M AY 2 0 10

White House Task Force on Childhood Obesity

Report to the President

SOLV ING THE PROBLEM 

OF CHILDHOOD OBESIT Y

W ITHIN A GENER ATION

Table of Contents

The Challenge We Face 3

I. Early Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

A. Prenatal Care 11

B. Breastfeeding 13

C. Chemical Exposures 17

D. Screen Time 18

E. Early Care and Education 19

II. Empowering Parents and Caregivers 23

A. Making Nutrition Information Useful 23

B. Food Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

C. Health Care Services 33

III. Healthy Food in Schools 37

A. Quality School Meals 37

B. Other Foods in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

C. Food-Related Factors in the School Environment 44

D. Food in Other Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . 46

IV. Access to Healthy, Affordable Food . . . . . . . . . . . . . . . . . . . . . . . . 49

A. Physical Access to Healthy Food 49

B. Food Pricing 55

C. Product Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

D. Hunger and Obesity 61
V. Increasing Physical Activity 65

A. School-Based Approaches 68

B. Expanded Day and Afterschool Activities . . . . . . . . . . . . . . . . . . . . 74

C. The “Built Environment” 78

D. Community Recreation Venues 82

Conclusion 87

Summary of Recommendations 89

Endnotes 99
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Letter to the President

Dear Mr. President,

I am pleased to present you with the White House Task Force on Childhood Obesity’s action plan for 

solving the problem of childhood obesity in a generation.

Parents across America are deeply concerned about their children’s health and the epidemic of childhood 

obesity.  One out of every three children is now overweight or obese, a condition that places them at 

greater risk of developing diabetes, heart disease, and cancer over the course of their lives.  This is not 

the future we want for our children, and it is a burden our health care system cannot bear.  Nearly $150 

billion per year is now being spent to treat obesity-related medical conditions.

Fortunately, there are clear, concrete steps we can take as a society to help our children reach adulthood at a healthy weight.  As you requested in the Memorandum you signed on February 9, our new 

interagency Task Force on Childhood Obesity has spent the past 90 days carefully reviewing the research, 

and consulting experts as well as the broader public, to produce a set of recommended actions that, 

taken together, will put our country on track to solving the problem of childhood obesity.  

We heard from a broad array of Americans, and received more than 2,500 public comments with specific 

and creative suggestions.  Twelve Federal agencies participated actively in the Task Force, and provided 

their ideas and expertise. They include the Departments of Agriculture, Defense, Education, Health and 

Human Services, Housing and Urban Development, Interior, Justice, and Transportation, as well as the 

Corporation for National and Community Service, the Environmental Protection Agency, the Federal 

Communications Commission, and the Federal Trade Commission.

Our recommendations focus on the four priority areas set forth in the Memorandum, which also form 

the pillars of the First Lady’s Let’s Move! campaign: (1) empowering parents and caregivers; (2) providing 

healthy food in schools; (3) improving access to healthy, affordable foods; and (4) increasing physical 

activity.  In addition, we have included a set of recommendations for actions that can be taken very early 

in a child’s life, when the risk of obesity first emerges.  

We cannot succeed in this effort alone.  Our recommendations are not simply for Federal action, but 

also for how the private sector, state and local leaders, and parents themselves can help improve the 

health of our children.  The Task Force will move quickly to develop a strategy for implementing this 

plan, working in partnership with the First Lady to engage stakeholders across society. Indeed, many 

Americans — including leaders in the public and private sectors — have already volunteered to join 

this effort, and are ready and waiting to put this plan in action.

Sincerely,

Melody Barnes

Chair, Task Force on Childhood Obesity, and Director, Domestic Policy Council

★ 3 ★

The Challenge We Face

The childhood obesity epidemic in America is a national health crisis. One in every three children 

(31.7%) ages 2-19 is overweight or obese.

1

 The life-threatening consequences of this epidemic create 

a compelling and critical call for action that cannot be ignored. Obesity is estimated to cause 112,000 

deaths per year in the United States,2 and one third of all children born in the year 2000 are expected to 

develop diabetes during their lifetime.

3

 The current generation may even be on track to have a shorter 

lifespan than their parents.

4

Along with the effects on our children’s health, childhood obesity imposes substantial economic costs.

Each year, obese adults incur an estimated $1,429 more in medical expenses than their normal-weight 

peers.

5

 Overall, medical spending on adults that was attributed to obesity topped approximately $40 

billion in 1998, and by 2008, increased to an estimated $147 billion.

6

 Excess weight is also costly during 

childhood, estimated at $3 billion per year in direct medical costs.

7

Childhood obesity also creates potential implications for military readiness. More than one quarter of all 

Americans ages 17-24 are unqualified for military service because they are too heavy.

8

 As one military 

leader noted recently, “We have an obesity crisis in the country. There’s no question about it. These are 

the same young people we depend on to serve in times of need and ultimately protect this nation.” 9

While these statistics are striking, there is much reason to be hopeful. There is considerable knowledge 

about the risk factors associated with childhood obesity. Research and scientific information on the 

causes and consequences of childhood obesity form the platform on which to build our national policies and partner with the private sector to end the childhood obesity epidemic. Effective policies and 

tools to guide healthy eating and active living are within our grasp. This report will focus and expand 

on what we can do together to:

1.	 create a healthy start on life for our children, from pregnancy through early childhood;

2.	 empower parents and caregivers to make healthy choices for their families;

3.	 serve healthier food in schools;

4.	 ensure access to healthy, affordable food; and

5.	 increase opportunities for physical activity.

Whatis Obesity?

Obesity is defined as excess body fat. Because body fat is difficult to measure directly, obesity is often 

measured by body mass index (BMI), a common scientific way to screen for whether a person is underweight, normal weight, overweight, or obese. BMI adjusts weight for height,10 and while it is not a perfect 

indicator of obesity,11 it is a valuable tool for public health. 

Adults with a BMI between 25.0 and 29.9 are considered overweight, those with a BMI of 30 or more are 

considered obese, and those with a BMI of 40 or more are considered extremely obese.

12 For children and 

adolescents, these BMI categories are further divided by sex and age because of the changes that occur 
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during growth and development. Growth charts from the Centers for Disease Control and Prevention 

(CDC) areused to calculate children’s BMI. Children and adolescents with a BMI between the 85th and 

94th percentiles are generally considered overweight, and those with a BMI at or above the sex-and 

age-specific 95th percentile of population on this growth chart are typically considered obese.

Determining what is a healthy weight for children is challenging, even with precise measures. BMI 

is often used as a screening tool, since a BMI in the overweight or obese range often, but not always, 

indicates that a child is at increased risk for health problems. A clinical assessment and other indicators 

must also be considered when evaluating a child’s overall health and development.

13

WhoDoes Obesity Impact? Prevalence andTrends

By gaining a deeper understanding of individuals who are impacted by obesity, we can better shape 

policies to combat it. Since 1980, obesity has become dramatically more common among Americans of 

all ages. Prevalence estimates of obesity in the U.S. are derived from the National Health and Nutrition 

Examination Survey (NHANES), conducted by the National Center for Health Statistics of the CDC.

Between the survey periods 1976–80 and 2007–08, obesity has more than doubled among adults (rising 

from 15% to 34%), and more than tripled among children and adolescents (rising from 5% to 17%).

14

The rapid increase in childhood obesity in the 1980s and 1990s has slowed, with no significant increase 

in recent years.

15 However, among boys ages 6–19, very high BMI (at or above the 97th percentile) 

became more common between 1999–2000 and 2007–08; about 15% of boys in this age group are in 

this category.

16 

Growth in Childhood Obesity, 1971 to Present

Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Surveys.

Note: Obesity is dened as BMI ≥ gender- and weight-specic 95th percentile from the 2000 CDC Growth Charts

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

1972 1976 1980 1984 1988 1992 1996 2000 2004 2008

Percent of children aged 2-19 who are obese
The Challenge We Face

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Race/Ethnic Disparities

Childhood obesity is more common among certain racial and ethnic groups than others. Obesity rates 

are highest among non-Hispanic black girls and Hispanic boys. Obesity is particularly common among 

American Indian/Native Alaskan children. A study of four year-olds found that obesity was more than 

two times more common among American Indian/Native Alaskan children (31%) than among white 

(16%) or Asian (13%) children. This rate was higher than any other racial or ethnic group studied.

17

Socioeconomic Disparities

Among adults, obesity rates are sometimes associated with lower incomes, particularly among women.

Women with higher incomes tend to have lower BMI, and the opposite is true, those with higher BMI 

have lower incomes.

18 A study in the early 2000s found that about 38% of non-Hispanic white women 

who qualified for the Supplemental Nutrition Assistance Program (known then as food stamps), were 

obese, and about 26% of those above 350% of the poverty line were obese.

19 Also, a recent study of 

American adults found lower rates of obesity among individuals with more education. Specifically, the 

study found that nearly 35% of adults with less than a high school degree were obese, compared to 

21% of those with a bachelor’s degree or higher.

20

The relationship between income and obesity in children is less consistent than among adult 

women,21and sometimes even points in the opposite direction. Another study from the early 2000s 

found that only among white girls were higher incomes associated with lower BMI. Among AfricanAmerican girls, the prevalence of obesity actually increased with higher socioeconomic status, suggesting that efforts to reduce ethnic disparities in obesity must target factors other than income and 

education, such as environmental, social, and cultural factors.

22

Childhood Obesity Rates by Race, Ethnicity, and Gender, 2007-08

Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Survey; 

Note: Obesity is dened as BMI ≥ gender- and weight-specic 95th percentile from the 2000 CDC Growth Charts

0%

5%

10%

15%

20%

25%

30%

Percent of children aged 12-19 who are obese

BOYS

GIRLS

BOYS

GIRLS

BOYS

GIRLS

Non-Hispanic White Non-Hispanic Black Hispanics

16.7%

14.5%

19.8%

29.2%

25.5%

17.5%
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Regional Disparities

Across the country, the prevalence of obesity has been found to be highest in southeast states such as 

Alabama, Mississippi, South Carolina, Tennessee, and West Virginia, as well as in Oklahoma. It is lowest 

in Colorado.

23 Another study showed obesity was most common among adults in the Midwest and the 

South, as well as among adults who did not live in metropolitan areas.

24

How Does Obesity Impact OurHealth?

Obese adults have an increased risk for many diseases, including type 2 diabetes, heart disease, some 

forms of arthritis, and several cancers.

25 Overweight and obese children are more likely to become 

obese adults.

26 Specifically, one study found that obese 6-8 year-olds were approximately ten times 

more likely to become obese adults than those with lower BMIs.

27 The association may be stronger for 

obese adolescents than younger children.

28 Obese children are also more likely to have increased risk 

of heart disease.

 29 One study found that approximately 70% of obese children had high levels (greater 

than 90th percentile) of at least one key risk factor for heart disease, and approximately 30% had high 

levels of at least two risk factors.

30 There is evidence that heart disease develops in early childhood and 

is exacerbated by obesity,31 and people as young as 21 have been found to display early physical signs 

of heart disease due to obesity.

32 Obese children are also more likely to develop asthma.33

Obesity is the most significant risk factor for type 2 diabetes, a disease once called “adult onset diabetes” 

because it occurred almost exclusively in adults until childhood obesity started to rise substantially. The 

number of hospitalizations for type 2 diabetes among Americans in their 20s has gone up substantially, 

for example.

34 A 2001 study found that more than 75% of children ages 10 and over with type 2 diabetes 

were obese.

35 Type 2 diabetes occurs more frequently among some racial and ethnic minority groups, 

and rates among American Indians are particularly high.

36

In addition to the physical health consequences, severely obese children report a lower health-related 

quality of life (a measure of their physical, emotional, educational, and social well-being). In fact, one 

study found that they have a similar quality of life as children diagnosed with cancer.

37 Childhood 

obesity is a highly stigmatized condition, often associated with low self-esteem, and obese children 

are more likely than non-obese children to feel sad, lonely, and nervous.

38 Obesity during childhood is 

also associated with some psychiatric disorders, including depression and binge-eating disorder, which 

may both contribute to and be adversely impacted by obesity.

39

What Causes Obesity?

Early Life

A child’s risk of becoming obese may even begin before birth. Pregnant women who use tobacco, gain 

excessive weight, or have diabetes give birth to children who have an increased risk of being obese during their preschool years.

40 Furthermore, although the evidence is not conclusive,41 rapid weight gain 

in early infancy has been shown to predict obesity later in life.

42 Racial and ethnic differences in obesity 

may also be partly explained by differences in risk factors during the prenatal period and early life.

43 
The Challenge We Face

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Studies show that early influences can affect obesity rates. The increased occurrence of obesity among 

children of obese parents suggests a genetic component.

44 Multiple twin and adoption studies also 

indicate a strong genetic component to obesity.

45 However, genes associated with obesity were present 

in the population prior to the current epidemic; genes only account for susceptibility to obesity and 

generally contribute to obesity only when other influences are at work. Genetic susceptibility to obesity 

is significantly shaped by the environment.

46 In addition to genetic factors, recent research has focused 

on other factors, such as maternal nutrition, environmental toxins, and the prenatal environment, which 

may shape later risk for childhood obesity.

Environmental Factors During Childhood

There have been major changes in Americans’ lifestyles over the last 30 years, as childhood obesity rates 

have been rising. This includes what and where we eat. Given the pace of modern life, Americans now 

consume more fast-food and sugar-sweetened beverages, eat outside the home more frequently,47 and 

spend less time enjoying family meals. In addition, prepared and processed food is easily accessible 

and inexpensive. These items are also heavily promoted, as evidenced in a Federal Trade Commission 

(FTC) report revealing that at least $1.6 billion is spent annually on food advertising directed to children 

and adolescents.

48 All this adds up to poor eating habits. For example, 13% of the daily caloric intake 

for 12-19 year-olds now comes from sugar-sweetened beverages.

49

At the same time, adults and children alike are getting less physical activity. Some schools have cut 

back on activities like physical education and recess, in part due to budget pressures at the state and 

local level. And children are increasingly driven to school by car or bus, rather than walking or biking.

50

In part, these shifts in transportation reflect changes in community design. Physical activity is higher 

in more “connected” communities that provide safe and reliable access to public transportation, as well 

as other forms of active transport like biking and walking.

51

Meanwhile, “screen time” has increased, including television viewing, which is directly associated with 

childhood and adult obesity.

52 Among children, watching television or time spent on computers or 

gaming systems takes away from engaging in physical activity like organized sports or informal playing.

It also has a more harmful effect on healthy eating habits; as children watch television, they are more 

likely to snack, including on the foods advertised.

53 In addition, screen time has been associated with 

children getting less and poorer quality sleep,54 and insufficient sleep has been linked to a heightened 

risk of obesity.

55

What CanWeDo?

While additional studies to identify the precise causes of obesity will be useful, we do not need to wait 

to identify specific actions that we can take as a society to prevent obesity. There are many examples 

of effective therapies for diseases whose cause has not been fully identified. For example, remission 

rates of acute lymphocytic leukemia in children have been dramatically improved over the last 20 years, 

although the causes of the disease remain uncertain. 

No single action alone will reverse the childhood obesity epidemic, although there is no question that 

improving eating habits and increasing physical activity are two critical strategies. As with tobacco 

prevention and control, comprehensive, multi-sectoral approaches are needed to address the many 
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behavioral risk factors associated with obesity.

56 These risk factors fall into three general categories: (1) 

material incentives, such as the cost of food or the desire to avoid poor health; (2) social norms, such as 

the nutritional and physical activity habits of friends and family, which influence us greatly; and (3) the 

broader environment, such as whether grocery stores and playgrounds are nearby or far away. Changes 

in each of these risk factors are possible. For example, with sound information, parents and caregivers 

will be able to seek out the most nutritious foods to improve their children’s health; changes in social 

norms can be brought about through movements such as the successful seatbelt buckling campaigns 

of the late 20th century; and changes can be made in the broader environment by eliminating “food 

deserts” or “playground deserts.”

In many parts of the country, we already have a head start, and initiatives that are already underway will 

provide instructive lessons. Comprehensive, community-wide efforts to reduce obesity have recently 

been initiated by both the public and private sectors. The American Recovery and Reinvestment Act of 

2009 included $1 billion in funding for prevention and wellness investments, more than half of which 

was directed to prevention strategies to reduce tobacco use and obesity rates. Specifically, $373 million supported direct community-based interventions and $120 million supported state-based efforts 

in all 50 states and 25 communities in urban, rural, and tribal areas. Funds to support comprehensive 

strategies were awarded to states in February and to communities in March. The recently-enacted 

Patient Protection and Affordable Care Act, as amended by the Health Care and Education Affordability 

Reconciliation Act (collectively referred to as the “Affordable Care Act”) provides for additional investments in chronic disease and improving public health, which could include community-based prevention strategies. In addition, the philanthropic sector has been leading the way with stepped-up, focused 

investments. For example, the Robert Wood Johnson Foundation has created a “Healthy Kids, Healthy 

Communities” initiative that is funding 50 communities to implement strategies to prevent childhood 

obesity,57 and the California Endowment recently launched a large-scale “Building Healthy Communities” 

project in 14 communities that will include a focus on childhood obesity prevention.

58

Reducing childhood obesity does not have to be a costly endeavor, however. And indeed, in many 

communities it simply cannot be. Times are tough, and federal, state, local, and family budgets are all 

feeling squeezed. But a great deal can be accomplished without significant expenditures, and some 

steps may ultimately save money.

59 While many of the recommendations in this report will require 

additional public resources, creative strategies can also be used to redirect resources or make more 

effective use of existing investments.

In total, this report presents a series of 70 specific recommendations, many of which can be implemented 

right away. Summarizing them broadly, they include:

• Getting children a healthy start on life, with good prenatal care for their parents; support for 

breastfeeding; adherence to limits on “screen time”; and quality child care settings with nutritious food and ample opportunity for young children to be physically active.

• Empowering parents and caregivers with simpler, more actionable messages about nutritional choices based on the latest Dietary Guidelines for Americans; improved labels on food 

and menus that provide clear information to help make healthy choices for children; reduced 

marketing of unhealthy products to children; and improved health care services, including BMI 

measurement for all children.
The Challenge We Face

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• Providing healthy food in schools, through improvements in federally-supported school 

lunches and breakfasts; upgrading the nutritional quality of other foods sold in schools; and 

improving nutrition education and the overall school environment.

• Improvingaccess tohealthy, affordable food, by eliminating “food deserts” in urban and rural 

America; lowering the relative prices of healthier foods; developing or reformulating food products to be healthier; and reducing the incidence of hunger, which has been linked to obesity.

• Gettingchildrenmorephysically active, through quality physical education, recess, and other 

opportunities in and after school; addressing aspects of the “built environment” that make it 

difficult for children to walk or bike safely in their communities; and improving access to safe 

parks, playgrounds, and indoor and outdoor recreational facilities.

Many of these recommendations are for activities to be undertaken by federal agencies. All such activities are subject to budgetary constraints, including the weighing of priorities and available resources 

by the Administration in formulating its annual budget and by Congress in legislating appropriations.

HowWillWe KnowWeHave Succeeded?

Our goal is to solve the problem of childhood obesity in a generation. Achieving that goal will mean 

returning to the expected levels in the population, before this epidemic began. That means returning to 

a childhood obesity rate of just 5% by 2030. Achieving this goal will require “bending the curve” fairly 

quickly, so that by 2015, there will be a 2.5% reduction in each of the current rates of overweight and 

obese children, and by 2020, a 5% reduction. Our progress can be charted through the CDC’s annual 

National Health and Nutrition Examination Survey (NHANES), which is aggregated every two years.

Bending the Curve: Childhood Obesity, 1972 to 2030

Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Surveys.

Note: Obesity is dened as BMI ≥ gender- and weight-specic 95th percentile from the 2000 CDC Growth Charts.

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

1972 1976 1980 1984 1988 1992 1996 2000 2004 2008

Percent of children aged 2-19 who are obese

2012 2016 2020 2024 2028

2007-08: 19.6%

2015: 17.1%

2020: 14.6%

2030: 5.0%
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In addition to monitoring the overall trends in childhood obesity, two key indicators will show the 

progress achieved:

1.	 The number of children eating a healthy diet, measured by those who follow the most 

recent, science-based Dietary Guidelines for Americans (Dietary Guidelines). We can monitor 

our progress through the U.S. Department of Agriculture’s (USDA) Healthy Eating Index (HEI), 

which reflects the intake of 12 dietary components: total fruit (including juice); whole fruit (not 

juice); total vegetables; dark green and orange vegetables and legumes; total grains; whole 

grains; milk products; meat and beans; oils; saturated fat; sodium; and calories from solid fats 

and added sugars. USDA generally regards a score of at least 80 out of 100 points as reflecting 

a healthy diet. Currently, the average child scores a 55.9 on the HEI.

60 To achieve a score of 80 

for the average child by 2030, the average child should score 65 by 2015, and 70 by 2020. Two 

indicators should be monitored particularly closely:

− Less added sugar in children’s diets. Children today consume a substantial amount 

of added sugars through a whole range of products. Using existing data sources, CDC’s 

National Center for Health Statistics can determine how much added sugar children are 

currently consuming. Targets for reducing added sugar will then need to be established 

that track the overall goal of driving obesity rates down to 5% by 2030.

− Morefruitsandvegetables.  Currently, children and adolescents consume far lower quantities of fruits and vegetables than recommended in the Dietary Guidelines. On average, children consumed only 64% of the recommended level of fruit and 46% of the recommended 

level of vegetables in 2003-04.  Average fruit consumption should increase to 75% of the 

recommended level by 2015, 85% by 2020, and 100% by 2030; vegetable consumption 

should increase to 60% of recommended levels by 2015, 75% by 2020, and 100% by 2030.

2.	 The number of children meeting current physical activity guidelines. Right now, the only 

regular survey that shows whether children are meeting the Physical Activity Guidelines is limited to high school students, and regular data on younger children is not available. Resources 

will have to be redirected to develop a survey instrument that can provide a full picture of 

physical activity levels among children of all ages. Once baseline data is available, targets for 

improving the level of physical activity among children will need to be established that track 

the overall goal of driving obesity rates down to 5% by 2030.

Additional benchmarks of success, tied to specific recommendations in this report, are included throughout. The Healthy People goals set every decade by experts convened by the U.S. Department of Health 

and Human Services will provide additional, complementary opportunities to measure our progress in 

helping children achieve and maintain a healthy weight.

Monitoring our progress and the impact of our interventions, so that we know what is working and 

what strategies or tactics need to be adjusted, will be critically important. This is not an easy challenge, 

but it is one that we can solve as a society, and within a generation.
★ 11 ★

I. Early Childhood

Studies show that approximately one in five children are overweight or obese by the time they reach 

their 6th birthday,61 and over half of obese children become overweight at or before age two.

62 Even 

babies are affected. Between 1980 and 2001, the prevalence of overweight infants under six months 

almost doubled, from 3.4% to 5.9%.

63 More can and must be done to ensure our youngest children 

begin life on a healthy path. 

This chapter provides recommendations for reducing the risk of obesity in the early years of a child’s 

life by:

• strengthening prenatal care;

• promoting breastfeeding;

• evaluating the impact of chemical influences in the environment;

• reducing “screen time;” and

• improving the quality of our nation’s child care settings so they can consistently support 

our children’s healthy development. 

A. Prenatal Care

Mothers’ pre-conception weight and weight gain during pregnancy are two of the most important 

prenatal determinants of childhood obesity. Several factors may influence the association of maternal 

weight and weight gain during pregnancy with long-term child health outcomes. These factors include 

maternal and paternal BMI, maternal smoking during pregnancy, blood sugar levels during pregnancy, 

fetal growth, birth weight, and infant feeding practices.

64

Higher maternal weight is a risk factor for gestational diabetes or related conditions during pregnancy.

Children born to mothers who had diabetes during pregnancy are at higher risk of being overweight 

and having gestational and type 2 diabetes. In a study of low-income children, there was a association 

between maternal BMI in the first trimester and the probability of being overweight at 2, 3, and 4 years 

of age.

Recent findings suggest that very low birth weight and very high birth weight are both associated 

with childhood obesity. Although the link between very high birth weight and childhood obesity is 

studied more, the link between low birth weight and obesity may be the result of accelerated growth 

immediately after birth. Babies who were “deprived of nutrition” before birth may be primed for accelerated growth after birth when exposed to a rich nutrient environment (which often consists of infant 

formula).

65 This rapid growth in the first few months and even perhaps the first days of postnatal life, 

are associated with increased risk of children being overweight.

66
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Maternal smoking during early pregnancy is associated with a 500% greater risk of obesity at age 5, and 

a 260% greater risk at ages 9-10.

67 The duration of smoking while pregnant and number of cigarettes 

smoked per day are both associated with increases in rates of childhood obesity.

68 Maternal smoking is 

linked to low intrauterine growth, which can be associated with accelerated postnatal growth and childhood obesity. Notably, the recently-enacted Affordable Care Act requires coverage of counseling and 

pharmacotherapy for cessation of tobacco use for pregnant women in Medicaid, with no cost-sharing 

for these services, effective October 1.

69

To improve children’s health, the Surgeon General recommends promoting effective prenatal counseling about: maternal weight gain; breastfeeding; the relationship between obesity and diabetes; and 

avoiding alcohol, tobacco, and drug use during pregnancy.

70 Recent clinical trials indicate that weight 

gain can be modified by prenatal counseling.

71 Currently, however, only about 30% of pregnant women 

receive appropriate counseling and guidance from a medical professional on how to achieve recommended weight goals during pregnancy.

72

Higher maternal weight gain during pregnancy is also associated with excess maternal weight retained 

afte childbirth.

73 A higher BMI after childbirth can be a health risk for the mother but also sets the stage 

for a higher pre-pregnancy weight in future pregnancies.

A more complete picture of maternal and child weight is needed to monitor these trends and better 

inform policymakers and health professionals.

Recommendations

Recommendation 1.1: Pregnant women and women planning a pregnancy should be informed of 

the importance of conceiving at a healthy weight and having a healthy weight gain during pregnancy, based on the relevant recommendations of the Institute of Medicine. Specifically, health 

care providers, as well as Federal, state, and local agencies, medical societies, and organizations that 

serve pregnant women or those planning pregnancies should provide information concerning the 

importance of conceiving at a normal BMI and having a healthy weight gain during pregnancy. Those 

who provide primary and prenatal care to women should offer them counseling on dietary intake and 

physical activity that is tailored to their life circumstances. In many cases, conceiving at a normal BMI 

will require some weight loss.

Recommendation 1.2: Education and outreach efforts about prenatal care should be enhanced 

through creative approaches that take into account the latest in technology and communications.

Partners in this effort could include companies that develop technology-based communications tools, 

as well as companies that market products and services to pregnant women or prospective parents.

Text4baby: ProvidingHealthTips to PregnantWomen andNew Parents

Text4baby, an educational program of the U.S. Department of Health and Human Services and the 

National Healthy Mothers, Healthy Babies Coalition, is a free mobile information service that provides pregnant women and new parents with health tips to help them give their babies the best possible start in life.
I . E arly Childhood

★ 13 ★

Benchmarks of Success

A higher percentage of women conceiving at a normal BMI, and at an appropriate gestational

weight gain during pregnancy, based on the Institute of Medicine’s gestational weight guidelines.

74

To measure this, HHS should redirect existing resources to prioritize routine surveillance of weight gain 

during pregnancy and postpartum weight retention on a nationally representative sample of women 

and to report the results by pre-pregnancy BMI (including all classes of obesity), age, racial/ethnic group, 

and socioeconomic status.

Some states also collect maternal and child weight information on birth certificates, and states should 

be encouraged to work with HHS to ensure that a complete set of data is collected. The 2003 version 

of the U.S. Standard Certificate of Live Birth includes fields for maternal pre-pregnancy weight, height, 

weight at delivery, and age at the last measured weight, facilitating improved public health surveillance.

75

By 2007, 24 states adopted this form, representing an estimated 60% of all births.

76 States should strive 

for 100% completion of fields related to maternal weight and height, as well as share data to provide 

a full national picture and regional snapshots. HHS should work with the remaining states to encourage adoption of the updated birth certificate form. The President’s FY2011 Budget includes increased 

resources for all States to have an electronic birth record in 2011.

As an interim step, prenatal counseling rates can be measured as a proxy. The Pregnancy Risk Assessment 

Monitoring System (PRAMS) is a surveillance project of the CDC and state health departments. PRAMS 

collects state-specific, population-based data on maternal attitudes and experiences before, during, 

and shortly after pregnancy, including information on prenatal counseling, cigarette use, alcohol use, 

breastfeeding, and pre-conception health (including height and weight). PRAMS will be revised to 

capture prenatal counseling on appropriate weight gain.

B. Breastfeeding

Children who are breastfed are at reduced risk of obesity.

77 Studies have found that the likelihood of 

obesity is 22% lower among children who were breastfed.

78 The strongest effects were observed among 

adolescents, meaning that the obesity-reducing benefits of breastfeeding extend many years into a 

child’s life. Another study determined that the risk of becoming overweight was reduced by 4% for each 

month of breastfeeding.

79 This effect plateaued after nine months of breastfeeding.

Despite these health benefits, although most (74%) babies start out breastfeeding, within three months, 

two-thirds (67%) have already received formula or other supplements. By six months of age, only 43% 

are still breastfeeding at all, and less than one quarter (23%) are breastfed at least 12 months.

80 In addition, there is a disparity between the prevalence of breastfeeding among non-Hispanic black infants and 

those in other racial or ethnic groups. For instance, a recent CDC study showed a difference of greater 

than 20 percentage points in 13 states.

81 
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The protective effect of breastfeeding likely results from a combination of factors. First, infant formula 

contains nearly twice as much protein per serving as breast milk. This excess protein may stimulate 

insulin secretion in an unhealthy way.

82 Second, the biological response to breast milk differs from that 

of formula. When feeding a baby, the mother’s milk prompts the baby’s liver to release a protein that 

helps regulate metabolism.

83 Feeding formula instead of breast milk increases the baby’s concentrations of insulin in his or her blood, prolongs insulin response,84 and, even into childhood, is associated 

with unfavorable concentrations of leptin, a hormone that inhibits appetite and controls body fatness.

85 

Despite the well-known health benefits of breastfeeding and the preference of most pregnant women 

to breastfeed,86 numerous barriers make breastfeeding difficult. For first-time mothers, breastfeeding 

can be challenging, even for those who intend to breastfeed. For those who have less clear intent to 

breastfeed, cultural, social, or structural challenges can prevent breastfeeding initiation or continuation.

For example, immediately after birth, many babies are unnecessarily given formula and separated from 

their mothers, making it harder to start and practice breastfeeding. Also, hospital staff are often insufficiently trained in breastfeeding support. 

The Joint Commission on the Accreditation of Hospitals, the body that accredits hospitals and health 

care organizations for most State Medicaid and Medicare reimbursement, now expects hospitals to 

track and improve their rates of exclusive breastfeeding. Hospitals that meet specific criteria for optimal 

breastfeeding-related maternity care are designated as “Baby Friendly” by Baby-Friendly U.S.A. This 

non-governmental organization has been named by the U.S. Committee for UNICEF as the designating 

authority for UNICEF/WHO standards in the United States. Currently only 3% of births in America occur 

in Baby-Friendly facilities.

87

Breastfeeding Initiation Rates by Race/Ethnicity

Source: Centers for Disease Control, Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention 

and Health Promotion. Breastfeeding Among U.S. Children Born 1999−2006, CDC National Immunization Survey. 

0

10

20

30

40

50

60

70

80

90

Overall Asian Hispanic Native Hawaiian

and Other

White,

Non-Hispanic

American Indian/

Native Alaskan

Black,

Non-Hispanic

73.9%

84.4% 82.1%

73.8%

69.9%

78.2%

56.5%
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While breastfeeding could be far more widespread than it is today, it is not a viable alternative for all 

mothers and babies. Specific guidance and support options should also be made available for those 

who cannot breastfeed. Parents and caregivers of babies also may benefit from guidance about when 

to start feeding them solid foods, since early introduction of solids (prior to six months) increases the 

risk for childhood obesity.

88

Workplace and Child Care Accommodations

Research has demonstrated that support is essential for helping mothers establish and continue breastfeeding as they return to work or school and make use of child care services.

89 Many women return 

to work soon after their baby’s birth, yet 75% of employers do not offer accommodations for them to 

breastfeed or express milk at work.

90

Changes are underway, however. Following the lead of states whose laws requiring employers to make 

accommodations, the recently-enacted Affordable Care Act requires employers to provide a reasonable 

break time and a place for breastfeeding mothers to express milk for one year after their child’s birth.

91

Employers with fewer than 50 employees are not subject to these requirements if compliance would 

impose an undue hardship. The location cannot be a bathroom, and must be shielded from view and 

free from intrusion from co-workers and the public. The return on investment of companies that assist 

breastfeeding employees through appropriate support and accommodations is well-documented.

Companies benefit through better employee retention, lower health care costs, and better work 

attendance.

92

Support for breastfeeding in child care settings is important as well. Among women whose infants are 

cared for outside the home, irrespective of their intent to breastfeed, those who report better support for 

breastfeeding from early learning settings (such as refrigerated storage for breast milk, a commitment 

to feed it to the child, or privacy space for on-site breastfeeding) are more likely to breastfeed longer.

93

Support Programs

In many communities, role models for breastfeeding are rare, and new mothers do not know where to 

turn for breastfeeding assistance. Volunteer networks of experienced breastfeeding mothers such as 

the La Leche League provide help for some mothers, but networks like this are not available in many 

communities. According to the CDC’s annual State Breastfeeding Report Card, there were 34 breastfeeding support groups per 100,000 live births in 2009, which means about one support group for every 

3000 new babies. Peer support programs, such as the Peer Counselor program delivered as part of the 

Special Supplemental Nutrition Program for Women, Infants and Children (WIC), provide counseling 

skills, training, and support to experienced breastfeeding mothers so they can effectively support new 

mothers. Recently, federal funds were provided to further expand the availability of peer counseling in 

local WIC clinics. Prenatal counseling on breastfeeding can also have positive impacts on breastfeeding 

rates,94 and pre- and postnatal intervention together with peer counseling is most effective.

95
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Recommendations

Recommendation 1.3: Hospitals and health care providers should use maternity care practices that 

empower new mothers to breastfeed, such as the Baby-Friendly hospital standards. Hospitals and 

health care providers should routinely provide evidence-based maternity care that empowers parents 

to make informed infant feeding decisions as active participants in their care, and improves new mothers’ ability to breastfeed successfully. Examples of specific practices and policies include: skin-to-skin 

contact between the mother and her baby; teaching mothers how to breastfeed; and early and frequent 

breastfeeding opportunities. 

Hospitals, health care providers, and health insurers should also help ensure that new mothers receive 

proper information and support on breastfeeding when they are released from the hospital.

Recommendation 1.4: Health care providers and insurance companies should provide information 

to pregnant women and new mothers on breastfeeding, including the availability of educational 

classes, and connect pregnant women and new mothers to breastfeeding support programs to help 

them make an informed infant feeding decision.

Recommendation 1.5: Local health departments and community-based organizations, working 

with health care providers, insurance companies, and others should develop peer support programs that empower pregnant women and mothers to get the help and support they need from 

other mothers who have breastfed. Peer support networks should exist in all communities across 

the country, allowing all new mothers to easily identify and obtain help from trained breastfeeding 

peer counselors. Community organizations can foster the creation of peer support networks through 

expansion of programs like the WIC Breastfeeding Peer Counseling program. They can work with local 

breastfeeding coalitions to ensure existence of other peer support networks, such as La Leche League 

groups or Nursing Mothers Councils. They can also foster the creation of mother-to-mother support 

groups in community health centers and advertise these groups, particularly as part of the hospital 

discharge process.

Early Head Start (EHS) programs that enroll pregnant women, including pregnant teenagers, can also 

support community breastfeeding networks. EHS can provide home visits and reach out to pregnant 

and breastfeeding mothers to encourage and support breastfeeding, including by providing professional and peer opportunities to disseminate information and provide on-going support. Funding for 

evidence-based home visitation programs in the recently-enacted Affordable Care Act96 will complement this program.

Private companies, including those that market baby products, can also help support and promote 

these types of community supports for mothers.

Recommendation 1.6: Early childhood settings should support breastfeeding. Child care centers and 

providers, health care providers, and government agencies should provide accurate information about 

the storage and handling of breast milk. They should also make sure child care employees and providers know how to store, handle, and feed breast milk, and understand the importance of breastfeeding.
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Benchmarks of Success

An increase in breastfeeding rates. Several government sources provide statistics on breastfeeding 

rates. The most comprehensive source of information is the National Immunization Survey, which 

provides annual national, state, and selected urban-area estimates of breastfeeding initiation, duration, 

and exclusivity.  In addition to questions on breastfeeding, the survey asks about the introduction of 

infant formula and other supplementary foods. As noted above, according to the survey, currently 30% 

of babies age nine months or younger are breastfed. This should increase by 5% every two years, so 

that by 2015, half of babies are breastfed for at least nine months.

C. Chemical Exposures

In addition to fetal “over-nutrition” or “under-nutrition,” it is possible that developmental exposure to 

endocrine disrupting chemicals (EDCs) or other chemicals plays a role in the development of diabetes 

and childhood obesity. Some scientists have coined the term “obesogens” for chemicals that they believe 

may promote weight gain and obesity. Such chemicals may promote obesity by increasing the number 

of fat cells, changing the amount of calories burned at rest, altering energy balance, and altering the 

body’s mechanisms for appetite and satiety. Fetal and infant exposure to such chemicals may result in 

more weight gain per food consumed and also possibly less weight loss per amount of energy expended.

The health effects of these chemicals during fetal and infant development may persist throughout life, 

long after the exposures occur.

97

Research on such chemicals suggests that the origins of obesity may lie not only in well-established 

risk factors such as diet and exercise, but also in the interplay between genes and the fetal and early 

postnatal environment. The National Institute of Environmental Health Sciences, the Environmental 

Protection Agency (EPA), and other research organizations have been working to understand the developmental origins of obesity and other diseases. Their activities have helped reveal the links between 

environmental chemicals and obesity and diabetes, providing a sufficient base of evidence to warrant 

future research efforts in this area. 

This issue could also be investigated further by the President’s Task Force on Environmental Health 

Risks and Safety Risks to Children, led by HHS and EPA. An increased understanding of chemical toxicity 

also adds strength to the existing recommendations for parents to avoid microwaving baby bottles or 

plastic containers that are not explicitly stated by the manufacturer as safe for use in microwaving.

98 

Government should work closely with industries to translate this emerging science into programs that 

supports product reformulation (for example, of plastic containers) as appropriate.

Recommendations

Recommendation 1.7: Federal and State agencies conducting health research should prioritize 

research into the effects of possibly obesogenic chemicals. As the research becomes clearer, reducing 

harmful exposures may require outreach to communities and medical providers, and could also entail 

regulatory action. 
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Benchmarks of Success

Astrongerknowledgeof chemicalexposures thatmayberelatedtoobesity. Emerging research will 

guide the direction of future intervention strategies for which progress metrics can then be developed.

The necessary research will control the timeline for at least the first 4-5 years. After that time, while 

research efforts will continue, there may be sufficient information to develop strategies to eliminate 

exposures identified as obesogenic.

D. ScreenTime

The American Academy of Pediatrics (AAP) recommends that children two years old and under should 

not be exposed to television, and children over age two should limit daily media exposure to only 1-2 

hours of quality programming.

99 In contrast to these recommendations, one study found that 43% of 

children under age two watch television daily, and 26% have a television in their room.

100 

Preschool aged children are also watching more television than recommended by the AAP. Ninety percent of children ages 4-6 use screen media for an average of two hours per day. Over 40% of children in 

this age group have a television in their bedroom, a third have a portable DVD player, and a third have a 

portable handheld video game player. Children from lower income families and children of color spend 

more time watching television and are more likely to live in a home where it is left on most of the time.

101

Studies show an association between television viewing and risk of being overweight in preschool 

children, independent of socio-demographic factors. Specifically, for each additional hour of television 

viewing, the odds ratio of children having a BMI greater than the 85th percentile was 1.06.

102 Having 

a television in the bedroom had a stronger association, with an odds ratio of 1.31. One study noted 

that preschool children who watched television for more than two hours a day were more likely to be 

overweight than children who watched television two hours or less daily.

103

Television viewing is also linked to dietary intake. Another study found that television exposure was 

correlated with fast-food consumption in preschool children, even after adjusting for a variety of sociodemographic and socio-environmental factors.

104

Recommendations

Recommendation 1.8: The AAP guidelines on screen time should be made more available to parents, 

and young children should be encouraged to spend less time using digital media and more time being 

physically active. Health care provider visits and meetings with teachers and early learning providers 

are an opportunity to give guidance and information to parents and their children. 

Recommendation 1.9: The AAP guidelines on screen time should be made more available in early 

childhood settings. Early childhood settings should be encouraged to adopt standards consistent with 

AAP recommendations not to expose children two years of age and under to television, as well as to limit 

media exposure for older children by treating it as a special occasion activity rather than a daily event.
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E. Early Care and Education

More than 3.5 million children under age five are cared for in child care centers, and many more are 

cared for through less formal arrangements while a parent works.

105 Children in child care centers 

spent an average of 33 hours a week in those settings.

106 Parents and child care providers are sharing 

the responsibility for a large and growing number of children during important developmental years.

Early childhood settings, including both child care centers and informal care, present a tremendous 

opportunity to prevent obesity by making an impact at a pivotal phase in children’s lives.

Physical Activity

Young children need opportunities to be physically active through play and other activities.  Physical 

activity assists children in obtaining and improving fine and gross motor skill development, coordination, balance and control, hand-eye coordination, strength, dexterity, and flexibility—all of which are 

necessary for children to reach developmental milestones.  

Preschool years, in particular, are crucial for obesity prevention due to the timing of the development 

of fat tissue, which typically occurs from ages 3-7. During these preschool years, children’s BMI typically 

reaches its lowest point and then increases gradually through adolescence and most of adulthood.

However, if this BMI increase begins before ages 4 to 6, research has suggested that children face a 

greater risk of obesity in adulthood.

107 

Features of the child care center environment, including policies regarding activity and provider training, 

as well as the presence of portable and fixed play equipment, influence the amount of physical activity 

children engage in while at child care.

108

Healthy Eating

Eating well is equally important for the healthy development of young children, and research has shown 

that public programs can improve the nutritional quality of the food consumed in child care settings.

Children in early childhood settings who are served by USDA’s Child and Adult Care Food Program 

(CACFP) eat healthier food than children who bring meals and snacks from home.

109 A comparison of 

meal quality among licensed early learning sites in California found that children eating meals provided 

in Head Start had the highest meal quality scores, followed by those eating in non-Head Start under 

CACFP. Meal quality scores were higher among center-based versus home-based facilities.

110 

Many programs have already seized the opportunity to provide healthier foods and have implemented 

evidence-informed initiatives that encourage healthy eating and fun, developmentally-appropriate 

physical activity. Still, there is room for improvement.

111 Empirically-based and practice-tested strategies for improving these settings have been identified and provide a basis for the recommendations 

outlined in this chapter. Through concerted and coordinated effort at the Federal, state, and local levels, 

today’s early learning settings can support healthy weight through the development of good habits for 

nutrition, physical activity, and screen time.

Each state creates and enforces its own child care licensing standards, as well as other program standards 

for center-based and family child care homes. Not all child care facilities are required to be licensed in 
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order to legally operate within a state, but they must meet some basic requirements. A recent review 

of state child care regulations by researchers at the Duke University School of Medicine, based on ten 

expert-derived healthy eating model regulations, found that states had an average of 3.7 healthy eating 

regulations for child care centers and 2.9 for family child care homes. No state had all ten model regulations. States had particularly few regulations relating to physical activity and screen time.

112

Workforce qualifications and training requirements for child care providers also vary widely from 

state to state. Many states are now implementing Professional Development Registries and other 

methods to better track and document the providers’ training sessions. They are also implementing 

observation and feedback opportunities to understand if training is being applied in the classroom. To 

incorporate recommended nutrition, physical activity, and screen standards into their curricula, Federal 

agencies and states can partner with national organizations such as the National Association of Child 

Care Resource and Referral Agencies (NACCRRA), the National Association for the Education of Young 

Children (NAEYC), and the National Head Start Association (NHSA), as well as community colleges and 

other training providers.

Parents are often unaware of quality elements when choosing child care and early education settings, 

including the importance of nutrition, physical activity, and screen time limits provided in these settings, 

and they can find it difficult to get this information. Quality Rating and Improvement Systems (QRISs) 

are State systems that rate the quality of early child care settings (which can include Pre-K, Head Start, 

child care, and others) based on a clear, common set of criteria. These rating systems can provide parents 

with reliable, consistent information that can help them make informed decisions.

Innovative Early Childhood Programs

There are several evidence-informed initiatives and interventions for early childhood settings to combat 

childhood obesity, including: 

• I am Moving, I am Learning, a proactive approach to childhood obesity in preschool classrooms that 

seeks to increase moderate to vigorous physical activity every day, improve the quality of movement 

activities intentionally planned and facilitated by adults, and promote healthy food choices. This 

approach is implemented by Head Start and has been adopted by some other child care programs as 

well.

• Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), an assessment tool for child care 

settings, which uses an organizational assessment of 14 areas of nutrition and physical activity policy, 

practices and environments to identify the strengths and limitations of the child care facility. NAP SACC 

also includes goal setting and action planning, continuing education and skill building for providers.

• Nemours Program: Delaware, under the leadership of Nemours, an integrated child health system, launched a statewide, multi-sector program to combat childhood obesity that includes changes in 

child care licensing to set healthy eating and physical activity standards, along with technical assistance, 

training and practical toolkits to help providers implement the standards. The new standards apply to 

all licensed center and family day care providers, impacting 54,000 children.
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Recommendations

Recommendation 1.10: The Federal government, incorporating input from health care providers 

and other stakeholders, should provide clear, actionable guidance to states, providers, and families 

on how to increase physical activity, improve nutrition, and reduce screen time in early child care 

settings. 

Recommendation 1.11: States should be encouraged to strengthen licensing standards and Quality 

Rating and Improvement Systems to support good program practices regarding nutrition, physical 

activity, and screen time in early education and child care settings. 

Both federal guidance and state policies and practices may be drawn from:

• The guidelines for Out-of-Home Child Care Programs that will be outlined in the soon-tobe released third edition of Caring for our Children: National Health and Safety Performance 

Standards.113 These nationally recognized standards include health and safety practices such as 

physical activity, nutrition, and limited screen time for children from birth to age 12 in all types 

of early childhood settings. 

• The National Association for Sport and Physical Education (NASPE) recommendation that all 

children in full-day child care are provided at least 60 minutes of structured and unstructured 

physical activity per day. Others have recommended that infants be provided opportunities 

for gross motor activity, and should not be unnecessarily confined.

• The revised Head Start Program Performance Standards, which include recommendations for 

health, nutrition, and physical environments.

Recommendation 1.12: The Federal government should look for opportunities in all early childhood 

programs it funds (such as the Child and Adult Care Food Program at USDA, the Child Care and 

Development Block Grant, Head Start, military child care, and Federal employee child care) to base 

policies and practices on current scientific evidence related to child nutrition and physical activity, 

and seek to improve access to these programs.

Benchmarks of Success

An increased number of states will adopt more stringent licensing standards that include nutrition, physical activity, and screen time that align with Caring for our Children: National Health and Safety 

Performance Standards, 3rd edition and coordinate across systems with Pre-K, Head Start, and child care.

New or enhanced data sources may be needed to monitor progress in this area.

★ 23 ★

II. Empowering Parents and Caregivers

Fundamentally, parents and caregivers are responsible for their children’s health and development.

They instill and promote certain values, reward or reinforce specific behaviors, and shape choices that 

form life-long healthy habits. Each day, parents and caregivers make decisions on food selection, eating 

patterns, physical activity, and sedentary habits like television viewing. Children learn from the choices 

adults make. Often it is an entire family that experiences being overweight or obese. 

Changes in the food and social environment over the past 20 years have made parents’ and caregivers’ 

roles in promoting health more challenging. Parents and caregivers want to provide good nutrition 

and regular physical activity, but often lack information that is clearly understandable and actionable.

Communities, businesses, health care providers, and governments can play a supportive role in providing 

helpful information and fostering environments that support parents’ and caregivers’ healthy choices.

For information to be useful to busy and overworked parents and caregivers, both the “what” and the 

“how” to deliver information must be considered. With a myriad of messages about what to eat and 

how to be active, the consistent delivery of specific, unambiguous, and actionable messages is critically important. In addition, the broader environment—including confusing claims or labels on food 

packages and marketing campaigns—can become a serious obstacle, by making unhealthy choices 

easy and healthy choices hard. 

This chapter describes current and proposed initiatives to empower parents and caregivers by:

• making nutrition information useful,

• improving food marketing and labeling practices, and

• strengthening health care providers’ role.

A. MakingNutrition Information Useful

Good nutrition plays an essential role in overall health. Healthy eating habits in childhood and adolescence are important for positive growth and development and can help children achieve and maintain 

a healthy weight. Today, the eating habits of many young people are inconsistent with the recommendations in the Federal Dietary Guidelines for Americans (Dietary Guidelines),114 thus increasing the 

risk of obesity.

To assist parents and caregivers in establishing healthy eating habits for children, they should have 

greater access to the right tools and resources that increase nutritional knowledge and help them make 

healthier choices.

Dietary Guidelines for Americans and the Food Pyramid

The Dietary Guidelines for Americans provide science-based advice for individuals over age two to promote health and reduce the risk of major chronic diseases through diet and physical activity. HHS and 

USDA work in partnership to review and update these guidelines every five years, based on an analysis 

of scientific evidence. The current Dietary Guidelines, issued in 2005, encourage most Americans to eat 
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fewer calories, be more physically active, and make wiser food choices. The 2010 Dietary Guidelines are 

under development, and will be released later this year. 

The Dietary Guidelines are intended to be the primary source of 

dietary health information for policymakers, nutrition educators, 

and health providers, helping to inform nutrition research priorities, influence industry product development, and support 

education initiatives. They affect the decisions both private and 

public institutions make, and ultimately, they are meant to inform 

consumers, including parents and caregivers, about how to make 

healthy choices.

The Dietary Guidelines also form the basis of Federal nutrition policy. For example, they must be applied 

in menu planning in the National School Lunch Program (NSLP), in education materials used by the 

Supplemental Nutrition Assistance Program (SNAP, formerly called food stamps), and in the development of information on the Nutrition Facts panel that appears on food packages.

The Food Pyramid is an educational system developed by USDA to translate the Dietary Guidelines into 

food-based recommendations and applications for the public. The broader MyPyramid Food Guidance 

System provides educational resources, messages and personalized tips about nutrition and physical 

activity, and extensive online interactive healthy eating tools.

MyPyramid.gov has reached millions of consumers, health professionals, and educators since it was 

launched in 2005, and is consistently one of the top five most popular federal web sites. Despite its 

popularity and prominence, the Food Pyramid has been subject to significant criticism for failing to 

communicate effective, actionable messages to consumers, which many observers have suggested are 

critical in changing behavior.

115 The MyPyramid system is currently being studied for improvements. 

In addition, the recently-enacted Affordable Care Act requires HHS, in consultation with private-sector 

experts, to maintain a website that provides science-based information to health care providers and 

consumers on guidelines for areas such as nutrition, regular exercise, and obesity reduction. The legislation also requires HHS to create a web-based prevention plan tool to help families make informed health 

decisions.

116 Parents and caregivers can also currently find information about nutrition and healthy eating 

at www.FruitsandVeggiesMatter.gov and through the We Can childhood obesity prevention program 

developed by the National Institutes of Health (wecan.nhlbi.nih.gov). Given the broad array of federal 

tools to help consumers make healthy choices, it is critical that these tools be developed and maintained 

in a manner that is coordinated and sending consistent messages.

Food Package Labeling 

Parents and children need accurate, clear, and consistent information on food packages in order to 

choose healthier foods. At present, the main source of consistent information is the detailed Nutrition 

Facts panel on food packages, designed by the Food and Drug Administration (FDA) pursuant to the 

Nutrition Labeling and Education Act of 1990. USDA regulates the labeling of meat and poultry products, 

and currently requires the Nutrition Facts to be displayed on processed products. USDA is in the process 

of requiring that the Nutrition Facts panel be displayed on other meat and poultry products, including 

The Dietary Guidelines

provide science-based advice 

about good dietary habits 

that can promote health and 

reduce the risk of major chronic 

disease.
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ground beef and cuts of meat, as well.

117 According to recent FDA surveys, consumers are increasingly 

seeking nutrition information about the food they purchase. 

The percent of the U.S. population that 

reports “often” reading a food label the 

first time they buy a product increased 

from 44% in 2002 to 54% in 2008. Of 

those that read food labels when purchasing a product for the first time in 

2008, the food label was most often used 

to: 

• See how high or low a food is in 

things like calories, salt, vitamins 

or fat (two-thirds of consumers).

• Get a general idea of the nutritional content of the food (over 

one-half of consumers).

Use of the Nutrition Facts nearly doubled 

in only four years, from 32% in 2004 to 

52% in 2008.

118 

Nutritional or health claims on the front 

of food packages have also increased, but 

these claims are sometimes seen as misleading. An FDA survey found that only 

about half or less of Americans trust the 

claims on the front of food packages.

119

FDA has the authority to review scientific 

evidence for nutrient content and health 

claims on food packages before they are 

used, and is increasingly taking action to 

help prevent the spread of misinformation. FDA has taken action recently to 

address some of the inappropriate use 

of claims in food labeling.

120

Despite its value and importance, the 

Nutrition Facts panel has been criticized 

as unduly detailed and complex. To make 

it easier for consumers to get information 

at a quick glance, FDA is currently investigating options for a standard, front-of 

“Spotthe Block”Campaign

HHS has launched a program called “Spot the Block” to 

encourage children and caregivers to read the Nutrition 

Facts panel. They have recently launched an education 

campaign based on “Spot the Block” that targets AfricanAmerican and Hispanic communities.

HHS tested the “Spot the Block” program with the Cartoon 

Network and the research findings showed the program is 

effective in getting children to respond to the messages.  

Specifically, there were significant increases in:

• children who think the Nutrition Fact panel is important 

to them (+21%);

• the likelihood children would tell their friends to check 

the Nutrition Facts panel (+48%); and

• the perceived importance of knowing the serving sizes 

of the food they eat (+71%).
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package label. FDA is also working to update the Nutrition Facts panel based on new scientific information and consumer research. 

Serving sizes also play an important role. In 2005, FDA began the process of reviewing data to update 

the reference amounts used to determine serving sizes on food packages. A specific concern was the 

presentation of serving size information on packages that may contain multiple servings but could 

reasonably be consumed at one time. For example, a 20 ounce bottle of soda is currently labeled as 

having multiple servings, but is often consumed all at once. FDA is currently analyzing comments and 

food intake survey data to determine steps to take and how changes in serving size will impact updates 

to the Nutrition Facts panel.

Menu Labeling 

The recently-enacted Affordable Care Act requires display of calorie counts by chain restaurants with 

20 or more locations and vending machine operators with 20 or more machines.

121 Chain restaurants 

must also make available for customers, upon request, more detailed nutritional information such as 

sodium and sugars, and the menu or menu board must also include a clear statement indicating the 

availability of this information. Chain restaurants must display this information on menus, menu boards, 

self-service lines, and in drive-through lanes. Vending machines must provide a clear and noticeable 

statement disclosing the calorie counts near each item or the selection button. Restaurants, retail food 

establishments, and vending machine owners who are not subject to these requirements can voluntarily 

register with HHS to be subject to these requirements. New York City implemented a similar law prior 

to enactment of the Affordable Care Act, and early research indicates it may have favorably affected 

eating habits, although firm conclusions cannot yet be drawn.

122

A recent study showed that both information and convenience can have a beneficial effect on how 

customers choose their meals.  The study indicates that when presented with calorie information (how 

many calories are contained in each menu item) and a calorie recommendation (how many calories men 

and women of varying activity levels should consume), people on average order meals with significantly 

fewer calories.  Indeed, the effect of providing this information reduced meals by almost 100 calories.

123

The study also showed that making healthier meal choices more convenient has a significant impact 

on consumption decisions.  For example, if healthier options are featured on a menu page and other 

options require a more active choice, it is likely that fast-food customers will order lower calorie meals.  

This finding is consistent with other studies showing that changes in how and where food is located can 

help promote healthy choices, suggesting the effectiveness of possible changes like moving vending 

machines farther from school cafeterias or moving fruit next to cash registers.

124  

Research has also shown that plate size in restaurants or at home can make a significant difference in 

how much food is consumed,125 and that portion sizes have grown substantially over time.

126 Eating 

dinner as a family is also associated with healthier eating.

127

Recommendations

Recommendation 2.1: The Federal government, working with local communities, should disseminate information about the 2010 Dietary Guidelines for Americans through simple, easily actionable messages for consumers and a next generation Food Pyramid. As HHS and USDA launch the 
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updated Dietary Guidelines in late 2010, they should include simple advice and messages for consumers.

Incorporating information about knowing daily caloric needs will be useful as menu labeling is implemented. For example, these messages could include:

• Drink water instead of soda or juice with added sugar; 

• Avoid foods that consist mainly of added sugars or fats;

• Eat more fruits, vegetables, whole grains, and lean proteins;

• Choose low-fat or fat-free dairy products (such as 1% or skim milk); and

• When possible, eat dinner together as a family.

Other important messages to share with parents include:

• The recommended amount of daily physical activity (one hour a day for children, as recommended by the companion Physical Activity Guidelines for Americans);

• The recommended amount of screen time; and

• The recommended amount of sleep (more than 10.5 hours a night for preschool-aged children 

and 12 hours for infants).

128

Any specific messages should be coordinated with the scientific recommendations of the Dietary 

Guidelines Advisory Committee. They should also be coupled with practical tips for parents on how 

to make these changes in their children’s lives. The tips should recognize the juggling act and time 

pressures that many parents and caregivers are facing. Suggestions for how to deliver these messages 

should also be sensitive to the risk of eating disorders among young people.

USDA and HHS should also research and disseminate information about the most effective ways to 

promote the Dietary Guidelines among children to impact their eating habits. This includes modernizing the “SNAP Ed” program, a nutrition education program for participants in SNAP (formerly known 

as food stamps), in a way that provides influential information to parents and caregivers. A recent study 

recommended that SNAP Ed be improved in a number of ways.

129

Recommendation 2.2: The FDA and USDA’s Food Safety and Inspection Service should collaborate 

with the food and beverage industry to develop and implement a standard system of nutrition labeling for the front of packages. The labeling system should be based on scientific research that assesses 

the formats people will notice, understand, and use to make healthy choices. To complement this effort, 

FDA should address portion size and continue its work to prevent misleading claims on food packages.

Recommendation 2.3: Restaurants and vending machine operators subject to the new requirement in 

the Affordable Care Act should be encouraged to begin displaying calorie counts as soon as possible.

Recommendation 2.4: Restaurants should consider their portion sizes, improve children’s menus, 

and make healthy options the default choice whenever possible. The improvements are particularly 

important since one-third of meals are consumed in restaurants,130 including many meals eaten by 

children at fast-food establishments.
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Benchmarks of Success

An increase in the number of parents who are better able to notice, understand, and use food

labels. FDA collects data on use of nutrition labels by adult consumers in households with children 

through the Health and Diet Survey and will be looking for a steady increase in the percentage using 

the labels.

In addition, as noted earlier in this report, it will be critically important to monitor the overall health of 

children’s diets and make steady progress toward improvements such as reducing added sugars and 

increasing fruit and vegetable consumption.

B. Food Marketing

Food marketing to children and adolescents is a big business. The Federal Trade Commission (FTC) estimates that, in 2006, food, beverage, and quick-serve restaurant companies spent more than $1.6 billion 

to promote their products to young people.

131 Children and adolescents are an important demographic 

for marketers for several reasons: (1) they are customers themselves; (2) they influence purchases made 

by parents and caregivers; and (3) they are the future adult market.

132 For many years, public health 

experts and others have argued that the marketing of energy-dense, low-nutrient food products to 

children and adolescents is one of many factors contributing to the obesity epidemic. While a causal link 

between marketing and increasing childhood obesity rates has yet to be firmly established,133 research 

indicates that advertising can have a strong influence on children. Young children in particular have 

difficulty distinguishing between television programming content and advertising, or comprehending 

the purpose of advertising.

134 Older children, and even adults, are influenced by advertising too.

The marketing of food products can also be a powerful tool to drive the purchase of healthy products 

and to communicate important information about healthy eating choices. For example, one study found 

that children ages 3-5 preferred the taste of the same foods if they thought they were from McDonald’s, 

rather than another source.

135 Key actors—from food and beverage companies, to restaurants, food 

retailers, trade associations, the media, government and others—all have an important role to play in 

creating a food marketing environment that supports, rather than undermines, the efforts of parents 

and other caregivers to encourage healthy eating among children and prevent obesity.

Current Climate, Recent Initiatives, and Industry Self-Regulation

Television advertising is the dominant form of marketing to both children and adolescents, comprising almost half of total youth-directed marketing expenditures according to the FTC.

136 However, food 

and beverage companies utilize a full range of other marketing techniques including print, internet 

advertising (such as advergames), product packaging, in-school marketing, cross-promotions, prizes 

and contests, and the use of popular licensed characters that appeal to children and adolescents.

137 

Notably, many advertising campaigns are fully integrated, using common themes across multiple 

promotional platforms.

138 

The use of licensed characters to market foods to children is particularly effective and pervasive.

Research conducted by the Sesame Street Workshop in 2005 found a strong influence of popular 
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licensed characters on preschoolers’ food preferences.139 When preschoolers were asked if they would 

rather eat broccoli or a Hershey’s chocolate bar, 78% of the children chose the chocolate bar and only 

22% chose broccoli. When an Elmo sticker was placed on the broccoli, however, 50% of the children 

chose broccoli. Not surprisingly, food marketers’ use of licensed characters in cross promotions targeting children has increased in recent years.

140 At the same time, the nutritional quality of the products 

promoted by these characters has decreased.

141 

In 2006, a Joint Task Force on Media and Childhood Obesity was established to examine the impact of 

media on childhood obesity and to develop voluntary industry standards to limit advertising that targets 

children. Senators Sam Brownback and Tom Harkin, former Federal Communications Commission (FCC) 

Chairman Kevin Martin, and former FCC Commissioner Deborah Taylor Tate convened the Task Force 

and members spanned from industry to government, and many others. The Task Force was unable to 

agree on either a uniform set of nutritional standards for defining healthy versus unhealthy foods, or 

media companies’ obligations to enforce advertising limits.

That same year, the Council of Better Business Bureaus established the Children’s Food and Beverage 

Advertising Initiative (CFBAI) in response to growing public concern and calls for the food and beverage 

industry to self-regulate. CFBAI was intended to change the ratio of food and beverage advertising 

messages directed to children under the age of 12 to encourage healthier eating and lifestyles.

142 Its 

16 current member companies (Burger King, Cadbury Adams, Campbell Soup, Coca-Cola, ConAgra 

Foods, Dannon, General Mills, Hershey, Kellogg, Kraft, Mars, McDonald’s, Nestle, PepsiCo, Post Foods, 

and Unilever) have agreed upon five central components:

1.	 100% of child-directed television, print, radio, and internet advertising must promote “healthier 

dietary choices” or “better-for-you” products;143

2.	 Products depicted in child-directed interactive games must be “better-for-you” foods or the 

games must incorporate healthy lifestyle messages;

3.	 Companies must reduce their use of third-party licensed characters in advertising that does not 

promote healthy dietary choices or healthy lifestyles;

4.	 Companies must not pay for or actively seek placement of their products in entertainment 

directed at children; and

5.	 Companies must not advertise food or beverage products in elementary schools.

Since its implementation, the efficacy of the CFBAI’s efforts has been subject to debate. FTC’s 2008 

report noted that the participating companies’ nutritional standards, as well as their definitions of “childdirected,” vary by company.

144 Within certain guidelines, each company developed its own nutritional 

standards for what constitutes a “better for you” food or a “healthy dietary choice.” Moreover, the FTC 

criticized the program for applying these standards only to certain forms of advertising. It recommended, among other things, that the CFBAI improve the quality and consistency of the nutritional 

standards and extend those standards to all advertising and promotional techniques, including product 

packaging and “point-of-sale” advertising (such as displays near a check-out counter).

145 
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A recent study analyzed the effectiveness of the CFBAI and found that it had not substantially shifted 

advertising for children toward healthier products.

146 Using one measure of nutritional quality, the study 

determined that, in 2009, advertisements for healthy products accounted for a very small fraction of 

all advertising by participating companies, while most advertising promoted foods of low nutritional 

value.

147 The study also found that companies participating in the CFBAI nearly doubled the use of 

licensed characters over the past four years, increasing from use in 8.8% of advertisements in 2005 

to 15.2% in 2009. Roughly half of all advertisements with these characters are for foods in the lowest 

nutritional category.

148 The CFBAI has criticized this study, and argues that its voluntary efforts have led 

to significant improvements in foods advertised to children.

149

Some media and entertainment companies have adopted policies limiting the types of foods for which 

they will license their popular characters.

150 In addition, one company has set nutritional standards for 

the food advertising it accepts on child-directed programming.

151 However, not all companies with 

popular entertainment properties have instituted similar policies, and the ones that have often use 

varying guidelines. 

Concern about the ineffectiveness of industry self-regulation led Congress in 2009 to direct the formation of an Interagency Working Group on Food Marketed to Children (IWG).

152 This group, comprised 

of representatives of the FTC, FDA, CDC, and USDA, was tasked with developing recommendations for 

uniform standards for foods marketed to children ages 17 and under, as well as the scope of media to 

which such standards should apply. The group released tentative voluntary standards in December 

2009 and is expected to publish proposed standards in the Federal Register for public comment in the 

near future. 

An examination of the food and beverage industry’s efforts to voluntarily limit marketing to children 

suggests the following conditions are necessary for meaningful improvement to occur through industrydirected initiatives:

1.	 First, self-regulatory groups must adopt a uniform set of nutritional standards. Without clear, 

consistent standards, there can be no objective basis for comparing different food products or 

measuring progress. The freedom of the CFBAI members to define what constitutes a “betterfor-you” food product has resulted in variations in the nutritional criteria used from one company to the next.

153 The IWG’s forthcoming recommendations on standards should be helpful 

here. More generally, Federal agencies with expertise in this area should work with industry to 

establish consistent standards based on the Dietary Guidelines that can be easily understood 

by both consumers and industry.

2.	 Second, any framework for voluntary reform must provide a level competitive playing field 

within the industry. If compliance results in significant competitive disadvantages to participating companies, long-term compliance becomes unsustainable. It is therefore critical to have 

broad participation by all companies that market food and beverage products to children.

These efforts must be supported by cooperation from the major media companies that target 

child audiences. Media companies can directly control the type and volume of advertisements 

shown on their platforms. Accordingly, they can impose limits on advertising, regardless of 
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advertisers’ participation in a voluntary scheme. Media companies’ use of uniform nutritional 

criteria would facilitate these efforts.

3.	 Third, to create a meaningful impact, self-regulation must apply to all forms of marketing 

across multiple platforms. The current voluntary guidelines allow extensive marketing of nonnutritious foods in a myriad of ways that target children. 

4.	 Finally, effective voluntary reform will only occur if companies are presented with sufficient 

reasons to comply. The prospect of regulation or legislation has often served as a catalyst for 

driving meaningful reform in other industries and may do so in the context of food marketing 

as well.

The Role of Federal Regulation of Advertising

The Federal Communications Commission (FCC)’s regulatory authority varies across industries and 

platforms. The FCC has some direct authority to regulate advertising on children’s television programs.

The Children’s Television Act limits the amount of commercial matter aired during children’s programming to no more than 10.5 minutes per hour on weekends and no more than 12 minutes per hour on 

weekdays. As implemented by the FCC, these limits apply to commercial television licensees, cable 

operators, and satellite television (DBS) providers. In addition, the Act specifically authorizes the FCC 

to review and evaluate the advertising duration limitations, and to modify them in accordance with the 

public interest based on demonstrated need.

154 

The FTC, which has extensively studied food marketing to children,155 is responsible for protecting 

consumers by preventing unfair or deceptive advertising. However, its ability to regulate child-directed 

advertising is limited. In 1981, in response to the FTC’s effort to regulate the advertising of sugary foods 

to children, Congress prohibited the agency from using its authority over unfair practices to adopt rules 

regarding children’s food advertising.

While new or revised rules to limit advertising during children’s programming may be helpful or even 

necessary to fully address the childhood obesity epidemic, such efforts must carefully consider freedom 

of speech interests. Furthermore, even if efforts to limit marketing to children are successful, they would 

only provide a partial solution given that children are heavily exposed to advertising not specifically 

directed to them. For example, half of the food advertisements children see on television occur on 

prime-time and other non-child directed programs.

156 Programs like American Idol and The Simpsons, 

which are popular among children and teens, are regarded as general audience or family programming 

because adults form such a large share of the audience.

157 In addition, children are increasingly exposed 

to many forms of marketing other than television advertising, including billboards, point-of-purchase 

displays, and content accessed through the Internet, mobile phones, and MP3 players.
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Recommendations

The Federal government can play a crucial role in improving the media environment for children with 

respect to the marketing of foods and beverages. It can do so while fully respecting the First Amendment 

right to free speech. Generally, this role includes:

• Bringing together key stakeholders to develop collaborative solutions;

• Providing guidance to industry on voluntary initiatives;

• Conducting consumer education and outreach campaigns; and 

• Promulgating laws and regulations when other methods prove insufficient. 

Recommendation 2.5: The food and beverage industry should extend its self-regulatory program 

to cover all forms of marketing to children, and food retailers should avoid in-store marketing that 

promotes unhealthy products to children. Currently, the CFBAI guidelines limit only certain types of 

child-directed advertising—including television, print, radio, and Internet—but do not apply to in-store 

advertising, product packaging, and many other forms of marketing. For truly meaningful and effective 

self-regulation, all forms of child-directed marketing should be covered. Retailers have an important 

role to play in this effort as well, since they control what products are placed at children’s eye level and 

can impact in-store advertising, including at the point-of-sale.

Recommendation 2.6: All media and entertainment companies should limit the licensing of their 

popular characters to food and beverage products that are healthy and consistent with sciencebased nutrition standards.

Recommendation 2.7: The food and beverage industry and the media and entertainment industry 

should jointly adopt meaningful, uniform nutrition standards for marketing food and beverages 

to children, as well as a uniform standard for what constitutes marketing to children. All nutrition 

standards should be based on the Dietary Guidelines. As part of this effort, the food and beverage 

industry should develop aggressive targets and metrics for increasing the proportion of advertisements 

for healthy foods and beverages across all marketing channels and platforms. The media and entertainment industry should develop uniform guidelines to ensure that a higher proportion of advertisements 

shown on their networks and platforms are for healthy foods and beverages. 

Recommendation 2.8: Industry should provide technology to help consumers distinguish between 

advertisements for healthy and unhealthy foods and to limit their children’s exposure to unhealthy 

food advertisements. The food and beverage industry and the media and entertainment industry 

should create an on-air labeling system that helps consumers easily distinguish between advertising for 

healthy and unhealthy foods. The FCC could also urge these industries to create innovative technologies that allow parents to block unhealthy food and beverage advertising from all programming. The 

nutritional standards should be uniform and based on the Dietary Guidelines.

Recommendation 2.9: If voluntary efforts to limit the marketing of less healthy foods and beverages 

to children do not yield substantial results, the FCC could consider revisiting and modernizing rules 

on commercial time during children’s programming. 
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Benchmarks of Success

A substantial yearly increase in the proportion of healthy food and beverage advertisements

targeting children such that, within three years, the majority of food and beverage advertisements 

directed to children promote healthy foods.

A substantial yearly decrease in the use of licensed characters to promote foods and beverages

that arenothealthy such that, within three years, licensed characters are used only to promote healthy 

foods and beverages. 

To measure progress, data-driven studies are needed to evaluate the nutritional content of foods 

advertised to children. The FTC’s follow up study, expected in 2011, will explore this issue, as well as 

shifts in consumption that have occurred following the implementation of industry self-regulation. It is 

critical to monitor and evaluate progress to support marketing efforts that reduce childhood obesity. If 

industries and government begin implementing recommendations immediately, meaningful progress 

could be achieved in three years. 

C. Health Care Services

BMI Measurement and Obesity Prevention

Parents and caregivers often do not realize when a child is overweight or obese. In fact, studies have 

consistently shown that parents do not accurately perceive the weight of their overweight or obese 

child.

158 To inform and make potentially serious health issues salient to parents and caregivers, several 

states and municipalities now require children’s BMI to be measured and shared with parents or caregivers. When aggregated, this data can also show the weight status over time in a student population, 

monitor progress of national health objectives,159 and monitor the effects of school-based physical 

activity and nutrition policies and programs. 

BMI is a measure of weight status at one point in time, so it is important for students, families, and policymakers to respond to trends in BMI measurements rather than one measurement point. For children 

and teenagers, BMI is used as a screening tool, not a diagnostic tool, meaning that it can suggest a child 

has a weight concern but does not determine a child’s weight status.

160 To understand a BMI score more 

accurately, health care providers often look at other measures. Additional assessments and tests can 

include a patient’s medical history, family history, diet, physical activity habits, and blood pressure, and 

laboratory tests such as cholesterol levels. By performing follow up assessments and tests, practitioners 

can determine if the student actually has excess body fat or other health risks related to obesity. 

A recent survey of practicing pediatricians found that nearly all respondents reported measuring height 

and weight at well-child visits, using growth charts as a reference. However, only about half calculate 

and assess BMI percentile for gender and age for children older than two years of age.

161 Most pediatricians reported that they lacked time to counsel on overweight or obesity and counseling alone has 

poor results, yet they noted that having simple diet and exercise recommendations would be helpful.

In another survey, only about 37% of overweight children and adolescents reported being told by a 

health care provider they were overweight.

162
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Some states are implementing school-based BMI measurement programs. These screening programs 

are designed to assess the weight status of individual students to detect those who are at risk for 

weight-related health problems. Screening results are sent to parents and typically include: the child’s 

BMI-for-age percentile; an explanation of the results; recommended follow up actions, if any; and tips 

on healthy eating, physical activity, and healthy weight management. To date, few studies have assessed 

the utility of these programs in preventing increases in obesity or their impact on weight-related 

knowledge, attitudes, and the behaviors of young people and their families.

163 These approaches merit 

further evaluation and review.

It is critical that health providers engage in BMI measurement. As the Surgeon General has noted, 

“people access the health care system through multiple channels, and medical care settings are an 

important avenue for preventing and controlling overweight and obesity. Clinicians are often the most 

trusted source of health information and can be powerful role models for healthy lifestyle habits.”164 

While uninsured families have decreased access to well-child care and thus BMI screening, the recentlyenacted Affordable Care Act will expand health care coverage and provide additional opportunities to 

support children’s health.

Parents and families should also receive specific information and counseling on healthy behaviors from 

their health care providers. These behaviors include increasing fruit and vegetable intake and physical 

activity time, limiting unhealthy behaviors such as consumption of high calorie foods with little nutritional value and sugar sweetened beverage intake, and reducing sedentary time. Providers should also 

be able to refer parents and caregivers to the appropriate community resources. 

An expert committee, convened by the American Medical Association (AMA), HHS’s Health Resources 

and Services Administration (HRSA), and the CDC, made recommendations, which have been endorsed 

by the American Academy of Pediatrics (AAP), on the prevention, assessment, and treatment of children 

who are overweight or obese.

165 The committee noted that health care provider offices and health care 

systems may need to change their organizational approach to effectively address obesity prevention.

More comprehensive and more useful care can be provided by integrating community resources, health 

care, and patient and family self-management. Health care providers may also need training on how 

to raise these issues most effectively with parents, since the stigma often associated with obesity can 

sometimes prevent clinicians from feeling comfortable discussing the implications of a high BMI.

166 

Similarly, it is important to avoid children feeling stigmatized due to their weight.

167

Obesity Treatment

The AAP-endorsed recommendations of the expert committee described above include four stages 

of treating obesity. The first stage is brief counseling, which can be delivered in a health care office.

Subsequent stages require more time and resources. Stage two is a structured plan, consisting of a 

balanced diet, supervised physical activity, reduced screen time, and logs to monitor behavior change.

Stages three and four include intensive interventions administered by expert obesity management 

professionals.

168
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The chronic care model also creates a new structure for treatment of chronic diseases by integrating 

community resources with health care and patient self-management. This approach is recommended 

for children who are overweight or obese.

169 The United States Preventive Services Task Force (USPSTF) 

found that effective, comprehensive weight-management programs for obese children ages 6 years 

and older incorporated counseling and other interventions that targeted diet and physical activity.

Interventions also included behavioral management techniques to assist behavior change, and those 

that focused on younger children incorporated parental involvement.

170

Recommendations

Recommendation 2.10: Pediatricians should be encouraged to routinely calculate children’s BMI 

and provide information to parents about how to help their children achieve a healthy weight. As 

part of the First Lady’s Let’s Move Initiative, the AAP pledged in February 2010 to engage in a range of 

efforts to achieve two primary goals: 

• Calculate BMI for every child at every well-child visit beginning at age 2, and provide information 

to parents about how to help their child achieve a healthy weight.

• Provide “prescriptions” for healthy active living, including good nutrition and physical activity, 

at every well-child visit, along with information for families about the impact of healthy eating 

habits and regular physical activity on overall health. Pediatricians can use their own prescription 

pads or existing handouts, or they can opt to use the healthy active living prescriptions created 

by the AAP and available at www.aap.org/obesity/whitehouse.

Recommendation 2.11: Federally-funded and private insurance plans should cover services necessary to prevent, assess, and provide care to overweight and obese children. HHS’s Center for Medicare 

and Medicaid Services is planning to send a letter to State Medicaid directors to clarify how these services 

are currently covered in Medicaid and the Children’s Health Insurance Program. The recently-enacted 

Affordable Care Act also requires each State to design a public awareness campaign on preventive and 

obesity-related services available to Medicaid enrollees.

171 Starting this year, the Act also requires new 

private plans to cover preventive services at no charge by exempting these benefits from deductibles 

and other cost-sharing requirements.

172 The Indian Health Service covers these services and has proposed an initiative on early identification and treatment of childhood and adult obesity in primary care 

in the President’s FY2011 Budget.

Recommendation 2.12: Dentists and other oral health care providers should be encouraged to 

promote healthy habits and counsel families on childhood obesity prevention as part of routine 

preventive dental care.

Recommendation 2.13: Medical and other health professional schools, health professional associations, and health care systems should ensure that health care providers have the necessary training 

and education to effectively prevent, diagnose, and treat obese and overweight children.
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Benchmarks of Success

Allprimary carephysicians shouldbe assessingBMI at allwell-childandadolescent visitsby2012.

All parents and caregivers should routinely receive nutrition and physical activity counseling

from their children’s health care providers by 2012.

BMI assessment and counseling trends can be tracked using the National Ambulatory Medical Care 

Survey. Additionally, in 2009 the National Committee on Quality Assurance (NCQA) added rates of BMI 

assessment and nutrition and physical activity counseling for children and adolescents to its “HEDIS” 

(Healthcare Effectiveness Data and Information Set) quality measures. The NCQA HEDIS measures 

provide a complementary tool for future tracking of provider assessment and counseling trends.

Key Questions for Future Research

Building the science for prevention will help to strengthen childhood obesity prevention efforts. Below 

are identified research areas for consideration when developing national research agendas:

• Research the link between traditional as well as non-television forms of advertising, such as the 

internet, and food preferences and consumption by children and adolescents.

• Test studies of family-based interventions (such as studies of parenting style, home availability 

of healthful food, and opportunities for physical activity).

• Identify and test approaches for community partnerships to disseminate and implement 

evidence-based obesity prevention programs.

• Understand how individuals interpret and are influenced by dietary and physical activity messages (such as interpersonal, cultural, and media messages, as well as food labels) through 

research on learning, cognition, information processing, persuasive communications, and 

message framing.

• Determine whether federal farm promotion (“check-off”) programs that promote certain 

agricultural products have an impact on Americans’ compliance with the Dietary Guidelines.

• Compare medical and surgical treatments and lifestyle changes to identify those that are most 

effective in improving obesity and health outcomes in children and adolescents.

• Test models for delivering obesity prevention and treatment to change the behaviors of health 

practitioners and translate or disseminate evidenced-based therapies to primary care practices.

• Examine effects of targeted strategies focused on subpopulations at elevated obesity risk, such 

as those in racial and ethnic minority populations, tribal populations, lower socioeconomic 

status, rural communities, people with disabilities, and individuals taking medications that can 

increase body weight (such as psychotropics or insulin).

• Examine the efficacy of increased habitual sleep time on metabolic regulation such as reducing body weight, regulating appetite, and improving glucose tolerance and insulin sensitivity.
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III. Healthy Food in Schools

The school environment strongly impacts the behavior, and thus the health and well-being of the 

students. Over 55 million American children are enrolled in elementary or secondary school.

173 These 

children spend over six hours each day at school, on average.

174 Over 90% of enrollees attend schools 

that offer one or more Federal nutrition assistance programs.

175 In addition, many students consume 

foods sold at school, but outside the school meal programs. Most children eat at least one meal at school, 

either brought from home or provided by the school. Many will have more than one meal, along with 

snacks and other supplementary foods. 

Beyond this, various educational and related activities, both at school and traveling to and from 

school, have an important impact on students’ nutrition and physical activity behaviors. Children’s 

choices depend on what is most visible and easily accessible; seemingly small differences in the school 

environment can have large effects on what children eat. The “choice architecture” intentionally or 

unintentionally designed into the school nutrition environment can make a decisive difference in our 

children’s behaviors and health.

Unfortunately, some key aspects of current school meals, other foods at school, and environmental 

factors are contributing to obesity and failing to support good nutrition and physical activity behaviors.

This chapter outlines a range of actions that families, communities, businesses, and governments at all 

levels can take to improve school foods and the school nutrition environment so they support and foster 

healthier food choices and help reduce childhood obesity. It focuses on four major areas:

• improvements in the quality of school meals; 

• changes in other foods available at school to ensure that all food sold at school support healthful diets; 

• modifications to curriculum, school program operations, and community policies and infrastructure to match changes in school foods; and

• revisions to policies and practices in juvenile justice and other institutional settings to ensure 

that all childhood and youth environments support healthy eating.

A. Quality School Meals

Meals provided under the federally-financed National School Lunch Program and School Breakfast 

Program must meet a range of food-based and nutrient-based standards to ensure they contribute 

effectively to a good diet. The most recent national study of the content of such meals, however, found 

that they were not always meeting program standards.
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• In the 2004-05 school year, although most school meals were consistent with meal pattern 

requirements and provided most key nutrients, 93-94% of meals failed to meet all nutritional 

standards, primarily due to not meeting standards for fat, saturated fat, or calories.

176

• Most schools offered students the opportunity to select a balanced meal, but few students made 

the healthful choice. In about 90% of all schools nationwide, a student had opportunities to 

select low-fat lunch options, but in only about 20% of all schools did the average lunch actually 

selected by students meet the standards for fat.

177

• Schools offered few whole grain foods in the school year 2004-05, and french fries and other 

similar potato products accounted for a disproportionate amount of the vegetable options on 

school lunch menus.

• Since the last time the Nutritional Standards and Meal Requirements for schools were set, the 

Dietary Guidelines have been updated. The Institute of Medicine recently provided recommendations for updated nutrition standards consistent with the 2005 Dietary Guidelines.

178

Those recommendations include increasing the amounts of fruits, vegetables and whole grains; 

reducing the amount of sodium and saturated fat provided; and setting a minimum and maximum number of calories for school meals. This must be done in a manner that is appealing and 

appetizing to children and in conjunction with effective nutrition education that helps students 

select and consume these foods. USDA is currently developing a regulatory proposal to guide 

schools in implementing updated standards.

Schools Meeting Nutrition Standards for

National School Lunch Program Meals, 2004-05

Source: U.S. Department of Agriculture, Food and Nutrition Service, Oce of Research, Nutrition and Analysis,

School Nutrition Dietary Assessment Study-III, Vol. I: School Foodservice, School Food Environment, and Meals O ered 

and Served, by Anne Gordon, et al. Project Ocer: Patricia McKinney. Alexandria, VA: 2007

0

20

40

60

80

100

Meals Served

Meals Oered

All 

Standards

Saturated Total Fat

Fat

Protein Calcium Vitamin A Vitamin C Iron Calories

100% 100% 99%

92%

88%

73%

88%

73% 71%

49%

86%

83%

28% 30%

19% 21%

6% 7%

Only 6-7% of schools

met all required standards
I I I . Healthy Food in Schools

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Recommendations

The meals served through the National School Lunch Program (NSLP) and the School Breakfast Program 

(SBP) are the main nutrition intervention in elementary and secondary schools, and are a substantial part 

of the diets of many school children. For schools to contribute effectively to reshaping eating behaviors, 

the meals offered at schools must model healthful choices and help improve healthful dietary intakes.

Because school meals programs operate as partnerships between local schools, communities, state 

educational agencies, and the Federal government, a multi-faceted strategy is needed to promote 

positive change. Key actions can help advance this goal.

Recommendation 3.1: Update Federal nutritional standards for school meals and improve the 

nutritional quality of USDA commodities provided to schools. USDA should issue revised meal pattern 

requirements for the National School Lunch and School Breakfast Programs based on the Institute of 

Medicine’s recommendations for standards that conform to the 2005 Dietary Guidelines for Americans.

While most of the foods used to prepare program meals are purchased by schools, foods that USDA 

distributes to schools are an important component of school meals. In recent years, USDA has made 

great improvements in the nutritional profile of foods that it gives to schools through its commodity 

support programs by reducing fat, sodium, and added sugars in many of its offerings. USDA should 

continue to seek and implement more improvements from commodity suppliers and reprocessors, 

and ensure that ordering and distribution systems favor school foods that meet the updated standards.

Engaging the Community to Improve School Food: Aptos Middle School, San Francisco, CA

Beginning in the 2003-04 school year, the San Francisco Unified School District began implementing new 

school policies that set nutritional requirements for all foods sold in school. The changes were developed 

through the involvement of parents, community leaders, public health practitioners, and local physicians, 

spearheaded by a local organization, Parents for Public Schools in San Francisco, to implement changes in 

school food.

At the same time, parents at San Francisco’s Aptos Middle School launched an effort specific to their school 

to change and improve the items sold on the snack bar menu. Student input on menu choices was an 

important guide to the menu changes. The success of the changes at Aptos in the 2002–03 school year 

helped establish the basis for the city-wide standards the following year.

The results include:

• Increased student satisfaction with school meals and increased participation in school meals programs.

• Increased service of fruits and vegetables.

• Better nutritional content of a la carte foods and increased revenue.

Source: Wojcicki, J.M., Heyman, M.B. (2006). Healthier Choices and Increased Participation in a Middle School Lunch Program: Effects 

of Nutrition Policy Changes in San Francisco.American Journal of Public Health, 96(9), 1542-1547.
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The HealthierUS Schools Challenge establishes rigorous criteria for schools’ food quality, participation 

in meal programs, physical activity, physical education, and nutrition education–the key components that 

make for healthy and active kids–and provides recognition for schools that meet these criteria.

Schools can participate in this model program by going to http://www.fns.usda.gov/tn/healthierus/index.html

and learning about the range of educational and technical assistance materials that promote key aspects 

of the Dietary Guidelines, including a Menu Planner for Healthy School Meals, which provides tips on 

serving more whole grains, fruits, and vegetables, and lower amounts of sugar, sodium, and saturated and 

trans-fats in school menus.

Food service workers in more than 75% of America’s schools—along with principals, superintendents, and 

school board members across America—have committed to work together to reach Let’s Move!

Challenge goals.

Recommendation 3.2: Increase resources for school meals. Improving meals requires an investment 

in better foods, as well as modernized preparation and service equipment. Costs for meal programs are 

shared by Federal, Tribal and state governments and families of participating children, and they each 

have a role in supporting meal improvements.

• The Federal government should increase program reimbursements to support the provision 

of healthier foods.

• States and local communities should ensure that only costs that support preparation and service 

of school meals are charged to food service accounts, and seek opportunities to focus additional 

resources on meal improvements as budgets permit.

• Local communities should review their school meal pricing policies to ensure that revenue for 

meals only partially subsidized by USDA (i.e. “paid meals”) keeps pace with free meals, in order 

to support full and prompt implementation of updated meals.

• School food service companies and other suppliers should constantly seek ways to improve the 

nutritional quality of the food they provide without increasing prices.

Recommendation 3.3: USDA should continue its outreach and technical assistance to help provide 

training for school food service professionals. To provide top-quality meals that are both healthy and 

appealing to students, local food service professionals need the tools, skills, and techniques to prepare 

and serve those meals. USDA should continue its program to build skills through guidance and technical assistance, and develop updated resources to support new standards. School districts should be 

encouraged to make meal improvements, as well as the food preparation training and knowledge a 

priority for their local food service team. Tribal, state and local policymakers can support these changes 

with accreditation requirements for food service professionals, and training funds to meet and sustain 
I I I . Healthy Food in Schools

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the requirements. Private sector partners, from philanthropy to chefs, can help support and provide 

this training.

Recommendation 3.4: Schools should consider upgrading their cafeteria equipment to support 

the provision of healthier foods, for example, by swapping out deep fryers for salad bars. Federal 

resources that were recently made available for this purpose were heavily over-subscribed, indicating a 

strong level of local interest in making these kinds of changes. To supplement public resources, private 

companies that manufacture this equipment, companies that benefit from the sales of healthier products, and philanthropic partners should explore ways to make these items more affordable for schools.

Recommendation 3.5: USDA should work with all stakeholders to develop innovative ways to 

encourage students to make healthier choices. Putting better meals on the lunch line is not enough.

The prominence, visibility, and easy accessibility of particular foods greatly matter and will inevitably 

have an effect on choice.

179 Where possible, healthy foods should be offered and presented in ways 

that encourage students to choose and consume them. This can improve students’ food selection and 

consumption. For example, schools can automatically provide vegetables with an entrée unless the 

student switches to a less nutritious side dish. USDA should support the development and demonstration of innovative strategies and schools should use them to make healthy meal choices easy and 

compelling for students.

Recommendation 3.6: USDA should work to connect school meals programs to local growers, and use 

farm-to-school programs, where possible, to incorporate more fresh, appealing food in school meals.

Schools should be encouraged to seek opportunities to purchase foods from local farm cooperatives.

USDA should work through its “Know Your Farmer, Know Your Food” initiative and Farm to School Tactical 

Team to identify and eliminate regulatory barriers to local procurement, assist schools in accessing local 

markets, and enable food producers to effectively serve their local schools. USDA, the Bureau of Indian 

Affairs and the Bureau of Indian Education at the Department of the Interior, should also collaborate 

to increase local, traditionally appropriate foods in Tribally-controlled school meal programs, such as 

bison and salmon.

Listening to Student Customers:“NoThankYou Bites”at Baltimore Public Schools

Chef Tony Geraci, Baltimore City Food Service Director, has undertaken a wide variety of strategies to 

engage students in making healthier choices in his low-income district. One of the most innovative is 

“No Thank You Bites,” in which schools make available to students two-ounce samples of a new entrée, 

fruit or vegetable item. Students that try a sample are given star stickers. Each month, students with stars 

are invited to a “Constellation Party,” at which Geraci and other district food service professionals are able 

to talk to the students about their preferences among the samples, and meal offerings more generally. 

Samples that are popular become part of the menu, and all of the input is used to shape future options.

As Geraci explained in Congressional testimony last fall, “We’re treating kids like the savvy consumers they 

are.... If a student likes what she tries, great. If not, she simply says, ‘No thank you.’ But everyone who 

works with us to expand their palates and their minds is rewarded and we listen to their suggestions.”
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Recommendation 3.7: Schools should be encouraged to make improvements in their school meal 

programs through the HealthierUS Schools Challenge in advance of updated Federal standards.

While Federal school meal standards are being updated, schools should be encouraged to start immediately to improve their food offerings by committing to meeting the Challenge. Many already have, with 

over 650 schools certified to date. Challenge schools meet a range of high standards for the quality of 

school meals and all food sold in school, as well as a number of other important criteria. As part of the 

First Lady’s Let’s Move campaign, the Administration is actively promoting and encouraging schools to 

meet the Challenge criteria. Food service workers in more than 75% of America’s schools—along with 

principals, superintendents, and school board members across America—have already committed to 

work together on this effort.

180

Benchmarks of Success

Achieving the HealthierUS School Challenge goals. Double the number of schools that meet the 

Challenge criteria by June 2011, and add another thousand schools in each of the following two years.

All elementary andsecondary schoolsofferingmealoptions thatmeet standards fortotalfat and

saturated fat by 2015. This can be measured by the USDA-commissioned School Nutrition Dietary 

Assessment Study. Assuming funds continue to be made available for this survey on a regular five year 

schedule, data on school year 2014-15 would be published in early 2017.

B. Other Foods in Schools

Foods offered in addition to and in competition with the meal program often do not contribute to a 

good diet. Such foods can be sold in the cafeteria, snack bars, vending machines, or other venues. Unlike 

foods served as part of the school meals programs, these foods are exempt from most Federal nutrition 

requirements. Often prominent and visible in schools, they contribute to obesity and unhealthy food 

choices.

A la carte lines allow students to choose cafeteria foods that may be part of a Federally-reimbursable 

program meal, without choosing healthy meal components that make that meal consistent with nutrition standards. As a result, students who choose a la carte foods are less likely to consume appropriate 

amounts of key foods and nutrients than those who do not.

181

Many schools offer foods in vending and snack bars that may undermine more balanced offerings at 

meal time. Foods commonly available in these venues include cookies, crackers, pastries, and other 

high-fat baked goods, as well as salty snacks and sports drinks.

182 

Some schools rely on food sales to cover the cost of extracurricular activities and other expenses.

183 This 

can lead to offerings driven by popularity and revenue potential, rather than nutrition. However, many 

schools found that offering healthier foods did not decrease revenue, and in some cases, increased 

revenue.

184

In too many schools, such foods facilitate poor nutritional choices for students,185 and accustom children 

to poor dietary practices that may ultimately contribute to obesity. They also undermine parents’ efforts 
I I I . Healthy Food in Schools

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to promote a healthy diet for their children. Evidence in some states reveals that setting standards 

for foods competing with program meals can improve students’ consumption of more healthy food 

options.

186

Recommendations

Like school meals, local schools must work hand-in-hand with Federal, Tribal, and state governments to 

reshape their competitive food policies. Key actions can help advance this goal.

Recommendation 3.8: Increase the alignment of foods sold at school, including in the a la carte 

lines and vending machines, with the Dietary Guidelines. Under current law, USDA has very limited 

authority to set and enforce standards for foods regularly sold outside the Federally-supported school 

meals programs. In the upcoming reauthorization of the Child Nutrition programs, the Administration is 

committed to gaining authority to develop and issue these standards for schools participating in USDA 

programs, and the food and beverage industry has stated its strong support for Congress providing 

USDA with this authority.

187 The standards would be developed through a transparent and participatory 

public rulemaking process, and the Institute of Medicine’s evidence-based recommendations for such 

standards188 can serve as a foundation for the USDA’s proposal.

Recommendation 3.9: Food companies should be encouraged to develop new products and reformulate existing products so they meet nutritional standards based on the Dietary Guidelines and 

appeal to children. Food manufacturers and marketers have a critical role to play in meeting new standards, and have already shown an ability to adapt their products to appeal to more nutrition-conscious 

consumers over the past several years. These industries should be encouraged to continue to use their 

energy and ingenuity to develop foods that schools can offer within and outside of the school meals 

programs. These foods should support healthy diets and offer the taste and convenience needed to 

appeal to students. For example, food companies should be encouraged to:

• Offer whole grain-rich bread and cereal products such as sandwich rolls and pastas;

• Reformulate entrees, sauces, and condiments to contain less sodium, while incorporating 

alternative flavorings and seasonings to maintain palatability; and

• Reduce the high levels of added sugars in many flavored milks and yogurts.

Benchmarks of Success

Assuming newFederal standards forthe nutritionalquality of allfoods inschools are ineffectby

2013, schools should achieve full substantive compliance by that date. In the meantime, progress 

can be measured by an increase in the number of schools meeting the HealthierUS School Challenge, 

described above. “Substantive compliance” is meant to denote full consistency between all foods sold 

in school and Federal standards; any non-compliant schools should be working on USDA-approved 

corrective actions to achieve substantive compliance.
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C. Food-Related Factors in the School Environment

Many facets of the school setting can affect children’s dietary choices. Some operate directly on their 

eating behaviors, while others are more subtle. In too many schools, the connection between service 

of meals and other foods at school and the responsibility to educate, enable, and motivate healthful 

nutrition habits is weak or non-existent.

Nutrition Education

More, and better, nutrition education is needed in many schools. While approximately 75% of schools 

require nutrition education as part of health curriculum requirements, the time spent on nutrition 

and dietary behavior has declined in recent years, and funding has been limited.

189 Many teachers are 

not equipped with the skills and knowledge to integrate and promote nutrition education into their 

classroom curricula. Research has shown that nutrition education interventions, if well designed and 

effectively implemented can improve dietary behaviors.

190 

Lunch Room Environment

Eating behaviors can also be shaped by the cafeteria and lunch room setting, such as the display and 

description of food and beverages, pricing and methods of payment, and the length of time and time 

of day made available to eat.

191 Some experiments indicate that these factors can promote healthy 

choices,192 although it is not yet clear precisely how such strategies can best be applied in schools. 

In addition, some schools’ meal service arrangements discourage some children, particularly low-income 

children, from taking advantage of school meals, undermining the impact of improvements in the 

nutritional quality of those meals. For example, one survey found that one-third of high schools had 

separate lines or rooms for the school lunch program and competitive foods. In many of those schools, 

the vast majority of the students standing in the lunch line were low income.

193 Marketing of food and 

beverages within schools has also grown substantially in recent years, and may influence food choices 

in ways that do not contribute to good health.

194

In addition, some middle and high schools permit students to leave campus for lunch. One study found 

that 29% of high schools reported having an “open campus” lunch policy.

195 For those who eat lunch 

off-campus, improvements in school meals will have little impact on their dietary intake. Some schools 

are also surrounded by fast-food restaurants with few healthy options.

196 

Schools should also be made aware of factors that can impact a child’s decision about what to eat, 

including food allergies and religious restrictions, and they should be encouraged to use existing options 

to accommodate children’s needs.

Recommendations

Recommendation 3.10: USDA and the U.S. Department of Education should collaborate with states 

to increase the availability and consistency of nutrition education in schools. States should be encouraged to ensure that teacher preparation requirements include basic nutrition knowledge and nutrition 

education as part of every teacher’s skill set. USDA and the U.S. Department of Education should work 

together to improve national standards and requirements for nutrition education. Teachers in local 
I I I . Healthy Food in Schools

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schools can explore interdisciplinary approaches to incorporate healthy eating in the school curriculum 

(for example, history may have a subject related to healthy diets, math may include how to calculate 

the needed caloric intake, foreign languages may have students design a menu). The Bureau of Indian 

Education, Teach for America, and other teacher corps programs could also expand their partnership 

to include nutrition education.

Recommendation 3.11: Where possible, use school gardens to educate students about healthy eating. School gardens offer opportunities for fun and physical activity while also serving as an important 

educational tool to help students understand how healthful food is produced. Some research suggests 

that school gardens used as part of a nutrition education strategy can increase knowledge of fruits 

and vegetables and influence behavior change among children.

197 Schools can further make the link 

between agriculture and nutritious food by inviting local farmers markets to operate from area school 

yards. Parents and students can also share their knowledge when shopping together for locally grown 

fruits and vegetables or participating in Community Supported Agriculture programs.

Recommendation 3.12: Technical assistance should be provided to schools about how to a cafeteria 

and lunch room environment can support and encourage a healthful meal. Factors such as the timing 

and length of the meal period; cleanliness and noise level in the dining room; and adequate space for 

eating can all play a role in what children consume. 

Recommendation 3.13: Schools should be encouraged to ensure that choosing a healthy school meal 

does not have a social cost for a child. Efforts that make school meals more nutritious and appealing 

cannot effectively improve students’ choices if other factors undermine their opportunity to select 

them. For example, many schools provide reimbursable meals at a different serving station than a la 

carte foods. Children can be discouraged from considering full meals if they are not exposed to them.

Furthermore, in schools where most meals are served free or at reduced-price, separating lines can create 

a perception that program meals are intended only for lower-income students, potentially creating a 

stigma that prevents children who cannot afford a la carte food from eating at all.

198 Schools should be 

encouraged to examine their operational practices to ensure that all students have a full opportunity 

to consider and choose a school meal.

Recommendation 3.14: Schools should be encouraged to consider the impact of food marketing on 

education. Food marketing can occur at school in a number of forms, including on scoreboards, food 

display cases, and vending machines; in student publications, educational materials provided “free” by 

food firms, branded fundraisers and food reward programs; and even market research conducted on 

campus.

199 Schools should be encouraged to limit school-based marketing that contributes to poor 

health. Private companies should be encouraged to voluntarily shift towards the promotion of healthy 

foods and away from advertising that promotes unhealthy products. 

Recommendation 3.15: School districts should be encouraged to create, post, and implement a 

strong local school wellness policy. Recognizing the critical role schools play in promoting students’ 

health, preventing childhood obesity, and combating poor nutrition and physical inactivity, Congress 

passed a law requiring school districts to establish a local wellness policy in 2004. This policy would 

sets goals for nutrition education, physical activity, campus food provision, and other school-based 

activities designed to promote student wellness. School boards and other community leaders should 
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work to ensure this policy reflects the abovementioned recommendations, while tailoring them to 

their communities’ needs. Tribes can work with the National Indian Education Association and National 

Indian School Board Association to develop an effective school wellness policy that reflects Tribal values 

and culture. USDA should also seek authority in the Child Nutrition and WIC Reauthorization Act to 

strengthen school wellness policy development, implementation, monitoring, and evaluation. The U.S.

Department of Education should work with USDA to support these efforts.

To aid in the development and implementation of the wellness policy, schools should consider establishing a health advisory council, as a number of communities have done. These councils, comprised of 

school officials and staff, parents, local public health authorities, and other community members, foster 

an exchange of information on a wide range of issues that influence the local school environment. They 

also provide support, oversight, and accountability for school nutrition improvement efforts.

200 

Benchmarks of Success

Increase in the number of school districts that provide a healthful school environment, which 

could include such features as nutrition education integrated into school programming; lunch room 

environments that support healthy eating; strong marketing policies; and a school health advisory 

council. Progress can be assessed using data from the School Health Policies and Programs Study 

(SHPPS), which is conducted every six years by CDC’s National Center for Chronic Disease Prevention 

and Health Promotion. The most recent SHPPS data is for 2006; the next study will be done in 2012 and 

released in 2013.

D. Food in OtherInstitutions

Other institutions that play a significant role in the lives of children and young adults do not consistently 

support healthful nutrition behaviors. 

Afterschool Programs

For many children, school activities do not end when the last bell rings. Afterschool programs, such 

as expanded day care centers, tutoring and other instruction programs, and 21st Century Community 

Learning Centers, serve children in elementary schools across the nation. In 2008, 56% of public elementary schools offered one or more such programs.

201 As with school during regular hours, the afterschool 

environment influences the eating behaviors of participating children. Because many of these programs 

operate in low-income communities where access to food may be more limited, incorporating healthful 

meals and snacks can be especially important. Federally-supported afterschool snacks are available 

through the National School Lunch Program (NSLP) and the Child and Adult Care Food Program (CACFP).

Support for more substantial meals like supper is available through CACFP for low-income communities, 

but currently in only a limited number of states.
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Juvenile Detention and Correctional Settings

While limited research exists on the nutritional services for youth in the juvenile detention and correctional facilities, anecdotal evidence suggests that many detained and incarcerated youth consume 

diets high in fat, cholesterol, and sodium and low in fresh fruit and vegetables. These types of diets are 

particularly problematic for incarcerated youth with special dietary needs. In addition, facilities may 

not employ or have access to licensed nutritionists or dietitians to oversee institutional food services.

Providing appropriate nutrition in juvenile detention and correctional settings is underscored by the 

population size and the risk factors for weight related problems facing these youth. Data shows that 

in 2007 more than 360,000 delinquency cases resulted in youth being placed in secure detention and 

nearly 149,000 resulted in youth being placed out of their home.

202 During a one-day count in 2008, 

approximately 80,000 youth were housed in 3,000 publicly and privately operated juvenile facilities, 

including public, private, and tribal facilities.

203

Many of these young people are at risk for or have serious health concerns that are often undiagnosed 

or untreated, and they experience physical and mental health problems at rates exceeding those in 

the general youth population.

204 They are frequently children who have experienced severe familial 

dysfunction, witnessed violence, or have been victims of physical and sexual abuse.

205 

Many juvenile detention centers operate the National School Lunch Program and School Breakfast 

Program, but it is unclear how many such institutions offer meals that are consistent with the programs’ 

nutritional requirements. Effective nutrition education, institutional food services, culinary arts, and 

recreational programming are critical components in addressing the overall health care needs of this 

vulnerable group. 

Recommendations

Recommendation 3.16: Promote good nutrition through afterschool programs. Afterschool programs face distinct circumstances and challenges beyond those that impact children and young 

people during the school day. States and communities can develop standards and strategies tailored 

for afterschool programs by building on and integrating the afterschool snack components of USDA’s 

Child Nutrition programs. The Federal government could develop and offer model approaches and 

resources to inform these efforts.

Recommendation 3.17: Promote healthy behaviors in juvenile correctional and related facilities.

States and localities should be encouraged to ensure that juvenile justice facilities use nutrition programs 

available to them, such as USDA’s school meal programs. Federal, state, and non-governmental organizations should collaborate to develop evidence-based programs and standards for health promotion and 

disease prevention services, including nutrition counseling, meal services, and recreational programs 

that meet the needs and circumstances of juvenile justice populations. Related programs such as 

organic fruit and vegetable gardening, farming, and culinary arts initiatives in juvenile justice facilities 

can potentially promote health, education, workforce development, and positive youth development.
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Benchmarks of Success

As this area is explored further, it may be appropriate to develop benchmarks to track progress in 

improving nutritional outcomes in these settings.

Key Questions for Future Research

• How can we make healthy foods more affordable for use in schools? And more attractive to 

children?

• What can we learn from behavioral economics to support healthful eating in schools, and how 

can schools promote healthful eating over the longer term?

• What are the correlative and/or causal linkages between exposure to food marketing in schools 

and food consumption patterns or obesity?

• How can effective school-based nutrition education models be identified and scaled up to 

national implementation?

• How does participation in the afterschool snack and meal programs supported by USDA affect 

children’s diets, opportunities for nutrition education and physical activity?

• To what extent are health promotion and disease prevention services such as nutrition counseling, improved diet, and recreational programs, provided to youth in the juvenile justice system? 

What evidence-based food services, nutritional education, and exercise programming can best 

address the needs of youth involved in juvenile justice systems?
★ 49 ★

IV. Access to Healthy, Affordable Food

Healthy options can be hard to find in too many communities. Millions of low-income Americans 

live in “food deserts,” neighborhoods that lack convenient access to affordable and healthy food.

Instead of supermarkets or grocery stores, these communities often have an abundance of fast-food 

restaurants and convenience stores. In addition, stores in low-income communities may stock fewer 

and lower quality healthy foods. When available, the cost of fresh foods in low-income areas can be 

high. Public transportation to supermarkets is often lacking, and long distances separate home and 

supermarkets in many rural communities and American Indian reservations. It is hard for residents of 

these areas—even those fully informed and motivated—to follow the necessary and recommended 

steps to maintain a healthy weight for themselves and their children. Too often, economic incentives 

strongly favor unhealthy eating, and accessibility, safety concerns, and convenience can also promote 

unhealthy outcomes.

Limited access to healthy food choices can lead to poor diets and higher levels of obesity and other 

diet-related diseases. In addition, limited access to affordable food choices can lead to higher levels of 

food insecurity, increasing the number of low- and moderate-income families without access to enough 

food to sustain a healthy, active life. There is a growing, though incomplete, body of research that finds 

an association between food insecurity and obesity, suggesting that hunger and obesity may be two 

sides of the same coin.

Many communities around the country have already taken steps to make healthy and affordable foods 

accessible to all residents because of the potential to improve diet quality and reduce obesity, as well 

as to create jobs, increase local investment and economic activity, and revitalize neighborhoods. This 

chapter recommends a comprehensive approach that builds on a promising start to mobilize public 

and private sector resources to make the healthy choice the easy choice for all Americans.

Specifically, this chapter lays out four key elements for ensuring access to healthy, affordable food:

• Convenient physical access to grocery stores and other retailers that sell a variety of healthy 

foods; 

• Prices that make healthy choices affordable and attractive;

• A range of healthy products available in the marketplace; and

• Adequate resources for consumers to make healthful choices, including access to nutrition 

assistance programs to meet the special needs of low-income Americans.

A. Physical Access toHealthy Food

Too many Americans live in communities with limited access to supermarkets and grocery stores.

Nationwide, USDA estimates that 23.5 million people, including 6.5 million children, live in low-income 

areas that are more than a mile from a supermarket. Of the 23.5 million, just under half have incomes 

at or below 200% of the poverty line, and almost 1 million do not have access to a car. USDA estimates 
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that 2.3 million people live in low-income rural areas that are more than ten miles from a supermarket; 

and again, just under half have low incomes.

206 

Limited access to healthy foods plays a significant role in poor dietary decisions. A scarcity of healthy 

foods makes it more difficult for low-income residents to adhere to a nutritious diet than for their 

counterparts in wealthier, resource-rich neighborhoods.

207 Residents with better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower levels of obesity.

Although less consistent, studies do suggest that residents with limited access to fast-food restaurants 

have healthier diets and lower levels of obesity.

208

Access to supermarkets, grocery stores, and specialty markets is important, in part, because they give 

consumers access to a variety of fruits and vegetables. Diets rich in fruits and vegetables offer a number 

of health benefits209 and have been linked to a lower prevalence of obesity or reduced weight gain.

210 

Most Americans, especially those with low income, consume far fewer fruits and vegetables than recommended by current dietary guidance,211 and a lack of easy accessibility may be one reason. A number of 

studies suggest that better retail access corresponds with healthier eating. Residents with more access 

to supermarkets or a greater abundance of healthy foods in neighborhood food stores consume more 

fresh produce and other healthful items. Without nearby access to healthy ingredients, families have a 

harder time meeting recommended dietary guidelines.

212

Some research has found significant associations between the availability of food stores and adolescent 

BMI. The availability of chain supermarkets was associated with lower adolescent BMI and overweight 

status, while the availability of convenience stores was associated with higher adolescent BMI and 

overweight status.

213

Many factors contribute to an individual’s overall diet, body weight, and the risk of developing dietrelated diseases such as diabetes or cardiovascular disease. Individual factors can explain some but 

not all of the differences in the rates in which different groups experience these problems. Attention 

on the relationship between retail food access and obesity has increased as researchers obtain a better understanding of the factors besides individual behaviors that may lead to differences in diet and 

health outcomes.
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FoodDeserts in Urban and Rural America
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Creative tools can be used to assess a community’s needs. For example, Michigan’s Department of Public 

Health has developed an online Nutrition Environment Assessment Tool (NEAT) to help communities 

assess the extent to which they promote and support healthy eating.

 214 The U.S. Department of Defense 

adopted this tool for use by commanding officers and other stakeholders to make similar assessments 

of military communities and facilities.

215 A number of policy interventions can lead to improved access 

to healthy, affordable food. Communities can bring supermarkets to underserved neighborhoods, help 

smaller groceries or corner stores expand their stock of healthy and affordable food, and develop other 

retail outlets such as farmers’ markets, public markets, cooperatives, farm stands, community-supported 

agriculture, and mobile vendors. These efforts also create jobs, bolster local economies, and revitalize 

neighborhoods, contributing to local economic development. A number of communities have undertaken these kinds of efforts, through projects such as Pennsylvania’s Fresh Food Financing Initiative.

Direct-to-consumer marketing outlets provide another path to increase healthy food access in underserved areas and stimulate economic development in rural communities across America. These opportunities, including farmers’ markets, farm stands, and community supported agriculture enterprises, are 

currently promoted by the USDA through its Know Your Farmer, Know Your Food Initiative.

There are also many publicly and privately managed facilities that are frequented by children and their 

families, including at meal times, such as national, state, and local parks, as well as privately-run amusement parks, sports venues, and other recreational facilities for children. These places can be considered 

small scale “food deserts” because meals or snacks are available for purchase but few, if any, healthy 

options are available.

Faith-based Organizations Find Creative Solutions to“FoodDeserts”

There is no one-size-fits-all solution to the problem of food deserts in America.  In some communities, it 

may be economically feasible to bring in a supermarket and sustain it over time; in others, the solution may 

be a mobile grocery store that comes through town once a week but provides access to healthy foods that 

community residents otherwise would lack.  

Some of the most creative strategies have come from faith-based organizations, many of which have a 

long tradition of helping to meet the food needs in their communities, through food pantries and other 

anti-hunger efforts. Here are just a few examples:

• The Central Detroit Christian Community Development Corporation operates the “Peaches & Greens”

ProduceTruck, which travels through the streets of central Detroit like an ice cream truck, stopping to 

sell fruits and vegetables to area residents.  The organization has also arranged for a number of corner 

stores to sell “Peaches & Greens” produce.

• In South Los Angeles, the First African Methodist Episcopal Church has arranged for the open-air So

Fresh Market to operate in its parking lot. The market welcomes families to participate in free activities 

and live entertainment, while fresh and natural foods are sold to promote a healthy lifestyle and patrons 

are invited to watch as cooks present quick and easy meal demonstrations.  Partnering with the market 

is part of a broader effort by the church to promote healthier eating among African Americans in the 

community.
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Recommendations

Recommendation 4.1: Launch a multi-year, multi-agency Healthy Food Financing Initiative to 

leverage private funds to increase the availability of affordable, healthy foods in underserved urban 

and rural communities across the country. As proposed in the President’s FY11 Budget, through this 

initiative, USDA, HHS, and the Treasury Department will partner to make over $400 million available to 

community development financial institutions, nonprofits, public agencies and businesses to promote 

interventions that expand access to nutritious foods. Such interventions include helping grocery stores, 

small businesses, and other retailers provide healthy food options in lower-income communities.

Interventions may also include helping improve supply chains to bring fruits, vegetables, and other 

healthy foods from rural agricultural areas to urban stores and markets. Private sector investments are 

a critical part of this initiative’s success, since they provide up-front capital and sustain the investments 

until these stores have a chance to establish themselves in the community and build a strong customer 

base.

In addition to these new resources, communities can access existing Federal grant and loan programs, 

as well as state, local, and private funds to create market opportunities for producers and to support 

regional planning systems that ensure greater access to healthy food in underserved areas. Resources 

include USDA’s Farmers’ Market Promotion Program, Specialty Crop Block Grants, Community Food 

Projects, Community Facilities Program, Business and Industry Guaranteed Loan Program, Healthy 

Urban Food Enterprise Development Center, and Sustainable Communities Regional Planning grants; 

HHS’ Community Economic Development Program; and the U.S. Department of Housing and Urban 

Development’s Community Development Block Grant and Choice Neighborhood initiative.

Land Use and Food System Planning

Many communities have had an opportunity to promote access to fresh foods and urban agriculture as a 

component of their land-use and food system planning processes. Across the country, projects are helping 

to create, enable, and fund community garden and urban agriculture programs, and developing zoning 

and permitting processes friendly to urban agriculture and healthy food access. Community gardens can 

provide culturally significant foods not available in local grocery stores. For example:

• The city of Fresno changed its zoning ordinance to allow farmers markets in all non-residential and 

certain single-family residential zones. Now, Fresno planners want to plan for urban agriculture in newly 

developing areas.

• Vendors in Kansas City who sell healthy foods pay a reduced permit fee. City planners also list recommended and excluded products for public vending in the city’s parks and recreational areas.

• New York City uses a combination of incentives and restrictions to get green produce carts in areas of 

the city with the least access to fresh fruits and vegetables.

• Detroit and Cleveland have reclaimed acres of vacant land and lots for community gardens.
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Recommendation 4.2: Local governments should be encouraged to create incentives to attract 

supermarkets and grocery stores to underserved neighborhoods and improve transportation routes 

to healthy food retailers. Incentives could include tax credits, grant and loan programs, and small 

business or economic development programs. Communities could also develop zoning requirements 

that create safe, non-motorized routes such as sidewalks, pedestrian malls, and bicycle paths between 

all neighborhoods and supermarkets, grocery stores, or other retailers who sell healthy food.

216 Local 

communities can also commit job training resources to ensure that a well-trained workforce is available 

for healthy food retailers who are considering locating in their area.

Recommendation 4.3: Food distributors should be encouraged to explore ways to use their existing 

distribution chains and systems to bring fresh and healthy foods into underserved communities. The 

private supply chains that have been developed to bring healthy foods to restaurants and less healthy 

items to corner stores and grocery stores should be deployed to bring healthy foods to communities 

that lack these retail options. USDA, as part of its Know Your Farmer, Know Your Food initiative, can also 

play a role in developing food hub distribution centers to increase opportunities for regional distribution.

Recommendation 4.4: Encourage communities to promote efforts to provide fruits and vegetables 

in a variety of settings and encourage the establishment and use of direct–to-consumer marketing 

outlets such as farmers’ markets and community supported agriculture subscriptions. Options that 

communities could consider include the following:

• Promote the use of WIC cash value vouchers, WIC and Seniors Farmers’ Market coupons, and 

SNAP benefits in farmers markets and other settings where fruits and vegetables are sold;

• Fund outreach, education, and transportation to encourage residents of lower-income neighborhoods and nutrition assistance program participants to use farmers’ markets and farm stands;

• Use land use policies to promote, expand, and protect potential sites for community gardens 

and farmers’ markets such as vacant city-owned land or unused parking lots;

• Develop community-based group activities that link procurement of affordable, healthy food 

with improving skills in purchasing and preparing food;

• Provide incentives to purchase and sell local native-grown produce to Indian schools and communities; and

• Consider the adoption of ordinances or by-laws that promote healthy food vendors and mobile 

fruit and vegetable vendors in low-income and geographically isolated neighborhoods.

Recommendation 4.5: Encourage the establishment of regional, city, or county food policy councils 

to enhance comprehensive food system policy that improve health. Experience in some communities 

has shown that food policy councils can bring together citizens and government officials to examine 

state or local food systems. This unique form of civic engagement assembles diverse food system 

stakeholders to develop food and agriculture policy recommendations.

Recommendation 4.6: Encourage publicly and privately-managed facilities that serve children, 

such as hospitals, afterschool programs, recreation centers, and parks (including national parks) to 

implement policies and practices, consistent with the Dietary Guidelines, to promote healthy foods 

and beverages and reduce or eliminate the availability of calorie-dense, nutrient-poor foods. 
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Healthy Foods in Our Parks

Healthy food is often hard to come by on America’s public lands. Traditionally, concessioners have provided visitors with a limited number of options, many of which are calorie-laden and highly processed. 

In cafeterias and snack stands across the National Park System, concessioners are beginning to provide a 

broader range of healthy, organic, and local foods. The Park Service administers approximately 600 concessions contracts across its 392 units, grossing about $1 billion annually. Recently, individual parks have 

taken the lead in working with their concessioners to revamp and revitalize traditionally limited, menus. 

At Golden GateNational Parks’MuirWoodsTrading Post, Ortega Family Enterprises provides a range 

of low-sugar, reduced-calorie, and organic food, much of which is locally sourced. All of these items are 

affordably priced and have raised profits for the park and the concessioner alike. Similarly healthy offerings 

can be found at the company’s other National Park outposts in New Mexico. Healthful concessions are also 

found in Yellowstone and GrandTetonNational Parks, which offer a range of all-natural and vegetarian 

options. Far away from the big western parks, the Statue of Liberty boasts a range of healthy options in a 

densely populated urban area. Baltimore’s Fort McHenry is preparing to open a new cafeteria based on a 

model school lunch program. And on the National Mall, concessioners are now serving low-fat snacks like 

fruit and yogurt and lunches like vegetable hummus wraps. 

Benchmarks of Success

Eliminate food deserts in America in seven years. To monitor progress towards this goal, USDA 

will estimate the number of people in low income areas more than a mile from a supermarket or large 

grocery store (10 miles in rural areas) every three years beginning in 2012, using demographic data from 

the American Community Survey and store location information from commercial sources and USDA’s 

directory of stores authorized to accept SNAP benefits.

B. Food Pricing

Prices have a large effect on consumer choices. Consumer behavior has shifted as food prices have 

declined and low cost, energy-dense foods have become more convenient. Technological advances 

have made food cheaper. One study found that food prices dropped in comparison to all other goods, 

over a 50 year period.

217 But these price advantages do not extend to all types of food. Over the last 30 

years, prices for fruits and vegetables increased nearly twice as fast as the price of carbonated drinks.

218

An increase in the price of fruits and vegetables relative to less healthy foods can reduce consumers’ 

incentives to purchase fruits and vegetables, resulting in less healthy diets. Some analyses suggest that 

energy-dense foods composed of refined grains, added sugars, or fats remain the lowest-cost option to 

the consumer.

219 It is widely believed that American consumers have seen a significant increase in prices 

of fruits and vegetables alongside a decrease in the prices of foods that contribute to obesity. Because of 

quality improvements in fresh fruits and vegetables, however, it is difficult to draw conclusions about the 

trends in prices and incentives. One recent analysis found that prices declined for commonly consumed 

fresh fruits and vegetables for which quality has remained fairly constant, as well as for snack foods.

This evidence suggests that the price of a healthy diet has not changed relative to an unhealthy one.

220
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Nonetheless, it is not disputed that the prices of some unhealthy foods have fallen, and that prices play 

a significant role in consumer choices.

Prices change over time for a variety of reasons. Better production and distribution technologies generate more and better goods, driving down prices. Foods that once were available only seasonally are 

now available year-round. Advances in food processing and packaging have introduced a multitude of 

ready-to-eat foods, available virtually anywhere and anytime. Farm programs have been designed to 

stabilize crop prices for farmers and may affect production decisions, commodity prices, and ultimately 

the prices consumers pay. State and local sales taxes imposed on soft drinks, candy, and snacks raise 

their cost relative to other food purchases. Nutrition assistance programs subsidize meals for millions 

of low-income Americans, reducing the relative price of food compared to other consumer needs. As 

a result, there are many opportunities to affect the cost of healthy food.

Studies suggest that if the price of a particular food increases or decreases, consumption will decrease 

or increase. Research has found increases in purchases of healthier foods when prices are reduced, and 

decreases in purchases of less healthy foods as prices increase.

221 The potential influence of food prices 

on consumption necessitates consideration of the extent to which changes in farm, tax, and subsidy 

policies might affect consumption patterns.

Agriculture Policy

Since the Great Depression, American farm policy has been designed to stabilize crop prices, keep 

farmers producing food and fiber, and provide American families with an abundant, affordable, and 

reliable food supply. Eligible farmers receive support through a variety of Federal programs. Nearly all 

the subsidies go to growers of five commodities: soybeans, corn, rice, wheat, and cotton. In comparison, 

relatively few subsidies support fruit and vegetable farmers, although the Food, Conservation, and 

Energy Act of 2008 included, for the first time, $1.3 billion in new funding over 10 years for specialty 

crops—fruits, vegetables, and nuts—and increased programs that support local agriculture and healthy 

foods. It also included a pilot project to allow planting of fruits and vegetables on base acres for USDA’s 

farm commodity price and income support programs in a limited number of states.

Additional studies should be conducted to determine whether current agricultural policy has an impact 

on the availability and pricing of different types of food and American diets. For example, the orientation 

of farm program payments toward a group of commodities may have an impact on the composition of 

the food supply and the relative availability of certain commodities. USDA’s Economic Research Service 

has estimated that to establish a sufficient supply of fruits and vegetables for all Americans to meet the 

Dietary Guidelines, U.S. producers would have to more than double their fruit acreage (from 3.5 million 

acres today, to 7.6 million) and increase vegetable acreage by nearly one and a half times (from 6.5 million acres today, to 15.3 million).

222

In addition, some research on the link between obesity and farm programs finds that our farm programs 

have had small and mixed effects on farm commodity prices, resulting in smaller effects on relative retail 

prices. Over the past 15 years, most farm subsidies have been in the form of direct income support that is 

not connected to actual production. One analysis found that direct income support did not significantly 

affect the affordability of food, either on the whole or within food groups.

223
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While farm subsidies have lowered some commodities’ prices, their effects may be countered by policies that restrict acreage or production, which potentially increase prices. In addition, the cost of farm 

commodities represent only a small and shrinking share of the cost of retail food products, on average 

less than 19%, making changes in commodity prices translate to small changes in the prices consumers 

pay.

224 One study found, for example, that the corn content of high fructose corn syrup represented 

about 1.6% of the value of soft drink manufacturing costs and sugar just 0.1%. In turn, small changes 

in prices are likely to induce only small changes in consumption.

225 As noted above, however, further 

research can help respond to the underlying questions.

Tax Policy 

The Institute of Medicine and others have recommended that governments implement a tax strategy 

to discourage consumption of foods and beverages that have minimal nutritional value as a step in the 

fight against childhood obesity. Based on the notion that consumers will respond to the increased food 

cost by reducing their consumption, a tax could generate considerable revenue to fund obesity-fighting 

programs.

226 Many states already tax caloric-sweetened food and beverages.

The effectiveness of taxing food purchases primarily depends on the degree to which consumers are 

aware of and respond to changes in food prices. One review suggests that the percentage change in 

consumption is generally smaller than the percentage change in price.

227 Consumers may, however, be 

fairly responsive to a price change in caloric-sweetened sodas, fruit drinks, and sports drinks. The extent 

of the response would certainly be affected by the size of the change in price. Recent research indicates 

that current state-level tax rates on soda purchases have had a relatively small impact on adolescent228 

and adult weights.

229 But a higher tax rate would likely have a greater impact on consumption, as evidenced by the effects of the substantial rise in tobacco taxes.

230

Major Federal Commodity Subsidies, FY 2009

(in Millions of Dollars)

Source: U.S. Department of Agriculture. (2010). Agricultural Outlook: Statistical Indicators, Table 35.

Retrieved April, 2010 from http://www.ers.usda.gov/Publications/AgOutlook/AOTables/

0

500

1,000

1,500

2,000

2,500

Grain Barley Peanuts

Sorghum

Cotton Corn Wheat Dairy Soybeans Rice

$2,176 $2,175

$1,224

$994

$596

$197

$98 $84

$411
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Retail State sales and vending machine “snack tax” rates, 2009

SalesTax Vending MachineTax

Product Number 

of States

Average

Tax Rate

Min

Rate

Max

Rate

Number

of States

Average

Tax Rate

Min

Rate

Max

Rate

Soda 33 5 2 1 2 7 0 39 5 3 1 2 8 0

Candy 29 4 8 1 0 7 0 37 5 1 1 0 8 0

Gum 28 4 7 1 0 7 0 38 5 0 1 0 8 0

Ice cream 18 4 2 1 0 7 0 35 5 0 1 0 8 0

Popsicles 16 4 0 1 0 7 0 33 5 0 1 0 8 0

Chips/pretzels 14 3 7 1 0 7 0 32 5 0 1 0 8 0

Milkshakes/

Baked goods 14 3 7 1 0 7 0 33 5 0 1 0 8 0

Source: Bridging the Gap: wwwimpacteen org/obesitystatedata htm

Subsidy Policy 

Providing incentives or subsidies to encourage greater consumption of healthier food choices offers an 

alternative to taxes on foods of limited nutritional value. In experiments, targeted price changes have 

increased purchases of healthier snacks from vending machines. For example, a 50% price reduction 

on fresh fruit and baby carrots in two secondary school cafeterias resulted in a four-fold increase in fresh 

fruit sales and a two-fold increase in baby carrot sales.

231 Another experiment used a simple color-coded 

label of red (least healthy), yellow, or green (most healthy) based on fat and calorie content and added a 

five cent “tax” (approximately 8% of the product’s value) on each red item. After one year, this resulted 

in a 5% decrease in sales of least healthy items, a 16% increase in the sale of most healthy items, and 

overall sales increased as well.

232

A recent study on the effect of price subsidies on healthy food consumption among SNAP participants 

suggests that a 10% subsidy for vegetables and fruits would increase vegetable consumption from 

1.26 cups to 1.33 cups per day, and fruit consumption from 0.89 cup to 0.97 cup. These increases in 

consumption bring individuals closer to the recommended levels, closing the gap by 4.7% for vegetables 

and 7% for fruits.

233

Since 2005, a group of farmers markets, foundations, local governments, and nonprofit organizations 

have collaborated on pilot incentive programs to expand USDA programs to improve the health and 

nutrition of low income families and their children. Wholesome Wave’s Double Value Coupon Program 

increases the value of SNAP and other program benefits when used at participating farmers markets, 

reducing the cost of fruits and vegetables for low-income participants. Initiated in 2008, the program 

has expanded to more than 60 markets in 12 states and the District of Columbia. Early results from 

participating farmers markets often indicate a 300% increase in SNAP and WIC use at farmers markets 

with the introduction of double voucher incentive programs.

234
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Recommendations

Recommendation 4.7: Provide economic incentives to increase production of healthy foods such 

as fruits, vegetables, and whole grains, as well as create greater access to local and healthy food 

for consumers. The upcoming reauthorization of programs governed by the Food, Conservation and 

Energy Act of 2008 provides another opportunity to strengthen Federal farm and food policy to help 

meet the needs of all Americans.

Recommendation 4.8: Demonstrate and evaluate the effect of targeted subsidies on purchases of 

healthy food through nutrition assistance programs. Through the Healthy Incentives Pilot, the Food, 

Conservation, and Energy Act of 2008 provided $20 million to determine if incentives provided to SNAP 

recipients at the point-of-sale increase the purchase of fruits, vegetables, or other healthful foods. The 

evaluation of this pilot, still in the early development stages, will offer solid evidence on whether a 

financial incentive can influence fruit and vegetable purchases and consumption. 

Recommendation 4.9: Analyze the effect of state and local sales taxes on less healthy, energy-dense 

foods based on nutrient content or categories with low nutritional value (such as soft drinks, candy, 

snack foods, and fast foods). 

Benchmarks of Success

By 2020, increase the availability of fruits and vegetables in the American food supply by 70%,

or 450 pounds per person per year. In 2008, the American food supply included 643.6 pounds of 

fruit and vegetables per person—about 251 pounds of fruit and 393 pounds of vegetables.

235 A recent 

USDA analysis suggested that to bring American diets into alignment with recommendations in the 

2005 Dietary Guidelines, consumption of fruit would have to increase by 132%, and consumption of 

vegetables would have to increase by 31%.

236 The increased supply of fruit and vegetables needed to 

support these consumption changes would total 1,096 pounds per person—an increase of 453 pounds, 

or over 70%.

USDA prepares these estimates of fruit and vegetables in the food supply on an annual basis, drawing on data from a variety of government and private sources, including farm production and stocks 

information from the Census of Agriculture, trade information from the U.S. Census Bureau and USDA’s 

Agricultural Marketing Service, and information on processed products from trade association reports.

Per capita estimates are calculated using population estimates for that particular year.

C. Product Formulation

In addition to ensuring access to supermarkets and grocery stores, these stores must also provide healthy 

options at affordable prices. Consumer demand plays an essential role in the range of foods available, 

yet decisions that the food and agriculture industries make in responding to these demands determine 

what is on store shelves. Parts of the food industry are undertaking efforts to reformulate products, and 

through concerted efforts, the marketplace can move faster and farther. To address the obesity crisis, 

we must expand and accelerate efforts to reformulate products, particularly those aimed at kids, so they 

have less fat, salt, and sugar, and more of the nutrients children need.
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It is easy for companies to take advantage of the human craving for sugary, fatty, salty foods by creating 

products that are sweeter, richer, and saltier than ever before. Doing so does not just respond to people’s 

natural inclinations, it also helps shape them. This is particularly dangerous for our Nation’s children, as 

these foods become embedded in their life-long eating habits.

There is another choice. Just as we can shape children’s preferences for high-calorie, low-nutrient foods, 

we can also shape their preference for high-quality, healthier foods. Making this a reality requires a 

serious industry-wide commitment to provide parents with healthier food options at affordable prices.

The food industry has shown that it can respond to new consumer demands, including demands related 

to health and nutrition. In 2008, manufacturers introduced about 23,000 new products, with claims such 

as “natural,” “fresh,” “organic,” “no preservatives,” “low or no trans fat,” and “high vitamin,” used to market 

about 25% of these new products.

237 In the competition for health-conscious consumers, processed 

food manufacturers quadrupled the average number of new whole-grain products introduced between 

2001 and 2006.

238 

Rather than finding creative ways to market existing products as healthy, we must develop new products 

proven to be healthy—products that help shape the health habits of an entire generation. Products like 

baby carrots and apple slices have proven appealing to children, as well as whole grains. Developing 

and marketing more of these products, as well as reducing sugar in items popular with children like 

flavored milk or yogurt, help children form healthy habits and ultimately, combat the obesity trend.

Recommendations

Recommendation 4.10: The food, beverage, and restaurant industries should be encouraged to 

use their creativity and resources to develop or reformulate more healthful foods for children and 

young people.

• Industries should be encouraged to shift product portfolios to promote new and reformulated 

child-oriented foods and beverages that are substantially lower in total calories, fats, salt, and 

added sugars, and higher in nutrient content. This should be informed by research about which 

products are favored by children, and in particular, by children at high risk for obesity.

• Restaurants should be encouraged to expand and actively promote healthier food, beverage, 

and meal options for children, and be attentive to the effects of plate and portion size, as noted 

in Chapter II.

Benchmarks of Success

Increase newproductintroductions that are consistentwith dietary recommendations and substantially lowerintotal calories,fat, salt, andaddedsugars. Proprietary data sources can be used to 

monitor the number and percent of annual product introductions with healthier formulations, such as 

low fat, no trans fat, low or no sodium, low or no sugar, added calcium, or reduced calories per serving.

Over time, it should be possible to monitor consumer purchases of these new product introductions to 

determine whether they have become a larger share of purchases and intake, using commercial data.
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D. Hunger and Obesity

In 2008, approximately 49 million people, including 17 million children, live in households struggling 

to put enough food on the table. In over 500,000 households, children skipped meals or ate less than 

needed because of lack of resources.

239 Scholars are increasingly discussing the possible correlation 

between weight status and food insecurity. This association seems paradoxical, since food insecurity 

results from inadequate resources to purchase enough food and obesity is a consequence of consuming 

too much. Still, a number of studies have suggested a possible correlation between food insecurity and 

obesity, especially in women.

240

This relationship may exist because the low cost of nutrient-poor, energy-dense foods promotes overconsumption of calories, leading to weight gain. To maintain adequate energy intake, people who must 

limit food costs may select lower-quality diets, consisting of high-energy, inexpensive foods. People eat 

fewer fruits and vegetables as food insecurity worsens. Food insecurity may also lead to various psychological and behavioral changes, such as a preoccupation with food, stress, depression, and physical 

limitations in adults—all of which can lead to an increased risk for obesity. In addition, because many 

food-insecure households receive assistance from one or more Federal nutrition assistance programs, 

it is important to consider whether these programs contribute to the obesity/food insecurity paradox, 

or help solve the paradox by providing access to healthier food, incentives for healthier choices, and 

effective nutrition education.

USDA administers 15 Federal nutrition assistance programs as our Nation’s first line of defense against 

hunger, including those mentioned above—the Supplemental Nutrition Assistance Program (SNAP, 

formerly food stamps), the National School Lunch Program (NSLP), the School Breakfast Program (SBP), 

and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The Federal 

government will invest more than $80 billion in the national nutrition safety net in fiscal year 2010, subsidizing meals and food purchases for more than 1 in 4 Americans. One-half of all children will participate 

in SNAP alone at some point during their childhood, including 90% of Arican-American children.

241

Given these programs’ extensive reach, it is important that they be part of the solution to childhood 

obesity. Data from the National Health and Nutrition Examination Survey show that generally there 

are more similarities than differences in the nutrient intakes, diet quality, and food choices of program 

participants compared to the rest of the American population.

242 A thorough assessment of the research 

in this field shows that WIC and school lunch and breakfast programs do not contribute to childhood 

obesity.

It remains important to ensure that those who are eligible for and in need of assistance have ready access 

to these programs. While these programs serve millions of low-income Americans, some people who 

need benefits do not participate; over one-third of individuals eligible for SNAP do not participate,243and 

40% of those eligible for WIC do not participate244.

 They may not be aware they are eligible, may not 

realize the size and value of benefits, or may find applying difficult or burdensome. Similarly, although 

meal programs exist in thousands of schools across the country, not all eligible children participate 

in the NSLP, and even fewer participate in the SBP. School lunch is served in around 100,000 schools, 

while the breakfast program is only available in 88,000 schools and almost two-thirds of children who 

eat a school lunch do not receive a school breakfast. Some bring healthy food from home, but others, 

especially in high schools, may forego a nutritious lunch or breakfast entirely. 
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Recommendations

Recommendation 4.11: Increase participation rates in USDA nutrition assistance programs through 

creative outreach and improved customer service, state adoption of improved policy options and 

technology systems, and effective practices to ensure ready access to nutrition assistance program 

benefits, especially for children. Improved policies and effective practices include streamlined and 

more timely application process, greater use of broad-based categorical eligibility and direct certification, and reductions of barriers to participation such as finger imaging. Access to feeding programs for 

children throughout the year can also be expanded by engaging state, local, Tribal, community leaders, 

and partnerships with allied organizations, advocacy groups, and communities.

Is PoorDiet a Low Income Problem?

In general, when one looks at both the food choices and the diet quality of nutrition program participants 

and other consumers, the similarities are more striking than the differences:

• A recent analysis of nutrition monitoring data (Cole et al., 2008), comparing the diets of participants in 

SNAP, WIC, and the school meals programs with nonparticipants and higher income consumers show 

that the diets of all groups fall far short of the Dietary Guidelines for Americans. All groups had very 

low intakes of whole grains, dark green and orange vegetables, and legumes, and high intakes of fat, 

saturated fat and added sugars.

• With regard to the shopping practices of SNAP participants specifically, consumer expenditure data 

suggest that they tend to buy the same categories of foods as other consumers. These differences are 

minor even though families at the high end of the income distribution spend over twice as much on food 

at home as those at the low end.

Nonetheless, some differences do appear to be linked to income:

• In 2003-04, people in low-income families had significantly lower intakes of total vegetables, dark green 

and orange vegetables and legumes, and whole grains than did higher income families.

• People in low-income families, compared with their counterparts, had lower (i.e. more healthful) intakes 

of sodium than higher-income families.

• The only significant difference in the quality of children’s diets by family income, as measured by the 

Healthy Eating Index, was that low-income children had a higher score for total vegetables. This may 

reflect low-income children’s greater participation in the National School Lunch Program (Guenther et 

al. 2008).

In general, the critical lesson from this evidence is that while some income-linked factors, such as improved 

access to healthy options, hold promise to support and influence better diets, almost all Americans, no 

matter their income need to make significant changes in their eating behaviors to promote good health.

Sources: Cole, N., Fox, M.K. (2008).Diet Quality of Americans by Food Stamp Participation Status: Data from the National Health and 

Nutrition Examination Survey. Washington, DC: Abt Associates, Inc.; Guenther, P.M., Juan, W., Mark, L., Hiza, H.A., Fugwe, T., Lucas, 

R. (2008). Diet Quality of Low-Income and Higher Income Americans in 2003-04 as Measured by the Healthy Eating Index-2005.

Nutrition Insight, 42.
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Benchmarks of Success

Increase participation among people eligible for SNAP benefits to 75% by 2015. USDA estimates 

annual participation rates based on the Annual Social and Economic Supplement to the Current 

Population Survey and administrative data on SNAP participants. The SNAP participation rate was 

65.8% in 2007.

IncreaseNationalSchool LunchProgramparticipationby2millionadditional children(upto60%

of all students) and School Breakfast Program participation by 3 million additional children (up

to 25% of all students) by 2015. USDA monitors participation in the school meal programs through 

periodic reporting by State administering agencies; information on school enrollments is available 

annually from the U.S. Department of Education. In 2009, 56% of enrolled students participated in lunch 

and 20% participated in breakfast.

Key Questions for Future Research

Making research in this area a priority may help to identify the relationship between access and consumption of healthy foods, as well as the causal links between access and diet related health outcomes.

Key issues to address with future research investments include:

• The definition, measurement, and consequences of food deserts on food access, diet, and 

weight outcomes;

• The impact of improved access on dietary quality and obesity rates;

• How agricultural policy may affect food prices and obesity rates;

• The comparative efficacy of sales taxes and price subsidies on weight outcomes; and

• The effectiveness of price incentives, including supplements that increase the value of farmers’ 

market purchases or incentives to promote the purchase of fruits, vegetables, and other healthful foods, especially for low-income populations;

In addition, there is need for tools proven to help communities assess their progress in helping residents 

eat healthy foods, increase their knowledge of potential steps to promote healthy eating and good 

nutrition among community residents, as well as identify and define influential actions. This includes 

tools that connect to and use existing databases (such those that track which products are being sold 

at grocery stores, through UPC codes) to help communities, industry, and policymakers assess progress 

in shifting toward increased consumption of healthy foods.

Finally, focusing investments in food technologies, research, and development may help to identify and 

produce new and reformulated child-oriented foods and beverages that are substantially lower in total 

calories, fats, salt, and added sugars.

★ 65 ★

V. Increasing Physical Activity

Physical activity is an essential component of a healthy lifestyle. In combination with healthy eating, it 

can help prevent a range of chronic diseases, including heart disease, cancer, and stroke, the three leading causes of death.

245 Risk factors for these diseases can begin early in life and be mitigated early in life 

by adopting regular physical activity habits. Physical activity helps control weight, builds lean muscle, 

reduces fat, and contributes to a healthy functioning cardiovascular system, hormonal regulatory system, 

and immune system; promotes strong bone, muscle and joint development; and decreases the risk of 

obesity.

246 Research has also found that physical activity is related to improvements in mental health, 

helping to relieve symptoms of depression and anxiety and increase self-esteem.

247 In addition, some 

studies show that physical activity is correlated with improved academic achievement.

248

According to the Physical Activity Guidelines for Americans, children and adolescents should participate in 

physical activity for at least 60 minutes every day.

249 The Physical Activity Guidelines, developed in 2008 

by a committee of experts convened by the U.S. Department of Health and Human Services, provide 

science-based guidance for Americans ages six and older. They recommend that children’s activity 

time include moderate to vigorous aerobic activity, muscle strengthening, and bone-strengthening 

exercises, and that young people should be encouraged to participate in age-appropriate, enjoyable, 

and diverse activities. There are many examples of physical activity, including not only team sports 

but also walking, biking, swimming, hiking, dancing, gardening, and many other group or individual 

activities. Recreational activities enjoyable to youth help ensure that they continue to engage in those 

activities. For example, a survey of Americans who participated in an outdoor activity found that 90% of 

them began doing so between the ages of five and 18.

250 Outdoor activities can be enjoyed in a variety 

of locations and are often less expensive, more accessible, and can foster life-long activity.

Physical Activity Guidelines for Children and Adolescents

Children and adolescents should get 60 minutes (1 hour) or more of physical activity daily.

• Moderate- or vigorous-intensity aerobic physical activity (such as running, hopping, skipping, jumping rope, swimming, dancing, and bicycling) should comprise most of the 60 or more minutes a day.

Vigorous-intensity physical activity should be included at least 3 days a week.

• Muscle-strengthening physical activity (such as playing on playground equipment, climbing trees, 

playing tug-of-war, lifting weights, or working with resistance bands) should be included at least 3 days 

of the week.

• Bone-strengthening physical activity (such as running, jumping rope, basketball, tennis, and hopscotch) should be included at least 3 days of the week.

Young people should be encouraged to participate in physical activities that are appropriate for their age, 

that are enjoyable, and that offer variety. For more information, see http://www.health.gov/paguidelines/.
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Children should have several opportunities to be active throughout the week and year round. Activity 

should be a normal part of a child’s day, from walking or biking to and from school, where appropriate, 

to participating in a physical education class, to engaging in active games during recess, after school, 

or in the summer at home, in a park, or on a playground. All children benefit and gain enjoyment from 

physical activity, regardless of ability or disability status, gender, or athletic inclinations and talents. The 

benefits of physical activity extend beyond childhood too—young people who grow up physically active 

are more likely to be active adults.

251

Young people who believe they are competent and have the skills to be physically active are more likely 

to be active.

252 Likewise, young people who feel supported by friends and families or are surrounded by 

others interested in physical activity, are more likely to participate in both structured and non-structured 

activities.

253 These social norms are powerful in determining people’s actions.

Unfortunately, our young people live in a social and physical environment that makes it easy to be 

sedentary and inconvenient to be active. Social and environmental factors that discourage physical 

activity include: community design centered around automobiles, limited access to low or no cost 

physical activity close to home (such as parks, recreation centers, and walking and biking paths); new 

technology that is sedentary in nature; and increased concerns about safety in neighborhoods. The 

results are startling. Fewer than one in five high school students meet the current recommendations of 

60 minutes of daily physical activity,254 and a recent study showed that adolescents now spend more than 

seven hours per day watching television, DVDs, movies, or using a computer or a mobile device like a cell 

phone or MP3 player.

255 Older adolescents are less likely than younger children to be physically active, 

and adolescent girls are less likely to be physically active than their male peers.

256 African-American and 

Hispanic adolescent girls are the least likely to be physically active.

High School Students Who Get at Least One Hour

of Exercise, Five Days a Week

Source: Centers for Disease Control and Prevention‘s National Youth Risk Behavior Surveillance—United States, 2007

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Total White Black Hispanic Other GIRLS GIRLS

43.7%BOYS

GIRLSBOYSGIRLSBOYSBOYSBOYSGIRLS

25.6%

46.1%

27.9%

41.3%

21.0%

38.6%

21.9%

39.7%

25.0%
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There are added barriers for vulnerable populations to become more physically active. Research shows 

that children with physical, sensory, and cognitive disabilities have substantially greater difficulty participating in regular physical activity, compared with the general population. A recent study showed 

that youth with physical disabilities had a 4.5 times higher rate of physical inactivity compared to youth 

without a disability, and they were twice as likely to report watching television for more than four hours 

per day.

257 Children with physical and developmental disabilities are significantly more likely to be obese 

or overweight compared with peers without disabilities of the same age.

258 However, there is growing 

awareness that many activity and health disparities reported among children and adults with disabilities 

are not necessarily a direct result of the disability, but rather a result of the challenges these individuals face in accessing community services and programs. Such challenges include poor accessibility of 

facilities, services, and programs, as well as environmental barriers such as lack of accessible equipment 

or transportation. To overcome these barriers and reduce disparities in physical activity, public schools 

must ensure that services, supports, and programs, including health and physical education programs, 

are equally accessible to eligible students with disabilities as to those without disabilities, pursuant to 

the Individuals with Disabilities Education Act (IDEA) and Title II of the Americans with Disabilities Act 

(ADA).

259 Many children who do not attend school or live in traditional community settings, such as 

those in juvenile detention and correctional centers, also have fewer opportunities for physical activity 

and consequently are less active.

260 

Much of the existing research suggests that coordinated, multi-component programs and policies are 

necessary to effectively change social norms, environments, and behaviors.

261 As part of a comprehensive approach to encourage young people to be more active, schools and communities should be 

encouraged to adopt common and consistent policies, practices, and expectations regarding these 

goals. They should also provide opportunities for healthy lifestyle choices in all childhood settings 

before, during, and after school, as well as on weekends, holidays, and school vacations.

262 This requires 

changes at all levels, including individual changes; choices, attitudes, and behaviors about physical 

activity; the structure of school days; teaching approaches; the physical environments of communities; 

Community Resources for EngagingYoung People withDisabilities in Physical Activity

BlazeSports America is a direct legacy of the 1996 Paralympic Games held in Atlanta, Georgia.This organization, with school and community programs in all states, includes sports, camps, and athletic competitions that seek to increase independence, improve health, and enhance overall quality of life for youth and 

adults with physical disabilities. The organization provides support and toolkits for schools and communities to help develop comprehensive programs and create opportunities for including students with 

disabilities in athletics and physical activity, including an equipment loan program. With programs geared 

for individuals throughout the lifespan, BlazeSports provides programs and services that moves children 

and youth through a continuum, starting with lessons on active play and teaching lessons on being active 

for life. More information on BlazeSports America can be found at: http://www.blazesports.org. 

Another nonprofit organization, the National Center for Physical Activity and Disability, offers 

a searchable database of programs by geographic region for students with disabilities at: 

http://www.ncpad.org/programs/index-title.php?letter=A.
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and policy decisions that govern our way of life.

263 This chapter details what can be done to increase 

children’s physical activity levels:

• in schools and in activities outside of school;

• in the community with the built environment;

• to improve the accessibility of parks and playgrounds; and 

• in indoor and outdoor recreational settings.

A. School-Based Approaches

Schools are a key setting to focus on, given the significant portion of time children spend there. Schools 

can undertake a combination of strategies and approaches to help children be more active including:

• Creating infrastructure and policies that increase access to and encourage physical activity for 

all students;

• Collecting valid and reliable data and using analytical tools and systems to understand student 

needs and fitness levels, and promoting approaches that are effective in changing physical 

activity behaviors and, ultimately, health outcomes;

• Maintaining strong physical education (PE) programs that engage students in moderate to 

vigorous physical activity for at least 50% of PE class time;

• Providing a variety of activities and specific skills so that students can be physically active not 

just during class but throughout the day and year; and

• Providing qualified school professionals who are trained in teaching methods to engage students in PE, including for students who face greater barriers to activity.

Most physical activity for students can be provided through a comprehensive school-based physical 

activity program. Such a program is anchored in quality PE and complemented by activities before, during, and after school, as well as in recess, other physical activity breaks, intramural and physical activity 

clubs, interscholastic sports, and walk and bike to school initiatives.

264 These initiatives should not take 

the place of PE, but should reinforce lessons taught in PE by providing opportunities to practice and 

apply the skills learned.

265

The components of a comprehensive physical activity program, as identified by the CDC and the National 

Association for Sport and Physical Education, are described in more detail below. Although the approach 

focuses on schools and school-related interventions, many community sectors play a role in design, 

implementation, or evaluation of these interventions. 

Schools are an important setting because of access to young people and the school’s influence on 

behavior, as well as the potential impact physical activity has on learning, cognition, and academic 

achievement. A recent study conducted by the CDC266 reviewed all relevant literature on the impact 

on education-related outcomes of school-based PE, recess, classroom-based physical activity, and 

extracurricular physical activities. Their analysis found that spending time on these four physical activity 
V. Increasing Physical Activity

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approaches had either a positive effect on academic achievement or, at minimum, did not detract from 

academic outcomes. Specifically:

• Eleven of the 14 studies on school-based PE showed one or more positive associations between 

this intervention and indicators of academic performance;

• All eight studies on recess found one or more positive association between recess and indicators 

of cognition, emotion, and academic behaviors, as well as a positive or no effect on children’s 

attention, concentration, and/or on-task classroom behavior;

• Eight of nine studies on classroom physical activity, either through physical activity breaks 

or learning activities designed to promote learning through physical activity, found positive 

associations between these activities and indicators of cognitive and academic behavior; and

• All 19 studies examining the relationship between participation in extracurricular physical activity, including afterschool sports or other afterschool physical activity programs, and academic 

performance found one or more positive associations.

Some school leaders have expressed concerns that a comprehensive physical activity program is too 

expensive, particularly during difficult economic times and tight budgets. However, there are many 

low-cost or no-cost steps that school leaders can take to improve the physical activity environment for 

all students and to promote student health without compromising academic pursuits. 

Policies that Support a Comprehensive Physical Activity Program 

Local wellness policies, required by USDA for all school districts participating in a school-based meal 

program, can be used to create district guidelines that can significantly impact physical activity requirements for students. There are many examples that individual school districts can draw from as they 

develop or refine their wellness policies. They range from specifying minutes of PE or recess requirements, to restrictions on the use of physical activity as punishment. For example, Michigan provides a 

model local wellness policy for its school districts, combining a quality PE program with a coordinated 

school health framework and presenting ideas such as recess before lunch and extra physical activity 

breaks as a reward instead of food snacks.

267 However, a recent nationwide study that assessed the 

effectiveness and relative quality of local wellness policies showed that only 18% of policies reviewed 

addressed recess and most did not address PE. Physical activity was often the weakest component of 

the wellness policies.

268 

Effective implementation of wellness policies is also critical. For example, a study conducted during the 

first year of local wellness policy implementation in rural Colorado revealed that policies were poorly 

or weakly worded, and ultimately, had little to no effect on physical activity. Competing pressures, lack 

of support and resources, and no monitoring or accountability were cited as reasons for the policies’ 

relative weakness.

269
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Physical Education (PE)

Physical Education (PE) is considered the cornerstone of a school-based comprehensive physical activity program. It provides the basis and opportunity for young people to gain the knowledge and skills 

needed to maintain physically active lifestyles throughout childhood and into adulthood. A quality PE 

program can increase student participation in physical activity, increase their physical fitness,270 and 

enhance their understanding about the purpose and methods of physical activity.

271 Participation in 

daily PE is associated with an increased likelihood of participating regularly in moderate to vigorous 

physical activity.

272 

The evidence strongly supports the correlation between school-based PE and increasing physical activity 

rates. The Task Force on Community Preventive Services is an independent, non-federal, volunteer body 

of public health and prevention experts tasked with reviewing evidence for interventions, providing 

recommendations that promote health, and identifying areas for further research. This group reviewed 

the literature and found that enhanced, school-based PE is an effective strategy for increasing physical 

activity among young people.

273 

The National Association for Sport and Physical Education recommends daily PE from kindergarten 

through grade 12, suggesting 150 minutes per week for elementary schools and 225 minutes per week 

for secondary schools.

274 Pursuant to their findings, a quality PE program should: 

• meet the needs of all students; 

• be an enjoyable experience for all students; 

• keep students active for most of PE class time; 

• teach self-management as well as movement skills; and 

• emphasize knowledge and skills for a lifetime of physical activity.

275

One of the resources available to school districts is the Physical Education Curriculum Analysis Tool 

(PECAT) issued by the CDC, which helps school districts conduct an analysis of their PE curriculum, based 

on national standards but with an option to customize to include local standards.

Effective school-based PE programs must also take into consideration children who are obese or who 

have physical or cognitive disabilities, chronic diseases (such as diabetes or asthma), or low levels of 

fitness. These children may need instruction in PE and physical activity programs to develop motor 

skills, improve physical fitness, and experience enjoyment and success. Nationwide, 62% of schools 

had students with long-term physical or cognitive disabilities or chronic diseases. Often, young people 

who have disabilities or chronic health conditions are discouraged from participating in PE class and 

other forms of physical activity. For example, among schools with students with physical disabilities, 

59% allowed these students to be exempt from enrolling in PE.

276

Influencing students’ attitudes towards and perceptions of physical activity may affect their involvement in physical activity outside of PE class.

277 Physical education should encourage students to view 

physical activity as important and enjoyable. Increasing students’ confidence in their ability to engage 

in physical activity increases the likelihood of enjoyment and therefore, the likelihood of regular par-
V. Increasing Physical Activity

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ticipation in physical activity.

278 Students are more likely to have positive attitudes towards physical 

activity if their needs and interests are met through a variety of activities. They should also understand 

the many benefits of physical activity, and should be able to apply their newly acquired skills through 

various opportunities. 

Another option for engaging students is to incorporate interesting PE lessons that make use of the 

natural environment. Outdoor education has an 

added advantage because students who become 

accustomed to outdoor activity are more likely to 

be active.

279 Depending on the climate, lessons can 

include activities as varied as hiking, canoeing, and 

snowshoeing. 

Despite the evidence supporting PE, due to budget 

pressures and other factors, fewer than one in six 

schools require at least three days a week of PE for 

the entire school year for all grades in the school. Only 

4% of elementary schools, 8% of middle schools, and 

2% of high schools provide daily PE or its equivalent 

for the entire school year for all students.

280 While 

most middle schools and high schools require PE, 

12% of middle schools and 25% of high schools allow 

students to be exempt from PE requirements because 

of participation in school sports. 14% of these middle 

schools and 20% of these high schools allow students 

to be exempt from PE for participation in school activities other than sports such as band or chorus. 

For many schools, the barriers to incorporating PE during the school day include lack of time and resources, 

such as trained staff, and competing priorities. As 

noted above, research has shown that allowing students to participate in PE does not detract from 

academics281 but rather may enhance academic achievement.

282

Some states and school districts already require daily PE for students. Like local wellness policies though, 

unless these requirements are followed, they may not yield the intended results. In Florida, for example, 

the legislature enacted a requirement for 30 minutes of PE for elementary schools and daily PE for middle 

school students beginning in the 2009-10 school year. Some reports on the effects of this policy show 

that school districts struggle to fully fund daily PE and classes are often too crowded to accommodate 

all students and meet the requirement.

283

Outdoor Education through the

Department ofthe Interior

Another strategy for getting kids physically 

active is to involve them in environmental 

education programs that involve outdoor 

activity. Interpretive programs and alternative PE lessons involving activities such as 

hiking, biking, wildlife watching, and kayaking can make outdoor education good for 

the body and brain, and at the same time, 

enhance young Americans’ exposure to and 

appreciation of our nation’s cultural, historic, 

and environmental resources. Additionally, 

the Fish and Wildlife Service and the National 

Park Service offer curriculum-based teacher 

training by field stations to classroom 

teachers and other educators to prepare 

their students for field trips to national parks, 

wildlife refuges, fish hatcheries, and other 

public lands. However, more can be done on 

the national level to encourage outdoor education on public lands as part of school-based 

curriculum. These programs also facilitate 

healthier lifestyles by emphasizing indoor 

and outdoor activity and exercise.
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Challenges and assessments can also be used to educate children and get them excited about being 

active. The President’s Challenge (originally established in 1966 as the Presidential Physical Fitness 

Award) was created at the recommendation of the President’s Council on Physical Fitness and Sports 

as a free, publicly-available tool intended both for assessment and engagement of children in fitnessenhancing activity. The Challenge has long provided fitness benchmarks for young people by means of 

a fitness test. However, the data that are used to classify young people into the three award categories 

are based on a nationwide sampling that may no longer be relevant, given the increased prevalence 

of overweight and obesity. While the original Challenge program focused primarily on measures of 

athletic performance, it has been expanded to include physical activity, in the form of the President’s 

Council also administers the Presidential Active Lifestyle Award (PALA). PALA helps children and adults 

build healthy habits by committing to regular physical activity five days a week for six weeks. The First 

Lady’s Let’s Move! campaign has set a goal of doubling the number of children in the 2010-11 school 

year who earn a PALA award.

Recess for Elementary School Students, Physical Activity Breaks for Older Students 

Regularly scheduled recess periods provide another opportunity for children to get part of their recommended 60 minutes of daily physical activity.

284 Recess allows children to apply skills learned in PE 

(such as decision making, cooperation, conflict resolution, and continued motor skill development).

285 It 

should not, however, replace PE or be used to meet time requirements set in PE policies. Recess also can 

provide the opportunity for children to enhance cooperation and negotiation skills, as well as improve 

attentiveness, concentration, and time-on-task in the classroom.

286 In addition, if recess is scheduled 

before lunch, students are likely to eat more food, including healthier foods, helping schools meet other 

desirable goals as well.

287

The Promise ofTechnology

Innovative and engaging teaching methods can motivate students to participate in PE, particularly those 

students who are not natural athletes or who do not enjoy “traditional PE.” Some students have been motivated by the use of technology in the PE classroom that enhances individual skills and teaches students 

how to monitor their own fitness levels. Examples of technologies that have been incorporated into PE 

classrooms in recent years include heart rate monitors and equipment that combines activity with video or 

television-enabled games. 

The promise of technology is still uncertain, however. Small, initial studies of these types of “exergaming” 

technologies suggest that these activities can help engage students who would not otherwise engage in 

activity and may burn more calories than being sedentary, but there are no studies yet showing a longterm effect on changing physical activity behaviors or on the overall impact on weight loss or children’s 

health. Additionally, these technologies can be prohibitively expensive for school districts to buy and maintain.
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Nearly all elementary schools provide regularly scheduled recess for students in at least one grade, but 

26% of all elementary schools do not provide regularly scheduled recess for students in all grades.

288 

The average length of recess was slightly less than 30 minutes, with more minutes offered for younger 

students. However, schools with more students from low-income families are even less likely to offer 

recess to students.

289 

Incorporating Movement into Curriculum and Classroom Activities

Schools can offer students breaks for movement during the school day, such as an extra few minutes 

for students to stretch before the beginning of a class, or integrating activity and movement into lessons. Some schools might offer physical activity in the classroom as part of planned lessons that teach 

mathematics, language arts, and other academic subjects through movement. These types of activities 

contribute to students’ accumulated physical activity during the school day.

290 In addition to promoting 

good health, physical activity within the regular classroom can enhance on-task classroom behavior of 

students291 and establish a school environment that promotes regular physical activity.

Recommendations

Recommendation 5.1: Developers of local school wellness policies should be encouraged to include 

strong physical activity components, on par with nutrition components. 

Recommendation 5.2: The President’s Challenge should be updated to ensure consistency with the 

Physical Activity Guidelines for Americans and to ensure ease of use and implementation by schools.

Private sector partners with an interest in physical activity should help enroll children in the Presidential 

Active Lifestyle Award program.

Recommendation 5.3: State and local educational agencies should be encouraged to increase the 

quality and frequency of sequential, age- and developmentally- appropriate physical education for 

all students, taught by certified PE teachers. Promising strategies include:

• Research-based curriculum and instructional methods that engage students in moderate to 

vigorous physical activity for at least 50% of PE class time;

• Instruction in a variety of lifetime fitness activities such as walking, hiking, snowshoeing, rock 

climbing, water sports, and biking as alternatives to team sports, which can also engage students 

in long-term outdoor recreation activities while helping to teach principles of activity.

• Partnership with private companies that support local educational agencies through the purchase of necessary equipment for PE classes.

Recommendation 5.4: State and local educational agencies should be encouraged to promote recess 

for elementary students and physical activity breaks for older students, and provide support to 

schools to implement recess in a healthy way that promotes physical activity and social skill development. Developers of teacher preparation programs should be encouraged to provide instruction on 

recess management and activity breaks for students. These can include in-service training to teachers 

and school professionals on actively engaging students, managing recess, and providing supervision 

during physical activity breaks, if appropriate.
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Recommendation 5.5: State and local educational agencies should be encouraged to provide 

opportunities in and outside of school for students at increased risk for physical inactivity, including 

children with disabilities, children with asthma and other chronic diseases, and girls. For example, 

local educational agencies, schools, and teachers should include considerations for ensuring physical 

activity for students with disabilities in their Individualized Education Plans, pursuant to the IDEA and/or 

the ADA; State and local educational agencies should be encouraged to follow the National Guidelines 

for Managing Asthma at Schools;292 and Title IX should be maintained and enforced to ensure gender 

equity.

Benchmarks of Success

Increase the number of high school students who participate in daily PE classes to 40% by 2015

and50%by2030. Currently, roughly 30% of high school students attend daily PE classes, a rate that has 

been relatively stable since about 1993. This data can be tracked using the national Youth Risk Behavior 

Survey. Note that while the quality of PE classes cannot be tracked with current survey instruments, the 

goal is to increase both quantity and quality. Similar progress for elementary students should be made, 

and can be tracked if data becomes available.

Increase the percentage of schools that offer recess to all students and grades in elementary

schools to 95% in 2015. As of 2006, only 79% of schools offered recess to all of these students. Data 

are collected every six years through the CDC’s School Health Policies and Practices Survey (SHPPS). The 

most recent SHPPS data is for 2006; the next study will be done in 2012 and released in 2013.

As noted earlier in this report, it will be critically important to monitor the overall increase in children’s 

level of aerobic physical activity and muscle-strengthening activity. An enhanced NHANES survey may 

provide additional data on younger children’s physical activity levels across the U.S. Additionally, the 

revamped President’s Challenge tool may offer children, families, and teachers an understanding of how 

their physical activity performance has improved over time.

B. ExpandedDay and Afterschool Activities

Expanded day and afterschool programs also offer schools an opportunity to collaborate with community partners to provide programming to many students. These programs can provide additional 

opportunities for learning, safe environments for students, and enrichment activities that integrate 

lessons about healthy living and additional opportunities for students to be active. Expanded day and 

afterschool activities can appeal to a variety of students’ interests, ranging from instruction in such 

subjects as art and nutrition to engagement in intramural sports and non-competitive lifetime physical 

activities. 

In the school setting, schools may rethink the length and structure of the school day and year, so students 

have the time they need to succeed, including through activities to improve their physical health, and 

teachers have the time they need to collaborate and improve their practice. While many of these schools 

have implemented an expanded day only recently, initial evidence suggests a positive relationship 

between expanded time programs and academic performance.

293 Research supports the effectiveness 

of well designed programs that expand learning time by a minimum of 300 hours per school year.

294 

Research also demonstrates that students that participate in evidence-based afterschool programs 

improved participants social and personal skills, as well as academic achievement.

295
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Other activities during the after-school hours 

can enhance physical activity, including 

intramural sports and lifetime activities. The 

National Association for Sport and Physical 

Education has outlined three characteristics 

that describe the positive attributes of intramural sports programs: (1) students have 

a choice of activities or participation; (2) 

every student is given equal opportunity to 

participate regardless of ability level; and (3) 

students have the opportunity to be involved 

with the planning and implementation of 

activities.

296 Intramurals can offer students 

an opportunity to experiment and participate in new activities without having to try 

out for a team or playing in a high-pressure 

environment. Almost half of all schools in 

2006 offered intramural programs.

297 Some 

intramural sports programs integrate academic content with physical activity or focus 

primarily on positive youth development, 

building social competencies, and connectedness between young people and adults.  

These types of programs, sometimes referred 

to as “sports-based youth development programs,” focus on building students’ social and emotional 

skills, enhancing positive relationships to peers and caring adults, developing youth leadership, and 

connecting with the broader community, with sports as the basis.

Lifetime physical activities such as walking, running, hiking, swimming, tennis, dancing, and biking can 

also be fun activities offered by programs and schools, including after-school programs.

298 Activities 

should provide opportunities for girls and boys; meet the needs of students at all levels of skills and physical abilities, particularly those that are not athletically gifted; and reflect student interest. Programs may 

combine these activities with other initiatives, such as community service or service learning programs 

that engage students in meaningful community work. And if schools do not go year around, many of 

the same program models could be used to increase physical activity in the summer.

The U.S. Department of Education’s 21st Century Community Learning Centers Program provides support for afterschool activities to students. The latest U.S. Department of Education data show that the 

centers served about 1.5 million students in 2008 in almost 10,000 sites and received over $1 billion in 

FY 2010. While the vast majority of the programs (9 out of 10) operated in schools, school districts were 

only directly responsible for administering approximately 60% of the programs. The remaining 40% 

were administered by community-based organizations and other eligible entities, including institutions 

of higher education, nationally-affiliated non-profit organizations, and for-profit organizations.

The Expanded LearningTime Model in

Massachusetts

Twenty-two schools in Massachusetts have received 

grants to adopt an expanding learning time model 

(ELT) and have incorporated more time for such activities through a variety of strategies including adding 

and/or expanding physical education classes; adding 

and/or expanding recess; and adding new health and 

fitness electives.  These schools have also initiated a 

range of community partnerships with entities such as 

YMCAs, Boys & Girls Clubs, and community centers to 

connect youth in these schools to the organizations’ 

staff and facilities.  

For  example, three middle schools in Boston that 

offer ELT offer a menu of health and fitness electives 

led by teachers and community partners, including a 

running club, step team, and competitive basketball, 

football, volleyball, and dance teams.  The schools have 

established partnerships with the Boston Ballet to 

offer dance, partner with the Charlestown Community 

Center and Boston Centers for Youth and Families to 

offer swimming, and offer break-dancing in partnership with the Bird Street Community Center.
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The Administration’s Blueprint to reauthorize the Elementary and Secondary Education Act proposes to 

reform and strengthen 21st Century Community Learning Centers Program by incorporating approaches 

that better integrate community involvement and comprehensively redesign and expand the school 

day. In addition to providing additional time for academic work, programs would also explicitly focus on 

providing enrichment activities, including those that improve mental and physical health, opportunities 

for experiential learning, and greater chances for families to actively engage in their children’s education.

Physical activity programs at the local level are often offered by a variety of providers, including park 

and recreation departments within local government, faith-based entities, or community centers like 

the YMCA or Boys and Girls Clubs. These outside partners can be of particular help in bringing in expertise and experience that might not always exist in schools or districts. Partnerships with parents and 

community-based organizations may increase the availability and quality of these programs, as well as 

the time students spend in physical activity.

299 They can also provide additional resources and supports.

In under-resourced communities, schools can provide the physical structure for after school, weekend, 

and summer programming. Community partners, with the support of local businesses or industry, can 

provide the personnel, programming, and support for activities. Some programs prefer to maintain relationships without formal agreements, while many others use more formalized agreements to delineate 

terms of the arrangement. Known as joint use agreements,300 these arrangements can maximize the 

school facility and allow students to access playgrounds, gymnasiums, basketball courts, pools, or fields 

before and after school hours. In practice, these joint use agreements are also forged between schools 

and non-governmental entities, and include conditions and considerations for liability, a concern often 

cited by schools. A recent study showed that when a school ground was opened to children, not only 

were more children active as compared to a similar community, they also reported declines in watching 

television, DVDs, and movies, as well as playing video games on weekdays.

301 

All students, regardless of gender, race or ethnicity, health status, physical, sensory, or cognitive disability, 

should have access to physical activity programs. Physical activity programs that overemphasize team 

sports and do not emphasize lifetime physical activities can exclude potential participants.

302 As noted 

above in the discussion of PE, effective programs must also take into consideration children who are 

obese or who have physical or cognitive disabilities, chronic diseases (such as diabetes or asthma), or low 

levels of fitness. These children may need instruction to develop motor skills, improve physical fitness, 

and experience enjoyment and success.

Soccer as a Building Block for Learning

America SCORES is an after-school program that combines soccer, creative writing, and service learning.  

With affiliates across the country, a pilot study of the America SCORES Bay Area in San Francisco showed 

that participants in the program had statistically significant lowering of BMI.  An unpublished national 

evaluation showed also showed that participants had an increased level of physical activity, increased 

reporting of feelings of self-confidence, self-efficacy, and enjoyment in learning, increased reporting of 

reading enjoyment and longer time reading independently, and gains in writing achievement.

Sources: Madsen K, Thompson H, Wlasiuk L, Queliza E, Schmidt C, Newman T.(2009).After-school program to reduce obesity in

minority children: A pilot Study.Journal of Child Health Care,13, 333; America SCORES Works.(n.d.). Retrieved from:

http://www.americascores.org/#/national/program/184.
V. Increasing Physical Activity

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Interscholastic Sports

Not surprisingly, participation in sports has been associated with higher levels of participation in overall 

physical activity.

303 One study suggested that adolescent participation in sports decreases cardiovascular risk factors, particularly for older adolescents.

304 Additionally, participation in sports programs 

has been associated with improved mental health and a reduction in risky health behaviors.

305 Girls 

in particular seem to benefit most from team sport participation; two recent studies suggested that 

girls who participated in athletics were healthier and had improved academic and career outcomes 

as adults.

306 Nationwide, 77% of middle schools and 91% of high schools offered interscholastic sports 

programs in 2006;307 in 2007, 56% of high school students reported that they had played on at least one 

sports teams run by their school or a community group.

308 With the economic challenges facing school 

districts over the last few years, some administrators have cut or considered cutting team sports. Some 

research suggests that as much as $2 billion was cut from youth sport program budgets nationwide in 

2008.

309 Other school districts have instituted “pay-to-play,” which requires students to pay a fee to play 

on a sport team. According to a recent assessment by the National Federation of State High School 

Associations, 33 states have schools with pay-to-play programs.

310 A recent study showed that fees up 

to $100 cause a 10% decrease in participation, while fees up to $200 cause a 20% decline.

311 Costs can 

vary dramatically depending on the school district; in some districts, the price is capped and in others, 

participation is expensive. For example, in one district, it can cost as much as $282 to run cross-country, 

$508 to play field hockey, and $969 to play football.

312 For some students, particularly low-income 

students, this fee is impossible to pay and excludes students from engaging in sports.

Recommendations

Recommendation 5.6: Federal, state, and local educational agencies, in partnership with communities and businesses, should work to support programs to extend the school day, including afterschool 

programs, which offer and enhance physical activity opportunities in their programs. 

• Districts, schools, local government, community-based organizations, and local businesses 

should partner together to create or enhance expanded day and afterschool programs that 

incorporate physical activity. 

• Support should be provided to expand participation in intramural sports programs and noncompetitive physical activity clubs that appeal to students who are not athletically gifted.

• Entities that accredit afterschool programs should include guidelines for incorporating age- and 

developmentally-appropriate physical activity in accreditation standards.

• State and local educational agencies should explore and execute joint use agreements to 

secure school facilities for out-of-school time activities and provide age- and developmentallyappropriate programming for students.
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• The Federal government should support state, local educational agencies, and nonprofit organizations by providing resources, including funding and technical assistance, to promote high 

quality after school programs and programs that comprehensively redesign and expand the 

school schedule for all students, and full-service community schools through the 21st Century 

Community Learning Centers program. Technical assistance should also focus on innovative 

methods that ensure inclusive opportunities to promote physical activity for students with 

disabilities, as well as strengthening partnerships. 

Recommendation 5.7: State and local educational agencies should be encouraged to support 

interscholastic sports and help decrease prohibitive costs of sports by curbing practices such as 

“pay-to-play,” working with other public and private sector partners.

• The Federal government should continue to support programs, such as those sponsored by 

the Corporation for National and Community Service, that train and develop more qualified 

coaches for intramural sports teams and programs, and should collaborate with state, and 

local governments, nonprofits, philanthropies, and private sector partners to ensure that these 

programs are more widespread.

• State and local governments should consider strategies to make facilities and coaches more 

available for local youth sports teams.

• College and university sports teams should engage K-12 teams to increase opportunities for 

young people to learn about sports and receive coaching, and local sports figures and businesses should become more involved in supporting or sponsoring K-12 sports teams.

C. The“Built Environment”

How communities are designed and function can promote—or inhibit—physical activity for children 

and adults. The built environment consists of all man-made structures, including transportation 

infrastructure, schools, office buildings, housing, and parks. Children’s ability to be physically active in 

their community depends on whether the community is safe and walkable, with good sidewalks and 

reasonable distances between destinations.

Research is still emerging on the exact interaction of the built environment and the impact on childhood obesity. Yet, a series of research studies suggests that attributes of our current built environment, such as low density development and sprawl, have had a negative impact on health outcomes, 

contributing to obesity and related health problems.

313 Several of these studies have found that areas 

with greater sprawl tend to have higher rates of adult obesity. The combination of greater distances 

between destinations as development sprawls outward from city centers and the lack of pedestrian 

and bicycle infrastructure contributes to eliminating walking and biking as options and to increased 

driving. One-fifth of all automobile trips in urban areas are one mile or less, and over two-fifths of these 

trips are under three miles,314 distances easily walked or biked if the proper infrastructure were available.

Low-income communities in particular often have a higher number of busy through streets, poor cycling 

and pedestrian infrastructure, and few high-quality parks and playgrounds—all elements which seem 

to deter physical activity.

315
V. Increasing Physical Activity

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On the other hand, communities that emphasize pedestrian-friendly design have the potential to bring 

about better health outcomes. Such designs help decrease automobile travel, increase opportunities 

for physical activity, enhance public safety, and improve air quality, while simultaneously preserving 

agricultural and other environmentally fragile areas. Research suggests that doubling residential density 

across a metropolitan area might lower household vehicle miles traveled by about 5 to 12%, and perhaps 

by as much as 25%, if coupled with other measures.

316 

Creating new walkable, bikable communities can be feasible, but retrofitting the vast majority of existing 

American communities poses a separate challenge. This includes revitalizing older, traditional neighborhoods, often found in center cities or towns, to make them more viable, active communities. It also 

includes retrofitting newer sprawling communities to diversify their transportation options, creating a 

more walkable street grid.

Before undertaking any major new development or planning initiatives, communities may consider 

completing an assessment of the potential health impacts of the development. For example, Health 

Impact Assessments (HIAs) describe a combination of procedures, methods, and tools used to judge 

a policy or project’s potential public health effects and the distribution of those effects within the 

population.

317 HIAs can be used to focus decision-makers’ attention on the health consequences of the 

projects and policies they are considering, particularly how land use decisions may impede or improve 

physical activity.

The existence of safe, convenient, and accessible facilities for walking and biking are likely to increase 

physical activity and make parents feel more secure about their children’s safety. However, they do not 

by themselves ensure more active lifestyles for residents of such communities. “Social environments” 

also play a role, including how community members feel about their neighborhood, how secure they 

feel, and how interested they are in participating in community-based physical activity. Evidence suggests that the combined effect of the built and social environment has an impact on rates of childhood 

obesity and overweight. A recent study found that: 

• Children living in unsafe neighborhoods or those characterized by poor housing and the presence of garbage and litter on streets had an approximately 30-60% higher chance of being 

obese or overweight than children living in better conditions.

• Children with low neighborhood amenities or those lacking neighborhood access to sidewalks or walking paths, parks or playgrounds, or recreation or community centers had 20-45% 

higher odds of becoming obese or overweight compared to children who had access to these 

amenities.

• The impact of the built environment was particularly strong for younger children (ages 10-11) 

and for girls. Girls ages 10-11 living in neighborhoods with the fewest amenities had 121-276% 

higher adjusted odds of being obese or overweight than those living in neighborhoods with 

the most amenities.

318
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In particular, violence shapes our everyday decisions about where to live, work, go to school, shop for 

groceries, play, and whether go for a walk in the neighborhood or to a local park. In one study, people 

who classified their neighborhood as “not at all safe” were three times more likely to be physically inactive 

during leisure time than those who considered their neighborhood to be “extremely safe.”319 Another 

study also found that walking habits vary according to an individual’s perception of safety and physical 

surroundings. For example, fear may lead someone to shop at a nearby convenience store, which may 

only contain unhealthy food, instead of walking further to a farmers market, or a grocery store that has 

healthy produce options.

320 Effective public safety measures, such as community based anti-crime and 

anti-gang initiatives, can reduce fear of crime and violence.  Where possible, such efforts should be 

targeted on specific “hot spots” for crime and violence that impede access to parks, playgrounds, and 

other recreational facilities, as well as routes to healthy eating options.

“Active Transport”: Safe Routes to School and Beyond

Active transport refers to approaches that encourage individuals to actively travel between their destinations throughout the day, such as by biking or walking. Children who walk or bike to school report 

being more physically active, including engaging in more moderate to vigorous physical activity, than 

those who travel by car, bus, or train.

321 

Programs like Safe Routes to Schools (SRTS), funded by the U.S. Department of Transportation (DOT), 

have proven an effective way to get students safely walking and biking to school. Serving students 

in grades K-8, the SRTS program supports capital investments, such as building sidewalks, crosswalks, 

creating better community designs, and providing other supports for active transport. Nearly 6,500 

schools are participating in the federal SRTS program, which has provided $612 million for this purpose 

since 2005. SRTS helped and continues to help increase the number of students walking to school322 

and decrease those being driven to school.

323 A study of SRTS sites in California showed a 38% increase 

in students walking to school.

324 

Even without dedicated funding, some communities have found creative ways to make safe passages for 

young people between homes and neighborhoods, schools, and after school activities. For elementary 

students, the “walking school bus” has been a successful model, in which adults walk to school with 

a group of students. For older students, creative partnerships with police departments have helped 

students travel between school and afterschool activities safely in some communities.

Still, in 2009, only 13% of students rode a bike or walked to school, down from 44% in 1969.

325 Similarly, 

the percentage of students riding a school bus has also declined and more students report coming 

to school by personal vehicle than other methods.

326 Parents cite many barriers to “active transport,” 

commonly referencing distance to school, traffic-related danger, and weather. In the same survey, 12% 

of parents cited fear of crime as a barrier. Six percent of parents also cited school policies that prohibit 

walking and biking to school as the reason their children did not walk or bike to school.

327 Bike and 

pedestrian safety is a real concern as well. In 2007, 14,000 children were injured and 300 killed by cars.

There is a “safety in numbers” trend, in which roadways generally become safer for everyone when more 

people are out walking and biking.

328
V. Increasing Physical Activity

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Recommendations

Recommendation 5.8: Reauthorize a Surface Transportation Act that enhances livability and physical activity. A complete network of safe bicycle and pedestrian facilities would allow children to take 

more trips through active transportation and get more physical activity. New Federal aid construction 

projects should accommodate bicyclists and pedestrians by incorporating “Complete Streets” principles.

As improvement projects for existing facilities are undertaken, transportation infrastructure should 

be retrofitted, where feasible, to support and encourage bicycle and pedestrian use. State and local 

money can also be leveraged to support safe facilities for children to walk or bike to places like parks, 

playgrounds, transit, and community centers. The reauthorization could adopt Complete Streets 

principles that would include routine accommodation of walkers and bicyclists for new construction, 

to influence retrofitting of existing communities, and to support public transportation. In addition, it 

could enhance authority for recreational areas on public lands. 

Recommendation 5.9: The Environmental Protection Agency should assist school districts that may 

be interested in siting guidelines for new schools that consider the promotion of physical activity, 

including whether students will be able to walk or bike to school. 

Recommendation 5.10: Communities should be encouraged to consider the impacts of built environment policies and regulations on human health. Local communities should consider integrating 

Health Impact Assessments (HIAs) into local decision-making processes, and the Federal government 

should continue to support the development of an HIA approach, tools, and supporting resources that 

promote best practices.

How Kids Get to School, 2009

Source: U.S. Department of Transportation, Federal Highway Administration Oce of Policy, National Household Travel Survey, 2009.

Other 3%

Bicycle 1%

Walk 12%

Car 44%

School Bus 40%
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Recommendation 5.11: The Federal Safe Routes to School Program (SRTS) should be continued and 

enhanced to accommodate the growing interest in implementing Safe Routes to Schools plans in 

communities. This can be facilitated by:

• Continuing aspects of current law, including requiring that every State maintain a full-time SRTS 

Coordinator, spending funds on both infrastructure projects and non-infrastructure activities, 

and continuing to operate the National Clearinghouse.

• Continuing Federal investments to increase opportunities for SRTS participation.

• Streamlining Federal requirements and reducing administrative burden for grants management 

to fit with the unique nature of SRTS projects and programs.

• Expanding funding eligibility to cover kindergarten through 12th grade.

• Developing improved surveillance and validated measures for tracking participation in SRTS 

and its impacts.

Recommendation 5.12: “Active transport” should be encouraged between homes, schools, and 

community destinations for afterschool activities, including to and from parks, libraries, transit, 

bus stops, and recreation centers. 

Benchmarks of Success

Increase by 50% by 2015 the percentage of children ages 5-18 taking safe walking and biking

trips toandfromschool. An increase of 50% would mean that 19.5% of school trips would be by biking 

or walking.  This data is available from the National Household Travel Survey, which is conducted every 

five to seven years, so there may be a delay in this data becoming available.

D. Community RecreationVenues

Parks and Playgrounds

Parks and playgrounds in a community can provide opportunities to run and play and may increase 

unstructured physical activity.

329 If children can easily access safe parks and playgrounds in good repair, 

they are more likely to engage in recreational physical activity there.

330 

National, state, and local parks are an ideal environment to be physically active, and increased access 

to parks is proven to promote physical activity among children331 and adolescents.

332 In addition to 

encouraging physical activity, parks and other natural landscapes can provide recreational experiences, 

opportunities to learn and grow, and places of quiet refuge. The Federal government provides support 

for state and local conservation and recreation initiatives through the Land and Water Conservation Fund 

(LWCF) State Assistance Program. The goal of this program is to increase access to a park, a river, or an 

area of open space close to home. As part of this initiative, funds can be used to enhance and support 

the further development of parks and playgrounds in communities. Other Federal programs provide 

funding to States and local entities for park and open space conservation and recreation trails and shared 

use paths, including HUD’s Community Development Block Grant program and DOT’s Transportation 

Enhancement program.
V. Increasing Physical Activity

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Private, nonprofit organizations and corporations have also supported park and playground development in communities. By engaging in park clean-ups and playground development, businesses can take 

part in initiatives that contribute to community cohesion and improve access to playgrounds and parks.

Outdoor and Indoor Venues

Outdoor recreation and access to nature play a vital role in the physical, psychological, spiritual wellbeing, health, and development of people of all ages.

333 The current poor health of many American 

children today, including increasing levels of obesity-related illnesses,334 attention deficit- hyperactivity, 

vitamin D deficiency, and myopia are being attributed, in part, to a generational decline in the level of 

outdoor recreation in natural environments.

Children’s level of physical activity has been shown to increase when they participate in environmental 

education programs that promote outdoor activity.

335 Children of all ages are healthier, happier, and 

have better social skills if they have frequent opportunities for free and unstructured play outdoors.

336

For these reasons, children need to be encouraged to connect with the outdoors—places that can 

promote both physical and emotional health. 

Communities still need to ensure adequate and accessible indoor facilities for physical activity. For students who are unable to play outside because of allergies or asthma, particularly during high-pollution 

days or inclement weather, communities should make sure indoor recreational facilities are available 

to children. Currently, 65% of schools allow for community use of physical activity or athletic facilities, 

a strategy that can increase opportunities for indoor activity.

337

Communities also must ensure that children actually are aware of the opportunities available to them.

The Task Force for Community Preventive Services found that informational outreach is essential to 

maximizing the results of improvements in access to physical activity.

338 In some communities, outreach 

was unnecessary, but in others, outreach and communications was needed.

Recommendations

Recommendation 5.13: Increase the number of safe and accessible parks and playgrounds, particularly in underserved and low-income communities. This can be accomplished in part by:

• Targeting LWCF funds to increase use of and access to parks and open space in low-income 

neighborhoods and communities that receive funding, and by expanding Tribes’ access to 

funding and strengthening their capacity to compete for funding.

• Businesses considering “adopting” (building and/or helping to maintain) parks and playgrounds 

in their communities.

• Foundations, community and faith-based organizations, and businesses engaging in community planning efforts to ensure their work in developing parks and playgrounds are enhanced 

and maintained over time, and are supportive of other community initiatives.

• Encourage development or renovation of playgrounds to include less asphalt and more natural 

terrain, so as to foster unstructured, “natural” play.
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Recommendation 5.14: The Federal government should continue to support investments in a wide 

range of outdoor recreation venues, such as National Parks, Forests, Refuges and other public lands, 

and expand opportunities for children to enjoy these venues. The U.S. Department of Interior and 

the National Forest Service maintain hundreds of millions of acres of public land, as well as rivers, parks, 

and other areas. 

• Federal land management agencies should work together along with state, Tribal and local 

agencies to promote and ensure access to a range of youth-appropriate activities on public 

lands and waters.  This includes transportation to help children get to and from parks and other 

public lands.

• Federal agencies should work with non profits, corporations, and local youth groups to 

strengthen partnerships and identify new opportunities for outdoor physical activities, programs, and events.

Recommendation 5.15: Local governments should be encouraged to enter into joint use agreements 

to increase children’s access to community sites for indoor and outdoor recreation.

Recommendation 5.16: The business sector should be encouraged to consider which resources and 

physical assets like fields and gyms can be used to increase students’ access to outdoor and indoor 

recreational venues. Corporations, for example, may have large grounds that they can make available for children in the community to play soccer or engage in other outdoor activities.

Recommendation 5.17: Entertainment and technology companies should continue to develop new 

approaches for using technology to engage children in physical activity.

Benchmarks of Success

Increase access to,useof, andthenumberof safe andaccessibleparks andplaygrounds,particularly inunderservedandlow-income communities. Partial data sources exist in the private sector to 

measure this, but work will need to be done to develop those sources and measure progress.
V. Increasing Physical Activity

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Key Questions for Future Research

• What are the teaching methods that best engage students in PE, including the relative benefits 

of technology in the PE classroom, for achieving long-term behavioral changes in physical 

activity habits?

• What kinds of outdoor activities for children are most likely to produce lasting increases in 

physical activity levels? Are the benefits different from indoor physical activity?

• How can we better target physical activity interventions to multiple communities, including 

diverse ethnic populations and children with disabilities? What are the most effective methods 

for reaching these populations?

• What are appropriate measurement tools for tracking trends in physical activity?

• Do health impact assessments change health outcomes in communities where they are used?

• What percentage of children lives within walking or biking distance from school or a park 

entrance?

• Does the built environment increase physical activity rates for children and reduce obesity? If 

so, what are the mechanisms for this reduction?

• How can the insights of behavioral economics, such as changing the default choice in a given 

situation, be used to promote physical activity among young people?

★ 87 ★

Conclusion

Taken together, the strategies and tactics outlined in this report should achieve the goal of solving the 

problem of childhood obesity within a generation. It will not be easy, and it will take action on all of our 

parts — parents and teachers, leaders in government and industry, and communities large and small.

But at the core of this endeavor is a simple concept we all embrace, which is that children should have 

good, nutritious food to eat and the chance to be physically active every day, so that they grow up into 

healthy adults.

The next step is to turn these ideas into action. Many partners stand ready to make this happen, and 

have already volunteered to be part of this effort by joining the First Lady’s Let’s Move! campaign.

Philanthropies will play a critical role in cementing private sector commitments to make concrete steps 

towards our shared goal, including but not limited to the action steps recommended in this report. And 

the Federal government must play a leadership role as well. The Task Force on Childhood Obesity and 

its 12 member agencies stand ready to take up that charge. Every day, approximately 11,000 children 

are born in America. We owe them our very best effort.

★ 89 ★

Summary of Recommendations

I. Early Childhood

Recommendation

Federal action

State or

local action

Private sector 

action

Page

Recommendation 1.1: Pregnant women and women planning a 

pregnancy should be informed of the importance of conceiving at a 

healthy weight and having a healthy weight gain during pregnancy, 

based on the relevant recommendations of the Institute of Medicine.

x x x 12

Recommendation 1.2: Education and outreach efforts about prenatal 

care should be enhanced through creative approaches that take into 

account the latest in technology and communications. Partners in 

this effort could include companies that develop technology-based 

communications tools, as well as companies that market products and 

services to pregnant women or prospective parents.

x 12

Recommendation 1.3: Hospitals and health care providers should use 

maternity care practices that empower new mothers to breastfeed, 

such as the Baby-Friendly hospital standards. 

x x x 16

Recommendation 1.4: Health care providers and insurance companies 

should provide information to pregnant women and new mothers on 

breastfeeding, including the availability of educational classes, and 

connect pregnant women and new mothers to breastfeeding support 

programs to help them make an informed infant feeding decision

x x x 16

Recommendation 1.5: Local health departments and communitybased organizations, working with health care providers, insurance 

companies, and others should develop peer support programs that 

empower pregnant women and mothers to get the help and support 

they need from other mothers who have breastfed

x x x 16

Recommendation 1.6: Early childhood settings should support 

breastfeeding x x x 16

Recommendation 1.7: Federal and State agencies conducting health 

research should prioritize research into the effects of possibly obesogenic chemicals. x 17
S O LV I N G T H E P RO B LEM O F C H I LD H O O D O B E S I T Y

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Recommendation 1.8: The AAP guidelines on screen time should 

be made more available to parents, and young children should be 

encouraged to spend less time using digital media and more time 

being physically active. 

x x 18

Recommendation 1.9: The AAP guidelines on screen time should be 

made more available in early childhood settings. x x 18

Recommendation 1.10: The Federal government, incorporating input 

from health care providers and other stakeholders, should provide 

clear, actionable guidance to states, providers, and families on how to 

increase physical activity, improve nutrition, and reduce screen time in 

early child care settings. 

x 21

Recommendation 1.11: States should be encouraged to strengthen 

licensing standards and Quality Rating and Improvement Systems to 

support good program practices regarding nutrition, physical activity, 

and screen time in early education and child care settings

x x 21

Recommendation 1.12: The Federal government should look for 

opportunities in all early childhood programs it funds (such as the 

Child and Adult Care Food Program at USDA, the Child Care and 

Development Block Grant, Head Start, military child care, and Federal 

employee child care) to base policies and practices on current scientific evidence related to child nutrition and physical activity, and seek 

to improve access to these programs

x 21
S ummary of Recommendations

★ 91 ★

II. Empowering Parents and Caregivers

Recommendation

Federal action

State or

local action

Private sector 

action

Page

Recommendation 2.1: The Federal government, working with local 

communities, should disseminate information about the 2010 Dietary 

Guidelines for Americans through simple, easily actionable messages 

for consumers and a next generation Food Pyramid. 

x 26

Recommendation 2.2: The FDA and USDA’s Food Safety and 

Inspection Service should collaborate with the food and beverage 

industry to develop and implement a standard system of nutrition 

labeling for the front of packages

x x 27

Recommendation 2.3: Restaurants and vending machine operators 

subject to the new requirement in the Affordable Care Act should be 

encouraged to begin displaying calorie counts as soon as possible

x 27

Recommendation 2.4: Restaurants should consider their portion 

sizes, improve children’s menus, and make healthy options the default 

choice whenever possible. 

x 27

Recommendation 2.5: The food and beverage industry should extend 

its self-regulatory program to cover all forms of marketing to children, 

and food retailers should avoid in-store marketing that promotes 

unhealthy products to children. 

x 32

Recommendation 2.6: All media and entertainment companies 

should limit the licensing of their popular characters to food and 

beverage products that are healthy and consistent with science-based 

nutrition standards

x 32

Recommendation 2.7: The food and beverage industry and the media 

and entertainment industry should jointly adopt meaningful, uniform 

nutrition standards for marketing food and beverages to children, as 

well as a uniform standard for what constitutes marketing to children. 

x 32

Recommendation 2.8: Industry should provide technology to help 

consumers distinguish between advertisements for healthy and 

unhealthy foods and to limit their children’s exposure to unhealthy 

food advertisements. 

x x 32
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Recommendation 2.9: If voluntary efforts to limit the marketing of 

less healthy foods and beverages to children do not yield substantial 

results, the FCC could consider revisiting and modernizing rules on 

commercial time during children’s programming

x 32

Recommendation 2.10: Pediatricians should be encouraged to 

routinely calculate children’s BMI and provide information to parents 

about how to help their children achieve a healthy weight. 

x 35

Recommendation 2.11: Federally-funded and private insurance plans 

should cover services necessary to prevent, assess, and provide care to 

overweight and obese children. 

x x 35

Recommendation 2.12: Dentists and other oral health care providers 

should be encouraged to promote healthy habits and counsel families 

on childhood obesity prevention as part of routine preventive dental 

care

x 35

Recommendation 2.13: Medical and other health professional 

schools, health professional associations, and health care systems 

should ensure that health care providers have the necessary training 

and education to effectively prevent, diagnose, and treat obese and 

overweight children

x 35
S ummary of Recommendations

★ 93 ★

III. Healthier Food in Schools

Recommendation

Federal action

State or

local action

Private sector 

action

Page

Recommendation 3.1: Update Federal nutritional standards for school 

meals and improve the nutritional quality of USDA commodities 

provided to schools. 

x 39

Recommendation 3.2: Increase resources for school meals. x x x 40

Recommendation 3.3: USDA should continue its outreach and 

technical assistance to help provide training for school food service 

professionals. 

x x x 40

Recommendation 3.4: Schools should consider upgrading their 

cafeteria equipment to support the provision of healthier foods, for 

example, by swapping out deep fryers for salad bars. 

x x x 41

Recommendation 3.5: USDA should work with all stakeholders to 

develop innovative ways to encourage students to make healthier 

choices. 

x x 41

Recommendation 3.6: USDA should work to connect school meals 

programs to local growers, and use farm-to-school programs, where 

possible, to incorporate more fresh, appealing food in school meals

x x x 41

Recommendation 3.7: Schools should be encouraged to make 

improvements in their school meal programs through the HealthierUS 

Schools Challenge in advance of updated Federal standards. 

x x x 42

Recommendation 3.8: Increase the alignment of foods sold at school, 

including in the a la carte lines and vending machines, with the Dietary 

Guidelines. 

x 43

Recommendation 3.9: Food companies should be encouraged to 

develop new products and reformulate existing products so they meet 

nutritional standards based on the Dietary Guidelines and appeal to 

children. 

x 43

Recommendation 3.10: USDA and the U.S. Department of Education 

should collaborate with states to increase the availability and consistency of nutrition education in schools. x x 44
S O LV I N G T H E P RO B LEM O F C H I LD H O O D O B E S I T Y

★ 94 ★

Recommendation 3.11: Where possible, use school gardens to educate students about healthy eating. x x 45

Recommendation 3.12: Technical assistance should be provided to 

schools about how to a cafeteria and lunch room environment can 

support and encourage a healthful meal

x 45

Recommendation 3.13: Schools should be encouraged to ensure that 

choosing a healthy school meal does not have a social cost for a child x 45

Recommendation 3.14: Schools should be encouraged to consider 

the impact of food marketing on education. x x 45

Recommendation 3.15: School districts should be encouraged to create, post, and implement a strong local school wellness policy. x x x 45

Recommendation 3.16: Promote good nutrition through afterschool 

programs. x x x 47

Recommendation 3.17: Promote healthy behaviors in juvenile correctional and related facilities. x x x 47
S ummary of Recommendations

★ 95 ★

IV. Access toHealthy, Affordable Food

Recommendation

Federal action

State or

local action

Private sector 

action

Page

Recommendation 4.1: Launch a multi-year, multi-agency Healthy 

Food Financing Initiative to leverage private funds to increase the 

availability of affordable, healthy foods in underserved urban and rural 

communities across the country.

x x x 53

Recommendation 4.2: Local governments should be encouraged to 

create incentives to attract supermarkets and grocery stores to underserved neighborhoods and improve transportation routes to healthy 

food retailers. 

x 54

Recommendation 4.3: Food distributors should be encouraged to 

explore ways to use their existing distribution chains and systems to 

bring fresh and healthy foods into underserved communities. 

x x 54

Recommendation 4.4: Encourage communities to promote efforts to 

provide fruits and vegetables in a variety of settings and encourage 

the establishment and use of direct–to-consumer marketing outlets 

such as farmers’ markets and community supported agriculture 

subscriptions. 

x

54

Recommendation 4.5: Encourage the establishment of regional, city, 

or county food policy councils to enhance comprehensive food system 

policy that improve health

x 54

Recommendation 4.6: Encourage publicly and privately-managed 

facilities that serve children, such as hospitals, afterschool programs, 

recreation centers, and parks (including national parks) to implement policies and practices, consistent with the Dietary Guidelines, 

to promote healthy foods and beverages and reduce or eliminate the 

availability of calorie-dense, nutrient-poor foods

x x x 54

Recommendation 4.7: Provide economic incentives to increase 

production of healthy foods such as fruits, vegetables, and whole 

grains, as well as create greater access to local and healthy food for 

consumers. 

x 59

Recommendation 4.8: Demonstrate and evaluate the effect of 

targeted subsidies on purchases of healthy food through nutrition 

assistance programs. 

x 59
S O LV I N G T H E P RO B LEM O F C H I LD H O O D O B E S I T Y

★ 96 ★

Recommendation 4.9: Analyze the effect of state and local sales taxes 

on less healthy, energy-dense foods x x 59

Recommendation 4.10: The food, beverage, and restaurant industries 

should be encouraged to use their creativity and resources to develop 

or reformulate more healthful foods for children and young people

x 60

Recommendation 4.11: Increase participation rates in USDA nutrition 

assistance programs through creative outreach and improved customer service, state adoption of improved policy options and technology systems, and effective practices to ensure ready access to nutrition 

assistance program benefits, especially for children. 

x x x 62
S ummary of Recommendations

★ 97 ★

V. Increasing Physical Activity

Recommendation

Federal action

State or

local action

Private sector 

action

Page

Recommendation 5.1: Developers of local school wellness policies 

should be encouraged to include strong physical activity components, 

on par with nutrition components.

x 73

Recommendation 5.2: The President’s Challenge should be updated to 

ensure consistency with the Physical Activity Guidelines for Americans 

and to ensure ease of use and implementation by schools. Private 

sector partners with an interest in physical activity should help enroll 

children in the Presidential Active Lifestyle Award program

x x 73

Recommendation 5.3: State and local educational agencies should be 

encouraged to increase the quality and frequency of sequential, ageand developmentally- appropriate physical education for all students, 

taught by certified PE teachers

x x 73

Recommendation 5.4: State and local educational agencies should be 

encouraged to promote recess for elementary students and physical 

activity breaks for older students, and provide support to schools to 

implement recess in a healthy way that promotes physical activity and 

social skill development.

x

73

Recommendation 5.5: State and local educational agencies should 

be encouraged to provide opportunities in and outside of school for 

students at increased risk for physical inactivity, including children with 

disabilities, children with asthma and other chronic diseases, and girls

x x 74

Recommendation 5.6: Federal, state, and local educational agencies, in partnership with communities and businesses, should work 

to support programs to extend the school day, including afterschool 

programs, which offer and enhance physical activity opportunities in 

their programs

x x x 77

Recommendation 5.7: State and local educational agencies should 

be encouraged to support interscholastic sports and help decrease 

prohibitive costs of sports by curbing practices such as “pay-to-play,” 

working with other public and private sector partners.

x x x 78

Recommendation 5.8: Reauthorize a Surface Transportation Act that 

enhances livability and physical activity. x x 81
S O LV I N G T H E P RO B LEM O F C H I LD H O O D O B E S I T Y

★ 98 ★

Recommendation 5.9: The Environmental Protection Agency should 

assist school districts that may be interested in siting guidelines for 

new schools that consider the promotion of physical activity, including 

whether students will be able to walk or bike to school

x x 81

Recommendation 5.10: Communities should be encouraged to 

consider the impacts of built environment policies and regulations on 

human health. 

x x 81

Recommendation 5.11: The Federal Safe Routes to School Program 

(SRTS) should be continued and enhanced to accommodate the 

growing interest in implementing Safe Routes to Schools plans in 

communities.

x 82

Recommendation 5.12: “Active transport” should be encouraged 

between homes, schools, and community destinations for afterschool 

activities, including to and from parks, libraries, transit, bus stops, and 

recreation centers. 

x x 82

Recommendation 5.13: Increase the number of safe and accessible 

parks and playgrounds, particularly in underserved and low-income 

communities

x x x 83

Recommendation 5.14: The Federal government should continue to 

support investments in a wide range of outdoor recreation venues, 

such as National Parks, Forests, Refuges and other public lands, and 

expand opportunities for children to enjoy these venues. 

x 84

Recommendation 5.15: Local governments should be encouraged to 

enter into joint use agreements to increase children’s access to community sites for indoor and outdoor recreationx 84

Recommendation 5.16: The business sector should be encouraged to 

consider which resources and physical assets like fields and gyms can 

be used to increase students’ access to outdoor and indoor recreational 

venues

x 84

Recommendation 5.17: Entertainment and technology companies 

should continue to develop new approaches for using technology to 

engage children in physical activity

x 84
★ 99 ★

Endnotes

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84.	 Lucas A., Boyes S., Bloom R., Aynsley-Green A.. (1981). Metabolic and endocrine responses to a milk 

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89.	 U.S. States Breastfeeding Committee. (2002).Breastfeeding and child care

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90.	 Society for Human Resource Management. (2009). 2009 Employee Benefits: Examining Employee 

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91.	 Section 4207 (“Reasonable Break Time for Nursing Mothers”) of the Patient Protection and Affordable 

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92.	 U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), 

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95.	 Chung M., Raman G., Trikalinos T., Lau J., Ip S. (2008). Interventions in primary care to promote 

breastfeeding: an evidence review for the U.S. Preventive Services Task Force.Annals of Internal Medicine, 

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96.	 Section 2951 (“Maternal, Infant, and Early Childhood Home Visitation Programs”) of the Patient 

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97.	 Examples of these chemicals include several estrogenic chemicals (e.g. genistein, diethylstilbestrol, 

bisphenol A), perfluorooctanoic acid (PFOA), smoking/nicotine, tributyltin, phthalates, fructose, 

monosodium glutamate, and certain organophosphate pesticides. In addition, other environmental 

chemicals have been associated with diabetes in humans, including arsenic, cadmium, dioxin, 

polychlorinated biphenyls (PCBs) and other types of halogenated organic compounds. Longnecker, M.

P., and Daniels, J. L. (2001). Environmental contaminants as etiologic factors for diabetes. Environmental 

Health Perspectives, 109(Supplemental 6), 871-6; Edwards, J. R., and Prozialeck, W. C. (2009). Cadmium, 

diabetes and chronic kidney disease.Toxicology and Applied Pharmacology, 238, 289-93; Schwartz, G.

G., Il’yasova, D., and Ivanova, A. (2003). Urinary cadmium, impaired fasting glucose, and diabetes in the 

NHANES III. Diabetes Care, 26, 468-70; Tseng, C. H. (2004). The potential biological mechanisms of arsenicinduced diabetes mellitus. Toxicology and Applied Pharmacology, 197, 67-83; Turyk, M., Anderson, H. A., 
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Knobeloch, L., Imm, P., and Persky, V. W. (2009). Prevalence of diabetes and body burdens of polychlorinated 

biphenyls, polybrominated diphenyl ethers, and p,p’-diphenyldichloroethene in Great Lakes sport fish 

consumers.Chemosphere, 75, 674-9; Uemura, H., Arisawa, K., Hiyoshi, M., Kitayama, A., Takami, H., Sawachika, 

F., Dakeshita, S., Nii, K., Satoh, H., Sumiyoshi, Y., Morinaga, K., Kodama, K., Suzuki, T., Nagai, M., and Suzuki, 

T. (2009). Prevalence of metabolic syndrome associated with body burden levels of dioxin and related 

compounds among Japan’s general population. Environmental Health Perspectives, 117, 568-73; Grun, F.

and B. Blumberg, Endocrine disrupters as obesogens. Mol Cell Endocrinol, 2009. 304(1-2): p. 19-29.

98.	 U.S. Department of Health and Human Services. (n.d.) Bisphenol A (BPA) Information for Parents. 

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99.	 American Academy of Pediatrics Committee on Public Education. (2001). Children, Adolescents, and 

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100.	 Rideout V., Vandewater E., Wartella, E. (2003).Zero to Six: Electronic Media in the Lives of Infants, Toddlers 

and Preschoolers. Menlo Park, C.A.: Henry J. Kaiser Foundation.

101.	 Rideout, V., Hame, E. (2006).The Media Family: Electronic Media in the Lives of Infants, Toddlers, 

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102.	 Dennison, B.A., Erb, T.A., & Jenkins, P.L. (2002). Television viewing and television in bedroom associated 

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103.	 Mendoza J.A., Zimmerman F.J., Christakis D.A.. (2007). Television viewing and obesity in U.S. preschool 

children.International Journal of Behavioral Nutrition and Physical Activity, 4(1), 44.

104.	 Taveras, E.M., Sandora, T.J., Shihm, M.C., Ross-Degnan, D., Goldmann, D.A., Gillman M.W. (2006). The 

association of television and video viewing with fast food intake by preschool-age children.Obesity (Silver 

Spring), 14(11), 2034-41.

105.	 U.S. Census Bureau. (2005). Survey of Program Participation: Child Care. Retrieved from:

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106.	 U.S. Census Bureau Survey of Income and Program Participation, Spring 2005, unpublished data.

107.	 Whitaker, R. C., Pepe, M. S., Knight, J. A., Seidel, K. D., & Dietz, W. H. (1998). Early adiposity rebound and 

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108.	 McWilliams C., et al. (2009). Best Practice Guidelines for PA in Child Care. Pediatrics,124(6), 1650-1659; 

Hannon, J.C., Brown B.B. (2008). Increasing preschoolers’ physical activity intensities: an activity-friendly 

preschool playground intervention.Preventative Medicine, 46(6); Dowda, M., Brown, W.H., McIver, K.L., et al.

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109.	 Bruening K.S., Gilbride J.A., Passannante M.R., McClowry S. (1999). Dietary intake and health outcomes 

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110.	 Chandran, K. (2009, September). Improving Nutrition in Child Care in America. Presentation for the 

Nemours Healthy Kids, Healthy Future Convening. Washington, DC.

111.	 Kaphingst, K.M., Story, M. (2009). Child Care as Untapped Setting for Obesity Prevention.Prevention 

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112.	 Benjamin, S.E., Finkelstein, J. (2010). Preventing Obesity in the Child Care Setting: Evaluating State 

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113.	 Caring for our Children: National Health and Safety Performance Standards is published by the National 

Resource Center for Health and Safety in Child Care and Early Education. The National Resource Center is 

funded by the Maternal and Child Health Bureau, U.S. Department of Health & Human Services, HRSA.
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114.	 Lin BH, Guthrie J, Frazao E. (2001). American children’s diets not making the grade.Food Review, 24(2), 

8-17; Center for Disease Control and Prevention. (2008). Youth Risk Behavior Surveillance—United States, 

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115.	 Bittman, M. (2009).Food Matters: A Guide to Conscious Eating. New York, NY: Simon & Schuster; Pollan, 

M. (2009).Food Rules: An Eater’s Manual. New York, NY: Penguin Books; Heath, C., Heath, D. (2010).Switch: 

How to Change Things When Change is Hard. New York, NY: Random House.

116.	 Section 4004 (“Education and Outreach Campaign Regarding Preventive Benefits”) of the Patient 

Protection and Affordable Care Act of 2010, Pub. L. No 111-148.

117.	 U.S. Department of Agriculture, Food Safety and Inspection Service. (2009). Nutrition Labeling of 

Single-Ingredient Products and Ground or Chopped Meat and Poultry Products: Proposed Rule.Federal 

Register, 74(242), 67735-67800.

118.	 U.S. Health and Human Services, Food and Drug Administration. (2010).Key Findings from 2002 and 

2008 U.S Food and Drug Administration’s Health and Diet Survey. [Factsheet]. Retrieved from:

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119.	 Choinière, C.J., Lando, A. (2008). 2008 Health and Diet Survey. Retrieved from:

http://www.fda.gov/Food/ScienceResearch/ResearchAreas/ConsumerResearch/ucm193895.htm

120.	 On March 3, 2010, FDA Commissioner issued an open letter to industry on the importance of accurate 

nutrition labeling of food products, and the agency issued Warning Letters to 17 manufacturers informing 

the firms that the labeling for 22 of their food products violate provisions of the Federal Food, Drug, and 

Cosmetic Act that require labels to be truthful and not misleading.

121.	 Section 4205 (“Nutrition labeling of standard menu items at chain restaurants”) of the Patient 

Protection and Affordable Care Act of 2010, Pub. L. No 111-148.

122.	 Nestle, M. (2010). Health Care Reform in Action—Calorie Labeling Goes National.New England Journal 

of Medicine. Retrieved from: http://www.NEJM.org

123.	 Wisdom, J., Downs, J.S., Loewenstein, G. (2010). Promoting Healthy Choices: Information versus 

Convenience.American Economic Journal: Applied Economics, 2, 164–178.

124.	 Wansink, B., Just, D.R., Payne, C.R. (2009). Mindless Eating and Healthy Heuristics for the Irrational.

American Economic Review: Papers & Proceedings, 99(2), 165–169.

125.	 Wansink, B., Kim J. (2005). Bad Popcorn in Big Buckets: Portion Size Can Influence Intake as Much as 

Taste. Journal of Nutrition Education and Behavior, 37(5), 242-5.

126.	 Nielsen, S.J., Popkin, B.M. (2003). Patterns and trends in food portion sizes, 1977-1998. Journal of the 

American Medical Association, 289(4), 450-453.

127.	 Anderson, S., Whitaker, R. (2010). Household routines and obesity in U.S. Pre-school-Aged Children.

Pediatrics, 125(3), 420-428; Taveras, E.M., Rifas-Shiman, S., et al. (2008). Short sleep duration in infancy and risk 

of childhood overweight. Archives of Pediatrics & Adolescent Medicine, 162(4), 305-311.

128.	 Anderson, S., Whitaker, R. (2010). Household routines and obesity in U.S. Pre-school-Aged Children.

Pediatrics, 125(3), 420-428; Taveras, E.M., Rifas-Shiman, S., et al. (2008). Short sleep duration in infancy and risk 

of childhood overweight. Archives of Pediatrics & Adolescent Medicine, 162(4), 900-906.

129.	 U.S. General Accounting Office. (2004).Nutrition Education: USDA Provides Services through Multiple 

Programs, but Stronger Linkages among Efforts Are Needed. Washington, D.C.: U.S. General Accounting Office.

130.	 Economic Research Service (ERS), U.S. Department of Agriculture (USDA). (1997). Understanding Food 

Prices.Food Review, 20(2).

131.	 Federal Trade Commission. (2008) Marketing Food to Children and Adolescents: A Review of Industry 

Expenditures, Activities, and Self-Regulation. Washington, D.C.: Federal Trade Commission. Retrieved from: 

http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf, at ES-1. 

132.	 Escobar-Chaves, S.L., Anderson, C.A. (2008). Media and Risky Behaviors. Children and Electronic 

Media. 18(1).Retrieved from: http://futureofchildren.org/futureofchildren/publications/docs/18_01_07.pdf
Endnotes

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133.	 Institute Of Medicine. Committee on Food Marketing and the Diets of Children and Youth. (2006).

Food Marketing to Children and Youth, Threat or Opportunity? Washington, D.C.: The National Academies Press.

134.	 Institute Of Medicine. Committee on Food Marketing and the Diets of Children and Youth. (2006). Food 

Marketing to Children and Youth, Threat or Opportunity? Washington, D.C.; The National Academies Press; 

Gantz, W. et al. (2007). Food for Thought, Television Advertising to Children in the United States. Menlo Park, 

C.A.: The Henry Kaiser Family Foundation.

135.	 Robinson T.N., Borzekowski D.L.G., Matheson D.M., Kraimer H.C. (2007). Effects of fast food branding 

on young children’s taste preferences.Archives of Pediatrics & Adolescent Medicine, 161, 792-797.

136.	 Federal Trade Commission. (2008).Marketing Food to Children and Adolescents: A Review of Industry 

Expenditures, Activities, and Self-Regulation. Washington, D.C.: Federal Trade Commission. Retrieved from: 

http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf, at ES-2, 8.

137.	 Federal Trade Commission. (2008).Marketing Food to Children and Adolescents: A Review of Industry 

Expenditures, Activities, and Self-Regulation. Washington, D.C.: Federal Trade Commission. Retrieved from: 

http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf, ES 4-6.

138.	 Federal Trade Commission. (2008).Marketing Food to Children and Adolescents: A Review of Industry 

Expenditures, Activities, and Self-Regulation. Washington, D.C.: Federal Trade Commission. Retrieved from 

http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf, ES-4.

139.	 Sesame Workshop. (2005, September 20).The Effectiveness of Characters on Children’s Food Choices [Press 

Release]. Retrieved at: http://archive.sesameworkshop.org/aboutus/inside_press.php?contentId=15092302.

140.	 Harris, J., et al. (2009). Marketing Foods to Children and Adolescents: Licensed Characters and Other 

Promotions on Packaged Foods in the Supermarket.Public Health Nutrition, 13(3), 409-417. This recent study 

by the Yale University Rudd Center for Food Policy and Obesity found a substantial increase (78%) in the 

number of food products with youth-oriented cross-promotions on packaging between 2006 and 2008. 

Nearly 75% of those cross-promotions involved the use of licensed characters. 

141.	 Harris, J., et al. (2009). Marketing Foods to Children and Adolescents: Licensed Characters and Other 

Promotions on Packaged Foods in the Supermarket.Public Health Nutrition, 13(3), 409-417.

142.	 Children’s Food and Beverage Advertising Initiative. (n.d.). Retrieved from: 

http://www.bbb.org/us/children-food-beverage-advertising-initiative/. 

143.	 Effective January 1, 2010, this principle was expanded to apply to advertising through video games 

and cell phones, as well as word-of-mouth advertising. Children’s Food and Beverage Advertising Initiative.

(n.d.). Retrieved from http://www.bbb.org/us/enhanced-core-principles/. 

144.	 Federal Trade Commission. (2008).Marketing Food to Children and Adolescents: A Review of Industry 

Expenditures, Activities, and Self-Regulation. Washington, D.C.: Federal Trade Commission. Retrieved from: 

http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf, 63-64.

145.	 Federal Trade Commission. (2008) Marketing Food to Children and Adolescents: A Review of Industry 

Expenditures, Activities, and Self-Regulation. Washington, D.C.: Federal Trade Commission. Retrieved from: 

http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf, 64-65.

146.	 Kunkel, D. et al. (2009).The Impact of Industry Self-Regulation on the Nutritional Quality of Foods Advertised 

on Television to Children. Retrieved from: http://www.childrennow.org/uploads/documents/adstudy_2009.pdf.

147.	 Kunkel, D. et al. (2009).The Impact of Industry Self-Regulation on the Nutritional Quality of Foods Advertised 

on Television to Children. Retrieved from: http://www.childrennow.org/uploads/documents/adstudy_2009.pdf

148.	 Kunkel, D. et al. (2009).The Impact of Industry Self-Regulation on the Nutritional Quality of Foods Advertised 

on Television to Children. Retrieved from: http://www.childrennow.org/uploads/documents/adstudy_2009.pdf

149.	 Letter from Maureen Enright, Assistant Director, CFBAI, and Elaine D. Kolish, Vice President and 

Director, CFBAI, to Marlene H. Dortch, Secretary, FCC, dated March 26, 2010, in MB Docket 09-194.

150.	 For example, the Walt Disney Company, Nickelodeon, Cartoon Network, and Sesame Workshop.
S O LV I N G T H E P RO B LEM O F C H I LD H O O D O B E S I T Y

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151.	 Federal Trade Commission Report to Congress. (2008).Marketing Food to Children and 

Adolescents: A Review of Industry, Expenditures, Activities and Self-Regulation. Retrieved from: 

http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf

152.	 U.S. House. Appropriations Committee.(2009). Division D – Financial Services and General 

Government,  Explanatory Statement, Title V, Independent Agencies, 983-84. Retrieved from: 

http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi dbname=111_cong_house_committee_prints&docid=f:47494d.pdf

153.	 Kunkel, D. et al. (2009).The Impact of Industry Self-Regulation on the Nutritional Quality of Foods Advertised 

on Television to Children. Retrieved from: http://www.childrennow.org/uploads/documents/adstudy_2009.pdf.

154.	 Section 303 (“Standards for children’s television programming”) of the Children’s Television Act of 

1990, Pub. L. 101-437.

155.	 FTC has played an important role in addressing issues of food marketing, childhood nutrition, and 

obesity. Since 2005, it has hosted three public workshops and issued two reports, including its landmark 

2008 report to Congress: Marketing Food to Children and Adolescents: A Review of Industry Expenditures, 

Activities, and Self-Regulation. FTC is currently preparing to conduct a follow up study, expected to be 

published in 2011, and is participating in the IWG to develop recommendations for voluntary uniform 

nutritional standards for child-directed food and beverage marketing.

156.	 Holt, D., Ippolito, P., Desrochers, D., Kelley, C. (2007).Children’s Exposure to TV Advertising in 1977 and 

2004. Washington, D.C.: Federal Trade Commission, Bureau of Economics Staff Report. ES-7-8. Retrieved 

from: http://www.ftc.gov/os/2007/06/cabebw.pdf

157.	 On average, more than 3 million children watched American Idol in 2005-2006 and more than 1 

million watched The Simpsons. By comparison, the average child audience for SpongeBob Square Pants was 

2 million. Federal Trade Commission. (2008).Marketing Food to Children and Adolescents: A Review of Industry 

Expenditures, Activities, and Self-Regulation. Washington, D.C.: Federal Trade Commission. Retrieved from: 

http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf, 15-16.

158.	 Doolen, J., Alpert, P.T., Miller, S.K. (2009). Parental disconnect between perceived and actual weight 

status of children: a metasynthesis of the current research.Journal of the American Academy of Nurse 

Practitioners, 21(3), 160-6.

159.	 National health objectives can be found in Healthy People 2010. Overweight and Obesity. (n.d.) Retrieved October 

15, 2009 from: http://www.healthypeople.gov/Document/html/uih/uih_bw/uih_4.htm#overandobese.

160.	 Freedman D., Wang J., Thornton J.C., et al. (2009). Classification of body fatness by body mass indexfor-age categories among children. Archives of Pediatrics & Adolescent Medicine,163(9), 805-11.

161.	 Klein, J.D., Sesselberg, T.S., Johnson, M.S., O’Connor, K.G., Cook, S., Coon, M., Homer, C., Krebs, N., 

Washington, R. (2010). Adoption of body mass index guidelines for screening and counseling in pediatric 

practice. Pediatrics, 125(2), 265-72.

162.	 Centers for Disease Control and Prevention. (2005). Children and teens told by doctors that they were 

overweight, United States, 1999-2002.Morbidity and Mortality Weekly Report, 54(34), 848-9.

163.	 Nihiser, A.J., Lee, S.M., Wechsler, H., McKenna, M,, Odom, E., Reinold, C., Thompson, D., GrummerStrawn, L. (2007). Body mass index measurement in schools.Journal of School Health. 77(10), 651-71; Nihiser, 

A.J., Lee, S.M., Wechsler, H., McKenna, M,, Odom, E., Reinold, C., Thompson, D., Grummer-Strawn, L. (2007).

Body mass index measurement in schools.Journal of School Health. 77(Supplemental 1), S89-97.

164.	 U.S. Department of Health and Human Services. (2010).The Surgeon General’s Vision for a Healthy and 

Fit Nation. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General. 

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165.	 Barlow, S.E. (2007). Expert Committee. Expert committee recommendations regarding the prevention, 

assessment, and treatment of child and adolescent overweight and obesity: summary report.Pediatrics, 120

(Supplemental 4), S164-92.

166.	 Brownell, K. and Puhl, R. (2003). Stigma and Discrimination in Weight Management and Obesity. The 

Permanente Journal 7(3), 21-23.
Endnotes

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167.	 Puhl, R.M., Latner, J.D. (2007). Stigma, obesity, and the health of the nation’s children. Psychological 

Bulletin 133(4), 557-80.

168.	 Barlow, S.E. (2007). Expert Committee. Expert committee recommendations regarding the prevention, 

assessment, and treatment of child and adolescent overweight and obesity: summary report.Pediatrics,120

(Supplemental 4), S164-92.

169.	 Barlow, S.E. (2007). Expert Committee. Expert committee recommendations regarding the prevention, 

assessment, and treatment of child and adolescent overweight and obesity: summary report.Pediatrics,120

(Supplemental 4), S164-92.

170.	 U.S. Preventive Services Task Force. (2010). Screening for Obesity in Children and Adolescents: U.S.

Preventive Services Task Force Recommendation Statement.Pediatrics, 125, 361-367. Retrieved from: 

http://www.ahrq.gov/CLINIC/uspstf/uspschobes.htm.

171.	 Section 4004 (“Education and Outreach Campaign Regarding Preventive Benefits”) of the Patient 

Protection and Affordable Care Act of 2010, Pub. L. no 111-148.

172.	 Section 1001 (“Sec. 2713. Coverage of Preventive Health Services”) of the Patient Protection and 

Affordable Care Act of 2010, Pub. L. no 111-148. 

173.	 U.S. Department of Education, National Center for Education Statistics. (2009).

Projections of Education Statistics to 2018, Table 1: Actual and projected numbers for enrollment 

in grades PK–12, PK–8, and 9–12 in elementary and secondary schools, by control of school: Fall 

1993 through fall 2018. Washington, D.C.: U.S. Government Printing Office. Retrieved from 

http://nces.ed.gov/programs/projections/projections2018/index.asp.

174.	 Silva, E. (2007).On the Clock: Rethinking the Way Schools Use Time. Washington, DC: Education Sector, 

2007.

175.	 U.S. Department of Agriculure. Program Administrative Data. Unpublished.

176.	 Gordon, A. et al. (2007).Dietary Assessment Study-III. Alexandria, VA: U.S. Department of Agriculture, 

Food and Nutrition Service, Office of Research, Nutrition and Analysis, School Nutrition.

177.	 Gordon, A. et al. (2007).Dietary Assessment Study-III. Alexandria, VA: U.S. Department of Agriculture, 

Food and Nutrition Service, Office of Research, Nutrition and Analysis, School Nutrition.

178.	 Institute of Medicine. (2010). School Meals: Building Blocks for Healthy Children. Washington, D.C.: The 

National Academies Press.

179.	 Mancino, L., Guthrie, J. (2009). Nudging in the Lunch Line.Amber Waves, 7(1). Retrieved 

from: http://www.ers.usda.gov/AmberWaves/March09/Features/LunchLine.htm.

180.	 School Nutrition Association. (2010, February, 9).SNA Partners with First Lady Michelle Obama’s Childhood 

Obesity Initiative. [Press Release]. Retrieved from: http://schoolnutrition.org/Blog.aspx?id=13585&blogid=564

181.	 Kubik, M. et al. (2003). The association of the school food environment with dietary behaviors 

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