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B
Methodology: Development
of the Committee’s
Recommendations
T o develop recommendations1 for accelerating progress in obesity prevention,
the committee undertook a series of steps. The process was informed primarily
by the development of a set of guiding principles (detailed in Chapter 4). As
described in Chapter 1, the committee was charged as a first step with review-
ing obesity-related recommendations from previous Institute of Medicine (IOM)
reports and other relevant sources. To this end, the committee identified recom-
mendations to review, organized and grouped these recommendations, and devel-
oped a process for reviewing and filtering them. Complementary (and parallel)
to the set of filtering criteria, an approach was used to help identify relationships
and synergies among the recommendations with the most promise to accelerate
progress in obesity prevention. Throughout the process, gaps were identified and
considered in developing the final set of recommendations. From these efforts, a
comprehensive approach to this study emerged that includes five critical areas,
linked as an interrelated system. The committee’s recommendations and strategies
and potential actions for implementation are presented in Chapters 5-9 (and again
in Appendix C). The following sections provide additional detail on how the com-
mittee developed its recommendations.
1 Asdescribed in Box 4-1, the term “recommendations” as used in this report refers in general to a group
of terms unless otherwise specified. Thus the committee’s “recommendations” include the recommendations
and their associated goals, strategies, and potential actions, and the review of prior “recommendations”
includes what others have identified as recommendations, interventions, actions, and strategies.
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IDENTIFICATION, ORGANIZATION, REVIEW, AND
FILTERING OF PRIOR RECOMMENDATIONS
Identification and Organization
The committee began by compiling all previous obesity-related recommenda-
tions from the IOM and other relevant sources. It should be noted that the IOM
and National Research Council (NRC) reports all were developed to fulfill a
specific task that defines the scope of each report and consequently may limit the
scope of its recommendations.
The general criterion used in deciding which recommendations to review was
that they were relevant to population-based obesity prevention approaches; that is,
they were intended to lower the mean body mass index (BMI) level and decrease
the rate at which people enter the upper end of the BMI distribution. Although
searches were not limited by the date of publication, the year 2005 marked the
beginning of the National Academies’ issuance of obesity prevention-related rec-
ommendations. The 2005 IOM report Preventing Childhood Obesity: Health in
the Balance and the 2005 Transportation Research Board report Does the Built
Environment Influence Physical Activity? demonstrated increasing recognition of
the complex, multifaceted nature of the many factors that influence energy bal-
ance (IOM, 2005; TRB/IOM, 2005). This recognition led to the examination of
obesity prevention strategies that moved beyond a biomedical model and an indi-
vidual behavior change approach to encompass multilevel, multisector policy and
environmental approaches. National Academies reports and reports outside of the
National Academies that include recommendations emerging from this conceptual-
ization were published mainly in 2005 and beyond (with some exceptions).
The criteria for including a report and consequently its recommendations in
the committee’s review were as follows:
• included only population-based obesity prevention strategies;
• used established procedures for making recommendations (e.g., evidence-
based, transparency in decisions made);
• included only environmental and policy strategies (as opposed to strategies
focused on individual behavior or biomedical approaches); and
• was derived from some type of expert task force or committee consensus.
The quest for relevant publications included an online search of several data-
bases and publication lists of relevant organizations and a review of references
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in reports that were identified. Committee members, public workshop presenters
and attendees, interested stakeholders, and the public also provided suggested
sources for review (see the end of this appendix for a list of reports included in the
review).
Approximately 800 obesity-prevention related recommendations were identi-
fied from these reports. To manage this large number of recommendations, the
committee organized them into 10 broad topics (school foods; health care; food
marketing; agriculture policy; physical activity, physical inactivity, transportation,
and the built environment; pregnancy, early childhood, and child care; nutrition
education and information; research, monitoring, and evaluation; food access and
pricing; other). Within each broad topic, similar recommendations were grouped
to help identify themes and continue to identify gaps.
Review and Filtering
Each recommendation that met the above inclusion criteria was reviewed
and coded on several dimensions based on the committee’s guiding principles (see
Chapter 4) so the committee could assess its promise for accelerating progress in
obesity prevention over the next decade. A textual description of each filter was
provided to the coder to ensure consistency in judgments. The filters used were
• policy or funding dependent;
• reach/scope;
• potential magnitude of impact;
• evidence base;
• reduction of disparities;
• geographic implementation to date;
• degree to which recommendation is actionable;
• measurability;
• unintended consequences;
• timeline to implementation; and
• feasibility, practicality, and cost if known.
At least two coders were assigned to each recommendation or group of related
recommendations. Each coder worked independently, and disagreements were
resolved through discussion. If consensus was not readily obtained by the pair of
coders, additional committee members were consulted. Once agreement had been
reached, both coders’ comments on the promise of the strategy were compiled,
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and a list of strategies based on the results of the coding exercise was developed.
These recommendations were shared with the full committee, revised, updated,
and consolidated as a result of further committee deliberations. The recommenda-
tions were judged against these filters using the information or evidence provided
in the reports in which the recommendations were offered. Additionally, related
information and evidence made available since the issuance of the original recom-
mendations, as well as information on the progress of their implementation, was
identified and considered to inform the coding process.
The search for and interpretation of relevant evidence for each recommenda-
tion was guided by a framework that was developed to inform decisions on obe-
sity prevention, integrating research evidence into a broader policy context (IOM,
2010a). This framework with which to locate, evaluate, and assemble evidence
to inform decisions on obesity prevention decision making (the L.E.A.D. frame-
work) was used to identify, locate, and evaluate the type of evidence appropriate
for the task of prioritizing the recommendations based on the best available sci-
entific evidence. Being concerned with locating evidence to help in assessing the
effects of the recommended interventions, the committee sought effectiveness
studies, as well as studies examining the presumed mechanism of the intervention
effects. Guided by the L.E.A.D. framework, the committee broadened its search
to include empirical comparative studies and evaluations commonly referred to as
impact assessments or outcome evaluations. Additionally, the committee consid-
ered implementation evidence to determine whether an intervention is still needed,
whether it had the intended effects with the expected impact, and whether changes
to the intervention might be necessary in the future. Finally, the committee took
into consideration political and practical concerns such as the cost, feasibility,
and practicality of implementing the interventions. To identify research related
to an intervention’s effectiveness, implementation, and relevance, the committee
searched a wide variety of data sources, including the scientific literature; grey
and unpublished literature; surveys, polls, and rankings; and government poli-
cies and programs. The committee focused its searches by first seeking and using
literature syntheses and updates, and if no recent syntheses were found, searched
for evidence on the particular recommendation of interest and also reached out
to states, communities, and localities that have implemented an intervention for
implementation-related research.
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IDENTIFICATION OF LINKAGES AMONG
FILTERED RECOMMENDATIONS
As described in Chapter 4 and recommended by the L.E.A.D. framework,
mapping the determinants of a problem can elucidate potential mechanisms and
dynamic pathways on which a more comprehensive approach should focus.
Accordingly, the committee mapped the pathways through which the most promis-
ing recommendations (as identified through the above process) relate, thus taking
a comprehensive systems approach that links the committee’s recommendations.
As the committee gathered and reviewed prior recommendations, it became
increasingly clear that to identify which recommendations were most likely to
accelerate progress in obesity prevention, the committee needed to understand and
map how the various recommendations would interact and reinforce or perhaps
inhibit progress. To this end, it was necessary to understand that for each recom-
mendation under consideration, there was a primary mechanism by which change
would be effected and that each had a set of prerequisites, accelerants, and inhibi-
tors that could potentially come into play during its implementation. The primary
mechanism describes the pathway, or how and why a recommendation would
help prevent obesity. Prerequisites are elements necessary for a recommendation
to be implemented or to be successful. Examples include public acceptance and
willingness and adherence to or enforcement of existing policies and regulations.
Accelerants are factors that will speed up the effectiveness or leverage the impact
of a recommendation. Examples include appropriate resources and well-organized
coalitions and partnerships, as well as tools and templates to offer guidance.
Inhibitors are elements that will slow the effectiveness of a recommendation or
impede its implementation. Examples include existing legislation, regulations, or
policies that prohibit action; a lack of guidance for implementation; a lack of pilot
programs implementing the recommendation; and a lack of public, private, or
political will and leadership.
The committee undertook a process of participatory model building to create
a systems map that would illustrate how the recommendations were interrelated.
As discussed in further detail in Chapters 2 and 3, the committee discussed the
determinants of obesity and what changes have occurred in the United States over
the past several decades as the obesity epidemic emerged. The committee analyzed
how past decisions influenced the current landscape, and considered why so many
private, public, individual, and societal decisions have been ineffective in achieving
intended objectives. Deliberations and discussions led the committee to accept that
answers to such questions might lie in the dynamic behavior of social, personal,
411
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environmental, political, and physical systems (Forrester, 1991), and that using
system mapping as a tool (i.e., a systems map) would enable the committee to
organize and make sense of the task at hand.
The result of these deliberations was the emergence of a comprehensive strat-
egy to link actions in five critical areas that served as the basis for the committee’s
recommendations. The next section provides a detailed discussion of the map of
the committee’s recommendations as an interrelated system of interventions.
DEVELOPMENT OF THE SYSTEMS MAP
The systems map in this report is a visual tool designed to aid in identifying
linkages among and between the committee’s recommendations and implementing
strategies. It allows visual communication of the latent potential effects of the rec-
ommendations and strategies both individually and synergistically, as well as how
they fit within the broader societal context. This map makes it possible to identify
strategies that may serve as prerequisites for other actions or may help reinforce
their impact. It also allows the discovery of “long chain” effects of strategies
that go beyond their immediate focus and impact. Finally, the map facilitated the
design of a cohesive set of strategies that support each other as a system, increas-
ing the effectiveness of the committee’s recommendations by approaching them
from multiple directions (see Figure B-1).
How to Read the Map
The map contains three shapes: squares, circles, and arrows. Squares are
labeled with letters (A through E) and represent the committee’s five recommen-
dations, as listed in the accompanying legend. Circles are labeled with numbers
(1 through 20) and represent the strategies suggested for implementing the recom-
mendations. The coloring of the strategies reflects the sector(s) of action they rep-
resent: the business community/private sector, the public sector, citizens and civic/
community organizations, health care, and worksites/employers. The recommen-
dations and strategies shown on the map and listed on the legend are described in
detail in Chapters 5 through 9.
An arrow indicates a connection between one strategy and another, between
a strategy and a recommendation, or between two recommendations. The arrows
are directional, indicating the flow of influence from one shape to another. An
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arrow pointing from a circle to a square can be read as “this strategy influences or
affects this recommendation.” Arrows may also be bidirectional, indicating posi-
tive feedback between the two shapes at its endpoints.
Construction of the Map
The systems map was constructed using an iterative process. Early in this
process, the entire committee was given a background presentation on systems
approaches and their use in other policy arenas. Working groups within the com-
mittee also participated in a thought exercise in which they were asked to identify
key systems links between strategies and recommendations that met the inclusion
criteria outlined above. Based on this exercise, discussions with the committee,
and input and assistance from IOM staff, an initial systems map was developed
and used to help frame the committee’s discussion of strategies and recommenda-
tions. As the committee’s deliberations proceeded, key systems connections were
identified by committee members and staff. These connections, along with feed-
back on the map’s design and a finalized set of recommendations and strategies,
were used to generate the final systems map. It is also important to note that as
individuals take a systems perspective when implementing these recommendations
and strategies, additional connections may be identified.
Each connection (arrow), whether between two strategies (circles), two recom-
mendations (squares), or one strategy and one recommendation, represents a care-
fully considered relationship of influence or impact identified by the committee
and/or staff that is based on the best available evidence or conceptual support. In
all cases, a clear mechanism for the flow of influence can be identified.
For example, Figure B-2 shows that the strategy of a nutrition labeling system
(a circle labeled 3 in the upper lefthand portion of the map) impacts the strategy
of food literacy in schools (a circle labeled 5 at the left and lower in the map)
because a simplified nutrition labeling system makes it easier for students to act
on the nutrition guidelines taught in schools. Thus an arrow points from circle 13
to circle 15 on the map.
Elsewhere on the map, the strategy of a social marketing program (a circle
labeled 11 in the upper center of the map) both impacts and is impacted by
the strategy of physical activity-related community programs (a circle labeled 2
nearby) (see Figure B-3). The two are mutually reinforcing. Thus arrows connect
the two circles in both directions.
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Appendix B
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B-1.eps
FIGURE B-1 Committee’s systems map for understanding and visualizing the interconnectedness
bitmap
of its recommendations and strategies.
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Legend for Figure B-1
Strategies* (Circles) Recommendations* [Squares]
(1) Physical and built environment [A] Prioritize promotion of physical activity
by increasing access and opportunities
(2) Physical activity-related community pro- for such activity.
grams [B] Reduce unhealthy food and beverage
options and increase healthier options.
(3) Physical education and physical activity [C] Transform the message environment.
in schools [D] Increase the support provided by
health care providers, insurers, and
(4) Physical activity in child care centers employers.
[E] Make schools a national focal point for
(5) Science and practice of physical activity obesity prevention.
(6) Sugar-sweetened beverages Sector of action (Color)
• Business community/private sector
(7) Food and beverage options for children
(Red)
in restaurants
• Public sector (Blue)
• Citizens and civic community organiza-
(8) Nutritional standards for all food and
tions (Green)
beverages
• Health care (Yellow)
Food and beverage retailing and distribu- • Worksites/employers (Orange)
(9)
tion policies
(10) U.S. agriculture policy and research
(11) Social marketing program
(12) Food and beverage marketing standards
for children
(13) Nutrition labeling system
(14) Nutrition education policies
(15) Food literacy in schools
(16) Health care and advocacy
(17) Coverage of and access to and incen-
tives for obesity prevention, screening,
diagnosis, and treatment
(18) Healthy eating and active living at work
(19) Weight gain and breastfeeding
(20) School food and beverage standards
*The strategies and recommendations as seen in the legend have been abbreviated. Appendix C
provides the complete content of each strategy and recommendation.
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FIGURE B-2 A directional connection arrow on the map. A small section of the map is magnified
here, and the arrow is highlighted in yellow. B-2.eps
bitmap
FIGURE B-3 A bidirectional connection on B-3.eps small section of the map is magnified here,
the map. A
and the two directional arrows are highlighted in yellow.
bitmap
Use of the Map
The map represents a visual systems organization of the recommendations and
strategies presented in the report. This systems view can be used to identify several
kinds of patterns in the content of the report, many of which would be less evi-
dent in a linear or categorical textual organization of the concepts.
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One important type of pattern is that of synergy between strategies that
extends their influence to a greater number of recommendations. For example,
strategy 14 (nutrition education policies) directly affects only recommendation
C (transform the message environment). A categorical mapping of recommenda-
tions and strategies would show only this connection. However, the systems map
also shows that through its connection to strategy 6 (sugar-sweetened beverages),
strategy 14 also indirectly influences recommendation B (reduce unhealthy food
and beverage options and increase healthier options) (Figure B-4). This type of
FIGURE B-4 An example of synergy. A subset-4.eps is magnified here. Direct influence
B of the map
of strategy 14 on recommendation C is shown, as well as indirect influence of strategy 14 via
bitmap
strategy 6 on recommendation B. Arrow tips of key connections are highlighted in yellow.
417
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synergy between strategies helps define a systems approach to obesity prevention
and demonstrates the potential for acceleration; the overall set of interventions
may add up to more than simply the sum of its parts.
A related structural pattern is a positive feedback or “reinforcing” loop. A
good example can be found in the center-right portion of the map, linking strate-
gies 1 (physical and built environment), 16 (health care and advocacy), and 18
(healthy eating and active living at work). Bidirectional links connect strategies 18
and 1; another set of bidirectional links connects strategies 1 and 16; and strategy
16 connects back to strategy 18. Figure B-5 shows how these three strategies are
mutually reinforcing and together may be more successful than any one on its
own. The connections in this feedback cycle also link actions across three differ-
ent sectors: citizens and civic/community organizations (strategy 1), health care
(strategies 16/18), and worksites/employers (strategy 18). The positive feedback
reinforcement between the three ultimately directly benefits recommendation D
(increase the support provided by health care providers, insurers, and employers),
as both strategy 16 and 18 flow into that recommendation.
A third type of pattern that can be identified using the map are “long chain”
effects of strategies that go well beyond their immediate focus or impact. For
example, strategy 15 (food literacy in schools) is linked directly only to recom-
FIGURE B-5 An example of positive feedback. A subset of the map is magnified here. Key direc-
B-5.eps
tional and bidirectional arrows are highlighted in yellow.
bitmap
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mendations C (transform the message environment) and E (make schools a
national focal point for obesity prevention). Using the systems map, however,
it can be seen that the impact of strategy 15 flows through to all the other rec-
ommendations (Figure B-6). It affects recommendation B via strategy 6 (sugar-
sweetened beverages), a two-step connection. It affects recommendation D by a
slightly longer chain, from strategy 15→6→18 (healthy eating and active living
at work). Finally, it reaches recommendation A by a long chain from strategy
15→6→18→1 (physical and built environment). Thus the systems map shows that
B-6.eps
FIGURE B-6 An example of long-chain connections. Key directional arrows are highlighted in
bitmap
yellow.
419
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nutrition education in schools can play a role directly or indirectly in all of the
recommendations in the report and is a systemically important strategy.
The map also can be used to assess the package of recommendations and
strategies in the report as a whole from a systems perspective and can serve as a
national roadmap for action to accelerate progress in obesity prevention that is
based on research evidence and the current level of progress in each area consid-
ered. The simultaneous implementation of the package of recommendations and
strategies would create combined impacts that could further accelerate progress in
preventing obesity. Indeed, a straightforward analysis of the map shows multiple
connections and multiple pathways leading to each of the five recommendations—
suggesting powerful overall systemic synergy as the strategies work together to
achieve the recommendations. Similarly, relationship patterns such as those iden-
tified in the examples above are numerous, suggesting that the strategies them-
selves have important reinforcement potential. Finally, and also important from
a systems perspective, the map shows many connections between strategies that
focus on different recommendations or that involve different sectors of action.
For example, strategies 13 and 15 (highlighted in Figure B-2) are connected to
each other—even though strategy 13 feeds directly only to recommendation B
and partially involves the business community/private sector, while strategy 15
feeds directly only to recommendation E and involves only the public sector. This
coordination across sectors and recommendations is a key feature of the overall
coordinated approach presented in this report.
Aside from the insight it provides into the system as a whole, the map is
arranged to permit different audiences to quickly identify areas of individual inter-
est. For example, the color coding of the strategies permits sectoral actors to iden-
tify those strategies in which they may be directly involved. Similarly, readers with
an interest in a particular recommendation can quickly trace all of the strategies
that feed directly or indirectly into that recommendation, as well as synergy with
other recommendations (arrows between squares).
BASIS FOR PHYSICAL ACTIVITY AND DIETARY RECOMMENDATIONS
The committee looked to the 2008 Physical Activity Guidelines for Americans
and the 2010 Dietary Guidelines for Americans to serve as the basis for defining
adequate physical activity, healthy eating, and healthy foods (HHS/USDA, 2010;
Physical Activity Guidelines Advisory Committee, 2008). In 2011, the release of
MyPlate (http://www.choosemyplate.gov) provided additional guidance on healthy
eating for the committee. These guidelines are based on the latest scientific evi-
Accelerating Progress in Obesity Prevention
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dence and provide information on achieving adequate activity levels, choosing
a nutritious diet, and maintaining a healthy weight to reduce the risk of many
adverse health outcomes. The key physical activity guidelines and overarching
concepts of the dietary guidelines are outlined in Box B-1.
The Physical Activity and Dietary Guidelines for Americans support the pre-
vention of overweight and obesity through the overarching concept of maintaining
calorie balance over time to achieve and sustain a healthy weight. To maintain
calorie balance, the guidelines highlight that individuals should improve physi-
cal activity and eating behaviors, increase physical activity and reduce sedentary
behavior, control total calorie intake, and maintain appropriate calorie balance
over the life span. More specifically, the guidelines provide information on key
physical activity goals over the life span, as well as foods to avoid and foods with
which to replace them.
REPORTS INCLUDED IN THE COMMITTEE’S REVIEW
(as of September 2010)
Institute of Medicine and National Research Council (by year)
Does the built environment influence physical activity? (TRB/IOM, 2005)
Preventing childhood obesity: Health in the balance (IOM, 2005)
Food marketing to children and youth: Threat or opportunity? (IOM, 2006a)
WIC food packages: Time for a change (IOM, 2006b)
Nutrition standards for foods in schools: Leading the way toward healthier
youth (IOM, 2007a)
Progress in preventing childhood obesity: How do we measure up? (IOM,
2007b)
Adolescent health services: Missing opportunities (NRC/IOM, 2009)
Local government actions to prevent childhood obesity (IOM, 2009a)
Weight gain during pregnancy: Reexamining the guidelines (IOM, 2009b)
Bridging the evidence gap in obesity prevention: A framework to inform deci-
sion making (IOM, 2010a)
Review of the nutrition guidelines for the Child and Adult Care Food Program
(IOM, 2011b)
School meals: Building blocks for healthy children (IOM, 2010b)
Early childhood obesity prevention policies (IOM, 2011a)
421
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BOX B-1
Physical Activity and Dietary Guidelines for Americans
The Physical Activity and Dietary Guidelines for Americans promote energy
balance and support prevention of obesity. The Physical Activity Guidelines are for
Americans 6 years of age and older, and the Dietary Guidelines are for Americans
2 years of age and older. These guidelines provide a strong evidence base on how
proper physical activity levels and a healthy diet help individuals maintain a healthy
body weight and contribute to progress in obesity prevention. Key Physical Activity
Guidelines and overarching concepts in the Dietary Guidelines include the following:
1. Focus on increasing physical activity levels.a
• Children and adolescents should participate in a minimum of 60 minutes
of moderate-intensity physical activity each day.
• Adults and older adults should participate each week in a minimum of
150 minutes of moderate-intensity physical activity, 75 minutes of vigor-
ous physical activity, or an equivalent combination of both.
• When older adults cannot engage in 150 minutes of moderate-intensity
physical activity because of physical limitations, they should be as physi-
cally active as their abilities will allow.
Non-Academies Reports (by year)
Recommendations to increase physical activity in communities (Task Force on
Community Preventive Services, 2002)
Public health strategies for preventing and controlling overweight and obesity
in school and worksite settings: A report on recommendations of the Task
Force on Community Preventive Services (Katz et al., 2005)
The Keystone Forum on away-from home foods: Opportunities for preventing
weight gain and obesity (Keystone Forum, 2006)
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2. Maintain calorie balance over time to achieve and sustain a healthy weight.b
• Increase physical activity and reduce sedentary behavior, improve physical
activity and eating behaviors, control total calorie intake, and maintain
appropriate calorie balance during each stage of life.
3. Focus on consuming nutrient-dense foods and beveragesb
• Establish a healthy eating pattern by reducing intake of sodium and calo-
ries from solid fats, added sugars, and refined grains and replacing them
with nutrient-dense foods and beverages, including fruits and vegetables,
whole grains, fat-free or low-fat milk or milk products, seafood, lean
meats and poultry, eggs, beans and peas, and nuts and seeds.
Individuals can visit http://www.ChooseMyPlate.gov and http://www.cdc.gov/
physicalactivity/everyone/guidelines for advice on how to follow these guidelines.
aPhysical Activity Guidelines for Americans (http://www.health.gov/paguidelines/).
bDietary Guidelines for Americans (http://www.health.gov/dietaryguidelines/).
Expert committee recommendations on the assessment, prevention and treat-
ment of child and adolescent overweight and obesity (Childhood Obesity
Action Network, 2007)
Recommendations for prevention of childhood obesity (Davis et al., 2007)
Promising strategies for creating healthy eating and active living environments
(Lee et al., 2008a)
Strategies for enhancing the built environment to support healthy eating and
active living environments (Lee et al., 2008b)
Physical Activity Guidelines for Americans (HHS, 2008)
423
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Recommended community strategies and measurements to prevent obesity in
the United States (Khan et al., 2009)
Action strategies toolkit: A guide for local and state leaders working to create
healthy communities and prevent childhood obesity (RWJF, 2009)
Shaping a healthier generation: Successful state strategies to prevent childhood
obesity (Mulheron and Vonasek, 2009)
Legislative task force on diabetes and obesity: Report to the California legisla-
ture (Greenwood et al., 2009)
F as in fat: How obesity threatens America’s future (Trust for America’s
Health, 2010)
Solving the problem of childhood obesity within a generation: White House
Task Force on Childhood Obesity report to the President (White House
Task Force on Childhood Obesity, 2010)
National physical activity plan for the United States (National Physical Activity
Plan, 2010)
Statement of policy, comprehensive obesity prevention (NACCHO, 2010)
The Surgeon General’s vision for a healthy and fit nation (HHS, 2010)
School-based obesity prevention strategies for state policymakers (CDC, date
unknown)
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