/Pub- 54 inkelstein EA, Graham WC, Malhotra R. F 64 Heerman WJ, Krishnaswami S, Barkin SL, lications/Nutrition-Profiles/Issue1_Nutri- Lifetime direct medical costs of childhood et al. Adverse family experience during tion_profiles_.pdf (accessed May 2014). obesity. Pediatrics, 133: 854-862, 2014. childhood and adolescent obesity. Obesity http://pediatrics.aappublications.org/ 24(3): 696-702, 2016. http://www.ncbi. 43 Research Packages. In Salud America! content/pediatrics/133/5/854.full.pdf nlm.nih.gov/pubmed/26853526 (ac- https://salud-america.org/research (ac- (accessed May 2016). cessed May 2016). cessed May 2014). 55 rasande L and Chatterjee S, 1749–1754, T 65 Bramlett MD and Radel LF. Adverse family 44 LaVeist TA, Gaskin D, and Richard P. Es- 2009. experiences among children in nonparental timating the economic burden of racial care, 2011-2012. National Health Statistics health inequalities in the United States. 56 arder W and Chang S. Childhood Obesity: M Reports; no. 74. Hyattsville, MD: National Int J Health Serv, 41(2): 231-238, 2011. Costs, Treatment Patterns, Disparities in Care, Center for Health Statistics, 2014. http:// and Prevalent Medical Conditions. Thomson www.cdc.gov/nchs/data/nhsr/nhsr074. MedStat Research Brief, 2005. http:// pdf (accessed May 2016). www.nptinternal.org/productions/chcv2/ healthupdates/pdf/Cost_of_childhood_ obesity.pdf (accessed May 2016). 124 TFAH • RWJF • StateofObesity.org 66 Mathew DB and Radel LF. Adverse family 73 rown DW, Anda RF, Tiemeier H, et al. B (EPSDT) Program; and Title V Maternal experiences among children in nonparen- Adverse childhood experiences and the and Child Health Program (MCH). tal care, 2011-2012. National Health Statis- risk of premature mortality. Am J Prev Med 83 Vital Signs: Progress on Childhood Obe- tics Reports, 74. 2014. http://www.cdc.gov/ 37(5): 389-396, 2009. sity. In Centers for Disease Control and Preven- nchs/data/nhsr/nhsr074.pdf (accessed 74 entral Iowa ACEs 360 Steering Commit- C tion, 2013. http://www.cdc.gov/vitalsigns/ July 216). tee. Adverse childhood experience in Iowa: childhoodobesity/ (accessed May 2014). 67 Suitts S. A New Majority — Low Income a new way of understanding lifelong health. 84 Pan L., McGuire LC, Blanck HM, Students Now a Majority in the Nation’s Findings from the 2012 Behavioral Risk Fac- May-Murriel AL, Grummer-Strawn LM. Public Schools. Atlanta, GA: South- tor Surveillance System. In Iowa ACEs 360, Racial/ethnic differences in obesity trends ern Education Foundation, 2015. 2013. http://www.iowaaces360.org/iowa-ac- among young low-income children. Amer http://www.southerneducation.org/ es-research.html (accessed May 2016). J Prev Med 2015 May; 48(5): 570-4. getattachment/4ac62e27-5260-47a5- 75 entral Iowa ACEs 360 Steering C 9d02-14896ec3a531/A-New-Majority-2015- 85 Vital Signs: Progress on Childhood Committee, 2013. Update-Low-Income-Students-Now.aspx Obesity, 2013. (accessed March 2016). 76 Core Meanings of the Strengthening Fami- 86 enters for Disease Control and Preven- C lies Protective Factors. In Center for the Study 68 Central Iowa ACEs 360 Steering Com- tion. Obesity Prevalence Among Low-In- of Social Policy, 2015. http://www.cssp.org/ mittee. Adverse childhood experience in come, Preschool-Aged Children—United reform/strengtheningfamilies/2015/Core- Iowa: a new way of understanding lifelong States, 1998-2008. Morbidity and Mortality Meanings-of-the-SF-Protective-Factors-2015. health. Findings from the 2012 Behavioral Weekly Report, 58(28): 769-773, 2009. http:// pdf (accessed August 2015). Risk Factor Surveillance System. In Iowa www.cdc.gov/mmwr/preview/mmwrhtml/ ACEs 360, 2013. http://www.iowaaces360. 77 horn B, Tadler C, Huret N, et al., No. T mm5828a1.htm (accessed May 2016). org/uploads/1/0/9/2/10925571/iowa_ WIC Participant and Program Characteristics 87 .S. Department of Health and Human U aces_360_pdf_web_new.pdf (accessed 2014. Prepared by Insight Policy Research Services, Health Resources and Services September 2014). under Contract No. AG?3198?C?11?0010. Administration, Maternal and Child Health Alexandria, VA: U.S. Department of Agri- 69 ational Scientific Council on the Devel- N Bureau. The Health and Well-Being of Children: culture, Food and Nutrition Service, 2015. oping Child. The Science of Early Childhood A Portrait of States and the Nation, 2011-2012. Development. Closing the Gap Between What 78 012: Percent of WIC Children Aged 2 2 Rockville, Maryland: U.S. Department of We Know and What We Do. Cambridge, MA: to 4 Years Who have Obesity. In Nutrition, Health and Human Services, 2014. http:// Harvard University, Center on the Devel- Physical Activity and Obesity: Data, Trends mchb.hrsa.gov/nsch/2011-12/health/ oping Child, 2007. http://developingchild. and Maps. https://nccd.cdc.gov/NPAO_ pdfs/nsch11.pdf (accessed May 2016). harvard.edu/resources/the-science-of-ear- DTM/IndicatorSummary.aspx?catego- 88 http://stateofobesity.org/children1017/ ly-childhood-development-closing-the-gap- ry=28&indicator=89 (accessed April 2016). between-what-we-know-and-what-we-do/ 89 Kann L, et al., 1-174, 2016. 79 SDA Finalizes Changes to the WIC U (accessed May 2016). Programs, Expanding Access to Healthy 90 High School YRBS. Youth Online. In 70 elitti VJ, Anda RF, Nordenberg D, et al. F Fruits and Vegetables, Whole Grains, Centers for Disease Control and Prevention, Relationship of Childhood Abuse and and Low-Fat Dairy for Women, Infants, https://nccd.cdc.gov/Youthonline/App/ Household Dysfunction to Many of the and Children. In U.S. Department of Default.aspx (accessed June 2016). Leading Causes of Death in Adults: The Agriculture, Food and Nutrition Service, 91 High School YRBS. 1999-2015 Results: Adverse Childhood Experiences (ACE) 2014. http://www.fns.usda.gov/pressre- Obesity Totals. In Centers for Disease Control Study. American J of Prev Med, 14(4): 245- lease/2014/003114 (accessed July 2016). and Prevention, https://nccd.cdc.gov/ 258, 1998. 80 utrition Program Facts: WIC — The N youthonline/App/Results.aspx?TT=B& 71 njury Prevention and Control: Division of I Special Supplemental Nutrition Program OUT=0&SID=HS&QID=QNOBESE&LI Violence Prevention. Adverse Childhood for Women, Infants and Children. In U.S. D=LL&YID=RY&LID2=&YID2=&COL=& Experiences (ACEs). In Centers for Disease Department of Agriculture, Food and Nutrition ROW1=&ROW2=&HT=&LCT=&FS=&- Control and Prevention. http://www.cdc. Service. http://www.fns.usda.gov/sites/de- FR=&FG=&FSL=&FRL=&FGL=&PV=&T- gov/violenceprevention/acestudy/index. fault/files/WIC-Fact-Sheet.pdf (accessed ST=&C1=&C2=&QP=&DP=&VA=CI&- html (accessed September 2014). July 2015). CS=Y&SYID=&EYID=&SC=&SO= (accessed June 2016). 72 iddlebrooks JS and Audage NC. The M 81 horn B, Tadler C, Huret N, et al., No. T Effects of Childhood Stress on Health across the AG?3198?C?11?0010, 2015. 92 oleman-Jensen A, Rabbitt MP, Gregory C, C Lifespan. Atlanta, GA: Centers for Disease et al. Household Food Security in the United 82 edNSS uses existing data from the fol- P Control and Prevention, National Center States in 2015, ERR-215. Washington D.C.: lowing public health programs for nutri- for Injury Prevention and Control, 2008. U.S. Department of Agriculture, Economic tion surveillance: Special Supplemental http://www.cdc.gov/ncipc/pub-res/pdf/ Research Services, 2016. http://www.ers. Nutrition Program for Women, Infants childhood_stress.pdf (accessed October usda.gov/media/2137663/err215.pdf (ac- and Children (WIC); Early and Periodic 2014). cessed September 2016). Screening, Diagnosis and Treatment TFAH • RWJF • StateofObesity.org 125 93 http://frac.org/pdf/frac_brief_under- 103 axman E. “Mapping Food Insecurity and W 113 Agency for Healthcare Research and standing_the_connections.pdf Distress in American Indian and Alaska Na- Quality. (2010). One in 16 Women Hos- tive Communities.” Urban Institute May 11, pitalized for Childbirth has Diabetes. 94 Trehaft S and Karpyn. The Grocery Gap. 2016. http://www.urban.org/urban-wire/ [News Release]. http://www.ahrq.gov/ Who Has Access to Healthy Food and Why mapping-food-insecurity-and-distress-amer- news/nn/nn121510.htm (accessed Octo- It Matters. Philadelphia, PA: The Food ican-indian-and-alaska-native-communities ber 2014). Trust and PolicyLink, 2013. http://the- (accessed May 2016). foodtrust.org/uploads/media_items/gro- 114 Randall B, Boast L, Holst L. Study of cerygap.original.pdf (accessed July 2016). 104 hild Food Insecurity in the United C WIC Participant and Program Character- States, 2014. In Feeding America, 2016. istics, 1994. Alexandria, VA: U.S. Depart- 95 Bell J, Mora G, Hagan E, et al. Access to http://map.feedingamerica.org/ ment of Agriculture, Food and Nutrition Healthy Food and Why It Matters: A Review of county/2014/child (accessed May 2016). Service, Office of Analysis, Nutrition and the Research. Philadelphia, PA: The Food Evaluation, 1995. Trust and PolicyLink, 2013. http://the- 105 oleman-Jensen A, et al., ERR-194, 2015. C foodtrust.org/uploads/media_items/ac- 115 Thorn B, Tadler, C, Huret C, et al. Study 106 orton LW. Access to Affordable & Nu- M cess-to-healthy-food.original.pdf (accessed of WIC Participant and Program Char- tritious Food: Understanding Food Deserts. July 2016). acteristics, 2014. Alexandria, VA: U.S. USDA ERS Workshop Powerpoint, 2008. Department of Agriculture, Food and 96 eeding America. Map the Meal Gap, 2016. F http://www.farmfoundation.org/news/ Nutrition Service, 2015. Highlights of the Finding for Overall and Child articlefiles/450-Morton.pdf (accessed Food Insecurity. http://www.feedingamerica. April 2014). 116 Randall B, Barlett S, Kennedy S. Study of org/hunger-in-america/our-research/ WIC Participant and Program Character- 107 axman E. “Mapping Food Insecurity and W map-the-meal-gap/2014/map-the-meal-gap- istics, 2004. Alexandria, VA: U.S. Depart- Distress in American Indian and Alaska Na- 2014-exec-summ.pdf (accessed May 2016). ment of Agriculture, Food and Nutrition tive Communities.” Urban Institute May 11, Service, Office of Analysis, Nutrition and 97 Coleman-Jensen A, et al., ERR-215, 2016. 2016. http://www.urban.org/urban-wire/ Evaluation, 2006. mapping-food-insecurity-and-distress-amer- 98 Bartfeld J, Dunifon R, Nord M, et al. What ican-indian-and-alaska-native-communities 117 Thorn B, Tadler, C, Huret C, et al. Study Factors Account for State-to-State Differences (accessed May 2016). of WIC Participant and Program Char- in Food Security? Economic Information acteristics, 2014. Alexandria, VA: U.S. Bulletin No. 20. Washington, D.C.: U.S. 108 er Ploeg M, Breneman V, Dutko P, et al. V Department of Agriculture, Food and Department of Agriculture, Economic Access to Affordable and Nutritious Food: Up- Nutrition Service, 2015. Research Service, 2006. http://www.ers. dated Estimates of Distance to Supermarkets usda.gov/media/860374/eib20_002.pdf Using 2010 Data, ERR-143, U.S. Depart- 118 Chen Y, Quick WW, Yang W, et al. Cost (accessed May 2016). ment of Agriculture, Economic Research of Gestational Diabetes Mellitus in the Service, 2012. http://www.ers.usda.gov/ U.S. in 2007. Popul Health Manag 12(3): 99 100 Years of U.S. Consumer Spending: media/956784/err143.pdf (accessed 165-174, 2009. http://www.ncbi.nlm. Data for the Nation, New York City, and April 2015). nih.gov/pubmed/19534581 Boston. In Bureau of Labor Statistics. http://www.bls.gov/opub/uscs/ (ac- 109 ridging the Gap and Salud America! B 119 Frequently Asked Questions: Nutrition cessed April 2015). Better Food in the Neighborhood and Latino During Pregnancy. In The American Kids, Issue Brief June 2013. https:// College of Obstetrics and Gynecologists, 100 Coleman-Jensen A, Gregory C, Singh A. salud-america.org/sites/saludamerica/ 2015. https://www.acog.org/~/ Household Food Security in the United States files/Better-Food-in-the-Neighborhood- media/For%20Patients/faq001.pdf?d- in 2013, ERR-173, U.S. Department of Issue-Brief.pdf (accessed March 2014). mc=1&ts=20140722T1740088740 (ac- Agriculture, Economic Research Service, cessed May 2016). September 2014. http://www.ers.usda. 110 conomic Research Service (ERS), U.S. E gov/media/1565415/err173.pdf (ac- Department of Agriculture (USDA). 120 Institute of Medicine. Preterm Birth: cessed April 2015). Food Access Research Atlas, http://www.ers. Causes, Consequences, and Prevention. usda.gov/data-products/food-access-re- Washington, D.C.: The National Acade- 101 Coleman-Jensen A, et al., ERR-194, 2015. search-atlas.aspx (accessed June 2013). mies Press, 2007.  http://www.ncbi.nlm. 102 McKernan S, Ratcliffe C, Steuerle E, nih.gov/books/NBK11358/ (accessed 111 ahl S, Eagle L, Baez C. Analyzing ad- D et al. Less Than Equal: Racial Disparities October 2014). vergames: Active diversions or actually in Wealth Accumulation. Washington, deception. An exploratory study of on- 121 Prematurity Campaign. In March of D.C.: Urban Institute, 2013. http:// line advergames content. Young Consum- Dimes. http://www.marchofdimes.com/ www.urban.org/UploadedPD- ers, 10(1): 46-59, 2009. mission/the-economic-and-societal-costs. F/412802-Less-Than-Equal-Racial-Dis- aspx (accessed October 2014). parities-in-Wealth-Accumulation.pdf 112 sterman MJK, Martin JA, Curtin SC, et O (accessed May 2014). al. Newly released data from the revised 122 Infant Health. In Centers for Disease Con- U.S. birth certificate, 2011. National Vital trol and Prevention. http://www.cdc.gov/ Statistics Report 62(4), 2013. Hyattsville, nchs/fastats/infant-health.htm (accessed MD: National Center for Health Statistics. May 2016). 126 TFAH • RWJF • StateofObesity.org 123 OECD. OECD Health Data: Health 132 eville CE, McKinley MC, Holmes VA, et N 142 errine CG, Nelson JM, Corbelli J, et P status: Health status indicators, OECD al. The relationship between breastfeed- al. Lactation and maternal cardio-met- Health Statistics (database). http://www. ing and postpartum weight change–a abolic health. Annu Rev Nutr, 36(627- oecd-ilibrary.org/economics/oecd-fact- systematic review and critical evaluation. 645), 2016. http://www.ncbi.nlm.nih. book_18147364 (accessed May 2016). International J Obs 38: 577-590, 2014. gov/pubmed/27146017 (accessed Au- gust 2016). 124 OECD. Health at a Glance: OECD Indi- 133 arlenski M, Bennett WL, Bleich WN, et J cators. Paris, France: OECD Publishing, al. Effects of breastfeeding on postpar- 143 he burden of suboptimal breastfeeding T 2015. http://www.oecd-ilibrary.org/ tum weight loss among U.S. women. Prev in the United States: a pediatric cost docserver/download/8115071e.pdf?expi Med, 69: 146-150, 2014. analysis. Pediatrics, 125(5): e1048-e1056, res=1463757238&id=id&accname=gu 2010. http://www.ncbi.nlm.nih.gov/ 134 enters for Disease Control and Preven- C est&checksum=2BBD58D3E0E49A3C4B- pubmed/20368314 (accessed August tion. (2013). U.S. breastfeeding rates 0455CC74527C89 (accessed May 2016). 2016). continue to rise. [Press Release]. http:// 125 AAP Reaffirms Breastfeeding Guidelines. www.cdc.gov/media/releases/2013/ 144 National Center for Chronic Disease In American Academy of Pediatrics, 2012. p0731-breastfeeding-rates.html (accessed Prevention and Health Promotion. http://www.aap.org/en-us/about-the- June 2015). Breastfeeding Report Care. Progressing aap/aap-press-room/Pages/AAP-Re- Towards National Breastfeeding Goals, 135 ener A, Ehlayel MS, Alsowaidi S, Sab- B affirms-Breastfeeding-Guidelines.aspx United States, 2016. Atlanta, GA: Cen- bah A. Role of breast feeding in primary (accessed June 2015). ters for Disease Control and Prevention, prevention of asthma and allergic dis- Division of Nutrition, Physical Activity, 126 Breastfeeding Initiatives: FAQ. In Ameri- eases in a traditional society. Eur Ann Al- and Obesity, 2016 http://www.cdc.gov/ can Academy of Pediatrics. https://www2. lergy Clin Immunol, 39(10): 337-343, 2007. breastfeeding/pdf/2016breastfeedingre- aap.org/breastfeeding/faqsBreastfeed- 136 ener A, Hoffmann GF, Afify Z, et al. B portcard.pdf (accessed August 2016).. ing.html (accessed June 2015). Does prolonged breastfeeding reduce 145 Children’s Defense Fund. The 127 nstitute of Medicine. Early Childhood Obe- I the risk for childhood leukemia and lym- State of America’s Children, 2014. sity Prevention Policies. Washington, D.C.: phomas? Minerva Pediatr, 60(2): 155-161, Washington, D.C.: Children’s De- National Academies Press, 2011. http:// 2008. fense Fund, 2014. http://www. www.iom.edu/~/media/Files/Report%20 137 auck FR, Thompson JMD, Tanabe H childrensdefense.org/library/state- Files/2011/Early-Childhood-Obesity-Pre- KO, et al. Breastfeeding and Reduced of-americas-children/2014-soac. vention-Policies/Young%20Child%20 Risk of Sudden Infant Death Syndrome: pdf?utm_source=2014-SOAC-PDF&utm_ Obesity%202011%20Report%20Brief.pdf A Meta-analysis. Pediatrics, 128(1): 103- medium=link&utm_cam- (accessed June 2015). 110, 2011. http://www.infantrisk.com/ paign=2014-SOAC (accessed July 2016). 128 Yan J, Liu L, Zhu Y, et al. The association content/breastfeeding-may-reduce-risk- 146 WHO. Interim Report of the Commis- between breastfeeding and childhood sudden-infant-death-syndrome-0#sthash. sion on Ending Childhood Obesity. Ge- obesity: a meta-analysis. BMC Public uE5kBdvY.dpuf (accessed June 2015). neva, Switzerland: WHO; 2015 Health, 14:1267, DOI: 10.1186/1471- 138 AP Reaffirms Breastfeeding Guidelines, A 2458-14-1267, 2014. http://bmc- 147 Gortmaker SL, Swinburn BA, Levy D, 2012. publichealth.biomedcentral.com/ et al. Changing the future of obesity: articles/10.1186/1471-2458-14-1267 139 acker A, Kelly Y, Iacovou M, Cable N, S science, policy, and action. Lancet, (accessed July 2016). Bartley M. Breast feeding and inter- 378(9793): 838–847, 2011. generational social mobility: what are 129 Young BE, Johnson SL, and Krebs NF. 148 Taveras EM, Perkins M, Woo Baidal JA, the mechanisms? Arch Dis Child, 98(9): Biological determinants linking infant et al. The Impact of the First 1,000 Days on 666-671, 2013. http://adc.bmj.com/ weight gain and child obesity: current Childhood Obesity. Durham, NC: Healthy content/early/2013/04/24/archdis- knowledge and future directions. Adv Eating Research, 2016. http://health- child-2012-303199.full (accessed June Nutr, 3: 675-686, 2012. yeatingresearch.org/wp-content/up- 2015). loads/2016/03/her_1000_days_final-1. 130 Ip S, Chung M, Raman G et al. Maternal 140 he JAMA Network, (2013). Breastfeed- T pdf (accessed May 2016). and Infant Health Outcomes in Developed ing Duration Appears Associated with In- Countries. Evidence Report/Technology 149 Food and Nutrition Service. 2017 Ex- telligence Later in Life. [Press Release]. Assessment No. 153. AHRQ Publication planatory Notes. In The Office of Budget http://media.jamanetwork.com/news- No. 07-E007. Rockville, MD: Agency for and Program Analysis, U.S. Department of item/4086/ (accessed June 2015). Healthcare Research and Quality, 2007. Agriculture, 2016. http://www.obpa.usda. 141 howdhury R, Sinha B, Jeeva Sankar C gov/32fns2017notes.pdf (accessed Au- 131 Stuebe A. The risks of not breastfeeding M, et al. Breastfeeding and maternal gust 2016). for mothers and infants. Rev Obstet Gyne- health outcomes: a systematic review and col 2(4): 222-231, 2009. meta-analysis. Acta Paediatrica 104(s467): 96-113, http://onlinelibrary.wiley.com/ doi/10.1111/apa.13102/abstract TFAH • RWJF • StateofObesity.org 127 150 Fiscal Year 2016 Federal Child Care 160 ox MK, Condon E, Griefel RR, et al. F 169 Improving Nutrition and Promoting and Related Appropriations. In Office of Food consumption patterns of young Wellness in Child Care With CACFP. In Child Care, Administration for Children & preschoolers: are they starting off on the Food Research and Action Center, http:// Families, 2016. http://www.acf.hhs.gov/ right path? J Am Diet Assoc 110(12 Suppl): www.frac.org/pdf/cacfp_bestpractices_ occ/resource/fiscal-year-2016-feder- s52-s59, 2010. http://www.andjrnl.org/ improving_nutrition_promoting_well- al-child-care-and-related-appropriations article/S0002-8223(10)01478-1/pdf (ac- ness.pdf (accessed July 2016). (accessed August 2016). cessed May, 2016). 170 Challenges and Opportunities Related 151 H.R.2029–Consolidated Appropriations 161 aavedra JM, Deming D, Dattilo A, et al. Les- S to Implementation of Child Care Nu- Act, 2016. 114th Congress (2015-2016). sons from the Feeding Infants and Toddlers trition and Physical Activity Policies in In Congress.gov, 2016. https://www.con- Study in North America: What children eat, Delaware. In Altarum Institute, 2009. gress.gov/bill/114th-congress/house- and implications for obesity prevention. Ann http://altarum.org/sites/default/files/ bill/2029/text (accessed August 2016). Nutr Metab 62(suppl 3): 27-36. uploaded-publication-files/Delaware- FocusGroup-ExecSummmary-FIN.pdf 152 H.R.2029, 2016. 162 aniels SR and Hassink SG. The role D (accessed July 2016). of the pediatrician in primary preven- 153 Briefel RR, Deming DM, Reidy KC. tion of obesity. Am Academy Ped, 136(1): 171 Institute of Medicine. Child and Adult Parents’ Perceptions and Adherence e275-e292, 2015 http://pediatrics.aap- Care Food Program. Aligning Dietary Guid- to Children’s Diet and Activity Recom- publications.org/content/136/1/e275 ance for All. Washington, DC: National mendations: the 2008 Feeding Infants (accessed May 2016). Academies Press, 2011. http://www.nap. and Toddlers Study. Prev Chronic Dis, edu/catalog/12959/child-and-adult- 12: 2015. http://dx.doi.org/10.5888/ 163 it BK, Fakhouri THI, Park S, et al. K care-food-program-aligning-dietary-guid- pcd12.150110 (accessed May 2016). Trends in sugar-sweetened beverage con- ance-for (accessed July 2016). sumption among youth and adults in the 154 Cook JC and Jeng K. Child Food Insecu- United States: 1999-2010. Am J Clin Nutr, 172 Matthews H, Schulman K, Vogtman J, et rity: The Economic Impact on Our Nation. 98(1): 180-188, 2013. al. Implementing the Child Care and Develop- Chicago, IL: Feeding America, 2009. ment Block Grant Reauthorization: A Guide http://www.nokidhungry.org/sites/ 164 arly Childhood Program Participation E for States. Washington, DC: National default/files/child-economy-study.pdf Survey of the National Household Edu- Women’s Health Law Center and CLASP, (accessed June 2015). cation Surveys Program (ECPP-NHES: 2015. http://www.clasp.org/issues/ 2012) National Center for Education Sta- 155 Fitness and your 2- to-3-year-old. In Kids child-care-and-early-education/pages/ tistics Web site. https://nces.ed.gov/pro- Health from Nemours. http://kidshealth. body/Intro_CCDBGGuide.pdf (accessed grams/digest/d14/tables/dt14_202.30. org/parent/nutrition_center/staying_ May 2016). asp (accessed May 2016). fit/fitness_2_3.html#cat20740 (accessed 173 S.1086 - Child Care and Development June 2015). 165 arly Childhood Program Participation E Block Grant Act of 2014. In Con- Survey of the National Household Edu- 156 Acitve Start. In Shape America, no date. gress.gov. http://beta.congress.gov/ cation Surveys Program (ECPP-NHES: http://www.shapeamerica.org/stan- bill/113th-congress/senate-bill/1086 2012) National Center for Education Sta- dards/guidelines/activestart.cfm (ac- (accessed May 2014). tistics Web site. https://nces.ed.gov/pro- cessed August 2016). grams/digest/d14/tables/dt14_202.30. 174 hild Care Aware. Recommended Lan- C 157 Institute of Medicine. Early Childhood asp (accessed May 2016). guage for CCDF State Plans to Support Obesity Prevention Policies. Washington, Creating Healthier Care Environments. 166 hild and Adult Care Food Program. In C D.C.: National Academies Press, 2011. Arlington, VA: Child Care Aware, 2015. U.S. Department of Agriculture, Food and http://www.iom.edu/~/media/Files/ http://usa.childcareaware.org/wp-con- Nutrition Service. http://www.fns.usda. Report%20Files/2011/Early-Child- tent/uploads/2015/10/cca_state_plan_rec- gov/cacfp/child-and-adult-care-food-pro- hood-Obesity-Prevention-Policies/ ommendations.pdf (accessed May 2016). gram (accessed May 2016). Young%20Child%20Obesity%20 175 Matthews H, Schulman K, Vogtman J, et 2011%20Report%20Brief.pdf (accessed 167 U.S. Department of Agriculture, (2016). al., 2015. June 2015). USDA Announces Effort to Strengthen Nutrition among Young Children, 176 Fiscal Year 2016 Federal Child Care and 158 Brown A, Shifrin DL, Hill DL. Beyond Create Healthy Habits Early. [Press Related Appropriations. In Adminis- ‘turn it off’: how to advise families on Release]. http://www.fns.usda.gov/ tration for Children & Families, Office media use” AAP News, 36(10), 2015. pressrelease/2016/fns-000616 (accessed of Child Care, 2016. http://www.acf. http://www.aappublications.org/con- May 2016). hhs.gov/programs/occ/resource/fis- tent/36/10/54 (accessed August 2016). cal-year-2016-federal-child-care-and-relat- 168 RAC Fact Sheet: Child and Adult F 159 Caring for Our Children. In Caring for ed-appropriations (accessed May 2016). Care Food Program (CACFP). In Food Our Children, no date. http://cfoc.nrck- Research and Action Center, 2009. ids.org/ (accessed August 2016). http://frac.org/newsite/wp-content/ uploads/2009/09/cncacfp.pdf 128 TFAH • RWJF • StateofObesity.org 177 uality Rating and Improvement Systems Q 187 ow YoungStar has an Impact in Wiscon- H 196 U.S. Department of Education, (2015). (QRIS). In Build Initiative. http://buildi- sin. In Wisconsin Department of Children U.S. Department of Education and Health nitiative.org/TheIssues/EarlyLearning/ and Families, no date. http://dcf.wiscon- and Human Services Award $237M in QualityQRIS.aspx (accessed July 2015). sin.gov/youngstar/impact.htm (accessed Early Education Grants to 18 States. May 2016). [Press Release]. http://www.ed.gov/news/ 178 QRIS State Contacts & Map, February press-releases/us-departments-education- 2015. In QRIS Network, 2015. http:// 188 ead State Program Facts, Fiscal Year H and-health-and-human-services-award- qrisnetwork.org/qris-state-contacts-map 2015. In Head Start, Early Childhood Learn- 237m-early-education-grants-18-states (accessed May 2016). ing & Knowledge Center, 2015. https:// (accessed May 2016). eclkc.ohs.acf.hhs.gov/hslc/data/fact- 179 QRIS Resource Guide. State Informa- sheets/2015-hs-program-factsheet.html 197 Spectrum of Opportunities for Obesity tion. In QRIS Guide, no date. https:// (accessed May 2016). Prevention in the Early Care and Ed- qrisguide.acf.hhs.gov/?do=qrisstate (ac- ucation Setting (ECE) CDC Technical cessed May 2016). 189 ead Start Performance Standards: H Assistance Briefing Document. In U.S. Proposed Rule by the Children and 180 Nemours Children’s Health System. Centers for Disease Control and Prevention. Families Administration on 06/19/2015, Summary of Obesity Prevention Stan- http://www.cdc.gov/obesity/downloads/ Summary. In Federal Register, 2015. dards in State Quality Rating and spectrum-of-opportunities-for-obesity-pre- https://www.federalregister.gov/ Improvement Systems (QRIS) and vention-in-early-care-and-education-set- articles/2015/06/19/2015-14379/ Licensing Regulations. In http:// ting_tabriefing.pdf (accessed May 2014). head-start-performance-standards (ac- qrisnetwork.org/resource/2016/ cessed August 2015). 198 National Early Care and Education summary-obesity-prevention-stan- Learning Collaboratives. In Nemours. dards-state-quality-rating-and-improve- 190 ead Start Early Learning Outcomes H http://www.healthykidshealthyfuture. ment-systems-qris (accessed May 2016). Framework 2015. In Early Childhood org/home/collaborate/ecelcproject/ Learning & Knowledge Center, 2015. 1 81 The Public Health Law Center provided about.html. https://eclkc.ohs.acf.hhs.gov/hslc/ the analysis of the YMCA of the USA’s hs/sr/approach/cdelf/index.html (ac- 199 Shuell J. Highlighting the New Opportu- Physical Activity and Screen Time stan- cessed August 2015) nities for Health, Nutrition, and Obesity dards of state child care licensing laws Prevention. In ChildCare Aware, 2015. and regulations as of February 2016. 191 dministration for Children & Families. A http://usa.childcareaware.org/wp-con- Analysis was sent to TFAH from the AH Getting Started with the Head Start Early tent/uploads/2015/10/HEALTH-NU- Voices for Healthy Kids. Learning Outcomes Framework. Washing- TRITION-OBESITYslides.pdf (accessed ton, D.C.: U.S. Department of Health 182 The Standards. Healthy Eating and 2016). and Human Services, 2015. https:// Physical Activity (HIEPA) Standards. In eclkc.ohs.acf.hhs.gov/hslc/hs/sr/ 200 Women, Infants and Children (WIC). The YMCA, 2016. http://www.ymca.net/ approach/pdf/getting-started.pdf (ac- Frequently Asked Questions About WIC. hepa/standards/ (accessed July 2016). cessed August 2015), In Food and Nutrition Service, U.S. Depart- 183 What are the Main Goals? In Let’s Move ment of Agriculture, 2016. http://www. 192 https://eclkc.ohs.acf.hhs.gov/hslc/hs/ Child Care, 2016. http://www.healthykid- fns.usda.gov/wic/frequently-asked-ques- sr/approach/pdf/ohs-framework.pdf shealthyfuture.org/home/startearly/ tions-about-wic (accessed August 2016). thegoal.html (accessed May 2014). 193 ead Start Program Facts Fiscal Year H 201 Centers for Disease Control and Preven- 2015. In Head Start: An Office of the Ad- 184 Our Partners. In Partnership for a Health- tion, 629-634. ministration for Children and Families, ier America. http://ahealthieramerica. Early Childhood Learning & Knowledge 202 Nutrition Program Facts, Food and org/our-partners/ (accessed May 2014). Center (ECLKC), 2016, https://eclkc. Nutrition Service: WIC—The Special 185 About YoungStar. In Wisconsin Department ohs.acf.hhs.gov/hslc/data/fact- Supplemental Nutrition Program for of Children and Families, 2016. http://dcf. sheets/2015-hs-program-factsheet.html Woman, Infants and Children. In U.S. wisconsin.gov/youngstar/program.htm (accessed May 2016). Department of Agriculture, Food and Nutri- (accessed May 2016). tion Service. http://www.fns.usda.gov/ 194 very Student Succeeds Act (ESSA). A E sites/default/files/WIC-Fact-Sheet.pdf 186 Addressing Childhood Obesity in the New Education Law. In U.S. Department (accessed June 2015). Early Care and Education Setting: Op- of Education, 2015. http://www.ed.gov/ portunities for Action. Quality Rating essa?src=rn (accessed May 2016). 203 WIC Farmers’ Market Nutrition Pro- & Improvement System (QRIS). In gram. In U.S. Department of Agriculture, 195 ornfreund L. Every Student Succeeds B Early Care and Education System, no date. Food and Nutrition Service. http://www.fns. Act and Early Learning. In New America http://www.eceobesityprevention.org/ usda.gov/fmnp/wic-farmers-market-nu- EdCenteral, 2015. http://www.edcentral. quality-rating-improvement-system-qris/ trition-program-fmnp (accessed June org/every-student-succeeds-act-ear- (accessed May 2016). 2015). ly-learning/ (accessed May 2016). TFAH • RWJF • StateofObesity.org 129 204 Women, Infants and Children (WIC): 214 .S. Department of Labor. Fact Sheet U 224 Karoly LA, Kilburn MR, Cannon JS. Breastfeeding Promotion and Support #73: Break Time for Nursing Mothers Under Early Childhood Interventions. Proven Re- in WIC. In U.S. Department of Agriculture, FLSA. Washington, D.C: U.S. Depart- sults, Future Promise. Santa Monica, CA: Food and Nutrition Service. http://www. ment of Labor, 2013. http://www.dol. RAND Corporation, 2005. http://www. fns.usda.gov/wic/breastfeeding-pro- gov/whd/regs/compliance/whdfs73.pdf rand.org/content/dam/rand/pubs/ motion-and-support-wic (accessed June (accessed May 2016). monographs/2005/RAND_MG341.pdf 2015). (accessed August 2016). 215 utrition, Physical Activity, and Obesity. N 205 About WIC: How WIC Helps. In U.S. Prevention Status Report, 2016. http:// 225 Washington State Institute for Public Pol- Department of Agriculture, Federal Nutrition www.cdc.gov/psr/national-summary/ icy (WSIPP). Nurse Family Partnership for Service. http://www.fns.usda.gov/wic/ npao.html (accessed May 2016). Low-Income Families. Olympia, WA: WSIPP, about-wic-how-wic-helps (accessed June 2012. http://www.wsipp.wa.gov/Report- 216 reastfeeding State Laws. In National B 2015). File/1485 (accessed August 2016). Conference of State Legislatures, 2015. 206 WIC: Solid Returns on Investment While http://www.ncsl.org/research/health/ 226 Nurse Family Partnership (NFP). A Rig- Reducing the Deficit. In National WIC breastfeeding-state-laws.aspx (accessed orously Tested Program with Measureable Association. https://s3.amazonaws.com/ July 2015). Results. Denver, CO: NFP, 2013. http:// aws.upl/nwica.org/WIC_Return_on_In- kanehomevisits.org/files/Resources/ 217 ational Conference of State Legisla- N vestment.pdf (accessed June 2015). NFP_Benefit_Cost.pdf (accessed August tures, 2015. 2016). 207 Bitler MP and Currie J. Does WIC Work? 218 enters for Disease Control and Pre- C The Effects of WIC on Pregnancy and 227 IMPact. In University of Pennsylvania, vention. Breastfeeding Report Card, United Birth Outcomes. J Policy Anal Manage, 2016. http://www.impact.upenn.edu/ States 2014. Atlanta, GA: Centers for 24(1): 73-91, 2004. http://www.prince- wp-content/uploads/2016/2015/07/ Disease Control and Prevention, 2014. ton.edu/~jcurrie/publications/Does_ Obesity-Start-Earl (accessed August http://www.cdc.gov/breastfeeding/ WIC_Work.pdf. 2016). pdf/2014breastfeedingreportcard.pdf 208 House Appropriations Committee. FY (accessed July 2015). 228 Veugelers PJ and Fitzgerald AL. Effec- 2016 Omnibus Summary — Agriculture tiveness of School Programs in Prevent- 219 exas Ten Step Star Achiever Breastfeed- T Appropriations. https://appropriations. ing Childhood Obesity: A Multilevel ing Learning Collaborative. In National house.gov/uploadedfiles/12.15.15_ Comparison. American Journal of Public Institute for Children’s Health Quality, 2016. fy_2016_omnibus_-_agriculture_-_sum- Health, 95(3): 432-35, 2005. http://breastfeeding.nichq.org/solu- mary.pdf (accessed May 2016). tions/texas-breastfeeding-collaborative 229 Gleason P and Suitor C. Food for thought: 209 Senate Agriculture Committee Passes (accessed May 2016). children’s diets in the 1990s. Princeton, NJ: Bipartisan Child Nutrition Reauthori- Mathematica Policy Research, Inc., 2001. 220 he AAP is Committed to a Toxic T zation. In United States Senate Committee Stress-Informed Federal Policy Agenda. 230 Briefel RR, Wilson A, and Gleason PM. on Agriculture, Nutrition, & Forestry, In American Academy of Pediatrics. http:// Consumption of low-nutrient, ener- 2016. http://www.agriculture.senate. www.aap.org/en-us/advocacy-and-pol- gy-dense foods and beverages at school, gov/newsroom/rep/press/release/ icy/federal-advocacy/Documents/TSSO- home, and other locations among school senate-agriculture-committee-passes-bi- nePager.pdf (accessed July 2015). lunch participants and nonparticipants. J partisan-child-nutrition-reauthorization Am Diet Assoc, 109(Suppl 90), 2009. (accessed May 2016). 221 ome Visiting. In Early Childhood Devel- H opment, Office of the Administration of for 231 Children’s Budge 2016. In First Focus, 210 The Improving Child Nutrition and Ed- Children and Families. http://www.acf.hhs. 2016.https://firstfocus.org/resources/ ucation Act. In Education & the Workforce gov/programs/ecd/programs/home-vis- report/childrens-budget-2016/ (ac- Committee, 2016. http://edworkforce. iting (accessed July 2015). cessed August 2016). house.gov/uploadedfiles/bill_sum- mary_-_improving_child_nutrition_and_ 222 awthorne A and Arons J. There’s No C 232 First Focus, 2016. education_act.pdf (accessed May 2016). Place Like Home. Home Visiting can Sup- 233 Department of Education. Student Finan- port Pregnant Women and new Parents. 211 Institute of Medicine. Early Childhood Obe- cial Assistance. Fiscal Year 2017 Budget Washington, D.C.: Center for American sity Prevention Policies. Washington, D.C.: Request. In U.S. Department of Education, Progress, 2010. http://cdn.american- The National Academies Press, 2011. 2016. https://www2.ed.gov/about/ progress.org/wp-content/uploads/is- overview/budget/budget17/justifica- 212 Legislation & Policy. Existing Legislation. sues/2010/01/pdf/home_visitation.pdf tions/o-sfa.pdf (accessed August 2016). In United States Breastfeeding Committee, (accessed May 2016). 2016. http://www.usbreastfeeding. 234 U.S. Department of Agriculture. FY 2017 223 urse-Family Partnership: Benefits and N org/p/cm/ld/fid=25 (accessed May Budget Summary. In U.S. Department of Cots. In Nurse-Family Partnership, 2014. 2016). Agriculture, 2016. http://www.obpa.usda. http://www.nursefamilypartnership. gov/budsum/fy17budsum.pdf (accessed 213 Information provided to TFAH from CMS. org/assets/PDF/Fact-sheets/NFP_Bene- August 2016). fit_Cost.aspx (accessed May 2016). 130 TFAH • RWJF • StateofObesity.org 235 First Focus, 2016. 245 enters for Disease Control and Preven- C 254 Taber DR, Chriqui JF, Perna FM, et al. tion. Health and Academic Achievement. Weight status among adolescents in states 236 resident Obama Releases Fiscal Year 2017 P Atlanta, GA: Centers for Disease Control that govern competitive food nutrition Budget Request: A Statement from The and Prevention, Division of Population content. Pediatrics, 130: 437-444, 2012. National Campaign to Prevent Teen and Health, 2014. Unplanned Pregnancy. In The National Cam- 255 arson N and Story M. Are Competitive L paign, 2016. https://thenationalcampaign. 246 .S. Department of Health and Human U foods sold at schools making our children org/press-release/president-obama-releas- Services. Physical Activity Guidelines Ad- fat? Health Affairs, 29(3): 430?435, 2010. es-fiscal-year-2017-budget-request (accessed visory Committee Report. Washington, DC: 256 Fox MK, Gordon A, Nogales R, et al. August 2016). U.S. Department of Health and Human Availability and consumption of compet- Services, 2008. 237 Rausch R. Nutrition and academic per- itive foods in US public schools. J Ameri- formance in school-age children the 247 hysical Activity Guidelines for Ameri- P can Diet Ass, 109(suppl 2): S57?S66, 2009. relation to obesity and food insufficiency. cans Midcourse Report Subcommittee 257 Cullen KW and Zakeri I. Fruits, vegeta- J Nutr Food Sci, 3(190), 2013. http:// of the President’s Council on Fitness, bles, milk, and sweetened beverages con- www.omicsonline.org/nutrition-and-ac- Sports & Nutrition. Physical Activity sumption and access to à la carte/snack ademic-performance-in-school-age-chil- Guidelines for Americans Midcourse Report: bar meals at school. Am J Public Health, dren-the-relation-to-obesity-and-food-in- Strategies to Increase Physical Activity Among 94(3): 463–467, 2004. sufficiency-2155-9600.1000190.pdf Youth. Washington, D.C.: U.S. Depart- (accessed May 2016). ment of Health and Human Services, 258 Kubik MY, Lytle LA, Hannan PJ, et al. 2012. http://www.health.gov/paguide- The association of the school food envi- 238 Sabia JJ. The effect of body weight on ad- lines/midcourse/pag-mid-course-report- ronment with dietary behaviors of young olescent academic performance. Southern final.pdf (accessed June 2013). adolescents. Am J Public Health, 93(7): Economic Journal, 73(4):871-900, 2007. 1168?1173, 2003. 248 hysical Activity Guidelines for Ameri- P 239 Jaswal R and Susma J. Obesity and aca- cans Midcourse Report Subcommittee 259 Kakarala M, Keast DR, and Hoerr S. demic performance in adolescents. Int J of the President’s Council on Fitness, Schoolchildren’s consumption of com- Edu Sci, 4(3): 275-278, 2012. Sports & Nutrition, 2012. petitive foods and beverages, excluding à 240 Datar A and Sturm R. Childhood over- la carte. J School Health, 80(9): 429?435, 249 enters for Disease Control and Pre- C weight and elementary school outcomes. 2010. vention. The Association Between International Journal of Obesity, 30(9): School-Based Physical Activity, Including 260 Rovner AJ, Nansel TR, Wang J, et al. 1449-1460, 2006. Physical Education, and Academic Per- Food sold in school vending machines is 241 Gable S, Krull JL, and Chang Y. Boys’ formance. Atlanta, GA: U.S. Department associated with overall student dietary in- and girls’ weight status and math perfor- of Health and Human Services, 2010. take. J Adolescent Health, 48(1): 13?19, mance from kindergarten entry through 2011. 250 ctive Living Research. Active Edu- A fifth grade: A mediated analysis. Child cation: Physical Education, Physical 261 Schwartz MB, Movak SA, and Fiore SS. Development, 83(5): 1822-1839, 2012. Activity and Academic Performance, An The impact of removing snacks of low 242 Yau PL, Castro MG, Tagani A, et al. Active Living Research Brief. San Diego, nutritional value from middle schools. Obesity and metabolic syndrome and CA: Active Living Research, University Health Education & Behavior, 36(6): functional and structural brain im- of California, San Diego, 2009. http:// 999?1011, 2009. pairments in adolescence. Pediatrics, www.activelivingresearch.org/files/ALR_ 262 Chriqui JF, Turner L, Taber DR, Cha- 130(4):e856-e864, 2012. Brief_ActiveEducation_Summer2009.pdf loupka FJ. Association between district (accessed June 2013). 243 Donnelly JE, Greene JL, Gibson CA, et and state policies and US public elemen- al. Physical activity across the curriculum 251 aras H. Nutrition and Student Perfor- T tary school competitive food and bever- (PAAC): A randomized controlled trial mance at School. Journal of School Health, age environments. JAMA Pediatr, 167(8): to promote physical activity and diminish 75(6): 199–213, 2005. 714-722, 2013. http://archpedi.jamanet- overweight and obesity in elementary work.com/article.aspx?articleid=1696280 252 leason, PM and Dodd AH. School G school children. Preventive Medicine, (accessed May 2014). breakfast program but not school 49(4): 336-341, 2009. lunch program is associated with lower 263 Kids Safe and Healthful Foods Project, 244 Story M, Nanney MS, Schwartz MB. Body Mass Index. J Am Diet Assoc, 109(2 (2012). School Budgets, Student Health Schools and obesity prevention: Creat- Suppl): S118-28, 2009. to Benefit from Higher Nutrition Stan- ing school environments and policies dards. [Press Release]. http://www. 253 ang S, Schwartz MB, Shebi FM, et W to promote healthy eating and physical healthyschoolfoodsnow.org/school-bud- al. School breakfast and body mass activity. The Milbank Quarterly, 87(1): 71- gets-student-health-to-benefit-from-high- index: a longitudinal observational study 100, 2009. er-nutrition-standards/ (accessed June of middle school students. Pediatric Obe- 2013). sity, online publication DOI: 10.1111/ ijpo.12127, 2016. TFAH • RWJF • StateofObesity.org 131 264 Joshi A., Kalb M, Beery M. Going Local: 273 Turner L, Ohri-Vachaspati P, Powell 280 U.S. Government Accountability Office. Paths to Success for Farm to School Programs. L, et al. Improvements and disparities School Meal Programs: Competitive Foods Are Los Angeles, CA: Occidental College and in types of foods and milk beverages Available in Many Schools; Actions Taken Community Food Security Coalition, offered in elementary school lunches, to Restrict Them Differ by State and Locality. 2006. http://departments.oxy.edu/ 2006–2007 to 2013–2014. Prev Chronic Washington, D.C.: U.S. Government uepi/cfj/publications/goinglocal.pdf Dis, 13: E39., 2016. http://www.cdc. Accountability Office, 2004. http:// (accessed March 2009). gov/pcd/issues/2016/15_0395.htm (ac- www.gao.gov/new.items/d04673.pdf (ac- cessed May 2016). cessed May 2009). 265 Upstream Public Health. HB 2800: Ore- gon Farm to School and School Garden Policy. 274 ational School Lunch Program. In N 281 http://www.fns.usda.gov/school-meals/ May 2011. http://www.upstreampubli- Food and Nutrition Service, U.S. Department school-meal-certification-data (accessed chealth.org/F2SHIA (accessed August of Agriculture. http://www.fns.usda.gov/ August 2016). 2012). sites/default/files/NSLPFactSheet.pdf 282 Schwartz MB, Henderson KE, Read (accessed April 2015). 266 Luepker RV, Perry CL, McKinlay SM, et M, et al. New school meal regulations al. Outcomes of a field trial to improve 275 he School Breakfast Program. In Food T increase fruit consumption and do not children’s dietary patterns and physical and Nutrition Service, U.S. Department of Ag- increase total plate waste. Childhood Obe- activity. The Child and Adolescent Trial riculture. http://www.fns.usda.gov/sites/ sity, 11(3): 242-247, 2015. http://online. for Cardiovascular Health. CATCH default/files/SBPfactsheet.pdf (accessed liebertpub.com/doi/pdfplus/10.1089/ collaborative group. JAMA, 275(10): April 2015). chi.2015.0019 (accessed June 2015). 768–778, 1996. 276 hildren from families with incomes C 283 http://healthyeatingresearch. 267 Whitt-Glover MC, Porter AT, Yancey at or below 130 percent of the poverty org/2016/01/new-research-students-se- TK, et al. Do Short Physical Activity level are eligible for free meals, and lecting-healthier-school-meals-with-updat- Breaks in Classrooms Work? San Diego, those with annual incomes between 130 ed-national-school-nutrition-standards/ CA: Active Living Research, 2013. http:// percent (around $30,615 for a family of 284 United States Department of Agricul- www.rwjf.org/en/research-publications/ four) and 185 percent (around $43,568 ture, Food and Nutrition Service, 2015. find-rwjf-research/2013/02/do-short- for a family of four) of the poverty level physical-activity-breaks-in-classrooms- are eligible for reduced-price meals (as 285 U.S. Department of Agriculture, 2016, work-.html (accessed June 2013). of the 2013 to 2014 school year). Chil- Press Release, No. 0172.16. dren from families above 185 percent of 268 Gortmaker SL, Lee RM, Mozaffarian RS, 286 U.S. Department of Agriculture, Food FPL may participate and pay full price.  et al. Effect of an after-school interven- and Nutrition Service. Evaluation of the tion on increases in children’s physical 277 uitts S. Research Bulletin: A New Major- S Fresh Fruit and Vegetable Program—Sum- activity. Medicine & Science in Sports & ity — Low Income Students Now a Majority mary. Alexandria, VA: U.S. Department Exercise, 44(3): 450–57, 2012. in the Nation’s Public Schools. Atlanta, GA: of Agriculture, 2013. http://www.fns. Southern Education Foundation, 2015. usda.gov/sites/default/files/FFVP_Sum- 269 Active Living Research. Promoting Phys- http://www.southerneducation.org/ mary.pdf (accessed June 2015). ical Activity Through the Shared Use of getattachment/4ac62e27-5260-47a5- School and Community Recreational Re- 287 Food Distribution: DoD Fresh Fruit and 9d02-14896ec3a531/A-New-Majority- sources. San Diego, CA: Active Living Re- Vegetable Program. In U.S. Department 2015-Update-Low-Income-Students-Now. search, 2012. http://activelivingresearch. of Agriculture, Food and Nutrition Service. aspx (accessed April 2015). com/files/ALR_Brief_SharedUse_ http://www.fns.usda.gov/fdd/dod-fresh- April2012.pdf (accessed June 2013). 278 nited States Department of Agriculture, U fruit-and-vegetable-program (accessed (2013). Agriculture Secretary Vilsack June 2015). 270 National Center for Safe Routes to School. Highlights New “Smart Snacks in School” How Children Get to School: School Travel Pat- 288 Special Milk Program Fact Sheet. In U.S. Standards; Will Ensure School Vending terns From 1969-2009. Chapel Hill, N.C.: Department of Agriculture, Food and Nutri- Machines, Snack Bars Include Healthy Safe Routes to School, 2011. http:// tion Service. http://www.fns.usda.gov/ Choices. [Press Release]. http://www.usda. www.saferoutesinfo.org/sites/default/ sites/default/files/SMP_Quick_Facts_0. gov/wps/portal/usda/usdahome?conten- files/resources/NHTS_school_travel_re- pdf (accessed June 2015). tid=2013/06/0134.xml (accessed May 2014). port_2011_0.pdf (accessed June 2015). 289 The Farm to School Census: National 279 nited States Department of Agriculture. U 271 hriqui JF, et al. The Impact of State Safe C Overview. In U.S. Department of Agricul- National School Lunch Program and Routes to School-related Laws on Elementary ture, Food and Nutrition Service. http:// School Breakfast Program: Nutrition Stan- School Walking and Biking Policies and Prac- www.fns.usda.gov/farmtoschool/cen- dards for All Foods Sold in School as Re- tices. Chicago, IL: Bridging the Gap, 2011. sus#/ (accessed June 2015). quired by the Healthy, Hunger-Free Kids 272 High School YRBS. Youth Online. In Act of 2010; Interim Final Rule. Federal Reg- Centers for Disease Control and Prevention, ister, 78(125): 39068-39120, 2013. http:// https://nccd.cdc.gov/Youthonline/ www.gpo.gov/fdsys/pkg/FR-2013-06-28/ App/Default.aspx (accessed June 2016). pdf/2013-15249.pdf (accessed May 2014). 132 TFAH • RWJF • StateofObesity.org 290 Food Research and Action Center. Hun- 299 enate Agriculture Committee Passes S 307 ESSA Title IV and School Health. Fre- ger Doesn’t Take a Vacation: Summer Nutri- Bipartisan Child Nutrition Reautho- quently Asked Questions. In ASCD, tion Status Report 2014. Washington, D.C.: rization. In U.S. Senate Committee on 2016. http://www.ascd.org/ASCD/pdf/ Food Research and Action Center, 2015. Agriculture, Nutrition & Forestry, 2016. siteASCD/policy/ESSA-Title-IV-FAQ_ http://frac.org/pdf/2015_summer_nu- http://www.agriculture.senate.gov/ Mar32016.pdf (accessed May 2016). trition_report.pdf (accessed July2015). newsroom/rep/press/release/sen- 308 S. 1177-Every Student Succeeds Act. ate-agriculture-committee-passes-bipar- 291 Food Research and Action Center. Hun- 114th Congress (2015-1016). https:// tisan-child-nutrition-reauthorization ger Doesn’t Take a Vacation: Summer Nutri- www.gpo.gov/fdsys/pkg/BILLS- (accessed May 2016). tion Status Report 2014. Washington, D.C.: 114s1177enr/pdf/BILLS-114s1177enr. Food Research and Action Center, 2015. 300 .S. Senate Committee on Agriculture, U pdf (accessed May 2016). http://frac.org/pdf/2015_summer_nu- Nutrition & Forestry, 2016. 309 Klein A. “ESEA Reauthorization: The trition_report.pdf (accessed July 2015). 301 chool Nutrition Association, (2016). S Every Student Succeeds Act Explained.” 292 Baranowski T, O’Connor T, Johnston C, Discussion Draft of House Child Nutri- Education Week November 30, 2015. et al. School year versus summer differ- tion Reauthorization Bill Completed. http://blogs.edweek.org/edweek/ ences in child weight gain: a narrative [Press Release.] https://schoolnutrition. campaign-k-12/2015/11/esea_reautho- review. Child Obes, 10(1):18-24, 2014. org/News/DiscussionDraftOfHouseCN- rization_the_every.html (accessed May ReauthorizationBillCompleted/ (ac- 2016). 293 ranckle R, Adler R, and Davison K. Ac- F cessed May 2016). celerated weight gain among children 310 ASCD, 2016. during summer versus school year and re- 302 RAC Analysis of the House Education F 311ASCD, 2016. lated racial/ethnic disparities: a systematic & Workforce Committee’s Majority Child review. Prev Chronic Dis, 11:E101, 2014. Nutrition Reauthorization Bill. In Food 312 Every Student Succeeds Act. Highlights Research & Action Center, 2016. http:// Regarding the Inclusion of Promise 294 von Hippel PT, Powell B, Downey DB, frac.org/frac-analysis-of-the-house-ed- Neighborhoods. In PolicyLink, no date. Rowland NJ. The effect of school on ucation-workforce-committees-majori- https://www.policylink.org/sites/de- overweight in childhood: gain in body ty-child-nutrition-reauthorization-bill/ fault/files/Highlights%20regarding%20 mass index during the school year and (accessed May 2016). the%20inclusion%20of%20Promise%20 during summer vacation. Am J Public Neighborhoods%20in%20the%20 Health, 97(4):696-702, 2007. 303 .R. 5003-Improving Child Nutrition H Every....pdf (accessed May 2016). and Education Act of 2016. 295 H.R. 5003-Improving Child Nutri- 313 Executive Office of the President. Every tion and Education Act of 2016. 304 epartment of Agriculture, Food and D Student Succeeds Act: A Progress Report In Congress.gov, 2016. https:// Nutrition Service. Child nutrition pro- on Elementary and Secondary Education. www.congress.gov/bill/114th-con- grams — income eligibility guidelines. Washington, D.C.: White House, 2015. gress/house-bill/5003?q=%7B%- Federal Register 80(61): 17026-17027. https://www.whitehouse.gov/sites/ 22search%22%3A%5B%22Improv- https://www.gpo.gov/fdsys/pkg/FR- whitehouse.gov/files/documents/ ing+Child+Nutrition+Integrity+and+Ac- 2015-03-31/pdf/2015-07358.pdf. ESSA_Progress_Report.pdf (accessed cess+Act%22%5D%7D&resultIndex=1 305 ohen JFW, Gorski MT, Hoffman JA, et C May 2016). (accessed May 2016). al. Healthier standards for school meals 314 .S. Department of Education. The U 296 U.S. Senate Committee on Agriculture, and snacks: impact on school food reve- Fiscal Year 2017 Education Budget Nutrition & Forestry. Improving Child nue and lunch participation rates. Amer Summary and Background Information. Nutrition Integrity and Access Act of J Prev Medicine, [Epub ahead of print], Washington, D.C.: U.S. Department of 2016. http://edworkforce.house.gov/ 2016. http://www.ajpmonline.org/ Education, 2016. http://www2.ed.gov/ uploadedfiles/improving_child_nutri- article/S0749-3797(16)30021-6/abstract about/overview/budget/budget17/ tion_and_education_act_of_2016.pdf (accessed May 2016). summary/17summary.pdf (accessed (accessed May 2016). 306 urke L. The Every Student Succeeds Act: B May 2016). 297 School Nutrition Association, (2015). More Programs and Federal Intervention in 315 U.S. Department of Education, 2016. Agreement Reached on School Nutrition Pre-K and K-12 Education. Backgrounder Standards. [Press Release.] https:// No. 3085. Washington, D.C.: The Heri- 316 entzell DR. “Connecticut Launches W schoolnutrition.org/News/Agreemen- tage Foundation, 2015. http://www.her- New Generation Accountability System tReachedOnSchoolNutritionStandards/ itage.org/research/reports/2015/12/ Designed to Provide More Holistic Picture (accessed May 2016). the-every-student-succeeds-act-more-pro- of School Performance.” Connecticut grams-and-federal-intervention-in-pre-k- State Department of Education (March 298 FRAC Analysis of Child Nutrition Re- and-k12-education. 2, 2016). http://www.sde.ct.gov/sde/ authorization Bill. In Food Research & lib/sde/pdf/pressroom/ct_launches_ Action Center, 2016. http://frac.org/ next_generation_accountability_sys- frac-analysis-of-child-nutrition-reauthori- tem_030216.pdf (accessed May 2016). zation-bill/ (accessed May 2016). TFAH • RWJF • StateofObesity.org 133 317 ational Models: The Children’s Aid N 327 OST Coalition: History, Vision, Goals. H 337 Hudson W. “For Schoolchildren, Society Community Schools. In Coalition In National Institute on Out-of-School Time, Where’s the Water?” CNN April 18, for Community Schools, 2016. http://www. no date. http://www.niost.org/About/ 2011. http://www.cnn.com/2011/ communityschools.org/aboutschools/na- history-and-vision (accessed May 2016). HEALTH/04/18/water.school.children/ tional_models.aspx#1 (accessed May 2016). (accessed April 2011). 328 tate Public Health Actions to Prevent and S 318 U.S. Department of Agriculture, Food Control Diabetes, Heart Disease, Obesity 338 Kant AK and Graubard BI. Contributors and Nutrition Service. 7 CFR Parts 210 and Associated Risk Factors and Promote of water intake in US children and ad- and 220. Local School Wellness Policy School Health. In U.S. Centers for Disease olescents: associations with dietary and Implementation Under the Healthy, Control and Prevention. http://www.cdc. meal characteristics—National Health Hungry-Free Kids Act of 2010. Federal gov/chronicdisease/about/state-public- and Nutrition Examination Survey 2005- Register 79(38): 10693-10706, 2014. health-actions.htm (accessed June 2015). 2006. Am J Clin Nutr, 92(4): 887-96, 2010. http://www.fns.usda.gov/sites/default/ 329 enters for Disease Control and Pre- C 339 http://www.cdc.gov/pcd/is- files/Local_School_Wellness_Proposed_ vention. School Health Guidelines to sues/2016/16_0108.htm Rule_022614.pdf (accessed May 2016). Promote Healthy Eating and Physical 340 Centers for Disease Control and Preven- 319 U.S. Department of Agriculture, (2016). Activity. Morbidity and Mortality Weekly tion (CDC). Increasing Access to Drinking USDA Announces Efforts to Make Report, 60(5): 2011. http://www.cdc.gov/ Water in Schools. Atlanta, GA: U.S. Depart- School Environments Healthier. [Press mmwr/pdf/rr/rr6005.pdf (accessed ment of Health and Human Services, Release, No. 0172.16]. June 2015). 2014. http://www.cdc.gov/healthy- 320 hriqui JF, Resnick EA, Schneider L, et C 330 chool Health Index. In U.S. Centers for S schools/npao/pdf/Water_Access_in_ al. School District Wellness Policies: Evalu- Disease Control and Prevention. http:// Schools.pdf (accessed May 2016). ating Progress and Potential for Improving www.cdc.gov/healthyyouth/shi/index. 341 Ungar L. “Lead Taints Drinking Water Children’s Health Five Years after the Federal htm (accessed June 2015). in Hundreds of Schools, Day Cares Mandate. Volume 3. Chicago, IL: Bridging 331 008 Physical Activity Guidelines for 2 Across USA.” USA Today March 17, 2016. the Gap Program, Health Policy Center, Americans. In U.S. Department of Health http://www.usatoday.com/story/news/ Institute for Health Research and Policy, and Human Services. http://www.health. nation/2016/03/17/drinking-water-lead- University of Illinois at Chicago, 2013. gov/paguidelines/guidelines/summary. schools-day-cares/81220916/ (accessed 321 U.S. Department of Agriculture, 2016, aspx (accessed June 2015). May 2016). Press Release, No. 0172.16. 332 enters for Disease Control and Preven- C 342 CDC, 2014. 322 State-Level School Food Marketing tion. Comprehensive school physical activity 343 Community Water Center and Environ- Polices. Oakland, CA: ChangeLab Solu- programs: A guide for schools. Atlanta, GA: mental Justice Coalition for Water. Are tions, 2014. U.S. Department of Health and Human We Providing Our Schools Kids Safe Drinking Services, 2013. 323 Piekarz E, Schermbeck R, Young SK, et Water? An Analysis of California’s Schools al. School District Wellness Policies: Evalu- 333 outh Physical Activity Guidelines Y Impacted by Unsafe Drinking Water. Vaselia, ating Progress and Potential for Improving Toolkit. In CDC, http://www.cdc.gov/ CA: Community Water Center, 2016. Children’s Health Eight Years after the Federal healthyyouth/physicalactivity/guide- https://d3n8a8pro7vhmx.cloudfront. Mandate. School Years 2006-2007 through lines.htm (accessed July 2015). net/communitywatercenter/pages/824/ 2013-2014. Vol 4. Chicago, IL: Bridging attachments/original/1462465769/ 334 bout School-Based Health Centers. In A the Gap Program and The National Well- CWC_MCL_05.05.16b.pdf?1462465769 California School-Based Health Alliance. ness Policy Study, Institute for Health (accessed May 2016). http://www.schoolhealthcenters.org/ Research and Policy, University of Illinois school-health-centers-in-ca/ (accessed 344 Loew T. “Lead Found in Drinking Water at Chicago, 2016. www.go.uic.edu/NWP- October 2015). in 10 Oregon Schools.” Statesman Journal Sproducts (accessed July 2016). March 23, 2016. http://www.states- 335 edicaid Payment for Services Pro- M 324 HealthMPowers: About Us. In HealthM- manjournal.com/story/tech/science/ vided without Charge (Free Care). Powers, 2016. http://healthmpowers. environment/2016/03/20/school-drink- In Centers for Medicare and Medicaid org/about-us-3-4/ (accessed May 2016). ing-water/81660898/ (accessed May Services. http://www.medicaid.gov/ 2016). 325 Georgia’s HealthMPowers SNAP-Ed Re- federal-policy-guidance/downloads/ port, 014-2015. In HealthMPowers, 2016. smd-medicaid-payment-for-services-pro- 345 Pohle A. “Four Boston Public Schools https://drive.google.com/file/d/0BzD- vided-without-charge-free-care.pdf (ac- Test Positive for Elevated Lead Levels in m2a6qKX9nc3Voa0p0TTdsU2M/view cessed June 2015). Drinking Water.” Boston.com News April (accessed May 2016). 26, 2016. https://www.boston.com/ 336 olabianchi N, Turner L, Hood NE, C news/education/2016/04/26/schools-el- 326 Results. In HealthMPowers, 2016. http:// Chaloupka FJ, Johnston LD. Availability evated-lead-levels (accessed May 2016). healthmpowers.org/results/results-3/ of drinking water in US public school (accessed May 2016). cafeterias. A BTG Research Brief. Chi- cago, IL: Bridging the Gap, 2014. 134 TFAH • RWJF • StateofObesity.org 346 Santora M. “Christie Orders Lead Tests 356 iekarz E, Lin W, Chriqui JF. Smart P 366 Lieberman M, Pedroso M, and Zimmer- for All New Jersey Public Schools.” New Snacks Fundraiser Exemption State Policies. man S. Making Strides, 2016. State Report York Times May 2, 2016. http://www. Quarterly Report. Updated March 1, Cards on Support for Walking, Bicycling, nytimes.com/2016/05/03/nyregion/ 2016. Chicago, IL: University of Illinois and Active Kids and Communities. Safe christie-orders-lead-tests-for-all-new-jer- at Chicago, Institute for Health Research Routes to School National Partnership, sey-public-schools.html (accessed May and Policy, 2016. http://www.ihrp. 2016. http://saferoutespartnership.org/ 2016). uic.edu/files/Fundraiser%20Exemp- resources/2016-state-report-cards (ac- tions_1Mar16.pdf (accessed April 2016). cessed May 2016). 347 Levy D. “Advocates: Testing Drinking Water in Schools a Must.” WNYT.com 357 0 State Analysis of Competitive Foods 5 367 National Prevention Council. Annual June 7, 2016. http://wnyt.com/news/ Laws Conducted by Voices For Health Status Report. Washington, D.C.: U.S. schools-drinking-water-testing/4162779/ Kids, September 2014. Department of Health and Human Ser- (accessed August 2016). vices, Office of the Surgeon General, 358 ohnston LD, O’Malley PM, Terry-McEl- J 2014. http://www.surgeongeneral.gov/ 348 Wines M, McGeehan P, and Schwartz rath YM, et al. School Policies and Practices priorities/prevention/2014-npc-status-re- J. “Schools Nationwide Still Grapple to Improve Health and Prevent Obesity: port.pdf (accessed May 2016). with Lead in Water.” The New York Times National Secondary School Survey Results, March 26, 2016. http://www.nytimes. School Years 2006–07 through 2009 –10. 368 Lieberman M, et al., 2016. com/2016/03/27/us/schools-nation- Volume 2. Ann Arbor, MI: Bridging the 369 Model Joint Use Agreement Resources: wide-still-grapple-with-lead-in-water.html Gap Program, Survey Research Center, Increasing physical activity by opening (accessed August 2016). Institute for Social Research, 2012. up school grounds. In Change Lab Solu- 349 School Breakfast Program Policy. In 359 hape America, American Heart Asso- S tions. http://changelabsolutions.org/ Center for Best Practices, 2015. https://best- ciation, Voices for Healthy Kids. 2016 publications/model-JUAs-national (ac- practices.nokidhungry.org/school-break- Shape of the Nation. Status of Physical cessed May 2013). fast/school-breakfast-policy-0 (accessed Education in the USA. Reston, VA: Shape 370 Cornwall G. “Playgrounds for All.” May 2016). America, 2016. http://www.shapeamerica. CITYLAB April 29, 2016. http://www. org/advocacy/son/2016/upload/Shape- 350 Center for Best Practices, 2015. citylab.com/navigator/2016/04/play- of-the-Nation-2016_web.pdf grounds-for-all/480597/ (accessed Mab 351 Food Research & Action Center. School 360 hape America, 2016. S 2016). Breakfast Scorecard. 2014-205 School Year. Washington, D.C.: Food Research & 361 . Segal (personal communication, April L 371 Ruggieri DG and Bass SB. A Comprehen- Action Center, 2016. http://frac.org/ 22, 2016: Education Commission of the sive Review of School-Based Body Mass pdf/School_Breakfast_Scorecard_ States. Response to information request Index Screening Programs and Their SY_2014_2015.pdf (accessed April 2016). on which states have recess policies). Implications for School Health: Do the Controversies Accurately Reflect the Re- 352 2016 State Legislative Summary: Jan- 362 hillon P, Evenson KR, Vaughn A, et C search? J School Health 85(1): 61-72, 2014. uary 1 through March 30. In School al. A Systematic Review of Interventions Nutrition Association, 2016. https:// for Promoting Active Transportation to 372 State School Health Policy Database. schoolnutrition.org/uploadedFiles/ School. International Journal of Behavioral Screening for Health Conditions. In Legislation_and_Policy/State_and_ Nutrition and Physical Activity, 8(10): National Association of State Boards of Ed- Local_Legislation_and_Regulations/ 2011. http://www.ijbnpa.org/con- ucation, 2014. http://www.nasbe.org/ Jan-Mar2016StateLegislativeQuarterlyRe- tent/8/1/10 (accessed April 2013). healthy_schools/hs/bytopics.php?topi- port.pdf (accessed April 2016). cid=4100 (accessed May 2016). 363 endel AM and Dannenberg AL. Revers- W 353 Community Food Systems. Final Results ing declines in walking and bicycling to 373 Obesity in Mississippi. A Report Com- of the 2015 Farm to School Census are school. Preventive Medicine, 48(6): 513- piled by the POWER Initiative. In Mis- In! In U.S. Department of Agriculture, Food 515, 2009. sissippi State Department of Health, 2013. and Nutrition Service, 2016. http://www. http://msdh.ms.gov/msdhsite/_static/ 364 umbaugh E and Frank L. Traffic Safety D fns.usda.gov/farmtoschool/farm-school resources/3593.pdf (assessed May 2016). and Safe Routes to Schools: Synthesizing (accessed April 2016). the Empirical Evidence. Transportation 374 Shape America, 2016. 354 U.S. Department of Agriculture, Food Research Record, 2009(1): 89-97, 2007. 375 Linchey J and Madsen KA. State require- and Nutrition Service, 2016. 365 afe Routes to School—50-State Review. S ments and recommendations for school- 355 ational Farm to School Network. State N In Public Health Law Center, August 2014. based screenings for Body Mass Index or Farm to School Legislative Survey, 2002-2014. http://publichealthlawcenter.org/re- Body Composition, 2010. Prev Chronic Dis Washington, D.C.: National Farm to sources/safe-routes-school-50-state-review 9(5): A101. http://www.cdc.gov/pcd/ School Network, 2015. http://www.farm- (accessed June 2016). issues/2011/sep/11_0035.htm (accessed toschool.org/policy (accessed May 2016). May 2016). TFAH • RWJF • StateofObesity.org 135 376 http://www.nationalacademies.org/ 385 ransportation Alternatives Program T 395 Wells HF and Buzby JC. Dietary Assess- hmd/Reports/2016/Assessing-Preva- (TAP) 2016 Apportionments. In Federal ment of Major Trends in U.S. Food Consump- lence-and-Trends-in-Obesity.aspx Highway Administration, U.S. Department tion, 1970-2005. Economic Information of Transportation, 2016. http://www. Bulletin No. 33. Washington, D.C.: U.S. 377 American Academy of Pediatrics. Policy fhwa.dot.gov/environment/transporta- Department of Agriculture, Economic Statement: Prevention of Pediatric Over- tion_alternatives/funding/apportion- Research Service, 2008. weight and Obesity. Pediatrics, 112(2): ments_obligations/tap_appor_ob_2016. 424-430, 2003 and Murray R. Response 396 Drewnowski A and Rehm CD. Consump- cfm (accessed August 2016). to ‘Parents’ Perceptions of Curricular tion of added sugars among US children Issues Affecting Children’s Weight in Ele- 386 hildren’s Budge 2016. In First Focus, C and adults by food purchase location and mentary Schools. Journal of School Health, 2016. https://firstfocus.org/resources/ food source. Am J Clin Nutr, 100(3): 901- 77(5): 223-230, 2007. report/childrens-budget-2016/ (ac- 907, 2014. http://ajcn.nutrition.org/con- cessed August 2016). tent/early/2014/07/16/ajcn.114.089458. 378 Institute of Medicine. Preventing Child- abstract (accessed July 2016). hood Obesity: Health in the Balance. Wash- 387 rewnowski A. Obesity, diets, and social D ington, D.C.: The National Academies inequalities. Nutr Rev, 67(Suppl 1): S36- 397 Ogden CL, Kit BK, Carroll MD, et al. Press, 2005. S39, 2009. Consumption of sugar drinks in the United States, 2005-2008. NCHS Data 379 ihiser AJ, Lee SM, Wechsler H, et al. N 388 rewnowski A and Specter SE. Poverty and D Brief, No. 71, 2011. http://www.cdc.gov/ Body mass index measurement in schools. Obesity: the role of energy density and en- nchs/data/databriefs/db71.pdf (ac- J Sch Health, 77(10): 651-671, 2007. ergy costs. Am J Clin Nutr, 79(1): 6-16, 2004. cessed July 2016). 380 WJF Commission to Build a Healthier F 389 rewnowski A and Darmon N. The eco- D 398 Kit BK, et al, 180-188, 2013. America. Time to Act: Investing in the nomics of obesity: dietary energy density Health of Our Children and Communities. and energy cost. Am J Clin Nutr, 82(Suppl 399 Han E and Powell LM. Consumption Princeton, NJ: Robert Wood Johnson 1): S265-S273, 2005. patterns of sugar-sweetened beverages Foundation, 2014. http://www.rwjf. in the United States. J Acad Nutr Diet 390 Coleman-Jensen A, et al., ERR-173, 2014. org/content/dam/farm/reports/re- 113(1):43-53, 2013. ports/2014/rwjf409002 (accessed May 391 .S. Department of Agriculture and U 400 Loss-Adjusted Food Availability: Spread- 2014). U.S. Department of Health and Human sheets—Calories. In U.S. Department of Ag- Services. Dietary Guidelines for Americans, 381 FWJF Commission to Build a Healthier riculture, Economic Research Service. http:// 2010. 7th Edition. Washington, DC: America, 2014. www.ers.usda.gov/Data/foodconsump- U.S. Government Printing Office, 2010. tion/spreadsheets/foodloss/Calories. 382 he Four Dimensions of Chronic Disease T http://www.cnpp.usda.gov/sites/de- xls#Totals!a1 (accessed March 5, 2010). Prevention: Working Toward Healthy fault/files/dietary_guidelines_for_ameri- People in Healthy Communities. In Cen- cans/PolicyDoc.pdf (accessed May 2015). 401 National Center for Chronic Disease ters for Disease Control and Prevention, 2015. Prevention and Health Promotion. State 392 ood Availability (Per Capita) Data System: F http://www.cdc.gov/chronicdisease/ Indicator Report on Fruits and Vegetables, Summary Findings. Compiled by ERS pdf/four-domains-factsheet-2015.pdf (ac- 2013. Atlanta, GA: Centers for Disease using data from USDA, Center for Nutri- cessed April 2015). Control and Prevention, 2013. http:// tion Policy and Promotion. Data as of Feb- www.cdc.gov/nutrition/downloads/ 383 Community Development Financial ruary 2015. In U.S. Department of Agriculture, state-indicator-report-fruits-vegeta- Institutions Fund. FY 2017 President’s Economic Research Service, 2015. http://www. bles-2013.pdf (accessed July 2015). Budget, 2016. https://www.treasury. ers.usda.gov/data-products/food-availabil- gov/about/budget-performance/ ity-(per-capita)-data-system/summary-find- 402 Gutherie J, Lin GH, Okrent A, et al. CJ17/13.%20CDFI%20FY%20 ings.aspx (accessed May 2015). Americans’ Food Choices at Home and 2017%20CJ.PDF (accessed August 2016). Away: How Do They Compare With Rec- 393 ortion Distortion. In National Heart, P ommendations. Washington, D.C.: U.S. 384 Department of the Treasury. Commu- Blood, and Lung Institute. http://www. Department of Agriculture, Economic nity Development Financial Institution nhlbi.nih.gov/health/educational/ Research Service, 2013. http://www.ers. Funds. Funding Opportunity Title: wecan/eat-right/portion-distortion.htm usda.gov/amber-waves/2013-february/ Amended Notice of Allocation Availabil- (accessed May 2015). americans-food-choices-at-home-and- ity (NOAA) for the Combined Calendar 394 .S. Department of Agriculture and U away.aspx#.UWMSp5PvuCk (accessed Year (CY) 2015-2016 Allocation Round U.S. Department of Health and Human April 2013). of the New Markets Tax Credit (NMTC) Services. Dietary Guidelines for Americans, Program. Federal Register, 81(76)23356, 403 2015 Restaurant Association Pocket 2010. 7th Edition. Washington, DC: 2016. https://www.cdfifund.gov/Docu- Factbook. In National Restaurant Associa- U.S. Government Printing Office. 2010. ments/2015%20NMTC%20NOAA%20 tion, 2015. https://www.restaurant.org/ http://www.cnpp.usda.gov/sites/de- Amendment.pdf (accessed August 2016). Downloads/PDFs/News-Research/re- fault/files/dietary_guidelines_for_ameri- search/Factbook2015_LetterSize-FINAL. cans/PolicyDoc.pdf (accessed May 2015). pdf (accessed May 2016). 136 TFAH • RWJF • StateofObesity.org 404 Gutherie J, et al., 2013. 415 ctive Living Topics. In Active Living A 424 Bridging the Gap and Salud America!, Research, 2016. http://www.activelivin- 2013. 405 Nutrition Labeling at Fast-Food and gresearch.org/audiences/about-advocat- Other Chain Restaurants. In Center 425 Bridging the Gap and Salud America!, ing-active-living (accessed April 2015). for Science in the Public Interest. http:// 2013. www.cspinet.org/nutritionpolicy/Nutri- 416 ommittee on Physical Activity, Health, C 426 Ver Ploeg M, Breneman V, Dutko P, et al. tion_Labeling_Fast_Food.pdf (accessed Transportation, and Land Use. Does Access to Affordable and Nutritious Food: Up- April 2013). the Built Environment Influence Physical dated Estimates of Distance to Supermarkets Activity? Examining the Evidence — Special 406 Chandon P and Wansink B. The bias- Using 2010 Data, ERR-143, U.S. Depart- Report 282. Washington, D.C.: National ing health halos of fast-food restaurant ment of Agriculture, Economic Research Academy of Sciences, 2005. http:// health claims: lower calorie estimates Service, 2012. http://www.ers.usda.gov/ books.nap.edu/catalog.php?record_ and higher side-dish consumption inten- media/956784/err143.pdf (accessed id=11203 (accessed April 2013). tions. Journal of Consumer Research, 34(3): April 2015). 301–314, 2007. 417 rank LD, Schmid TL, Sallis JF, et al. F 427 Bridging the Gap and Salud America! Linking Objectively Measured Physical 407 urton S, Creyer E, Kees J, et al. Attack- B Better Food in the Neighborhood and Activity with Objectively Measured Urban ing the obesity epidemic: the potential Latino Kids, Issue Brief June 2013. Form: Findings from SMARTRAQ. Am J health benefits of providing nutrition in- https://salud-america.org/sites/ Prev Med, 28(2S2): 117-125, 2005. formation in restaurants. American Journal saludamerica/files/Better-Food-in-the- of Public Health, 96(9): 1669–1675, 2006. 418 undle AG and Heymsfield SB. Can walk- R Neighborhood-Issue-Brief.pdf (accessed able urban design play a role in reducing March 2014). 408 Johnson W, Corrigan S, Schlundt D, et the incidence of obesity-related condi- al. Dietary restraint and eating behavior 428 Food Access Research Atlas. In U.S. De- tions? JAMA 315(20): 2175-2177. http:// in the natural environment. Addictive Be- partment of Agriculture, Economic Research jama.jamanetwork.com/article.aspx?arti- haviors, 15(3): 285–290, 1990. Service, 2016. http://www.ers.usda.gov/ cleid=2524165 (accessed May 2016). data-products/food-access-research-atlas. 409 Centers for Disease Control and Preven- 419 Armah N. “Making Equity Count in the aspx (accessed May 2016). tion, (2013). One in Five Adults Meet Built Environment.” NAACP Blog April 7, Overall Physical Activity Guidelines. 429 Dahl S, et al., 46-59, 2009. 2014. http://www.naacp.org/blog/entry/ [Press Release]. http://www.cdc.gov/ making-equity-count-in-the-built-environ- 430 Institute of Medicine. Food Marketing to media/releases/2013/p0502-physical-ac- ment (accessed May 2014). Children: Threat or Opportunity? Washing- tivity.html (accessed June 2013). ton, DC: National Academies Press, 2006. 420 ridging the Gap and Salud America! B 410 Physical Activity. In Healthy People.gov, Active Play and Latino Kids. Issue Brief, 431 Harris JL, Schwartz MB, Brownell KD, et 2014. https://www.healthypeople. July 2013 https://salud-america.org/ al. Fast food FACTS: Evaluating fast food gov/2020/topics-objectives/topic/physi- sites/salud-america/files/Active-Play-Is- nutrition and marketing to youth. Hartford, cal-activity/objectives (accessed July 2016). sue-Brief.pdf (accessed May 2016). CT: University of Connecticut, Rudd Cen- 411 Physical Activity Guidelines Advisory ter for Food Policy and Obesity, 2010. 421 ell JF, Wilson JS, and Liu GC. Neigh- B Committee. Physical Activity Guidelines borhood greenness and 2-year changes 432 Yancey AK, Cole BL, Brown R, et al. A Advisory Committee Report, 2008. Washing- in body mass index of children and cross-sectional prevalence study of eth- ton, DC: U.S. Department of Health and youth. American Journal of Preventive Medi- nically targeted and general audience Human Services, 2008. . cine, 35(6): 547-553, 2008. outdoor-related advertising. Milbank Q, 412 Carlson SA, Fulton JE, Pratt M, Yang 2009: 87(1): 155-184, 2009. 422 icycling and Walking in the United States, B Z, Adams EK. Inadequate physical 2014 Benchmarking Report. Washington, 433 Harris JL, Schwartz MB, Munsell CR, et activity and healthcare expenditures D.C.: Alliance for Biking & Walking, al. Fast Food FACTS 2013: Measuring Prog- in the United States. Progress in Cardio- 2014. http://www.aarp.org/content/ ress in Nutrition and Marketing to Children vascular Diseases, 2014. http://dx.doi. dam/aarp/livable-communities/docu- and Teens. Hartford, CT: Rudd Center org/10.1016/j.pcad.2014.08.002. ments-2014/2014-Bike-Walk-Benchmark- for Food Policy & Obesity, University of 4 13Carlson SA, Fulton JE, Pratt M, Yang Z, ing-Report.pdf (accessed May, 2016). Connecticut, 2013. http://fastfoodmar- Adams EK. Inadequate physical activity keting.org/media/fastfoodfacts_report. 423 ational Recreation and Park Associa- N and healthcare expenditures in the pdf (accessed August 2016). tion. Parks and Recreation in Underserved United States. Prog Cardiovasc Dis, 57:315- Areas: A Public Health Perspective. Ash- 434 Bridging the Gap and Salud America!, 323, 2015. . burn, VA: National Recreation and Park Healthier Marketing and Latino Kids, 414 Hesketh KR, Goodfellow L, Ekelund Association, 2013. http://www.nrpa. Issue Brief August 2013. https://sa- U, et al. Activity levels in mothers and org/uploadedFiles/nrpa.org/Publica- lud-america.org/sites/salud-america/ their preschool children. Pediatrics, tions_and_Research/Research/Papers/ files/Healthier-Marketing-Issue-Brief.pdf. 133(4):e973-e980, 2014. Parks-Rec-Underserved-Areas.pdf (ac- cessed May 2014). TFAH • RWJF • StateofObesity.org 137 435 Bridging the Gap and Salud America!, 444 inancing Healthy Food Options. In F 453 olicy Efforts & Impacts: Illinois. In Health P Healthier School Snacks and Latino Community Development Financial Institu- Food Access Portal, no date. http://healthy- Kids, Issue Brief May 2013. https:// tions Fund, U.S. Treasury. http://www. foodaccess.org/policy-efforts-and-impacts/ salud-america.org/sites/salud-amer- cdfifund.gov/what_we_do/Financing- state-and-local/illinois (accessed May 2015). ica/files/Healthier%20School%20 HealthyFoodOptions.asp?programID=13 454 olicy Efforts & Impacts: Illinois. In Health P Snacks%20-%20Issue%20Brief.pdf. (accessed April 2016) Food Access Portal, no date. http://healthy- 436 Bridging the Gap and Salud America!, 445 ffice of Community Services. Healthy O foodaccess.org/policy-efforts-and-impacts/ Issue Brief August 2013. Food Financing Initiative. In U.S. De- state-and-local/illinois (accessed May 2015). partment of Health & Human Services, Ad- 437 he Four Dimensions of Chronic Disease T 455 Healthy Food. Close to Home. In Fresh- ministration for Children & Families, 2016. Prevention: Working Toward Healthy works. http://www.cafreshworks.com/ http://www.acf.hhs.gov/programs/ocs/ People in Healthy Communities. In (accessed April 2015). programs/community-economic-de- Centers for Disease Control and Prevention. velopment/healthy-food-financing (ac- 456 New Orleans Fresh Food Retailer Ini- http://www.cdc.gov/chronicdisease/ cessed May 2016). tiative. In Hope Enterprise Corporation. pdf/four-domains-factsheet-2015.pdf (ac- http://www.hope-ec.org/index.php/ cessed April 2015). 446 apital Impact Partners. Financing for C new-orleans-fresh-food-retailer-initiative Health Foods. Policy Brief. Arlington, VA: 438 Cawley J, Meyerhoefer C. The medical (accessed April 2015). Capital Impact Partners, 2015. http:// care costs of obesity: an instrumental www.capitalimpact.org/wp-content/ 457 Healthy Food Financing Initiative. In variables approach. Journal of Health Eco- uploads/2015/12/2015-Capital-Impact_ Office of Community Services, U.S. nomics, 31(1): 219-230, 2012. HealthyFood_PolicyBrief.pdf. Department of Health and Human Services. 439 Healthy Eating Research. Bringing http://www.acf.hhs.gov/programs/ocs/ 447 Capital Impact Partners, 2015. Healthy Foods Home: Examining In- programs/community-economic-de- equalities in Access to Food Stores. 448 ew Markets Tax Credit Program. In N velopment/healthy-food-financing (ac- Minneapolis, MN: Healthy Eating Research, Community Development Financial Institu- cessed June 2015). 2008. http://healthyeatingresearch. tions Fund. http://www.cdfifund.gov/ 458 Treuhaft S and Karpyn A. The Grocery org/wp-content/uploads/2013/12/ what_we_do/programs_id.asp?progr- Gap: Who Has Access to Healthy Food and HER-Bringing-Healthy-Foods- amID=5 (accessed May 2015). Why It Matters. Oakland, CA and Phila- Home_7-2008.pdf (accessed April 2015). 449 apital Impact Partners, 2015. C delphia, PA: Policy Link and The Food 440 Morland K, Roux A, and Wing S. Super- Trust, 2010. http://thefoodtrust.org/ 450 rnst & Young (EY). The Campaign to E markets, other food stores, and obesity: uploads/media_items/grocerygap.origi- End Obesity. The New Markets Tax Credit: the Atherosclerosis Risk in Communities nal.pdf (accessed April 2014). Opportunities for Investment in Healthy Foods Study. American Journal of Preventive Medi- and Physical Activity, 2013. http://cam- 459 The Reinvestment Fund, 2008. cine, 30(4): 333-339, 2006. paigntoendobesity.org//documents/ 460 Factsheet on the New Proposed Nutri- 441 Morland K, Wing S, and Roux A. The ExecutiveSummaryofNMTCStudy.pdf tion Facts Label. In U.S. Food and Drug contextual effect of the local food En- 451 U.S. Department of Agriculture. Administration. http://www.fda.gov/ vironment on residents’ diets: The Ath- “Obama Administration Announces Food/GuidanceRegulation/GuidanceD- erosclerosis Risk in Communities Study. Additional Support to Help Communi- ocumentsRegulatoryInformation/Label- American Journal of Public Health, 92(11): ties Boost Local Food Economies.” U.S. ingNutrition/ucm387533.htm (accessed 1761-1767, 2002. Department of Agriculture June 9, 2014. May 2015). 442 Moore L, Roux A, Nettleton J, et al. http://www.usda.gov/wps/portal/usda/ 461 U.S. Food and Drug Administration. Associations of the local food environ- usdahome?contentid=2014/06/0114. Food labeling: revisions of the Nutri- ment with diet quality—A comparison xml (accessed June 2015). tion and Supplement Facts Labels. 21 of assessments based on surveys and 452 McKalip D. “Local Food, Local Places: CFR Part 101. Federal Register, 81(103): geographic information systems: The Bringing Expertise and Creative Think- 33742-33999, 2016. https://www.gpo. Multi-Ethnic Study of Atherosclerosis. ing to Community Economic Develop- gov/fdsys/pkg/FR-2016-05-27/pdf/2016- American Journal of Epidemiology 167(8): ment.” The White House Blog December 11867.pdf (accessed August 2016), 917-924, 2008. 3, 2014. https://www.whitehouse.gov/ 462 U.S. Department of Health and Human 443 The Reinvestment Fund. The Economic blog/2014/12/03/local-food-local-plac- Services and U.S. Department of Ag- Impacts of Supermarkets on their Surround- es-bringing-expertise-and-creative-think- riculture. 2015-2020 Dietary Guidelines ing Communities, Philadelphia, PA: The ing-community-economic- (accessed for Americans. Washington, D.C.: U.S. Reinvestment Fund, 2008. https:// May 2015). Department of Health and Human www.reinvestment.com/wp-content/ Services, 2015. http://health.gov/ uploads/2015/12/Economic_Impact_ dietaryguidelines/2015/guidelines/ (ac- of_Supermarkets_on_Their_Surround- cessed May 20160. ing_Communities-Brief_2007.pdf. 138 TFAH • RWJF • StateofObesity.org 4 63Christeson W and Clifford W. Retreat is 478 Food Insecurity Nutrition Incentive Pro- 491 Ford CN, Ng SW, Popkin BM. Ten-year not an option: healthier school meals protect gram. In Wholesome Wave, 2014. http://www. beverage intake trends among US pre- our children and our country. Washington, wholesomewave.org/our-initiatives/advo- school children: rapid declines between D.C.: Mission Readiness, 2014. cacy-policy/food-insecurity-nutrition-incen- 2003 and 2010 but stagnancy in recent tive-program/ (accessed April 2016). years. Pediatric Obesity, 11(1): 47-53, 2016. 464 National Prevention Council, 2014. 479 009-2012 Outcomes and Trends Full 2 492 Hu FB. Resolved: there is sufficient 465 National Prevention Strategy. Annual Report. In Wholesome Wave’s Double Value scientific evidence that decreasing sug- Status Report. Washington, D.C.: U.S. Coupon. https://drive.google.com/ ar-sweetened beverage consumptions Department of Health and Human Ser- file/d/0B9xO2Xo4OIC4UU12c2JQV- will reduce the prevalence of obesity and vices, Office of the Surgeon General, 0VhdnM/edit?pli=1 (accessed May, obesity-related disease. Obesity Reviews, 2014. http://www.surgeongeneral.gov/ 2014). 14: 606-619, 2013. priorities/prevention/2014-npc-status-re- port.pdf (accessed June 2016). 480 ho We Are. In Seeds of Hope, 2016. W 493 Malik VS, Willett WC, and Hu FB. Sug- http://seedsofhope.ladiocese.org/ (ac- ar-sweetened beverages and BMI in 466 Christeson W and Clifford W. Retreat is cessed May 2016). children and adolescents: reanalysis of not an option: healthier school meals protect a meta-analysis. Am J Clin Nutr, 89:438-9; our children and our country. Washington, 481 bout Us. In DINE for life, no date. A author reply 9-40, 2009. D.C.: Mission Readiness, 2014. http://www.dineforlife.org/contact-us. php (accessed May 2016). 494 Martin-Calvo N, Martinez-González MA, 467 Policy Atlas. In National Complete Streets Bes-Rastrollo M, et al. Sugar-sweetened Coalition. http://www.smartgrowthamer- 482 bout the Garden Kitchen. In Garden A carbonated beverage consumption ica.org/complete-streets/changing-pol- Kitchen, 2016. http://thegardenkitchen. and childhood/adolescent obesity: a icy/complete-streets-atlas (accessed org/ (accessed May 2016). case-control study. Public Health Nutr, April 2016). 483 utrition, Physical Activity, and Obesity. N 17(10): 2185-2193, 2014. 468 Lieberman M, et al., 2016. Prevention Status Report, 2016. http:// 495 Babey SH, Jones M, Yu H et al. Bubbling www.cdc.gov/psr/national-summary/ 469 Lieberman M, et al., 2016. Over: Soda Consumption and Its link to Obe- npao.html. sity in California. Los Angeles, CA: UCLA 471 Oliveira V. The Food Assistance Land- 485 ark S, Xu F, Town M, et al. Prevalence P Center for Health Policy Research, 2009. scape: FY 2014 Annual Report, EIB-137. of sugar-sweetened beverage intake http://healthpolicy.ucla.edu/publica- Washington, D.C.: U.S. Department of among adults - 23 States and the District tions/Documents/PDF/Bubbling%20 Agriculture, Economic Research Service, of Columbia, 2013. MMWR, 65(7): 169- Over%20Soda%20Consumption%20 March 2015. http://www.ers.usda.gov/ 174, 2016.http://www.cdc.gov/mmwr/ and%20Its%20Link%20to%20Obe- media/1806461/eib137.pdf (accessed volumes/65/wr/mm6507a1.htm (ac- sity%20in%20California.pdf. May 2015). cessed July 2016). 496 Malik VS, Popkin BM, Bray GA, et al. 472 http://www.fns.usda.gov/sites/default/ 486 aylor K. “Coke and Pepsi are Facing a T Sugar-sweetened beverages and risk files/pd/34SNAPmonthly.pdf Terrifying Reality.” Business Insider March of metabolic syndrome and type 2 di- 473 Goldman N, Ettinger de Cuba S, 29, 2016. http://www.businessinsider. abetes: a meta-analysis. Diabetes Care, Sheward R, et al. Food Security Protects com/people-drinking-less-coke-and- 33(11):2477-2483, 2010. Minnesota Children’s Health. Series — pepsi-2016-3 (accessed June 2016). 497 de Koning L, Malik VS, Kellogg MD, et Hunger: A New Vital Sign. Boston, MA: 487 asater G, Piernas C, Popkin BM. Bever- L al. Sweetened beverage consumption, Children’s HealthWatch, 2014. age patterns and trends among school- incident coronary heart disease, and 474 Bovell A, Ettinger de Cuba S, Scully K, et aged children in the US, 1989-2008. Nutr biomarkers of risk in men. Circulation, al. Making SNAP Work for Families Leaving J., 10: 103, 2011. 125(14):1735-1741, S1, 2012. Poverty. Series — Hunger: A New Vital 488 ean Intake of Energy and Mean Con- M 498 Chriqui JF, Eidson SS, Chaloupka FJ. Sign. Boston, MA: Children’s Health- tribution (kcal) of Various Foods Among State Sales Taxes on Regular Soda (as Watch, 2014. US Population, by Age, NHANES 2005– of January 1, 2014) — BTG Fact Sheet. 475 Goldman N, Ettinger de Cuba S, 06. In National Cancer Institute, 2016. Chicago, IL: Bridging the Gap Program, Sheward R, et al., 2014. http://epi.grants.cancer.gov/diet/food- Health Policy Center, Institute for Health sources/energy/table1b.html?&url=/ Research and Policy, University of Illinois 476 State SNAP-Ed Allocations. In U.S. De- diet/foodsources/energy/table1b.html at Chicago, 2014. http://www.bridging- partment of Agriculture, 2016. https:// (accessed June 2012). thegapresearch.org/_asset/s2b5pb/ snaped.fns.usda.gov/sites/default/files/ BTG_soda_tax_fact_sheet_April2014.pdf uploads/StateSNAP-EdAllocationsFebru- 489 it BK et al., 180-188, 2013. K (accessed April 2014). ary2016.pdf (accessed April 2016). 490 esirow MSC and Welsh JA. US chil- M 477 What we do. In Wholesome Wave, no date. dren: National Health and Nutrition Ex- http://www.wholesomewave.org/ (ac- amination Survey 2001-2010. J Acad Nutr cessed May 2016). Diet, 115: 559-566, 2015. TFAH • RWJF • StateofObesity.org 139 499 liferis L. “Berkely Decides to Try Taxing A 508 ergtold J, Akobundo E, and Peterson E. B 518 Selvin E, Parrinello CM, Sacks DB, et Away Its Soda Habit.” NPR Health News The FAST Method: estimating uncondi- al. Trends in prevalence and control of November 5, 2015. http://www.npr.org/ tional demand elasticities for processed diabetes in the United States, 1988-1994 blogs/health/2014/11/05/361730578/ foods in the presence of fixed effects. and 1999-2010. Annals of Internal Medi- berkeley-decides-to-try-taxing-away-its-so- Journal of Agricultural and Resource Econom- cine, 160(8): 517-525, 2014. da-habit (accessed April 216). ics, 29(2): 276-295, 2004. 519 National Center for Chronic Disease 500 Aliferis L. “Here’s What would be 509 en S, Lin B, Smallwood D et al., 309-321. Y Prevention and Health Promotion, Divi- Taxed — or Not — in Berkeley Soda sion of Diabetes. 2014 National Diabetes 510 ahl R, Bird R, and Walker M. The un- B Tax Measures.” KQED News Octo- Statistics Report. Atlanta: GA: Centers for easy case against discriminatory excise ber 29, 2014. http://ww2.kqed.org/ Disease Control and Prevention, 2014. taxation: soft drink taxes in Ireland. Pub- stateofhealth/2014/10/29/heres- http://www.cdc.gov/diabetes/data/ lic Finance Review, 31(5): 510-533, 2003. what-would-be-taxed-or-not-in-sf-berke- statistics/2014statisticsreport.html (ac- ley-soda-tax-measures/#more-22233 511 haloupka FJ, Powell LM, Chriqui JF. C cessed July 2016). (accessed April 2016). Sugar-Sweetened Beverage Taxes and Public 520 Statistics about Diabetes. In American Health. A BTG Research Brief. Chicago, 501 Lochner T. “Berkeley City Council allo- Diabetes Association. http://www.diabetes. IL: Bridging the Gap Program, Health Pol- cates soda tax funds, declares homeless org/diabetes-basics/statistics/ (accessed icy Center, Institute for Health Research shelter crisis.” East Bay Times January 20, May 2015). and Policy, University of Illinois at Chi- 2016. http://www.eastbaytimes.com/ cago, 2009. http://www.rwjf.org/content/ 521 enters for Disease Control and Pre- C breaking-news/ci_29408347/berkeley- dam/farm/reports/issue_briefs/2009/ vention, (2010). Number of Americans city-council-allocates-soda-tax-funds-de- rwjf43487 (accessed May 2016). with Diabetes Projected to Double or clares (accessed July 2016). Triple by 2050. [Press Release]. http:// 512 acobson MH and Brownell KD. Small J 502 Nadolny TL. “Soda tax passes; Phil- www.cdc.gov/media/pressrel/2010/ Taxes on Soft Drinks and Snack Foods adelphia is first big city in nation to r101022.html (accessed March 2011). to Promote Health. American Journal of enact one.” Philly.com June 18, 2016. Public Health, 90(6): 854-57, 2000. 522 Statistics about Diabetes. In American http://articles.philly.com/2016-06-18/ Diabetes Association. http://www.diabetes. news/73844306_1_philadelphia-city- 513 ongressional Budget Office. Healthcare C org/diabetes-basics/statistics/ (accessed council-tax-credit-first-such-tax (accessed Budget Options, Volume 1. Washington, May 2015). July 2016). D.C.: U.S. Congress, 2008, p. 206. 523 Total Prevalence of Diabetes & Pre-Di- 503 Aliferis L. “San Francisco Voters Will De- 514 Colchero, M. A., B. M. Popkin, J. A. Rivera abetes. In American Diabetes Association. cide on Soda Tax in November.” KQED and S. W. Ng (2016). Beverage purchases http://diabetes.org/diabetes-statistics/ News June 21, 2016. http://ww2.kqed. from stores in Mexico under the excise prevalence.jsp (accessed April 2008). org/stateofhealth/2016/06/21/san-fran- tax on sugar sweetened beverages: obser- cisco-voters-will-decide-on-soda-tax-in-no- vational study. BMJ 352: h6704. http:// 524 Total Prevalence of Diabetes & Pre-Di- vember/ (accessed July 2016). www.bmj.com/content/352/bmj.h6704 abetes. In American Diabetes Association. http://diabetes.org/diabetes-statistics/ 504 Cohen L. “Soda Tax Proponents Submit 515 olaneri K. “Philly Wants to Tax Soda C prevalence.jsp (accessed April 2008). Petition for Vote in Boulder, Colorado.” to Raise Money for Schools.” NPR April Reuters June 28, 2016. http://www.reu- 8, 2016. http://www.npr.org/sections/ 525 Dabelea D, Mayer-Davis EJ, Saydan S, ters.com/article/idUSL1N19K1T0 (ac- thesalt/2016/04/08/473548273/philly- et al. Prevalence of Type 1 and Type 2 cessed July 2016). wants-to-tax-soda-to-raise-money-for- Diabetes Among Children and Adoles- schools (accessed May 2016). cents From 2001 to 2009. JAMA, 311(17): 505 Andreyeva, T, Long M, and Brownell K. 1778-1786, 2014. The impact of food prices on consump- 516 adolny TL. “Soda Tax Passes; Philadelphia N tion: a systematic review of research on is First Big City in Nation t Enact One.” 526 Statistics about Diabetes. In American price and elasticity of demand for food. Philly.com June 18, 2016. http://www.philly. Diabetes Association. http://www.diabetes. American Journal of Public Health, 2009. com/philly/news/politics/20160617_Phil- org/diabetes-basics/statistics/ (accessed adelphia_City_Council_to_vote_on_soda_ May 2015). 506 Yen S, Lin B, Smallwood D, et al. De- tax.html (accessed 2016). mand for non-alcoholic beverages: the 527 American Heart Association. Heart Disease case of low-income households. Agribusi- 517 sterl M. “Philadelphia City Council E and Stroke Statistics — 2006 Update. Dal- ness, 20(3): 309-321, 2004. Approves Sweetened Beverage Tax. Levy las: American Heart Association, 2006. Could Raise Prices by 25% to 30% If 507 Raper, K, Wanzala M, and Nayga R. 528 Roger VL, Go AS, Lloyd-Jones DM, Passed Along Fully to Customers” The Wall Food expenditures and household de- et al. Heart disease and stroke statis- Street Journal June 16, 2016. http://www.wsj. mographic composition in the US: a tics — 2011 update: a report from the com/articles/philadelphia-city-council-ap- demand systems approach. Applied Eco- American Heart Association. Circulation, proves-sweetened-beverage-tax-1466104155 nomics, 34(8): 981-992, 2002. 123:e18, 2011. (accessed August 2016). 140 TFAH • RWJF • StateofObesity.org 529 Centers for Disease Control and Pre- 540 ang Y, Chen X, Song Y, et al. Associa- W 550 Cawley J and Meyerhoefer C. The Med- vention. Prevalence of Abnormal Lipid tion between Obesity and Kidney Disease. ical Care Costs of Obesity: An Instru- Levels among Youths — United States, Kidney International, 73(1): 19-33, 2008. mental Variables Approach. Journal of 1999-2006. Morbidity and Mortality Weekly Health Economics, 31(1): 219-230, 2012; 541 eydoun MA, Beydoun HA, Wang Y. B Report, 59(2): 29-33, 2010. And Finkelstein, Trogdon, Cohen, et al. Obesity and central obesity as risk factors Annual Medical Spending Attributable 530 merican Heart Association. Heart Disease A for incident dementia and its subtypes: a to Obesity. Health Affairs, 2009. and Stroke Statistics — 2006 Update. Dallas: systematic review and meta-analysis. Obes American Heart Association, 2006. Rev, 9(3): 204-218, 2008. 551 Cawley J, Rizzo JA, and Haas K. Occupa- tion-specific absenteeism costs associated 531 Obesity Statistics — U.S. Trends. In The 542 u WL, Atti AR, Gatz M, et al. Midlife X with obesity and morbid obesity. Journal Obesity Society. http://www.obesity.org/ overweight and obesity increases late- of Occupational and Environmental Medi- statistics/obesity_trends.asp (accessed life dementia risk: A population-based cine, 49(12): 1317–24, 2007. April 2008). twin study. Neurology, 76(18): 1568-1574, 2011. 552 Gates D, Succop P, Brehm B, et al. Obe- 532 hat Are the Health Risks of Overweight W sity and presenteeism: the impact of and Obesity? In National Heart, Lung, 543 Strine TW, Mokdad AH, Dube SR, et al. body mass index on workplace productiv- and Blood Institute. http://www.nhlbi. The association of depression and anxi- ity. J Occ Envir Med, 50(1): 39-45, 2008. nih.gov/health/dci/Diseases/obe/obe_ ety with obesity and unhealthy behaviors risks.html (accessed May 2010). among community-dwelling US adults. Gen- 553 Trogdon JG, Finkelstein EA, Feagan CW, eral Hospital Psychiatry, 30(2): 127-137, 2007. et al. State- and payer-specific estimates of 533 Obesity and African Americans. In U.S. annual medical expenditures attributable Department of Health and Human Services 544 ariepy G, Nitka D, Schmitz N. The G to obesity. Obesity, 20(1):2 14-220, 2012. Office of Minority Health. http://minority- association between obesity and anxiety health.hhs.gov/templates/content.aspx- disorders in the population: A systematic 554 The Robert Wood Johnson Foundation, ?ID=6456 (accessed May 2014). review and meta-analysis. International the American Stroke Association, and Journal of Obesity 34(3): 407-419, 2010. the American Heart Association. A Na- 534 odriguez CY. “Beautiful but deadly: R tion at Risk: Obesity in the United States, A Latinos’ curves put them at risk.” CNN. 545 hao G, Ford WE, Dhingra S, et al. De- Z Statistical Sourcebook. Dallas, TX: Amer- com October 17, 2013. http://www.cnn. pression and anxiety among US adults: ican Heart Association, 2005. http:// com/2013/10/15/health/latino-cardio- Associations with body mass index. Inter- www.americanheart.org/downloadable/ vascular-disparities/ (accessed May 2014). nal Journal of Obesity 33(2): 257-266, 2009. heart/1114880987205NationAtRisk.pdf 535 Obesity and Cancer Risk. In National 546 etry NM, Barry D, Pietrzak RH, et al. P (accessed April 14, 2008). Cancer Institute at the National Institutes of Overweight and obesity are associated 555 Finkelstein EA, Trogdon JG, Cohen JW, Health. http://www.cancer.gov/cancer- with psychiatric disorders: results from et al. Annual medical spending attrib- topics/factsheet/Risk/obesity (accessed the National Epidemiologic Survey on utable to obesity: payer-and service-spe- May 2014). Alcohol and Related Conditions. Psycho- cific estimates. Health Affairs, 28(5): som Med, 70(3): 288–297, 2008. 536 Calle EE, Rodriguez C, Walker K, et al. w822-w831, 2009. Overweight, obesity, and mortality from 547 Labad J, Price JF, Stracha MWJ, et al. 556 Arterburn DE, Maciejewski ML, Tsevat cancer in a prospective studied cohort Symptoms of depression but not anxiety J. Impact of morbid obesity on medical of U.S. adults. The New England Journal of are associated with central obesity and car- expenditures in adults. Int J Obes, 29(3): Medicine, 348:1625-1638, 2003. diovascular disease in people with type 2 334-339, 2005. diabetes: the Edinburgh Type 2 Diabetes 537 Moore SC, Lee IM, Weiderpass E, et al. Study. Diabetologia 53(3): 467-471, 2010. 557 Teuner CM, Menn P, Heier M, et al. Im- Association of leisure-time physical activ- pact of BMI and BMI change on future ity with risk of 26 types of cancer in 1.44 548 ratt LA, Brody DJ. Depression and Obe- P drug expenditures in adults: results from million adults. JAMA Intern Med, [Epub sity in the U.S. Adult Household Popu- the MONICA/KORA cohort study. BMC ahead of print], 2016. http://archinte. lation, 2005-2010. NCHS Data Brief, 167, Health Services Research, 13(424), 2013. jamanetwork.com/article.aspx?arti- 2014. http://www.cdc.gov/nchs/data/ cleid=2521826 (accessed May 2016). databriefs/db167.pdf (access April 2015). 558 Peitz GW, Troyer J, Jones AE, et al. Association of body mass index with 538 NHIS Arthritis Surveillance. In Centers 549 imon GE, Ludman EJ, Linde JA, et al. S increased cost of care and length of stay for Disease Control and Prevention. http:// Association between obesity and depres- for emergency department patients with www.cdc.gov/arthritis/data_statistics/na- sion in middle-aged women. General chest pain and dyspnea. Circ Cardiovasc tional_data_nhis.htm#excess (accessed Hospital Psychiatry 30(1): 32-39, 2008. Qual Outcomes, 7(2): 292-298, 2014. June 2008). 559 Accountable Care Organizations (ACO). 539 Non-alcoholic fatty liver disease. In In Centers for Medicare and Medicaid Ser- American Liver Foundation. http://www. vices. http://www.cms.gov/Medicare/ liverfoundation.org/abouttheliver/info/ Medicare-Fee-for-Service-Payment/ nafld/ (accessed May 2015). ACO/ (accessed May 2014). TFAH • RWJF • StateofObesity.org 141 560 Dooyema CA, Belay B, Foltz JL, Williams 567 ruit and Vegetable Prescription F 574 Healthy Food in Health Care Pledge. In N, Blanck HM. The childhood obesity re- Program. In Wholesome Wave, 2014. Health Care Without Harm, 2016. https:// search demonstration project: a compre- http://www.wholesomewave.org/ noharm-uscanada.org/issues/us-can- hensive community approach to reduce our-initiatives/nationalnutritionin- ada/healthy-food-health-care-pledge childhood obesity. Child Obes 2013; 9 (5): centivenetwork/currentprojects/ (accessed August 2016). 454-459. fruit-and-vegetable-prescription-proj- 575 Kranz AM, Browner DK, McDermid L, et ects/ (accessed August 2016). 561 Galewitz P. “Seniors’ Obesity-Counseling al. Using Electronic Health Record Data Benefit Goes Largely Unused.” Kaiser 568 ruit and Vegetable Prescription Pro- F for Healthy Weight Surveillance in Chil- Health News November 20, 2014. http:// gram. In Rural Health Information Hub, dren, San Diego, California, 2014. Pre- www.medpagetoday.com/PublicHealth- 2016. https://www.ruralhealthinfo. venting Chronic Disease, 13:150422. Policy/Medicare/48753 (accessed June org/community-health/project-exam- DOI: http://dx.doi.org/10.5888/ 2015). ples/897 (accessed August 2016). pcd13.150422, 2016. https://www.cdc. gov/pcd/issues/2016/15_0422.htm (ac- 562 Petrin C, Prakash K, Kahan S, et al. 569 holesome Wave. Wholesome Wave’s Fruit W cessed August 2016). Medicaid Fee-for-Service Treatment of Obe- and Vegetable Prescription Program, New sity Interventions. Washington, D.C.: York City: 2013 Outcomes. Washington, 576 National Academies (2016). “Assess- The George Washington University, D.C.: Wholesome Wave, 2014. http:// ing Prevalence and Trends in Obesity: Department of Health Services Man- www.wholesomewave.org/wp-content/ Navigating the Evidence.” [Report in agement and Leadership, 2016. http:// uploads/2014/10/FVRx-2013_HHC_Re- Brief]. http://www.nationalacademies. stopobesityalliance.org/wp-content/ port.pdf (accessed August 2016). org/hmd/~/media/Files/Report%20 assets/2016/04/Medicaid%20FFS%20 Files/2016/Obesity-RiB.pdf (accessed 570 andro L. “Doctors Dole Out Prescrip- L Treatment%20of%20Obesity.%20 August 2016). tions for Exercise.” The Wall Street Journal 2016%20(4)%20(1).pdf. December 8, 2014. http://www.wsj. 577 Kranz AM, et al., 2016. 563 American Academy of Pediatrics (2015). com/articles/doctors-dole-out-prescrip- 578 Mathews Burwell S. 2015 Annual Re- “New AAP Report Targets Lack of Ade- tions-for-exercise-1418080961 (accessed port on the Quality of Care for Children in quate Food as Ongoing Health Risk to August 2016). Medicaid and CHIP. Washington, D.C.: U.S. Children.” https://www.aap.org/ 571 ealth Care Without Harm (2016). H U.S. Department of Health and Human en-us/about-the-aap/aap-press-room/ Menu of Change: Healthy Food in Health Services, 2016. https://www.medicaid. Pages/Lack-of-Adequate-Food.aspx (ac- Care — A 2015 Program Report with gov/medicaid-chip-program-informa- cessed August 2016). Highlights and Survey Results. https://no- tion/by-topics/quality-of-care/down- 564 Feeding America. Map the Meal Gap. harm-uscanada.org/sites/default/files/ loads/2015-child-sec-rept.pdf (accessed Chicago, IL: Feeding America, 2016. documents-files/3875/Menu%20of%20 May 2016). http://www.feedingamerica.org/ Change%20Report%202015_6-21-16.pdf 579 Childhood Obesity Research Demon- hunger-in-america/our-research/map- (accessed August 2016). stration Project (CORD). Implementing the-meal-gap/2014/map-the-meal-gap- 572 ealth Care Without Harm. Expanding H Strategies Across the Community to Help 2014-exec-summ.pdf (accessed May Antibiotic Stewardship The Role of Health Families with Childhood Obesity. In 2016). Care in Eliminating Antibiotic Overuse in CDC, Division of Nutrition, Physical Activity, 565 Child Food Insecurity in the United Animal Agriculture (White paper). Reston, and Obesity, 2015 http://www.cdc.gov/ States. In Feeding America, 2016. http:// VA: Health Care Without Harm, 2014. nccdphp/dnpao/division-information/ map.feedingamerica.org/county/2014/ https://noharm-uscanada.org/sites/ programs/researchproject.html (ac- child (accessed May 2016). default/files/documents-files/2735/Ex- cessed May 2016). panding%20Antibiotic%20Stewardship. 566 Gitterman, B.A., Chilton, L.A., Cotton, 580 iabetes Prevention Program (DPP). D pdf (accessed August 2016). W.H., Duffee, J.H., Flanagan, P., Keane, In NIH.gov http://www.niddk.nih.gov/ V.A., Krugman, S.D., Kuo, A.A., Lin- 573 ealth Care Without Harm. Menu of H about-niddk/research-areas/diabetes/ ton, J.M., McKelvey, C.D., Paz-Soldan, Change: Healthy Food in Health Care — diabetes-prevention-program-dpp/Docu- G.J. (2015). Promoting food security A 2015 Program Report with Highlights ments/DPP_508.pdf (accessed July 2015). for all children. Pediatrics,136(5), and Survey Results. Reston, VA: Health 581 Alberti P, Sutton K, Baer I. Community pp.e1431-e1438. http://pediatrics.aap- Care Without Harm, 2016. https://no- Health Needs Assessments: Engaging Com- publications.org/content/136/5/e1431 harm-uscanada.org/sites/default/files/ munity Partners to Improve Health. Analysis (accessed August 2016). documents-files/3875/Menu%20of%20 in Brief 14(11), 2014. Washington: Change%20Report%202015_6-21-16.pdf D.C.: Association of American Medical (accessed August 2016). Colleges. https://www.aamc.org/down- load/419276/data/dec2014community- health.pdf. 142 TFAH • RWJF • StateofObesity.org 582 Rosenbaum S, Kindig DA, Bao J, et al. The value of the nonprofit hospital tax exemption was $24.6 billion in 2011. Health Affairs, [Epub 10.1377], 2015. http://content.healthaffairs. org/content/early/2015/06/18/ hlthaff.2014.1424.abstract (accessed May 2016). 583 Internal Revenue Service. Report to Congress on Private, Tax-Exempt, Tax- able, and Government-Owned Hospitals. January 2015. https://www.vha.com/ AboutVHA/PublicPolicy/Community- Benefit/Documents/Report_to_Con- gress_on_Hospitals_Jan_2015.pdf. (accessed February 2016). 584 Young GJ, Chou CH, Alexander J, et al. Provision of community benefits by tax-exempt U.S. hospitals. N Engl J Med, 368: 1519-1527, 2013. http://www.nejm. org/doi/pdf/10.1056/NEJMsa1210239 (accessed May 2016). 585 Rosenbaum S, et al., [Epub 10.1377], 2015. 586 Young GJ, et al., 1519-1527, 2013. 587 Donahue S. Childhood obesity. Report from the first round of CHNA’s and im- plementation strategies. Health Progress, 96(5): 80-83, 2015. https://www.chausa. org/docs/default-source/health-prog- ress/community-benefit-childhood-obe- sity.pdf?sfvrsn=0 (accessed July 2016). TFAH • RWJF • StateofObesity.org 143 1730 M Street, NW, Suite 900 www.rwjf.org Washington, DC 20036 Route 1 and College Road East (t) 202-223-9870 P.O. Box 2316 (f) 202-223-9871 Princeton, NJ 08543-2316