9
Assessing the Nation’s Progress in Preventing Childhood Obesity

The nation’s growing recognition of the obesity crisis as a major health concern for its children and youth has led to an array of diverse efforts aimed at increasing physical activity and promoting healthful eating. These efforts, however, generally remain fragmented and are implemented on a small-scale. Furthermore, there is a lack of systematic tracking and evaluation of childhood obesity prevention interventions. Compared with the strong commitment and heavy infusion of governmental and private-sector resources to other major public health concerns, such as an impending infectious disease outbreak or bioterrorism, there is a marked underinvestment in the prevention of childhood obesity and related chronic diseases.

Accelerating the pace of change toward healthier lifestyles will require leadership, political will, increased resources, and sustained commitment. Additionally, broader-based efforts are needed to scale up programs and interventions found to be effective.

It is time to think strategically about what is required to create and institutionalize changes now to reverse the childhood obesity epidemic over future decades. Which state will be the first to reverse its escalating obesity rate? How will industry contribute to the response, beyond its incremental expansion of food, beverage, and meal products to full and profitable healthful product lines? When will social norms shift toward embracing active lifestyles and foods and beverages that contribute to a healthful diet?

The Institute of Medicine (IOM) Health in the Balance report (IOM, 2005) emphasized the collective responsibility that all sectors share for shaping an adequate response to the childhood obesity epidemic. All stake-



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Progress in Preventing Childhood Obesity: How Do We Measure Up? 9 Assessing the Nation’s Progress in Preventing Childhood Obesity The nation’s growing recognition of the obesity crisis as a major health concern for its children and youth has led to an array of diverse efforts aimed at increasing physical activity and promoting healthful eating. These efforts, however, generally remain fragmented and are implemented on a small-scale. Furthermore, there is a lack of systematic tracking and evaluation of childhood obesity prevention interventions. Compared with the strong commitment and heavy infusion of governmental and private-sector resources to other major public health concerns, such as an impending infectious disease outbreak or bioterrorism, there is a marked underinvestment in the prevention of childhood obesity and related chronic diseases. Accelerating the pace of change toward healthier lifestyles will require leadership, political will, increased resources, and sustained commitment. Additionally, broader-based efforts are needed to scale up programs and interventions found to be effective. It is time to think strategically about what is required to create and institutionalize changes now to reverse the childhood obesity epidemic over future decades. Which state will be the first to reverse its escalating obesity rate? How will industry contribute to the response, beyond its incremental expansion of food, beverage, and meal products to full and profitable healthful product lines? When will social norms shift toward embracing active lifestyles and foods and beverages that contribute to a healthful diet? The Institute of Medicine (IOM) Health in the Balance report (IOM, 2005) emphasized the collective responsibility that all sectors share for shaping an adequate response to the childhood obesity epidemic. All stake-

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Progress in Preventing Childhood Obesity: How Do We Measure Up? holders can be instrumental in making changes to social norms throughout the nation so that obesity will be acknowledged as an important and preventable health outcome and healthful eating and regular physical activity will be accepted and encouraged as the standard (IOM, 2005). What is needed is for the childhood obesity epidemic to reach a “tipping point” (Gladwell, 2000), where small collective changes within and across all sectors will produce a substantial effect so that the obesity epidemic will be acknowledged, environmental changes will take hold, communities will be mobilized, and individuals and families will aspire to pursue healthy behaviors and active lifestyles as the social norm. This report has sought to provide an extension of the Health in the Balance report. It has emphasized the need for the evaluation of obesity prevention actions across all sectors so that effective evidence-based approaches can be identified, scaled up, adapted to diverse settings and contexts, and widely disseminated. The committee developed five broad conclusions (Box 9-1) based on its assessment of progress in preventing BOX 9-1 Conclusions The country is beginning to recognize that childhood obesity is a serious public health problem that increases morbidity and mortality and that has substantial economic and social costs. However, the current level of investment by the public and private sectors still does not match the extent of the problem. Government, industry, communities, schools, and families are responding to the childhood obesity epidemic by implementing a variety of policies, programs, and other interventions. All of these stakeholders bring strong values and beliefs to obesity-related issues, but evidence-based approaches are needed to guide the nation’s collective actions in the response. Current data and evidence are inadequate for a comprehensive assessment of the progress that has been made in preventing childhood obesity across the United States. Although the best available evidence should be used to develop an immediate response to the childhood obesity epidemic, a more robust evidence base that identifies promising practices must be developed so that these interventions can be scaled-up and supported in diverse settings. Evaluation serves to foster collective learning, accountability, responsibility, and cost-effectiveness to guide improvements in childhood obesity prevention policies and programs. Multiple sectors and stakeholders should commit adequate resources to conduct these evaluations. Surveillance, monitoring, and research are fundamental components of childhood obesity prevention evaluation efforts. Multiple sectors and stakeholders should conduct evaluations of different types and at different levels to assess and stimulate progress over the short term, intermediate term, and long term to reverse the childhood obesity trend and improve the health of the nation’s children and youth.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? childhood obesity. These conclusions serve as the foundation for the report’s recommendations and the specific implementation actions discussed in the previous chapters. The United States is still in an early phase of developing a coherent and comprehensive response to obesity as a national public health challenge. A mature understanding of the long-term investments and scope of an adequate response is needed. Many countries and regions around the world are similarly recognizing the extent of their own obesity and chronic disease challenges and are beginning to take constructive steps to formulate comprehensive strategies or action plans that promote health and that aim to prevent overweight and obesity in their populations. These strategies and plans often include evaluation components that can be used to assess their own progress (Table 9-1). The World Health Organization estimates that obesity and related chronic diseases account for approximately 60 percent of the overall rate of mortality worldwide and 47 percent of the global burden of disease (WHO, 2002). Many middle-income countries around the world, including Brazil, China, Indonesia, Mexico, Russia, and Vietnam, are experiencing obesity epidemics that vary by socioeconomic groups (Doak et al., 2000, 2005; IOM, 2007; Wang et al., 2002). Countries with transitional economies often face the dual challenges of both malnutrition and overnutrition (Ezzati et al., 2005; Gillespie and Haddad, 2003; Hawkes, 2006; WHO, 2006a). Additionally, obesity and cardiovascular disease risks are expected to increase in low- and middle-income countries, which, along with the persistent burden of infectious diseases and malnutrition, may further exacerbate global health inequities (Ezzati et al., 2005). A greater understanding is needed of the dietary and physical activity patterns that lead to the co-existence of obesity, under-nutrition, and micronutrient deficiencies in developing countries, as well as the environmental, economic, and social trends that influence them. Evidence-based guidance for the design, implementation, and evaluation of effective programs and policies that address this double burden is also needed (Doak et al., 2000, 2005; Hawkes, 2006). Effective and innovative practices to prevent childhood obesity and the lessons learned are beginning to be shared internationally; however, more can be accomplished with a coordinated global dissemination effort. CHANGING SOCIAL NORMS Healthful diets and regular physical activity are far from the accepted social norm, although there is a growing awareness by the public that obesity has health, economic, and social consequences. A Harvard School of Public Health poll of 2,033 adults nationwide found that an estimated

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Progress in Preventing Childhood Obesity: How Do We Measure Up? TABLE 9-1 Examples of Countries and Regions that Have Developed Strategies or Action Plans to Promote Healthful Eating and Physical Activity and to Prevent Obesity Country Strategy or Action Plan Source Australia Best Options for Promoting Healthy Weight and Preventing Weight Gain in New South Wales Gill et al. (2005) Canada Improving the Health of Canadians: Promoting Healthy Weights Canadian Institute for Health Information (2006) Chile Global Strategy Against Obesity Ministry of Health (2005) Denmark National Action Plan Against Obesity. Recommendations and Perspectives National Board of Health (2003) Finland Finnish Nutrition Recommendations 2005 Government Resolution on Policies to Develop Health-Enhancing Physical Activity in Finland National Nutrition Council, National Public Health Institute, Ministry of Agriculture and Forestry (2005) Ministry of Social Affairs and Health (2002) France Taking Charge of Obesity in Children and Adolescents Agence Nationale d’Accréditation et d’Évaluation en Santé (2003) Ireland Obesity: The Policy Challenges. The Report of the National Taskforce on Obesity National Taskforce on Obesity (2005) The Netherlands Living Longer in Good Health Ministry of Health, Welfare, and Sport (2004) Norway Prescriptions for a Healthier Norway Ministry of Social Affairs (2002–2003)   The Action Plan on Physical Activity 2005–2009: Working Together for Physical Activity Departemente Ministries (2005) Portugal National Programme Against Obesity Portuguese Ministry of Health and Portuguese General Directorate of Health (2004) Slovenia Resolution on The National Programme of Food and Nutrition Policy 2005–2010 National Institute of Public Health, Republic of Slovenia (2005) Spain Spanish Strategy for Nutrition, Physical Activity and Prevention of Obesity Ministry of Health and Consumer Affairs (2005)

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Country Strategy or Action Plan Source Sweden Background Material to the Action Plan for Healthy Dietary Habits and Increased Physical Activity Healthy Dietary Habits and Increased Physical Activity: The Basis for an Action Plan National Food Administration and National Institute of Public Health (2005) National Institute of Public Health (2005) United Kingdom Choosing Health: Making Healthy Choices Easier National Health Service (2004) United States The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity DHHS (2001) Region Strategy or Action Plan Source Europe European Ministerial Charter on Counteracting Obesity WHO (2006b)   Children’s Environment and Health Action Plan for Europe WHO (2004b)   Green Paper—Promoting Healthy Diets and Physical Activity: A European Dimension for the Prevention of Overweight, Obesity and Chronic Diseases Commission of the European Communities (2005)   Diet, Physical Activity and Health—EU Platform for Action European Commission (2006) Global Diet, Nutrition and the Prevention of Chronic Diseases WHO (2003, 2004a, 2006a)   Global Strategy on Diet, Physical Activity, and Health     Preventing Chronic Diseases: A Vital Investment   Latin America Global Strategy on Healthy Eating, Physical Activity and Health (DPAS): Implementation Plan for Latin America and the Caribbean 2006–2007 PAHO/WHO (2005, 2006a,b)   Regional Strategy and Plan of Action on an Integrated Approach to the Prevention and Control of Chronic Diseases, Including Diet, Physical Activity, and Health     Regional Strategy on Nutrition in Health and Development 2006–2015  

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Region Strategy or Action Plan Source Nordic Health, Food, and Physical Activity. Nordic Plan of Action on Better Health and Quality of Life Through Diet and Physical Activity Nordic Council of Ministers for Fisheries and Aquaculture, Agriculture, Foodstuffs, and Forestry; The Nordic Council of Ministers for Social Security and Health Care (2006) Pacific Obesity in the Pacific: Too Big to Ignore Secretariat of the Pacific Community (2002) 75 percent of Americans view obesity as either an extremely serious or very serious public health problem (Blendon et al., 2005). The majority of Americans believe that scientific experts have been accurately portraying (58 percent) or underestimating (22 percent) the health risks of obesity, with only 15 percent believing that scientific experts have overestimated obesity-related health risks (Blendon et al., 2005). Other surveys have found that the public perceives obesity to be a growing threat to health (Evans et al., 2005, 2006; IFIC Foundation, 2006; Pew Research Center, 2006; Wall Street Journal Online and Harris Interactive, 2005, 2006). Although there is more public support for certain interventions to reduce obesity, especially obesity among children and youth, the public’s support for such interventions as sending body mass index (BMI) report cards home to parents, requiring standardized food portions in restaurants, and regulating the advertising and marketing of less healthful foods and beverages is divided (Evans et al., 2005, 2006; Pew Research Center, 2006; Wall Street Journal Online and Harris Interactive, 2005, 2006). Data from marketing research firms also suggest that Americans’ attitudes toward obese individuals are shifting from rejection to acceptance and that Americans may be more tolerant of heavier body types. The NPD Group’s National Eating Trends Survey found that 24 percent of 1,900 survey respondents indicated that overweight individuals were less attractive in 2005, whereas 55 percent of respondents found this to be the case in 1985 (Associated Press, 2006). There may be a substantial difference in Americans’ perception of what constitutes healthy habits and what they actually do. A telephone survey of 12,000 adults found that three quarters of obese respondents described their eating habits as either “very healthy” or “somewhat healthy,” and nearly one-half of the survey respondents indicated they exercised three or more times weekly (Thomson Medstat, 2006).

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Moreover, a survey of 1,000 Americans found that 9 out of 10 consumers were unable to provide an accurate estimate of their recommended calorie intakes, three-quarters of obese consumers underestimated their weight, only one-third of consumers believe that the health information that they receive is consistent, and taste and cost remain more important drivers of choice than healthfulness (IFIC Foundation, 2006). Another survey of 2,200 adult consumers found that only 17 percent had ever visited the U.S. Department of Agriculture’s (USDA’s) MyPyramid website; only a quarter (24 percent) stated that they understood food labels; nearly three-quarters (72 percent) indicated that if food does not taste good, they will not eat it, despite its nutritional value; and one-half of the consumers surveyed did not know how much fat, carbohydrate, or salt to consume in a 2,000-calorie diet (Yankelovich, 2006). Trend data show that the rate of participation in physical activity declines as American children get older. More than one-third of high school students (grades 9 to 12) do not regularly engage in physical activity, more than 11 percent of high school students get no moderate to vigorous physical activity, and 30 percent of states do not mandate physical education for elementary and middle school students (NASPE and AHA, 2006). Between 1981 and 1997, children’s free playtime decreased by 25 percent, attributed to the increased amount of time spent in structured activities. A desirable social norm to work toward, especially for preschoolers, is to promote unstructured outdoor play in their lives (Burdette and Whitaker, 2005). For older children and adolescents, a social norm to aspire to is the integration of physical activity or active living into their lives every day. Social movements related to promoting public and environmental health (e.g., tobacco control, underage drinking, seatbelt use, recycling, and reducing litter) have historically resulted from actions in which the population is made aware of a problem, educated, and mobilized over years and decades to challenge power structures and societal norms to address social problems (Economos et al., 2001; Kersh and Morone, 2002). Meaningful social change often involves the tensions and interactions among three different cultures: a private-sector market culture, a public-sector bureaucratic culture, and a nonprofit relational culture (Gecan, 2002). It will take time to change social norms that have become deeply embedded in American society. Parents often use electronic media, such as television to manage busy schedules; maintain peace in the household; and facilitate family routines with their children, such as relaxing, eating, and falling asleep (Rideout and Hamel, 2006). Media now have a more central role in socializing today’s children and youth than ever before (IOM, 2006). The promotion of obesity prevention as a successful social change movement and evaluation of the extent of the changes in social norms are imminent challenges. A coherent approach is needed to assess the progress of this

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Progress in Preventing Childhood Obesity: How Do We Measure Up? social movement to change actions and behaviors toward healthier choices and lifestyles. Assessing the extent of change in social norms and values related to obesity will require the use of diverse measurement approaches. Media content analyses can show how popular depictions of people and activities (e.g., healthful eating and physical activity) are portrayed. Patterns and trends in school recess, physical education, food and beverage sales, active transport, and many other intermediate outcomes are potential indicators of progress, as is the trajectory of the way in which social norms are codified through changes in policies and regulations. Surveillance systems, such as the Behavioral Risk Factor Surveillance System and the Youth Risk Behavior Surveillance System (YRBSS), and public opinion polls will provide insights into the extent to which attitudes and behaviors are changing. However, extensive research is needed to identify how healthy choices can be made accessible and desirable—as well as how sedentary pursuits and less healthful choices can be made undesirable—without stigmatizing high-risk populations or those who are already obese. Furthermore, these changes need to be relevant to children and youth of all socioeconomic, cultural, and racial/ethnic backgrounds. NEXT STEPS Given the range of actions that are needed to move forward in preventing childhood obesity, the committee has identified immediate next steps that it deems essential priority actions in the near future. The committee strongly encourages that all childhood obesity prevention policies and interventions be evaluated to learn what works and what does not work and to broadly share that information. Meaningful and sustained efforts will need to be connected across multiple sectors of society so that childhood obesity prevention becomes accepted as a collaborative responsibility among government, communities, industry, schools, and at home. Furthermore, the collective body of knowledge and evidence of these efforts as they are evaluated will serve to further build and inform the field of obesity prevention. Government The federal, state, and local governments are actively engaged in childhood obesity prevention efforts. However, as noted above, the levels of funding and resources invested in these efforts and their evaluation are not commensurate with the seriousness of this public health problem. Government at all levels should provide coordinated leadership for the prevention of obesity in children and youth.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? A critical next step for the federal government is to establish a high-level task force on childhood obesity prevention, as recommended in the Health in the Balance report (IOM, 2005), and as underscored in this report. The committee recommends that the president request that the secretary of the U.S. Department of Health and Human Services (DHHS) convene this high-level task force and the task force include as members the secretaries or senior officials of DHHS and the U.S. Departments of Agriculture, Education, Transportation, Housing and Urban Development, Interior, Defense, and other relevant departments and agencies. The purpose of the task force would be to ensure coordinated budgets, policies, and requirements for obesity prevention programs and to establish effective interdepartmental collaboration and priorities for action. Furthermore, the federal government should provide a sustained commitment and long-term investment in childhood obesity prevention initiatives found to be effective (such as the VERB™ campaign) and those that are vital to measuring progress (such as national surveillance efforts to track trends in the obesity epidemic). Surveillance systems—such as the National Health and Nutrition Examination Survey, the School Health Policies and Programs Study (SHPPS), the Youth Media Campaign Longitudinal Survey, YRBSS, and the National Household Transportation Survey—should be expanded to include relevant obesity-related outcomes. Surveillance systems that monitor the precursors of dietary and physical activity behaviors, such as changes in policies and the built environment, need to be expanded or developed. Additionally, monitoring systems for USDA programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Food Stamp Program, and the school meals programs should be developed that assess a range of obesity-related outcomes for children and youth. State and local governments should also demonstrate leadership on this issue and commit resources and policies that lead to actions that implement and evaluate changes in schools and communities. Industry Certain segments of relevant industries, including the food, beverage, restaurant, food retail, leisure and recreation, physical activity and fitness, and entertainment industries have responded constructively to the childhood obesity epidemic. However, other corporations in these industries are not yet engaged in obesity prevention; and other segments of the industry, such as the fitness, spectator sports, and transportation sectors, have not shown adequate involvement in obesity prevention actions. Nevertheless, careful and independent evaluations are needed to determine if industry is making a sufficient investment, sustained commitment, and whether those

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Progress in Preventing Childhood Obesity: How Do We Measure Up? initiatives proposed by industry will be effective and contribute to desirable outcomes. Evaluation of industry’s efforts to prevent childhood obesity should focus on an assessment and tracking over time of the proportion of a company’s product portfolio and marketing resources devoted to developing, packaging, and promoting healthful products. There is also a need to track industry’s changes in portion sizes and easily conveyed nutritional information for healthy products that consumers eat as well as the products that promote physical activity. Additionally, there is a need to assess the promotion of consistent health messages to young people and the public by all relevant industries and all media platforms—print, broadcast, cable, electronic, mobile, and wireless. Industry and the public health community should work toward nurturing and strengthening partnerships that support obesity prevention efforts. To expand the federal research capacity to study the ways in which marketing influences children’s and adolescents’ attitudes and behaviors, industry is encouraged to provide data on pricing strategies, consumer food purchases, and consumption trends from proprietary retail scanner systems, household scanner panels, household consumption surveys, and marketing research. The collaborative work should examine the quality of the data, consider reducing the cost to make the data accessible, and establish priorities for applying the information to promote healthful diets and physical activity. Corporate responsibility can be demonstrated by sharing marketing research findings, to the greatest extent possible, which will assist the public health sector to develop, implement, and evaluate more effective childhood obesity prevention policies, programs, and interventions. Data sharing will need to balance many considerations including transparency, public accessibility, the demands of the competitive marketplace, and legal issues. In certain cases, it may be appropriate for the data to be released after a time lag to keep the public informed with relatively recent data. The committee recommends that the public and private sectors engage in a collaborative process that will assist relevant stakeholders to share proprietary data for the public good. Communities Communities vary widely in the extent and nature of the resources available for changing the built and social environments to facilitate physical activity and the selection of low-calorie and high-nutrient foods and beverages that support a healthful diet. A number of state and local governments, foundations, and youth-related organizations are demonstrating innovative and collaborative approaches to childhood obesity prevention. However, much remains to be learned, transferred, and disseminated in

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Progress in Preventing Childhood Obesity: How Do We Measure Up? order to identify the most effective evidence-based interventions that continue even when seed funding and external resources are no longer available. The committee identified two immediate next steps for communities. The development of a validated community self-assessment tool, such as a community health index, will help communities identify their strengths and gaps in designing and evaluating childhood obesity-prevention efforts, ranging from local programs and evaluation capacity to the local physical and built environments, and the extent of community involvement. Additionally, relevant nonprofit organizations and government agencies should partner in developing a means to compile and disseminate effective community-based childhood obesity prevention interventions. A web-based database or repository of published and unpublished literature, case studies, and promising intervention websites is needed. Congress should appropriate funds for the CDC, in partnership with the Department of Transportation, the Department of the Interior, and other relevant federal agencies, private-sector and nonprofit organizations, and community stakeholders to develop this type of well-validated tool that can be used in economically and culturally diverse communities. Additionally, the National Association of County and City Health Officials, in partnership with government agencies and other nonprofit and voluntary health organizations, should develop a means of compiling and sharing community-based evaluation results, lessons learned, and community action plans as well as provide links to resources, templates, and evaluation tools. A web-based database or repository of published and unpublished literature, case studies, and promising intervention websites is needed. Schools Schools are the current focus of many childhood obesity prevention efforts, particularly changes to the school food and beverage environment. Less attention has been paid to increasing physical activity in schools, although this issue seems to be gaining momentum. As is true for community efforts, wide variations in the extent of the efforts and resources available for investment in obesity prevention by individual schools, school districts, and state agencies are observed. Federal law requires that schools receiving federal funds for school meals must develop school wellness policies by the fall of 2006, which has stimulated school-based health promotion and obesity prevention efforts across the country. Additionally, teachers, food service personnel, school administrators, and state and federal agency staff have developed many creative and innovative approaches to improve students’ diets and to increase physical activity, but these need to be evaluated. Sustained attention is needed for this issue as well as changes that can improve the nutritional quality of foods and beverages that are

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Progress in Preventing Childhood Obesity: How Do We Measure Up? available and the opportunities for physical activity offered in preschool, child-care, and after-school programs. The committee encourages states and school districts to bolster their physical education and physical activity requirements and standards, as should preschool, child-care, and after-school programs. Accountability mechanisms are needed for state school nutrition and physical activity standards that include increased transparency and dissemination of school-by-school reports on success in meeting these standards. Home Many families across the country are aware of their role in preventing childhood obesity and are actively making changes toward healthier lifestyles, whereas others are not yet engaged in change. Just as families may periodically evaluate their economic health and long-term strategies, their disaster preparedness, and their children’s academic progress, it is important for families to periodically assess their health-related home environment and practices. A next step for parents, caregivers, children, and adolescents is to periodically assess the home environment and ask the following questions: Are parents knowledgeable about healthy feeding strategies for their children? Are the foods and beverages that are available and prepared in the home healthful and served in reasonable portion sizes? Is physical activity emphasized and a family priority? Do families have established rules or guidelines limiting leisure screen time? Incremental changes are valuable and signal that progress is occurring. Conclusion A succinct assessment of the nation’s progress in preventing childhood obesity is not feasible given the diverse and varied nature of America’s communities and population. However, it can be said that awareness of obesity has been raised, actions have begun, coordination and prioritization of limited resources are critical, and evaluation of interventions within and across all sectors is essential. A long-term commitment to create a healthy environment for our children and youth is urgently needed. This commitment will require widespread changes in social norms, institutions, and practices beyond those that directly involve children and youth. REFERENCES Agence Nationale d’Accréditation et d’Évaluation en Santé. 2003. Prise en Charge de l’Obésité de l’Enfant et de l’Adolescent. France. [Online]. Available: http://www.sante.gouv.fr/ [accessed June 8, 2006].

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