C

The Committee’s Recommendations, Strategies, and Action Steps

The Committee on Accelerating Progress in Obesity Prevention offers the following recommendations and strategies and action steps for implementation (see Chapters 5 through 9 for individual research evidence and support). Each recommendation, strategy, and action step has positive acceleration potential, but the committee is recommending that the simultaneous implementation of these recommendations by key stakeholders and sectors will create combined impacts (or “synergies”) that can further accelerate progress in preventing obesity.

GOAL 1: Make physical activity an integral and routine part of life.

RECOMMENDATION 1

Communities, transportation officials, community planners, health professionals, and governments should make promotion of physical activity a priority by substantially increasing access to places and opportunities for such activity.

Strategy 1-1: Enhance the Physical and Built Environment

Communities, organizations, community planners, and public health professionals should encourage physical activity by enhancing the physical and built environment, rethinking community design, and ensuring access to places for such activity.



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C The Committee’s Recommendations, Strategies, and Action Steps T he Committee on Accelerating Progress in Obesity Prevention offers the following recommendations and strategies and action steps for implementa- tion (see Chapters 5 through 9 for individual research evidence and support). Each recommendation, strategy, and action step has positive acceleration potential, but the committee is recommending that the simultaneous implementation of these recommendations by key stakeholders and sectors will create combined impacts (or “synergies”) that can further accelerate progress in preventing obesity. GOAL 1: Make physical activity an integral and routine part of life. RECOMMENDATION 1 Communities, transportation officials, community planners, health professionals, and governments should make promotion of physical activity a priority by sub- stantially increasing access to places and opportunities for such activity. Strategy 1-1: Enhance the Physical and Built Environment Communities, organizations, community planners, and public health profes- sionals should encourage physical activity by enhancing the physical and built environment, rethinking community design, and ensuring access to places for such activity. 427

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Potential actions include • communities, urban planners, architects, developers, and public health pro- fessionals developing and implementing sustainable strategies for improving the physical environment of communities that are as large as several square miles or more or as small as a few blocks in size in ways that encourage and support physical activity; and • communities and organizations developing and maintaining sustainable strategies to create and/or enhance access to places and programs where people can be physically active in a safe and enjoyable way. Strategy 1-2: Provide and Support Community Programs Designed to Increase Physical Activity Communities and organizations should encourage physical activity by provid- ing and supporting programs designed to increase such activity Potential actions include • developing and implementing ongoing physical activity promotion cam- paigns that involve high-visibility, multiple delivery channels and multiple sectors of influence; • developing and implementing physical activity strategies that fit into people’s daily routines—strategies that are most effective when tailored to specific interests and preferences; and • developing and implementing strategies that build, strengthen, and maintain social networks to provide supportive relationships for behavior change with respect to physical activity. Strategy 1-3: Adopt Physical Activity Requirements for Licensed Child Care Providers State and local child care and early childhood education regulators should establish requirements for each program to improve its current physical activity standards. Accelerating Progress in Obesity Prevention 428

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Potential actions include • requiring each licensed child care site to provide opportunities for physi- cal activity, including free play, and outdoor play, at a rate of 15 minutes per hour of care; as a minimum, immediate first step, each site providing at least 30 minutes of physical activity per day for half-day programs, and 1 hour for full-day programs. Strategy 1-4: Provide Support for the Science and Practice of Physical Activity Federal, state, and local government agencies should make physical activity a national health priority through support for the translation of scientific evidence into best-practice applications. For federal-level government agencies, potential actions include • the Department of Health and Human Services (HHS) establishing pro- cesses for the regular and routine communication of scientific advances in understanding the health benefits of physical activity, particularly with respect to obesity prevention (these processes could include, but are not limited to, regularly scheduled updates of the Physical Activity Guidelines for Americans and reports of the U.S. Surgeon General); and • all federal government agencies with relevant interests developing priority strategies to promote and support the National Physical Activity Plan, a trans-sector strategy for increasing physical activity among Americans. For state and local health departments, potential actions include • developing plans and strategies for making promotion of physical activity a health priority at the state and local levels. 429 Appendix C

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GOAL 2: Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice. RECOMMENDATION 212 Governments and decision makers in the business community/private sector1 should make a concerted effort to reduce unhealthy food and beverage options2 and substantially increase healthier food and beverage options at affordable, competitive prices. Strategy 2-1: Adopt Policies and Implement Practices to Reduce Overconsumption of Sugar-Sweetened Beverages Decision makers in the business community/private sector, in nongovernmental organizations, and at all levels of government should adopt comprehensive strate- gies to reduce overconsumption of sugar-sweetened beverages.3 For schools and other locations where children and adolescents are cared for, potential actions include • prohibiting access to sugar-sweetened beverages; • providing a variety of beverage options that are competitively priced and are recommended by and included in the Dietary Guidelines for Americans; and • making clean, potable water available. For the business community/private sector, nongovernmental organizations, and governments, potential actions include 1 The business community/private sector includes private employers and privately owned and/or operated locations frequented by the public, such as movie theaters, shopping centers, sporting and entertainment venues, bowling alleys, and other recreational/entertainment facilities. 2 Although there is no consensus on the definition of “unhealthy” foods/beverages, the term refers in this report to foods and beverages that are calorie-dense and low in naturally occurring nutrients. Such foods and beverages contribute little fiber and few essential nutrients and phytochemicals, but contain added fats, sweeteners, sodium, and other ingredients. Unhealthy foods and beverages displace the consumption of foods recommended in the Dietary Guidelines for Americans and may lead to the development of obesity. 3 Sugar-sweetened beverages are defined to include all beverages containing added caloric sweeteners, including, but not limited to, sugar- or otherwise calorically sweetened regular sodas, less than 100 percent fruit drinks, energy drinks, sports drinks, and ready-to-drink teas and coffees. Accelerating Progress in Obesity Prevention 430

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• making clean, potable water readily available in public places, worksites, and recreation areas; • making a variety of beverage options that are competitively priced readily available in public places, worksites, and recreation areas; • implementing fiscal policies aimed at reducing overconsumption of sugar- sweetened beverages through (1) pricing and other incentives to make healthier beverage options recommended by the Dietary Guidelines for Americans more affordable and, for governments, (2) substantial and spe- cific excise taxes on sugar-sweetened beverages (e.g., cents per ounce of liq- uid, cents per teaspoon of added sugar), with the revenues being dedicated to obesity prevention programs; • supporting the work of community groups and coalitions to educate the public about the risks associated with overconsumption of sugar-sweetened beverages; and • developing social marketing campaigns aimed at reducing overconsumption of sugar-sweetened beverages. For the food and beverage industry, potential actions include • developing and promoting a variety of beverage options for consumers, including a range of healthy beverage options, beverages with reduced sugar content, and smaller portion sizes (e.g., 8-ounce containers). For health care providers such as physicians, dentists, registered dietitians, and nurses, potential actions include • performing routine screening regarding overconsumption of sugar-sweet- ened beverages and counseling on the health risks associated with consump- tion of these beverages. Strategy 2-2: Increase the Availability of Lower-Calorie and Healthier Food and Beverage Options for Children in Restaurants Chain and quick-service restaurants should substantially reduce the number of calories served to children and substantially expand the number of affordable and competitively priced healthier options available for parents to choose from in their facilities. 431 Appendix C

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Potential actions include • developing a joint effort (modeled after the Healthy Weight Commitment initiative) to set a specific goal for substantially reducing the total annual calories served to children in these facilities; and • ensuring that at least half of all children’s meals are consistent with the food and calorie guidelines of the Dietary Guidelines for Americans for moderately active 4- to 8-year-olds and are competitively priced. Strategy 2-3: Utilize Strong Nutritional Standards for all Foods and Beverages Sold or Provided Through the Government, and Ensure That These Healthy Options Are Available in All Places Frequented by the Public Government agencies (federal, state, local, and school district) should ensure that all foods and beverages sold or provided through the government are aligned with the age-specific recommendations in the Dietary Guidelines for Americans. The business community and the private sector operating venues frequented by the public should ensure that a variety of foods and beverages, including those recom- mended by the Dietary Guidelines for Americans, are sold or served at all times. For government agencies, potential actions include • the federal government expanding the healthy vending/concession guidelines to include all government-owned and/or -operated buildings, worksites, facilities,4 and other locations where foods and beverages are sold/served; and • all state and local government-owned and -operated buildings, worksites, facilities, and other locations where foods and beverages are sold/served (including through vending machines and concession stands) adopting and implementing a healthy food and beverage vending/concession policy. 4 “Government-owned and -operated buildings, worksites, and facilities” is defined broadly to include not only places of work but also locations such as government-owned and/or -operated child care centers, hos- pitals, and other health care/assisted living facilities, military bases, correctional facilities, and educational institutions. Accelerating Progress in Obesity Prevention 432

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For the business community/private sector, potential actions include • the business community and private-sector entities that operate places fre- quented by the public ensuring that a variety of food and beverage options are competitively priced and available for purchase and consumption in these places,5 including food and beverages that are aligned with the recom- mendations of the Dietary Guidelines for Americans. Strategy 2-4: Introduce, Modify, and Utilize Health-Promoting Food and Beverage Retailing and Distribution Policies States and localities should utilize financial incentives such as flexible financ- ing or tax credits, streamlined permitting processes, and zoning strategies, as well as cross-sectoral collaborations (e.g., among industry, philanthropic orga- nizations, government, and the community) to enhance the quality of local food environments, particularly in low-income communities. These efforts should include encouraging or attracting retailers and distributors of healthy food (e.g., supermarkets) to locate in underserved areas and limiting the concentration of unhealthy food venues (e.g., fast-food restaurants, convenience stores). Incentives should be linked to public health goals in ways that give priority to stores that also commit to health-promoting retail strategies (e.g., through placement, promo- tion, and pricing). Potential actions include • states creating cross-agency teams to analyze and streamline regulatory pro- cesses and create tax incentives for retailing of healthy foods in underserved neighborhoods; • states and localities creating cross-sectoral collaborations among the food and beverage industry, philanthropy, the finance and banking sector, the real estate sector, and the community to develop private funding to facilitate the development of healthy food retailing in underserved areas; and • localities utilizing incentive tools to attract retailing of healthy foods (e.g., supermarkets and grocery stores) to underserved neighborhoods, such as through flexible financing or tax credits, streamlined permitting processes, 5 “Places frequented by the public” includes, but is not limited to, privately owned and/or operated loca- tions frequented by the public such as movie theaters, shopping centers, sporting and entertainment venues, bowling alleys, and other recreational/entertainment facilities. 433 Appendix C

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zoning strategies, grant and loan programs, small business/economic devel- opment programs, and other economic incentives. Strategy 2-5: Broaden the Examination and Development of U.S. Agriculture Policy and Research to Include Implications for the American Diet Congress, the Administration, and federal agencies should examine the impli- cations of U.S. agriculture policy for obesity, and should ensure that such policy includes understanding and implementing, as appropriate, an optimal mix of crops and farming methods for meeting the Dietary Guidelines for Americans. Potential actions include • the President appointing a Task Force on Agriculture Policy and Obesity Prevention to evaluate the evidence on the relationship between agriculture policies and the American diet, and to develop recommendations for policy options and future policy-related research, specifically on the impact of farm subsidies and the management of commodities on food prices, access, affordability, and consumption; • Congress and the Administration establishing a process by which federal food, agriculture, and health officials would review and report on the pos- sible implications of U.S. agriculture policy for obesity prevention to ensure that this issue will be fully taken into account when policy makers consider the Farm Bill; • Congress and the U.S. Department of Agriculture (USDA) developing policy options for promoting increased domestic production of foods recommend- ed for a healthy diet that are generally underconsumed, including fruits and vegetables and dairy products, by reviewing incentives and disincentives that exist in current policy; • as part of its agricultural research agenda, USDA exploring the optimal mix of crops and farming methods for meeting the current Dietary Guidelines for Americans, including an examination of the possible impact of smaller- scale agriculture, of regional agricultural product distribution chains, and of various agricultural models from small to large scale, as well as other efforts to ensure a sustainable, sufficient, and affordable supply of fresh fruits and vegetables; and Accelerating Progress in Obesity Prevention 434

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• Congress and the Administration ensuring that there is adequate public funding for agricultural research and extension so that the research agenda can include a greater focus on supporting the production of foods Americans need to consume in greater quantities according to the Dietary Guidelines for Americans. GOAL 3: Transform messages about physical activity and nutrition. RECOMMENDATION 3 Industry, educators, and governments should act quickly, aggressively, and in a sustained manner on many levels to transform the environment that surrounds Americans with messages about physical activity, food, and nutrition. Strategy 3-1: Develop and Support a Sustained, Targeted Physical Activity and Nutrition Social Marketing Program Congress, the Administration, other federal policy makers, and founda- tions should dedicate substantial funding and support to the development and implementation of a robust and sustained social marketing program on physical activity and nutrition. This program should encompass carefully targeted, cultur- ally appropriate messages aimed at specific audiences (e.g., tweens, new parents, mothers); clear behavior-change goals (e.g., take a daily walk, reduce consumption of sugar-sweetened beverages among adolescents, introduce infants to vegetables, make use of the new front-of-package nutrition labels); and related environmental change goals (e.g., improve physical environments, offer better food choices in public places, increase the availability of healthy food retailing). For Congress, the Administration, and other federal policy makers, working with entertainment media, potential actions include • providing a sustained source of funding for a major national social market- ing program on physical activity and nutrition; and • designating a lead agency to guide and oversee the federal program and appointing a small advisory group of physical activity, nutrition, and marketing experts to recommend message and audience priorities for the program; ensuring that the program includes a balance of messages on 435 Appendix C

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physical activity and nutrition, and on both individual behavior change and related environmental change goals; and exploring all forms of market- ing, including message placement in popular entertainment, viral and social marketing, and multiplatform advertising—including online, outdoor, radio, television, and print. For foundations, working with state, local, and national organizations and the news media, potential actions include • enhancing the social marketing program by encouraging and supporting the news media’s coverage of obesity prevention policies through the develop- ment of local and national media programs that engage individuals in the civic debate about local, state, and national-level environmental and policy changes, including such steps as providing resources to enable journalists to cover these issues and enhancing the expertise of local, state, and national organizations in engaging the news media on these issues. Strategy 3-2: Implement Common Standards for Marketing Foods and Beverages to Children and Adolescents The food, beverage, restaurant, and media industries should take broad, com- mon, and urgent voluntary action to make substantial improvements in their marketing aimed directly at children and adolescents aged 2-17. All foods and beverages marketed to this age group should support a diet that accords with the Dietary Guidelines for Americans in order to prevent obesity and risk factors asso- ciated with chronic disease risk. Children and adolescents should be encouraged to avoid calories from foods that they generally overconsume (e.g., products high in sugar, fat, and sodium) and to replace them with foods they generally undercon- sume (e.g., fruits, vegetables, and whole grains). The standards set for foods and beverages marketed to children and ado- lescents should be widely publicized and easily available to parents and other consumers. They should cover foods and beverages marketed to children and adolescents aged 2-17 and should apply to a broad range of marketing and adver- tising practices, including digital marketing and the use of licensed characters and toy premiums. If such marketing standards have not been adopted within 2 years by a substantial majority of food, beverage, restaurant, and media companies that market foods and beverages to children and adolescents, policy makers at the local, state, and federal levels should consider setting mandatory nutritional Accelerating Progress in Obesity Prevention 436

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standards for marketing to this age group to ensure that such standards are implemented. Potential actions include • all food and beverage companies, including chain and quick-service restau- rants, adopting and implementing voluntary nutrition standards for foods and beverages marketed to children and adolescents; • the Children’s Food and Beverage Advertising Initiative and National Restaurant Association Initiative, as major self-regulatory marketing efforts, adopting common marketing standards for all member companies, and actively recruiting additional members to increase the impact of improved food marketing to children and adolescents; • media companies adopting nutrition standards for all foods they market to young people; and • the Federal Trade Commission regularly tracking the marketing standards adopted by food and beverage companies, restaurants, and media companies. Strategy 3-3: Ensure Consistent Nutrition Labeling for the Front of Packages, Retail Store Shelves, and Menus and Menu Boards That Encourages Healthier Food Choices The Food and Drug Administration (FDA) and the USDA should implement a standard system of nutrition labeling for the front of packages and retail store shelves that is harmonious with the Nutrition Facts panel, and restaurants should provide calorie labeling on all menus and menu boards. Potential actions include • The FDA and USDA adopting a single standard nutrition labeling system for all fronts of packages and retail store shelves, the FDA and USDA con- sidering making this system mandatory to enable consumers to compare products on a standard nutrition profile, and the guidelines provided by the Institute of Medicine (2011) being used for implementation; and • restaurants implementing the FDA regulations that require restaurants with 20 or more locations to provide calorie labeling on their menus and menu boards, and the FDA/USDA monitoring industry for compliance with this policy. 437 Appendix C

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Strategy 3-4: Adopt Consistent Nutrition Education Policies for Federal Programs with Nutrition Education Components USDA should update the policies for Supplemental Nutrition Assistance Program Education (SNAP-Ed) and the policies for other federal programs with nutrition education components to explicitly encourage the provision of advice about types of foods to reduce in the diet, consistent with the Dietary Guidelines for Americans. Potential actions include • removing the restrictions on the types of information that can be included in SNAP-Ed programs and encouraging advice about types of foods to reduce; • disseminating, immediately and effectively, notification of the revised regu- lations, along with authoritative guidance on how to align federally funded nutrition education programs with the Dietary Guidelines; and • ensuring that such full alignment of nutrition education with the Dietary Guidelines applies to all federal programs with a nutrition education com- ponent, particularly programs that target primary food shoppers in low- income families (e.g., the Expanded Food and Nutrition Education Program and the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]). GOAL 4: Expand the role of health care providers, insurers, and employers in obesity prevention. RECOMMENDATION 4 Health care and health service providers, employers, and insurers should increase the support structure for achieving better population health and obesity prevention. Strategy 4-1: Provide Standardized Care and Advocate for Healthy Community Environments All health care providers should adopt standards of practice (evidence-based or consensus guidelines) for prevention, screening, diagnosis, and treatment of overweight and obesity to help children, adolescents, and adults achieve and Accelerating Progress in Obesity Prevention 438

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maintain a healthy weight, avoid obesity-related complications, and reduce the psychosocial consequences of obesity. Health care providers also should advocate, on behalf of their patients, for improved physical activity and diet opportunities in their patients’ communities. Potential actions include • health care providers’ standards of practice including routine screening of body mass index (BMI), counseling, and behavioral interventions for chil- dren, adolescents, and adults to improve physical activity behaviors and dietary choices; • medical schools, nursing schools, physician assistant schools, and other rel- evant health professional training programs (including continuing education programs), including instruction in prevention, screening, diagnosis, and treatment of overweight and obesity in children, adolescents, and adults; and • health care providers serving as role models for their patients and providing leadership for obesity prevention efforts in their communities by advocat- ing for institutional (e.g., child care, school, and worksite), community, and state-level strategies that can improve physical activity and nutrition resources for their patients and their communities. Strategy 4-2: Ensure Coverage of, Access to, and Incentives for Routine Obesity Prevention, Screening, Diagnosis, and Treatment Insurers (both public and private) should ensure that health insurance cover- age and access provisions address obesity prevention, screening, diagnosis, and treatment. Potential actions include • insurers, including self-insured organizations and employers, considering the inclusion of incentives in individual and family health plans for maintaining healthy lifestyles; • insurers considering (1) benefit designs and programs that promote obesity screening and prevention and (2) innovative approaches to reimbursing for routine screening and obesity prevention services (including preconception 439 Appendix C

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counseling) in clinical practice and for monitoring the performance of these services in relation to obesity prevention; and • insurers taking full advantage of obesity-related provisions in health care reform legislation. Strategy 4-3: Encourage Active Living and Healthy Eating at Work Worksites should create, or expand, healthy environments by establishing, implementing, and monitoring policy initiatives that support wellness. Potential actions include • public and private employers promoting healthy eating and active living in the worksite in their own institutional policies and practices by, for example, increasing opportunities for physical activity as part of a wellness/health promotion program, providing access to and promotion of healthful foods and beverages, and offering health benefits that provide employees and their dependents coverage for obesity-related services and programs; and • health care organizations and providers serving as models for the incorpora- tion of healthy eating and active living into worksite practices and programs. Strategy 4-4: Encourage Healthy Weight Gain During Pregnancy and Breastfeeding, and Promote Breastfeeding-Friendly Environments Health service providers and employers should adopt, implement, and monitor policies that support healthy weight gain during pregnancy and the initiation and continuation of breastfeeding. Population disparities in breastfeeding should be specifically addressed at the federal, state, and local levels to remove barriers and promote targeted increases in breastfeeding initiation and continuation. Potential actions include • all those who provide health care or related services to women of child- bearing age offering preconception counseling on the importance of con- ceiving at a healthy BMI; Accelerating Progress in Obesity Prevention 440

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• medical facilities, prenatal services, and community clinics adopting policies consistent with the Baby-Friendly Hospital Initiative; • local health departments and community-based organizations, working with other segments of the health sector, providing information on breastfeeding and the availability of related classes to pregnant women and new mothers, connecting pregnant women and new mothers with breastfeeding support programs to help them make informed infant feeding decisions, and devel- oping peer support programs that empower pregnant women and mothers to obtain the help and support they need from other mothers who have breastfed; • workplaces instituting policies to support breastfeeding mothers, including ensuring both private space and adequate break time; and • the federal government using Prevention Fund dollars to support implemen- tation of the Baby-Friendly Hospital Initiative nationwide, and providing funding to support community-level collaborative efforts and peer counsel- ing with the aim of increasing the duration of breastfeeding. GOAL 5: Make schools a national focal point for obesity prevention. RECOMMENDATION 5 Federal, state, and local government and education authorities, with support from parents, teachers, and the business community and the private sector, should make schools a focal point for obesity prevention. Strategy 5-1: Require Quality Physical Education and Opportunities for Physical Activity in Schools Through support from federal and state governments, state and local educa- tion agencies and local school districts should ensure that all students in grades K-12 have adequate opportunities to engage in 60 minutes of physical activity per school day. This 60-minute goal includes access to and participation in quality physical education. 441 Appendix C

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For Congress, potential actions include • strengthening the local wellness policy requirement in Section 204 of the Healthy, Hunger-Free Kids Act of 2010 (Public Law 111-296, 111th Cong., 2d sess. [December 13, 2010], 124, 3183) or the Elementary and Secondary Education Act (Public Law 89-19, 89th Cong., 1st sess. [April 11, 1965] 27, 20) by including a requirement for local education agencies to develop and implement a K-12 quality physical education curriculum with profi- ciency assessments. For state legislatures and departments of education, potential actions include • enacting policies with appropriate funding to ensure the provision of daily quality physical education at school for all students in grades K-12; and • developing, requiring, and financially supporting the implementation of K-12 curriculum standards for quality physical education that (1) are aligned with guidance from practice and/or professional associations and appropriate instructional practice guidelines, and (2) ensure that at least 50 percent of class time is spent in vigorous or moderate-intensity physical activity. For local education agencies, potential actions include • adopting requirements that include opportunities for daily physical activity outside of physical education, such as active transport to school programs, intramural sports and activity programs, active recess, classroom breaks, after-school physical activity programming, and integration of physical activity into curricula lesson plans. For local school districts, potential actions include • improving and maintaining an environment that is conducive to safe physi- cal education and physical activity. Accelerating Progress in Obesity Prevention 442

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Strategy 5-2: Ensure Strong Nutritional Standards for All Foods and Beverages Sold or Provided Through Schools All government agencies (federal, state, local, and school district) providing foods and beverages to children and adolescents have a responsibility to provide those in their care with foods and beverages that promote health and learning. The Dietary Guidelines for Americans provide specific science-based recom- mendations for optimizing dietary intake to prevent disease and promote health. Implementation of these guidelines would shift children’s and adolescents’ dietary intake to prevent obesity and risk factors associated with chronic disease risk by increasing the amounts of fruits, vegetables, and high-fiber grains they consume; decreasing their consumption of sugar-sweetened beverages, dietary fat in gen- eral, solid fats, and added sugars; and ensuring age-appropriate portion sizes of meals and other foods and beverages. Federal, state, and local decision makers are responsible for ensuring that nutrition standards based on the Dietary Guidelines are adopted by schools; these decision makers, in partnership with regulatory agencies, parents, teachers, and food manufacturers, also are responsible for ensuring that these standards are implemented fully and that adherence is moni- tored so as to protect the health of the nation’s children and adolescents. For the USDA, potential actions include • adopting nutrition standards for all federal child nutrition programs (i.e., the School Breakfast, National School Lunch, Afterschool Snack, Summer Food Service, and Special Milk programs) that are aligned with guidance on optimal nutrition; and • adopting nutrition standards for all snacks and beverages sold/served out- side of federal child nutrition programs that are aligned with guidance on optimal nutrition. For state legislatures and departments of education, potential actions include • adopting nutrition standards for foods sold/served outside of federal child nutrition programs that are aligned with guidance on optimal nutrition. 443 Appendix C

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For school boards and state departments of education, potential actions include • developing school district policies (including wellness policies for districts participating in federal child nutrition programs) and related regulations that include nutrition standards for foods sold/served outside of the federal programs that are aligned with guidance on optimal nutrition. Strategy 5-3: Ensure Food Literacy, Including Skill Development, in Schools Through leadership and guidance from federal and state governments, state and local education agencies should ensure the implementation and monitoring of sequential food literacy and nutrition science education, spanning grades K-12, based on the food and nutrition recommendations in the Dietary Guidelines for Americans. For the federal government, potential actions include • USDA developing K-12 food and nutrition curriculum guides that can be used by states and updating information in these guides as appropriate with each periodic revision of the Dietary Guidelines for Americans; and • as USDA develops regulations to implement Section 204 of the Healthy, Hunger-Free Kids Act of 2010 (Public Law 111-296, December 13, 2010), including a requirement for local education agencies to adopt and imple- ment a K-12 food and nutrition curriculum based on state and federal guidance. For states, state legislatures, and departments of education, potential actions include • state legislatures and departments of education adopting, requiring, and financially supporting K-12 standards for food and nutrition curriculum based on USDA guidance; • state departments of education establishing requirements for training teachers in effectively incorporating nutrition education into their curricula; • states requiring teacher training programs to include curriculum require- ments for the study of nutrition; Accelerating Progress in Obesity Prevention 444

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• state legislatures and departments of education adopting and requiring proficiency assessments for core elements of their state food and nutrition curriculum standards in accordance with the Common Core State Standards Initiative, and local education agency wellness policies articulating ways in which results of food and nutrition education proficiency assessments can be used to inform program improvement; and • state and local departments of education, working with local education agency wellness policies, to link changes in the meals provided through child nutrition services with the food literacy and nutrition education cur- riculum to the extent possible. REFERENCE IOM (Institute of Medicine). 2011. Examination of front-of-package nutrition rating systems and symbols: Promoting healthier choices. Washington, DC: The National Academies Press. 445 Appendix C

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