4
Government

Government serves several vital functions in a national public health crisis such as the childhood obesity epidemic. First and foremost the government provides leadership, which it demonstrates by making the response to the obesity epidemic an urgent public health priority and coordinating the public- and private-sector response. Galvanizing the response involves political commitment, policy development, prioritized funding, and coordination of programs. Other necessary elements of an adequate government response to the obesity epidemic are a strong governmental workforce, an enhanced organizational capacity, and a robust information-gathering system to monitor progress and guide programs and policies (Baker et al., 2005). Another key governmental function at the federal, state, and local levels is to improve the health status of the population and reduce inequities in health status among population groups (Health Canada, 2001; IOM, 2003).

In responding to the obesity epidemic, federal, state, and local government agencies across the nation share in the core public health responsibilities listed in Box 4-1 (IOM, 1988, 2003; NACCHO, 2005). Research and technical assistance for implementing, evaluating, and achieving national and regional objectives are primarily the responsibilities of the federal government, whereas program planning, implementation, and evaluation are state and local government responsibilities in partnership with other sectors (TFAH, 2006).

Two major recommendations in the Health in the Balance report were that “government at all levels should provide coordinated leadership for the



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Progress in Preventing Childhood Obesity: How Do We Measure Up? 4 Government Government serves several vital functions in a national public health crisis such as the childhood obesity epidemic. First and foremost the government provides leadership, which it demonstrates by making the response to the obesity epidemic an urgent public health priority and coordinating the public- and private-sector response. Galvanizing the response involves political commitment, policy development, prioritized funding, and coordination of programs. Other necessary elements of an adequate government response to the obesity epidemic are a strong governmental workforce, an enhanced organizational capacity, and a robust information-gathering system to monitor progress and guide programs and policies (Baker et al., 2005). Another key governmental function at the federal, state, and local levels is to improve the health status of the population and reduce inequities in health status among population groups (Health Canada, 2001; IOM, 2003). In responding to the obesity epidemic, federal, state, and local government agencies across the nation share in the core public health responsibilities listed in Box 4-1 (IOM, 1988, 2003; NACCHO, 2005). Research and technical assistance for implementing, evaluating, and achieving national and regional objectives are primarily the responsibilities of the federal government, whereas program planning, implementation, and evaluation are state and local government responsibilities in partnership with other sectors (TFAH, 2006). Two major recommendations in the Health in the Balance report were that “government at all levels should provide coordinated leadership for the

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Progress in Preventing Childhood Obesity: How Do We Measure Up? BOX 4-1 Public Health Mission and Government Responsibilities Mission: The mission of public health is to fulfill society’s interest in ensuring the existence of conditions in which people can be healthy. Core Functions: All levels of government are responsible for conducting health assessments, health policy development, and the assurance of health. To accomplish its mission, public health agencies should establish operational linkages with other public sector agencies responsible for health-related functions. The execution of public health functions requires technical, political, management, program, and fiscal capacities at all levels. State government is the central force in public health and is the public-sector entity that bears primary responsibility for health. Federal Government Responsibilities Support knowledge development and dissemination through data collection, research, and information exchange Establish national objectives and priorities on interstate and national health issues Provide technical assistance to support states and localities in determining objectives and carrying out actions on national and regional objectiveness Provide funds to states to strengthen their capacity for services to achieve adequate minimum health services and achieve national health objectives Ensure that its actions and services are in the interest of the entire nation, as in the case of epidemics, interstate environmental actions, and food and drug inspections State Government Responsibilities Conduct health assessments based on statewide data Ensure an adequate statutory base for health activities in the state Establish health objectives, delegate responsibilities, and hold local governments accountable prevention of obesity in children and youth” and an “increased level and sustained commitment of federal and state funds and resources are needed” to sufficiently address the childhood obesity epidemic. Additionally, the report recommended that state and local government should “provide coordinated leadership and support for childhood obesity efforts, particularly for populations at high risk of childhood obesity, by increasing resources and strengthening policies that promote opportunities for physical activity and healthful eating” (IOM, 2005a, p. 147–148). Many of the efforts that have already been implemented by federal, state, and local governments play an essential role in the response to childhood obesity in the United States. The number of existing governmental

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Ensure organized statewide efforts for personal, educational, and environmental health; provide access to health services; and solve health problems Guarantee the availability of a minimum set of health care services Support local health care service capacity, especially when disparities in local abilities exist with fiscal, administrative, technical capacity, and direct action Local Government Responsibilities Assess, monitor, and provide surveillance for local health problems and resources with consideration of physical, behavioral, environmental, social, and economic conditions Prevent, investigate, minimize, and contain adverse health effects Ensure compliance with public health laws and ordinances Lead planning and response for public health emergencies Develop policy and leadership to engage the community, ensure the equitable distribution of public resources, and develop public-private partnerships to deliver activities commensurate with community needs Implement health promotion programs Coordinate public health system efforts in an intentional, noncompetitive, and nonduplicative manner Address health disparities. Ensure that high-quality services for the protection of public health, including personal health care, are accessible to all people; that the community receives proper consideration in the allocation of federal, state, and local resources for public health; and that the community and media are informed about how to obtain public health services Serve as a resource to local governing bodies, policy makers, community-based organizations, other governmental agencies, entities engaged in public health issues, and researchers SOURCES: Adapted from IOM (1988, 2003); NACCHO (2005). activities with the potential to reverse the childhood obesity epidemic is vast, dynamic, and difficult to track systematically over time. The prevention of childhood obesity will require contributions from all sectors of society. Government can play a special role by augmenting its own capacity in such a way that it stimulates and enhances the capacities and activities of other sectors of society. In order to continue to focus attention on the childhood obesity epidemic and encourage sustained efforts from all sectors of society, government will need to consistently acknowledge the importance of preventing childhood obesity. In addition to implementing and sustaining new programs, governmental agencies at all levels need to reexamine their existing policies and initia-

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Progress in Preventing Childhood Obesity: How Do We Measure Up? tives that may hinder progress toward childhood obesity prevention. Examples include school siting policies that locate schools far outside of walking distance from the neighborhoods that those schools serve; U.S. agricultural policies including marketing practices, nutrition standards, agricultural subsidies, and procurement policies for agricultural commodity programs that affect the types and quantities of foods and beverages available in schools, communities, and through federal food assistance programs; land use policies that do not encourage mixed use of residential and business space and that subsequently discourage walking to neighborhood stores or businesses; and school policies that shorten the length of time in the school day devoted to healthy school meals and physical activity. This chapter provides an overview of the role of government at all levels in the response to the childhood obesity epidemic. It provides examples of the policies, programs, and activities undertaken by federal, state, and local governmental agencies to reverse the current obesity epidemic and prevent a future rise in childhood obesity rates. The chapter examines the approaches needed to effectively evaluate policies and interventions and explores the factors that constitute success for the governmental sector. The chapter also recommends next steps in assessing progress with regard to leadership; implementing and evaluating policies and interventions and developing evaluation capacity; enhancing surveillance, monitoring, and research efforts; and using and disseminating the evidence from evaluation results. SETTING THE CONTEXT The severity of the obesity epidemic in the United States was first observed and publicized with data from the Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a system that uses telephone interviews for health surveillance and is jointly managed by the 50 state health departments and the Centers for Disease Control and Prevention’s (CDC’s) National Center for Chronic Disease Prevention and Health Promotion. In 1991, BRFSS data showed that four states had adult obesity prevalence rates of 15 to 19 percent and that no states had rates of 20 percent or greater. By 2004, BRFSS showed that 7 states had adult obesity prevalence rates of 15 to19 percent, 33 states had adult obesity rates of 20 to 24 percent, and 9 states had adult obesity rates of 25 percent or greater (CDC, 2005a). The National Health and Nutrition Examination Survey (NHANES), a CDC surveillance system that is based on personal interviews and a physical examination and that was initiated in 1971, also revealed a rapidly evolving obesity epidemic in children, adolescents, and adults (Flegal et al., 2002; Ogden et al., 2002, 2006; Troiano et al., 1995). CDC presented the emerging data to the U.S. Congress at a House Appropriations Hearing in

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Progress in Preventing Childhood Obesity: How Do We Measure Up? 2000 and warned of a growing obesity epidemic in children and adults. These data, coupled with evidence that obesity is not merely a cosmetic issue but leads to an array of serious health problems and comorbidities (Williams et al., 2005) as well as increasing health care costs (DHHS, 2001; Finkelstein et al., 2003, 2004; Wang and Dietz, 2002), were sufficient to raise national concern about the urgency of the epidemic and to stimulate congressional action. In 2001, the U.S. Surgeon General issued the Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity to stimulate the development of specific agendas and actions targeting this growing public health problem (DHHS, 2001). In 2002, the Institute of Medicine (IOM) undertook a congressionally mandated study to develop a blueprint for a comprehensive action plan that is summarized in the report, Preventing Childhood Obesity: Health in the Balance (IOM, 2005a). The recommendations from that report focused on the actions needed by multiple stakeholders; the report called on government at all levels to take a leadership role and to bring resources to bear on this important health concern. The present IOM committee recommends increased efforts to address the government recommendations of the Health in the Balance report (Boxes 4-2 to 4-4) and to incorporate an evaluation component into all policies, programs, and initiatives. To explore the breadth of childhood obesity prevention activities currently under way in the government sector—and whether and how they are being evaluated—the committee reviewed and drew information from a variety of sources, including those described in Chapter 1, as well as information and data from federal and state government surveillance and reporting systems, reports, and websites and from interviews conducted with selected state health officials; federal regulatory agencies; and federal representatives of the health, agriculture, and education sectors. A complete and systematic inventory of federal, state, and local government policies, programs, and activities relevant to childhood obesity prevention was beyond the charge of the committee and the scope of this progress report. However, a selected list of recent federal agency programs, initiatives, and surveillance systems relevant to childhood obesity prevention is compiled in Appendix D. FEDERAL GOVERNMENT The federal government has a responsibility to address public health crises including the childhood obesity epidemic through ensuring sufficient capacity to provide essential public health services; responding when a health threat is apparent across the entire country, region, or many states; providing assistance when the responses are beyond the jurisdictions of individual states; helping to formulate the public health goals of state and

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Progress in Preventing Childhood Obesity: How Do We Measure Up? BOX 4-2 Recommendations for Federal, State, and Local Government from the 2005 IOM report Preventing Childhood Obesity: Health in the Balance Government at all levels should provide coordinated leadership for the prevention of obesity in children and youth. The president should request that the Secretary of the U.S. Department of Health and Human Services (DHHS) convene a high-level task force that includes the Secretaries or senior officials from DHHS, Agriculture, Education, Transportation, Housing and Urban Development, Interior, Defense, and other relevant agencies to ensure coordinated budgets, policies, and program requirements and to establish effective interdepartmental collaboration and priorities for action. An increased level and a sustained commitment of federal and state funds and resources are needed. To implement this recommendation, the federal government should: Strengthen research and program efforts addressing obesity prevention, with a focus on experimental behavioral research and community-based intervention research and on the rigorous evaluation of the effectiveness, cost-effectiveness, sustainability, and scaling up of prevention interventions. Support extensive program and research efforts to prevent childhood obesity in high-risk populations with health disparities, with a focus on both behavioral and environmental approaches. Support nutrition and physical activity grant programs, particularly in states with the highest prevalence of childhood obesity. Strengthen support for relevant surveillance and monitoring efforts, particularly the National Health and Nutrition Examination Survey (NHANES). Undertake an independent assessment of federal nutrition assistance programs and agricultural policies to ensure that they promote healthful dietary intake and physical activity levels for all children and youth. Develop and evaluate pilot programs within the nutrition assistance programs that would promote healthful dietary intake and physical activity and scale up those found to be successful. To implement this recommendation, state and local governments should: Provide coordinated leadership and support for childhood obesity prevention efforts, particularly those focused on high-risk populations, by increasing resources and strengthening policies that promote opportunities for physical activity and healthful eating in communities, neighborhoods, and schools. Support public health agencies and community coalitions in their collaborative efforts to promote and evaluate obesity prevention interventions. 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. Community coalitions should be formed to facilitate and promote crosscutting programs and communitywide efforts. SOURCE: IOM (2005a).

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Progress in Preventing Childhood Obesity: How Do We Measure Up? BOX 4-3 Recommendations for the U.S. Department of Health and Human Services from the 2005 IOM report Preventing Childhood Obesity: Health in the Balance Advertising and Marketing Industry should develop and strictly adhere to marketing and advertising guidelines That minimize the risk of obesity in children and youth. To implement this recommendation: The Secretary of the U.S. Department of Health and Human Services should convene a national conference to develop guidelines for the advertising and marketing of foods, beverages, and sedentary entertainment directed at children and youth with attention to product placement, promotion, and content. Multimedia and Public Relations Campaign The U.S. Department of Health and Human Services should develop, implement, and evaluate a long-term national multimedia and public relations campaign focused on obesity prevention in children and youth. To implement this recommendation: The campaign should be developed in coordination with other federal departments and agencies and with input from independent experts to focus on building support for policy changes, providing information to parents, and providing information to children and youth. Rigorous evaluation should be a critical component. Reinforcing messages should be provided in diverse media and effectively coordinated with other events and dissemination activities. The media should incorporate obesity issues into its content, including the promotion of positive role models. Nutrition Labeling Nutrition labeling should be clear and useful so that parents and youth can make informed product comparisons and decisions to achieve and maintain energy balance at a healthy weight. To implement this recommendation: The Food and Drug Administration should revise the Nutrition Facts panel to prominently display the total calorie content for items typically consumed at one eating occasion in addition to the standardized calorie serving and the percent Daily Value. The Food and Drug Administration should examine ways to allow greater flexibility in the use of evidence-based nutrient and health claims regarding the link between the nutritional properties or biological effects of foods and a reduced risk of obesity and related chronic diseases. Built Environment The U.S. Department of Health and Human Services and the U.S. Department of Transportation should: Fund community-based research to examine the impact of changes to the built environment on the levels of physical activity in the relevant communities and populations. SOURCE: IOM (2005a).

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Progress in Preventing Childhood Obesity: How Do We Measure Up? BOX 4-4 Recommendations for Other Relevant Federal Agencies Recommendations from the 2005 IOM report Preventing Childhood Obesity: Health in the Balance U.S. Department of Education Schools Schools should provide a consistent environment that is conducive to healthful eating behaviors and regular physical activity. To implement this recommendation: Federal and state departments of education and health and professional organizations should Develop, implement, and evaluate pilot programs to explore innovative approaches to both staffing and teaching about wellness, healthful choices, nutrition, physical activity, and reducing sedentary behaviors. Innovative approaches to recruiting and training appropriate teachers are also needed. U.S. Department of Transportation Built Environment The U.S. Department of Health and Human Services and the U.S. Department of Transportation should Fund community-based research to examine the impact of changes to the built environment on the levels of physical activity in the relevant communities and populations. Federal Trade Commission Advertising and Marketing Industry should develop and strictly adhere to marketing and advertising guidelines that minimize the risk of obesity in children and youth. To implement this recommendation: The Federal Trade Commission should have the authority and resources to monitor compliance with food and beverage and sedentary entertainment advertising practices. U.S. Department of Agriculture Schools Schools should provide a consistent environment that is conducive to healthful eating behaviors and regular physical activity. To implement this recommendation: The U.S. Department of Agriculture, state and local authorities, and schools should Develop and implement nutritional standards for all competitive foods and beverages sold or served in schools. Ensure that all school meals meet the Dietary Guidelines for Americans. Develop, implement, and evaluate pilot programs to extend school meal funding in schools with a large percentage of children at high risk of obesity. SOURCE: IOM (2005a).

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Progress in Preventing Childhood Obesity: How Do We Measure Up? local governments; and assisting states when they lack resources or expertise to adequately respond to a public health crisis (TFAH, 2006). The U.S. Congress and several federal executive branch departments have become actively engaged in obesity prevention. The U.S. Department of Health and Human Services (DHHS) and the U.S. Department of Agriculture (USDA) are demonstrating leadership in these efforts, with growing involvement of the U.S. Department of Education and the U.S. Department of Transportation. However, a great deal more must be accomplished. Examples of the federal agency programs, initiatives, and surveillance systems that support and monitor the prevention of obesity in U.S. children and youth are discussed throughout this chapter, with additional information provided in Appendix D, including information on the extent and the nature of federal evaluation efforts based on the available data. It should be noted that this report is not a complete and systematic inventory of government programs and initiatives, as this was not the charge to the committee. Rather, the committee highlights some of the efforts that illustrate the key roles of government and that point to further work that can be done to increase the opportunities for children and youth to become more physically active and improve their eating patterns and diets. Leadership Leadership is an essential function of the federal government as it determines the priorities for funding and brings its considerable resources to bear on the problem. Government leadership influences the actions of those working within the federal government and across other sectors. Evidence of leadership includes the acknowledgement of and commitment to address a problem, followed by the development of a plan of action, the establishment of policies, and the commitment of financial and human resources to carry out a comprehensive and coordinated plan. The Health in the Balance report recommended federal leadership through the following actions (IOM, 2005a): The president should appoint a high-level task force to coordinate federal agency responses. DHHS and the Federal Trade Commission (FTC) should develop guidelines with broad stakeholder input for the advertising and marketing of foods, beverages, and sedentary entertainment directed at children and youth, with attention to product placement, promotion, and content. The U.S. Food and Drug Administration (FDA) should revise the Nutrition Facts panel on packaged food and beverage products. FDA should allow industry to have greater flexibility to use evidence-based nutrient and health claims regarding the link between

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Progress in Preventing Childhood Obesity: How Do We Measure Up? the nutritional properties or the biological effects of foods and a reduced risk of obesity and related chronic diseases. USDA should develop nutritional standards for competitive foods and beverages available in schools. An example of demonstrated federal leadership is an initial stakeholder workshop, jointly organized by FTC and DHHS, to develop guidelines for the advertising and marketing of foods, beverages, and sedentary entertainment to children and youth. In July 2005, FTC and DHHS held a joint workshop, Marketing, Self-Regulation, and Childhood Obesity, that provided a forum for industry, academic, public health advocacy, and government stakeholders, as well as consumers, to examine the role of the private sector in addressing the rising childhood obesity rates. A summary of the workshop (FTC and DHHS, 2006) contains recommendations and next steps for industry stakeholders, including a request that industry strengthen self-regulatory measures to advertise responsibly to children through the Children’s Advertising Review Unit (CARU). FTC and DHHS indicated that both of these federal institutions plan to closely monitor the progress made on the recommendations in the joint FTC and DHHS summary report (FTC and DHHS, 2006). Moreover, Congress has requested that the FTC compile information on food and beverage marketing activities and expenditures targeted to children and adolescents. The FTC will be soliciting public comment on these issues, and the results will be submitted in a report to Congress as mandated in Public Law 109-108 (FTC, 2006) (Chapter 5). Recent actions by FDA are providing steps toward improving consumer nutrition information. In April 2005, FDA released two advance notices of proposed rulemaking to elicit stakeholder and public input about two recommendations of the FDA Obesity Working Group: the first action was to make calorie information more prominent on the Nutrition Facts label and the second action provides more information about serving sizes on packaged foods (FDA, 2006). In September 2005, FDA issued a final rule on the nutrient content claims definition of sodium levels for the term healthy (FDA, 2006). The IOM committee awaits further progress that FDA can make toward finalizing the rulemaking and exploring the use of evidence-based nutrient and health claims regarding the link between the nutritional properties or biological effects of foods and a reduced risk of obesity and related chronic diseases. Joint efforts by USDA and DHHS resulted in the release of the sixth edition of the Dietary Guidelines for Americans 2005, which provide specific recommendations on the consumption of foods in different food groups, fats, carbohydrates, sodium and potassium, and alcoholic beverages; food safety; and physical activity (DHHS and USDA, 2005). The Dietary Guidelines and their graphic representation, MyPyramid, are an

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Progress in Preventing Childhood Obesity: How Do We Measure Up? important source of consumer nutrition information that should provide the basis for federal food and nutrition assistance programs, nutrition education, and nutrition policies. The Child Nutrition and WIC Reauthorization Act (P.L. 108-265) provided another step forward for childhood obesity prevention efforts. In 2004, Congress initiated and passed the legislation, which requires school districts participating in the National School Lunch Program (NSLP) or School Breakfast Program (SBP) to establish a local school wellness policy by the beginning of the 2006–2007 school year (CNWICRA, 2004). As outlined in the legislation, the school wellness policies should include goals for nutrition education, physical activity, guidelines for foods and beverages served throughout school campuses, and other school-based activities that are designed to promote student wellness in a manner that the local educational agency determines is appropriate. The USDA secretary, in coordination with the secretary of education and in consultation with the DHHS secretary, acting through CDC, are charged with providing technical assistance to establish healthy school nutrition environments, reducing childhood obesity, and preventing diet-related chronic diseases. The act establishes a plan for measuring the implementation of the local school wellness policy, supported by $4 million in appropriated funds (CNWICRA, 2004) (Chapter 7). The committee encourages the systematic monitoring and evaluation of the implementation and the impacts and outcomes of these policies throughout the nation’s school districts and local schools. Progress is also under way to develop nutrition standards for competitive foods and beverages that are available in schools. In fiscal year (FY) 2005, Congress directed IOM to conduct a study to develop comprehensive recommendations for appropriate nutritional standards for competitive foods (Hartwig, 2004; IOM, 2006a). The study is in progress and when it is complete, the committee recommends that Congress, USDA, CDC, and other relevant agencies take expeditious action on developing national nutrition standards for competitive foods and beverages in schools. The federal government has also demonstrated leadership in setting specific goals for childhood obesity prevention. DHHS incorporated into its Strategic Plan FY 2004–2009 an objective for the Indian Health Service to decrease obesity rates among American Indian/Alaska Native (AI/AN) children by 10 percent during this 5-year period (DHHS, 2004). However, the committee noted that federal leadership fell short of an important recommendation in the Health in the Balance report, in that no progress was made toward the establishment of a presidentially appointed high-level task force to make childhood obesity prevention a national priority and to coordinate activities and budgets for this goal across federal agencies. Because childhood obesity prevention is a national priority that requires the collective efforts of many federal departments and agencies, the

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Progress in Preventing Childhood Obesity: How Do We Measure Up? tion are urgently needed so that effective interventions can be scaled up, adapted to different contexts, and widely disseminated. Each of the report’s four recommendations presented in Chapter 2 is directly relevant to promoting leadership and collaboration and improving the evaluation efforts of government policies and interventions. The following text provides the report’s recommendations and summarizes the specific implementation actions for government that are needed. Recommendation 1: Government, industry, communities, schools, and families should demonstrate leadership and commitment by mobilizing the resources required to identify, implement, evaluate, and disseminate effective policies and interventions that support childhood obesity prevention goals. Implementation Actions for Government Federal, state, and local government should each establish a high-level task force to identify priorities for action, coordinate public-sector efforts, and establish effective interdepartmental collaborations. To accomplish this, The president of the United States should request that the secretary of the DHHS convene a high-level task force involving the secretaries or senior officials from all relevant federal government departments and agencies (e.g., the U.S. Departments of Agriculture, Education, Defense, Interior, and Transportation; the Federal Communications Commission; and the Federal Trade Commission) to coordinate departmental budgets, policies, and research efforts and establish effective interdepartmental collaboration and priorities for action. State governments should convene high-level task forces involving the state departments of health, education, agriculture; the land-grant cooperative extension services, and other relevant agencies. Childhood obesity prevention should be a priority that is reflected in each state government’s public statements, policies and programs, budgets, research efforts, and interagency collaboration. Local government agencies should convene community- or regional-level task forces to provide coordinated leadership in preventing childhood obesity by increasing resources, collaborating with community stakeholders, and developing or strengthening policies and programs that promote opportunities for physical activity and healthful eating in communities and neighborhoods.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Recommendation 2: Policy makers, program planners, program implementers, and other interested stakeholders—within and across relevant sectors—should evaluate all childhood obesity prevention efforts, strengthen the evaluation capacity, and develop quality interventions that take into account diverse perspectives, that use culturally relevant approaches, and that meet the needs of diverse populations and contexts. Implementation Actions for Government Federal and state government departments and agencies should consistently evaluate the effects of all actions taken to prevent childhood obesity and strengthen the evaluation capacity, paying particular attention to culturally relevant evaluation approaches. To accomplish this, The actions of federal agencies, including policies that have been implemented, should be consistently evaluated to determine whether these actions and policies provide evidence of leadership and to identify the promising actions that are likely to be the most effective in preventing childhood obesity. The U.S. Congress should increase federal support for capacity-building activities such as the CDC’s State-Based Nut1rition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases and Steps to a HealthierUS Program. Federal and state agencies should assess and strengthen the capacities of state and territorial health departments to provide leadership and technical assistance, enhance surveillance efforts, and implement and evaluate programs to prevent childhood obesity. DHHS, other federal agencies, and private-sector partners should work toward evaluating existing media efforts (including Small Step and Small Step Kids!) with the goal of developing, coordinating, and evaluating a more comprehensive, long-term, national multimedia and public relations campaign focused on obesity prevention in children and youth. Recommendation 3: Government, industry, communities, and schools should expand or develop relevant surveillance and monitoring systems and, as applicable, should engage in research to examine the impact of childhood obesity prevention policies, interventions, and actions on relevant outcomes, paying particular attention to the unique needs of diverse groups and high-risk populations. Additionally, parents and caregivers should monitor changes in their family’s food, beverage, and physical activity choices and their progress toward healthier lifestyles.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Implementation Actions for Government Government at all levels should develop new surveillance systems or enhance existing surveillance systems to monitor relevant outcomes and trends and should increase funding for obesity prevention research. To accomplish this, Federal and state government surveillance systems should monitor the full range of outcomes in the evaluation framework. Surveillance systems—such as NHANES, SHPPS, YMCLS, YRBSS, and NHTS—should be expanded to include relevant obesity-related outcomes. Surveillance systems that monitor the precursors of dietary and physical activity behaviors, including policies that have been implemented and structural, institutional, and environmental outcomes should be expanded or developed. All states should have a mechanism in place to monitor childhood obesity prevalence, dietary factors, physical activity levels, and sedentary behaviors through population-based sampling over time. The U.S. Congress should appropriate sufficient funds to support research on obesity prevention research (e.g., efficacy, effectiveness, quasiexperimental, cost-effectiveness, sustainability, and scaling up research) to improve program implementation and outcomes for children and youth. Recommendation 4: Government, industry, communities, schools, and families should foster information-sharing activities and disseminate evaluation and research findings through diverse communication channels and media to actively promote the use and scaling up of effective childhood obesity prevention policies and interventions. Implementation Actions for Government Government at all levels should commit to the long-term support and dissemination of childhood obesity prevention policies and interventions that have been proven to be effective. To accomplish this, Federal, state, and local governments should publicly disseminate and promote the results of evaluations of childhood obesity prevention policies and interventions. The federal government should provide a sustained commitment and long-term investment to adequately support and disseminate childhood obesity prevention interventions that are proven to be effective—such as the VERB campaign. Further,

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