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Progress in Preventing Childhood Obesity: How Do We Measure Up? 6 Communities As noted in the Health in the Balance report (IOM, 2005), childhood obesity prevention efforts are ultimately about strengthening com munity capacity and mobilizing community resources and involvement. Whether the community in question is large or small, rural or urban, or termed a neighborhood or barrio, it will inevitably comprise smaller relational networks that include faith-based organizations; worksites; schools; and a variety of government, nonprofit, and voluntary organizations. This chapter uses the term community to denote a geographic entity but acknowledges the strengths and opportunities brought about by groups of people who are linked by social ties; who share common interests, perspectives, and ethnic or cultural characteristics; and who engage in joint action in particular geographic locations or settings (MacQueen et al., 2001). Communities across the nation are increasingly aware of the childhood obesity epidemic, and this awareness is being transformed into active efforts to improve community access to foods and beverages that contribute to a healthful diet and increase opportunities for regular physical activity. However, the extent of these changes and the degree to which city councils, local businesses, schools, faith-based organizations, local health departments, and other organizations with a stake in the health and quality of life of children and youth are actively engaged in this issue may vary widely. The community-based approach to the prevention of childhood obesity
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Progress in Preventing Childhood Obesity: How Do We Measure Up? builds on the reality that communities have numerous resources and assets that, if they are mobilized strategically, can directly affect the health and well-being of children and adolescents. These resources and assets can be accessed through the nonprofit organizations that work directly with children and youth. Planning and community development agencies that determine the physical design and use of resources in the built environment, such as paths, parks, and neighborhoods, can make the built environment more user-friendly and thus encourage physical activity. Health care professionals and systems through which primary care services are delivered can address childhood obesity as part of their regular delivery of care. Faith-based organizations, community coalitions, foundations, and worksites can address community and family well-being and are increasingly doing so. Schools are also a vital asset that serve as a link between families and communities and have the capacity to strengthen and reinforce childhood obesity prevention strategies and initiatives and will be discussed more thoroughly in Chapter 7. The present Institute of Medicine (IOM) committee recommends increased efforts to address the community-based recommendations presented in the Health in the Balance report (Box 6-1) and to incorporate an evaluation component into all policies, programs, and initiatives. This chapter highlights the key actions that need to be taken to activate a community’s assets around the common goal of preventing childhood obesity. It begins with a brief review of key strategies associated with effective community-based prevention efforts. That review is followed by examples of progress that focus on mobilizing communities, improving the built environment, and enhancing the role of health care providers and the health care system in childhood obesity prevention. The chapter concludes with recommendations for guiding communities to assess their progress in establishing promising childhood obesity prevention efforts. KEY ELEMENTS OF COMMUNITY-BASED STRATEGIES Although communities may vary widely in their demographics and resources, efforts to engage communities in promoting healthy lifestyles generally involve active grassroots efforts that build on the strengths of the residents and the locale. Mobilizing community participation, developing partnerships, and creating synergistic actions were some of the many themes that emerged from the discussions at the committee’s symposium, Progress in Preventing Childhood Obesity: Focus on Communities, held in Atlanta, Georgia, on October 6 and 7, 2005, in collaboration with the Healthcare Georgia Foundation and the Robert Wood Johnson Foundation (RWJF) (Appendix G). The key elements of community-based strategies are discussed below.
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Progress in Preventing Childhood Obesity: How Do We Measure Up? BOX 6-1 Recommendations for Communities from the 2005 IOM report, Preventing Childhood Obesity: Health in the Balance 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 community-wide efforts. To implement this recommendation: Private and public efforts to eliminate health disparities should include obesity prevention as one of their primary areas of focus and should support community-based collaborative programs to address social, economic, and environmental barriers that contribute to the increased obesity prevalence among certain populations. 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. Communities should improve access to supermarkets, farmers’ markets, and community gardens to expand healthful food options, particularly in low-income and underserved areas. Built Environment Local governments, private developers, and community groups should expand opportunities for physical activity, including recreational facilities, 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. To implement this recommendation: Local governments, working with private developers and community groups should Revise comprehensive plans, zoning and subdivision ordinances, and other planning practices to increase the availability of and accessibility to opportunities for physical activity in new developments. Leadership Committed and sustained leadership is a common and essential element emerging from promising community-based efforts to address childhood obesity. At a minimum, leadership is viewed as the investment of adequate resources and the commitment of the institutions and organizations that engage in obesity prevention efforts. The sustainability of community-improvement initiatives has been attributed to leaders’ transition from a
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Progress in Preventing Childhood Obesity: How Do We Measure Up? Prioritize capital improvement projects to increase opportunities for physical activity in existing areas. Improve the street, sidewalk, and street-crossing safety of routes to school; develop programs to encourage walking and bicycling to school; and build schools within walking and bicycling distance of the neighborhoods that they serve. Community groups should Work with local governments to change their planning and capital improvement practices to give higher priority to opportunities for physical activity. 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. Health Care 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 individual and population-based obesity prevention efforts. To implement this recommendation: Health care professionals should routinely track body mass indices, offer relevant evidence-based counseling and guidance, serve as role models, and provide leadership for obesity prevention efforts in their communities. Professional organizations should disseminate evidence-based clinical guidance and establish programs on obesity prevention. Training programs and certifying entities should require obesity prevention knowledge and skills in their curricula and examinations. Insurers and accrediting organizations should provide incentives for maintaining a healthy body weight and include screening and obesity preventive services in routine clinical practice and quality assessment measures. SOURCE: IOM (2005). focus on projects addressing the symptoms of societal problems (e.g., chronic disease outcomes) to a focus on changing the underlying cultures, incentives, and settings that give rise to these symptoms (Norris and Pittman, 2000). Because of the multiple sectors and stakeholders involved in childhood obesity prevention, leadership on this issue can come from the private or the public sector: from government leaders, health care professionals, school administrators and staff, community residents, and local business leaders. Leaders at the forefront of change in this area are often inspired by
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Progress in Preventing Childhood Obesity: How Do We Measure Up? a personal health problem or by an interest in health promotion. Individual and organizational leadership are needed as driving forces in sustaining collaborative efforts, dedicating resources, and working to change social norms that support healthier lifestyles. Building Community Coalitions Community coalitions consist of public- and private-sector organizations, together with individual citizens, working to achieve a shared goal through the coordinated use of resources, leadership, and action and the provision of direction in these areas. The synergistic effects of these collaborative partnerships result from the multiple perspectives, talents, and expertise that are brought together to work toward a common goal. However, challenges exist in developing and refining appropriate methods to evaluate the impact of coalition efforts on a variety of outcomes (Fawcett et al., 2000; Lasker et al., 2001; Roussos and Fawcett, 2000; Shortell, 2000). The efforts needed to prevent childhood obesity require a diverse set of skills and expertise—from renovating community recreational facilities to developing multimedia campaigns to promote healthy lifestyles. Because childhood obesity prevention is central to the health of the community’s children and youth, the development of community coalitions is a particularly relevant means of addressing this issue. The characteristics of successful coalitions include focusing on a well-defined and specific issue, determining common goals, and keeping the coalition focused on providing leadership and direction rather than micromanaging the solutions (Kreuter et al., 2000). All these characteristics are attainable for community coalitions focused on childhood obesity prevention. The diverse set of community organizations and businesses that need to be involved to address childhood obesity includes more than just those stakeholders in the traditional health-related disciplines. These other organizations and businesses that are stakeholders include the building industry, food and beverage companies, the restaurant and food retail sectors, the entertainment industry and the media, the educational community, the public safety sector, transportation divisions, parks and recreation departments, environmental organizations, community rights advocates, youth-related organizations, foundations, employers, and universities, among others. Many stakeholders who might not have considered childhood obesity prevention as an area of interest now find that they have an important role to play in working toward healthier communities. Nevertheless, these organizations face challenges in developming and maintaining community coalitions. These challenges include effectively addressing competing priorities, transforming organizational cultures, and identifying sustainable funding sources.
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Progress in Preventing Childhood Obesity: How Do We Measure Up? Cultural Relevance Building on a community’s cultural assets to enhance childhood obesity prevention efforts is fundamental to the promotion of grassroots involvement and the sustainability of policies, programs, and initiatives. The extent to which culturally competent adaptations are made can greatly affect intervention and policy outcomes (Chapter 3). Culturally appropriate enhancement strategies can be categorized as peripheral (developing packaging to appeal to a particular group by using certain colors, images, graphics, pictures of group members, or titles), evidential (presenting data and information documenting the impact of the relevant health issue on a specific group), linguistic (increasing accessibility by using the preferred language or dialect of the group), constituency based (drawing directly on the experiences of group members through their inclusion as project staff or their substantive engagement as decision makers), and sociocultural (integrating the group’s normative attitudes, values, and practices into messages and approaches) (Hopson, 2003; Kreuter et al., 2003). Sufficient Resources and Sustained Commitment Community-wide childhood obesity prevention efforts require careful planning and coordination, well-trained staff, and sufficient resources. Success is greatly enhanced by community engagement in the issue, which can take a great deal of time and effort to achieve. Insufficient resources may result in messages and other planned campaign interventions that are inadequate to achieve the exposure necessary to change the awareness, knowledge, attitudes, beliefs, or behaviors of target groups over time, especially among high-risk populations. Furthermore, a sustained commitment is needed from community leaders, as implementing the changes necessary to alter the physical environment can be both time and resource intensive. For example, the revision of city zoning or planning policies may require extensive time, including the time required to engage community residents, organizations, and businesses in discussions on the proposed changes. Focus on Safety Safety is an important construct of the social environment that is likely to influence childhood obesity prevention efforts (Lumeng et al., 2006). Crime rates and residents’ perceptions of neighborhood safety will affect the likelihood that people will walk or bicycle in their neighborhoods. These barriers include both “stranger danger” and “traffic danger,” which are important influences on the decisions that parents make regarding their children’s outdoor play and mode of transportation to school and which also influence the decisions that adolescents make regarding walking or
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Progress in Preventing Childhood Obesity: How Do We Measure Up? cycling for transport (Carver et al., 2005). Many of the ongoing walk-to-school efforts (e.g., the Safe Routes to Schools program) began as efforts to address child safety concerns. It is anticipated that both community safety and obesity prevention efforts would mutually benefit from attempts to enhance the community environment and that other benefits would also ensue. Community-Based Participatory Research Developing effective intervention actions in communities involves the activation of community group members to take ownership and influence the content and implementation of interventions, the evaluation process, and the dissemination of findings. These concepts are often grouped under the rubric community-based participatory research. This research paradigm recalls the historical roots of public health, in which problems were identified and addressed through collaboration with the public or community for the common good (Israel et al., 1998). By nature, community-based participatory interventions are culturally competent and congruent with the needs and values of a target group because the methods emerge from affected communities as well as university, government, and foundation partners. As discussed in Chapter 3, this is an area of particular relevance for planning, implementing, and evaluating culturally relevant interventions involving racially, ethnically, and culturally diverse subpopulations at high risk for obesity and related chronic diseases. Building on Multiple Social and Health Priorities As discussed in Chapter 3, childhood obesity prevention may not rank high as a priority for some communities and neighborhoods that are facing more immediate concerns such as poverty, crime, violence, underperforming schools, and limited access to health care. The opportunity in these communities is to identify and support efforts that can produce many potential benefits; for example, improving playgrounds and recreational facilities may enhance safety, reduce crime, increase physical activity, and improve quality of life. Finding common ground may serve as a key element in garnering sufficient investment for sustained efforts. The challenge is that many of these efforts are resource intensive and require significant political commitment and social support to be accomplished. Building and strengthening the partnerships between organizations working to empower communities can result in collective efficacy, which has been described as “the willingness of community members to look out for each other and intervene when trouble arises” (Cohen et al., 2006). A recent study found that adolescents living in communities with higher levels of collective efficacy had
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Progress in Preventing Childhood Obesity: How Do We Measure Up? lower body mass index (BMI) levels than those living in communities without a strong sense of connection. These differences remained significant even while the level of neighborhood disadvantage was held constant. This suggests that even youth living in neighborhoods of higher socioeconomic status may be adversely affected when they lack a connection to their community (Cohen et al., 2006). EXAMPLES OF PROGRESS IN PREVENTING CHILDHOOD OBESITY IN COMMUNITIES Given that the United States has approximately 36,000 incorporated cities and towns and many more locales (U.S. Bureau of the Census, 2006), the committee can provide only selected examples of the array of positive changes that are occurring throughout the nation in response to childhood obesity. As sufficient outcome data with which to evaluate the effectiveness of various policies, programs, and interventions are not yet available for most of the efforts, the descriptions provided are intended to highlight the many and varied efforts that have been and that are being made to address the problem of childhood obesity. They are characterized here as promising practices rather than best practices because sufficient evidence to directly link the effort with reducing the incidence or prevalence of childhood obesity and related co-morbidities is lacking. Mobilizing Communities Communities that promote healthy lifestyles and that actively engage their citizens in improving access to opportunities for healthful eating and regular physical activity draw on the talents, resources, and energies of multiple community stakeholders. As noted earlier, efforts to prevent childhood obesity compete with many other efforts to address health and social priorities for the scarce resources that are available at the local level. Furthermore, challenges often arise when attempts are made to coordinate programs under completely different administrative structures (e.g., schools and local health departments) within the community, state, and region. However, these challenges can be effectively confronted in many communities. Programs and initiatives at the community level often work to engage children, youth, and adults in obesity prevention efforts focused on all age groups. Community Programs and Initiatives The nature and breadth of community-based programs and initiatives vary widely and may involve community youth organizations, voluntary
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Progress in Preventing Childhood Obesity: How Do We Measure Up? health organizations, and public-private partnerships. Programs may also range from multi-city and well-resourced efforts sponsored by corporations or national organizations to efforts sponsored by individual communities engaging in specific projects or programs such as building a playground or expanding bike trails. Likewise, the scope of the evaluation may be modest or sophisticated, and the outcome indicators or performance measures may differ depending on the purpose for which they are intended (Chapter 2). Evaluation methodologies may range from research-based efforts with multiple comparison groups to assessments using more modest outcome measures, such as implementing a policy that supports a capital improvement project to build a new community playground where parents can engage in physical activity with their children. A number of national youth-related organizations are working with their multiple local chapters to incorporate obesity prevention efforts and goals into their programs, often with the support of foundation or corporate sponsors. For example, Girl Scout councils have developed partnerships with community parks and recreation departments, sports organizations, as well as schools and colleges for physical activity instruction and facilities. Girl Scout programs that are focused on healthy lifestyles include shape UP! and GirlSports (Girl Scouts, 2006). Additionally, the Girl Scouts organization conducted focus group research with online surveys of more than 2,000 8- to 17-year-old girls to explore how they view obesity, how they define health, and what motivates them to lead a healthy lifestyle (Girl Scout Research Institute, 2006). Other examples are also available. The YMCA has instituted YMCA Activate America™, a long-term commitment to obesity prevention that focuses on improving their programs; providing community leadership; and developing strategic partnerships with universities, government, and corporations (YMCA, 2006). The Boys and Girls Clubs of America feature a number of fitness-related programs, including Triple Play: A Game Plan for the Mind, Body and Soul. The Coca-Cola Company and Kraft Foods Inc. have sponsored that program with the goal of increasing healthy habits and physical activity, and promoting healthful diets (BGCA, 2006). At the IOM committee’s symposium in Wichita, Kansas, students presented a local 4-H-sponsored mentoring program, Kansas Teen Leadership for Physically Active Lifestyles, in which high school students engage with elementary school children in after-school and summer programs focused on promoting physical activity and healthful eating (Sparke et al., 2005). Community centers, after-school programs, and summer camps are often used as sites for obesity prevention interventions. For example, the GEMS (Girls Health Enrichment Multisite Studies) set of research-based studies has examined a variety of approaches (e.g., dance, team building, games, aerobics, nutrition education, and reduced television viewing) that
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Progress in Preventing Childhood Obesity: How Do We Measure Up? are being implemented in community settings to engage 8- to 10-year-old African-American girls in obesity prevention and management (Baranowski et al., 2003; Beech et al., 2003; Robinson et al., 2003; Story et al., 2003). Faith-based organizations are also becoming more engaged in promoting healthy lifestyles. The leaders of many faiths are realizing that messages about physical health and spiritual health are congruent. Indeed, participants at the IOM committee’s symposium on healthy communities in Atlanta described several efforts being undertaken by different faith-based groups to promote health (Appendix G). This process often starts with the minister addressing his or her own health concerns as well as encouraging congregation members to make healthful nutrition and physical activity choices as a way of demonstrating their concern for others and the church family. Congregations are encouraging members to bring healthier meals to church potluck gatherings and are sponsoring health fairs, cooking and exercise demonstrations, physical activity classes, and informational sessions on how to improve the health of the congregation. Others are partnering with local health departments or other health care providers to offer health screenings at places of worship, a setting where people may feel more comfortable than they would in a health clinic. Some congregations have parish nurses or ministers who provide health information, facilitate health promotion activities, and conduct health screenings for congregational members (Brudenell, 2003; Chase-Ziolek and Iris, 2002). Research-based efforts are evaluating the effectiveness of faith-based approaches to obesity prevention; for example, a program called Healthy Body Healthy Spirit is an intervention funded by the National Heart, Lung, and Blood Institute to increase physical activity and the levels of consumption of fruits and vegetables among African Americans recruited through churches (Resnicow et al., 2005). National efforts that work at the community level often involve successful collaborations among federal agencies, corporations, and community-based, youth-related organizations (Chapters 4 and 5). The numerous ongoing public-private collaborations include Action for Healthy Kids (a collaborative public-private effort focused on changes in schools and involving a number of partners including Aetna Foundation, the American Public Health Association, Centers for Disease Control and Prevention [CDC], the Department of Education, the Kellogg’s Fund, the National Dairy Council, the National Football League, the National PTA, the Robert Wood Johnson Foundation, and USDA) (Action for Healthy Kids, 2006) and the 5 A Day for Better Health Program (a national public-private partnership with multiple collaborators including the American Heart Association, American Cancer Society, Association of State and Territorial Directors of Health Promotion and Public Health Education, CDC, National Alliance for Nutrition and Activity, National Cancer Institute, Pro-
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Progress in Preventing Childhood Obesity: How Do We Measure Up? duce for Better Health Foundation, Produce Marketing Association, United Fresh Fruit and Vegetable Association, and USDA (PBH, 2006) (Chapter 4). Other national initiatives include NikeGO, sponsored by Nike, Inc. (Nike, 2006); Girls on the Run, sponsored by New Balance and the Kellogg Company (Girls on the Run, 2006); America on the Move® (2006), a nonprofit organization that promotes small lifestyle changes to increase physical activity and reduce calorie intake, with multiple sponsors including PepsiCo and Cargill; and the Women’s National Basketball Association’s Be Smart - Be Fit - Be Yourself program for youth (WNBA, 2005). Evaluations of these programs vary in scope. For example, the America On the Move Foundation’s assessment strategy includes scientific research in clinical environments of America On the Move programs conducted through the University of Colorado’s Center for Human Nutrition; evaluation of the national online program for individuals and groups based on pre- and post-intervention data and on programs customized for specific settings; and survey data collection through national and state-based instruments of individuals’ health-related knowledge, beliefs, and behaviors, including actual physical activity levels (through the use of stepometer data) (Wyatt et al., 2004). Numerous state and federal programs operate at the local level. For example, six cities, five counties, and three American Indian tribes have received funding through the STEPS to a HealthierUS Cooperative Agreement Program (Steps Program) that enables communities to develop an action plan, a community consortium, and an evaluation strategy that supports chronic disease prevention and health promotion (DHHS, 2006) (Chapter 4). Cooperative extension services are another example of federal, state, and local partnerships that work through land-grant universities and local extension offices to disseminate information to families and individuals and engage communities to work on a range of nutrition- and agriculture-related issues (CSREES, 2006). Additionally, federal food and nutrition programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), provide opportunities to convey information about dietary and physical activity changes to the parents of young children and to the employees working in these programs (Box 6-2; Chapters 4 and 8). Furthermore, work site efforts focused on improving employee health often have direct and indirect benefits for children and youth by providing parents with information that they can use to influence the nutrition and physical activity behaviors of their children. For example, the National Business Group on Health has developed a tool kit for employers and fact sheets for parents focused on healthy weight for families (NBGH, 2006).
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Progress in Preventing Childhood Obesity: How Do We Measure Up? To accomplish this, Communities should make childhood obesity prevention a priority through the coordinated leadership of local government, community organizations, local businesses, health care organizations, and other relevant stakeholders. These efforts would involve increased resources, an emphasis on collaboration among community stakeholders, and the development and implementation of policies and programs that promote opportunities for physical activity and healthful eating, particularly for high-risk communities. 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 Communities Community stakeholders should strengthen evaluation efforts at the local level by partnering with government agencies, foundations, and academic institutions to develop, implement, and support evaluation opportunities and community-academic partnerships. To accomplish this, Federal and state agencies, foundations, academic institutions, community-based nonprofit organizations, faith-based groups, youth-related organizations, local governments, and other relevant community stakeholders should Increase funding and technical assistance to conduct evaluations of childhood obesity prevention policies and interventions, Develop and widely disseminate effective evaluation training opportunities, and Develop and support community-academic partnerships. 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 Communities Community stakeholders and relevant partners should expand the capacity for local-level surveillance and applied research and should develop tools for community self-assessment to support childhood obesity prevention efforts. To accomplish this, Federal and state agencies, foundations, academic institutions, community-based nonprofit organizations, faith-based groups, youth-related organizations, local governments, and other relevant community stakeholders should Expand the surveillance of outcomes of community-level activities and changes to the built environment, as they relate to childhood obesity prevention; Facilitate the collection, analysis, and interpretation of relevant local data and information; Develop, refine, and disseminate community assessment tools, such as a community health index; Develop methods for the rapid evaluation of natural experiments; Explore the use of spatial mapping technologies to assist communities with their assessment needs and to help communities make changes that increase access to opportunities for healthy lifestyles; and Encourage the evaluation of interventions to examine both the risk and protective factors related to obesity. 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 Communities Community stakeholders should partner with foundations, government agencies, faith-based organizations, and youth-related organizations to publish and widely disseminate the evaluation results of community-based childhood obesity prevention efforts. To accomplish this, Community stakeholders should publish evaluation results using diverse communication channels and media; and develop incentives to encourage the use of promising practices.
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