A variety of approaches have been used, all with the goal of providing a concise and consistent collection of data that can be formatted for dissemination to the community. A CHSI report contains information on behavioral risks, preventive services use, access, and summary health measures.
These measures could rate the built and social environments, local school policies and practices Chapter 7 , the community food environment, and the degree of involvement of local businesses, organizations, and other groups in supporting and participating in obesity prevention efforts. To streamline efforts and encourage communities to engage in these types of evaluation efforts, common evaluation tools should be developed and shared, while also ensuring that evaluation tools have the flexibility to be sensitive to the needs of local communities.
This is an area where it will be important to build on tools those discussed above and others that have already been developed. Communities should use evaluation tools e. Mobilizing communities to address childhood obesity will involve changes in the social and built environment.
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Several large-scale community-based interventions—primarily focused on improving diet and physical activity levels to address cardiovascular outcomes—show the feasibility of such efforts, although much remains to be learned about how to increase their effectiveness, particularly with regard to obesity prevention in youth. Efforts to address other public health issues such as tobacco prevention and control provide models for community coalition efforts.
A relatively new field of research is merging urban planning, transportation, and public health research tools to examine the impact of the built environment on human health. Observational and correlational studies, primarily conducted in adult populations, have shown that features in the built environment such as the walkability of neighborhoods or availability of recreational facilities are associated with level of physical activity.
A few small-scale intervention studies have examined the effects of changes to the built environment; however, research is needed to explore what specific changes to the built environment will be the most effective in preventing childhood obesity. The committee recommends the implementation and evaluation of a range of community changes to facilitate improved nutrition and increased physical activity.
These efforts are an integral part of a comprehensive approach to create healthier environments for children and youth. Recommendation 6: Community Programs. Local governments, public health agencies, schools, and community organizations should collaboratively develop and promote programs that encourage healthful eating behaviors and regular physical activity, particularly for populations at high risk of childhood obesity.
Commu nity coalitions should be formed to facilitate and promote cross-cutting programs and community-wide efforts. Private and public efforts to eliminate health disparities should include obesity prevention as one of their primary areas of focus and. Community child- and youth-centered organizations should promote healthful eating behaviors and regular physical activity through new and existing programs that will be sustained over the long term.
Community evaluation tools should incorporate measures of the availability of opportunities for physical activity and healthful eating. Recommendation 7: Built Environment. Local governments, private developers, and community groups should expand opportunities for physical activity including recreational facili ties, parks, playgrounds, sidewalks, bike paths, routes for walking or bicycling to school, and safe streets and neighborhoods, especially for populations at high risk of childhood obesity. Local governments, working with private developers and commu nity groups, should:. Revise comprehensive plans, zoning and subdivision ordinances, and other planning practices to increase availability and accessibility of opportunities for physical activity in new devel opments.
Prioritize capital improvement projects to increase opportuni ties for physical activity in existing areas. Improve the street, sidewalk, and street-crossing safety of routes to school, develop programs to encourage walking and bicy cling to school, and build schools within walking and bicycling dis tance of the neighborhoods they serve.
Work with local governments to change their planning and capital improvement practices to give higher priority to opportuni ties for physical activity. Because health care is usually provided at the local level, it is best addressed in a community context. Health-care professionals have frequent opportunities to encourage children and youth to engage in healthful lifestyles. Unfortunately, treatment of obesity per se is rarely considered a reimbursable interaction between patient and doctor, and our current health-care system is not yet focused on preventive measures for childhood obesity.
But the health-care delivery system can still have a significant impact on this issue.
It is now up to health-care professionals and their professional organizations, as well as health insurers and quality improvement and accrediting agencies, to make obesity prevention a part of routine preventive health care. Health-care professionals—physicians, nurses, and other clinicians—have an influential role to play in preventing childhood obesity. They also have the authority to elevate concern about childhood obesity and advocate for preventive efforts. The National Health Interview Survey found that Although there is little direct evidence of the impact of height, weight, and BMI screening and tracking on preventing obesity in children, BMI measures for adults have been found to be both easy to measure and a highly reliable method for identifying patients at risk of morbidity and mortality due to obesity McTigue et al.
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A survey of pediatric health-care providers, however, found that more used clinical impression. Because there are standardized BMI charts for children, and given that BMI is a reasonably good surrogate for adiposity, it is sensible to include BMI calculations in all health supervision visits for children. Behaviors that can be targeted include those most closely associated with improved nutrition and increased physical activity: increased breastfeeding, limited consumption of sweetened beverages, reduced television viewing or other screen time, and a greater amount of outdoor play Whitaker, Careful attention should be paid to minimizing the stigmatization of obesity Schwartz and Puhl, Studies of such counseling on obesity-related issues have shown positive results.
In one trial, African-American families were randomized to receive primary-care-based counseling alone or counseling plus a behavioral intervention including goal-setting and an electronic television-time manager as part of their regular clinic visits Ford et al. In the between-group comparison, the behavioral intervention group reported medium to large and statistically significant increases in organized physical activity and increases in playing outside. There was also a slight decrease for the intervention group in the number of meals eaten in front of the television, though the differences were not statistically significant Ford et al.
A four-month primary-care-based assessment and counseling intervention involving adolescents showed the feasibility of such efforts and found short-term improvements in dietary and physical activity outcome measures Patrick et al. More generally, studies of counseling for adults may provide insights into the potential effectiveness of counseling for children and their parents. The USPSTF review of dietary intake counseling for adults in primary-care settings found it to be effective in reducing dietary fat consumption and.
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The best evidence was for patients with known risk factors for cardiovascular and other chronic diseases, but there was also fair evidence that brief counseling in primary care can produce some improvements in diet among unselected patients as well. Similar reviews of studies that focused on physical activity counseling of adults in primary care found mixed results, although most of the studies showed a trend toward increased physical activity in the intervention groups Sallis et al.
For example, a nonrandomized controlled trial in healthy sedentary adults found short-term increases in moderate physical activity, particularly walking, among those who had received three to five minutes of physical activity counseling by their physician Calfas et al. Although research on the effectiveness of counseling children and their caregivers about obesity prevention is limited to date, and much remains to be learned, the seriousness of the problem and the emergence of tested strategies argue for routine counseling.
The evidence that routine smoking-cessation counseling is effective, at least in changing adult behaviors, is another precedent for this kind of guidance DHHS, a. Additionally, as visible and influential members of their communities, health-care professionals can serve as role models for good nutrition, for being physically active, and for maintaining a healthy weight. Health-care professionals can also have influential voices in increasing community awareness and advocating for actions to prevent childhood obesity.
By giving speeches or conducting workshops at schools, testifying before legislative bodies, working in community organizations, or speaking out in any number of other ways, health-care professionals can press for changes to make the community one that supports and facilitates healthful eating and physical activity.
A notable precedent is that physicians and other healthcare professionals have played crucial roles in changing tobacco-related behaviors; they have been advocates both at the local and national levels, and they have served as personal role models by quitting smoking or by not starting in the first place. Pediatricians, family physicians, nurses, and other clinicians should take active roles in the prevention of obesity in children and youth.
As discussed above, this includes routinely measuring height and weight; tracking BMI; and providing feedback, interpretation, counseling, and guidance on obesity prevention to children, parents, and other caregivers. This assumes that clinicians will have learned the appropriate skills to deliver these preventive services, which has implications for training at all levels see below.
They should also serve as role models for healthful eating and regular physical activity and take leadership roles in advocating for childhood obesity prevention in local schools and communities.
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Similarly, health-care professional organizations and their members have important roles to play in advocating across the range of community institutions for obesity prevention activities and policies AAP, Areas of possible involvement include health insurance coverage policies, school nutrition and physical education, and community recreation and zoning policies.
Professional organizations can also be influential in encouraging their members to adopt a more healthful lifestyle and serve as role models to their patients as well as to become more active in their offices and communities in working to prevent obesity. Furthermore, many professional organizations are providing information on topics relevant to obesity prevention. The American Medical Association recently published a part monograph on assessment and treatment of adult obesity Kushner, ; similar materials on children should also be prepared.
Collaboration between groups could broaden their effectiveness; if health-care professional organizations work together to implement obesity prevention programs and initiatives and develop clinical guidance, they would help ensure that consistent messages are reaching both health-care professionals and their patients. Health- and medical-care professional organizations should make child hood obesity prevention a high-priority goal for their organizations.
This includes creating and disseminating evidence-based clinical guidance and other materials on obesity prevention; establishing programs to encourage members to be role models for proper nutrition and physical activity; advocating for childhood obesity prevention initiatives; and coordinating their efforts, wherever possible, with other health-care professional organizations.
It is also critical to address current limitations in health-care training with regard to obesity prevention, nutrition, and physical activity. Medical and other health-care students have traditionally received little education in nutrition and physical activity; further, instruction on counseling about these topics generally has not been included either in medical school or primary-care residency training curricula Taren et al. Such omissions should be corrected in curricula at all levels, from preclinical science through the clinical training years and into postgraduate training programs and continuing medical education for practicing clinicians.
In addition, if. Programs such as the Nutrition Academic Award Program sponsored by the National Heart, Lung, and Blood Institute have begun to focus attention on improving nutrition education efforts in medical schools Pearson et al.
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Health-care professional schools, postgraduate training programs, continuing profes sional education programs, professional organizations, and certifying enti ties should require knowledge and skills related to obesity prevention e. Until recently, health-care concerns had largely focused on the treatment—as opposed to the prevention—of obesity, particularly the severe forms of adult obesity. Furthermore, the high economic costs of obesity Chapter 2 provide incentives to health-care insurers and health plans to encourage healthful lifestyles and thereby reduce their costs.
The health-care insurance industry in particular has several paths by which it may address obesity prevention. For individuals and their families, health insurance companies and health plans can develop innovative strategies for encouraging policy holders and their children to maintain a healthy weight, increase their levels of physical activity, and improve the quality of their diet. Creative options may include incentives for participating in and documenting regular physical activity, or programs that provide discounts or other incentives for wellness-related products. For example, one insurance company includes discounts on health and wellness magazines as well as lowered fees for health club memberships and weight-reduction programs for adults CIGNA, Furthermore, health-care insurers can take an active role in community coalitions and other activities; one example is the Jump Up and Go Program in Massachusetts Blue Cross Blue Shield of Massachusetts, It will be particularly important for healthcare insurers and health plans to consider incentives that are useful to high-.
For the providers of health-care services, it is important that obesity prevention including assessment of weight status as well as counseling on nutrition and physical activity become a routine part of clinical care. Moreover, measures related to successful delivery of clinical preventive services, such as rates of screening tests, should be important components of healthcare quality-improvement programs that are promoted by health plans. The National Committee for Quality Assurance NCQA and other national quality-improvement and accrediting organizations should add obesity prevention efforts—such as routine measurement and tracking of BMI, counseling of children and their parents on diet and exercise—to the measures they develop and assess.
There may also be opportunities for incorporating obesity prevention measures and counseling into ongoing federal, state, and local programs that provide disease prevention and health promotion services to children. More than 8. As with other sectors, those involved in delivering and paying for health care need to become more proactive, preferably through a multifocal, coordinated set of initiatives, in working with families to promote physical activity and healthful diets among children.
Medicare has recently removed barriers to coverage for obesity-related services DHHS, Although this, of course, does not relate directly to children, it is an action that may well be emulated by other insurers and for preventive services as well as for treatment.
Health insurers, health plans, and quality-improvement and accrediting organizations should designate childhood obesity prevention as a priority health promotion issue. Furthermore, health plans and health-care insurers should provide incentives to individuals and families to maintain healthy body weight and engage in routine physical activity. Health insurers, health plans, and quality improvement and accrediting organizations such as NCQA should include screening and obesity prevention services e.
The health-care community offers a range of opportunities for interactions with children and youth regarding obesity prevention. Several controlled trials of counseling by health-care providers have resulted in patient improvements in physical activity levels or diet, although these studies have generally been conducted with small numbers of patients and have focused on counseling of adult patients.
Further research is needed on effective counseling or other types of obesity prevention interventions that could be provided in health-care settings.
Improved professional education regarding obesity prevention is an important next step, as is the active involvement of health professional organizations, insurers, and accrediting organizations, in making childhood obesity prevention efforts a priority. Pediatricians, family physicians, nurses, and other clinicians should engage in the prevention of childhood obesity. Health-care professional organizations, insurers, and accrediting groups should support indi vidual and population-based obesity prevention efforts.
Health-care professionals should routinely track BMI, offer relevant evidence-based counseling and guidance, serve as role mod els, and provide leadership in their communities for obesity preven tion efforts. Professional organizations should disseminate evidence-based clinical guidance and establish programs on obesity prevention. Training programs and certifying entities should require obe sity prevention knowledge and skills in their curricula and examina tions. Insurers and accrediting organizations should provide incen tives for maintaining healthy body weight and include screening and obesity preventive services in routine clinical practice and quality assessment measures.
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