State of Obesity 2014 PDF

ISSUE REPORT
The State
of Obesity:
Better Policies for a
Healthier America
2014
SEPTEMBER 2014
Acknowledgements
Trust for Americas 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 the health and health care of all Americans. We are
striving to build a national Culture of Health that will enable all Americans to live longer, healthier lives now and for generations to come. For
more information, 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

John Gates, JD
Founder, Operator and Manager
Nashoba Brook Bakery
David Fleming, MD
Director of Public Health
Seattle King County,
Washington
Tom Mason
President
Alliance for a Healthier
Minnesota
Arthur Garson, Jr., MD, MPH

Director, Health Policy Institute
Texas Medical Center
Eduardo Sanchez, MD, MPH

Deputy Chief Medical Officer
American Heart Association
Theodore Spencer
Secretary of the Board, TFAH
Senior Advocate, Climate Center
Natural Resources Defense
Council
Cynthia M. Harris, PhD, DABT

Vice President of the Board,
TFAH
Director and Professor
Institute of Public Health,
Florida A&M University
Robert T. Harris, MD
Treasurer of the Board, TFAH
Medical Director
North Carolina Medicaid
Support Services
CSC, Inc.
REPORT AUTHORS
CONTRIBUTORS
PEER REVIEWERS
Jeffrey Levi, PhD.

Executive Director
Trust for Americas Health
and Professor of Health Policy
Milken Institute School of
Public Health at the George
Washington University
Susan D. Promislo, MA
Senior Communications Officer
Robert Wood Johnson
Foundation
TFAH thanks the following individuals and organizations for their

time, expertise and insights in reviewing all or portions of the State of
Obesity report. The opinions expressed in the report do not necessarily
represent the views of these individuals or their organizations.
Kristen M. Gurdin, JD
Legal Counsel
Robert Wood Johnson
Foundation
Niiobli Armah IV, MA

Director, Health Programs
NAACP
Carla I. Plaza, MPH

Consultant
National Council of La Raza
Cliff Despres, B.J.,

Communications Director,
Salud America!, Institute for
Health Promotion Research,
The University of Texas Health
Science Center at San Antonio
Amelie G. Ramirez, Dr.P.H.,

Director, Salud America!,
Institute for Health Promotion
Research,
Jack Rayburn, MPH

Senior Government Relations
Manager
Kipling J. Gallion, M.A.,

Deputy Director, Salud
America!, Institute for Health
Promotion Research,
Christopher J. Revere, MPA

Director, Office of Child Health
Policy & Advocacy
Nemours
Cover photos, clockwise from top left, courtesy of: Shuttersock; Jordan Gantz,
used with permission from RWJF; Matt Moyer, used with permission from RWJF
Shutterstock; Matt Moyer, used with permission from RWJF; Shutterstock
Daniella Gratale
Senior Manager of Advocacy
Nemours
Laura M. Segal, MA
Director of Public Affairs
Rebecca St. Laurent
Health Policy Research
Manager
Barbara Ferrer, PhD, MPH, ED

Health Commissioner
Boston, Massachusetts
Gail Christopher, DN
President of the Board, TFAH
Vice President for Policy and
Senior Advisor
WK Kellogg Foundation
TFAH RWJF StateofObesity.org
Kimberly Elliott, MA
Director of Policy Outreach
Robert Wood Johnson
Foundation
Burness Communications
Jennifer Arice White, MSPH

Program Manager, Health
Programs & Partnerships
NAACP
I N TRO DUCT IO N
The following is a letter from Risa

Lavizzo-Mourey, MD, MBA, president
and CEO of the Robert Wood Johnson
Foundation (RWJF), and Jeffrey Levi,
PhD, executive director of the Trust
for Americas Health (TFAH)
After ten years of F as in Fat, we are excited to unveil a
The State of
Obesity:
Obesity Policy
series
INTRODUCTORY LETTER
The State of Obesity
new name for this report: The State of Obesity: Better

Policies for a Healthier America. Why? Well, quite
simply, we believe the F no longer stands for failure.
We launched the first F as in Fat report in response to
the urgent call from national leaders, including the U.S.
Surgeon General, to create a public health response that
matched the level of a crisis that had reached epidemic
proportions in the United States.1 Our goal was to raise
awareness about the seriousness of the obesity epidemic
and present ideas on how to overcome it.
So what is the state of obesity in
about what works to change public
America today? We are starting to see
policies, improve school and
signs of progress. After decades of
community environments and
alarming increases, this years report
strengthen industry practices in ways
shows us that childhood obesity rates
that support and promote healthy
have stabilized in the past decade. We
eating and physical activity. Weve
also know that rates have declined
seen that when schools, parents,
in a number of places around the
policymakers, industry leaders and
country from Anchorage, Alaska to
community champions join forces,
Philadelphia, Pennsylvania.
they can create a Culture of Health

that helps to make healthy choices
the easy, affordable and accessible
choices for everyone.
This is success worth heralding,

brought about in part through
committed action by policy makers
SEPTEMBER 2014
Since then, weve learned a lot
For the first time in a decade, data also show a downward trend in
obesity rates among young children from low-income families in
many states.
across the nation. But this progress
Our efforts to reverse the obesity
is still early and fragile.
epidemic will not be successful until
Unfortunately, the progress is more

mixed for adults. Over the past 30
years, adult obesity rates have sharply
risen, doubling since 1980. Today,
that rate of increase is beginning
to slow. In 2005, every state but
one reported an increase in obesity
rates; this past year, only six states
experienced an increase. Ultimately,
however, adult rates remain far
too high across the nation, putting
millions of Americans at higher
risk for a range of serious health
problems, from type 2 diabetes to
heart disease.
Significant disparities also persist.
Rates are disproportionately higher
in the South, among lower-income
Americans and among racial and
ethnic minorities.
we close these disparity gaps. Our

challenge moving forward is to
take what weve learned and apply
it more intensively in communities
where obesity rates remain extremely
high. In essence, we must ensure
that everyone has the opportunity to
achieve a healthy weight by redoubling
efforts to reduce health disparities.
Such commitment will be essential if
we are to meaningfully reduce peoples
risks for a range of serious health
problems, rein in high healthcare
costs, and extend equal opportunity for
good health to everyone in the nation.
In this report, we focus on some
of the highest-impact approaches,
including implementation of
policies to: increase physical activity
before, during and after school;
offer nutritious food and beverages
For example, adult obesity rates for
at school; make healthy, affordable
Blacks were at or above 40 percent
food prevalent in all communities;
in 11 states, 35 percent in 29 states
ensure healthy food and beverage
and 30 percent in 41 states. And
marketing practices; engage
rates of adult obesity among Latinos
healthcare professionals to more
were above 35 percent in five states
effectively prevent obesity both
and above 30 percent in 23 states.
within and outside the clinic walls,
Among Whites, adult obesity topped
in collaboration with community
30 percent in 10 states, and no state
partners; and intensify our focus
had a rate higher than 34 percent.
on prevention in early childhood.
Matt Moyer, used with permission from RWJF
This emphasis on early childhood
of our children and families are able
is particularly important because
to make healthy choices where they
research tells us that if you can avoid
live, learn, work and play.
obesity early on, youre much more

likely to maintain a healthy weight
into adolescence and adulthood.
We know we still have much

more work to do. We must spread
approaches that work to every
Through the years, weve also
community. This report is an urgent
learned that reversing the obesity
call to action for our nation and an
epidemic is not enough; we need
essential step for building a strong,
to support strategies to assure that
vibrant Culture of Health that
everyone in America can be as
provides everyone in America with
healthy as they can through regular
the opportunity to maintain a healthy
physical activity and good nutrition.
weight and live a healthy life.
This will only happen if and when all
S EC T I ON 1 :
SECTION 1: OBESITY RATES AND TRENDS
The State of
Obesity:
Key Findings
Obesity Rates and Trends

There is increasing evidence that obesity rates are stabilizing
for adults and children but the rates remain high,
putting millions of Americans at risk for increased health
problems. Rates of severe obesity are continuing to increase
in adults, and more than one-in-ten children becomes
obese as early as the ages of 2 to 5.
Moreover, racial and ethnic disparities
poorer and less educated Americans
persist, with Blacks and Latinos
experiencing higher rates of obesity
experiencing higher rates of obesity
than more affluent and higher
compared with Whites. Inequities also
educated populations.
persist in income and education, with
OBESITY RATES REMAIN HIGH3

l
Adults: More than a third of adults
(34.9 percent) were obese as of 2011
of children (ages 2 to 19) were obese in
to 2012. More than two-thirds of adults
2011 to 2012, and 31.8 percent were
were overweight or obese (68.5 percent).
Children: Approximately 16.9 percent
Nearly 40 percent of middle-aged
either overweight or obese.7

l
adults, ages 40 to 59, were obese
percent) were obese starting in early
(39.5 percent), compared with
childhood (2- to 5-year-olds).
younger adults, ages 20-39, (30.3
percent) or older adults, ages 60 and

l
More than 6 percent of adults were

severely obese (body mass index
(BMI) of 40 or higher).
By ages 12 to 19, 20.5 percent of

children and adolescents were obese.
over, (35.4 percent).6

l
More than one-in-ten children (8.4
More than 2 percent of young children

were severely obese, 5 percent of 6to 11-year-olds were severely obese
and 6.5 percent of 12- to 19-year-olds
were severely obese.8
SEPTEMBER 2014
Adult Obesity in America 2011-12
Childhood Obesity in America 2011-12
34.9%
68.5%
16.9%
31.8%
Obese
Overweight or Obese
Obese
Overweight or Obese
STABILIZING AT A HIGH RATE

l
1960
Adults: Over the past 35 years, obesity
2014
Children: Childhood obesity rates have
rates have more than doubled. From
more than tripled since 1980.10 The
2009 to 2010 to 2011 to 2012, rates
rates have remained the same for the
remained the same. The average
past 10 years.11
+24 lbs.
American is more than 24 pounds

heavier today than in 1960.9
OBESITY BY RACE
RACIAL AND ETHNIC INEQUITIES

l
50
Adults: 47.8 percent of African
Black
Americans, 42.5 percent of Latinos,
Latino
45
32.6 percent of Whites and 10.8
White
47.8%
45%
Percent
percent of Asian Americans were obese

(2011 to 2012).12
l
Children: 20.2 percent of African

14.3 percent of White children ages 2
39.4%
36.8%
35
American, 22.4 percent of Latino and

to 19 were obese.
42.5%
40
30
13
32.6%
32.6%
30.6%
29.4%
8.5 percent of African American
25
children and 6.6 percent of Latino

children were severely obese
1999 2002
2003 2004
2011 2012
Sources: Wang Y and Beydoun MA. The Obesity Epidemic in the United StatesGender, Age, Socioeconomic,
Racial/Ethnic, and Geographic Characteristics: A Systematic Review and Meta-Regression Analysis. Epidemiol
Rev, 29: 6-28, 2007. And, CDC/NCHS, National Health and Nutrition Examination Survey, 2011-2012.
(1999 to 2012).
Obesity and Overweight Rates for Adults, National Health and Nutrition Examination Survey (NHANES), 2011 to 201214, 15
White Both
Genders
32.6%
Latino Both
Genders
42.5%
African American
White Men
Both Genders
47.8%
32.4%
Latino
Men
40.1%
African American
Men
37.1%
White
Women
32.8%
Latino
Women
44.4%
African American
Women
56.6%
Obese
Obese and
67.2%
77.9%
76.2%
71.4%
78.6%
69.2%
63.2%
77.2%
82%
Overweight Combined
Note: the Centers for Disease Control and Prevention (CDC) uses the term Hispanic in analysis. White = Non-Hispanic Whites; African Americans =
Non-Hispanic African Americans
Obesity and Overweight Rates for Children Ages 2 to 19, NHANES, 2011 to 201216
Girls
White Girls
Latino Girls
African American
Girls
10.1%
Boys
White Boys
Latino Boys
Severely Obese
N/A
4.8%
7.3%
N/A
3.3%
7.9%
Obese (including
17.2%
15.6%
20.6%
20.5%
16.7%
12.6%
24.1%
Severely Obese)
Obese and
31.6%
29.2%
37%
36.1%
32.0%
27.8%
40.7%
Overweight Combined
Note: CDC uses the term Hispanic in analysis. White = Non-Hispanic Whites; African Americans = Non-Hispanic African Americans
African American
Boys
10.1%
19.9%
34.4%
NOTE: Adult Overweight = BMI for 25 to 29.9; Adult Obesity = BMI of 30 or more; Adult Severe Obesity = BMI of 40 or more.
Childhood Overweight = BMI at or above the 85th percentile and lower than the 95th percentile for children of the same age and
sex; Childhood Obesity = BMI at or above the 95th percentile for children of the same age and sex;
Severe Childhood Obesity = BMI greater than 120 percent of 95th percentile for children of the same age and sex.
A. A
DULT OBESITY AND
OVERWEIGHT RATES
Two states have adult obesity rates above 35 percent, 20

states have rates at or above 30 percent, 42 states have
rates above 25 percent and every state is above 20 percent.
In 1980, no state was above 15 percent; in 1991, no state was
above 20 percent; in 2000, no state was above 25 percent;
and, in 2007, only Mississippi was above 30 percent.
Since 2005, there has been some
Mississippi and West Virginia had
evidence that the rate of increase
the highest rates of obesity at 35.1
has been slowing across the states. In
percent, while Colorado had the
2005, every state but one experienced
lowest rate at 21.3 percent. Nine
an increase in obesity rates from the
of the 10 states with the highest
previous year; from 2007 to 2008,
rates of obesity are in the South.
rates increased in 37 states; from
Northeastern and Western states
2009 to 2010, rates increased in 28
comprise most of the states with the
states; and, from 2010 to 2011, rates
lowest rates of obesity.17
increased in 16 states (in 2011, CDC

changed methodologies for the
Behavioral Risk Factor Surveillance
System (BRFSS)), (see discussion
in rates and rankings methodology
for more details on the differences).
Between 2011 and 2012, only one
state had an increase. Between 2012
and 2013, six states had increases.
In 2010, the U.S. Department of

Health and Human Services (HHS)
set a national goal to reduce the adult
obesity rate from 33.9 percent to 30.5
percent by 2020, which would be a
10 percent decrease.18 Healthy People
2020 also set a goal of increasing the
percentage of people at a healthy
weight from 30.8 percent to 33.9
percent by 2020; as of 2012, 26 states
fell short of that goal.19
2013 ADULT OBESITY RATES
WA
ND
MT
MN
VT
OR
ID
WY
UT
IL
CO
KS
MO
AZ
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
OK
IN
NH
MA
NY
MI
IA
NE
NV
ME
WI
SD
VA
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA
n <25%
FL
AK
n >25% & <30%

n >30% & <35%
HI
n >35%
Territory
Guam
Puerto Rico
Obesity Rate
27
27.9
(Note: Reflects BRFSS methodological changes

made in 2011. Estimates should not be
compared to those prior to 2010)20
CHART ON OBESITY AND OVERWEIGHT RATES

ADULTS
Overweight &
Obese
Obesity
Diabetes
Physical Inactivity
Hypertension
States
2013 Percentage
2013 Percentage
Ranking
(95% Conf Interval)
(95% Conf Interval)
2013 Percentage
(95% Conf Interval)
Ranking
2013 Percentage
(95% Conf Interval)
Ranking
2013 Percentage
(95% Conf Interval)
Ranking
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
32.4% (+/-1.7)
28.4% (+/-1.9)*
26.8% (+/-2.5)
34.6% (+/-1.9)
24.1% (+/-1.1)
21.3% (+/-0.9)
25% (+/-1.5)
31.1% (+/-1.8)*
22.9% (+/-1.9)
26.4% (+/-1.1)
30.3% (+/-1.4)
21.8% (+/-1.4)
29.6% (+/-1.8)*
29.4% (+/-1.7)
31.8% (+/-1.2)
31.3% (+/-1.4)
30% (+/-0.8)
33.2% (+/-1.4)
33.1% (+/-2.1)
28.9% (+/-1.3)
28.3% (+/-1.2)
23.6% (+/-1.1)
31.5% (+/-1.1)
25.5% (+/-1.4)
35.1% (+/-1.6)
30.4% (+/-1.7)
24.6% (+/-1.2)
29.6% (+/-1.1)
26.2% (+/-2.3)
26.7% (+/-1.5)
26.3% (+/-1.2)*
26.4% (+/-1.3)
25.4% (+/-1.2)
29.4% (+/-1.3)
31% (+/-1.5)
30.4% (+/-1.2)
32.5% (+/-1.4)
26.5% (+/-1.6)
30% (+/-1.2)
27.3% (+/-1.5)
31.7% (+/-1.3)
29.9% (+/-1.9)
33.7% (+/-1.8)*
30.9% (+/-1.4)
24.1% (+/-1)
24.7% (+/-1.4)
27.2% (+/-1.3)
27.2% (+/-1.2)
35.1% (+/-1.5)
29.8% (+/-1.8)
27.8% (+/-1.6)*
13.8% (+/-1.1)*
7.1% (+/-1.1)
10.7% (+/-1.6)
11.5% (+/-1.1)
10.2% (+/-0.8)
6.5% (+/-0.5)^
8.3% (+/-0.8)
11.1% (+/-1.1)
7.8% (+/-1)
11.2% (+/-0.7)
10.8% (+/-0.8)
8.4% (+/-0.9)
8.4% (+/-0.9)
9.9% (+/-1)
11% (+/-0.7)
9.3% (+/-0.7)
9.6% (+/-0.4)
10.6% (+/-0.8)
11.6% (+/-1.1)
9.6% (+/-0.8)
9.8% (+/-0.7)
8.5% (+/-0.7)
10.4% (+/-0.7)
7.4% (+/-0.8)
12.9% (+/-1)
9.6% (+/-0.9)
7.7% (+/-0.7)
9.2% (+/-0.7)*
9.6% (+/-1.5)
9.2% (+/-0.9)
9.2% (+/-0.7)
10.7% (+/-0.9)
10.6% (+/-0.9)
11.4% (+/-0.8)
8.9% (+/-0.8)
10.4% (+/-0.7)V
11% (+/-0.8)
9.2% (+/-0.9)
10.1% (+/-0.7)
9.3% (+/-0.9)
12.5% (+/-0.8)
9.1% (+/-1)
12.2% (+/-1.1)
10.9% (+/-0.9)
7.1% (+/-0.5)
7.8% (+/-0.8)
9.8% (+/-0.8)
8.6% (+/-0.6)
13% (+/-0.9)
8.2% (+/-1)
8.6% (+/-0.8)
1
49
15
7
21
51
43
10
45
9
14
41
41
23
11
30
26
17
6
26
24
40
19
48
3
26
47
32
26
32
32
15
17
8
37
19
11
32
22
30
4
36
5
13
49
45
24
38
2
44
38
31.5% (+/-1.7)*
22.3% (+/-1.8)*
25.2% (+/-2.5)
34.4% (+/-1.9)*
21.4% (+/-1.1)*
17.9% (+/-0.9)
24.9% (+/-1.5)*
27.8% (+/-1.7)*
19.5% (+/-2)
27.7% (+/-1.2)*
27.2% (+/-1.4)*
22.1% (+/-1.5)*
23.7% (+/-1.7)*
25.1% (+/-1.7)*
31% (+/-1.2)*
28.5% (+/-1.4)*
26.5% (+/-0.7)*
30.2% (+/-1.4)
32.2% (+/-2.1)
23.3% (+/-1.3)*
25.3% (+/-1.2)*
23.5% (+/-1.2)*
24.4% (+/-1.1)
23.5% (+/-1.4)*
38.1% (+/-1.7)*
28.3% (+/-1.6)*
22.5% (+/-1.2)*
25.3% (+/-1.1)*
23.7% (+/-2.2)
22.4% (+/-1.5)*
26.8% (+/-1.2)*
24.3% (+/-1.3)*
26.7% (+/-1.3)
26.6% (+/-1.3)*
27.6% (+/-1.5)*
28.5% (+/-1.3)*
33% (+/-1.4)*
18.5% (+/-1.5)*
26.3% (+/-1.1)*
26.9% (+/-1.6)*
26.9% (+/-1.2)*
23.8% (+/-1.7)
37.2% (+/-1.9)*
30.1% (+/-1.5)*
20.6% (+/-1)*
20.5% (+/-1.3)*
25.5% (+/-1.3)*
20% (+/-1.1)
31.4% (+/-1.4)
23.8% (+/-1.7)*
25.1% (+/-1.6)*
6
43
28
3
45
51
31
14
49
15
17
44
36
29
8
11
23
9
5
40
26
38
32
38
1
13
41
26
36
42
20
33
21
22
16
11
4
50
24
18
18
34
2
10
46
47
25
48
7
34
29
40.3% (+/-1.7)
29.8% (+/-1.9)
30.7% (+/-2.4)
38.7% (+/-1.9)
28.7% (+/-1.1)
26.3% (+/-0.9)
31.3% (+/-1.4)
35.6% (+/-1.7)
28.4% (+/-1.8)
34.6% (+/-1.1)
35% (+/-1.4)
28.5% (+/-1.5)
29.4% (+/-1.6)
30.1% (+/-1.7)
33.5% (+/-1.1)
31.4% (+/-1.3)
31.3% (+/-0.7)
39.1% (+/-1.4)
39.8% (+/-2)
33.3% (+/-1.3)
32.8% (+/-1.2)
29.4% (+/-1.1)
34.6% (+/-1.1)
27% (+/-1.3)
40.2% (+/-1.6)
32% (+/-1.6)
29.3% (+/-1.2)
30.3% (+/-1.1)
30.6% (+/-2.3)
30.1% (+/-1.4)
31.1% (+/-1.2)
29.5% (+/-1.3)
31.5% (+/-1.3)
35.5% (+/-1.3)
29.7% (+/-1.4)
33.5% (+/-1.2)
37.5% (+/-1.3)
31.8% (+/-1.5)
33.7% (+/-1.1)
33.8% (+/-1.5)
38.4% (+/-1.3)
30.7% (+/-1.8)
38.8% (+/-1.8)
31.2% (+/-1.3)
24.2% (+/-0.9)
31.1% (+/-1.4)
32.5% (+/-1.3)
30.4% (+/-1.1)
41% (+/-1.5)
32.3% (+/-1.7)
28.7% (+/-1.4)
2
39
32
7
45
50
27
10
48
13
12
47
42
37
17
26
27
5
4
19
20
42
13
49
3
23
44
36
34
37
30
41
25
11
40
17
9
24
16
15
8
32
6
29
51
30
21
35
1
22
45
8
28
34
3
46
51
43
13
49
37
18
50
23
25
9
12
19
5
6
27
29
48
11
41
1
16
45
23
40
35
39
37
42
25
14
16
7
36
19
31
10
21
4
15
46
44
32
32
1
22
30
68.2% (+/-1.7)
66.1% (+/-2)
61.8% (+/-2.7)
69.9% (+/-1.9)
60.1% (+/-1.3)
56.4% (+/-1.1)
62.5% (+/-1.7)
64.6% (+/-1.9)
53.8% (+/-2.4)
62.8% (+/-1.2)
65.7% (+/-1.5)
55.4% (+/-1.6)
64.9% (+/-1.9)
64.7% (+/-1.8)
67.3% (+/-1.3)
67% (+/-1.4)*
65.3% (+/-0.8)
67.3% (+/-1.4)
67.4% (+/-2.2)
64.8% (+/-1.4)
64.1% (+/-1.4)
58% (+/-1.3)
66.2% (+/-1.2)
61.1% (+/-1.5)V
69.3% (+/-1.7)
65.5% (+/-1.7)
61.4% (+/-1.4)
65.5% (+/-1.2)
64.9% (+/-2.5)
61.8% (+/-1.7)
62.8% (+/-1.3)
62.7% (+/-1.5)
61.3% (+/-1.4)
66.1% (+/-1.4)
67.6% (+/-1.6)
65.1% (+/-1.4)
67.9% (+/-1.4)
59.9% (+/-1.7)
64.5% (+/-1.2)
64.6% (+/-1.7)
66.5% (+/-1.3)
67% (+/-1.9)
68.4% (+/-1.8)*
66.1% (+/-1.5)
59.2% (+/-1.2)
61.9% (+/-1.6)
64% (+/-1.5)
61.4% (+/-1.3)
68.8% (+/-1.5)
66.5% (+/-1.9)
64.4% (+/-1.8)
Source: Behavior Risk Factor Surveillance System (BRFSS), CDC. Red and * indicates a statistically significant increase and green and V indicates a statistically significant decrease.
10
AND RELATED HEALTH INDICATORS IN THE STATES

CHILDREN AND ADOLESCENTS
2013 YRBS
Percentage of
Obese High School
Students (95%
Conf Interval)
Alabama
17.1 (+/- 2.7)
Alaska
12.4 (+/- 2.1)
Arizona
10.7 (+/- 2.7)
Arkansas
17.8 (+/- 2.2)
California
N/A
Colorado
N/A
Connecticut
12.3 (+/- 2.3)
Delaware
14.2 (+/- 1.4)
D.C.
N/A
Florida
11.6 (+/- 1.2)
Georgia
12.7 (+/- 1.7)
Hawaii
13.4 (+/- 1.9)
Idaho
9.6 (+/- 1.5)
Illinois
11.5 (+/- 1.8)
Indiana
N/A
Iowa
N/A
Kansas
12.6 (+/- 2.1)
Kentucky
18.0 (+/- 2.5)
Louisiana
13.5 (+/- 2.7)
Maine
11.6 (+/- 1.6)
Maryland
11.0 (+/- 0.4)
Massachusetts 10.2 (+/- 1.8)
Michigan
13.0 (+/- 1.8)
Minnesota
N/A
Mississippi
15.4 (+/- 2.4)
Missouri
14.9 (+/- 2.8)
Montana
9.4 (+/- 1.1)
Nebraska
12.7 (+/- 2.0)
Nevada
11.4 (+/- 2.0)
New Hampshire 11.2 (+/- 1.7)
New Jersey
8.7 (+/- 2.2)
New Mexico
12.6 (+/- 2.4)
New York
10.6 (+/- 1.1)
North Carolina
12.5 (+/- 1.9)
North Dakota
13.5 (+/- 1.8)
Ohio
13.0 (+/- 2.4)
Oklahoma
11.8 (+/- 2.0)
Oregon
N/A
Pennsylvania
N/A
Rhode Island
10.7 (+/- 1.3)
South Carolina
13.9 (+/- 2.5)
South Dakota
11.9 (+/- 2.3)
Tennessee
16.9 (+/- 1.9)
Texas
15.7 (+/- 1.9)
Utah
6.4 (+/- 1.9)
Vermont
13.2 (+/- 2.1)
Virginia
12.0 (+/- 1.3)
Washington
N/A
West Virginia
15.6 (+/- 2.3)
Wisconsin
11.6 (+/- 2.1)
Wyoming
10.7 (+/- 1.4)
States
2011 PedNSS
Percentage of
Percentage of High School
Percentage of Obese
Overweight High
Students Who Were
Low-Income Children
School Students Physically Active At Least 60
Ages 2-4
(95% Conf Interval)
Minutes on All 7 Days
15.8 (+/- 2.7)
24.8 (+/- 2.4)
14.1%
13.7 (+/- 2.6)
20.9 (+/- 2.8)
N/A
12.7 (+/- 1.9)
21.7 (+/- 2.5)
14.5%
15.9 (+/- 2.5)
27.5 (+/- 3.0)
14.2%
N/A
N/A
16.8%V
N/A
N/A
10.0%*
13.9 (+/- 1.6)
26.0 (+/- 3.2)
15.8%
16.3 (+/- 1.7)
23.7 (+/- 2.0)
N/A
N/A
N/A
13.1%
14.7 (+/- 1.2)
25.3 (+/- 1.4)
13.1%V
17.1 (+/- 2.1)
24.7 (+/- 2.2)
13.2%V
14.9 (+/- 2.0)
22.0 (+/- 1.5)
9.2%
15.7 (+/- 1.3)
27.9 (+/- 2.7)
11.5%V
14.4 (+/- 1.7)
25.4 (+/- 2.3)
14.7%
N/A
N/A
14.3%
N/A
N/A
14.4%V
16.3 (+/- 1.8)
38.3 (+/- 2.3)
12.7%V
15.4 (+/- 2.1)
22.5 (+/- 2.6)
15.5%
16.4 (+/- 1.9)
N/A
N/A
14.2 (+/- 0.9)
22.3 (+/- 1.6)
N/A
14.8 (+/- 0.4)
21.6 (+/- 0.6)
15.3%V
12.9 (+/- 1.7)
23.0 (+/- 2.3)
16.4%V
15.5 (+/- 1.3)
26.7 (+/- 2.8)
13.2%V
N/A
N/A
12.6%V
13.2 (+/- 2.6)
25.9 (+/- 3.5)
13.9%V
15.5 (+/- 2.3)
27.2 (+/- 2.6)
12.9%V
12.9 (+/- 1.2)
27.7 (+/- 1.7)
11.7%
13.8 (+/- 1.6)
32.3 (+/- 2.6)
14.3%
14.6 (+/- 2.5)
24.0 (+/- 2.6)
12.7%
13.8 (+/- 1.6)
22.9 (+/- 2.3)
14.6%V
14.0 (+/- 2.2)
27.6 (+/- 3.7)
16.6%V
15.0 (+/- 1.8)
31.1 (+/- 2.4)
11.3%V
13.8 (+/- 1.1)
25.7 (+/- 3.3)
14.3%V
15.2 (+/- 2.2)
25.9 (+/- 2.6)
15.4%
15.1 (+/- 1.8)
24.7 (+/- 2.5)
13.1%
15.9 (+/- 2.0)
25.9 (+/- 3.7)
12.4%
15.3 (+/- 2.4)
38.5 (+/- 3.4)
N/A
N/A
N/A
14.9%
N/A
N/A
12.2%*
16.2 (+/- 2.5)
23.2 (+/- 3.8)
16.6%
16.8 (+/- 2.1)
23.8 (+/- 3.0)
N/A
13.2 (+/- 1.6)
27.7 (+/- 2.5)
15.2%V
15.4 (+/- 2.3)
25.4 (+/- 3.1)
14.2%*
15.6 (+/- 1.6)
30.0 (+/- 2.4)
N/A
11.0 (+/- 2.2)
19.7 (+/- 2.7)
N/A
15.8 (+/- 1.0)
25.4 (+/- 1.9)
12.9%
14.7 (+/- 1.4)
23.8 (+/- 1.6)
N/A
N/A
N/A
14.0%V
15.5 (+/- 2.0)
31.0 (+/- 2.4)
14.0%
13.0 (+/- 1.2)
24.0 (+/- 2.3)
14.0%
12.8 (+/- 1.2)
28.2 (+/- 2.0)
N/A
Source: Youth Risk Behavior Survey (YRBS) 2013, CDC. YRBS data are collected every 2 years. Percentages are as reported on the CDC website and can be found at <http://www.cdc.gov/HealthyYouth/
yrbs/index.htm>. Note that previous YRBS reports used the term "overweight" to describe youth with
a BMI at or above the 95th percentile for age and sex and "at risk for overweight" for those with a BMI
at or above the 85th percentile, but below the 95th percentile. However, this report uses the terms
"obese" and "overweight" based on the 2007 recommendations from the Expert Committee on the
Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity convened by
the American Medical Association. "Physically active at least 60 minutes on all 7 days" means that
the student did any kind of physical activity that increased their heart rate and made them breathe
hard some of the time for a total of least 60 minutes per day on each of the 7 days before the survey.
Source: CDC. Obesity Among

Low-Income, Preschool-Aged
ChildrenUnited States, 20082011. Vital Signs, 62(Early
Release): 1-6, 2013. http://
www.cdc.gov/mmwr/preview/
mmwrhtml/mm62e0806a1.
htm. Red and * indicates a
statistically significant increase
and green and V indicates
a statistically significant decrease from 2008-2011.
2011 National Survey of Childrens Health

Percentage of
Obese Children
Ages 10-17
Ranking
Percentage Participating in
Vigorous Physical Activity
Every Day Ages 6-17
18.6% (+/- 3.9)

14.0% (+/- 3.3)
19.8% (+/- 4.6)
20.0% (+/- 4.2)
15.1% (+/- 4.1)
10.9% (+/- 3.6)
15.0% (+/- 3.2)
16.9% (+/- 4.1)
21.4% (+/- 5.5)
13.4% (+/- 3.3)
16.5% (+/- 3.8)
11.5% (+/- 2.6)
10.6% (+/- 3.4)
19.3% (+/- 3.9)
14.3% (+/- 3.7)
13.6% (+/- 3.2)
14.2% (+/- 3.6)
19.7% (+/- 3.9)
21.1% (+/- 4.0)
12.5% (+/- 3.0)
15.1% (+/- 3.7)
14.5% (+/- 3.5)
14.8% (+/- 3.6)
14.0% (+/- 3.7)
21.7% (+/- 4.4)
13.5% (+/- 3.0)
14.3% (+/- 3.4)
13.8% (+/- 3.1)
18.6% (+/- 4.2)
15.5% (+/- 3.6)
10.0% (+/- 2.9)
14.4% (+/- 3.7)
14.5% (+/- 3.2)
16.1% (+/- 4.0)
15.4% (+/- 3.8)
17.4% (+/- 3.7)
17.4% (+/- 3.6)
9.9% (+/- 2.8)
13.5% (+/- 3.5)
13.2% (+/- 3.3)
21.5% (+/- 4.1)
13.4% (+/- 3.3)
20.5% (+/- 4.2)
19.1% (+/- 4.5)
11.6% (+/- 3.3)
11.3% (+/- 2.7)
14.3% (+/- 3.6)
11.0% (+/- 3.1)
18.5% (+/- 3.4)
13.4% (+/- 3.1)
10.7% (+/- 4.2)
11
32
7
6
21
47
23
16
3
38
17
44
49
9
28
35
31
8
4
42
21
25
24
32
1
36
28
34
11
19
50
27
25
18
20
14
14
51
36
41
2
38
5
10
43
45
28
46
13
38
48
32.7%
32.9%
26.4%
31.6%
25.2%
28.3%
25.8%
26.5%
26.8%
31.5%
30.6%
28.7%
25.5%
23.5%
28.6%
31.2%
28.2%
32.3%
31.1%
32.0%
24.4%
25.5%
27.7%
28.7%
27.7%
33.7%
32.4%
31.3%
22.4%
28.1%
25.3%
29.6%
24.6%
31.6%
30.4%
28.5%
34.9%
28.5%
27.0%
25.2%
30.3%
30.2%
34.5%
29.0%
18.1%
33.3%
26.1%
28.5%
34.1%
28.3%
30.2%
Source: National Survey of Children's Health, 2011. Health Resources and Services
Administration, Maternal and Child Health Bureau. * & red indicates a statistically
significant increase and V & green indicates a statistically significant decrease
(p<0.05) from 2007 to 2011. Over the same time period, SC had a statistically
significant increase in obesity rates, while NJ saw a significant decrease.
11
OBESITY RATES BY AGE AND ETHNICITY 2013

Obesity Rates by Age
18-25 Years Old
2013 Percentage
(95% Conf
Interval)
Alabama
20.6% (+/-2.7)
Alaska
15.4% (+/-3)
Arizona
18.9% (+/-3.6)
Arkansas
26.2% (+/-3.9)
California
13.9% (+/-1.5)
Colorado
11.4% (+/-1.6)
Connecticut
14.1% (+/-2.7)
Delaware
14.6% (+/-2.8)
D.C.
11.3% (+/-3.4)
Florida
13.8% (+/-2.1)
Georgia
17.8% (+/-2.5)
Hawaii
15.3% (+/-2.3)
Idaho
15.9% (+/-3)
Illinois
13.8% (+/-2.6)
Indiana
20.4% (+/-2.3)
Iowa
17.2% (+/-2.3)
Kansas
18.5% (+/-1.6)
Kentucky
19.4% (+/-2.5)
Louisiana
17.3% (+/-2.6)
Maine
15.3% (+/-2.1)
Maryland
15.1% (+/-2.4)
Massachusetts 13.1% (+/-1.6)
Michigan
18.1% (+/-1.9)
Minnesota
14.4% (+/-1.8)
Mississippi
25.1% (+/-2.8)
Missouri
18% (+/-2.7)
Montana
14.2% (+/-2)
Nebraska
15.8% (+/-1.5)
Nevada
13.8% (+/-2.9)
New Hampshire 14.2% (+/-2.9)
New Jersey
13.3% (+/-1.9)
New Mexico
17.9% (+/-2.2)
New York
11.7% (+/-2)
North Carolina 19.1% (+/-2.3)
North Dakota 16.3% (+/-2.6)
Ohio
16.7% (+/-2.2)
Oklahoma
23.8% (+/-2.8)
Oregon
13.5% (+/-2.5)
Pennsylvania
17.3% (+/-1.9)
Rhode Island
15.1% (+/-2.8)
South Carolina 18.8% (+/-2.1)
South Dakota 16.9% (+/-2.7)
Tennessee
16.4% (+/-3.4)
Texas
17.7% (+/-2.1)
Utah
12.8% (+/-1.4)
Vermont
14.8% (+/-2.6)
Virginia
15.2% (+/-2.5)
Washington
14.2% (+/-1.7)
West Virginia
24.3% (+/-3.2)
Wisconsin
15.9% (+/-3.2)
Wyoming
12
Rank
5
28
9
1
41
50
40
35
51
42
15
29
24
42
6
19
11
7
17
29
32
47
12
36
2
13
37
26
42
37
46
14
49
8
23
21
4
45
17
32
10
20
22
16
48
34
31
37
3
24
26-44 Years Old

2013 Percentage
(95% Conf
Interval)
34.4% (+/-1.9)
27.4% (+/-2.1)
26.7% (+/-2.5)
36.5% (+/-2.4)
25.5% (+/-1.1)
21.6% (+/-1.1)
26.3% (+/-1.6)
29.4% (+/-2.1)
21.1% (+/-2)
27.7% (+/-1.6)
30.2% (+/-1.7)
26.9% (+/-1.7)
28.2% (+/-2.1)
28.5% (+/-2)
31.8% (+/-1.5)
30.9% (+/-1.6)
31.8% (+/-1.1)
33.1% (+/-1.6)
36.9% (+/-2.1)
29.7% (+/-1.5)
28.4% (+/-1.5)
22.4% (+/-1.1)
33.2% (+/-1.5)
26% (+/-1.3)
37.8% (+/-1.8)
30.7% (+/-1.9)
24.9% (+/-1.5)
30% (+/-1.1)
28.5% (+/-2.3)
28.6% (+/-1.8)
24.8% (+/-1.2)
30.5% (+/-1.5)
24.2% (+/-1.5)
30.4% (+/-1.4)
31.5% (+/-1.9)
31.2% (+/-1.4)
33.5% (+/-1.5)
28.8% (+/-1.9)
29.4% (+/-1.3)
28.5% (+/-1.8)
34.3% (+/-1.5)
29.6% (+/-2)
33.8% (+/-2.3)
31.8% (+/-1.4)
24.5% (+/-1)
25.5% (+/-1.7)
27.3% (+/-1.6)
27.8% (+/-1.3)
36% (+/-1.8)
28.2% (+/-2.1)
Rank
5
37
40
3
43
50
41
24
51
35
20
39
32
28
11
16
11
10
2
22
31
49
9
42
1
17
45
21
28
27
46
18
48
19
14
15
8
26
24
28
6
23
7
11
47
43
38
34
4
32
Obesity Rates by Ethnicity
45-64 Years Old

2013 Percentage
(95% Conf
Interval)
38.6% (+/-1.4)
31.7% (+/-1.8)
30.3% (+/-2)
38% (+/-1.7)
29.3% (+/-1)
24.6% (+/-0.9)
27.9% (+/-1.3)
34.7% (+/-1.7)
31.6% (+/-1.9)
31.3% (+/-1.3)
34.7% (+/-1.3)
25.2% (+/-1.4)
33.1% (+/-1.7)
34% (+/-1.6)
37.1% (+/-1.2)
35.9% (+/-1.2)
35.1% (+/-0.8)
37.1% (+/-1.3)
39.9% (+/-1.5)
33% (+/-1)
33.7% (+/-1.2)
28% (+/-0.9)
36.1% (+/-1.1)
30.2% (+/-1.1)
39.9% (+/-1.3)
36.4% (+/-1.5)
29.4% (+/-1.2)
34.5% (+/-0.9)
29.4% (+/-2.1)
30.4% (+/-1.3)
28.6% (+/-1)
30.3% (+/-1.1)
29.6% (+/-1.3)
34.6% (+/-1.2)
36.2% (+/-1.5)
35.1% (+/-1.1)
36.9% (+/-1.2)
31.2% (+/-1.5)
33.8% (+/-1.1)
30% (+/-1.3)
37% (+/-1.2)
34.1% (+/-1.8)
37.7% (+/-1.8)
36% (+/-1.4)
31% (+/-1)
27.7% (+/-1.2)
34.5% (+/-1.4)
31.6% (+/-1)
38.7% (+/-1.4)
34.8% (+/-1.7)
Rank
4
30
38
5
45
51
48
19
31
33
19
50
28
25
7
15
16
7
1
29
27
47
13
40
1
11
43
22
43
37
46
38
42
21
12
16
10
34
26
41
9
24
6
14
35
49
22
31
3
18
65+ Years Old

2013 Percentage
(95% Conf
Interval)
27.5% (+/-1.3)
28.8% (+/-2.7)
22.6% (+/-1.8)
26.2% (+/-1.5)
21.5% (+/-1.1)
19.4% (+/-1)
25.5% (+/-1.4)
28.4% (+/-1.6)
23% (+/-1.8)
23.7% (+/-1.1)
25.8% (+/-1.4)
15.7% (+/-1.3)
27.1% (+/-1.7)
28.5% (+/-1.7)
28.9% (+/-1.2)
29.5% (+/-1.2)
26.1% (+/-0.8)
28% (+/-1.4)
30.5% (+/-1.5)
25.9% (+/-1.1)
26.4% (+/-1.3)
23.1% (+/-1.1)
29.7% (+/-1.2)
25% (+/-1.4)
28.4% (+/-1.3)
27% (+/-1.5)
22.6% (+/-1.2)
27.4% (+/-0.9)
22.5% (+/-2.2)
25.6% (+/-1.3)
26.1% (+/-1.2)
20.3% (+/-1.2)
25.8% (+/-1.7)
25.9% (+/-1.2)
27.1% (+/-1.5)
28.7% (+/-1.2)
26.7% (+/-1.2)
25.4% (+/-1.4)
29.1% (+/-1.1)
24.5% (+/-1.4)
26.4% (+/-1.2)
27% (+/-1.9)
26.6% (+/-1.7)
27% (+/-1.4)
25.2% (+/-1.2)
24.9% (+/-1.3)
26.7% (+/-1.5)
26.1% (+/-1)
28.5% (+/-1.5)
29.7% (+/-2)
Rank
14
7
44
26
47
50
35
11
43
41
32
51
16
9
6
4
27
13
1
30
24
42
2
38
11
18
44
15
46
34
27
49
32
30
16
8
21
36
5
40
24
18
23
18
37
39
21
27
9
2
15.5% (+/-2.9) 27 27.7% (+/-1.9) 35 30.6% (+/-1.5) 36 21.5% (+/-1.4) 47
Obesity among
Blacks
2013 Percentage
(95% Conf
Rank
Interval)
41.8% (+/-1.9) 7
37.9% (+/-9.4) 21
32.5% (+/-7.5) 38
42.2% (+/-3.5) 4
34.8% (+/-3.1) 31
30.5% (+/-4.1) 40
33.2% (+/-3.3) 36
37.3% (+/-2)
24
35.6% (+/-2)
28
34.8% (+/-2.6) 31
37.2% (+/-1.9) 25
41.1% (+/-11.2) 8
N/A
N/A
38.7% (+/-3.5) 16
42.5% (+/-3.2) 3
39.5% (+/-7.1) 12
39.2% (+/-3)
15
42% (+/-4)
5
41.9% (+/-2.1) 6
N/A
N/A
37.5% (+/-1.7) 23
33.6% (+/-2.9) 35
39.3% (+/-2.4) 14
29.8% (+/-3.9) 42
42.9% (+/-1.7) 1
40% (+/-3.5)
11
N/A
N/A
33.7% (+/-3.9) 34
34.9% (+/-5.4) 30
27.7% (+/-11.3) 43
34.5% (+/-2)
33
30.1% (+/-6.8) 41
32.7% (+/-2.7) 37
40.4% (+/-1.9) 9
24.7% (+/-11) 46
36% (+/-2.5)
27
38.7% (+/-3.6) 16
39.5% (+/-11) 12
35.6% (+/-2.4) 28
31.4% (+/-4.9) 39
42.6% (+/-1.5) 2
26.1% (+/-12.7) 44
40.4% (+/-3.5) 9
38.2% (+/-2.9) 20
26% (+/-7.9)
45
20.2% (+/-11.5) 47
38.5% (+/-2.4) 18
37.6% (+/-5)
22
36.5% (+/-6.4) 26
38.5% (+/-5.7) 18
N/A
Obesity among
Latinos
2013 Percentage
(95% Conf
Rank
Interval)
27.3% (+/-8.6) 38
28.4% (+/-6.8) 32
33.8% (+/-3.4) 8
34.3% (+/-6.4) 7
30.7% (+/-1.2) 21
28% (+/-1.8) 35
32.5% (+/-3.1) 13
29.2% (+/-5.3) 30
18.5% (+/-5) 51
26.4% (+/-2.1) 43
28.1% (+/-4) 34
29.4% (+/-3.5) 29
35.3% (+/-4.9) 5
29.9% (+/-3.7) 24
33.2% (+/-4.3) 11
37.6% (+/-5.3) 1
33.5% (+/-2.7) 10
24.5% (+/-6.6) 48
32.6% (+/-7) 12
24.2% (+/-6.8) 49
25.9% (+/-3.9) 45
31% (+/-2.2) 19
35.4% (+/-4.7) 3
30.5% (+/-4.6) 22
28.2% (+/-7) 33
33.6% (+/-7.3) 9
29.6% (+/-6.1) 28
30.4% (+/-2.7) 23
27.3% (+/-3.2) 38
24.7% (+/-8.3) 47
27.5% (+/-1.8) 36
29.8% (+/-1.2) 25
27.3% (+/-2.3) 38
27% (+/-3.1) 42
36.2% (+/-9)
2
30.9% (+/-5.5) 20
31.3% (+/-3.5) 17
31.2% (+/-4.6) 18
34.8% (+/-3.9) 6
27.5% (+/-3.2) 36
29.7% (+/-5.2) 26
31.5% (+/-7.7) 16
25.6% (+/-9.4) 46
35.4% (+/-1.6) 3
26.1% (+/-2.3) 44
27.1% (+/-8.5) 41
24.1% (+/-4) 50
29.7% (+/-2.8) 26
32.1% (+/-8.6) 15
32.4% (+/-8.1) 14
N/A 29.2% (+/-4.5)
Obesity among
Whites
2013 Percentage
(95% Conf Rank
Interval)
29.8% (+/-1)
11
26.1% (+/-1.3) 32
22% (+/-1.2)
48
32% (+/-1.3)
2
22.4% (+/-0.7) 45
18.8% (+/-0.6) 50
23.5% (+/-0.9) 43
27.4% (+/-1.1) 23
10% (+/-1.2)
51
24.5% (+/-0.8) 38
26.2% (+/-1)
30
19.3% (+/-1.5) 49
26.8% (+/-1.1) 26
27% (+/-1)
25
30.1% (+/-0.8) 8
30.1% (+/-0.8) 8
29.2% (+/-0.5) 13
31% (+/-0.8)
3
30.4% (+/-1.2) 6
28.5% (+/-0.7) 19
25.3% (+/-0.8) 36
22.4% (+/-0.6) 45
30.1% (+/-0.8) 8
25.5% (+/-0.7) 34
30.7% (+/-1.1) 5
28.8% (+/-1)
15
23.4% (+/-0.7) 44
28.6% (+/-0.6) 17
24.7% (+/-1.3) 37
27.1% (+/-0.9) 24
24.4% (+/-0.8) 40
22.2% (+/-0.9) 47
23.6% (+/-0.9) 42
26.6% (+/-0.9) 27
29.1% (+/-0.9) 14
29.4% (+/-0.8) 12
31% (+/-0.9)
3
26.2% (+/-0.9) 30
28.7% (+/-0.7) 16
25.9% (+/-1)
33
27.5% (+/-0.8) 21
28.1% (+/-1.1) 20
30.2% (+/-1.2) 7
26.5% (+/-1)
28
24.1% (+/-0.6) 41
24.5% (+/-0.8) 38
26.3% (+/-0.9) 29
27.5% (+/-0.7) 21
33.8% (+/-0.9) 1
28.6% (+/-1.1) 17
30 25.5% (+/-1)
34
Obesity Rates for Baby Boomers (45-to 64-year-olds)

WA
ND
MT
MN
VT
OR
ID
WY
MI
IA
NE
NV
IL
UT
CO
KS
IN
MO
OK
LA
TX
PA
OH
WV
TN
AR
NM
VA
NJ
DE
MD
DC
CT
RI
NC
SC
MS
NH
MA
NY
KY
CA
AZ
ME
WI
SD
AL
Obesity Rates for Seniors (65-+ year-olds)
GA
WA
MN
VT
ID
WY
UT
IN
IL
CO
KS
MO
OK
AZ
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
NH
MA
NY
MI
IA
NE
NV
ME
WI
SD
OR
HI
ND
MT
FL
AK
VA
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI
Obesity Rates for Young Adults (18- to 25-year-olds)

WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
UT
IL
CO
KS
MO
AZ
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
OK
IN
VA
NJ
DE
MD
DC
NC
SC
MS
AL
NH
MA
NY
MI
IA
NE
GA
ME
CT
RI
n <15%
n >20% & <25%
n >35% <40%
n >15% & <20%
n >25% <30%
n >40%
n >30% <35%
FL
AK
HI
STATES WITH THE HIGHEST OBESITY RATES

Rank
State
1
1 (tie)
3
4
5
6
7
8
9
10
Mississippi
West Virginia
Arkansas
Tennessee
Kentucky
Louisiana
Oklahoma
Alabama
Indiana
South Carolina
Percentage of Adult Obesity

(Based on 2013 Data,
Including Confidence Intervals)
35.1% (+/-1.6)
35.1% (+/-1.5)
34.6% (+/-1.9)
33.7% (+/-1.8)
33.2% (+/-1.4)
33.1% (+/-2.1)
32.5% (+/-1.4)
32.4% (+/-1.7)
31.8% (+/-1.2)
31.7% (+/-1.3)
Note: For rankings, 1 = Highest rate of obesity.
STATES WITH THE LOWEST OBESITY RATES

Rank
State
51
50
49
48
46 (tie)
46 (tie)
45
44
43
42
Colorado
Hawaii
D.C.
Massachusetts
California
Utah
Montana
Vermont
Connecticut
New York
Percentage of Adult Obesity

(Based on 2013 Data,
Including Confidence Intervals)
21.3% (+/-0.9)
21.8% (+/-1.4)
22.9% (+/-1.9)
23.6% (+/-1.1)
24.1% (+/-1.1)
24.1% (+/-1)
24.6% (+/-1.2)
24.7% (+/-1.4)
25% (+/-1.5)
25.4% (+/-1.2)
Note: For rankings, 51 = Lowest rate of obesity.
13
1991
PAST OBESITY TRENDS AMONG U.S. ADULTS
WA
MN
VT
ID
WY
IL
UT
CO
KS
MO
OK
LA
TX
WV
TN
AR
NM
PA
OH
KY
CA
AZ
IN
VA
2005 to 2007 Combined Data
NH
MA
NY
MI
IA
NE
NV
ME
WI
SD
OR
BRFSS: 1991, 1993 to 1995, 1998 to 2000, and
ND
MT
NJ
DE
MD
DC
CT
(BMI >30, or about 30lbs overweight for 54 person)
RI
NC
SC
MS
AL
GA
19931995 Combined Data

FL
AK
WA
HI
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
IL
UT
CO
KS
OK
LA
TX
WV
TN
AR
NM
PA
OH
KY
CA
AZ
IN
MO
NH
MA
NY
MI
IA
NE
VA
ME
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI

WA
ND
MT
MN
VT
ID
WY
UT
IL
CO
KS
OK
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
AZ
IN
MO
NH
MA
NY
MI
IA
NE
NV
ME
WI
SD
OR
VA
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA

FL
AK
WA
ND
MT
MN
HI
VT
WI
SD
OR
ID
WY
NV
UT
IL
CO
KS
MO
n No Data
n >20% <25%
n <10%
n >25% <30%
n >10% & <15%
n >30%
n >15% & <20%
AZ
NM
TX
AL
GA
FL
AK
VA
NC
SC
MS
HI
14
WV
TN
AR
LA
PA
OH
KY
CA
OK
IN
NH
MA
NY
MI
IA
NE
NJ
DE
MD
DC
ME
CT
RI
RATES AND RANKINGS METHODOLOGY11

The analysis in The State of Obesity
BRFSS made two changes in methodology
compares data from the Behavioral Risk
for its dataset starting in 2011 to make
Factor Surveillance System.
the data more representative of the total
BRFSS is the largest ongoing telephone

health survey in the world. It is a
state-based system of health surveys
established by CDC in 1984. BRFSS
population. The changes included making

survey calls to cell phone numbers and
adopting a new weighting method:
l
The first change is including and then
completes more than 400,000 adult
growing the number of interview calls
interviews each year. For most states,
made to cell phone numbers. Estimates
BRFSS is the only source of population-
today are that three in 10 U.S.
based health behavior data about chronic
households have only cell phones.
disease prevalence and behavioral risk

factors.
The second is a statistical measurement

change, which involves the way the
BRFSS surveys a sample of adults in
data are weighted to better match the
each state to get information on health
demographics of the population in the
risks and behaviors, health practices for
state.
preventing disease and healthcare access

mostly linked to chronic disease and
injury. The sample is representative of the
population of each state.
The new methodology means the BRFSS

data will better represent lower-income
and racial and ethnic minorities, as well
as populations with lower levels of formal
Washington, D.C., is included in the
education. Although generalizing is difficult
rankings because CDC provides funds
because of these variables, it is likely
to the city to conduct a survey in an
that the changes in methods will result
equivalent way to the states.
in somewhat higher estimates for the
The data are based on telephone surveys

by state health departments, with
assistance from the CDC. Surveys ask
occurrence of behaviors that are more

common among younger adults and to
certain racial and ethnic groups.
people to report their weight and height,
The change in methodology makes direct
which is used to calculate BMI. Experts
comparisons to data collected prior to
say rates of overweight and obesity are
2011 difficult.
probably slightly higher than shown by the

data because people tend to underreport
their weight and exaggerate their height.22
More information on the methodology is

available in Appendix A.
15
DEFINITIONS OF OBESITY AND OVERWEIGHT

Obesity is defined as an excessively high
and lower than the 95th percentile
amount of body fat or adipose tissue in
for children of the same age and sex;
relation to lean body mass.
23,24
Overweight
childhood obesity is defined as a BMI
refers to increased body weight in relation
at or above the 95th percentile for
to height, which is then compared to a
children of the same age and sex; and
standard of acceptable weight.25 Body
severe childhood obesity is defined as
mass index is a common measure
a BMI greater than 120 percent of 95th
expressing the relationship (or ratio) of
percentile for children of the same age
weight to height. The equation is:
and sex.
BMI =
Weight in pounds
(Height in inches) x (Height in inches)
x 703
Adults with a BMI of 25 to 29.9
BMI is considered an important measure
are considered overweight, while
for understanding population trends. For
individuals with a BMI of 30 or more
individuals, it is one of many factors
are considered obese.
that should be considered in evaluating
For children, overweight is defined as

a BMI at or above the 85th percentile
SOCIOECONOMICS AND OBESITY
healthy weight, along with waist size, body

fat composition, waist-to-hip ratio, blood
pressure, cholesterol level and blood sugar.26
An analysis of the 2012 BRFSS data looking at income, level

of schooling completed and obesity finds strong correlations
between obesity and income, and between obesity and education:
l
Over 35 percent of adults age 26 and older who did not

graduate high school were obese, compared with 22.1 percent
of those who graduated from college or technical college.
Thirty-three percent of adults who earn less than $15,000 per

year were obese, compared with 25.4 percent of those who
earned at least $50,000 per year.27
35.3% of adults with

no high school diploma
are obese
22.1% of adults who

graduated college or
technical college are obese
An analysis of obesity, income and education from the 20052008 NHANES found that:28
l
Among men, obesity prevalence is similar at all income levels

whereas among women obesity prevalence increases as income
decreases.
Among men, education level is not significantly related to obesity prevalence, but among women obesity prevalence increases
as education decreases.
16
B. CHILDHOOD AND
YOUTH OBESITY AND
OVERWEIGHT RATES
1. STUDY OF CHILDREN FROM LOW-INCOME FAMILIES (2011)
The Pediatric Nutrition Surveillance Survey (PedNSS), which

examines children between the ages of 2 and 5 from lowerincome families,29 found that 14.4 percent of this group
was obese in 2011, compared with 12.1 percent of all U.S.
children of a similar age.30 The data for PedNSS is based on
actual measurements rather than self-reported data.
The obesity rates increased from 1999
and Latino children (17.5 percent).
(12.7 percent) to 2011 (14.4 percent),
From 2008 to 2011, 18 states out of the
although rates have remained stable
40 states and D.C. that participate in the
since 2003. The highest obesity rates
survey and the U.S. Virgin Islands had a
were seen among American Indian and
statistically significant decrease, and only
Alaska Native children (20.8 percent)
three states increased during this time.
PedNSS 199831
WA
ND
MT
MN
VT
ID
WY
UT
IL
CO
KS
OK
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
AZ
IN
MO
NH
MA
NY
MI
IA
NE
NV
ME
WI
SD
OR
VA
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI
PedNSS 2011
WA
n <10%
n >10% & <15%
MN
VT
WI
SD
OR
n No Data
ND
MT
ID
WY
n >15%
NV
UT
MI
IA
NE
IL
CO
KS
MO
AZ
NM
TX
LA
PA
OH
WV
TN
AR
NH
MA
NY
KY
CA
OK
IN
VA
NJ
DE
MD
DC
ME
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI
17
2. STUDY OF CHILDREN AGES 10 TO 17 (2011)
The most recent data for childhood statistics on a state-bystate level are from the 2011 National Survey of Childrens
Health (NSCH).32 According to the study, obesity rates
for children ages 10 to 17, defined as BMI greater than the
95th percentile for age group, ranged from a low of 9.9
percent in Oregon to a high of 21.7 percent in Mississippi.
Seven of the 10 states with the highest
The NSCH study is based on a survey
rates of obese children are in the
of parents in each state. The data are
South. Only two states had statistically
derived from parental reports, so they
significant changes for rates of obese
are not as reliable as measured data,
children between the 2007 to 2011
such as NHANES and PedNSS, but
surveys: South Carolina saw an increase
they are the only source of comparative
and New Jersey saw a decrease.
state-by-state data for children.
PROPORTION OF CHILDREN AGES 10 TO 17 CLASSIFIED AS OBESE BY STATE

Obese 10- to 17-Year-Olds, 2011 NSCH
WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
UT
IL
CO
KS
MO
OK
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
AZ
IN
VA
NC
SC
MS
AL
GA
FL
AK
HI
n No Data n <10% n >10% & <15% n >15% & <20% n >20% <25%
n >25% <30% n >30%
Source: National Survey on Childrens Health, 2011.
18
NH
MA
NY
MI
IA
NE
NJ
DE
MD
DC
ME
CT
RI
STATES WITH THE HIGHEST RATES OF OBESE 10- TO 17-YEAR-OLDS

Rank
States
1
Mississippi
2
South Carolina
3
D.C.
4
Louisiana
5
Tennessee
6
Arkansas
7
Arizona
8
Kentucky
9
Illinois
10
Texas
Note: For rankings, 1 = Highest rate of obesity.
Percentage of Obese 10- to 17-year-olds

(95 percent Confidence Intervals)
21.7% (+/- 4.4)
21.5% (+/- 4.9)
21.4% (+/- 5.5)
21.1% (+/- 4.0)
20.5% (+/- 4.2)
20.0% (+/- 4.2)
19.8% (+/- 4.6)
19.7% (+/- 3.9)
19.3% (+/- 3.9)
19.1% (+/- 4.5)
Seven of the states with

the highest rates of obese
10- to 17-year-olds are
in the South.
STATES WITH THE LOWEST RATES OF OBESE 10- TO 17-YEAR-OLDS

Rank
States
51
Oregon
50
New Jersey
49
Idaho
48
Wyoming
47
Colorado
46
Washington
45
Vermont
44
Hawaii
43
Utah
42
Maine
Note: For rankings, 51 = Lowest rate of obesity.
Percentage of Obese 10- to 17-year-olds

(95 percent Confidence Intervals)
9.9% (+/- 2.8)
10.0% (+/- 2.9)
10.6% (+/- 3.4)
10.7% (+/- 4.2)
10.9% (+/- 3.6)
11.0% (+/- 3.1)
11.3% (+/- 2.7)
11.5% (+/- 2.6)
11.6% (+/- 3.3)
12.5% (+/- 3.0)
19
3. STUDY OF HIGH SCHOOL STUDENTS (2013)
The Youth Risk Behavior Surveillance System (YRBSS) includes both national and state
surveys that provide data on adolescent obesity and overweight rates, most recently in
2013.33 The information from the YRBSS is based on self-reported information.
There was an increase from 1999 to
of 38.5 percent in Oklahoma to a low
2013 in the prevalence of students
of 19.7 percent in Utah, with a median
13.7 percent of high school
nationwide who were obese (10.6
prevalence of 25.4 percent.
students were obese, and 16.6
percent to 13.7 percent) and who
According to the national survey,
percent were overweight.
34
The latest state surveys also found
were overweight (14.2 percent to 16.6
a range of obesity levels: a low of
percent).35 Students also reported on
6.4 percent in Utah to a high of
whether or not they participated in
18.0 percent in Kentucky, with a
at least 60 minutes of physical activity
median prevalence of 12.4 percent.
every day of the week. The most recent
Overweight prevalence among high
state surveys, conducted in 42 states,
school students ranged from a low of
found a wide range in the percentage
11.0 percent in Utah to a high of 17.1
of high school students who were
percent in Georgia, with a median
physically active for at least 60 minutes
prevalence of 14.9 percent.
per day seven days a week, from a high
PERCENTAGE OF HIGH SCHOOL STUDENTS WHO WERE OBESE

Selected U.S. states, Youth Risk Behavior Surveillance System, 2013
WA
14
OR
MN
10
11
6
CA
11
12 15
13
12
13
16
15
16
14
11
13
13
13
11
13
12
12
PA
13
18
16
17
15 17
12
9
14
11
12
12
11
10
11
12
13
14
12
12
13
n No Data n <10% n 10% 14% n 15% 19%

Source: YBRS. Trend maps from 2003 to 2013 are available at: http://www.cdc.gov/healthyyouth/
obesity/obesity-youth.htm.
20
PERCENTAGE OF OBESE AND OVERWEIGHT U.S. HIGH SCHOOL

STUDENTS BY SEX
Obese
10.9%
16.6%
13.7%
Female
Male
Total
Overweight
16.6%
16.5%
16.6%

STUDENTS BY RACE/ETHNICITY
Obese
13.1%
15.7%
15.2 %
13.7%
White*
Black*
Latino
Total**
Overweight
15.6%
19.1%
18.3%
16.6%
Notes: CDC uses the term Hispanic in their analysis. *Non-Hispanic. **Other race/ethnicities are
included in the total but are not presented separately.

STUDENTS BY SEX AND RACE/ETHNICITY
Obese
White*
Black*
Latino
Total**
Female
9.7%
16.7%
11.4%
10.9%
Overweight
Male
16.5%
14.8%
19.0%
16.6%
Female
14.3%
22.8%
19.2%
16.6%
Male
16.9%
15.2%
17.4%
16.5%
Notes: CDC uses the term Hispanic in their analysis. *Non-Hispanic. **Other race/ethnicities are
included in the total but are not presented separately.
21
C. ADDITIONAL TRENDS
The 10 states with the highest
1. TYPE 2 DIABETES
Diabetes rates have nearly doubled
percent of people with diabetes are
in the past 20 years from 5.5
overweight or obese.
rates of type 2 diabetes are all
percent in 1988 to 1994 to 9.3
in the South. Alabama had the
percent in 2005 to 2010.36 More
highest rate at 13.8 percent.
than 25 million American adults

have diabetes and another 79 million
have prediabetes. The CDC projects
that one-in-three adults could have
diabetes by 2050.37 More than 80
Approximately 215,000 children

(ages 2 to 20) have diabetes and 2
million teens (ages 12 to 19) have
prediabetes.38, 39 Youth type 2 diabetes
(ages zero to 19) increased 30.5
percent from 2001 to 2009.40
STATES WITH THE HIGHEST RATES OF ADULT DIABETES

Rank
State
1
2
3
4
5
6
7
8
9
10
Alabama
West Virginia
Mississippi
South Carolina
Tennessee
Louisiana
Arkansas
North Carolina
Florida
Delaware
Percentage of Adult Diabetes

(Based on 2013 Data, Including Confidence Intervals)
13.8% (+/-1.1)*
13% (+/-0.9)
12.9% (+/-1)
12.5% (+/-0.8)
12.2% (+/-1.1)
11.6% (+/-1.1)
11.5% (+/-1.1)
11.4% (+/-0.8)
11.2% (+/-0.7)
11.1% (+/-1.1)
Obesity
Ranking
8
1
1
10
4
6
3
25
37
13
*Note: For rankings, 1 = Highest rate of type 2 diabetes
STATES WITH THE LOWEST RATES OF ADULT DIABETES

Rank
State
51
49 (tie)
49 (tie)
48
47
45 (tie)
45 (tie)
44
43
41 (tie)
41 (tie)
Colorado
Alaska
Utah
Minnesota
Montana
D.C.
Vermont
Wisconsin
Connecticut
Hawaii
Idaho
Percentage of Adult Diabetes

6.5% (+/-0.5)^
7.1% (+/-1.1)
7.1% (+/-0.5)
7.4% (+/-0.8)
7.7% (+/-0.7)
7.8% (+/-1)
7.8% (+/-0.8)
8.2% (+/-1)
8.3% (+/-0.8)
8.4% (+/-0.9)
8.4% (+/-0.9)
*Note: For rankings, 51 = Lowest rate of type 2 diabetes
22
Obesity
Ranking
51
28
46
41
45
49
44
22
43
50
23
2. HEART DISEASE AND HYPERTENSION

One in four Americans has some
One in three adults has high blood
form of cardiovascular disease.
pressure, a leading cause of stroke.44
The 10 states with the highest
Heart disease is the leading cause of
Approximately 30 percent of cases of
rates of hypertension are all in
death responsible for one in three
hypertension may be attributable to
deaths in the United States.
obesity, and the figure may be as high
the South. West Virginia had the
41, 42
At least one out of every five U.S.

teens has abnormal cholesterol, a
major risk factor for heart disease
among obese teens, 43 percent
(more than two in five) have
abnormal cholesterol.43
as 60 percent in men under age 45.45
highest rate at 41 percent.
People who are overweight are more

likely to have high blood pressure,
high levels of blood fats and high LDL
(bad cholesterol), which are all risk
factors for heart disease and stroke.46
STATES WITH THE HIGHEST RATES OF ADULT HYPERTENSION

Rank
State
1
2
3
4
5
6
7
8
9
10
West Virginia
Alabama
Mississippi
Louisiana
Kentucky
Tennessee
Arkansas
South Carolina
Oklahoma
Delaware
Percentage of Adult Hypertension

41% (+/-1.5)
40.3% (+/-1.7)
40.2% (+/-1.6)
39.8% (+/-2)
39.1% (+/-1.4)
38.8% (+/-1.8)
38.7% (+/-1.9)
38.4% (+/-1.3)
37.5% (+/-1.3)
35.6% (+/-1.7)
Obesity
Ranking
1
8
1
6
5
4
3
10
7
13
*Note: For rankings, 1 = Highest rate of hypertension.
STATES WITH THE LOWEST RATES OF ADULT HYPERTENSION

Rank
State
51
50
49
48
47
45 (tie)
45 (tie)
44
42 (tie)
42 (tie)
Utah
Colorado
Minnesota
D.C.
Hawaii
California
Wyoming
Montana
Idaho
Massachusetts
Percentage of Adult Hypertension

24.2% (+/-0.9)
26.3% (+/-0.9)
27% (+/-1.3)
28.4% (+/-1.8)
28.5% (+/-1.5)
28.7% (+/-1.1)
28.7% (+/-1.4)
29.3% (+/-1.2)
29.4% (+/-1.6)
29.4% (+/-1.1)
Obesity
Ranking
46
51
41
49
50
46
30
45
23
48
*Note: For rankings, 51 = Lowest rate of hypertension.
23
3. OTHER HEALTH RISKS

In addition to diabetes, heart disease and
percent of cases among women are
hypertension, obesity is related to dozens
related to overweight and obesity.49
of serious health problems. For instance:

l
Cancers Attributable to Obesity
diagnosed with arthritis are
links between maternal health
overweight or obese.50
chronic diseases and increased risks
Women
in men is attributable to obesity.48

l
An estimated 24.2 percent of kidney

disease cases among men and 33.9
33.9%
24.2%
Women
Men
Arthritis Attributable to Obesity
70%
Women
24
Both overweight and obesity at

midlife independently increase the
risk of dementia, Alzheimers disease
Approximately 20 percent of cancer

in women and 15 percent of cancer
Men
Kidney Disease Attributable to Obesity
before, during and after childbirth.47
15%
Almost 70 percent of individuals
A growing body of evidence shows

conditions - including obesity,
20%
and vascular dementia.51, 52

l
Obese adults are more likely to

have depression, anxiety and other
mental health conditions.53
4. PHYSICAL INACTIVITY IN ADULTS

Eighty percent of American adults
adults.57 Studies have also found the
do not meet the aerobic and muscle
more sedentary the mother, the more
Mississippi had the highest
strengthening recommendations for
sedentary the child, and the more
reported percentage of inactivity
physical activity.
physically active the mother, the more
among adults at 38.1 percent.
54
Sixty percent of
adults are not sufficiently active to

achieve health benefits.55 There are
also health risks to being sedentary
(physically inactive), including
increased risk of mortality and
metabolic syndrome.56 Sedentary
adults pay $1,500 more per year in
healthcare costs than physically active
physically active the child early in life.58

Reports of physical inactivity rates among
adults are based on the number of
State
1
2
3
4
5
6
7
8
9
10
Mississippi
Tennessee
Arkansas
Oklahoma
Louisiana
Alabama
West Virginia
Indiana
Kentucky
Texas
inactive adults in the past year.
survey respondents who responded that

they did not engage in physical activity
or exercise during the previous 30 days
other than doing their regular jobs.
STATES WITH THE HIGHEST PHYSICAL INACTIVITY RATES

Rank
Forty states has rising rates of
Percentage of Adult Physical Inactivity

38.1% (+/-1.7)*
37.2% (+/-1.9)*
34.4% (+/-1.9)*
33% (+/-1.4)*
32.2% (+/-2.1)
31.5% (+/-1.7)*
31.4% (+/-1.4)
31% (+/-1.2)*
30.2% (+/-1.4)
30.1% (+/-1.5)*
Obesity
Ranking
1
4
3
7
6
8
1
9
5
15
*Note: For rankings, 1 = Highest rate of physical inactivity.
Adults who do not meet the

aerobic and muscle strengthening
recommendations for physical activity
80%
Adults who are not sufficiently active
to achieve health benefits
STATES WITH THE LOWEST PHYSICAL INACTIVITY RATES, 2012

Rank
State
51
50
49
48
47
46
45
44
43
42
Colorado
Oregon
D.C.
Washington
Vermont
Utah
California
Hawaii
Alaska
New Hampshire
Percentage of Adult Physical Inactivity

17.9% (+/-0.9)
18.5% (+/-1.5)*
19.5% (+/-2)
20% (+/-1.1)
20.5% (+/-1.3)*
20.6% (+/-1)*
21.4% (+/-1.1)*
22.1% (+/-1.5)*
22.3% (+/-1.8)*
22.4% (+/-1.5)*
Obesity
Ranking
51
36
49
32
44
46
46
50
28
35
60%
*Note: For rankings, 51 = Lowest rate of physical inactivity.
25
D. ADULT FRUIT
AND VEGETABLE
CONSUMPTION, 201159
The foods around us make it difficult to maintain a healthy

weight. Making healthy foods the easily available and
affordable option will improve our chances to achieve
and maintain a healthy weight.60 Diets high in fruits and
vegetables may reduce the risk of cancer and other chronic
diseases and also provide essential vitamins and minerals,
fiber and other nutrients that are important for good health.
Most fruits and vegetables are naturally low in fat and calories
and are filling.61 Increasing consumption of fruits and
vegetables is a necessary step to improving overall health.
Nationally, 37.7 percent of adults consume fruits less than one time a day and
22.6 consume vegetables less than one time a day.
Lynn Johnson, used with permission from RWJF
26
SECTI O N 2:
CURRENT STATUS:
National recommendations call for children and

adolescents to get at least 60 minutes of physical activity
per day, most of which should be moderate or vigorous in
intensity.62 The first U.S. report card on physical activity for
children and youth, which was released in April 2014 by the
National Physical Activity Plan Alliance and the American
College of Sports Medicine, found that only about a quarter
of children ages 6 to 15 meet that recommendation.63
According to the report, America earned a D- for overall
physical activity, a C- for school-based physical activity and
an F for active transportation, which primarily assessed the
The State of
Obesity:
Obesity Policy
Series
PHYSICAL ACTIVITY BEFORE, DURING AND AFTER SCHOOL
Physical Activity Before, During

and After School
percentage of youths who walk or bicycle to school.

Efforts to provide physical education
physical activity organizations, and
and increase physical activity often
opening physical activity facilities to
focus on schools because that is where
families outside of school hours.
school-age children spend a significant

portion of their day. There are a
number of types of physical activity
that schools can support as part of a
Comprehensive School Physical Activity
Program (CSPAP), which encompasses
physical education, interscholastic
activity clubs, classroom physical
activity breaks, before school access
to physical activity opportunities or
facilities, recess for elementary school
students, walking and biking to school,
sharing facilities with community
Education Program (PEP), the only

federal funding stream for physical
education programs, provides
federal grants to school districts
and community organizations that
implement comprehensive physical
fitness and nutrition programs for
students designed to help reach
state physical education standards.
Authorized by the Elementary and
Secondary Education Act (ESEA),
$74.6 million was appropriated for
PEP in Fiscal Year (FY) 2014.64
SEPTEMBER 2014
sports, intermural sports and physical
The Carol M. White Physical
While all 50 states have enacted physical education

standards or requirements, the scope of these laws and
the degree to which they are funded and enforced varies
significantly. Currently, no more than 5 percent of school
districts nationwide have a wellness policy that requires
the recommended amount of daily physical education
time,65 and children at highest risk for obesity are the
least likely to attend schools that offer recess.66
The Presidential Youth Fitness
ESEA was last reauthorized in 2002
Communication tools to help
for five years; since 2007, Congress
physical educators increase
Program and Lets Move!
has enacted temporary extensions
awareness about their work in the
Active Schools are two other
of the current law. In the interim,
classroom; and
federal programs that help

schools improve students
physical fitness.
proposals have included increasing

resources for PEP, providing funding
for schools to hire additional physical
education teachers and requiring
school boards to collect and publish
data on the extent to which they have
Options to recognize fitness and

physical activity achievements.67
Hundreds of schools nationwide have

already received funding to help bring
Presidential Youth Fitness Program
resources to their schools.
physical education and physical
Lets Move! Active Schools is a
The Presidential Youth Fitness Program

provides a model for fitness education
that helps physical educators assess, track
and recognize youth fitness and physical
activity. The program provides resources
and tools for physical educators to
improve their current physical education
process, which includes:
l
FITNESSGRAM health-related
fitness assessment;
Instructional strategies to promote

student physical activity and fitness;
made progress in meeting national

activity standards.
28
program that helps teachers,

principals, administrators and parents
create environments that enable
all students to get and stay active.
Schools that sign up for the program
are guided through a process that
helps them build a team, make a plan
and access free in-person trainings,
program materials and activation
grants, and direct, personal assistance
from certified professionals. Once
schools achieve their fitness goals,
they are publicly recognized and
celebrated for their achievement.68
Other federal programs are designed
programming.70 Starting in 2014, the
began consideration of legislation to
to provide additional physical activity
Boys & Girls Clubs of America and
reauthorize MAP-21 as the current
opportunities for students and young
the National Recreation and Park
program will expire on October 1, 2014.
children. For example, 21st Century
Association agreed to provide at least
Community Learning Centers,
30 minutes of physical activity during
administered by the Department of
after-school and summer programs.71
Education, is the exclusive federal
More than half of states have adopted

Complete Streets policies,72 which help
ensure that road planning considers
The federal government also provides
all users by incorporating features
funding for programs supporting
such as sidewalks and bike lanes. A
physical activity outside of school-based
growing number of states also have
settings. The U.S. Department of
enacted legislation to facilitate joint-use
In 2011, national standards for physical
Transportations (DOT) Transportation
agreements,73 which allow community
activity in out-of-school time programs
Alternatives program provides grants
members to use facilities like school
were developed and adopted by the
to states and localities to fund walking
athletic fields and playgrounds for
National AfterSchool Association.
and biking projects. However, overall
physical activity outside of the school day,
These standards include a requirement
funding levels for these projects,
but approximately 70 percent of school
for at least 60 minutes of moderate
including Safe Routes to School (SRTS),
districts nationwide have no policy
and vigorous physical activity per day
were reduced when Congress last
regarding such agreements.74 In recent
while children are in care for a full-
reauthorized the surface transportation
years, 14 states have adopted policies and
day program and 30 minutes for a
law, known as Moving Ahead for
national standards have been developed
half-day program. The YMCA of the
Progress in the 21st Century (MAP-21),
to help increase the amount of physical
USA committed to these standards
in 2012. MAP-21 is authorized through
activity youths accumulate while
in its early learning and after-school
the end of FY 2014; Recently, Congress
attending after-school programs.75
funding source for various types of

after-school programming, including
recreation activities.
69
29
Source: Active Living Research
WHY PHYSICAL ACTIVITY IN AND OUT OF SCHOOL MATTERS:

l
Physical activity provides a wide
Nationwide, more than 8 million children
associated with improved academic
people. Research has shown that
performance, enhanced academic focus
school programs. Integrating physical
regular physical activity can strengthen
and better behavior in the classroom.
activity into the daily routine of such
maintain a healthy weight and reduce

the likelihood of high blood pressure,
cholesterol or type 2 diabetes.76
and adolescents participate in after78
programs can lead to increased physical
Well-structured physical education
activity among youths.81
programs can result in children who

are more active.79 In addition, providing
Cooperation between schools and
short activity breaks during the school
communities also can help. When
A systematic review of 50 studies
day can increase physical activity in
young people have access to school
found that the majority found a positive
students and improve some measures
recreational facilities outside of school
association between physical activity
of health, such as muscle strength,
hours, they tend to be more active.82
and academic performance.
endurance and flexibility.
77
30
Regular physical activity also is
variety of health benefits for young
muscles and bones, help young people
80
Policy Recommendations:
l
School districts, with support from federal, state and local governments, should provide
regular physical activity opportunities in schools and communities to help children and
adolescents be active for at least 60 minutes per day.
Schools should conduct student fitness assessments to help assess rates of childhood obesity
and evaluate the extent to which physical education and/or physical activity programs help
students maintain or achieve a healthy weight.
School wellness policies should address physical education and physical activity in
after-school and out-of-school programs, including school partnerships with nonprofit
organizations. Wellness programs also should consider the needs of faculty and staff, so
they can be role models for students and more healthy and productive educators.
Schools and communities nationwide should prioritize joint-use agreements to provide

access to school facilities for recreational use outside of school hours.
21st Century Community Learning Centers and other after-school providers should adopt
the National AfterSchool Associations Healthy Eating and Physical Activity standards.
ADDITIONAL RESOURCES:
Institute of Medicine: Educating the Student Body: Taking
Active Living Research: Active Education: Physical
Physical Activity and Physical Education to School:
Education, Physical Activity and Academic Performance:
http://www.iom.edu/Reports/2013/Educating-the-Student-Body-
http://www.activelivingresearch.org/activeeducation
Taking-Physical-Activity-and-Physical-Education-to-School.aspx
Active Living Research: Policies and Standards for
U.S. Department of Health and Human Services: Physical
Promoting Physical Activity in After-School Programs:
Activity Guidelines for Americans Midcourse Report: Strategies
http://www.activelivingresearch.org/afterschool
to Increase Physical Activity Among Youth:
CDCs Comprehensive School Physical Activity Programs:
http://www.health.gov/paguidelines/
A Guide for Schools.
Active Living Research: School Policies on Physical Education
http://www.cdc.gov/healthyyouth/physicalactivity/cspap.htm
and Physical Activity:

http://www.activelivingresearch.org/schoolpolicy
31
STATE SCHOOL-BASED PHYSICAL ACTIVITY AND HEALTH SCREENING LAWS

Physical Education and Activity
l
Every state has some physical
Twenty-eight states currently
playgrounds, tracks and fields, but they
education requirements for students.
have laws supporting shared use
are not accessible to the community.
However, these requirements are
of facilities, including: Alabama,
Many schools keep their facilities closed
often limited or not enforced, and
Arizona, Arkansas, California,
after school hours for fear of liability in
many programs are inadequate.
Delaware, Georgia, Hawaii, Idaho,
the event of an injury, vandalism and
Indiana, Kansas, Kentucky,
the cost of maintenance and security.
Louisiana, Michigan, Minnesota,
Some states and communities have
Mississippi, Missouri, Nebraska,
laws encouraging or requiring schools
North Carolina, North Dakota,
to make facilities available for use by
Oklahoma, South Carolina, South
the community through shared- or joint-
Dakota, Tennessee, Texas,
use agreements.84 These agreements
Utah, Virginia, Washington and
allow school districts, local governments
Wisconsin.
and community-based organizations to
83
Many states have started enacting laws

requiring schools to provide a certain
number of minutes and/or a specified
difficulty level of physical activity.
Twenty-one specifically require schools
to provide physical activity or recess
during the school day: Arizona, Colorado,
Connecticut, Hawaii, Illinois, Indiana, Iowa,
32
Shared-use Agreements
Kentucky, Louisiana, Maine, Mississippi,
Many communities do not have enough
Missouri, Nevada, New Hampshire, North
safe and accessible places for people
Carolina, North Dakota, Ohio, South
to be physically active, indoors and out.
Carolina, Tennessee, Texas and Virginia.
Schools often have gymnasiums,
overcome common concerns, costs and

responsibilities that come along with
opening school property to the public
after hours.
HEALTH ASSESSMENT AND HEALTH EDUCATION

Physical activity, nutrition and other factors impact the overall health of students. A number of states have instituted legislation
to conduct health assessments to help parents, schools and communities understand the health of children and teens, and
nearly every state requires some form of health education classes for students.
Health Assessments
l
childs medical home, and the Institute
Twenty-one states currently
of Medicine (IOM) recommends annual
have legislation that requires
school-based BMI screenings.
BMI screening or weight-related
has identified safeguards for schools who
assessments other than BMI.
conduct BMI screenings to ensure they
85, 86
CDC
focus on promoting health and positive

l
States with BMI screening
Just over 88 percent of states and

39.1 percent of districts required
each school to have a school health
education coordinator.
Wellness Policies
Wellness policies are written documents
wellness for children.87
requirements: Arkansas, California*,
that guide a local education agency or
Florida, Illinois, Maine, Missouri,
Health Education
New York, North Carolina, Ohio,
school districts process to establish a
Only two states Colorado and
healthy school environment. Wellness
Oklahoma, Pennsylvania, Tennessee,
Oklahoma do not require schools
policies were originally required by the
Vermont and West Virginia.
to provide health education.
Child Nutrition and WIC Reauthorization
States with other weight-related
Health education curricula often include
screening requirements: Delaware,
community health, consumer health,
Iowa, Louisiana, Massachusetts,
environmental health, family life, mental
Nevada, South Carolina and Texas.
and emotional health, injury prevention
As of July 2010, statewide distribution of diabetes risk information to

schoolchildren, California Education
Code 49452.7, replaced individual
BMI reporting, California Education
Code 49452.6.
BMI and other health assessments

are intended to help schools and
communities assess rates of childhood
obesity, educate parents and students
and safety, nutrition, personal health,

prevention and control of disease and
substance use and abuse. The goal of
school health education is to prevent
premature deaths and disabilities by
improving the health literacy of students.88
Act of 2004 and updated and

strengthened by the Healthy Hunger-Free
Kids Act (HHFKA) of 2010. Each local
education agency participating in the
National School Lunch Program (NSLP)
and/or School Breakfast Program must
develop a wellness policy. At a minimum,
wellness policies must include specific
goals for: nutrition promotion; nutrition
education; physical activity; and other
school-based activities that promote
According to a 2012 CDC study, health
student wellness. Since the update to
education standards and curricula vary
the rule in 2010, local education agencies
greatly from school to school.
are now required to periodically measure
89
The percentage of states that require
and serve as a means to evaluate obesity
districts or schools to follow national
prevention and control programs in that
or state health education standards
school and community. The American
increased from 60.8 percent in 2000
Academy of Pediatrics (AAP) recommends
to over 90 percent in 2012; the
that BMI should be calculated and
percentage of districts that required
plotted annually for all youth as part of
this of their schools increased from
normal health supervision within the
68.8 percent to 82.4 percent.
and provide an assessment of the

wellness program to the public including
the implementation of the wellness policy,
the extent to which the schools are in
compliance with the policy, how well the
policy compares to model policies and
a description of the progress made in
attaining the wellness policy goals.90
33
STATE ACTIVE TRANSPORTATION LAWS

Safe Routes to Schools
l
Safe Routes to School programs
pedestrians.91, 92, 93 While every state
operate in all 50 states and
currently participates in some form of
Washington, D.C., benefiting close
SRTS activities, implementation and
to 15,000 schools. Every state
funding support varies.
and Washington, D.C., has an SRTS
Complete Streets Policies
coordinator.
Twenty-eight states and Washington,

D.C. have adopted Complete Streets
Department of Transportation to
Policies: California, Colorado,
promote walking and biking to school.
Connecticut, Delaware, Florida,
The program supports improving
Georgia, Hawaii, Illinois, Louisiana,
sidewalks, bike paths and safe street
Maryland, Massachusetts, Michigan,
crossings; reducing speeds in schools
Minnesota, Mississippi, New Jersey,
zones and neighborhoods; addressing
New York, North Carolina, Oregon,
distracted driving; and educating
Pennsylvania, Rhode Island, South
people about pedestrian and bike
Carolina, Tennessee, Texas, Vermont,
safety. The program includes a range of
Virginia, Washington, West Virginia
partners, such as educators, parents,
and Wisconsin.
planners, business and community

leaders, health officials and members
of the community. Early studies of the
program have shown a positive effect on
physically active travel among children
SRTS was created by the U.S.
students, government officials, city
34
and a reduction in crashes involving
Complete Streets policies encourage

physical activity and green
transportation, walking and cycling and
building or protecting urban transport
systems that are fuel-efficient, spacesaving and promote healthy lifestyles.
SECTI O N 3:
CURRENT STATUS:
The Healthy, Hunger-Free Kids Act, enacted in December

2010, directed the U.S. Department of Agriculture
(USDA) to update the nutrition standards for school
meals for the first time in more than a decade, and
update standards for school snacks and drinks for the first
time in more than 30 years.
The healthier lunch standards went
85 percent of these authorities were
into effect at the beginning of the
making do with a less-efficient process
2012 to 2013 school year and the
or a workaround.
healthier breakfast standards started

going into effect at the beginning of
the 2013 to 2014 school year. By the
spring of 2014, 86 percent of schools
across the country were certified as
serving healthier meals that met the
updated nutrition standards, and thus
were receiving an additional six cents
per meal in federal reimbursement.94
Meals that meet the standards include
SECTION 3: SCHOOL FOODS AND BEVERAGES
School Foods and Beverages
The State of
Obesity:
Obesity Policy
Series
Schools also sell snacks and drinks

outside of breakfast and lunch, in
vending machines, school stores and
la carte lines. These items, sometimes
called competitive foods because
they compete with school meals for
students spending, have historically
included unhealthy items such as salty
chips, candy and sugary drinks.
more fruits, vegetables and whole

grains, low-fat dairy products and
fewer unhealthy sugars and fats.
Although the vast majority of schools
Schools Serving Healthier Meals That

Meet the Updated Nutrition Standards
as of Spring 2014
are meeting the updated standards,

many could be doing more easily
kitchen equipment. Research
conducted in the fall of 2012 found
that 88 percent of school food
authorities need one or more piece
of equipment to help them meet
the updated standards.95 More than
86%
SEPTEMBER 2014
and efficiently with updated school
36
In June 2013, USDA published an interim final rule

establishing healthier nutrition standards for competitive
foods. These Smart Snacks in School standards require
schools to provide snacks and beverages with more whole
grains, low-fat dairy, fruits, vegetables and lean protein.
They also set limits on fat, sugar and salt.96 Schools are
required to begin implementing these standards at the
beginning of the 2014 to 2015 school year.97
In addition, in November 2013, USDA
of poverty could offer free meals to
conducted additional rulemaking
students without requiring household
under the Healthy, Hunger-Free Kids
applications. A final rule has not been
Act and released a proposed rule
published; however, USDA published
that would make it easier for school
additional interim guidance in
districts to take advantage of the
February 2014 to help schools move
community eligibility option. Under
forward with implementation for the
this statutory requirement, schools
2014 to 2015 school year.
with a disproportionately high level
WHY SCHOOL FOODS AND BEVERAGES MATTER:

l
Millions of children rely on the school
Kids eat less of their lunch, consume
meals program. For some children,
more fat, take in fewer nutrients
the only reliable meals they have are in
and gain weight when schools sell
school. During the average school day
unhealthy snacks and drinks outside
in 2011, more than 31 million children
of meals.102, 103, 104, 105, 106, 107, 108
ate school lunch, and 12.5 million ate
Children and teens in states with
Children and teens
strong laws restricting the sale of
school breakfast.
98
can consume up to half of their total
unhealthy snack foods and beverages
daily calories at school.99,100
in school gained less weight over a
Breakfast
12.5 million
Lunch
31 million
three-year period than those living in
Strong school nutrition policies can
states with no such policies.109
have a positive impact on childrens

health. Elementary schools are less
Average daily number of children who ate

school meals in 2011
Healthier standards also can help
likely to sell candy, ice cream, sugary
schools budgets. A health impact
drinks, cookies, cakes and other
assessment found that when schools
unhealthy snacks when states or school
serve healthier snacks and drinks, they
districts have policies that limit the sale
generally see their total food service
of such items.101
revenues increase.110
Percentage of daily calories

consumed at school
50%
37
he USDA should continue to monitor state and local

T
implementation of both updated school meal and snack
food and beverage standards and provide adequate
training and technical assistance where needed to states,
localities, industry and school nutrition organizations.
Adequate funding is important for ensuring schools
have the tools and resources they need to provide
healthy and appealing meals necessary to meet nutrition
standards set by USDA.
States and localities should consider reinforcing updated

national standards by providing additional funding and
technical assistance for implementing healthier standards,
encouraging inclusion of nutrition goals on school
improvement plans, or applying nutrition standards more
broadly by extending the standards beyond the school day
via an updated school wellness policy.
School districts should take advantage of the community

eligibility option to help ensure students are consuming
meals that comply with the updated school meal
nutrition standards. The community eligibility option
enables school districts with a certain percentage of
students qualifying for free or reduced-price meals to
provide free meals to all students, reducing paperwork
burdens for both families and schools and ensuring all
students have easy access to free, healthy meals.
Free and clean drinking water should be made available

to all students throughout the school day.
38
Kids Safe & Healthful Foods Project: Health Impact Assessment: National Nutrition Standards for Snack and a la Carte Foods
and Beverages Sold in Schools:
http://www.pewhealth.org/uploadedFiles/PHG/Content_Level_Pages/Reports/KS_HIA_revised%20WEB%20FINAL%2073112.pdf
Kids Safe & Healthful Foods Project: States Need Updated School Kitchen Equipment:
http://www.healthyschoolfoodsnow.org/states-need-updated-school-kitchen-equipment/
Robert Wood Johnson Foundation: Competitive Foods Resources:
http://www.rwjf.org/en/topics/rwjf-topic-areas/school-snacks.html
Healthy Eating Research: Influence of Competitive Food and Beverage Policies on Childrens Diets and Childhood Obesity:
http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/07/influence-of-competitive-food-and-beverage-policies-onchildren-.html
Institute of Medicine: Nutrition Standards for Foods in Schools: Leading the Way toward Healthier Youth:
http://www.iom.edu/Reports/2007/Nutrition-Standards-for-Foods-in-Schools-Leading-the-Way-toward-Healthier-Youth.aspx
CDC: Implementing Strong Nutrition Standards in Schools: Financial Implications.
http://www.cdc.gov/healthyyouth/nutrition/pdf/financial_implications.pdf
39
2012 NATIONAL SCHOOL MEAL STANDARDS

The new requirements are being phased in over five years, starting during the 2012-13 school year. States with standards that
are stronger than the new national standards will be able to retain those standards.
FOOD GROUP
PAST REQUIREMENTS
NEW REQUIREMENTS
Fruits and Vegetables
to cup of fruit and

vegetables combined per day
to 1 cup of vegetables plus to 1 cup of fruit per day
Vegetables
No specifications as to type
of vegetable subgroup
Weekly requirements for: dark green, red/orange, beans/peas, starchy, others (as
defined in 2010 Dietary Guidelines)
Meat/Meat Alternate
1.5- to 2-ounce equivalent

(daily minimum) (ounce
equivalent minimum)
Daily minimum and weekly ranges:

Grades K-5: 1-ounce equivalent minimum daily (8 to 10 ounces weekly)
Grades 6-8: 1-ounce equivalent minimum daily (9 to 10 ounces weekly)
Grains
8 servings per week (minimum

of 1 serving per day)
Daily minimum and weekly ranges:

Grades K-5: 1-ounce equivalent minimum daily (8 to 9 ounces weekly)
Whole Grains
Encouraged
At least half of the grains must be whole grain-rich beginning July 1, 2012. Beginning
July 1, 2014, all grains must be whole grain-rich.
Milk
1 cup; Variety of fat contents

allowed; flavor not restricted
1 cup; Must be fat-free (unflavored/flavored) or 1% low-fat (unflavored)
Sodium
Reduce, no set standards
TARGET 1: SY 2014-15
Lunch
Lunch
Lunch
1230mg (K-5);
935mg (K-5)
640mg (K-5);
1360mg (6-8);
1035mg (6-8);
710mg (6-8);
1420mg (9-12)
1080mg (9-12)
740mg (9-12)
Breakfast
Breakfast
Breakfast
540mg ( K-5);
485mg ( K-5);
430mg ( K-5);
600mg (6-8);
535mg (6-8);
470mg (6-8);
640mg (9-12)
570mg (9-12)
500mg (9-12)
Water
No set standards
Schools participating in the NSLP are required to make potable water available to
children at no charge in the place where lunches are served during the meal service.
Source: Food and Nutrition Service, USDA. Ounce equivalent (ounce equivalent) means the having the same nutritional value as in a standard
ounce of that food group. http://www.fns.usda.gov/cnd/Governance/Legislation/comparison.pdf
40
STATE SCHOOL-BASED NUTRITION AND FOOD LAWS

Competitive Foods
analysis of all current state competitive
The Healthy, Hunger-Free Kids Act of
foods laws, available at http://foods.
2010 required USDA to release new
bridgingthegapresearch.org/#, and re-
national standards for competitive foods
cently released a new report examining
in schools. USDA defines competitive
whether existing state laws are aligned
foods as any food or beverage served
with the new USDA standards. The
or sold at school that is not part of the
report found that 38 states have com-
USDA school meals program.111 These
petitive food standards, but none of
foods are sold in la carte lines, in
the states laws fully met USDAs stan-
school vending machines, in school
dards. On average, states met four
stores, or through bake sales. The
out of the 18 USDA competitive food
interim final rule for Smart Snacks in
provisions and states were more likely
School was released in June 2013 and
to meet the USDA beverage provisions
becomes effective during the 2014 to
than snack provisions. Overall, the
2015 school year.112 States with stan-
report concluded that implementation
dards that are stronger than the new
and compliance of the new provisions
national standards will be able to retain
will likely be easier in states with exist-
those standards.
ing laws and that technical assistance

should be provided to those areas that
The nonprofit, nonpartisan Bridging
have few to no competitive food provi-
the Gap organization conducts an
sions in place.113
41
SMART SNACKS IN SCHOOL NUTRITION STANDARDS

FOOD/NUTRIENT
STANDARD
EXEMPTION TO STANDARD
General Standard
for Competitive
Food.
To be allowable, a competitive food item must:
1. Meet all of the proposed competitive food nutrient

standards; and
F resh fruits and vegetables with no added ingredients

except water are exempt from all nutrient standards.
anned and frozen fruits with no added ingredients

C
except water, or are packed in 100 percent juice, extra
light syrup, or light syrup are exempt from all nutrient
standards.
anned vegetables with no added ingredients except

C
water or that contain a small amount of sugar for
processing purposes to maintain the quality and
structure of the vegetable are exempt from all nutrient
standards.
educed fat cheese (including part-skim mozzarella) is

R
exempt from the total fat standard.
uts and seeds and nut/seed butters are exempt from

N
the total fat standard.
roducts consisting of only dried fruit with nuts and/or

P
seeds with no added nutritive sweeteners or fats are
exempt from the total fat standard.
eafood with no added fat is exempt from the total fat

S
standard.
2. Be a grain product that contains 50 percent or more whole

grains by weight or have whole grains as the first ingredient*; or
3. Have as the first ingredient*one of the non-grain main
food groups: fruits, vegetables, dairy, or protein foods (meat,
beans, poultry, seafood, eggs, nuts, seeds, etc.); or
4. Be a combination food that contains at least cup fruit
and/or vegetable; or
5. Contain 10 percent of the Daily Value (DV) of a nutrient of
public health concern (i.e., calcium, potassium, vitamin D, or
dietary fiber).
*If water is the first ingredient, the second ingredient must be
one of items 2, 3 or 4 above.
NSLP/School
Breakfast Program
(SBP) Entre Items
Sold A la Carte
Any entre item offered as part of the lunch program or the

breakfast program is exempt from all competitive food standards
if it is sold as a competitive food on the day of service or the day
after service in the lunch or breakfast program.
Sugar-Free
Chewing Gum
Sugar-free chewing gum is exempt from all competitive food

standards.
Grain Items
Acceptable grain items must include 50 percent or more whole

grains by weight, or have whole grains as the first ingredient.
Total Fats
Acceptable food items must have 35 percent calories from

total fat as served.
Combination products are not exempt and must meet all

the nutrient standards.
42
Saturated Fats
Acceptable food items must have < 10 percent calories from

saturated fat as served.
Trans Fats
Zero grams of trans fat as served
Sugar
Acceptable food items must have 35 percent of weight from

total sugar as served.
ried whole fruits or vegetables; dried whole fruit or

D
vegetable pieces; and dehydrated fruits or vegetables
with no added nutritive sweeteners are exempt from
the sugar standard.
ried whole fruits, or pieces, with nutritive sweeteners

D
that are required for processing and/or palatability
purposes (i.e. cranberries, tart cherries, or blueberries)
are exempt from the sugar standard.
roducts consisting of only exempt dried fruit with nuts

P
and/or seeds with no added nutritive sweeteners or
fats are exempt from the sugar standard.
FOOD/NUTRIENT
STANDARD
Sodium
Snack items and side dishes sold a la carte: 230 mg sodium per
item as served, lowered to 200 mg July 1, 2016.
EXEMPTION TO STANDARD
Entre items sold a la carte: 480 mg sodium per item as served,

including any added accompaniments.
Calories
Snack items and side dishes sold a la carte: 200 calories per item
as served, including any added accompaniments.
Entre items sold a la carte: 350 calories per item as served
including any added accompaniments.
Accompaniments
Use of accompaniments is limited when competitive food is sold to

students in school. The accompaniment must be included in the nutrient
profile as part of the food item served and meet all proposed standards.
Caffeine
Elementary and middle school: foods and beverages must be

caffeine-free with the exception of trace amounts of naturally
occurring caffeine substances.
Entre items served as an NSLP or SBP entre

are exempt on the day of or day after service in
the program meal.
High School: foods and beverages may contain caffeine.

Beverages
Elementary School:
l
Plain water or plain carbonated water;
Low fat milk, unflavored ( 8 fl oz);
onfat milk, flavored or unflavored ( 8 fl oz), including nutritionally

N
equivalent milk alternatives as permitted by the school meal
requirements;
100 percent fruit/vegetable juice ( 8 fl oz); and
00 percent fruit/vegetable juice diluted with water (with or without

1
carbonation) and no added sweeteners ( 8 fl oz).
Middle School
l
Plain water or plain carbonated water (no size limit);
Low-fat milk, unflavored (12 fl oz);
on-fat milk, flavored or unflavored (12 fl oz), including

N
nutritionally equivalent milk alternatives as permitted by the school
meal requirements;
100 percent fruit/vegetable juice (12 fl oz); and

1
carbonation) and no added sweeteners (12 fl oz).
High School
l
Plain water or plain carbonated water (no size limit);
Low-fat milk, unflavored (12 fl oz);
on-fat milk, flavored or unflavored (12 fl oz), including

N
nutritionally equivalent milk alternatives as permitted by the school
meal requirements;
100 percent fruit/vegetable juice (12 fl oz);

1
carbonation) and no added sweeteners (12 fl oz);
ther flavored and/or carbonated beverages (20 fl oz)that are

O
labeled to contain 5 calories per 8 fl oz, or 10 calories per
20 fl oz; and
ther flavored and/or carbonated beverages (12 fl oz) that are

O
labeled to contain 40 calories per 8 fl oz, or 60 calories per 12 fl oz.
Source: USDA, http://www.fns.usda.gov/sites/default/files/allfoods_summarychart.pdf

43
WATER AVAILABILITY
Research shows that children are not drinking recommended
levels of water during the school day
114
and that children who
The Healthy, Hunger-Free Kids Act of 2010 requires schools to

provide easily accessible, clean water to students at no cost.
drink more water consume less sugar and other beverages.
In 2013, the Partnership for a Healthier America launched a
Although water fountains have been available in most schools
Drink Up campaign to support increased water availability
for decades, there are issues that discourage students from
and consumption everywhere, not just in schools.117
115
drinking water at school. For example, many schools do not

have enough water fountains to supply all of the students,
and most schools do not make cups available to encourage
students to take more water from the fountains. The cost of
providing cups may be a barrier in some schools.116
According to new research by Bridging the Gap, during the 2011

to 2012 school year 86 percent of elementary, 87 percent
of middle, and 89 percent of high school students attended
schools that reported meeting the drinking water requirement.118
HOW SCHOOLS MET FEDERAL DRINKING WATER REQUIREMENTS, 2011 TO 2012

Elementary Schools
Middle Schools
High Schools
Fountains only
64.1%
61.9%
60.6%
Dispensers only
13.3%
14.9%
11.9%
Fountains and dispensers
7.5%
9.3%
16.6%
Other combinations
1.4%
1.4%
0.3%
13.6%
12.6%
10.6%
Did not meet requirement
Source: Colabianchi N, Turner L, Hood NE, Chaloupka FJ, Johnston LD. Availability of drinking water in US public school cafeterias. A BTG Research
Brief. Chicago, IL: Bridging the Gap, 2014.
FARM-TO-SCHOOL PROGRAMS
Farm-to-school programs have shown results in improving
student participation in the school meals program, improve
students nutritional intake.119 For example, a study by
household food security and strengthen connections within
researchers at the University of California, Davis found that
Oregons food economy.121
farm-to-school programs not only increase consumption of

fruits and vegetables, but actually change eating habits,
leading students to choose healthier options at lunch.120 A
recent health impact assessment examining the Oregon
farm-to-school reimbursement law found that the law
would create and maintain jobs for Oregonians, increase
44
All 50 states and Washington, D.C. have farm-to-school

programs but only 35 states and Washington, D.C. have
established mandatory programs. Also, within states, many
programs cover only select students or schools rather than
all students or schools.
SCHOOL HEALTH PROFILES, 2012i

Every other year CDC uses surveys to
assess the current status of various
school practices and policies among
middle schools and high schools in
states and a selection of large urban
Percentage of Secondary Schools That Allowed Students to Purchase Fruit

(not fruit juice) from One or More Vending Machines or at the School Store,
Canteen, or Snack Bar.
WA
OR
VT
WI
ID
WY
NV
IL
UT
CO
KS
MO
OK
physical education and physical
LA
TX
activity; tobacco-use prevention; and
WV
TN
AR
NM
VA
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA
nutrition. Below is a selection of maps
FL
AK
showing what percentage of middle
PA
OH
KY
CA
AZ
IN
ME
NH
MA
NY
MI
IA
NE
status of a range of topics including,

education requirements and content;
MN
SD
areas. The school profiles follow the

but not limited to: school health
ND
MT
HI
schools and high schools in each state

have specific nutrition policies and
procedures in place.
n No Data n <20% n >20% & <30% n >30% & <40% n >40%
Percentage of Secondary Schools That Allowed Students to Purchase Soda

Pop or Fruit Drinks (that are not 100 percent juice) From Vending Machines
or at the School Store, Canteen, or Snack Bar.
WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
UT
IL
CO
KS
MO
AZ
NM
TX
Source: Demissie Z, Brener ND, McManus

T, Shanklin SL, Hawkins J, Kann L. School
Health Profiles 2012: Characteristics of
Health Programs Among Secondary Schools.
Atlanta: Centers for Disease Control and
Prevention, 2013.
WV
TN
AR
LA
PA
OH
KY
CA
OK
IN
NH
MA
NY
MI
IA
NE
VA
NJ
DE
MD
DC
ME
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI
n No Data n <15% n >15% & <30% n >30% & <45% n >45%
45
Percentage of Secondary Schools That Allowed Students to Purchase

Sports Drinks From Vending Machines or at the School Store, Canteen,
or Snack Bar.
WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
IL
UT
CO
KS
MO
OK
LA
TX
WV
TN
AR
NM
PA
OH
KY
CA
AZ
IN
NH
MA
NY
MI
IA
NE
VA
ME
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI
n No Data n <20% n >20% & <40% n >40% & <60% n >60%
Percentage of Secondary Schools That Did Not Sell Baked Goods, Salty
Snacks, Candy, Soda Pop or Fruit Drinks (that are not 100 percent
juice), or Sports Drinks in Vending Machines, at the School Store,
Canteen, or Snack Bar.
WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
UT
IL
CO
KS
MO
OK
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
AZ
IN
VA
NC
SC
MS
AL
GA
FL
AK
HI
n No Data n <20% n >20% & <40% n >40% & <60% n >60%
46
NH
MA
NY
MI
IA
NE
NJ
DE
MD
DC
ME
CT
RI
Percentage of Secondary Schools That Priced Nutritious Foods and Beverages at a Lower Cost While Increasing the Price of Less Nutritious Foods
and Beverages.
WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
IL
UT
CO
KS
MO
OK
LA
TX
WV
TN
AR
NM
PA
OH
KY
CA
AZ
IN
NH
MA
NY
MI
IA
NE
VA
ME
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI
n No Data n <5% n >5% & <10% n >10% & <15% n >15%
Percentage of Secondary Schools That Prohibited Advertisements

for Candy, Fast-Food Restaurants, or Soft Drinks on School Grounds
(including on the outside of the school building, on playing fields, or
other areas of the campus).
WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
UT
IL
CO
KS
MO
OK
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
AZ
IN
NH
MA
NY
MI
IA
NE
VA
NJ
DE
MD
DC
ME
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI
n No Data n <45% n >45% & <55% n >55% & <65% n >65%
47
Percentage of Secondary Schools That Permitted Students to Have a

Drinking Water Bottle with Them During the School Day in All Locations.
WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
IL
UT
CO
KS
MO
OK
LA
TX
WV
TN
AR
NM
PA
OH
KY
CA
AZ
IN
NH
MA
NY
MI
IA
NE
VA
ME
NJ
DE
MD
DC
CT
RI
NC
SC
MS
AL
GA
FL
AK
HI
n No Data n <45% n >45% & <60% n >60% & <75% n >75%
Percentage of Secondary Schools That Offered a Free Source of Drinking

Water in the Cafeteria During Meal Times.
WA
ND
MT
MN
VT
WI
SD
OR
ID
WY
NV
UT
IL
CO
KS
MO
OK
NM
TX
WV
TN
AR
LA
PA
OH
KY
CA
AZ
IN
VA
NC
SC
MS
AL
GA
FL
AK
HI
n No Data n <85% n >85% & <90% n >90% & <95% n >95%
48
NH
MA
NY
MI
IA
NE
NJ
DE
MD
DC
ME
CT
RI
SECTI O N 4:
CURRENT STATUS:
More than 29 million Americans lack access to healthy,

affordable foods. They live in food deserts, meaning
they do not have a supermarket or supercenter within a
mile of their home if they live in an urban area, or within
10 miles of their home if they live in a rural area.122
Families living in lower-income
families and individuals. In2011,
neighborhoods and in communities
the most recent year with data, the
of color are particularly hard hit: ZIP
poorest Americans spent 16.1 percent
codes with the highest concentration of
of their income on food while middle-
Blacks have about half the number of
and high-income residents spent
chain supermarkets compared with ZIP
only 13.2 percent and 11.6 percent
codes with the highest concentration of
respectively.125 Increasing access to
Whites, and ZIP codes with the highest
healthy foods has become a priority
concentrations of Latinos have only a
for policy-makers across the country.
third as many.
One strategy is the use of Healthy
123
Many of these same
neighborhoods also are struggling with
Food Financing Initiatives (HFFI), a
high rates of obesity, unemployment
public-private partnership in which
and depressed economies. One study
grants and loans are provided to
evaluating food accessibility on22
full-service supermarkets or farmers
Native American reservations in
markets that locate in lower-income
Washingtonstate observed physical
urban or rural communities.
The State of
Obesity:
Obesity Policy
Series
SECTION 4: HEALTHY, AFFORDABLE FOODS
Healthy, Affordable Foods
and financial barriers to accessing

healthy food: 15 reservations did not
have an on-reservation supermarket or
grocery store, yet the cost of shopping
Difference in Chain Supermarket

Distribution between Communities
at off-reservation supermarkets was

about 7 percent higher than the
Data from the Bureau of Labor

Statistics shows that relative food
costs have fallen over the past three
decades, but not for lower-income
Predominantly White Communities
50% Less
Predominantly Black Communities
66% Less
Predominantly Latino Communities
SEPTEMBER 2014
national reference cost.
124
Healthy food financing programs
retail as a rebuilding strategy after
are active in 21 states and have been
Hurricane Katrina. The Fresh Food
funded with a variety of federal, state,
Retailer Initiative provides direct
local and philanthropic dollars. For
financial assistance to retail businesses
example, the California FreshWorks
by awarding forgivable and/or low-
Fund has raised $272 million to
interest loans to supermarkets and
bring grocery stores, fresh produce
other fresh food retailers.127 Most
markets and other healthy food retail
recently, the Circle Foods store
stores to communities that do not
destroyed by Hurricane Katrina
have them.
reopened this year with the help of
126
In New Orleans, the
City Council prioritized healthy food
such assistance.
The most successful program to date is the Pennsylvania Fresh

Food Financing Initiative (FFFI), which since 2004 has financed
supermarkets and other fresh food outlets in 78 urban and rural
areas serving 500,000 city residents.128 In the process, FFFI has
created or retained 4,860 jobs in underserved neighborhoods. Home
values near new grocery stores have increased from 4 percent to
7 percent, and local tax revenues also have increased.129
Increase in HFFI Authorization
2011-13
$109 million
2014
$125
million
The federal government has been
The New Market Tax Credit (NMTC)
funding HFFI grants through the U.S.
also encourages investment in
Department of Health and Human
lower-income communities. To
Services and the Department of
date, the program has distributed
Treasury since 2011. To date, HFFI
$39.5 billion in federal tax credit
has distributed more than $109 million
authority matched by private sector
in grants across the country, helping to
investments. The NMTC helped
support the financing of grocery stores
finance 49 supermarket and grocery
and other healthy food retail outlets
store projects between 2003 and 2010
including farmers markets, food hubs
that improved healthy food access
and urban farms. The Agriculture
in lower-income communities for
Act of 2014, known as the Farm Bill,
more than 345,000 people, including
passed in February 2014, authorizes
197,000 children.130
$125 million for the federal HFFI and,

for the first time, creates a permanent
home for the program in the U.S.
Department of Agriculture.
50
Direct food assistance programs are
education component provides
It also included updated stocking
another strategy to increase access to
federal grants to states for efforts to
requirements for retailers that
healthy foods. Nutrition assistance
help participants get the most out of
accept SNAP benefits to help ensure
programs comprise more than two-
their benefits by encouraging smart
SNAP beneficiaries have healthier
thirds of the federal Farm Bill. The
shopping and healthy eating habits.
options. The law also created the
largest is the Supplemental Nutrition
SNAP also licenses eligible farmers
Food Insecurity Nutrition Incentive
Assistance Program (SNAP), which
markets so participants can use their
grant program and provided $100
provided $76.06 billion in benefits
benefits at those locations. The 2014
million to test and evaluate strategies
to 47.6 million Americans in FY
law included a variety of reforms
to incentivize SNAP beneficiaries to
2013.
to the SNAP program and reduced
purchase of fruits and vegetables.
131
In addition to providing
monthly benefits, SNAPs nutrition
132
funding for the program as well.
WHY ACCESS TO HEALTHY AFFORDABLE FOOD MATTERS:

l
Supermarkets and supercenters provide
23.5 million
Americans dont have access to a
supermarket within a mile of their home
Is the distance
70 percent of
30 Miles
Mississippi food
stamp-eligible families
live from the closest
large grocery store
mile of their homes are 25 percent to
healthy, high-quality products at the low-
46 percent less likely to have a healthy
est cost, and shoppers generally prefer
diet than those with the most supermar-
these stores to smaller grocery stores
kets near their homes.136

l
New and improved grocery stores can
Adults living in neighborhoods with super-
catalyze commercial revitalization in a
markets or with supermarkets and grocery
community. An analysis of the economic
stores have the lowest rates of obesity
impacts of five new stores that opened
(21 percent), and those living in neighbor-
with FFFI assistance found that, for four
hoods with no supermarkets and access
of the stores, total employment sur-
to only convenience stores, smaller gro-
rounding the supermarket increased at a
cery stores, or both had the highest rates
faster rate than citywide trends.137
(32 percent to 40 percent obesity;).134

l
Blacks living in a census tract with a

supermarket are more likely to meet
dietary guidelines for fruits and veg-
32%
Adults with no supermarkets within a
the most reliable access to a variety of
and convenience stores.133

l
etable consumption, and for every ad-
Percent of African
Americans who live
in a census tract
with a supermarket
Percent of Whites
who live in a
census tract with a
supermarket
ditional supermarket in a tract, produce

Increase in fruit and
vegetable consumption
for Blacks with each
new supermarket in
their neighborhood
consumption rose 32 percent. Among

Whites, each additional supermarket
corresponded with an 11 percent in-
8%
31%
crease in produce consumption.135
Source: PolicyLink, The Grocery Gap
51
Jordan Gantz, used with permission from RWJF
The federal government, states and cities should

continue to prioritize and fund Healthy Food Financing
Initiatives efforts as a health and economic strategy.
Food assistance programs should encourage and

incentivize the purchase of healthy foods and evaluate
strategies to determine which are most effective at
improving consumption and health outcomes.
Do All Americans Have Access to Healthy Affordable Foods? Robert Wood Johnson Foundation. December 2012:
http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/12/do-all-americans-have-equal-access-to-healthy-foods-.html
Healthy Food Access Portal: http://www.healthyfoodaccess.org/
The Grocery Gap: Who Has Access to Healthy Food and Why it Matters Policy Link and The Food Trust.
http://www.policylink.org/site/c.lkIXLbMNJrE/b.5860321/k.A5BD/The_Grocery_Gap.htm
Bringing Healthy Foods Home: Examining Inequalities in Access to Food Stores Healthy Eating Research. June 2008:
http://www.healthyeatingresearch.org/images/stories/her_research_briefs/her%20bringing%20healthy%20foods%20home_7-2008.pdf
County Health Rankings Food Environment Index:
http://www.countyhealthrankings.org/our-approach/health-factors/diet-and-exercise
52
STATE SUGAR-SWEETENED BEVERAGE TAXES

A number of studies have shown that relative prices of foods and
Office estimated that a federal excise tax of three cents per 12
beverages can lead to changes in how much people consume
ounces of SSBs could have generated an estimated $24 billion
them.
138, 139, 140
Several studies have estimated that a 10 percent
increase in the price of sugar-sweetened beverages (SSBs) (including soft drinks and juices) could reduce consumption of them
in revenue between 2009 and 2013.145, 146

l
34 states and Washington, D.C., currently include soda

among items for which they charge sales tax: Alabama,
by 8 percent to 11 percent.141, 142, 143 As of 2012, the tax rate for
Arkansas, California, Colorado, Connecticut, Florida, Hawaii,
every state with a soda tax is 7 percent or below and, of those
Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine,
with a soda tax, 14 states have a tax rate of 5 percent or lower.144
Maryland, Minnesota, Mississippi, Missouri, New Jersey,
Researchers at Yale University estimated that, if a national
New York, North Carolina, North Dakota, Ohio, Oklahoma,
soda tax of a penny per 12 ounces were instituted, it would
Pennsylvania, Rhode Island, South Dakota, Tennessee, Texas,
generate $1.5 billion a year, and the Congressional Budget
Utah, Virginia, Washington, West Virginia and Wisconsin.147
SUGAR-SWEETENED BEVERAGES: CONSUMPTION AND IMPACT

l
Sugar-sweetened beverage consumption: Consumption
utes to weight gain and is also a major contributor to obesity
of SSBs rose significantly from the 1970s until 1999.148
and type 2 diabetes.159 A number of studies have shown a
From 1999 to 2010, consumption has begun to decline
significant link between SSB consumption and weight gain
(a decrease of 63 calories for youth and 45 calories for
in children.160 A recent study found that children who con-
adults.)149 However, SSB consumption is still high. Accord-
sumed a large amount of SSBs (at least five servings per
ing to the 2011 BRFSS from six states, almost 25 percent
week) were almost 3.5 times more likely to be obese than
of adults drank SSBs at least once a day and over 10 per-
those who never or almost never consumed SSBs.161 Adults
cent consumed at least two SSBs per day.150 BRFSS found
who drink a soda or more per day are 27 percent more likely
that odds of drinking SSBs one or more times per day were
to be overweight than those who do not drink sodas, regard-
significantly greater among younger adults; males; Blacks;
less of income or ethnicity. They also have a 26 percent
adults with lower education; low-income adults; and adults
higher risk for developing type 2 diabetes and a 20 percent
who were physically inactive.
151
According to studies through
the mid-2000s, 90 percent of children ages 6 to 11 drank

an SSB daily, and SSBs were the top calorie source for
teens.152, 153 Nearly half of 2- to 3-year-olds consume a SSB
daily, and a quarter to a third consume whole rather than
low-fat or nonfat milk.154, 155, 156, 157 Children ages 2 to 5 are
estimated to consume 124 calories per day7 percent of
their total daily energy intakefrom SSBs.158
l
higher risk for a heart attack.162, 163, 164

l
Improved health from lowering sugar-sweetened beverage

consumption: Children who reduced their consumption of
added sugar by the equivalent of one can of soda per day
had improved glucose and insulin levels. Eliminating one
can of soda per day, regardless of any other diet or exercise
change, can reduce a childs risk for type 2 diabetes.165 An
analysis from 1999 to 2010 found that among a representa-
Increased health risks related to sugar-sweetened bever-
tive sample of adults in the United States, intake of SSBs
age consumption: The growing body of evidence from many
has trended down, and several biomarkers of chronic dis-
studies reveals that regular consumption of SSBs contrib-
ease have significantly improved over the past 12 years.166
53
S EC T I ON 5 :
SECTION 5: FOOD AND BEVERAGE MARKETING
The State of
Obesity:
Key Findings
Food and Beverage Marketing

CURRENT STATUS:
The food and beverage industry spends nearly $2 billion

annually to market foods and beverages to children and
adolescents in the U.S., reaching young people in the places
where they live, learn and play. A report from the Institute of
Medicine concluded that food advertising affects childrens
food choices, food purchase requests, diets and health.167
Although there has been some progress in reducing the
amount of food marketing directed at children, the majority
of foods marketed to children remains unhealthy.168
SEPTEMBER 2014
In the last year, some individual com-
obesitythat will enable PMA to use
panies have made changes regarding
Sesame Street characters for free to pro-
their marketing practices. In October
mote fruits and vegetables to children.
2013, the Produce Marketing Asso-
Subway committed to PHA that its chil-
ciation (PMA) and Sesame Workshop
drens menu items would meet nutrition
made commitments to the Partnership
standards and that it would spend $41
for a Healthier America (PHA)an
million over the next three years on ef-
organization dedicated to working with
forts to market the healthier menus and
the private sector to address childhood
fruit and vegetable options to children.
McDonalds said it would phase out the listing of soda on the kids meal section of its menu boards.
In addition to steps taken by
criteria do not cover marketing on
children is through schools. This mar-
individual companies, the industrys
packages or in stores, toy give-aways
keting happens through signs, score-
overall self-regulatory effort, the
and other premiums, many forms of
boards, posters, branded fundraisers,
Childrens Food and Beverage
marketing in elementary schools, any
corporate incentive programs, scholar-
Advertising Initiative (CFBAI), has
marketing in middle and high schools,
ships and education materials. Only
made changes. In January 2014,
branded merchandise, or brand
20 percent of public school districts
CFBAI adopted new uniform nutrition
advertisingadvertising that promotes
have a policy that addresses food mar-
criteria for the 17 participating
an overall brand, not a specific product.
keting, and only half of those districts
companies.
169
The new standards
set stronger limits on the amount

of calories, sugar, fats and sodium
in the foods marketed to children
than did earlier, company-specific
standards. But the standards still allow
companies to market some unhealthy
foods and beverages to young people,
including popsicles, fruit-flavored
snacks, marshmallow treats and
several sugary cereals.
The CFBAI standards also use a narrow
definition of marketing. The nutrition
Finally, CFBAI only covers children up

to age 11, even though recent research
shows that adolescents are vulnerable
to many of the marketing tactics
companies use.170 Older children
and adolescents may be particularly
vulnerable to advertising because
they are more independent, use more
media, and are more likely to eat and
drink unhealthy foods and beverages.
specifically prohibit unhealthy food

and beverage marketing.171 To address the problem, the USDA, as part
of its rule making for local school wellness policy implementation, included
a provision to limit unhealthy food
and beverage marketing in schools.
Once the rule is finalized, school
districts would need to have policies
in place that only allow marketing of
foods and beverages that meet the
One key place where food and bev-
updated Smart Snacks in School nutri-
erage companies continue to reach
tion standards set by USDA.172
WHY FOOD MARKETING MATTERS:

Spending by Food and Beverage Companies
on Marketing to 2 to 17 year-olds in 2009
Food and beverage companies spent
of unhealthy foods.175 Ten percent of
$1.79 billion in 2009 on marketing to
elementary schools and 30 percent of
young people ages 2 to 17.
high schools serve branded fast food
173
$1.79
Billion!
weekly; 19 percent of high schools
The same year, companies spent $149
serve it every day.176
million on in-school marketing, the

third largest spending category behind
Spending by Food and Beverage

Companies on In-School
$149
Marketing in 2009
Million!
YUM!
Vending contracts remain a major form
television and premiums, or incentives
of in-school marketing, but contribute
to purchase foods, such as toys
minimal financial support to schools:
with fast-food meals, t-shirts, music
approximately $2 to $4 per student
downloads, etc.
annually. Middle and high schools with
174
During the 2010 to 2011 school year,

10 percent of school districts had
Cool!
strong policies restricting the marketing
a high percentage of lower-income

students have more vending contracts
than other schools.177
55
56
SDAs final local school wellness policy regulation

U
should include strong implementation, monitoring,
compliance and reporting requirements for food and
beverage marketing.
nce schools put into place their updated local school
O
wellness policies limiting unhealthy food and beverage
marketing on school campuses, school officials, students,
parents and other key stakeholders must work to ensure
that food and beverage marketing is limited to those
foods that meet the USDAs Smart Snacks in School
nutrition standards.
FBAI should strengthen its nutrition standards for
C
food marketing to children to include a strong positive
nutritional requirement, cover children up to age 14,
and ensure that all companies self-regulatory policies
cover all media.
edia and entertainment companies should jointly adopt
M
meaningful, uniform nutrition standards to prevent the
marketing of unhealthy foods and beverages to children.
overnment agencies, researchers and independent
G
groups should continue to monitor and evaluate food
marketing expenditures and practices, childrens
exposure to marketing and advertising for unhealthy
foods and beverages and the effectiveness of industrys
voluntary actions.
tate and local governments should consider regulation
S
of marketing in local communities, including in schools,
publicly owned facilities, stores, restaurants and outdoor
advertising. Local governments should enforce existing
or adopt strong zoning restrictions on marketing, such
as limits on signs in store windows.
SECTI O N 6:
CURRENT STATUS:
On February 7, 2014, President Obama signed the

Agriculture Act of 2014 known as the Farm Bill into
law.178 There are several provisions of the Farm Bill, which
was last reauthorized in 2008, that have a direct impact on
whether American families have access to healthy foods.
In fact, the nutrition title (Title IV) comprises 79 percent
of the Farm Bills total authorized funding.179
The largest federal nutrition
program is the Supplemental
SNAP helped approximately
Nutrition Assistance Program,
47.6 million low-income
formerly known as food stamps,
individuals put food on the
which, in FY 2013, helped

approximately 47.6 million low-
table in FY 2013.
The State of
Obesity:
Obesity Policy
Series
SECTION 6: THE 2014 FARM BILL AND OBESITY PREVENTION
The 2014 Farm Bill and Obesity

Prevention
income individuals put food on

the table by providing an average
Allows SNAP benefits to be used at
monthly benefit of $133 per
more types of retailers. The Farm
person.
Bill permits participants to use SNAP
180
It also included several
provisions that could expand access
benefits to purchase Community
to healthy, affordable foods for
Supported Agriculture shares
SNAP participants.
(CSAs), which allow consumers
What the Farm Bill Does:

l
to pay in advance for a share of a

farmers production and, in return,
receive a weekly share of the results,
healthier food options. The Farm
such as a box of fresh fruits and
Bill changed retailers stocking
vegetables. It also clarifies that
requirements to include at least
SNAP retailers are responsible for
seven items in each of four basic
paying for their own Electronic
food categories fruits and
Benefit Transfer (EBT) equipment
vegetables, grains, dairy and meat
to help expand participation by
and perishable items in at least
farmers markets, farm stands and
three of these categories.
other non-traditional retailers.
SEPTEMBER 2014
Requires SNAP retailers to carry
Expands nutrition education and
purchase; 4) a food and agriculture
obesity prevention activities. The
service learning grant program to
Farm Bill added promotion of
increase knowledge and improve
physical activity as a component
nutritional health among children in
of SNAPs nutrition education
school settings; 5) a grant program
program (SNAP-Ed), which provides
to provide up to 50 percent of the
grants to state SNAP agencies for
costs of local incentive programs that
nutrition education and obesity
give SNAP participants additional
prevention activities.
benefits for produce when they
Incentivizes expanded access

to healthy foods in low-income
communities. The Farm Bill
creates numerous grant programs
to incentivize expanded access
to healthy foods in low-income
communities, including 1) $125
6) a Pulse School Pilot that provides

the U.S. Department of Agriculture
$10 million through 2017 to
purchase peas, lentils, chickpeas and
hummus to use in school breakfasts
and lunches.
million in funding for the federal
Another strategy the Farm Bill takes
HFFI to provide grants and tax
to promote healthier eating is a shift
incentives to food retailers to
in its approach to subsidies. U.S. farm
operate in underserved communities
policy has traditionally encouraged
(for more details see the report section on
the overproduction and use of cheap
Healthy, Affordable Foods); 2) a pilot
commodities, while the prices for
program to give up to eight states
fruits and vegetables have steadily
flexibility in procuring unprocessed
increased.181 In the 2014 Farm Bill,
fruits and vegetables for school
traditional commodity subsidies were
nutrition programs; 3) Food
cut by more than 30 percent, to $23
Insecurity Nutrition Incentive grants
billion over 10 years, while funding
for SNAP retailers, government
for fruits and vegetables and organic
agencies and organizations that seek
programs increased by more than
to increase the purchase of fruits
50 percent over the same period, to
and vegetables by SNAP participants
about $3 billion.182
through incentives at the point of
58
purchase fruits and vegetables; and
WHY FEDERAL NUTRITION PROGRAMS MATTER:

U.S. Population
Participating in SNAP
60%
Increase
in SNAP
Participation
since 2007
Since 2007, participation in SNAP has
more than half (13.5 million) of whom are
and includes about 15 percent of the
low-income, live in food deserts or areas
American population.
Almost half of
lacking access to fresh, healthful, afford-
SNAP recipients 45 percent are
able food.188 Only about 70 percent of
children.184 In 2012, SNAP lifted 4.9
all census tracts in the country currently
million Americans including 2.2 million
have at least one store that offers a vari-
children above the poverty line.
ety of affordable fruits and vegetables.189
185
45% of SNAP Recipients are Children
According to USDA data and other
Twenty-eight states have a farm-to-school

or farm-to-preschool policy. Ten states
fewer fruits, vegetables and whole
have child care regulations that align with
grains.
In 2013, only 21 percent of
national standards for fruits while four
farmers markets in the United States
states have child care regulations that align
accepted SNAP benefits.
with national standards for vegetables.190
187
studies, SNAP participants consume

186
An estimated 23.5 million Americans
increased by more than 60 percent

183
15%
The Department of Agriculture should implement all

nutrition-related provisions of the 2014 Farm Bill in a
timely manner.
Schools and early child care centers should align their

food policies with national standards for fruit and
vegetable consumption.
Continued resources to sustain assistance to families in

need remain an important strategy moving forward.
59
EXPERT COMMENTARY
BY MICHEL NISCHAN, CEO and Founder,
Wholesome Wave
Wholesome Wave is a 501(c)(3)

nonprofit dedicated to making
healthy, locally and regionally
Improving the Health of

Communities by Increasing
Access to Affordable, Locally
Grown Foods
When my son was diagnosed with type 1 diabetes, I became
painfully aware of the direct connection between food and
health. As a chef, this realization caused me to transform
grown food affordable to
the way I fed my family and customers. Fresh, nutrient-
everyone, regardless of income.
dense, locally grown foods became the foundation for the

type of diet that would give my son and restaurant guests
the best long-term health.
Quickly, though, I recognized that not
farmers, farmers markets, healthcare
every family can afford to purchase
providers and government entities
healthy foods. As a result, I founded
to form networks that improve
Wholesome Wave in 2007.
health, increase fruit and vegetable
We work collaboratively with

underserved communities, nonprofits,
consumption and generate revenue

for small and mid-sized farms.
DOUBLE VALUE COUPON PROGRAM

In 2008, we launched the Double
Farmers and farmers markets benefit
Value Coupon Program (DVCP), a
from this approach, and have been
network of more than 50 nutrition
key allies as we work towards federal
incentive programs operated at 305
and local policy change. In 2013,
farmers markets in 24 states and
federal nutrition benefits and DVCP
Washington, D.C. The program
incentives accounted for $2.45 million
provides customers with a monetary
in sales at farmers markets.191
incentive when they spend their federal

nutrition benefits at participating
farmers markets. The incentive
matches the amount spent and can be
used to purchase healthy, fresh, locally
grown fruits and vegetables.
60
Communities also see an increase

in economic activity. The $2.45
million spent at local farmers
markets creates a significant ripple
effect. In addition to the dollars
spent at markets, almost one-third of DVCP consumers
a behavior change that hopefully continues well after
said they planned to spend an average of nearly $30 at
market season ends.193
nearby businesses on market day, resulting in more than

$1 million spent at local businesses. We also see that the
demographics of market participants are more diverse
Today, the program reaches more than 35,800
our approach breaks down social barriers and allows
participants and their families and impacts more
consumers who receive federal benefits to be seen as
than 3,500 farmers.
critical participants in local economies.192

Equally as important, people are eating healthier. Our
Combined with the new Food Insecurity Nutrition
2011 Diet and Behavior Shopping Study indicated
Incentives Program in the latest Farm Bill, this approach
90 percent of DVCP consumers increased or greatly
is now being scaled up with $100 million allocated for
increased their consumption of fresh fruit and vegetables
nutrition incentives over five years.
FRUIT AND VEGETABLE PRESCRIPTION PROGRAM

We developed the Fruit and Vegetable Prescription
Program (FVRx) to measure health outcomes linked to
fruit and vegetable consumption. The four to six month
program is designed to provide assistance to overweight
and obese children who are affected by diet-related diseases
such as type 2 diabetes. In 2013, the program impacted
1,288 children and adults in five states and Washington,
D.C. Nearly two-thirds of the participants are enrolled in
SNAP and roughly a quarter receive Women, Infants and
Children (WIC) benefits.
The model works within the normal doctor-patient
relationship. During the visit, the doctor writes a prescription
for produce that the patients family can redeem at
participating farmers markets. The prescription includes
at least one serving of produce per day for each patient and
each family member i.e., a family of four would receive $28
per week to spend on produce.
61
In addition to the prescription, there are follow-up

monthly meetings with the practitioner and a nutritionist
to provide guidance and support for healthy eating, and to
measure fruit and vegetable consumption. Other medical
follow-ups are performed, including tracking BMI.
Average Increase in Fruit and
Vegetable Consumption
FVRx improves the health of
2012 alone, FVRx brought in $120,000
participants. Forty-two percent of
in additional revenue for the 26
child participants saw a decrease
participating markets.195
in their BMI and 55 percent of

participants increased their fruit and
55%
vegetable consumption by an average

of two cups. In addition, families
reported a significant increase in
household food security.194
In less than seven years, Wholesome

Wave has extended its reach to
25 states and D.C. and is working
with more than 60 communitybased organizations, community
healthcare centers in six states, two
Each dollar invested in the program
hospital systems, and many others.
provides healthier foods for
Our work proves that increasing
participants, boosts income for small
access to affordable healthy food is
and mid-sized farms and supports
a powerful social equalizer, health
the overall health of the community.
improver, economic driver and
As with the DVCP, there are benefits
community builder.
for producers and communities. In
WHOLESOME WAVE IS WORKING TO CHANGE THE WORLD WE EAT IN.

AS THE NUMBER OF ON-THE-GROUND PARTNERS INCREASES, WE GET
CLOSER TO A MORE EQUITABLE FOOD SYSTEM FOR EVERYONE. THIS
MEANS HEALTHIER CITIZENS AND COMMUNITIES, AND A MORE VIBRANT
ECONOMY NATIONWIDE.
62
SECTI O N 7:
Obesity Prevention Inside and

Outside The Doctors Office
CURRENT STATUS:
SECTION 7: THE 2014 FARM BILL AND OBESITY PREVENTION
The State of
Obesity:
Obesity Policy
Series
Many Americans only have doctors appointments once

or twice a year. The rest of the year they are often on
their own to try to find ways to follow their doctors 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.196
such as education, access to healthy
treating a vast range of diseases,
food, job opportunities, safe housing,
injuries and other medical
environment and toxic stress that
conditions. But their training and
fundamentally shape how long or
healthcare delivery incentives do not
well people live, according to a
emphasize addressing the root causes
report by the RWJF Commission to
of health problems that occur outside
Build a Healthier America.197
of the healthcare system factors
SEPTEMBER 2014
Health professionals are adept at
For instance, individuals whose
These approaches, however, are often
doctors counsel them that they are
not taken because the U.S. health
at risk for health problems related
system has traditionally focused on
to obesity, such as prediabetes, are
covering activities that occur directly
often left to try to follow their doctors
within a healthcare setting and are
advice on their own in their daily lives
aimed at helping someone who is sick
where nutritious foods are costly and
get well. The old, disjointed fee-for-
can be hard to access, and it is hard to
service model and siloed systems have
find time and convenient, safe places
dis-incentivized coordinated care, and
for physical activity.
have been ineffective at preventing

chronic disease and reducing
Connecting healthcare inside the

doctors office with communitybased health and other social
and billing practices have constrained

insurers from paying for programs that
are not directly delivered by doctors
can provide ongoing support,
and other licensed medical providers,
improve health where people

live, learn, work and play.
such as community health workers and

obesity counselors, or that help support
the health of an entire neighborhood
rather than focusing on a specific
individual who is tied to a specific
Approaches can range from doctors

providing direction and information for
patients, such as writing prescriptions
for healthy, active living, including
good nutrition and physical activity
to educating families about the
importance of healthy eating habits,
regular activity and sleep at every
well-child visit to referring patients
to resources or health management
programs in their community, such
as at their local YMCA or nutrition
counseling support.
For example, outdated regulations
service programs and resources

education and opportunities to
64
healthcare costs.198
diagnosis and billing code. Currently,

nearly half of all Americans do not
access many commonly recommended
preventive services, which can include
obesity and nutrition education
or prediabetes and blood pressure
screenings.199 Some private insurers
cover some evidence-based community
prevention programs, such as the
Diabetes Prevention Program (DPP),
but these efforts are limited and not
well known or understood in the
provider community.
In response, many public and private
Integrating public health and
insurers are increasingly expanding
healthcare via new approaches, such
coverage for proven community-based
as Accountable Care Organizations
programs to achieve better results
(ACOs) and global payment
for improving health and reducing
and wellness trust models.
obesity rates. One factor that
Coordination efforts can increase
contributed to this was the enactment
the focus on improving the overall
of the Affordable Care Act (ACA),
health of the insurance pool and
which has helped create incentives
offer strong incentives to providers
and mechanisms for new models
to deliver the most effective care
to improve focus on a coordinated
strategies possible, and to maximize
continuum of care that begins with
effectiveness, including community-
a focus on prevention inside and
based prevention programs and
outside the doctors office. Several
services to provide support to
provisions that help support the
patients to be able to follow doctors
prevention and control of obesity and
advice in their daily lives. ACOs
related diseases include:
are groups of healthcare providers
that prioritize coordinated care and
Requiring new plans (private, self-
quality goals to achieve improved
insurers and Medicare) to cover
health for their patients which
screening and counseling for obesity
reduce costs.200
with no cost to the patient through copayments, co-insurance or deductibles.

l
Providing incentives to encourage

state Medicaid programs to cover
more preventive services. In
2013, the Centers for Medicare
and Medicaid Services (CMS)
issued a rule that would give
states greater flexibility in what
types of providers could provide
recommended preventive services,
such as for obesity education and
counseling activities.
Updating tax-exempt hospitals

community benefit requirement by
requiring a community health needs
assessment and implementation
strategy in order to maintain taxexempt status. New U.S. Treasury
Regulations on community benefit
administered by the Internal Revenue
Service could address whether a
community benefit implementation
strategy may include activities related
to obesity prevention.
65
WHY BETTER INTEGRATION OF MEDICAL CARE AND SUPPORT WHERE PEOPLE LIVE, LEARN, WORK AND PLAY MATTERS:
Average monthly savings that individuals
with type 2 diabetes achieve with
preventive care
10%
$3,185
per person
per year
To maximize effectiveness and better
helped program participants lose 5
help patients follow their doctors
percent to 7 percent of their body
advice, providers and insurers, including
weight (10 to 14 pounds for a 200-
state Medicaid programs, can use an
pound person). Participants work with
integrated approach that focuses on
a lifestyle coach in a group setting for
community-based prevention and public
one year. The program includes 16 core
health. For instance, a new model that
sessions (usually one per week) and six
created an Affordable Care Community
post-core sessions (one per month).202
(ACC) in Akron, Ohio, involves a

coordinated clinical-community
published a review of more than 200
prevention approach and has reduced
studies and concluded that most
the average cost per month of care for
Average body weight

loss of YMCAs DPP
participants
cardiovascular disease could be
individuals with type 2 diabetes by more
prevented or at least delayed until
than 10 percent per month over 18
-5% to -7%
old age (65 and older) through a
months. A second project, a diabetes
combination of direct medical care and
self-management program, resulted in
community-based prevention programs
estimated program savings of $3,185
and policies.203
per person per year.201 This initiative

also led to a decrease in diabetesrelated emergency department visits.
l
Reviews of the CDC-led National

Diabetes Prevention Program, an
evidence-based lifestyle change
program, show that it can help people
cut their risk of developing type 2
diabetes in half. One study found that
making modest behavior changes
66
The American Heart Association
There are approximately 2,900 nonprofit

hospitals in the United States and
financial benefits to these hospitals from
federal, state and local tax preference
was estimated to be worth $12.6 billion
annually in 2002. Some of this funding
can be used to promote population
health improvement that extends beyond
hospital walls and in to the community.204
Encourage and incentivize new health system

approaches, such as ACOs, to incorporate community
obesity prevention programs to help them be successful
in improving health and lowering costs.
Government and private insurers should implement

policies and programs to increase the use and
improved integration of clinical and community-based
preventive services, particularly among communities
where services are underutilized.
Medicaid should provide additional technical assistance

and education to increase uptake in use of the new
regulations for preventive services that allow states to
reimburse a broader array of health providers and entities.
Medicaid should identify and disseminate community

prevention best practices by Medicaid programs,
including Medicaid Managed Care Organizations.
Broader healthcare delivery reform efforts, such as

the CMS Innovation Center-funded State Innovation
Models, should ensure that community-based
prevention to control obesity costs are included.
The U.S. Department of Treasury should continue

to clarify the use of community benefit dollars by
nonprofit hospitals to improve population health.
67
EXAMPLES OF IMPROVING THE CLINICAL-COMMUNITY CONTINUUM OF CARE

l
A number of providers have been using the Chronic Disease
of health to create a Community Referral Project, so doctors
Self-Management Program (also known as Better Choices,
have access and information about programs in their commu-
Better Health), which helps doctors connect patients to
nities and can refer and match patients to those resources.
community-based health workshops. Referred patients have
an extended opportunity during a series of
Bikes have partnered to create a Prescribe-
workshops to learn about effective exercise,
a-Bike program. Doctors and nurses can
good nutrition, communicating with health
write prescriptions for the local bike share
professionals and families about needs and

other strategies. The program, which is
based on an evidence-based model developed at Stanford University, has shown results in improved health outcomes, reduced
$20 for ike

Prescribe-a-B
referral systems to connect patients with community-support

programs. For example:
l
their patients to rent a bike for $5 to $80

less than the regular charge. The program
helps support health, equity and access to
income Boston residents.206
self-management techniques.205
A number of health systems and providers are also creating
program, New Balance Hubway, that allow
affordable transportation for more lower-
utilization of healthcare and increase use of
The Boston Medical Center and Boston
Integrating clinical care with community-based programs is

a focus of HHSs Million Hearts, a national initiative that
aims to prevent 1 million heart attacks and strokes by 2017.
A key objective is reducing uncontrolled high blood pressure
The Division of Health Promotion and Chronic Disease Pre-
which obesity can contribute to by supporting improved
vention in the Iowa Department of Health has partnered with
nutrition, increased physical activity, integrated medical care
the Iowa Primary Care Association (IPCA) and local boards
and other strategies.
Total Health: Public Health and Healthcare in Action Case Study. T. Norris. Kaiser Permanente:
http://healthyamericans.org/health-issues/prevention_story/total-health-public-health-and-health-care-in-action
Hospital Community Benefits after the ACA: Present Posture, Future Challenges. The Hilltop Institute Hospital Community
Benefit Program:
http://www.hilltopinstitute.org/publications/HospitalCommunityBenefitsAfterTheACA-PresentFutureIssueBrief8-October2013.pdf
68
EXPERT COMMENTARY
BY JOHNNA REED, vice president,
business development, Bon Secours
Connecting Diabetes Care from

the Clinic to the Community
Health System
In 2011, the Bon Secours St. Francis Health System in

Greenville, South Carolina created a Diabetes Integrated
Practice Unit (IPU) to foster a new environment that
improves the health of patients with, or at risk of
developing, type 2 diabetes.
Since most of the factors that influence
health exist outside of the doctors
The program also emphasizes
office, weve learned the importance of
the importance of prevention,
connecting our patients to resources

in their communities. This helps them
to avoid developing additional
in their daily lives and better supports
health risks or problems in the
their ongoing medical care.
future. We help prediabetics
The goal of the Diabetes IPU is to
avoid the progression to
connect patients with community
diabetes and help diabetics
resources that can help benefit their
avoid developing additional
health through improved nutrition,

increased physical activity and support
conditions.
to manage their condition. The

program also ensures that physicians
The program is designed around a
and other caregivers have sufficient
network of community and clinical
time to focus on their patients needed
resources, providers and technology.
care. This added time also allows

providers and patients to work together
to understand how obesity, prediabetes
and diabetes can affect health and daily
While the program hub is at St.

Francis Millennium, the programs
themselves are delivered where
life and to set goals that work for each
patients areat work, home, and
patients unique circumstances.
throughout the community.
69
The Diabetes IPU includes an extensive coordinated

team of care givers, including a primary care physician,
ophthalmology, cardiology, nephrology and podiatry
services, and an endocrinologist who consults with
the primary care physicians regarding innovations in
diabetes care and assists with the care of patients facing
particular medical challenges.
The medical care is managed by a
educator, pharmacist, and an exercise
registered nurse care coordinator. Its
physiologist to help patients get to a
also important to note that our care
healthy weight. It is not just a clinical-
team includes a psychologist, social
centered approach its a total
worker, registered dietician, diabetes
community health approach.
HOW THE IPU WORKS:

A patients initial visit with the diabetes
an introduction to exercise with an exercise
team begins with a fasting blood draw
physiologist who provides an easy, low
to determine blood glucose, HbA1c,
stress overview of exercise options.
cholesterol, and other relevant lab values.

Following the blood draw, patients are
provided a diabetes-appropriate breakfast.
Next, the patient is asked to participate
in a small group discussion about issues
they have in dealing with diabetes,
led by a diabetes educator and nurse.
Facilitators are continually surprised at the
level of engagement in these groups
patients tend to share readily and openly.
The group discussion not only introduces
patients to others who share similar
health and lifestyle challengesincluding
being overweight or obese and struggling
to engage in physical activity and eat
healthybut also enables the nurse
facilitator to determine the best match for
the patient with individual caregivers. After
the discussion, the entire group receives
70
In the course of this first morning, the

patient sees the primary physician,
psychologist, diabetes educator, and
registered dietitian. Each patient also
receives a retinal scan and foot exam.
Finally, patients are served a diabetesfriendly lunch with the clinical team present
to answer questions about the food or
anything else related to diabetes.
However, our work doesnt stop when
the patient leaves the clinic. Because
the needs of patients with type 2
diabetes require support and resources
in the community, our diabetes program
provides worksite and home services.
After their visit, a team member meets
with patients in their home to assess the
support network available and to identify
From the patient perspective, the most important

measure is improvement in the ability to live
Weight
45 lbs.
BMI
33.7 to 27.5
Waist
Size
44" to 36"
Health
areas where patients will face particular
enjoy daily activities). With each patient,
shared medical group appointments; and
challenges. Our teams then work with
the care team identifies capabilities that
engaged often with our dietician. While
family and employers to inform and
are motivating and meaningful and track
he hasnt yet reached all his top-level
facilitate improvements in the home and
their improvement. While these measures
goals, he lost more than 45 lbs., reduced
work environments and sometimes in the
require greater effort to quantify, they are
his BMI from 33.7 to 27.5 and his waist
local grocery stores and pharmacies.
often the drivers of peoples long-term
size from 44 to 36, and no longer needs
commitment to lifestyle change and health.
mealtime insulin coverage.
workplace assessment to determine how
Patients have responded incredibly well. A
The most successful patients are the
each patients work setting impacts his
recent patient entered the program hoping
ones who receive a continuum of care
or her health. For example, if there is no
to improve his health, get off regular
from the clinic to their community. Our
access to healthy foods, we work with
insulin and lose about 60 lbs. With the
model improves a physicians capability
the employer to improve the food options
diabetes teams help, he understood the
by bringing all of the necessary community
at a worksite. It might be surprising
need to deny barriers and stressors, such
resources together. Research shows that
that employers have been incredibly
as fast food and sugary drinks, and was
what happens outside the doctors office
supportive, however they fully understand
very successful.
can have a major impacteither positive
Often, the care team conducts a thorough
the importance of having a healthy, happy,

and productive workforce.
Through the program, he increased

glucose monitoring from to three to four
From the patient perspective, the most
times daily; went from not exercising at
important measure is improvement in the
all to exercising four times a week at the
ability to live (i.e., to work, participate in
facility we recommended to him; attended
family life, attend important events, and
all prescribed education opportunities and
or negativeon our health. Thats why

we began the Diabetes IPU model and
why well continue using it to fight obesity
and improve the care of individuals with
prediabetes or diabetes.
71
S EC T I ON 8 :
SECTION 8: COST CONTAINMENT AND OBESITY PREVENTION
The State of
Obesity:
Key Findings
Cost Containment and

Obesity Prevention
CURRENT STATUS:
Obesity is one of the biggest drivers of preventable

chronic diseases and healthcare costs in the United
States. Currently, estimates for these costs range from
$147 billion to nearly $210 billion per year.207 In
addition, job absenteeism related to obesity costs $4.3
billion annually.208
If obesity rates continue on their
heart disease and stroke, hypertension,
current trajectory, by 2030, combined
arthritis and obesity-related cancer
medical costs associated with treating
increases exponentially.210 Twenty
preventable obesity-related diseases
years ago, only 7.8 million Americans
are estimated to increase by between
had been diagnosed with diabetes
$48 billion and $66 billion per year,
but, today, approximately 25.8 million
and the loss in economic productivity
Americans have the disease.211 More
could be between $390 billion and
than 75 percent of hypertension cases
$580 billion annually.
can be attributed to obesity.212 And,
209
As obesity rates rise, the risk of

developing obesity-related health
problems type 2 diabetes, coronary
Americans Diagnosed with Diabetes

1994
approximately one-third of cancer

deaths are linked to obesity or lack of
physical activity.213
Hypertension
Attributed to
Obesity
Cancer Deaths
Linked to
Obesity
75%
33%
7.8
million
SEPTEMBER 2014
2014
25.8
million
However, if obesity trends were lowered by reducing the average

adult BMI by only 5 percent, millions of Americans could be spared
from serious health problems and preventable diseases, and the
country could save $29.8 billion in five years, $158 billion in 10
years and $611.7 billion in 20 years.214
Reducing obesity and improving
$16 billion annually within five years.
health can help lower costs through
Thats a return of $5.60 for every $1
fewer trips to the doctors office,
invested.216 Out of the $16 billion,
tests, prescription drugs, sick days,
Medicare could save more than $5
emergency room visits and admissions
billion and Medicaid could save more
to the hospital, and lowered risk for a
than $1.9 billion. Expanding the use
wide range of diseases.
of prevention programs would better
To date, there has not been a

sustained strong national focus on
prevention to deliver the potential
inform the most effective, strategic

public and private investments that
yield the strongest results.
results despite a growing number

of studies that demonstrate the
positive returns many strategies and
programs can deliver for improving
health and productivity and lowering
costs.
215
For instance, a 2008 study by
FIVE-YEAR ROI ON $10 PER PERSON

COMMUNITY-BASED INVESTMENT
Medicare
$5 billion
Medicaid
$1.9 billion
the Urban Institute, The New York

Academy of Medicine (NYAM) and
TFAH found that an investment of
$10 per person in proven communitybased programs to increase physical
activity, improve nutrition and
prevent smoking and other tobacco
use could save the country more than
Other Insurance $9.1 billion
73
WHY CONTAINING OBESITY-RELATED HEALTHCARE COSTS MATTERS:

Difference in Emergency Room Costs for
Patients Presenting With Chest Pains
Compared with a Normal-weight Patient
22%
41%
28%
Higher
Overweight
HIGHER HEALTHCARE COSTS FOR ADULTS

l
Higher
Higher
Obese
Severly Obese
Overweight and obesity in childhood
Obese adults spend 42 percent more
is associated with $14.1 billion in
on direct healthcare costs than healthy-
additional prescription drug, emergency
weight people.217
room and outpatient visit costs annually.
Per capita healthcare costs for severely
The average total health cost for a
or morbidly obese (BMI >40) were 81
child treated for obesity under private
percent greater than for normal weight
insurance is $3,743, while the average
adults.218 Around $11 billion was spent
health cost for all children covered by
on medical expenditures for morbidly
private insurance is $1,108.224
obese U.S. adults in 2000.

l
Total Annual Private Insurance

Child Healthcare Expenses
Hospitalizations of children and youths
Moderately obese (BMI between 30 and
with a diagnosis of obesity nearly
35) individuals are more than twice as
doubled between 1999 and 2005, while
likely as normal weight individuals to be
total costs for children and youths with
prescribed prescription pharmaceuticals
obesity-related hospitalizations increased
to manage medical conditions.219
from $125.9 million in 2001 to $237.6

million in 2005 (in 2005 dollars).225
All Children
$1,108
Obese Children
$3,743
Obesity-related Hospitalization Costs for

Children and Youths
Obese
DECREASED WORKER PRODUCTIVITY
were 41 percent higher for severely
AND INCREASED ABSENTEEISM
obese patients, 28 percent higher for
weight patients.220
Obesity is associated with lower

which costs employers $506 per obese
HIGHER HEALTHCARE COSTS FOR CHILDREN
2005
$7,503
worker per year.227
Obesity contributes an estimated

incremental lifetime medical cost of
$237.6
million
As a persons BMI increases, so do the
$19,000 per 10-year-old child when
number of sick days, medical claims and
compared with a normal-weight 10-year-
healthcare costs associated with that
old child. When multiplied by the
person.228 Obese women used 5.19 more
number of obese 10-year-olds in the
sick days and obese men used an excess
United States, lifetime medical costs
of 3.48 sick days compared with normal
for just this cohort would amount to
weight individuals, according to a 2014
approximately $14 billion in direct
German study.229
medical costs.221, 222
$51,091
Obese children had $194 higher

outpatient visit expenditures, $114
productivity while at work (presenteeism),
74
Obesity-related job absenteeism costs

$4.3 billion annually.226
for overweight patients than for normal-
Annual Medical Claims per 100 Full-time

Employees
Healthy-weight
emergency rooms with chest pains
obese patients and 22 percent higher
2001
$125.9
million
Costs for patients presenting at
HIGHER WORKERS COMPENSATION CLAIMS

l
A number of studies have shown
higher prescription drug expenditures
obese workers have higher workers
and $25 higher emergency room
compensation claims.230, 231, 232, 233, 234, 235
expenditures, based on a two-year
Medical claims cost $7,503 for healthy-
Medical Expenditure Panel Survey.223
weight workers and $51,091 for obese

workers (annual costs, United States).236
Preventing obesity and its related chronic diseases should

be a major focus of healthcare cost-containment efforts.
Funding for obesity-prevention programs will be

important to achieve results in improving health and
reducing healthcare costs. Programs and policies
should include a wide range of partners to ensure
success, including businesses, schools, community- and
faith-based organizations, economic and community
developers and health and social service providers.
Because community-based obesity- and diseaseprevention programs can significantly cut healthcare
costs, funding for evidence-based programs at all levels of
government will continue to be important.
Community-based programs must include the ability to

evaluate effectiveness and cost savings, and demonstrate
how savings can be shared among partners, including
businesses and the healthcare system, and reinvested to
continue to support and expand prevention activities.
Bending the Obesity Cost Curve. Trust for Americas Health. February 2012:
http://healthyamericans.org/assets/files/TFAH%202012ObesityBrief06.pdf
Return on Investments in Public Health Saving Lives and Money. The Robert Wood Johnson Foundation.
December 2013: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/12/return-on-investments-in-public-health.html
Assessing the Economics of Obesity and Obesity Interventions. M.J. OGrady and J.C. Capretta.
Campaign to End Obesity. March 2012: http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2012/03/new-reportshows-importance-of-calculating-full-cost-savings-of-.html
75
FEDERAL FUNDING FOR OBESITY PREVENTION

Public health programs are funded through
$1.16 billion in FY 2012, but then ex-
improving nutrition, and increasing
a combination of federal, state and local
perienced a 17 percent cut in FY 2013.
activity within NCCDPHPreceived
dollars. Analyses from a number of or-
The FY 2014 Omnibus Appropriations
total amounts of ($47.5 million) in FY
ganizations, including the IOM, NYAM,
Bill restored $185 million to chronic dis-
2013 and ($49.5 million) in FY 2014,
CDC and a range of other experts have
ease programs, largely as part of Pre-
the division experienced a 21 percent
found that public health has been severely
vention and Public Health Fund dollars
cut to its core activities. Instead of
underfunded for decades and does not re-
to reach a total of $1.15 billion.
adding to the funding base to be able
ceive sufficient support to carry out many

core functions, including programs to prevent disease and obesity.
237
Despite the increase, the overall limited

nature of funding for prevention has
meant decreased and inconsistent
Much of the federal support for obesity
support for the various categorical
prevention is through grants to states
disease-prevention and health-
distributed through CDCs National Cen-
promotion programs.
ter for Chronic Disease Prevention and
to focus on high-priority initiatives,

including breastfeeding, early child
care education and a new highrisk obesity initiative that provides
$5 million in competitive grants to
communities where obesity rates are
above 40 percent, the funds to support
For example, while the Division of
these efforts have been carved out
Nutrition, Physical Activity and Obesity
from DNPAOs overall budget, leaving
Federal funding for chronic disease
(DNPAO)a division that specifically
significantly less money for grants to
prevention reached an all-time high of
focuses on the obesity epidemic,
states and core program activities.
Health Promotion (NCCDPHP).
DIVISION OF NUTRITION, PHYSICAL ACTIVITY AND OBESITY FY 2013 TO 2014 FUNDING

FY 2013
FY 2014
DNPAO Total
$47.5 million
$49.5 million
Breastfeeding initiative
$2.5 million
$8 million
$4 million
$4 million
Early child care education (ECE)

High-risk obesity
Total unrestricted for core activities
n/a
$5 million
$41 million
$32.5 million
*21 percent decrease in unrestricted funds from FY 2013 to 2014
Although the State Public Health Actions
sity prevention, while diabetes and heart
State Public Health Actions to Prevent
funding opportunity announcement (FOA)
disease received $20.7 million and $23.3
and Control Diabetes, Heart Disease,
provides funding to all 50 states and D.C.
million, respectively. Currently, CDC does
Obesity and Associated Risk Factors and
to conduct public health functions related
not have sufficient or sustained funds to
Promote School Health, aims to efficiently
to obesity prevention such as epidemiology
maintain obesity prevention activities or to
implement cross-cutting strategies in a
and surveillance activities, DNPAO funding
build upon or scale effective programs.
variety of settings that improve multiple
for state level obesity prevention strategies

with expanded reach and impact related
to nutrition and physical activity has decreased and are funded at lower levels
that those related to diabetes and heart
disease. For example, in FY2013 DNPAO
provided $16.7 million to states for obe-
76
In FY 2013, NCCDPHP released a FOA

that brings together four programs that
were previously standalone programs:
heart disease and stroke; nutrition,
physical activity and obesity; school
health; and diabetes. The FOA, entitled
chronic diseases and conditions, while

maintaining categorical appropriation
funding levels and performance targets.
Coordination is intended to improve the
impact of efforts to prevent obesity and
conditions related to obesity, such as
diabetes and heart disease.
CDC CHRONIC DISEASE FUNDING FROM FY 2003 TO FY 2014 ($ IN MILLIONS)

$1400
Chronic Disease Funding
Prevention and Public Health Fund
$1200
$800
$411
$59
$1000
$790
$818
2003
2004
$900
$834
$825
$834
$301
$244
$905
$882
$446
$774
$756
$740
$712
2011
2012
2013
2014
$600
$400
$200
$0
2005
2006
2007
2008
2009
2010
* FY 2010 to 2014 values are supplemented by the Prevention and Public Health Fund
PREVENTION AND PUBLIC HEALTH FUND ALLOCATIONS (FY 2010 TO 2022):

ACTUAL CURRENT FUNDING [UNDER P.L. 112-96] VS. INTENDED FUNDING ESTABLISHED BY ACA
The Prevention and Public Health Fund was created to supplement, not supplant, support for prevention programs. The Prevention Fund
supports many measures aimed at obesity prevention, including the CDCs Division of Nutrition, Physical Activity and Obesity Prevention.
However, discretionary funding for chronic disease prevention experienced cuts between FY 2009 and 2013. In addition, the Fund also
experienced cuts from the originally intended allocation levels. The ACA originally allocated $21 billion for the Prevention Fund from FY
2010 to FY 2022. The Fund has experienced cuts or reallocations of nearly one-third, dropping it to $14.5 billion, nearly a 32.3 percent cut.
$2.25
$2.00
$1.00
$1.00
$1.00
$0.75
$0.75
$0.50
$0.50
$1.50
$1.50
2020
2021
$2.00
$1.75
$1.50
$0.50
$1.25
$0.25
$1.00
$1.00
$0.75
$0.50
$0.051
$0.332
$1.25
$1.25
2018
2019
$0.072
$0.928
$1.00
$1.00
$1.00
2014
2015
2016
2017
$0.75
$0.617
$0.50
$0.25
$0.00
2010
2011
2012
Under P.L. 112-96 (Current level)
2013
CMS Health Insurance Enrollment Support
Sequestration
2022
As Established in ACA
77
DIVISION OF NUTRITION, PHYSICAL ACTIVITY AND OBESITY

DNPAO supports healthy eating,
extend their work and reinforce
active living and obesity prevention
consistent public health recommenda-
by creating healthy options in our
tions with promising practice.
nations child care centers, schools,

worksites, cities and communities.
Partnerships with state, local, territorial and tribal health departments,
private enterprise, nonprofit organizations and healthcare professionals
and coordination with other agencies
The division focuses on improving dietary

quality to support healthy child development and reduce chronic disease;
increasing physical activity for people of
all ages; and decreasing prevalence of
obesity through prevention of weight gain
and maintenance of healthy weight.
DIVISION OF POPULATION HEALTH, SCHOOL HEALTH BRANCH

CDCs Division of Population Health
and Promote School Health. With
(DPH), School Health Branch addresses
this funding, the division supports
nutrition, physical activity and obesity
all 50 states by funding state health
in schools. In addition to research
departments to address nutrition and
and evaluation activities, the School
physical activity in schools. It also
Health Branch in DPH supports the
provides additional enhanced funding
school specific activities in the CDC
to 32 of the 50 states to support
Funding Opportunity Announcement,
even more work around policies and
State Public Health Actions to Prevent
practices around school physical
and Control Diabetes, Heart Disease,
activity, nutrition and managing chronic
Obesity and Associated Risk Factors
conditions in schools, including obesity.
CUTS TO STATE PUBLIC HEALTH FUNDING

In addition to the funding cuts at
than $1.3 billion, based on the total
the national level, state-level public
states budgets from those years,
health funding has also experienced
adjusted for inflation.238 Budget
significant cuts, with median per
cuts have led state and local health
capita spending decreasing from
departments to cut more than 45,700
$33.71 in FY 2008 to $27.49 in FY
jobs across the country since 2008.239
2013. This represents a cut of more
78
STATE GRANTS CHART

CDC funds many state and local efforts to prevent and control obesity and related diseases. The table below provides a summary
of these grants.
State Public Health Actions:
Enhanced Component
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
# of States
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
32
School Health Grants1
REACH1, 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
50*
Community Transformation
Grants1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
30
40
3
3
* The new Funding Opportunity Announcement (FOA) (launched Oct 1 2014) State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and
associated Risk Factors, and promote School Health provides a basic level of funding to all 50 states ((School health range: $46,000- $76,000); and an enhanced
level of funding to 32 states ((school health range: $78,000-$223,000).
79
S EC T I ON 9 :
SECTION 9: EARLY CARE AND EDUCATION (ECE) AND OBESITY
The State of
Obesity:
Key Findings
Early Care and Education (ECE)

and Obesity
CURRENT STATUS:
More than 8 percent of preschoolers in the United States

were obese in 2011 to 2012, and an additional 23 percent
of children ages 2 to 5 were overweight.240
OBESE 2 TO 5 YEARS, 2011 TO 2012 NHANES241
8.4%
3.5%
11.3%
16.7%
Total
White
Black
Latino
According to PedNSS, the obesity
ages of zero and 5 regularly spend a
rate among preschool children from
significant amount of time in non-
low-income families is higher than the
parental child care settings. 243
national average, but there are signs

of progress. In 2011, 14.4 percent
of 2- to 4-year-olds from low-income
families were obese an increase
from 12.7 percent in 1999. However,
from 2008 to 2011, obesity rates
among this population decreased in
18 states and the U.S. Virgin Islands,
and increased in only three states.242
The IOM has recommended

including specific requirements
related to physical activity, sedentary
activity and feeding in child care
regulations.244 The American
Academy of Pediatrics, American
Public Health Association (APHA)
and National Resource Center for
Health and Safety in Child Care and
SEPTEMBER 2014
A number of strategies to reduce
Early Education have identified 50
obesity among young children focus
components that all types of early care
on improving nutrition, increasing
and education settingsincluding
physical activity and reducing screen
centers and family child care homes
time in child care and early education
should include in standards for infant
settings since more than half of
feeding, nutrition, physical activity
American children between the
and screen time.245
SOME KEY RECENT EFFORTS AND PROGRAMS TO IMPROVE CHILD CARE QUALITY WITH RESPECT TO
OBESITY PREVENTION INCLUDE:
l
Lets Move! Child Care encourages
YMCA, the Boys and Girls Clubs
subsidies for low-income families
ECE providers to meet a basic set of
of America and others have made
to obtain child care so parents can
best practices in five goal areas:
commitments to meet the Lets
pursue work, education, or training
Move! Child Care goals as part of the
opportunities.250 CCDBG offers broad
Partnership for a Healthier America.247
guidance and flexibility to states for
1) P
hysical activity: provide one
to two hours of physical activity
throughout the day, including
outside play when possible;
creating both the child care assistance
The Child and Adult Care
program and a program of basic
Food Program (CACFP) is a
regulation for child care operations.
federal nutrition assistance
2) S
creen time: none for children
entitlement program that provides
The CCDBG Reauthorization Act of
reimbursement for meals and
2014 (S.1086) would reauthorize the
snacks for more than 3.2 million
program through FY 2020. For the
children from low-income families
first time, the bill includes provisions
in child care centers and child care
for child care provider training
services provided in family homes.
around healthy eating and physical
CACFP regulates meal patterns and
activity as an allowable activity for
at every meal, eat meals family-
portion sizes, provides nutrition
quality improvement and would
style whenever possible and avoid
education and offers sample menus
allow states to make healthy eating
serving fried foods;
and training in meal planning
and physical activity a part of their
under age 2 and for those 2 years

and older, limit screen time to 30
minutes per week during child
care and no more than one to two
hours per day at home;
3) F
ood: serve fruits or vegetables
4) B
everages: give water during
and preparation to help providers
health and safety requirements. The
comply with nutrition standards.
bill cleared the Senate in March
248
meals and throughout the day
2014 but has not yet been considered
and avoid sugary drinks. For
ECE programs or facilities that are not
children two years and older,
required to meet CACFP meal pattern
serve low- or non-fat milk and
standards can do so voluntarily to
Additionally, in May 2013, the
four to six ounces maximum of
ensure that meals and snacks meet
Administration for Children and
100 percent juice a day; and
the nutritional needs of infants and
Families proposed a rule to require
children.
states to provide pre-service training
249
5) I nfant feeding: provide breast

milk to infants of mothers who
wish to breastfeed, welcome
mothers to nurse mid-day and
support parents decisions with
infant feeding.246
The Department of Defense, General
Services Administration, Bright
Horizons, Knowledge Universe, the
Learning Care Group, New Horizons,
The Healthy, Hunger-
by the House as of July 2014.
Free Kids Act directed USDA to
to participating providers regarding
improve and better align the CACFP
age-appropriate nutrition, feeding,
nutrition standards with the dietary
including support for breastfeeding
guidelines, though updated standards
and physical activity as a component
have not yet been proposed.
of the minimum health and safety
The Child Care and Development

Block Grant (CCDBG) is the primary
federal funding stream for child
training. The public comment

period has closed, but the final rule
is still pending.
care in the United States, providing
81
Head Start is a federal child
eating behaviors and attitudes for
development program that serves
children; and 5) facilities provide
more than one million children
opportunities for outdoor and
between the ages of 3 to 5 from
indoor active play.252
low-income families.251 Head Starts

focus on school readiness includes
a provision requiring that, by
health, nutrition, education, social
2020, the Dietary Guidelines
services and parental engagement
for Americans include nutrition
components. Head Start programs
and dietary guidelines designed
are required to adhere to federal
specifically for children from
regulations that ensure: 1) parents
birth until age 2. In addition,
receive guidance on nutrition
SNAP-Ed dollars can be delivered
and physical activity; 2) facilities
to childcare centers if the majority
participate in the CACFP; 3) meals
of children meet the general
and snacks provide one-third to
low-income standard (household
one-half of the daily nutritional
incomes of <185 percent of the
needs of children in part- or full-day
Federal Poverty Guidelines).253
programs; 4) staff model healthy
Obese or Overweight in Kindergarten
WHY OBESITY RATES AMONG YOUNG CHILDREN MATTER:

l
12.4%
Obese
14.9%
Overweight
Obese or Overweight in 8th Grade
82
17%
Obese
Overweight
Children who are overweight or obese
obese by eighth grade. When the
are likely to be obese as adults. Being
children entered kindergarten, 12.4
overweight or obese can put them at
percent were obese and another 14.9
higher risk for health problems
percent were overweight; in eighth grade,
such as heart disease, hypertension,
20.8 percent were obese and 17 percent
type 2 diabetes, stroke, asthma and
were overweight. Overweight 5-year-olds
osteoarthritis during childhood and
were four times as likely as normal-
as they age.
weight children to become obese.255
254
20.8%
The 2014 Farm Bill includes
A study of more than 7,700 children
Children who are overweight or obese
found that a third of the children who
are likely to score poorer academically in
were overweight in kindergarten were
math than their normal-weight peers.256
hild care providers and early childhood educators

C
should provide opportunities for physical activity and
healthy eating for the children they serve, including:
ntering into shared-use agreements with community

E
partners to utilize outdoor space for physical activity.
I dentifying creative ways to purchase and prepare

healthy foods and physical activity equipment at a lower
cost, including local sourcing, purchasing cooperatives,
group purchasing organizations and central kitchens.
stablishing gardens and participating in farm-to-child

E
care programs, if available.
ngaging families in menu planning and physical

E
activity events.
SDA should issue updated meal patterns for CACFP, as

U
per the Healthy, Hunger-Free Kids Act.
he Office of Head Start should ensure that nutrition
T
and physical activity standards and initiatives are reviewed
and updated regularly to ensure they reflect current
national recommendations.
besity prevention strategies should be incorporated into
O
the licensing of child care facilities and states should integrate obesity prevention (nutrition, physical activity, screen
time, professional development and parent and family engagement) into their Quality Rating and Improvement System (QRIS) a states voluntary, comprehensive approach
that incentivizes quality improvement of ECE programs.
tates and localities should provide comprehensive
S
obesity prevention pre-service training as well as technical
assistance and continuing education for child care and
early education providers.
83
CASE STUDIES
l
Maryland requires all child care
based day care across the state.
providers, including home-based
The grants were used to establish
care, to follow CACFP nutrition
connections with local growers
guidelines and additional nutrition
and farmers, to develop direct
standards, including 1) making
purchasing relationships to buy
water available inside and outside;
local fruits and vegetables for
2) serving skim or one percent
CACFP snacks and meals and
milk to children over 2-years-old;
sustain change in child care
3) serving whole milk to 1- to
settings.The initiative reached 292
2-year-olds who are not on breast
child care centers and day care
milk or formula, or 2 percent
homes serving more than 14,000
milk to those at risk for obesity
preschool children and their
or hypercholesterolemia; and 4)
parents or guardians. Caregivers
developing a plan for introducing
partnered with parents to bring
age-appropriate solid foods.
some of the same lessons being
Marylands success in implementing
taught in school to homes such
the guidelines has been attributed
as teaching children and parents
to its collaborative work and
how to start their own gardens so
to its regular dissemination of
they could serve more fruits and
information and resources to
vegetables.258
child care providers across the

state. The states education and
health departments work together
in partnership with outside
organizations and local child care
resource and referral agencies.257
l
84
C alifornias CACFP has created

a recognition program called
Preschools Shaping Healthy
Impressions through Nutrition
and Exercise (SHINE). An early
child care facility can become
The Texas Farm to Child Care
a Preschools SHINE site if
programs goal is to improve the
they require online training,
health and nutrition of children
attend training forums, conduct
in child care and early education
self-assessments of their
settings by encouraging the
environments and develop
purchase of local produce. In
policies and practices related to
2010, USDAs Food and Nutrition
enhanced nutrition standards,
Service awarded $1 million
mealtime environments,
in CACFP grants to the Texas
classroom nutrition education,
Department of Agriculture. A
edible gardens, physical activity,
portion of the grant was used
wellness policies, professional
to establish Farm to Child Care
development, partnerships and
initiatives in centers and home-
leadership teams. 259
CDC AND ECE PROGRAMS

CDC has made obesity prevention in
D.C. for chronic disease prevention
Indiana, Kansas, Missouri and
early care and education a high priority.
efforts. All grant recipients are
New Jersey and year two (FY 2013)
The agency provides funding, training
required to promote physical activity
funding expanded the project to
and technical assistance to a variety
in ECE settings and many are also
Kentucky, Los Angeles County and
of state and community agencies
implementing nutrition standards.
Virginia. By the end of FY 2014,
and other organizations to implement

obesity prevention efforts targeting ECE
settings. Some key projects include:
l
Nemours expects to reach almost
National Early Care and Education
64,000 children in 717 centers
Learning Collaboratives Project:
across nine states.261
This five-year cooperative agreement,
Childhood Obesity Research
Development of a framework and
launched in 2012, funds Nemours
technical assistance materials for
to establish and implement ECE
Demonstration Project (CORD):
obesity prevention efforts targeting
learning collaboratives in states to
This four-year cooperative agreement
ECE settings and regular convening of
make improvements in nutrition,
provides funding to four grantees to
stakeholders working on these efforts
breastfeeding support, physical
improve nutrition and physical activity
and dissemination of resources.
activity and screen time. Participating
behaviors among children ages 2 to
providers exchange ideas with
12 years covered by the Childrens
peers, learn from experts, share
Health Insurance Program. CORD
tools and receive training to assist
project grantees are working with
them in improving their policies
60 ECEs in Texas, California and
and practices. Year one (FY 2012)
Massachusetts to provide training,
provided funding to Arizona, Florida,
technical assistance and support.
260
State Public Health Actions to

Prevent and Control Diabetes, Heart
Disease, Obesity and Associated Risk
Factors and Promote School Health:
This five-year cooperative agreement
funds all 50 states and Washington,
85
Nemours: Childhood Obesity Prevention Toolkit for Rural Communities

Children living in rural areas are 25
time, community initiatives and health-
percent more likely than those living
care. The toolkit also includes policy
in metropolitan areas to be obese or
recommendations and an overview of
overweight.262 Often, long distances
their evaluation process.
separate the home from opportunities

for physical activity or healthy eating, as
well as from healthcare providers, which
can prevent families from addressing
obesity and promoting health.263
Obesity prevention initiatives profiled

in the toolkit incorporate the following
elements: dynamic leadership from
within the community; multi-sector
partnerships focused on shared goals
To help rural communities address
and culturally appropriate messages;
these barriers, Nemours, a foundation
youth empowerment and family en-
that operates an integrated childrens
gagement; training for providers;
health system, prepared a Childhood
hands-on learning techniques for chil-
Obesity Prevention Toolkit for Rural
dren and families; leveraging of public
Communities. The toolkit provides
and private funding; and creative solu-
a range of strategies and success
tions. The profiled communities lever-
stories to assist practitioners in child-
age their unique rural resources and
serving sectors, including: early care
benefit from close community bonds to
and education, schools, out-of-school
improve childrens health.
Lets Move! Child Care. Nemours:
http://www.healthykidshealthyfuture.org/welcome.html
Preventing Childhood Obesity in Early Care and Education Programs. American Academy of Pediatrics, American Public Health
Association and National Resource Center for Health and Safety in Child Care and Early Education:
http://nrckids.org/default/assets/File/PreventingChildhoodObesity2nd.pdf
Childhood Obesity Prevention Toolkit for Rural Communities. Nemours:
http://www.nemours.org/content/dam/nemours/wwwv2/filebox/service/healthy-living/growuphealthy/nhps/Childhood%20
Obesity%20Prevention%20Strategies%20for%20Rural%20Communities.pdf
86
EXPERT COMMENTARY
BY DEBRA POOLE, owner, Georgetowne
Home Preschool
Good Nutrition is Key to a Good

Start for Children
When I started Georgetowne Home Preschool in Ocala,
Florida 20 years ago, I was more than 100 pounds
overweight and had little understanding of how important
eating healthy was to happiness, health and success.
I was raised with poor nutritional
required fruit and vegetables at
habits in a poor family we
breakfast and snack time.
seemingly didnt have the money or

the information we needed to buy
healthy foods.
Floridas efforts were ahead of its

time! In 2010, the Healthy, HungerFree Kids Act required the USDA to
This all changed when I started to
develop standards for CACFP meals
take care of other peoples children.
that are consistent with the Dietary
Part of my preparation for becoming a
Guidelines for Americans. This new
child care provider included reviewing
national standard will help preschools
an incredibly helpful nutrition
in other states with less rigorous
curriculum and additional healthy
standards than Floridas.
eating information supplied by the

state of Florida. I started to realize the
importance of diverse and healthy
I guarantee that once preschools
foods. As I began practicing good
fully buy into providing nutritious
nutrition, my eating habits changed and
meals and snacks, their children
my activity levels improved dramatically.

I lost 100 pounds as a result.
I had to bring this good feeling to
my kids. I joined Floridas Child
Care Food Program (CCFP) to
help these children eat healthy and
improve their overall learning skills.
Thankfully, our states nutrition
standards are quite strongfor more
than a decade, CCFP has limited
sugary foods and drinks and has
will be happier, healthier and

more productive.
Of course, we need to ensure kids buy
into this concept of eating healthy.
When some parents bring me their
little 4-year-olds, they say things like
my son is a picky eater. He only eats
mac n cheese or chicken nuggets and
doesnt like fruits or vegetables.
87
Quite frankly, I think we underestimate a childs ability to adapt and

willingness to explore.
For example, when I start teaching
will give them superpowerswhich,
and working with the children, I show
when you think about the health
them a plate and say, lets put a lima
benefits of fruits and vegetables, isnt
bean on there. If they say they dont
so far off. They love it! Sure enough,
want it, I turn it into a fun adventure
an adventurous and tough 4-year-old
and tap into their imagination. I get
volunteers and the rest follow suit
out the magnifying glasses and have
and soon everyone is eating lima
them check their tongues for the
beans and other fruits and vegetables.
lima bean taste bud or tell them it
WE MAKE ALL OF OUR OWN FOOD ON SITE WITH THE KIDS. THE
CHILDREN SMELL AND TOUCH AND INTERACT WITH FOODS.
We put up pictures of fruits and
teaches responsibility and gives me the
vegetables theyve never seen before.
opportunity to introduce foods at the
And then we set up a grocery store in
right pace and portion size for each
the kitchen and the kids go shopping
child. I also shop at warehouses and
and pretend to buy these things.
roadside stands and avoid canned foods
Typical days also include as much

physical activity as possible, including
Ive found that my parents are highly
and swimming. And, of course, we focus
supportive of this approachthey
on learning from start to finish, with
appreciate what it means for their
kindergarten preparatory assignments,
kids, and have been inspired to eat
computer work, 3-D projects, or
healthier at home as well
shopping, for instance) and group

action games on our circle time rug.
Our emphasis on nutrition is the

foundation on which our success has
been built. Its all about giving children
People always want to know how all
the tools and skills they need to make
this is possible on a tight budget. First,
healthy choices and grow up healthy.
I serve everything family style, which
healthier and tastes better, too.
stretching, dancing, playing, bike riding
dramatic play (acting out grocery store
88
buying fresh or frozen is typically
SECTI O N 10:
Lynn Johnson, used with permission from RWJF
Obesity Prevention in Black

Communities
CURRENT STATUS:
Inequities in a range of factors income, stable and

affordable housing, access to quality education and
SECTION 10: OBESITY PREVENTION IN BLACK COMMUNITIES
The State of
Obesity:
Obesity Policy
Series
others all influence a persons chance to live a longer,

healthier life.264 These inequities and disparate access
to affordable, healthy food or safe places to be physically
active, contribute to higher rates of obesity and related
illnesses in Black communities.
l
African American adults are nearly 1.5
women) compared with 67.2 percent
times as likely to be obese compared
of Whites (including 71.4 percent of
with White adults. Approximately
men and 63.2 percent of women).266
47.8 percent of African Americans

of men and 56.6 percent of women)
African American Obesity or Overweight
compared with 32.6 percent of Whites

(including 32.4 percent of men and
32.8 percent of women).265 More
69%
82%
Men
Women
than 75 percent of African Americans

are overweight or obese (including 69
percent of men and 82.0 percent of
SEPTEMBER 2014
are obese (including 37.1 percent
Overweight Children Ages 2 to 19

1999 2012
35.1%
28.5%
20.2%
14.3%
Black
White
Black
White
Overweight and obesity rates also
(BMI greater than 120 percent of
tend to be higher among African
the weight and height percentiles
American children compared with
for an age rage) as of 2012.269
White children, with obesity rates

increasing faster at earlier ages and
with higher rates of severe obesity.
From 1999 to 2012, 35.1 percent of
African American children ages 2 to
19 were overweight, compared with
28.5 percent of White children; and
20.2 percent were obese compared
with 14.3 percent of White children.267
Nationally, in 2011 to 2012, 20.5
percent of African American girls
were obese compared with 15.6
percent of White girls, and 19.9
percent of African American boys
percent of White boys.268
More than 8 percent of African
90
Obese Children Ages 2 to 19

1999 2012
M
ore than 11 percent of African
American children ages 2 to 5 were
obese, compared with 3.5 percent of
White children. By ages 6 to 11, 23.8
percent of African American children
percent of Whites.270 Three-quarters
of the difference in rates that arise
between African American and White
children happens between the third
and eighth grades.271
Addressing these disparities
requires making healthier
choices easier in peoples daily
lives by removing obstacles that
make healthy, affordable food
less accessible and ensuring
American children ages 2 to 19
communities have more safe and
were severely obese, compared
accessible places for people to be
with 3.9 percent of White children
physically active.
Obese African American Girls 2011
Obese White Girls 2011
20.5%
15.6%
African American Children Living Below the Poverty Line
Americans Living
in Communities
With One or More
Supermarkets
38%
42.7%
African American children under

the age of 18

the age of 5
8%
31%
Black
White
Access to affordable, healthy food:
neighborhoods, without regard
Lower-incomes and poverty correlate
to income, predominantly Black
physically active: Achieving a healthy
strongly with an increase in obesity,
neighborhoods have the most
energy balance also requires engaging
since less nutritious, calorie-dense
limited access to supermarkets and
in sufficient amounts of physical activ-
foods are often less expensive than
to the healthier foods such markets
ity.283 As of 2010, African Americans
healthier foods.272 African American
sell.278 According to the 2013 YRBS,
were 70 percent less likely to engage
families have earned $1 for every $2
11.3 percent of Black youths did
in physical activity than Whites.284 Ac-
earned by White families for the past
not eat vegetables during the prior
cording to the 2013 YRBS, 21.5 per-
30 years.
week, compared to 4.5 percent of
cent of Black youth did not participate
White youths.
in at least one hour of daily physical ac-
age 18 and 42.7 percent of children
students are almost twice as likely
tivity during the prior week, compared
under age 5 live below the poverty
to not eat breakfast daily compared
with 12.7 percent of White youth.285
line,274 and more than 12 percent
with their White peers, which can be
of African American families live in
a contributing factor to less healthy
deep poverty (at less than 50 percent
eating patterns overall, weight gain
of the federal poverty threshold).275
and poorer performance in school.280
273
More than 38 percent of
One in four African American
Black high school
279
Limited access to safe places to be
Children in neighborhoods that lack

access to parks, playgrounds and
recreation centers have a 20 percent
to 45 percent greater risk of becoming
Higher exposure to marketing of
overweight.286 National-based studies
less nutritious foods: Each day,
show that access to public parks, public
African American children see
pools and green space is much lower
twice as many calories advertised
in neighborhoods largely occupied by
in fast food commercials as White
African Americans.287 Safety concerns
children.281 The products most
also further limit outdoor activities
Families in predominantly minority
frequently marketed to African
among African American children.
and low-income neighborhoods
Americans are high-calorie, low-
Sidewalks in African American
have limited access to supermarkets
nutrition foods and beverages.
communities are 38 times more likely
and fresh produce.A study of
Billboards and other forms of
to be in poor condition According to
selected communities found that
outdoor advertisements, which often
a recent study, how African American
only 8 percent of African American
promote foods of low nutritional
mothers perceive neighborhood safety,
residents lived in areas with one or
value, are 13 times denser in
and specifically the threat of violence,
more supermarkets, compared with
predominantly African American
strongly influences the amount of daily
31 percent of White residents.
neighborhoods than White
outdoor play in which their young
When compared with other
neighborhoods.
daughters participate.288
families are food insecure (not

having consistent access to adequate
food due to lack of money or other
resources), compared with 11
percent of White households.276
277
282
91
FEMALE OBESITY BY RACE/ETHNICITY
MALE OBESITY BY RACE/ETHNICITY
60
56.6%
50
44.4%
40
53.9%
49.0%
50
40.1%
42.3%
39.1%
40
30
29.7%
31.0%
26.6%
20
10
15.4%
34.0%
38.4%
36.1%
30.7%
32.8%
30.2%
28.2%
27.9%
30
24.4%
31.6%
31.1%
37.1%
32.4%
27.3%
23.3%
20
15.4%
Black
Latino
16.8%
Black
15.7%
White
1971-1974 1976-1980 1988-1994 1999-2002 2003-2004 2011-2012
21.3%
20.7%
16.5%
10
12.5%
Latino
White
12.4%
1971-1974 1976-1980 1988-1994 1999-2002 2003-2004 2011-2012
WHY INEQUITIES IN OBESITY RATES MATTER:

Obesity Related Healthcare Costs for
Preventable Diseases
2014
$23.9
billion
The rates of deaths from heart disease
among Latinos, African Americans and
and stroke are almost twice as high
Whites for a set of preventable diseases
among African Americans than Whites.289
(diabetes, heart disease, high blood
$50
billion
sity) cost the healthcare system $23.9
American adults are twice as likely as
billion annually.292 Based on current
White adults to have been diagnosed
trends, by 2050, this is expected to
with diabetes by a physician.290

The annual medical costs associated
with obesity have been estimated as
high as $190 billion (in 2005 dollars)
accounting for 21 percent of all medical spending.291 High rates of chronic
illnesses, which in many cases are preventable, are among the biggest drivers
of healthcare costs and reduce worker
productivity. A study by the Urban Institute found that the differences in rates
many of which are often related to obe-
type 2 diabetes are overweight. African
2050
92
pressure, renal disease and stroke
More than 80 percent of people with
double to $50 billion a year.

l
Eliminating health inequalities closing

the gaps in the health differences by race
and ethnicity could lead to reduced
medical expenditures of $54 billion to
$61 billion a year and recover $13 billion
annually due to work lost as a result of
illness and around $250 billion per year
due to premature deaths, according to a
study of 2003 to 2006 spending.293, 294
ll public and private investments in community

A
prevention should directly involve local communities
throughout the process, including partnering
with Black residents and organizations, as well as
understanding the assets and resources within each
community, to determine priorities and develop
culturally relevant and sustainable solutions.
quity should be a criterion and measure for grants
E
authorized to address obesity in communities in order
to ensure that addressing disparities is a priority goal
for a given project or program, and that grantees
are held accountable for addressing disparities. For
example, at the outset, a programs needs assessments
should identify gaps in health outcomes, behaviors and
other community features, and evaluation plans should
include measures to demonstrate progress toward
closing those gaps. Grant requirements must be assessed
for feasibility in all communities, to ensure the goals
are appropriate and match the existing resources of
communities with high percentages of racial and ethnic
minorities and low-income populations.
upport should be increased at the federal, state and local
S
levels to address racial and ethnic inequities in obesity.
olicies should require that health programs include
P
culturally sensitive communications and language, and
a variety of communication methods and channels
including social media should be used to most effectively
reach communities of color.
93
94
trategies and programs need to be developed in

S
conjunction with and led by community leaders and
members, including the implementation of common
practices, such as joint-use agreements, to allow
community members to use playgrounds and fields
when school is not in session and improving zoning
rules for increased grocery stores in low-income
communities.
I ncrease grant programs encouraging minority business
owners to open grocery stores in low-income communities
and ensure that initiatives are sustainable and provide the
appropriate support ranging from financing initiatives
to safe, accessible transportation for members of the
community to keep groceries stores open.
tandards should be set to limit the amount of
S
advertising of foods and beverages of low nutritional
value, particularly advertising targeting Black children,
via television, radio, new digital media (internet, social
media, digital apps, mobile phones, tablets, etc.),
outdoor ads and point-of-sale product placements.
Policies should help encourage increased marketing of
healthy foods and beverages to children and families.
EXAMPLES OF STRATEGIES AND CASE STUDIES:

l
Nutrition assistance programs can help lower-income families
the public for recreation and sports during nonschool hours.
gain access to more affordable food and provide information
The NAACP Mississippi State Conference is working to imple-
about healthy eating. In 2011, more than 3.9 million African
ment shared-use agreements with their partner organizations in
American families received SNAP benefits,295 and, as of
majority minority school districts. Their initial efforts have been
2012, 20 percent of women and children enrolled in the WIC
focused in the Jackson and Indianola school districts. Although
program were African American.
296
Programs such as SNAP-
the work of the NAACP Mississippi State Conference has been
Ed, a partnership between USDA and the states that provides
health-focused, they have helped leverage shared-use agree-
education to help families learn how to eat healthier within a
ments to help improve health at the same time they help meet
limited budget, and revisions to the WIC food packages that
other needs within the community. This has spoken directly to
include healthier options, have resulted in increased con-
the needs of the communities they serve.
sumption of more nutritious foods among participants.
297, 298
For decades, Tennessees childhood obesity rates have steadily
Over the last decade, Philadelphia has implemented a com-
increased, while equity gaps between Black and White children
prehensive strategy to reduce obesity rates among children.
widen. In Tennessee, 43.9 percent of African American children
Between 2006 and 2010, the city experienced nearly a 5 per-
are obese compared with 21.1 percent of White children.299 To
cent reduction in the obesity rates among children in grades K
address childhood obesity, the NAACP Tennessee State Confer-
through 12. The biggest declines were reported among kids and
ence developed an advocacy action plan that expands existing
teens of color: the obesity rate among African American boys
competitive foods guidelines in Jackson-Madison and Haywood
dropped by 7.6 percent. The city created strategies to help im-
County School Districts. This policy addresses competitive
prove access to healthy foods and increase physical activity and
food sales at school activities such as fundraisers and conces-
engaged a wide-range of partners. Efforts included removing all
sions. To gain support for the competitive food sales policy, the
sodas and sugar-sweetened drinks from public school vending
NAACP Tennessee State Conference developed partnerships
machines; implementing a comprehensive, district-wide school
with key stakeholders, including parents and families, faith-
wellness policy; banning deep fryers in school kitchens and
and community-based organizations, businesses, and others,
switching to 1 percent and skim milk; and requiring chain restau-
and engaged the NAACP youth councils to help with proposed
rants to post calorie information on menus and menu boards.
alternative food and non-food options for school fundraisers.
In addition, they targeted interventions in neighborhoods most
Many states, including Tennessee, have existing policies on the
in need, such as providing education to public school students
built environment, school-based policies and competitive foods.
whose families were eligible for SNAP and creating new financ-
However, many of these policies are not being implemented
ing methods to attract grocers to open stores in lower-income
or expanded. Closing persistent disparities requires advocates
neighborhoods and supporting safe recreation spaces.
and public health professionals to build upon existing policies
The state of Mississippi passed a law in 2012 authorizing

local schools boards to allow school property to be used by
and hold the responsible entities accountable for implementing

them and measuring progress.
NAACP Childhood Obesity Advocacy Manual: http://action.naacp.org/page/s/childhood-obesity-manual
Office of Minority Health: U.S. Department of Health and Human Services. http://minorityhealth.hhs.gov/
95
Maximizing The Impact of

Obesity-Prevention Efforts
In Black Communities:
KEY FINDINGS AND STRATEGIC RECOMMENDATIONS
MAY 2014
On behalf of the Trust For Americas Health, the Robert Wood Johnson Foundation
and the NAACP, Greenberg Quinlan Rosner Research conducted a set of nine one-onone, in-depth-interviews among public health leaders in Black communities across
the country. The participants represent both the public and private sectors and include
health professionals, academics and community organizers, among others. The study
was designed to evaluate barriers to and pinpoint solutions for reducing obesity in
Black communities. All interviews were conducted between April 29 and May 8, 2014.
Black health leaders and activists are deeply aware of the

challenges they face in combating the obesity epidemic that
disproportionately affects Black communities. They come
to the debate with very clear insight into these challenges,
from specific barriers at the community level to broader,
systemic hurdles that extend state- and nationwide.
These health leaders generally feel that
many identified policy approaches to
about healthy choices and how to
prevent and control obesity offer strong
make these choices more relevant
promise, but that there have been a
to their daily lives;
number of hurdles that get in the way

of these policies being successfully
implemented in Black communities.
sustained programs, including the

need to 1) engage leaders to feel
and take shared ownership of the
on to improve the implementation of
long-term success of an initiative;
policies, including:
and 2) create models where local,
environmental factors, particularly

less access to healthy, affordable
foods and a shortage of safe,
accessible spaces for physical activity;
3. Developing partnerships and
They identified three key areas to work
1. Addressing socioeconomic and
96
2. Providing increased education
state and national organizations

form lasting collaborations, access
to ongoing resource and a shared
set of priorities and goals.
Many work with low-income individuals living in food deserts or food swamps
(where there is a glut of unhealthy fast food options) and if healthy food is
available, it is usually not economical.
ADDRESSING SOCIOECONOMIC AND ENVIRONMENTAL FACTORS TO PROMOTE HEALTHY, AFFORDABLE
NUTRITION AND ACCESS TO SAFE PLACES TO BE ACTIVE.
Recommendation: Focus on making existing policy initiatives more scalable, sustainable and equitable across all
neighborhoods and income levels.
The health leaders interviewed felt there is
a lot of attention on making healthier foods

more affordable and accessible, and devel-
oping safe, accessible places for people to
Making healthy foods more affordable
resources available in higher-income versus
and available in all neighborhoods.
lower-income neighborhoods ranging from
Adopting public safety and crime reduction

initiatives to give families safe access to
be physically active but the hurdles to
recreational facilities and parks.
achieving these goals are still very steep.

l
Focusing on improving nutrition and
While the general policy approaches toward
increasing activity for young children,
obesity prevention and control are viewed
such as through efforts or regulations
favorably, there is a strong sense that the
in daycare centers.
initiatives introduced on the ground level are

not scalable or sustainable in their current
forms. There is also recognition that the resources invested in these solutions are often
short-term grants and are woefully insufficient
to match the scope of the problems.
Some key policies the health leaders
stressed included:
l
Allowing the community to use school

facilities for non-school recreational
activities before and after school hours.
ACCESSIBLE, AFFORDABLE
HEALTHY NUTRITION
well-kept green spaces to quality grocery

stores. And there is a desire for continued
focus on policy changes that help improve
resources for everyone, which, they believe,
will help an entire community thrive. For
instance, the leaders emphasized that the
inability to access healthy food was both
a financial and geographical hurdle. Many
They stressed the importance of devel-
work with low-income individuals living in
oping strategies for the range of other
food deserts or food swamps (where there
factors that impact health such as ac-
is a glut of unhealthy fast food options) and
cessible, safe, affordable transportation
if healthy food is available, it is usually not
and housing as a coordinated part of
economical.
any successful effort to address obesity.
These leaders also stress the importance of
They also quickly point out the need to find
designing or redesigning the physical infra-
improved ways to make these initiatives
structure of a neighborhood to incorporate
equitable across all neighborhoods.
safe, accessible sidewalks, public transpor-
There is an acute sense of the different
tation options, parks and exercise trails.
We need to increase the opportunity for healthy food. All

healthy options are concentrated in one area of my city;
availability is different, based on different neighborhoods.
The access is there,

but for people with
limited resources,
they cant afford it.
A healthy community should SAFE, ACCESSIBLE PLACES TO BE ACTIVE

have some place thats safe
Equitable access to green space. On the more affluent side of my city, there are sidewalks
and welcoming. And the
a lot of them have been redone. There are biking lanes. And then you have other areas; we
ability for all family members
have three income-based housing projects within a half mile radius, and theres not much
to be outdoors, to exercise
openly in a safe environment. green space available there. There is also a city park, but its been largely neglected.
97
The participants also emphasized a real need to increase education attainment to

combat the greater socioeconomic and environmental factors at play.
EDUCATING ABOUT HEALTHY CHOICES AND MAKING THEM MORE RELEVANT TO DAILY LIFE
Recommendation: Focus on policies and programs that are social, enjoyable and integrated into daily life and routines.
The health leaders raised concerns that
The participants also emphasized a real
in their own communitiesare healthy
there is not enough information available
need to increase education attainment to
cooking classes, and taking advantage of
in many Black communities about why and
combat the greater socioeconomic and envi-
shared-use agreements to start walking
how to make healthy choices. Specifically,
ronmental factors at play. For instance, the
clubs, athletic teams and dance classes
there was concern about the lack of edu-
health leaders emphasized the need to in-
for both children and adults.
cation provided by both schools and the
crease education to promote good nutrition
medical community. Giving a community
and increased physical activity to counter
funding to combat obesity is not enough
the fact that food of lower nutritional value
Black community leaders are quick to
is often more easily available and cheaper,
point out that change cannot start to take
and there is such heavy intensity of market-
hold unless there is a proper education
ing junk food in these communities.
campaign to accompany these resources.
meet people where they are, and make efforts fit into peoples needs. Every person,
neighborhood, or community has different
needs; a one size fits all approach to reducing obesity is not sustainable. This goes
The health leaders stressed that some of the
hand in hand with the social aspect the
Another challenge is that conversations
most important ingredients to creating suc-
programs need to be relevant to the specific
about the obesity epidemic often focus
cessful, long-lasting programs are often not
community. Many of the participants high-
on the issue of weight rather than on
addressed: making them social, enjoyable
lighted cooking classes as an effective way
health. For example, education about
and integrated into daily life and routines.
to reach Black communities, not just for the
how good nutrition and increased physical activity can reduce risk for or help
manage type 2 diabetes, heart disease
and stress is lacking. There also is not
enough information about ways to manage buying healthy food within a budget.
INCREASED EDUCATION ABOUT

HEALTH AND HEALTHY CHOICES
Theres very little preventive advice. Most

times, people arent getting any advice
on how to get healthy and make small
changes, even from their doctor.
MAKING INITIATIVES SOCIAL AND FUN
For kids, [these efforts] would work if

you make it fun and social, if you did
it around games, activities and sports.
Kids want to be part of the group; its
social for them.
98
In addition, they emphasized the need to
For instance, the health leaders in these

Black communities place a high premium
on the need to teach healthy behaviors in
a social atmosphere. As an example, some
of the most effective programs they highlightedor would like to see implemented
Schools need to educate students about nutrition,

so they can make better choices. Parents need
to be educated because they did not have the
advantage of schools that were providing that sort
of informationI think we can all become better
advocates for promoting healthy options.
social aspect but also for the usefulness in

teaching nutrition and even food budgeting.
This needs to become part of the lifestyle.
We need to figure out ways to make Southern cuisine healthier. There has to be a way
to retain some of the style and tradition, but
with healthier options, said one participant.
It takes commitment from the

community to see that this is not fly by
night. We need to continue to work with
young people to get them to see, early
on in life, that if youre healthier, you
feel better, you learn better.
There was a man in our community that was working on losing some weight,
and so he was getting on the radio, encouraging and challenging parents,
students, everybody, to come walk with him. And he wanted a really, really
large group of peoplethey would walk for 30 minutes, and for kids, every time
you walked, you got to put your name in for a drawing. That worked really well.
DEVELOPING PARTNERSHIPS AND SUSTAINABILITY

Recommendations: Focus on building lasting programs and community engagement including buy-in from the outset,
shared ownership and goals, coordination with existing assets and efforts and providing programs and services that
help connect with the needs and interests of the members of the community from the outset.
The health leaders reported feeling that
consistent communication across groups.
a community leader or organization heavily
many of the obesity initiatives introduced
It is also important to learn about the
involved in the effort and a sense that
in their communities do not have built-in
organizations and agencies already in a
the initiative was helping support multiple
goals of sustainability, long-term focus or
neighborhood or community. In many
objectives within a community, such as
strategies that engage people within the
cases, there are groups such as
a shared-use agreement that supports
community to take ownership. They report
initiatives by other community- and faith-
youth sports or walking clubs, which can
there is a need to improve the connection
based organizations or are provided through
help foster stronger social and community
between state and national agencies and
education or other social service systems
connections, provide a safe afterschool
local communities, including mechanisms
that already exist with shared visions,
environment and serve as a crime
to get buy-in from individuals within the
but there may be limited or no attempts
prevention strategy. The most positive
community, as well as from policymakers
to understand, connect and coordinate
examples of policies and activities focused
and other change agents.
with their efforts. The leaders stress the
on making healthy decisions part of a daily
importance of making sure public health
routine for both adults and children.
Building sustainable programs in a

community requires this buy-in at the
outset. National and state groups often
have the ability to develop and evaluate
particular approaches and provide
officials consult with the communities about

existing assets, structures and processes
as an essential ingredient when trying to
make systemic changes.
The leaders acknowledge there is often

a lot of discussion about community
engagement as part of public health
initiatives and underscore the importance
financial resources, but unless the
The leaders discussed examples of
of having a shared definition of what this
community has shared ownership and
effective programs, which included having
means from the communitys perspective.
a shared sense that an initiative is a

priority or fit for that community, there
is little likelihood that the initiative will
gain traction or be successful. Local
health leaders have a strong interest
in partnering with national and state
groups because they recognize the
expertise and resources those groups
provide. Yet local health leaders also are
calling for more shared priority-setting
and additional support for technical
assistance aimed at engaging and
training leaders in communities to take
ownership of initiatives.
The leaders reported the main procedural
barrier to programs comes from a lack of
coordination which could be addressed
by ensuring there is a shared vision
from the outset and that there is clear,
99
The leaders discussed examples of effective programs,

which included having a community leader or organization
heavily involved in the effort and a sense that the
initiative was helping support multiple objectives within a
community, such as a shared-use agreement that supports
youth sports or walking clubs
BUILDING SUSTAINABILITY
I think, when you have these parachute programs where they kind
of drop in, do work and disappear, thats not effective. But when
theres an investment in empowering the community to become the
program, and become leaders of the program, thats very effective.
I think what works is when groups and organizations,

and even individuals, get community buy-in. Thats
very important, because when you look at it from the
standpoint of implementing programs or policies,
then it has to be sustainableso even if funding runs
out, then youve made inroads within the community.
IMPROVING PARTNERSHIPS AND COORDINATION
Someone has to step up, take the

lead, and say, Heres what wed
like to do, would you like to sit at
the table with us?
Theres sometimes a general lack of engagement between organizations. Organizations become sort
of a silo, and Im thinking it becomes siloed because of funding. Everybody wants to identify funding
sources and go out and do the work. But the challenge in that is that even if youre competing against
organizationsin some senseto get the funding, you want to hold on to what you have. Andthey
dont fully engage other organizations in a way where everybody benefits from it.
For me, from start to finish, the process has to include community
engagement and data engagement. So, every decision that we make along
the way, we make it based on community input AND data input. And let both
tell us where we need to go.
I think we need to get the word out in a

way that the community understands. And
I think, often, the state agencies dont drill
it down, or they dont know how to get it
to the folks that need it the most.
NAACP Childhood Obesity Advocacy Manual.:
http://action.naacp.org/page/s/childhood-obesity-manual
Office of Minority Health,: U.S. Department of Health and Human Services.
http://minorityhealth.hhs.gov/
Overweight and Obesity Among African American Youth. Leadership for
Healthy Communities. Spring 2014.
http://www.leadershipforhealthycommunities.org/resources-mainmenu-40/
fact-sheets/700-overweight-and-obesity-among-african-american-youths
100
EXPERT COMMENTARY
BY LEON T. ANDREWS, Jr., Senior Fellow,
National League of Cities
The Next Step in Reducing

Obesity in Cities, Towns
and Counties: Focusing on
Vulnerable Populations
Not too long ago, managing obesity was seen solely as an
individual responsibility. However, as obesity rates began
their steady climb upward over the last decade or so, local
leaders and residents began to understand more fully the
risks obesity can pose to their neighborhoods, communities
and cities, and the role good government policy and action
can have in helping people get and stay healthy.
As this shift in public consciousness
of policies and programs that promote
The most effective policies
grew, mayors in cities across the
healthy communities.
have been put in place by local
country began to champion public
leaders that were able to tap into
policies that promote healthy
specific community resources.
eating and active living. These

policies are meant to create more
walkable, bikeable and transitaccessible neighborhoods, and
to encourage better use of and
increased connectivity between
recreation centers and parks. They
have commonly been implemented
through shared-use agreements, land
use agreements, community gardening
initiatives and complete streets and
active transportation policies.
Today, policies to increase healthy

eating and active living are being
implemented all across the country.
For instance, in Philadelphia, Mayor
Michael Nutter has led a number
of policies that have revamped how
the city approaches public health
through food financing. The mayor,
his staff and partners have forged
public-private partnerships and
provided incentives resulting in
almost 20 retail sites offering fresh
fruits and vegetables to low-income
neighborhoods in Philadelphia.
Clearly, mayors have an important
Elsewhere in Pennsylvania and across
role to play in forming partnerships
the country, weve seen the Fresh
and using their influence to put
Food Financing Initiative become
policies aimed at reducing obesity in
a major model for assisting lower
motion. They are uniquely positioned
income people gain access to fresh,
to encourage citywide implementation
affordable food.
101
Weve also seen shared-use agreements welcomed wholeheartedly in communities throughout the
South. In larger southern cities, complete streets policies have been incredibly important, while in both
large and smaller communities mayors have worked to maximize community gardens and farmers
markets. In particular, mayors have embraced policies that require farmers markets to accept Women,
Infants and Children and Supplemental Nutrition Assistance Program benefits.
For example, in Mississippi,
most. There is far more to be done in
and ensuring appropriate city lands
communities have particularly
this arena mayors want to know how
are optimized for play.
embraced land use protection for
to target policies to ensure they are
community gardens. And Jackson, Miss.
reaching their most vulnerable citizens.
is one of a few cities to really look at

how their city is oriented and figure out
ways to improve walking and biking.
There is similar work going on
in Hernando and Tupelo, Miss.,
Charleston, S.C., Little Rock, Ark., and
Baton Rouge, La. Some of these cities
dont get mentioned as often as they
should, but they are definitely leading
the way in making policy changes that
engaged in LMCTC and moving
Unfortunately, we arent there yet, but
forward important policy work focused
the conversations are happening and
on children and vulnerable populations.
the wheels are starting to turn faster.
Also, there is a strong southern presence
And there is reason for optimism.
Arkansas, Mississippi, Alabama
One notable example is Lets Move!

Cities, Towns and Counties (LMCTC),
which is focused on several important
areas connected to health disparities,
including: training early childcare
and other states, which is particularly

important given that regions high
obesity rates and poverty levels. These
are exactly the places we need to reach
to truly stem the tide of obesity.
and education providers to promote
LMCTC is just one opportunity for
physical activity and healthy eating;
mayors to maximize their leadership and
At the same time, while the creation
providing healthy foods to school-
use their voice in addressing the health
and support for these polices are great
aged children before, during and
of their community, and, in particular,
wins in the battle against obesity, its
after school and/or during the
the health of vulnerable populations.
unclear whether they are actually
summer; increasing access to healthy
When we talk about moving the needle,
reaching and benefiting those in
foods where cities offer and sell food;
this is the logical progression.
result in healthier communities.
the most vulnerable neighborhoods.

Complete streets policies, for
example, have helped cities redesign
their downtown, but often left other
neighborhoods where more
economically disadvantaged people
reside largely untouched.
The next step in the fight against
obesity is moving from action to
evaluating impact, i.e., making sure
that health-promoting policies reach
the communities that need them the
102
So far, 425 local elected officials are
SECTI O N 11:
CURRENT STATUS:
Inequities in access to healthcare, the quality of care

received and opportunities to make healthy choices where
people live, learn, work and play all contribute to the rates
of obesity being higher for Latino adults and children
compared to Whites. Also contributing to the higher rates
of obesity is the fact that Latino communities experience
higher rates of hunger and food insecurity, limited
access to safe places to be physically active and targeted
marketing of less nutritious foods.300, 301
Latinos are the fastest growing
Rates of severe obesity (BMI greater
population in the United States it
than 120 percent of the weight and
is estimated that nearly one in three
height percentiles for an age rage) are
children will be Latino by 2030
also higher among Latino children
so addressing these disparities
ages 2 to 19 (6.6 percent) compared
is essential for the well-being of
with White children (3.9 percent).305
The State of
Obesity:
Obesity Policy
Series
SECTION 11: OBESITY PREVENTION IN LATINO COMMUNITIES
Obesity Prevention in Latino

Communities
individuals and families and to help

contain skyrocketing U.S. healthcare
spending and increase the nations
Obese or Overweight Adults
productivity.302
l
42 percent of Latino adults are
77%
67.2%
Latino
White
obese compared with 32.6 percent of

Whites.303 More than 77 percent of
Latino adults are overweight or obese,
compared with 67.2 percent of Whites.
22.4 percent of Latino children ages
2 to 19 are obese, compared with
Obese or Overweight Children

Ages 2 to 19
14.3 percent of White children.304

More than 38.9 percent of Latino
children are overweight or obese,
38.9%
28.5%
Latino
White
compared with 28.5 percent of

White children.
SEPTEMBER 2014
Population Living Below the Poverty Line
11%
16.7%
3.5%
26.1%
13.1%
Latino
White
Latino
White
Latino
years in the United States, White
Greater accessibility to supermarkets
children are much higher starting at
families have earned $2 for every $1
is consistently linked to decreased
a young age for 2 to 5 year olds,
that Latino families earned.
rates of overweight and obesity.315
those of Whites (16.7 percent

compared with 3.5 percent).
306
By
ages 6 to 11, 26.1 percent of Latino

children are obese compared with
13.1 percent of Whites. Almost
three-quarters of differences in the
rates between Latino and White
children happens by third grade.307
310
A number of studies have shown

that when Latino families do not
have enough money for everyone
to eat full and nutritious meals,
there is an increased risk of obesity,
particularly among the children in
the household.311 Latino children
consume higher amounts of sugarsweetened beverages than other
Strategies to address these disparities
children,312 and one study in Houston,
must include a sustained and
from 2000 to 2004, found that two out
comprehensive approach targeting
of every three foods Latino children
the challenges that stem from
consumed included pizza, chips,
neighborhoods, schools, workplaces
desserts, burgers or soda/juice.313
and marketing environments that make

it difficult to access healthy affordable
foods and be physically active.
In part, this is because there is a link

between income and food choice
often the less expensive options that
Lack of access to affordable healthy
are purchased to help stretch budgets
food: Nearly one in four Latino
are lower in nutritional quality. Low-
households are considered food
income Latino families spend about
insecure (when having consistent
one-third of their income on food,
access to adequate food is limited by
and much of the food purchased is
lack of money or other resources),
calorie-dense, low in fiber and high in
compared with 11 percent of White
fat, sodium and carbohydrates.314
households.308 Approximately 23
percent of Latino families are living
in poverty,309 and over the past 30
104
23%
And, the obesity rates for Latino
the rates are more than quadruple
White
Studies have found that there is

less access to supermarkets and
nutritious, fresh foods in many urban
and lower-income neighborhoods
and less healthy items are also
often more heavily marketed at the
point-of-purchase through product
placement in these stores.316, 317
Latino neighborhoods have one-third
the number of supermarkets as nonLatino neighborhoods.318 According
to the 2013 YRBS, 9.3 percent of
Latino youths did not eat vegetables
during the prior week, compared to
4.5 percent of White youths.319
In addition to food access issues at
home and in their neighborhoods,
Latino students also tend to have
increased access to unhealthy
foods at school.320 A number of
studies have found that schools
with a higher proportion of Latino
students tend to have weaker policies
regarding access to competitive foods
in schools, and may be less likely to
Lack of access to healthy foods in
implement nutritional guidelines for
neighborhoods is also a problem.
competitive foods.321
SNAP Participation by Latinos in 2011
21.4%
Latinos
received
benefits
34.9%
Latinos
eligible
for SNAP
STUDIES HAVE FOUND THAT 84 PERCENT OF YOUTH-TARGETED FOOD ADVERTISING ON SPANISHLANGUAGE TV PROMOTES FOOD OF LOW NUTRITIONAL VALUE.
l
Barriers due to language, culture and
immigration officials. There can
marketers, particularly due to their
immigration status: Several factors
be limited information and lack
increasing proportion of the U.S.
can prevent many Latinos from
of understanding by the potential
population and relative spending
participating in programs that could
participants and the workers in the
power. Between 2010 and 2013, fast
provide increased access to healthier
programs themselves, who also may
food restaurants increased their over-
choices. Health education and
not be trained to understand how
all advertising expenditures on Span-
programs including ones designed
to provide services for people of
ish-language TV by 8 percent. Latino
to improve nutrition, increase activity
different immigration status or for
preschoolers viewed almost one fast
and prevent obesity-related health
Spanish speakers. Finally, there exists
food ad on Spanish-language TV
problems are often not made
a history of issues and stigma within
every day in 2013, a 16 percent in-
available in Spanish and not sensitive
systems, which can make it harder
crease from 2010. In addition, low-in-
to cultural differences. In addition,
for many Latinos to choose to take
come Latino neighborhoods have up
many health education workers
advantage of available benefits. In
to nine times the density of outdoor
have not been trained to work with
2011, 34.9 percent of all Latinos
advertising for fast food and sugary
Latino populations. Often access to
were eligible for SNAP but only 21.4
drinks as high-income White neigh-
needed programs is further impeded
percent received benefits.
borhoods,324 and Latino children are
when immigration status is related to

eligibility for different nutrition and
health programs, or when potential
beneficiaries fear involvement of
322, 323
Higher exposure to marketing of

less nutritious foods: Latinos are a
major and increasing target for food
more likely to attend a school that

is close to fast-food restaurants and
convenience stores.325
105
Only one-third of Latinos live
Limited access to safe places to be
Elementary schools with a majority
physically active: Physical activity is
of Latino students are less likely than
within walking distance of a
important for maintaining a healthy
those with a majority of White students
park compared with almost
energy balance.
to have 20 minutes of recess daily or
half of all Whites.
found trends showing Latinos often
150 minutes of physical education
have less access to safe places to play
a week.329 Latino children are less
or be active.
likely to be in after-school activities
326
Studies have
In 2011, Latino adults were 30 percent

less likely to engage in physical activity
as Whites.327 According to the 2013
YRBS, 16.2 percent of Latino youth
did not participate in at least one
hour of daily physical activity during
the prior week, compared with 12.7
percent of White youth.328
where they are physically active, due to

factors including cost of participation,
transportation and language barriers.330
And, more than 80 percent of Latino
neighborhoods did not have an
available recreational facility, compared
to 38 percent of White neighborhoods,
according to a 2003 to 2004 study.331
WHY INEQUITIES IN OBESITY RATES MATTER:

U.S. Latino Population in 2012 = 18%
U.S. Latino Population in 2060 > 30%

l
Reducing health disparities among
Latinos is important for the future
many cases are preventable, are among
health of the country and can help
the biggest drivers of healthcare costs
save billions of dollars in healthcare
and reduced worker productivity. A study
costs because the U.S. Latino
by the Urban Institute found that the dif-
population is expected to grow from
ferences in rates among Latinos, African
18 percent in 2012 to more than 30
Americans and Whites for a set of pre-
percent in 2060.332
ventable diseases (diabetes, heart disease, high blood pressure, renal disease
Latinos are disproportionately affected
and stroke many of which are often re-
by diabetes, with 13.2 percent of
lated to obesity) cost the healthcare sys-
Latinos over age 18 having diabetes,
tem $23.9 billion annually.335 Based on
compared with 7.6 percent of Whites in
current trends, by 2050, this is expected
the same age group.333

l
Population Over 18 with Diabetes
Latinos are more likely to suffer a

stroke compared to other ethnic
groups. Specifically, Mexican
Americans suffer 43 percent more
13.2%
7.6%
from stroke the leading cause of

disability and the third-leading cause of
death than Whites.334
Latino
106
White
High rates of chronic illnesses, which in
to double to $50 billion a year.

l
Eliminating health inequalities could lead

to reduced medical expenditures of $54
billion to $61 billion a year, and recover
$13 billion annually due to work lost by
illness and about $250 billion per year
due to premature deaths, according to a
study of 2003 to 2006 spending.336, 337
nsure community-based obesity prevention and

E
control strategies are culturally and linguistically
appropriate and use sustained and comprehensive
interventions to maximize effectiveness. Policy solutions
must consider and target the variety of factors that
impact an individuals environment. Efforts must be
culturally competent and include English- and Spanishlanguage communications campaigns and delivery of
social services that use respected, trusted messengers
and appropriate channels.
I ncrease access to and utilization of promotores
(community health workers, peer leaders and health
advocates) who more effectively connect Latino
communities with public health services, the healthcare
system and other social services. Promotores play an
important role in promoting community-based health
education and prevention in a manner that is culturally
and linguistically appropriate.338 New Medicaid
regulations permitting reimbursement of community
health workers should be leveraged to increase the role
of promotores in obesity prevention.
rovide education to Latino parents about childhood
P
obesity, and the importance of healthy eating and
physical activity, in a culturally sensitive way. Education
should include information about enrolling in federal
programs designed to ensure healthy and adequate
nutrition, such as SNAP.
107
108
tandards should be set to limit the amount of advertising

S
of foods of low nutritional value, particularly advertising
targeting Latino children, via television, radio, new digital
media (internet, social media, digital apps, mobile phones,
tablets, etc.), outdoor ads and point-of-sale product placements. Policies should help encourage increased marketing
of healthier food products to children and families.
ealthy food financing initiatives should help to recruit
H
additional grocery stores and support the availability of
affordable, healthy products within existing stores in
predominately Latino communities.
artnerships between government, businesses, faithP
based groups, community organizations, schools
and others should be promoted to increase access to
healthy, affordable food and safe places for physical
activity in Latino communities and neighborhoods.
These partnerships should leverage the local resources
and abilities of each of these partners.
upport for addressing racial and ethnic inequities in
S
obesity at the federal, state and local levels should
be increased.
EXAMPLES OF STRATEGIES AND CASE STUDIES

l
A number of nutrition assistance programs, including SNAP,
predominantly Latino urban community. Today, additional
the WIC program, CACFP and school meal programs, can help
pilot programs have been launched throughout the country.
increase access to affordable food and provide education
Part of the success of the program is attributed to the use
about how to eat healthier food on a limited budget.
of social and culturally competent media among planners
and program staff, and the delivery of information to the resi-
The National Council of La Raza (NCLR) estimates that 17
dents by other bilingual community members.346
percent of SNAP beneficiaries are Latino.339 Participation

in SNAP can help provide access to healthier foods. For
mately 1,000 bodegas to increase their offerings of low-fat
living in food-insecure homes were more likely to be at
milk and 450 bodegas to increase their offerings of fruits
risk for becoming overweight (more than 42 percent) than
and vegetables. The city provided promotional and educa-
Mexican American SNAP children coming from homes
tional materials to encourage consumers to buy the health-
without food security challenges (36 percent).340 Another
ier products and call on their local bodega to participate.
component of SNAP, SNAP-Ed, can help participants choose
The campaign led to increased sales of low-fat milk in 45
budget-friendly, healthier foods.
341
SNAP-Ed is a partnership
percent of participating bodegas, increased sales of fruits in
between USDA and the states that aims to provide SNAP
32 percent of participating bodegas, and increased sales of
participants or eligible non-participants with the skills and
vegetables in 26 percent of bodegas.347
knowledge to make healthy choices within a limited budget

and choose active lifestyles consistent with federal dietary
with high rates of poverty, where two-thirds of residents are
positive behavior changes and gains in food

security as a result of SNAP-Ed.342
Latinos comprise approximately 40 percent of
Healthy RC Kids Partnership focused on Southwest Cucamonga, a predominantly Latino community in California
guidance. Researchers and local implementers report
New York Citys Healthy Bodega Initiative recruited approxi-
instance, one study found that Mexican American children
considered obese or overweight. The area had few
Participation in
the WIC Program
participants in the WIC program.343 Studies
Healthy RC Kids was established by the city and
Latinos
to offer healthier foods improved availability,
included collaboration with residents and more than
40%
variety and sales of healthy food and increased
50 community stakeholders to identify barriers to
consumption of fruits, vegetables, whole grains

and low-fat milk.
Latino children in families
healthy eating and active living. As a result, more

All other ethnicities 60%
receiving WIC benefits were more likely to be at
stores selling fresh produce and residents had limited access to safe, open space for physical activity.
have shown that revisions to WIC food packages
344
neighborhood amenitiesthere were no grocery
community gardens and farmers markets were created and the City Council amended the development
a healthy height and weight compared with Latino children
code to allow vacant land to be used to grow produce and to
who were eligible for benefits but not participating in WIC.345
allow farmers markets in expanded areas of the city. This
Active Living Logan Square was designed to increase physical activity among Latino children in Chicago and promote
partnerships between school administrators, local policymakers and community members. With city approval, the
partnership piloted three Open Streets events, closing four
to eight miles of road to motorized vehicles, for use by over
10,000 residents from five diverse communities, in order
to help createsafe, inviting places for physical activity in a
eventually led to a new farmers market in Rancho Cucamonga

and plans to open one in Southwest Cucamonga. A United
Way grant allowed the Partnership to implement the Bringing
Health Home Program, which provides matching subsidies of
up to $50 a month to help Southwest Cucamonga residents
purchase fresh produce at local farmers markets. The city also
provides incentives and information for farmers markets to accept payments from food assistance program recipients.348
109
COMER BIEN349
110
In an effort to gain greater understand-
U.S.-born children. Respondents talked
ing of the food environment among
to NCLR about buying and preparing
Latino families, NCLR conducted a
food, community resources and the
video and story-banking project that
health of their children. The interviews
captured the experiences of Latino
help gain perspective into the barriers
parents and caregivers around the
Latinos face in feeding their families
country in feeding their families. The
and strategies for how to improve nutri-
stories feature individuals who range
tion, ranging from monthly budgeting
from multigenerational U.S. citizens to
to learning to cook traditional cultural
first-generation immigrants raising their
foods in healthier ways.
PROMOTORES: USING LATINO COMMUNITY HEALTH WORKERS TO REACH VULNERABLE POPULATIONS

Promotores play an important role in
Salud America!356, 357, 358
better food in the neighborhood and
promoting community-based health edu-
Salud America! is an RWJF-funded re-
healthier school snacks.
cation and prevention in a manner that
search network that aims to prevent
is culturally and linguistically appropri-
Salud America! launched a Growing Healthy
obesity among Latino children. Since the
ate, particularly among populations that
Change initiative to bring together evidence,
start of Salud America! in 2007, the net-
have been historically underserved and
new policies, success stories, social media
work has developed essential scientifc
uninsured.350 Promotores are especially
and resources to help individuals and com-
evidence, research, communications and
important because they typically share
munities develop capacity to create healthy
a wealth of information to raise aware-
the ethnicity, language, socioeconomic
policy changes in the six key areas. The
ness of Latino childhood obesity, build
status and life experience of the com-
Growing Healthy Change website allows
the field of researchers working to reduce
munity members they serve.351
you to input your address and find concrete
the epidemic and empower stakeholders
policy initiatives happening in your neigh-
Evidence shows that promotores help
to take action and create change.
borhood, school, city or state to improve
improve intervention outcomes. A
Salud America! works to improve Latino
nutrition, physical activity and marketing
systematic review of evidence-based
childrens health by targeting six key
aimed at Latino kids. The website also of-
obesity treatment interventions for La-
areas that could make the greatest ad-
fers many resources, success stories and
tino adults in the U.S. found that the
vances in reducing obesity in the least
videos of real-life Salud Heroes of change
two interventions with the largest effect
amount of time: sugary drinks, healthier
to inspire and help individuals, groups and
marketing, active play, active spaces,
communities to create their own change.
sizes used promotores.
352
Both studies
involved promotores as the intervention

implementers in the community.353, 354
In 2011, HHS launched the Promotores
de Salud Initiative in an effort to
educate the Latino community about
available healthcare services and other
benefits made possible by the ACA.
Since the launch, the HHS Promotores
de Salud Steering Committee has
worked to improve Latino access to
health information and services.355
AP Images/Paul Chou
Salud America!: The RWJF Research Network to Prevent Obesity Among Latino Children: http://salud-america.org/
Salud America! Growing Healthy Change: http://www.communitycommons.org/salud-america/
Comer Bien. National Council of La Raza:
http://www.nclr.org/index.php/issues_and_programs/health_and_nutrition/healthy_foods_families/comer_bien/
Office of Minority Health, U.S. Department of Health and Human Services: http://minorityhealth.hhs.gov/
111
Maximizing The Impact of

Obesity-Prevention Efforts
In Latino Communities:
MAY 2014
On behalf of Trust For Americas Health
KEY FINDINGS AND STRATEGIC RECOMMENDATIONS

Health leaders interviewed for the study are acutely
and Salud America!, Greenberg Quinlan
aware of how the Latino community is disproportionately
Rosner Research conducted a set of
affected by Americas obesity epidemic but they are
10 one-on-one, in-depth-interviews
among public health leaders in Latino
also optimistic about how well-thought-out and effectively
communities across the country.
implemented policies can help achieve better health.
The participants represent both the
Overall, they feel the general policy approaches that have
public and private sectors and include

academics, health professionals and
been identified for how to respond to the obesity epidemic
community and business leaders,
are on the right track but policy development is only half
among others. The study was designed

to assess barriers to and identify
solutions for reducing and preventing
the battle, and the implementation of those policies has

been relatively limited in the Latino community.
obesity in Latino communities. All

interviews were conducted between
The interviews revealed two core
April 22 and May 1, 2014.
issues that must be addressed to
partnerships between national/state
improve implementation:
organizations and communities.
1. Community engagement needs

to happen simultaneously with
investment of resources, or else the
investment will not bring the level
of cultural change that is needed.
This includes making community
input, leadership, accountability
and sustainability priority goals
at the outset and building
programs that match the interests
of the community and will motivate
participation.
112
2. P
revention efforts must be true
Resources and technical assistance

typically flow from top down, but
effective implementation requires
understanding and integrating with
the priorities, perspectives and existing
resources within those communities.
This means going beyond prescriptive
measures and grants by improving
coordination and synergies with other
efforts, establishing shared goals and
ownership and providing training and
assistance to build leadership within
the community.
NUTRITION, ACTIVITY AND SOCIOECONOMICS

BARRIER: Socioeconomic factors amplify the barriers that can get in the way of physical activity and access to healthy food.
RECOMMENDATION: Help make healthier choices easier by increasing access to and opportunities for physical activity
and healthy eating but dont stop there.
The leaders in the Latino communities were
these efforts; 2) these programs must
developed so the community has a way to
very supportive of a wide range of obesity
become more focused and efficient, and
make use of these expanded resources.
prevention policy approaches ranging
also be developed within the context of
from healthy food financing initiatives to im-
programs that address other socioeco-
proving the built environment to improving
nomically linked issues, such as quality
nutrition and activity in schools to improving
housing, education, crime reduction and
and increasing public education initiatives
transportation; and 3) efforts must proac-
to supporting shared-use agreements to
tively engage members of the community.
allow members of the community to have
For example, instead of just opening
daily lives by making communities more
access to school and community centers
schools for community use during non-
walkable and improving public transit.
for recreational purposes during off-hours.
school hours, soccer leagues, walking
But they unanimously agreed that: 1)

more resources are needed to support
In addition, a number of the leaders recommended focusing on solutions that

improve health along with overall quality of
life, including:
l
Helping people integrate health into their
Making opportunities for good health fun
clubs, community cooking classes and
and social, such as cooking classes,
other organized social programs should be
walking clubs and community gardens.
AFFORDABLE, ACCESSIBLE FOOD AND SAFE PLACES TO BE ACTIVE

Socioeconomics
The built environment doesnt make
We have healthy food in close

proximity, but we dont have
AFFORDABLE, healthy food.
healthy choices easy for individuals. There

arent safe parks for kids to play. As a
result, poor choices are made. We need
safe and fun recreational activities.
Structural Concerns and

Building Motivation
Awesome. Improving nutrition

and increasing activity for young
children, such as through efforts
or regulations in daycare centers]
would work, because little kids
want to be part of the group.
Make it social.
The obstacles are finances,

which is not unique. But we
also have less access to
healthy food; stores dont have
healthy products.
I would definitely support [shared use agreements], and I think it would work. I think a significant number
of people in my community cant afford a gym, so its important for them to have access. A place to walk,
do laps, get moving. But theres also a need to have a structure and organization in placegroups walking
together, for example. We need to put a motivation and structure in place, along with access.
[Making water available as an alternative to

sugary drinks is] good, but there needs to be a
lot more. You need infrastructure new pipes
because the water tastes bad or is unsafe. You
need education on why water is better.
Good. But [shared-use

agreements] would be most
effective if schools have an
active role in organizing and
supporting it.
113
EDUCATION AND CULTURE

BARRIER: Education and cultural differences contribute to less knowledge
about nutrition and activity. Many people do not understand which options are
healthier or why they should choose healthier options. This is reinforced by
disproportionate marketing of unhealthy foods in these communities.
RECOMMENDATION: Keep educating and raising awareness; make it relevant
to peoples lives.
The Latino health leaders emphasized that
edge that immigration status can impact
simply putting the physical resources into
access to healthcare, they universally agreed
place is not enough. Physical resources
that the bigger concern is that the less
need to go hand-in-glove with education cam-
healthy habits adopted by many immigrants
paigns that focus on how to eat healthier
after they come to the United States have a
and be more physically activeand how eat-
negative impact on their health. The leaders
ing well and being active can be enjoyable,
largely reported that most of the informa-
help reduce stress, and lower risk for or help
tion about nutrition and physical activity was
manage type 2 diabetes and other chronic
available in both Spanish and English, but
diseases. The health leaders noted the
they were concerned about getting useful in-
importance of personal responsibility, but
formation in a sustained and supportive way
also acknowledged that there needs to be
to the people who could most benefit from it.
increased education about which resources

are available and how to be healthy, including how to make healthy choices easier even
within the context of economic constraints.
In fact, increasing education was viewed as
even more important to give people the tools
and information about resources to combat
economic barriers particularly to actively
promote healthy foods in areas where unhealthy options are often more easily available and viewed as cheaper.
Neither cultural nor language barriers were
raised organically during the interviews, but
when asked directly, the leaders responded
that cultural issues in particular contribute to
obesity. For instance, many Latino families
work to maintain cultural food traditions, but
then the problem is exacerbated by habits
rooted in U.S. culture, including driving more
instead of walking, adopting bigger portion
sizes, buying more processed foods or using
less healthy ingredients because they are
readily available. While the leaders acknowl114
The health leaders stressed the importance

of tailoring policies and approaches in ways
that make better nutrition and increased
physical activity relevant to peoples daily
lives. For instance, one participant explained that some activities, like soccer and
dancing, are often more popular, are more
social and have more cultural resonance
than others, such as weightlifting.
Investing in a social component for obesity
prevention initiatives is also important. A
number of health leaders raised concerns
about a lack of social cohesion in the Latino
community, which takes away the motivation
to learn from others, positive peer pressure
influences and the ability to join in community activities. For example, shared-use
agreements can help serve as an impetus
for getting members of the community together and creating groups like recreational
sports, walking or exercise groups, or cooking clubs, where healthy activities are combined with positive social experiences.
Education
Cultural Influences
There definitely needs to be more education for kids, but also older
adults. We need to make it part of normal daily activities, integrate it
into school and home life. They need to hear this message everywhere,
that its OK and importantthey need to hear at school, church, at
the doctor, in retail, on TV and in the media. A lot of times there are
resources, but people dont know about them.
The question is how

to improve while still
retaining cultural aspects
you can be healthy eating
Latino food.
As an immigrant, I think
its more about a later
adoption of unhealthy,
American eating habits. The
longer youre here, you start
to pick up on unhealthy
habits like fast food.
Social Solutions
We need people to come

together. There almost
needs to be a social
pressure that everyone
feels, that they need to
get on board. There has
to be a social element.
The programs most embraced are the ones

that are free and open to everyone. Also
the ones that are fun. People want to feel
better they may not know they need to lose
weight or have diabetes, but they are willing
to try riding a bike to feel better generally.
Fun and accessible, people will respond to.
We have failed a lot. But what has

finally worked is the social aspect. We
created social programs where we eat
together, exercise together, play, laugh,
experience life together. And while were
gathering, we tackle the issues that
contribute to obesity.
115
COLLABORATION, SHARED OWNERSHIP AND SUSTAINABILITY

BARRIER: Programs and efforts often 1) are based on short-term initiatives
or grants and 2) do not include community input or leadership recruitment,
coordination with other efforts within the given community or partnership building
at the outset. As a result, programs do not gain traction and are not sustainable.
RECOMMENDATION: Make sustainability, continuity and community input
primary goals at the outset.
Health leaders emphasized that if people
area. Health leaders expressed that im-
from the communities themselves are not
proved coordination and context would help
empowered to have ownership of obesity-
programs be more efficient and gain trac-
prevention initiatives, the programs
tion more quickly with community members
are not viable. Currently, there is not a
who are already invested. For instance, if
systemic or widely successful replicable
a community has worked hard to build a
model for how to create empowerment
crime reduction effort that has gained mo-
and leadership within local communities.
mentum and community engagement within
There is a weak connection to state and
a neighborhood, then it would be most ef-
national entities, where the local groups
ficient to find ways to build physical activity
are appreciative of resources, but there is
programs, such as neighborhood walking
also a feeling that these organizations and
programs or improving parks, within the
funding mechanisms tend to drop in and
context of that existing movement.
out, leaving local leaders overwhelmed

and unable to create lasting change alone.
over time, rather than focus on short-term
need support and technical assistance
initiatives. This requires thinking about
that the national and state groups can pro-
ongoing funding opportunities, tying new
vide. Policies must strike a balance that
resources with ongoing programs and creat-
allows local leaders to identify priorities
ing partnerships within a community to en-
and approaches that are most appropriate
sure that communities are fully invested in
within their own community and also builds
efforts. Getting upfront input and ownership
on the expertise and support provided by
is also key to sustainability. The leaders ex-
national research and initiatives.
pressed the importance of letting the com-
introduced without considering existing programs, resources and expertise in a given

community. These initiatives are not coordinated with or built on existing local efforts,
identified priorities or the culture of a given
to consider the sustainability of programs
At the same time, local communities also
In addition, many times new initiatives are
116
Health leaders also emphasized the need
munity itself be part of the oversight and

evaluation of a program to ensure efforts
are efficiently and effectively meeting the
communitys goals. The fact that resources
are scarce and critical, but often not well
spent, is a great source of frustration.
Coordination and Thoughtful Planning
Sustainability
Right now there is a lot of activity going on

across the country, but its very chaotic. And
within each community theres not typically
much alignment of interests. Resources
get diluted quickly. Or there are too many
things being done with too few resources.
Theres too much going on and not enough
coordination and organization.
Making individuals part of the process. Build

community participation so it doesnt stop when
the grant is over. The question is how do we get
a relatively small grant to have an afterlife?
There are a lot of people doing

similar things. Some groups take
ownership and thats great. But
theres not a lot of communication
between groups trying to do the
same thing. It creates duplication.
The things that work are when the

programming includes training the
community members and empowering
people who participate so they can
take over. Need to encourage them to
go on and start their own walking club.
A lot of things are twoyear grants that just

go away. Those are not
successful.
Upfront Community Engagement and Shared Ownership
We often fail to identify natural community leaders that can organize

and mobilize people.
The only way is if the people who participate
take ownership. Its not fair to fund two-year
programsresults wont happen in that short a
window. There needs to be longer periods of time
to implement and educate. We need time to start
to see the benefitsonce people see that they
can take ownership and go help others.
Coordination and Improved Efficiency and Effectiveness
We dont need national

groups to prescribe the
remedy, but we do need
help in determining a
roadmap for achieving it.
What makes it work is a very well-oiled and

coordinated infrastructureat the national level or
local levelbut the best examples are happening at
both levels. The infrastructure has the money and
know-how to provide support to local communities.
We need to define what each

sector is doing so its in synergy
with what other sectors are doing.
So everyones action is coordinated
instead of being a mixed basket.
AP Images/Paul Chou
117
EXPERT COMMENTARY
BY DR. ROSE GOWEN, MD, Commissioner
At-large, Brownsville, Texas
Tu Salud Si Cuenta: How

Improving Health Benefits the
Entire Community
In 2000, the University of Texas School of Public Health
placed a satellite campus in Brownsville, a largely Latino
city on the Texas-Mexico border. Researchers set to work
identifying the health risks our community faced and
designing creative solutions for our unique population.
One of the first things the research
involve clinicians in public health. At
The researchers found that 80
team did in response was launch
the time, I was a practicing physician
percent of Brownsville residents
Tu Salud Si Cuenta, a Spanish-
and the day I met Dr. McCormick my
language program on local TV and
public health education began.
were overweight or obese and

one-third were diabetichalf of
radio stations. Dr. Belinda Reininger,

an assistant professor at the School
those people didnt even know
of Public Health, developed the
they had diabetes.
program. She understood the

importance of educating people about
their health, but she also knew she
and her team had to do more.
I started by writing a weekly column in

the newspaper. I wrote about playing
outside at my grandmothers house
when I was a kid and the healthy
meals shed cook for usactivities that
had fallen by the wayside with time. I
challenged community leaders to make
Thats when Dr. McCormick, dean
sidewalks and bicycle trails a priority
of the Brownsville campus invited
instead of building tollways. The
me to participate in their efforts. He
column captured attention and the
and his team believed it was critical to
community began to listen and learn.
CULTIVATING ACCESS TO HEALTHY FOODS

We also backed our words with action.
shoppers would purchase; and how to
Dr. Reininger suggested starting a
attract growers. Our goal was to create
farmers market to help make fresh
a certified Texas farmers market in
fruits and vegetables more affordable
a city park, which meant navigating a
and accessible. We looked at examples
great deal of red tape and securing a
of successful farmers markets as we
modest amount of funding.
considered where to locate; what
118
AP Images/Paul Chou
When Su Clinica, a local Federally
now operates year long, and has
Qualified Health Center, wrote the
spawned the creation of two sister
Brownsville Farmers Market into a
markets in neighboring cities.
grant to reduce obesity, we launched

the market. That grant allowed us to
create a voucher program to entice
people to try the produce. Community
workers distributed vouchers that
could be redeemed at the farmers
Our wellness coalition then started a

community garden program, which
was sparked by a grower who received
a grant for mentoring and developing
neighborhood gardens.
market to schools, homeless shelters,
To help launch the Tres Angeles
wound care centers and other places
garden, promotoras went door-to-door in
to reach those most at risk. Opening
the Buena Vida neighborhood. Interest
day was embraced by all and we sold
was huge: plots sold for $15 a season and
50 dozen farm eggs in 30 minutes!
sold out fast.
The market has been very successful,
Our gardeners have not only been able to feed themselves, they also sell the
excess at the farmers market and earn $200 a week. Thats a big deal in a
neighborhood where the average monthly income is $400.
A second garden is now in place, a
and have replaced empty lots with
third is being built and a fourth is
welcoming gathering spaces filled
being planned. The gardens are in
with smiles and hope. This initiative
low-income areas spread throughout
is not just about health and nutrition;
the city. They are supervised, include
it is very much about economic and
nutrition education programs
community building.
119
HELPING PEOPLE BE MORE ACTIVE

In addition to helping people eat
We looked further at the built
healthier, we also needed to make it as
environment and designed the Belden
or two from school had to
easy as possible for them to be active.
Trail. By using grants and leveraging
take a bus each day because
This was challenging because in many
additional funds from the city,
parts of the city, sidewalks were nonexis-
community and national foundations,
tent, in disrepair or disconnected.
we turned a dangerous alleyway into
Kids who were only a block
their streets were not safe for

walking or biking.
We passed complete streets, sidewalk

and safe-passing ordinances. Then we
began a Build a Better Block Project
income neighborhood.
The biggest lesson weve learned about
turning a block into an optimal
addressing health among the Latino
version of itselfwide sidewalks,
community in Brownsville is that we
street lights, bicycle lanes, engaging
cant just talk about health. We have to
storefrontsfor a day. The idea is to
explain how good health benefits all.
let people try it on for size.
Healthy children are happier and do
in need of revitalization. To prepare

for BBB, the School of Public Healths
dietician worked with restaurants to
develop healthier options and streets
were transformed into pedestrian-
better in school. Businesses see more

customers when its safe and easy for
people to walk and bicycle around
town. Farmers markets and gardens
stimulate local economies and help
families on tight budgets.
only spaces. Businesses on the block
Working collaboratively and
and even those several blocks away
proactively is working in Brownsville.
saw increased foot traffic and earned
Together were making changes that
more money in one day than they
will benefit our children today and
usually do in a month.
future generations to come.
AP Images/Paul Chou
connects several schools in a low-
(BBB). The BBB concept involves
At first, we chose a block downtown
120
a well-lit mile-long concrete path that
Methodology for Obesity and Other Rates Using BRFSS

Annual Data
Data for this analysis was obtained from
ethnicity researchers report results for
the Behavioral Risk Factor Surveillance
Whites, Blacks and Latinos and gender.
System dataset (publicly available on the
Another variable, overweight was created
web at www.cdc.gov/brfss). The data
to capture the percentage of adults in a
were reviewed and analyzed for TFAH and
given state who were either overweight or
RWJF by Daniel Eisenberg, PhD, Associate
obese. An overweight adult was defined
Professor, Health Management and Policy
as one with a BMI greater than or equal
at the University of Michigan School of
to 25 but less than 30. For the physical
Public Health.
inactivity variable a binary indicator equal
BRFSS is an annual cross-sectional survey

designed to measure behavioral risk
factors in the adult population (18 years of
age or older) living in households. Data are
collected from a random sample of adults
(one per household) through a telephone
survey. The BRFSS currently includes data
from 50 states, the District of Columbia,
Puerto Rico, Guam and the Virgin Islands.
Variables of interest included BMI,
physical inactivity, diabetes, hypertension
and consumption of fruits and vegetables
five or more times a day. BMI was
calculated by dividing self-reported weight
height in meters. The variable obesity
is the percentage of all adults in a given
state who were classified as obese
(where obesity is defined as BMI greater
than or equal to 30). Researchers also
provide results broken down by race/
to one was created for adults who reported

not engaging in physical activity or exercise
during the previous thirty days other than
their regular job. For diabetes, researchers
created a binary variable equal to one if
the respondent reported ever being told
by a doctor that he/she had diabetes.
Researchers excluded all cases of
gestational and borderline diabetes as
well as all cases where the individual was
either unsure, or refused to answer.
To calculate prevalence rates for
hypertension, researchers created a dummy
variable equal to one if the respondent
answered Yes to the following question:
Have you ever been told by a doctor, nurse or
other health professional that you have high
blood pressure? This definition excludes
respondents classified as borderline
hypertensive and women who reported being
diagnosed with hypertension while pregnant.
SEPTEMBER 2014
in kilograms by the square of self-reported
The State of
Obesity:
Appendix A
APPENDIX A: LATINOS AND OBESITY PREVENTION
Methodology for Behavioral

Risk Factor Surveillance
System for Obesity, Physical
Activity and Fruit and Vegetable
Consumption Rates
Endnotes
1 The Surgeon Generals Call To Action To
Prevent and Decrease Overweight and Obesity.
Rockville, MD: U.S. Department of Health
and Human Services, 2001.
11 Ogden CL, Carroll MD, Kit BK, Flegal

KM. Prevalence of childhood and adult
obesityin the United States, 2011-2012.
JAMA. 2014;311(8):806-814.
2 Robbins JM, Mallya G, Polansky M, Schwarz

DF. Prevalence, Disparities, and Trends in
Obesity and Severe Obesity Among Students
in the Philadelphia, Pennsylvania, School
District, 20062010. Prev Chronic Dis, 9, 2012.
12 Ibid.
3 Defining Overweight and Obesity. In

Centers for Disease Control and Prevention.
http://www.cdc.gov/obesity/adult/defining.html (accessed May 2014).
4 Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey, 2011-2012. Prevalence
of Obesity among Adults: United States,
2011-2012.
5 Ogden CL, Carroll MD, Kit BK, Flegal KM.
Prevalence of childhood and adult obesity
in the United States, 2011-2012. JAMA.
2014;311(8):806-814.
6 Centers for Disease Control and Prevention.
National Health and Nutrition Examination
Survey, 2011-2012. Prevalence of Obesity
among Adults: United States, 2011-2012.
7 Ogden CL, Carroll MD, Kit BK, Flegal KM.
Prevalence of childhood and adult obesity
in the United States, 2011-2012. JAMA.
2014;311(8):806-814.
8 Skinner AC, Skelton J, Prevalence and
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10 F
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13 Ibid.
14 Ibid.
15 An R. Prevalence and Trends of Adult
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17 Census regions of the United States. Northeast: CT, ME, MA, NH, NJ, NY, PA, RI, VT;
Midwest: IL, IN, IA, KS, MI, MN, MO, NE,
ND, OH, SD, WI; South: AL, AR, DE, DC,
FL, GA, KY, LA, MD, MS, NC, OK, SC, VA,
TN, TX, VA, WV; West: AK, AZ, CA, CO,
HI, ID, MT, NM, NV, OR, UT, WA, WY.
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20 Pregnant women were included in calculations of BMI prior to 2011 and the
height standards also changed in that
year. Users can see that the calculated
variables changed from _BMI4 to _BMI5
(and _BMI4CAT and _BMI5CAT). They
can also see that the variable for height
used in the calculations changed in that
year. Data users are cautioned against
trending before and after 2011. Documentation on the changes can be found
on the BRFSS website in the calculated
variable reports for the respective years.
21 Description of BRFSS and changes in
methodology provided by CDC.
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ISSUE REPORT

TFAH BOARD OF DIRECTORS

Arthur Garson, Jr., MD, MPH

Eduardo Sanchez, MD, MPH

Cynthia M. Harris, PhD, DABT

Jeffrey Levi, PhD.

TFAH thanks the following individuals and organizations for their

Niiobli Armah IV, MA

Carla I. Plaza, MPH

Cliff Despres, B.J.,

Amelie G. Ramirez, Dr.P.H.,

Jack Rayburn, MPH

Kipling J. Gallion, M.A.,

Christopher J. Revere, MPA

Barbara Ferrer, PhD, MPH, ED

TFAH RWJF StateofObesity.org

Jennifer Arice White, MSPH

The following is a letter from Risa

After ten years of F as in Fat, we are excited to unveil a

The State of Obesity

new name for this report: The State of Obesity: Better

about what works to change public

America today? We are starting to see

policies, improve school and

signs of progress. After decades of

community environments and

alarming increases, this years report

strengthen industry practices in ways

shows us that childhood obesity rates

that support and promote healthy

have stabilized in the past decade. We

eating and physical activity. Weve

also know that rates have declined

seen that when schools, parents,

in a number of places around the

policymakers, industry leaders and

country from Anchorage, Alaska to

community champions join forces,

they can create a Culture of Health

This is success worth heralding,

Since then, weve learned a lot

Our efforts to reverse the obesity

is still early and fragile.

epidemic will not be successful until

Unfortunately, the progress is more

TFAH RWJF StateofObesity.org

we close these disparity gaps. Our

For example, adult obesity rates for

at school; make healthy, affordable

Blacks were at or above 40 percent

food prevalent in all communities;

in 11 states, 35 percent in 29 states

ensure healthy food and beverage

and 30 percent in 41 states. And

marketing practices; engage

rates of adult obesity among Latinos

healthcare professionals to more

were above 35 percent in five states

Adults: More than a third of adults

Children: Approximately 16.9 percent

Nearly 40 percent of middle-aged

More than 6 percent of adults were

By ages 12 to 19, 20.5 percent of

More than one-in-ten children (8.4

More than 2 percent of young children

Adults: Over the past 35 years, obesity

Children: Childhood obesity rates have