Fit WIC: Programs to Prevent 

Childhood Overweight in 

Your Community 

Final Report
Fit WIC: Programs to Prevent Childhood Overweight In Your Community 

1 

 

Fit WIC: Programs to Prevent Childhood 

Overweight in Your Community 

Final Report 

 

Office of Analysis, Nutrition, and Evaluation 

USDA, Food and Nutrition Service 

3101 Park Center Drive, Room 1014 

Alexandria, VA 22302-1500 

Principal Investigator: Project Officer: 

Patricia Crawford, DrPH, RD Ed Herzog, MA, MPS 

University of California, Berkeley USDA, Food and Nutrition Service 

 

This report is available on the Food and Nutrition Service website: http://www.fns.usda.gov/oane.

Suggested Citation:

“Fit WIC: Programs to Prevent Childhood Overweight in Your Community,” Special Nutrition Program 

Report Series, No. WIC-05-FW, Project Officer: Ed Herzog. U.S. Department of Agriculture, Food and 

Nutrition Service, Office of Analysis, Nutrition, and Evaluation, Alexandria, VA:2005. 

The United States Department of Agriculture (USDA) prohibits discrimination in its programs and activities on the basis of race, color, national 

origin, gender, religion, age, disability, political beliefs, sexual orientation and marital or familial status. (Not all prohibited bases apply to all 

programs.) To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and 

Independence Avenues, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider 

and employer. 

United States Food and 

Department of Nutrition 

Agriculture Service 

May 2005

Special Nutrition Programs

Report No. WIC-05-FW
Fit WIC: Programs to Prevent Childhood Overweight In Your Community 

2

Acknowledgements 

The Food and Nutrition Service is grateful to the many individuals who contributed to this 

project and the production of this final report. 

The final report was edited by Monica Schaeffer, Ed Herzog, Kelly Moore, and Pat Crawford. 

The report is based on reports provided by the five Fit WIC state agencies- California, the Inter 

Tribal Council of Arizona; Kentucky; Vermont; and Virginia. Members of each project team are 

listed in Appendix B. 

We also thank the WIC staff and participants who participated in data collection and Fit WIC 

activities in each of the five states. This project would not have been possible without their 

cooperation and support. 
Fit WIC: Programs to Prevent Childhood Overweight In Your Community 

3

Executive Summary 

Childhood obesity has reached epidemic proportions in the United States, increasing 

dramatically in recent decades. The predicted consequences of this epidemic of obesity, both for 

our nation’s health and for our economy, have stimulated a concerted effort by health researchers 

to understand its causes and work toward its prevention. 

In 1999, the Food and Nutrition Service (FNS) of the United States Department of Agriculture 

(USDA) funded a childhood obesity prevention initiative called Fit WIC. The purpose of this 

project was to find ways in which the FNS administered program, the Special Supplemental 

Nutrition Program for Women, Infants, and Children (WIC), could respond to this epidemic. 

FNS recognized that WIC has widespread access to young children from low-income families, a 

population at great risk for obesity, and that reaching very young children is critical to preventing 

the problem before it begins. 

Five WIC State agencies were funded by FNS through a competitive grant process to participate 

in Fit WIC. The agencies chosen were California, the Inter Tribal Council of Arizona, Kentucky, 

Vermont, and Virginia. Concerned and motivated staff in the State agencies partnered with 

social scientists from local universities to assess their respective WIC environments and to 

develop and pilot overweight prevention programs. 

During the assessment phase, the five Fit WIC teams learned a great deal about how childhood 

obesity and related issues impact WIC participants, staff, and their communities. Some 

important findings include: 

• Many parents of overweight preschool children did not see their children as overweight, 

nor were they particularly concerned about their children’s weight. 

• Parents were eager to receive information on ways to promote healthy behaviors in their 

families. 

• WIC staff members wanted to reach parents more effectively. They wanted new 

knowledge and skills to improve their education sessions with participants. 

• Community groups were eager to work toward the prevention of obesity, but were 

sometimes uninformed about the issue of childhood overweight or about how the WIC 

program could complement their efforts. 

Utilizing the information gained during the assessment phase, each Fit WIC project team 

developed and implemented an intervention appropriate for their specific setting and population. 

Their successes indicate that WIC does indeed have potential to impact national efforts to 

prevent obesity in young children. WIC can implement immediate changes to educational 

protocols in local clinics to better address weight issues with families, and can link with 

community groups to strengthen local efforts. With additional funding, WIC can position itself 

as a leader in the prevention of overweight and can meaningfully work with families and 
Fit WIC: Programs to Prevent Childhood Overweight In Your Community 

4

communities to stem the increasing rates of childhood obesity. The five Fit WIC projects 

provide a sound basis for designing and evaluating future intervention programs in WIC. 

Based upon their experiences and conclusions, the five Fit WIC teams have made 

recommendations for change in the WIC program. These recommendations, if adopted, would 

allow WIC to contribute significantly to the national effort to prevent childhood obesity. The Fit 

WIC teams recommend that the WIC program: 

1. Develop and encourage the use of participant-centered assessment and education 

procedures. 

2. Adopt physical activity as an essential element of nutrition assessment and education. 

3. Foster the potential of WIC staff members to be role models for healthy behaviors. 

4. Change the focus of participant education from weight to healthy lifestyle. 

5. Expand and update training for WIC staff. 

6. Provide wellness opportunities at work for WIC staff. 

7. Establish partnerships with community agencies to develop comprehensive communitywide interventions. 

8. Be allocated additional funding for increased staffing levels in WIC so that more staff 

time can be devoted to individual counseling and group education. 

9. Fund additional research to evaluate the impact of obesity prevention initiatives in the 

WIC setting. 

10. Fund research to study ways to change the WIC food package. 

The following report examines the current childhood obesity epidemic, describes the Fit WIC

assessment findings, outlines the five Fit WIC obesity prevention programs, and expands on the 

above recommendations for future action. 
5

FINAL REPORT 

Fit WIC: Programs to Prevent Childhood Overweight In 

Your Community 

Table of Contents 

Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 

The Problem of Childhood Obesity —Why Act Now? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 

The Food and Nutrition Service Responds—The WIC Call To Action. . . . . . . . . . . . . . . . . . . 10 

The Problem of Childhood Obesity—Why Act Through WIC? . . . . . . . . . . . . . . . . . . . . . . . . 12 

The Fit WIC Response—The Development of the Fit WIC Programs 

What Was Already Known About the Causes of Overweight . . . . . . . . . . . . . . . . . . . . . . . . 14 

What the Fit WIC Project Teams Learned in Their Assessments of WIC Sites. . . . . . . . . . . . 15 

Insights Learned From WIC Participants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 

Insights Learned From WIC Staff and Communities. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

The Fit WIC Response—The Five Fit WIC Intervention Programs. . . . . . . . . . . . . . . . . . . . . . 21 

California: A Multifaceted, Community-Based Approach to Overweight Prevention. . . . . . . .22 

Inter Tribal Council of Arizona, Inc.: A Clinic-Based Approach to Overweight Prevention 

 in American Indian Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 

Kentucky: Beyond Nutrition Counseling: Reframing the Battle Against Obesity. . . . . . . . . . 26 

Vermont: The Fit WIC Activity Kit: Tools for Overcoming Barriers to Active Physical Play. . 28 

Virginia: An Anticipatory Guidance Model for Physical Activity and Nutrition. . . . . . . . . . . . 30 

The Fit WIC Response—Summary of Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 

The Fit WIC Response—Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 

Appendix A: References on Childhood Overweight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 

Appendix B: Contributors to the Fit WIC Projects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 

Appendix C: Useful Tools Produced by the Five Fit WIC Project Teams. . . . . . . . . . . . . . . . . 44
The Problem of Childhood Obesity—Why Act Now? 

6

4

7

11

15

0

2

4

6

8

10

12

14

16

Prevalence of 

Overweight (%)

1971-74 1976-80 1988-94 1999-00

National Health and Nutrition Examination Survey

The Problem of Childhood Obesity—Why Act Now? 

The prevalence of childhood obesity is increasing. 

American children are gaining weight—more children and more weight than ever before. The 

problem is everywhere—no matter which neighborhood, state, or region you visit, American 

children are gaining weight faster than at any other point in our nation’s history. 1 In recent 

testimony given before the United States Senate, Eric M. Bost, USDA Under Secretary of the 

Food, Nutrition and Consumer Services, said: “In the past 20 years, the percentage of children 

who are overweight has doubled and the percentage of adolescents who are overweight has more 

than tripled.”2

The magnitude of this problem is illustrated in Figure 1. In 2000, 15% of children in this country 

aged 6-11 years were overweight:3 more than 3 times the prevalence shown in the early 70’s. 

Rates of overweight in preschool children enrolled in the Special Supplemental Nutrition 

Program for Women, Infants, and Children (WIC) were similar, ranging from 10-16%, 

depending on age or ethnicity (see Figures 2 and 3). 

Figure 1. Increasing Prevalence of Overweight in Children Aged 6-11 Years with Time4

 

1

 For a list of some important scientific articles describing the prevalence of childhood overweight, see Appendix A. When cited 

in this document, they are referenced by author and year of publication in the footnotes. 2

 Eric M. Bost, Under Secretary, Food, Nutrition and Consumer Services; testimony before the Subcommittee on Agriculture, 

Rural Development, and Related Agencies on April 14, 2005. http://www.fns.usda.gov/cga/Speeches/CT041405-a.html 3

 In this report, we will use the terms “overweight” and “obesity” interchangeably. “Obesity” is a lay term commonly used to 

describe this epidemic. The term “overweight” is used by the scientific community because it can be precisely defined 

by using the calculated value, Body Mass Index (BMI): body weight in kilograms divided by height (or length) in 

meters squared. BMI is more highly correlated with body fat than any other indicator of height and weight. Because of 

childhood differences in body fatness with growth and gender, no single value of BMI can be used to define the limits 

of healthy weight in children, as can be done for adults. To evaluate weight status in children, “BMI-for-age” is plotted 

on gender specific growth charts published by the CDC. Using those percentile growth charts, “overweight” is defined 

as a BMI-for-age at or above the 95th percentile; “at risk of overweight” is defined as a BMI-for-age from the 85th up 

to but not including the 95th percentile of the CDC Growth Charts. For details, see 

http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm (accessed 3 June 03). 4

 CDC, NCHS. “Prevalence of overweight among children and adolescents: United States, 1999-2000.” 

http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm (accessed 3 June 03).
The Problem of Childhood Obesity—Why Act Now? 

7

0

5

10

15

20

25

30

35

< 1 year 1 year 2 years 3 years 4 years

Age of WIC Child

% of WIC Children

At risk of overweight Overweight

Figure 2. Prevalence of overweight and overweight risk by age in WIC children in 20005

Also of concern from a public health point of view is the number of children, especially 

preschoolers, who are at risk of becoming overweight: 11-19% of children enrolled in WIC fall 

into the at risk category depending on age or ethnicity (Figures 2 and 3). Although overweight is 

increasing in all groups, rates of overweight vary by families’ income and ethnicity, and age of 

child. Among children enrolled in WIC, Hispanic and Native American children have higher 

rates of overweight compared to other racial/ethnic groups (Figure 3). 

 

5

 See footnote 3 for definitions of overweight and overweight risk. Data in the chart are from an internal FNS analysis using 

participant information collected from State WIC agencies in April 2000 for the report, “WIC Participant and Program 

Characteristics 2000”, WIC-02-PC, by Susan Bartlett, Ramona Olvera, Nicole Gill, and Michele Laramie. Project 

Officer, Julie Kresge. U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and 

Evaluation Alexandria, VA: 2002. http://www.fns.usda.gov/oane/MENU/Published/WIC/FILES/pc2000.pdf (accessed 

3 June 03). 
The Problem of Childhood Obesity—Why Act Now? 

8

0

5

10

15

20

25

30

35

40

African-American Asian Hispanic Native American White

Race/Ethnicity of WIC Child

% of WIC Children

Overweight At Risk of Overweight

Figure 3. Prevalence of overweight and overweight risk by ethnicity in WIC children in 20005

The consequences of childhood obesity are long lasting and detrimental to the public health. 

Childhood obesity is one of the most complex health problems currently confronting the nation, 

with serious medical and financial implications for the future.6

 “One of the most significant 

concerns from a public health perspective is that we know a lot of children who are overweight 

grow up to be overweight or obese adults, and thus at greater risk for some major health 

problems such as heart disease and diabetes,” said Centers for Disease Control and Prevention 

director Dr. Julie Gerberding.7 The consequences of childhood obesity include physical, 

psychological, and social problems, as well as complications associated with obesity continuing 

into adulthood. 

Certain chronic conditions that were once thought to affect only adults are now seen in 

overweight children. It has been estimated that by 5-10 years of age, 60% of overweight 

children have at least one biochemical or clinical cardiovascular risk factor associated with 

obesity and 25% have two or more.8

 The problems overweight children may experience include: 

• High blood pressure 

• Hyperlipidemia (the presence of an abnormally large amount of fat in the blood) 

 

6

 For a list of some important scientific articles describing the consequences of childhood overweight, see Appendix A. When 

cited in this document, they are referenced by author and year of publication in the footnotes. 7

 “Obesity Still On The Rise, New Data Show”, News Release, Oct. 8, 2002. CDC/NCHS Press Office. U.D. Dept. of Health and 

Human Services http://www.dhhs.gov/news/press/2002pres/20021008b.html (accessed 3 June 03). 8

 Freedman et al., 1999, as cited in “National Center for Chronic Disease Prevention and Health Promotion, Nutrition and 

Physical Activity”, http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/powerpoint/slides/028.htm (accessed 3 

June 03).
The Problem of Childhood Obesity—Why Act Now? 

9

• Stress on weight bearing joints 

• Type 2 diabetes (also called “adult-onset” diabetes) 

• Breathing difficulties 

• Low self-esteem 

• Social discrimination 

The persistence of overweight into adulthood may be the greatest health risk for overweight 

children. According to the Surgeon General of the United States, if the high rate of obesity in 

this country persists, obesity may soon cause as much preventable disease and death as cigarette 

smoking.9

 Obesity in adulthood is associated with an increased rate of morbidity and mortality 

from: 

• Hyperlipidemia 

• Cardiovascular disease 

• Type 2 diabetes 

• Certain forms of cancer 

The economic consequences of the obesity epidemic for the health care system in the United 

States are substantial. As reported by the Surgeon General9

, direct and indirect costs related to 

obesity and overweight were estimated to be $117 billion in 2000. This represents an 18% 

increase from obesity-related costs in 1995. Costs will undoubtedly continue to increase if the 

prevalence of obesity increases in this country. 

The Surgeon General issued a “Call to Action” in 2000. 

In 2000, in recognition of and in response to the growing epidemic of obesity, the Surgeon 

General of the United States made a strong statement of concern and determination to address 

this national problem; he issued a “Call To Action To Prevent and Decrease Overweight and 

Obesity.”10 The Surgeon General expressed a commitment to develop new communication and 

action strategies directed at reducing the prevalence of overweight and obesity in this country. 

Two of the principles to which the Surgeon General’s “call to action” was committed were: 

3⁄4 To identify effective and culturally appropriate interventions to prevent and treat 

overweight and obesity 

3⁄4 To develop and enhance public-private partnerships to help implement this vision 

The Surgeon General expressed the conviction that “...taking action to address overweight and 

obesity will have profound effects on increasing the quality and years of healthy life and on 

eliminating health disparities in the United States. . .. Many people believe that dealing with 

overweight and obesity is a personal responsibility. To some degree they are right, but it is also 

a community responsibility (italics added).” 

 

9

 U.S. Department of Health and Human Services. “The Surgeon General's Call to Action to Prevent and Decrease Overweight 

and Obesity.” [Rockville, MD]: U.S. Department of Health and Human Services, Public Health Service, Office of the 

Surgeon General; [2001]. Available from: US GPO, Washington. http://www.surgeongeneral.gov/topics/obesity/ 

(accessed 3 June 03). 10 U.S. Department of Health and Human Services. “The Surgeon General's Call to Action to Prevent and Decrease Overweight 

and Obesity.” [Rockville, MD]: U.S. Department of Health and Human Services, Public Health Service, Office of the 

Surgeon General; [2001]. Available from: US GPO, Washington. http://www.surgeongeneral.gov/topics/obesity/ 

(accessed 3 June 03). 
The FNS Responds—The WIC Call To Action 

10

The Food and Nutrition Service Responds to the Urgent 

Need for Solutions—The WIC Call to Action 

The Food and Nutrition Service (FNS) was among the agencies to respond early to the increasing 

prevalence of childhood overweight with its own “call to action.” Recognizing the important 

role that FNS programs could potentially play in stemming the epidemic, the agency acted well 

before this issue was in the national spotlight and before the Surgeon General issued his “Call To 

Action.” 

FNS made available $1.8 million in fiscal year 1999 to fund cooperative agreements between 

FNS and five WIC State agencies to develop new, innovative strategies to prevent overweight in 

children, specifically targeting WIC program participants. This three-year project was called Fit 

WIC,

11 and had the following goals: 

 To identify changes that State agencies and local WIC operations could make to 

become more responsive to the problem of childhood overweight 

 To develop intervention programs for the WIC setting based on assessments of 

their WIC sites 

 To create an Implementation Manual, based upon the states’ experiences in the 

three-year program, to guide State and local WIC clinics and other interested 

health professionals and organizations in their own implementation of the 

programs developed12 

Figure 3. WIC State agencies participating in Fit WIC 

Through a competitive grant process, five WIC State agencies (California, the Inter Tribal 

Council of Arizona, Inc. (ITCA), Kentucky, Vermont, and Virginia) were provided funds to 

participate in the project (see Figure 3). Together, the five projects formed Fit WIC and worked 

 

11 FNS originally called this project The WIC Childhood Obesity Prevention Projects; it was renamed Fit WIC by the project 

teams. 12 The Implementation Manual and the project materials developed by the five states have recently been made available to State 

and local WIC agencies and other health professionals across the country. The manual and materials are available 

online at the WIC Works Resource System: http://www.nal.usda.gov/wicworks/
The FNS Responds—The WIC Call To Action 

11

closely with each other and with staff from FNS and the Centers for Disease Control and 

Prevention. Each State agency established project teams consisting of State agency staff and 

social scientists from local universities.13 Each project team conducted a needs assessment of 

their WIC environment, clients, and staff, then developed and implemented an overweight 

prevention program responsive to the identified needs. 

 

13 See Appendix B for the list of WIC and academic professionals participating in Fit WIC.

Fit WIC was a consortium of WIC State agencies and social 

scientists, cooperating to develop childhood obesity prevention 

programs responsive to the needs of local WIC agencies and 

their participants.
The Problem of Childhood Obesity—Why Act Through WIC? 

12

The Problem of Childhood Obesity--Why Act Through 

WIC? 

WIC is in the right place at the right time. 

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

administered by the Food and Nutrition Service of the USDA, provides nutrition information, 

supplemental nutritious foods, and referrals to other health, welfare, and social service agencies 

to about 8 million low-income pregnant women, infants, and children up to age five every 

month. WIC participants come from all race and ethnicity groups, and include those most at risk 

for childhood overweight. WIC services are available throughout every state in the United 

States, on Indian Reservations and in U.S. territories. WIC has a positive reputation among its 

participants: The great majority of WIC participants indicate they are “very satisfied” with 

services they receive from WIC.14

Acting to prevent overweight is the best approach. 

It is well known that overweight is a very difficult problem to treat. Once individuals have 

become overweight, it is expensive and time consuming for them to attempt weight loss, and 

frequently impossible for them to sustain their weight loss. Therefore, it is critical to prevent 

weight problems before they begin. 

Early childhood is the best time to prevent childhood overweight. 

Many children, especially children in low-income families, are already overweight when they 

reach school age. School based programs aimed at reducing overweight, while important, may 

come too late to effectively prevent long-term weight problems. Moreover, it has been reported 

 

14 U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis Nutrition and Evaluation, “National Survey of 

WIC Participants, 2001 Final Report”, by Nancy Cole et al.; Project Officer, Julie Kresge. Alexandria, VA: 2001. This 

report is available on the Food and Nutrition Service website: http://www.fns.usda.gov/oane/ (accessed 22 July 03). 

Since it is difficult to lose weight and maintain weight 

loss, early prevention of excessive weight gain is 

critical. 

WIC has widespread access to preschool children in low-income 

families. These children are among those at greatest risk of 

overweight.
The Problem of Childhood Obesity—Why Act Through WIC? 

13

that preschoolers are more likely than school-aged children to modify lifestyle behaviors.15 

Reaching parents and children when they are developing eating patterns and relationships can 

help prevent overweight and ensure the development of healthy habits. 

 

15 Davis and Christoffel, 1994. 

Reaching parents of young children is key to children 

developing healthy eating and physical activity habits. 
Fit WIC: Programs to Prevent Childhood Overweight In Your Community 

14 

The Fit WIC Response—The Development of the Fit WIC

Programs

What Was Already Known About the Causes of Overweight 

At the outset of the project, the five Fit WIC teams reviewed and summarized current 

information regarding the causes and development of overweight among children.16 Some welldocumented factors included: 

1. Genetics versus environment 

Although genetics play a very important role in weight gain, rapid increases in the prevalence 

of childhood obesity over the past few decades point to the important role also played by 

environmental factors. An increase in childhood obesity of the current magnitude and speed 

cannot be due to genetic changes alone. Rather, the increase points to an environment that 

promotes the development of obesity. The physical and social environments in which 

children live influence their lifestyle, health habits and, ultimately, their weight. 

2. Physical activity 

Low levels of physical activity have been linked to increased overweight among children.17

Opportunities for physical activity are very limited in many communities. Physical activity 

has been cut from many school schedules. Communities are developed around the 

automobile. Safety concerns and childcare schedules keep children in their homes during 

playtime. As reported by the CDC, walking and bicycling by children aged 5–15 years 

dropped 40% during the last two decades.18

3. Sedentary behavior 

Direct observation of preschool physical activity has shown that substantial portions of free 

playtime are spent engaged in sedentary behavior.19 Children are spending more time than 

ever before with computers and video games. A relationship of prolonged television viewing 

and some other sedentary behaviors to weight status in childhood has been reported.20 

Young children who watch more than 5 hours of TV per day were up to five times as likely 

to be overweight as those who watch 0-2 hours per day.21 Television time has been 

positively correlated with children’s requests for advertised foods and to overall caloric 

intake.22 Research indicates that the impact of increased sedentary behavior may be 

independent of the impact of decreased physical activity.23 

 

16 For a list of some important scientific articles describing the causes of childhood overweight, see Appendix A. When cited in 

this document, they are referenced by author and year of publication in the footnotes. 17 Obarzanek et al., 1994; Sallis, 1993. 

18 National Center for Chronic Disease Prevention and Health Promotion. “Physical Activity. Promoting Better Health: A Report 

to the President”, http://www.cdc.gov/nccdphp/dash/physicalactivity/promoting_health/background.htm (accessed 3 

June 03). 19 DuRant, 1994. 

20 Dietz and Gortmaker, 1985; Hernandez et al., 1999. 21 Gortmaker et al., 1996. 

22 Taras et al., 1989. 

23 Salmon et al., 2000. 
The Fit WIC Response—The Development of the Fit WIC Programs 

15

4. Eating behavior 

Certain eating patterns have been associated with childhood obesity: a low intake of fruit and 

vegetables;24 a high intake of sweetened beverages, such as soft drinks;25 and a high intake of 

fast foods and of high-fat snack foods.26 Food consumption away from home, including fast 

food consumption, has increased, resulting in a higher consumption of fat and calories.27 

Certain meal-related parenting techniques also contribute to childhood nutrition problems. 

For example, when parents use food as a reward, or restrict or coerce a child’s food intake, 

children may develop eating patterns conducive to overweight.28 Conversely, excessively 

permissive child-feeding practices, such as allowing children to snack at will, may result in 

overeating.29

What the Fit WIC Project Teams Learned In Their Assessments of WIC Sites 

During the first year of the project, each Fit WIC project team conducted assessments to help 

shape the development of intervention strategies. Teams collected information from WIC 

participants, staff and communities in their region, using interviews, surveys, and focus groups, 

to gauge attitudes and beliefs surrounding the issue of childhood overweight. Much of the 

research used qualitative techniques and the results must be interpreted accordingly. Despite 

differences in geography, population, and race/ethnicity of staff and participants at the five 

project sites, common themes emerged in the information gathered. The insights learned by the 

project teams about their WIC participants, staff and communities are summarized below. 

 

24 Müller et al., 1999; Neumark-Sztainer et al., 1996. 

25 Ludwig, Peterson and Gortmaker, 2001. 

26 Müller et al., 1999; Tanasescu et al., 2000. 27 US Department of Agriculture, Agricultural Research Service. “What and where our children eat – 1994 nationwide survey 

results.” Research news press release. http://www.barc.usda.gov/bhnrc/foodsurvey/Kidspr.html (accessed 29 May 

2003). 28 Birch, Fisher, and Grimm-Thomas, “The development of children’s eating habits.” In: HL Meiselman (ed.), Food Choice, 

Acceptance, and Consumption. Glasgow, England: Blackie, 1996; Birch 1999. 29 Birch and Fisher, 1995. 

Parenting choices may influence nutrition, physical activity, 

weight gain and the prevalence of childhood overweight. 
The Fit WIC Response—The Development of the Fit WIC Programs 

16

Figure 4. Prevalence of Overweight in Children in Fit WIC State Agencies30

0

5

10

15

20

25

30

35

California ITCA Kentucky Vermont Virginia

% of children

Insights Learned From WIC Participants 

1. Parents did not perceive overweight as a problem for preschool children. 

Although the actual prevalence of overweight among the children at Fit WIC sites was 

high (see Figure 4) and comparable to the nation as a whole, most parents31 were not 

worried about overweight for their preschool children. They believed that overweight 

was a problem for preschoolers only when it affected a child’s activities, caused 

unhappiness, or was accompanied by other medical conditions. In fact, many parents, 

particularly recent immigrants, felt that a little extra weight indicated good health in a 

child. Some parents were more concerned about perceived underweight in their children 

than with overweight. Most parents of overweight children did not think their child was 

even “a little” overweight, and most also had difficulty identifying other heavy children 

as overweight, except in the most extreme cases. 

2. Parents were knowledgeable about WIC’s health messages, but struggled to put 

knowledge into practice. 

Although parents did not seem concerned about overweight, they did express concern 

about the health and welfare of their children and were interested in learning skills to help 

them lead healthier lives. When asked to think about how young children might become 

 

30 Overweight prevalence in Fit WIC participants was reported by VA (ages 2-4 years). Overweight prevalence in the entire State 

WIC agency was reported by CA (ages 1-4 years), ITCA (ages 1-4 years), KY (ages 2-4 years), and VT (all infants and 

children enrolled in WIC). Definition of overweight varied by project team: a weight for height >90th percentile for 

CA, > 95th percentile for VT and ≥90th percentile for ITCA and KY. VA defined overweight as a BMI greater than 95th

percentile. 31 We use the term “parents” to describe the individuals who were interviewed or surveyed during the course of this project. 

While a majority of these “parents” were biological mothers, other care giving adults—fathers, foster parents, 

grandparents, adoptive parents, and other relatives – were also included. 

Parents cannot be motivated to solve a problem if they do not recognize 

it as a problem.
The Fit WIC Response—The Development of the Fit WIC Programs 

17

overweight, parents generally blamed genetics and behaviors such as inadequate physical 

activity and consuming too much food or the “wrong” foods. Lack of self-control, poor 

parenting, stress in the family, and inadequate attention from parents were identified as 

potential causes of overweight. Many WIC parents reported having a basic 

understanding of nutrition and exercise, and they acknowledged the importance of 

establishing good eating habits in their children at an early age. 

WIC parents talked freely about the many challenges they face in adopting healthy habits 

and expressed a desire to receive more in-depth and how-to information from WIC to 

help them overcome those barriers. 

3. Parents lacked information about desirable activity levels for their families. 

While most WIC parents believed that physical activity was important to the health of 

their children, few could define adequate physical activity. Many WIC parents said that 

their child was “always doing something” or “always running around,” to describe what 

they thought was adequate exercise. Other parents felt that their child would benefit 

from more exercise, but had difficulty defining how much exercise was sufficient. Most 

WIC parents felt that their own level of activity was “normal” regardless of the 

frequency or duration of activity, indicating a lack of information or knowledge as to 

desirable levels of activity for adults as well as children. 

4. WIC families face social and economic barriers to a healthy lifestyle.

WIC families struggle with a variety of issues that hinder their ability to promote a 

healthy lifestyle within their families. Many parents have overextended schedules, 

leaving little time and energy to devote to a healthy diet and exercise. WIC families 

often live in areas that are unsafe or lack adequate play-space or programs. 

Many WIC parents complained that their attempts to provide healthful foods and physical 

activity for their children were hampered by other adults living in the household. For 

example, some mothers said that their husbands had poor eating habits, which made it 

very difficult to feed their children healthfully. Others said that they could not turn off 

the TV, because another adult living with them insisted on keeping it on at all times. 

Consequently, parents expressed interest in WIC activities that involve the entire family, 

so that other family members could learn and provide support for a more healthful 

lifestyle. 

Parents are motivated to learn about techniques for healthier lifestyles.

Parents recognize the importance of physical activity, but have trouble 

identifying what and how much activity is appropriate.
The Fit WIC Response—The Development of the Fit WIC Programs 

18

Some WIC parents were more worried about running out of food altogether than about 

the types of food that they chose. Almost half of the surveyed California Fit WIC

participants, for example, reported being worried about running out of food at some time 

during the month. 

5. WIC families receive conflicting health messages from health care providers. 

Parents complained of receiving conflicting health messages from providers such as 

physicians, WIC, and other organizations. For example, some parents were told by their 

pediatrician that their child was overweight but not to worry, and then were told by a 

WIC provider that they needed to address the issue. Conflicting messages are frustrating 

for parents and make it challenging for WIC staff to address these issues, since many 

parents would prefer to ignore the possibility that their child may be overweight.

Insights Learned From WIC Staff and Communities

1. WIC staff had concerns about addressing childhood obesity with their participants.

Unlike the WIC parents surveyed, most WIC staff members were concerned about the 

prevalence of overweight among the children served by WIC. They felt that 

inappropriate diet and feeding approaches, and inadequate physical activity, including too 

much TV, were contributing factors to the obesity they observed in WIC children. 

Despite their concern, many staff members were uncomfortable talking to WIC parents 

about childhood obesity. They felt that the limited nutrition education time available was 

inadequate to deal with this complex and sensitive problem. Staff perceived parents to be 

in denial of the problem, and sometimes even offended when the topic was discussed. 

Some staff were concerned that educating a mother about childhood obesity might make 

her feel guilty or might interfere with the rapport between educator and participant. 

Therefore, working with staff to overcome these obstacles is critical to the success of any 

counseling efforts. 

Healthy lifestyle recommendations must take into account the 

cultural and socioeconomic environment in which WIC clients live.

Due to conflicting messages from health providers, parents may 

not recognize that their child is overweight.
The Fit WIC Response—The Development of the Fit WIC Programs 

19

Adding to the complexity of the staff-participant relationship is the fact that up to 50% of 

the staff in each state reported that they themselves were overweight. Consequently, 

some felt themselves to be poor role models and were uncomfortable counseling WIC 

parents about overweight issues. 

2. Staff expressed a need for additional training on topics related to childhood 

overweight. 

Staff members wanted more training and resources to address the issue of childhood 

overweight more effectively. Some staff requested better educational materials for 

parents, and specific training for themselves on topics such as: 

• The causes of and treatments for childhood overweight 

• Age-appropriate dietary and physical activity approaches to the problem 

• Ways to open a discussion with parents about overweight 

• How to deal with resistant parents and motivate and empower them

• How to identify family barriers

• Assessing and discussing long-term risks associated with early obesity

3. Staff identified institutional barriers to effective obesity education within WIC. 

Staff members most often mentioned two particular institutional barriers to effective 

obesity prevention in the WIC setting: 

a) Inadequate resources 

Many staff members felt that they could do a better job counseling about weight issues if 

they had more time to work with parents one-on-one. Additionally, parents said they 

would like more time with a WIC dietitian. Unfortunately, within the current structure of 

WIC, the dietitian’s participant contact time is usually spent with a limited number of 

high-risk individuals. Overweight children may not be identified as high risk and thus 

may not receive education from dietitians.32 

b) The WIC food package 

Several staff members expressed frustration that the WIC foods currently available to 

participants are inconsistent with an obesity prevention message. Staff members felt that 

the WIC foods were too high in fat and not reflective of current nutrition 

recommendations for children. They felt that the WIC food package does not reflect the 

current standards on which WIC’s nutrition education is based: the Food Guide Pyramid 

 

32 Criteria used for designation of high-risk participants are at state discretion and vary from state to state. 

Staff need special training and resources if they are to effectively 

educate clients in an obesity prevention program within the 

framework of WIC.
The Fit WIC Response—The Development of the Fit WIC Programs 

20

developed by the USDA; the recommendations of the American Academy of Pediatrics 

regarding children’s juice consumption (no more than 4-6 oz per day); and the American 

Cancer Society’s 5-A-Day fruit and vegetable campaign. The WIC food package does not 

include whole fruits or vegetables, and it provides 9 oz of juice per child each day. Food 

package changes, as recommended in a recent report by the Institute of Medicine 

(IOM)33, are currently under consideration by the USDA. 

4. Limited community resources influence lifestyle choices of WIC participants. 

Some of the Fit WIC project teams examined broader community factors, which impact 

families’ abilities to adopt a healthier lifestyle. Many WIC communities lack resources 

for physical activity and convenient access to nutritious foods and/or fresh produce. 

Further, many communities lack any organized effort to address these issues. 

Many of the community groups and individuals with an interest in the issue of childhood 

overweight had limited knowledge of the local WIC programs. Most community 

stakeholders surveyed were uncertain about the services WIC provides. They recognized 

a need to have more consistent health messages delivered by agencies serving their 

communities, and were eager to work with WIC towards this end.

 

33 WIC Food Packages: Time for a Change (2005). Committee to Review the WIC Food Packages, Food and Nutrition Board, 

Institute of Medicine of the National Academies. The National Academies Press; Washington, DC. 
The Fit WIC Response—The Five Fit WIC Intervention Programs 

21

The Fit WIC Response—The Five Fit WIC Intervention 

Programs 

Each project team used the information collected during the first year assessment to develop an 

intervention appropriate to their situation. While each project team developed a unique 

intervention, several key concepts, which emerged from the first year of assessment, formed the 

basis of the interventions. Those key concepts were as follows: 

• Parents were eager to receive information on how to live healthier lifestyles, even if they 

were not concerned about their children’s weight 

• Staff members were interested in learning how to deliver that information to parents more 

effectively; they wanted new knowledge and skills to improve their education sessions 

with participants 

• Community groups were concerned about the rising rates of childhood overweight and 

were responsive when leadership was offered by WIC 

The following pages summarize the five Fit WIC programs. The summaries include information 

about the demographics of the respective WIC State agency, the goals of the particular Fit WIC

program, and a brief description of how the program worked and what it accomplished. 

Each program is also described in detail in the manual entitled “Fit WIC: Programs to Prevent 

Childhood Overweight in Your Community”.34 This manual was prepared by the Fit WIC

project teams for use by WIC administrators, clinicians, and educators as a step-by-step guide for 

the implementation of the five Fit WIC programs. It was distributed to all WIC State agencies 

and is available online at the WIC Works Resource System. 

 

34 See Appendix C for a more detailed description of the Implementation Manual and the associated materials produced by the Fit 

WIC projects and how to obtain them. 
The Fit WIC Response—The California Intervention Program 

22

THE STATE OF CALIFORNIA 

A Multifaceted, Community-Based Approach to Overweight Prevention 

California served nearly 1.3 million WIC participants each month at 650 sites throughout the 

state in 2002. Most of California’s WIC participants are Hispanic (70%); the remainder is a 

diverse mix of other racial and ethnic groups. 

Goals 

The goals of the California Fit WIC project were to: 

9 Engage WIC participants in practical, effective, learner-centered educational 

experiences to prevent childhood overweight 

9 Incorporate physical activity promotion into all aspects of WIC services 

9 Provide staff with the tools, support, and information they need to become nutrition 

and physical activity role models for participants 

9 Develop community coalitions to support community-wide, environmental policy, 

and organizational changes to prevent childhood overweight 

Methods 

California’s Fit WIC project was based upon a multi-faceted community-based model called the 

Spectrum of Prevention,35 which outlines six levels on which to intervene in order to address 

complex public health issues. The approach of the California team acknowledged the 

importance of individual education and sharing of information, but also recognized the critical 

importance of simultaneously working with communities and coalitions, changing organizational 

practices, and examining local and legislative policies that affect the social and physical 

environments in which people live. 

 

Three local WIC clinics were chosen to participate in the project. Fit WIC staff members in each 

clinic were provided with a variety of training sessions, which focused on how to talk with 

parents about weight and feeding issues, and how to help families increase physical activity. 

Training and support activities also promoted the wellness of WIC staff, strengthening the 

position of staff as role models for participants. Finally, each clinic developed new, interactive 

group-education classes to promote prevention of overweight. Topics included cooking, 

gardening, and the importance of physical activity. 

In addition to the activities within the local WIC clinics, Fit WIC staff in each clinic organized a 

task force of local community leaders, organizations, and individuals. Task force groups met 

monthly and worked toward identifying and implementing interventions to increase physical 

activity and improve the nutritional status of families in their communities. 

Accomplishments 

As a result of the intervention, staff members at Fit WIC sites reported being more physically 

active than their peers at control sites. Staff members also were significantly more likely to 

report: 

• Feeling that their workplace supported their efforts to be physically active and make 

healthy food choices 

 

35 A community action model developed by the Prevention Institute of Berkeley, CA: 

http://www.preventioninstitute.org/index.html (accessed 3 June 03). 
The Fit WIC Response—The California Intervention Program 

23

• Noticing a change in the types of foods served during staff meetings and snacks at 

their worksite 

• Feeling that physical activity had become a higher priority at their worksite 

• Feeling very comfortable encouraging WIC parents to do physical activities with their 

children 

• Making positive changes in the way they talk with parents about weight issues 

Staff members acknowledged the benefit of the new the trainings and reported positive impacts 

on their lives--both at work and at home. 

Fit WIC participants rated the new classes highly. They were significantly more likely to report 

helping their child to watch less television in the past year, were significantly more likely to see 

WIC as a resource to help them be more physically active with their children, and were 

somewhat more likely to report helping their child to be more physically active in the past year. 

The Fit WIC community task forces garnered a great deal of local support and were successful 

in: 

• Advocating for a state bill to improve school nutrition programs 

• Certifying a local farmers’ market and implementing the WIC Farmers’ Market 

nutrition program 

• Securing more than $300,000 in grant funding to implement a local community 

garden project 

• Training local medical providers, childcare providers, and parks and recreation staff 

in obesity prevention issues 

• Participating in numerous community activities, festivals and events 

At the end of the project, community agencies saw WIC as a leader in efforts to prevent 

childhood overweight. All community task force members surveyed reported interest in 

continuing their efforts to combat childhood overweight in their communities. 

Implications 

The California Fit WIC project demonstrated the power of working on many levels 

simultaneously to achieve a desired result. The project demonstrated that WIC staff members 

who model healthy behaviors feel more effective in their work. The project showed that WIC 

can be a powerful community leader in preventing childhood overweight. With an investment in 

time in the beginning, sustainable changes can be achieved in WIC programs as well as in the 

greater communities served by WIC. 
The Fit WIC Response—The Inter Tribal Council of Arizona Intervention Program 

24

THE INTER TRIBAL COUNCIL OF ARIZONA 

A Clinic-Based Approach to Overweight Prevention in American Indian Children 

The Inter Tribal Council of Arizona, Inc. (ITCA) served 9,000 WIC participants each month in 

2002; 75% were Native American. Overweight is the most prevalent nutrition problem for 

the over 5,000 children enrolled in the ITCA WIC program, with over 40% of the children ages 

2-4 identified as overweight or at risk for overweight.36

Goals 

The goals of the ITCA Fit WIC project were to: 

9 Improve the staff’s comfort level with providing nutrition and physical activity 

education to overweight participants 

9 Re-focus nutrition education sessions to emphasize the parent-child feeding 

relationship rather than the specific foods consumed 

9 Increase the opportunities for physical activity for preschoolers and introduce them to 

good nutrition 

Methods 

To help staff members feel more comfortable in discussing weight issues with WIC participants, 

staff members were supported in their efforts to develop and meet personal goals for nutrition 

and physical activity. Staff participated in regularly scheduled small group meetings in which 

they received supporting information, discussed obstacles, and set and tracked their goals. 

 

Staff also received training and tools to help them teach participants about mealtime parenting 

strategies. A new care plan and questionnaire was developed to elicit information about feeding 

relationship issues from WIC caregivers. This information was then used in conducting the 

participant’s education sessions. 

Staff learned new skills to lead discussion groups on important nutrition topics with adult WIC 

participants. Guidelines to assist staff in conducting these facilitated discussion groups were 

developed. Additionally, new classes and activities for children were developed. These included 

involving children in reading stories about food, helping to prepare a healthy snack, and 

participating in enjoyable physical activities. 

Accomplishments 

Successes were realized in all project focus areas. Staff members who participated in project 

activities reported more positive changes in their own lifestyle, such as an increase in exercise, a 

change in diet, or watching less television, than did staff in the control group. They also 

demonstrated improvement in knowledge surrounding feeding-relationship issues. Staff were 

more likely to discuss physical activity with participants, and more likely to feel successful and 

competent in their counseling skills. Some staff members who facilitated group activities with 

caregivers or children felt unprepared for their role initially, but ultimately, were gratified by and 

enjoyed the experience and felt the sessions were effective. Parents and other caregivers who 

participated in group activities expressed an appreciation for this approach as a supplement to 

 

36 From the Pediatric Nutrition Surveillance System (PedNSS) of the Centers for Disease Control and Prevention, 2001, 

http://www.cdc.gov/nccdphp/dnpa/pednss.htm (accessed May 22, 2003).
The Fit WIC Response—The Inter Tribal Council of Arizona Intervention Program 

25

individual counseling and welcomed the opportunity to interact with other WIC participants 

during their WIC visit. 

The newly developed classes for children were particularly successful. The children participated 

enthusiastically in the story sessions, physical activities and in preparing and eating the snacks. 

Parents expressed appreciation for the opportunity to bring their child to a class in WIC and 

many asked if they could bring children of friends or relatives. Staff members especially 

enjoyed providing the classes to children and were most eager to implement this part of the 

program. 

Implications 

The Inter Tribal Council of Arizona Fit WIC project demonstrated that WIC could successfully 

implement obesity prevention programs in a Native American setting. Staff training resulted in 

more confident and competent staff and more satisfied and engaged participants, both children 

and adults. Encouraging and supporting WIC staff in their efforts to improve their own health 

habits was critical to improving their confidence and competence. Incorporation of physical 

activity as an educational element was a key element in promoting prevention of childhood 

overweight in this setting. Creative curricula and programmatic changes provided opportunities 

for WIC children to learn about nutrition and physical fitness. 
The Fit WIC Response—The Kentucky Intervention Program 

26

THE STATE OF KENTUCKY 

Beyond Nutrition Counseling: Reframing the Battle Against Obesity 

The Kentucky WIC Program served 113,000 participants each month during 2002, about 70% of 

whom lived in rural areas. Most participants are non-Hispanic whites (85%), 11% are African 

Americans and 3% are Hispanics. 

Goal 

The goals of the Kentucky Fit WIC project team were to increase the awareness of WIC staff of: 

9 How WIC families perceive the problem of childhood overweight 

9 Challenges faced by WIC families, particularly in the area of parenting, as they try to 

prevent or manage overweight in their children 

9 The methods they themselves currently use with participants in education sessions 

about this problem 

Methods 

Qualitative research conducted in Kentucky WIC prior to Fit WIC suggested that the dialogue 

that occurs between WIC health professionals and parents during nutritional counseling sessions 

often fails to create an effective partnership in preventing or treating obesity. Communication 

barriers between WIC health professionals and participants included differing views on how to 

define obesity, what causes it, when it becomes a problem, the context in which it occurs, and 

what to do about it. 

To address these barriers, the Kentucky project developed a documentary-style video entitled 

"Beyond Nutrition Counseling: Reframing the Battle Against Obesity.” The video documented 

the daily challenges WIC families face in feeding their children. The video also exposed the gap 

between the reality of the WIC families’ lives and the way in which they are provided with 

information in the WIC setting. The provocative content of the video was designed to make 

health professionals reflect on their own counseling techniques, on the current structure of WIC, 

and on how both might be changed to improve WIC’s responsiveness to the problem of 

childhood obesity. 

The intervention developed by the Kentucky Fit WIC team consisted of showing the video to a 

group of WIC health professionals and then immediately conducting a facilitated discussion with 

the group about the video’s content. The video exposed barriers to effectively working on 

weight issues in WIC, and the discussion was designed to help the discussants generate ways to 

overcome those barriers in their work. 

Accomplishments 

An evaluation of the Fit WIC Kentucky intervention was conducted with 150 health care 

professionals attending the Kentucky Maternal and Child Health Conference in 2001. The video 

was well received: Viewers felt that the video powerfully illustrated the challenges of addressing 

weight issues in the WIC program. After viewing the video and participating in the facilitated 

group discussions, viewers were better able to identify barriers and solutions suggested in the 

video. The intervention (video plus facilitated group discussion) produced positive, measurable, 

short-term changes in perceptions of health care professionals about barriers and solutions to the 

problem of overweight in low-income preschool children.
The Fit WIC Response—The Kentucky Intervention Program 

27

Implications

Altering perceptions of WIC staff about the barriers that families experience in WIC and in their 

own lives to achieving healthy lifestyles is a first step in helping staff and participants find 

solutions to those barriers. Using the Fit WIC Kentucky videotape in conjunction with facilitated 

discussion provides an innovative approach to altering perceptions of health care professionals 

and can be used in other health-care settings as well. 
The Fit WIC Response—The Vermont Intervention Program 

28

THE STATE OF VERMONT 

The Fit WIC Activity Kit: Tools for Overcoming Barriers to Active Physical Play

The Vermont WIC program served nearly 16,000 participants each month in 2002. Most 

Vermont WIC participants are white and most live in rural areas. Vermont’s WIC food packages 

are home-delivered to participants weekly—a structure that differentiates Vermont from the 

other Fit WIC State agencies. 

Goal 

The primary goal of the Vermont Fit WIC project was to increase active physical playtime and 

decrease sedentary time for three- and four-year olds through a family-based intervention. 

Methods 

Vermont WIC parents told the Fit WIC project team that they valued physical activity, but were 

unsure about the types or amount that would be appropriate for their preschool-aged children. 

To respond to this uncertainty, the Vermont Fit WIC project team developed a “Fit WIC Activity 

Kit,” using the concepts of social cognitive theory as a framework.37 The Activity Kit contained 

written materials and other items specifically selected to overcome barriers to, and increase 

opportunities for, active physical play. To build behavioral capability and self-efficacy, the kit 

included an instructional notebook for parents that provided messages about the importance of 

physical activity, ideas for everyday activities, skill building games, a community directory of 

recreational facilities, and an activity calendar. To support the transition from knowledge to 

behavior, the kit also contained specific active play items: a beach ball; beanbags; and a cassette 

tape of children’s songs. Maps and public transportation schedules were also provided. 

The Activity Kit was distributed to all three- and four year old WIC participants, regardless of 

weight status, giving WIC staff a venue in which to interact positively about the topic of physical 

activity with all preschool-aged participants. This approach served as a preventive measure for 

normal weight children, and also facilitated the more sensitive task of addressing the topic of 

childhood obesity with parents of overweight children. 

Accomplishments 

The Fit WIC Activity Kit was very well received by the participating families and by the WIC 

staff at the Fit WIC sites. Ninety–five percent of WIC mothers reported using the Activity Kit, 

with 71% using it more than 4 times during the first 2 weeks. Three to five months later, at the 

time of follow-up, usage had dropped somewhat but was still frequent. Ninety-seven percent of 

mothers reported they would use the Fit WIC materials again in the future. Compared to a 

control group of Vermont WIC mothers who did not receive the Fit WIC intervention, mothers 

who used the Fit WIC Activity Kit reported an improvement in their child’s active play skills, 

and in their own ability to teach play skills to their child. 

Additionally, mothers responded that the Vermont Fit WIC Activity Kit helped them connect 

with their child, inspired new parent-child activity ideas, and reminded them of the importance of 

physical activity and play. Many mothers who had children of varying ages said the Activity Kit 

was adaptable to a wide range of family ages and interests. 

 

37 According to social cognitive theory, people learn not only through their own experiences but also by observing the actions of

others and the results of those actions. This theory is often used as the framework for behavioral interventions. 
The Fit WIC Response—The Vermont Intervention Program 

29

Implications 

Providing parents with physical activity resources and information in the kit format utilized by 

the Vermont project team is an effective approach to overweight prevention and health 

promotion within the current structure of the WIC program. 
The Fit WIC Response—The Virginia Intervention Program 

30

THE STATE OF VIRGINIA 

An Anticipatory Guidance Model for Physical Activity and Nutrition 

Virginia served nearly 130,000 WIC participants each month during 2002. The state’s WIC 

participants are ethnically diverse, and come from a mix of urban, rural, and suburban settings. 

Goals 

The goals of the Virginia Fit WIC program were to: 

9 Incorporate the concept of anticipatory guidance38 into the individual and group 

education sessions conducted by WIC nutritionists 

9 Foster parental role modeling of healthy behaviors to WIC children 

9 Encourage staff to present themselves as co-participants and role models in making 

nutrition and physical activity changes 

9 Use a multi-front, community effort to ensure that WIC participants receive 

consistent and reinforcing messages in their communities 

Methods 

The Virginia Fit WIC team developed six “key” health messages related to obesity prevention to 

promote in the WIC site and among partnering community agencies. The messages included: 1) 

encourage your child to get moving every day, 2) take time to eat together and talk with your 

family, 3) limit television viewing to one hour per day, 4) serve water at snacks, 5) offer your 

child 5 fruits and vegetables each day, and 6) play with your kids. 

A variety of strategies were used to promote these key messages. First, individual education 

sessions were developed using new tabletop displays of low-literacy guidance cards. The 

guidance cards helped the WIC staff identify the needs and concerns of the WIC parent 

regarding the child's activity, nutrition and growth. In addition, the guidance cards helped to 

guide the participant in setting realistic personal goals related to the key message being 

discussed. 

Second, group education sessions were designed around the six key messages. Participants 

engaged in discussion and goal setting at the WIC site, recorded healthy behaviors at home, and 

were reinforced for their positive efforts at their next WIC visit. Through this process, WIC 

parents were encouraged to become role models for their children, by improving their own eating 

and activity behaviors. 

Third, to encourage staff to model healthy behaviors for participants and demonstrate that fitness 

is a goal for everyone, a staff fitness component was included. WIC staff members were 

encouraged to use the stairs rather than the elevator, to engage in fitness “competitions” and to 

bring brown-bag healthy lunches from home. 

Fourth, educational materials promoting the six key messages were distributed to collaborating 

community health and service agencies, at meetings organized by Fit WIC staff. With the 

 

38 In “anticipatory guidance” based education, parents are taught to anticipate their children’s readiness to engage in different 

types of physical activity and mealtime behaviors and to guide their children in the development of related skills, 

thereby promoting healthy weight. See Story, Hold, and Sofka, eds. Bright Futures in Practice: Nutrition. Arlington, 

VA: National Center for Education in Maternal and Child Health, 2000. 
The Fit WIC Response—The Virginia Intervention Program 

31

partner agencies using the educational materials and promoting the same six messages to their 

clients, WIC clients received consistent and reinforced health messages. 

 

Finally, in order to effectively provide community linkages, a list of community resources was 

prepared. WIC nutritionists used the list during education sessions to refer participants to helpful 

community agencies. 

Accomplishments 

Following implementation of the Virginia Fit WIC project in a WIC clinic in northern Virginia, 

WIC parents reported positive changes in some health-related behaviors: They more often 

engaged their children in active play; increased the amount of water (vs. sweetened beverages) 

they offered to their children; and were more confident about their ability to prevent overweight 

in their children. They were also more likely to report observing WIC staff in healthy behaviors 

than were parents in a control site. 

Implications 

The six key messages used in the Virginia Fit WIC project are simple messages that can readily 

be used to promote healthy weight in children. The efficacy of WIC staff members can be 

increased through training on obesity prevention and by increasing staff awareness of and 

comfort in their role-model relationship with participants. Staff must be encouraged and 

supported in their efforts to make healthy lifestyle choices for themselves. Community wide 

promotion of health messages by WIC can support efforts made at the WIC site to prevent 

childhood overweight. 
The Fit WIC Response—Summary of Findings 

32

The Fit WIC Response—Summary of Findings 

The successes of Fit WIC indicate that WIC is positioned to play a significant role in efforts to 

prevent obesity in preschool children. What follows is a list of findings of the five Fit WIC 

project teams. 

• Training, specialized educational materials, and increased time with participants allowed 

staff to effectively address the complex issue of childhood overweight with WIC parents. 

• Education sessions that focused on healthy behaviors were more effective than those 

which focused on weight issues, since parents often fail to identify overweight in their 

own children. 

• Parents were eager to receive information on healthy lifestyle choices, and especially 

wanted activities that involved the entire family in their efforts. 

• WIC staff felt that training, appropriate educational materials, and more time with 

participants allowed them to build the rapport essential for addressing the sensitive issue 

of childhood overweight with WIC parents. 

• Physical activity promotion is an important adjunct to the promotion of healthy eating. 

• When provided with wellness opportunities in the work place, staff felt they could be 

more effective health educators. They could more easily provide positive modeling of 

healthy behaviors for WIC participants and better understand the obstacles faced by 

overweight participants. 

• Community stakeholders recognized the role of WIC as a leader and partner in obesity 

prevention efforts. 
Appendix 

33

The Fit WIC Response—Recommendations 

The WIC program was created by Congress to provide low-income pregnant women, infants and 

children with nutrition education, nutritious supplemental foods, and referrals to other health, 

welfare and social service agencies during critical times of growth and development. The 

original purpose of WIC’s nutrition education was to teach pregnant and postpartum participants 

(whose diets were inadequate) about the value of good nutrition. With the increasing prevalence 

of childhood overweight in the nation, especially in low-income-families, the need to adapt the 

nutrition education and services offered by WIC agencies has become clear. To help address the 

complex problem of obesity and its related health problems, the scope of nutrition education and 

training in WIC must be expanded and new teaching methods must be introduced. 39 

The following recommendations for institutional change in WIC were made by the Fit WIC

project teams with the goal of making WIC more responsive and effective in the fight against the 

epidemic of childhood obesity. The recommendations are based on the experiences of the Fit 

WIC project teams and on the results of their qualitative research. These findings are limited in 

the extent to which they can be generalized to other contexts. However, the clinical and research 

experiences of the project teams, both individually and collectively, in the field of childhood 

overweight prevention are extensive. The project teams propose that if these recommendations 

were to be followed, the WIC program could contribute significantly to the nation’s efforts to 

prevent childhood overweight. At the same time, the Fit WIC project teams recognize that 

further research needs to be done to evaluate the impact of interventions in the WIC clinic on 

physical activity levels, eating patterns and prevalence of overweight in WIC participants. 

What Can Be Done Within the Current WIC Program Structure 

1. Develop and encourage the use of participant-centered assessment and education 

procedures. 

The purpose of participant assessment should be not only to determine risk and 

eligibility, but also to gather information for subsequent participant-centered nutrition 

education strategies. When WIC staff use participant-centered assessment techniques, 

they can tailor their nutrition education sessions to the needs and circumstances of 

participants. As a result, staff will be able to develop more effective counseling 

relationships with participants. 

2. Adopt physical activity as an essential element of nutrition assessment and education. 

Integrating the topic of physical activity into assessment procedures and education will 

enable local WIC programs to foster the spectrum of health behaviors necessary to 

prevent childhood overweight in their participants.

 

39 United Sates General Accounting Office. Report to Congressional Committees, GAO-02-142. “Food Assistance: WIC Faces 

Challenges in Providing Nutrition Services”, pages 10-12. December 2001. Available for downloading on 

http://www.gao.gov/.
Appendix 

34

3. Foster the potential of WIC staff members to be role models for healthy behaviors.

Providing staff with a supportive work environment conducive to healthy eating and 

physical activity can empower staff members to make changes in their personal health 

habits. Staff who practice the healthy habits that they teach can become more confident 

and effective health educators. Within the current WIC structure and at no additional 

expense, a site can encourage group walks at lunch, activity breaks for WIC staff, and 

healthy snacks at group gatherings. 

4. Change the focus of participant education from weight to healthy lifestyle. 

WIC parents and staff often differ in their perceptions of overweight and its causes, and 

parents often fail to recognize that their child is overweight. Therefore, discussions that 

focus specifically on weight are not likely to be productive. When the discussion centers 

on improving health behaviors within the entire family, rather than on the child’s weight, 

nutrition education is likely to be more effective, and the entire family will benefit. This 

would also allow all children, regardless of current weight status, to be included in 

nutrition education protocols aimed at promoting healthy lifestyles. Educators should 

weave practical, how-to information and skill building activities into every aspect of WIC 

education. 

WIC Program Enhancements Likely to Require Additional Funding Beyond 

the Current WIC Appropriation 

1. Expand and update training for WIC staff. 

Training should include these specific areas and topics: 

3⁄4 The causes, prevention and treatment of childhood overweight 

3⁄4 Successful methods to open a discussion with parents about overweight 

3⁄4 Successful intervention strategies, including dealing with resistant parents, 

helping families to identify barriers, and motivating participants 

3⁄4 The barriers that WIC participants face in their everyday lives to achieving a 

healthy lifestyle for themselves and their families 

3⁄4 Cultural issues related to the topic of childhood overweight 

3⁄4 The differences in perception about overweight that exist between WIC staff and 

participants 

2. Provide wellness opportunities at work for WIC staff. 

This could take many forms, from exercise classes on site, to activity breaks, to the use of 

incentives for documented improvements in health-related behaviors. All staff, even the 

“front-line” support staff, should be included in wellness activities,40 to maximize the 

benefit of these programs.

3. Establish partnerships with community agencies to develop comprehensive communitywide interventions. 

 

40 For activities that involve a program cost, WIC Policy Memorandum #95-5 and OMB circulars A-87 and A-122 currently 

provide guidelines regarding allowable costs. 
Appendix 

35

The scope of the problem of childhood obesity requires a community-wide effort. By 

working with community groups, WIC can garner support for sustainable community 

changes that will impact the health habits of residents. WIC staff will need additional 

time and training to develop the leadership skills necessary for forming community task 

forces or work groups. This effort will support the effectiveness of WIC’s educational 

messages and programs in the broader community. 

4. Increase staffing levels in WIC so that more staff time can be devoted to individual 

counseling and group education. 

Current staffing levels do not allow adequate time for WIC staff to address the complex 

issue of childhood obesity. Although all clients are offered nutrition education, extended 

contact time is usually reserved for clients who meet high-risk criteria not related to 

obesity. 

What Next? The Future of WIC’s Role in Childhood Obesity Prevention 

1. Fund additional research to evaluate the impact of obesity prevention initiatives in the 

WIC setting. 

While the Fit WIC projects suggested a number of promising program opportunities, they 

were not designed to evaluate the effects of programmatic change on children’s dietary 

habits, physical activity levels or weight status. Future efforts of WIC in the area of 

childhood obesity prevention should build on the success of Fit WIC and rigorously 

evaluate activities and materials developed through Fit WIC as well as the 

recommendations contained in this report. 

2. Fund research to study ways to change the WIC food package. 

The WIC food package should reflect current federal guidelines for a healthful diet using 

the Dietary Guidelines for Americans, the Food Guide Pyramid and the Food Guide 

Pyramid for Children. In September 2003, FNS contracted with the Institute of Medicine 

(IOM) to complete a thorough, independent review of the WIC food package; results and 

recommendations were released by the IOM in April, 2005 and FNS is currently 

reviewing the report recommendations. 

By adopting these recommendations and continuing to pursue strategies to prevent overweight 

in the WIC setting, the WIC program can contribute significantly to the national effort to prevent 

childhood obesity. 
Appendix 

36

Appendix A. References on Childhood Overweight 

The Prevalence of Childhood Overweight

Alaimo K, Olson CM, Frongillo EA. Low family income and food insufficiency in relation to 

overweight in US Children: Is there a paradox? Archives of Pediatric and Adolescent 

Medicine 2001;155:1161-1167. 

Crawford PB, Story M, Wang MC, Ritchie LD, Sabry ZI. Ethnic issues in the epidemiology of 

childhood obesity. Pediatric Clinics of North America 2002;48:855-78. 

Flegal KM, Carroll MD, Ogden CL, Johnson, CL. Prevalence and trends in obesity in US Adults, 

1999-2000. Journal of the American Medical Association 2002;288: 1723-1727.

Flegal KM, Carroll RJ, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United 

States: prevalence and trends, 1960-1994. International Journal of Obesity and Related 

Metabolic Disorders 1998;22:39-47. 

Galuska DA, Serdula M, Pamuk E, Siegel PZ, Byers T. Trends in overweight among U. S. adults 

from 1987 to 1993: a multistate telephone survey. American Journal of Public Health 

1996;86:1729-35. 

Kuczmarski RJ, Carroll MD, Flegal KM, Troiano RP. Varying body mass index cutoff points to 

describe overweight prevalence among U.S. adults: NHANES III (1988 to 1994). Obesity 

Research 1997;5:542-8. 

Mei Z, Scanlon KS, Grummer-Strawn LM, Freedman DS, Yip R, Trowbridge FL. Increasing 

prevalence of overweight among U. S. low-income preschool children. The Centers for 

Disease Control and Prevention Pediatric Nutrition Surveillance, 1983-1995. Pediatrics 

1998;101(1):e12. http://www.pediatrics.org/cgi/content/full/101/1/e12.

Mokdad AH, Serdula MK, Deitz WH, Bowman BA, Marks JS, Koplan JP The spread of the 

obesity epidemic in the United States, 1991-1998. Journal of the American Medical 

Association 1999;282:1519-1522. 

Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among 

US children and adolescents. Journal of the American Medical Association 

2002;288:1728-1732. 

Ogden CL, Troiano RP, Briefel RR, Kuczmarski RJ, Flegal KM, Johnson CL. Prevalence of 

overweight among preschool children in the United States, 1971 through 1994. Pediatrics 

[serial online] 1997;99:E1. http://www.pediatrics.org/cgi/content/full/99/4/e1.

Popkin BM, Udry JR. Adolescent obesity increases significantly in second and third generation 
Appendix 

37

U.S. immigrants: The National Longitudinal Study of Adolescent Health. Journal of 

Nutrition 1998;128:701-706. 

Strauss RS, Pollack HA. Epidemic Increase in Childhood Overweight, 1986-1998. Journal of the 

American Medical Association 2001;286:2845-2848. 

Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence 

and trends for children and adolescents: The National Health and Nutrition Examination 

Surveys, 1963 to 1991. Archives of Pediatric and Adolescent Medicine 1995;149:1085-

91. 

Yip R, Parvanta I, Scanlon K, Borland EW, Russell CM, Trowbridge FL. Pediatric nutrition 

surveillance system-United States, 1980-1991. Morbidity and Mortality Weekly Report 

1992;41:1-41. 

Social Context and Causes of Overweight

Baughcum AE, Burklow KA, Deeks CM, Powers SW, Whitaker RC. Maternal feeding practices 

and childhood obesity: a focus group study of low-income mothers. Archives of Pediatric 

and Adolescent Medicine 1998;152:1010-14. 

Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. Maternal perceptions of 

overweight preschool children. Pediatrics 2000;106(6):1380-6. 

Baughcum AE, Powers SW, Bennett Johnson S, Chamberlin LA, Deeks CM, Jain A, Whitaker 

RC. Maternal feeding practices and beliefs and their relationships to overweight in early 

childhood. Journal of Developmental and Behavioral Pediatrics 2001;22(6):391-408. 

Birch LL. Development of food preferences. Annual Review of Nutrition 1999;19:41-62. 

Birch LL, Fisher JO. Development of eating behaviors among children and adolescents. 

Pediatrics 1998;101 (suppl.):539-49. 

Chagnon YC, Perusse L, Bouchard C. The human obesity gene map: the 1997 update. Obesity 

Research 1998;6:76-92. 

Dietz WH Jr, Gortmaker SL. Do we fatten our children at the television set? Obesity and 

television viewing in children and adolescents. Pediatrics. 1985 May;75(5):807-12. 

DuRant RH, Baranowski T, Johnson M, Thompson WO. The relationship among television 

watching, physical activity and body composition of young children. Pediatrics 1994;94: 

449-55. 
Appendix 

38

Flegal KM, Harlan WR, Landis JR. Secular trends in body mass index and skinfold thickness 

with socioeconomic factors in young adult women. American Journal of Clinical 

Nutrition 1988;48:535-43. 

Garn SM, Bailey SM, Solomon MA, Hopkins PJ. Effect of remaining family members on fatness 

prediction. American Journal of Clinical Nutrition 1981;34:148-53. 

Gortmaker SL, Must A., Sobol AM, Peterson K, Colditz GA, Dietz WH. Television viewing as a 

cause of increasing obesity among children in the United States, 1986-90. Archives of 

Pediatric and Adolescent Medicine. 1996:150:356-62. 

Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened 

drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001 Feb 

17;357(9255):505-8. 

Muller MJ, Koertzinger I, Mast M, Langnase K, Grund A. Physical activity and diet in 5 to 7 

years old children. Public Health Nutrition 1999;2:443-444. 

Neumark-Sztainer D, Story M, Resnick MD, Blum RW. Correlates of inadequate fruit and 

vegetable consumption among adolescents. Preventative Medicine 1996;25(5):497-505. 

Obarzanek E, Schreiber GB, Crawford PB, Goldman SR, Barrier PM, Frederick MM, Lakatos E. 

Energy intake and physical activity in relation to indexes of body fat: the National Heart, 

Lung, and Blood Institute Growth and Health Study. American Journal of Clinical 

Nutrition 1994;60(1):15-22. 

Salmon J, Bauman A, Crawford D, Timperio A, Owen N. The association between television 

viewing and overweight among Australian adults participating in varying levels of 

leisure-time physical activity. International Journal of Obesity 2000; 24: 600-6. 

Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature. 

Psychological Bulletin 1989;105:260-75. 

Stunkard AJ. Socioeconomic status and obesity. Wiley: Ciba Foundation Symposium 201, 1996. 

Taras HF, Sallis JF, Patterson TL, Nader PR, Nelson JA. Television’s influence on children’s 

diet and physical activity. Developmental and Behavioral Pediatrics 1989;10:176-80. 

Consequences of Overweight

Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual deaths attributable to 

obesity in the United States. Journal of the American Medical Association 

1999;282:1530-8. 

Bray, GA. Complications of obesity. Annals of Internal Medicine 1985;103(6[Pt 2]):1052-62. 
Appendix 

39

Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW. Body-mass index and mortality in a 

prospective cohort of U.S. adults. New England Journal of Medicine 1999;341:1097-105. 

Davis K, Christoffel KK. Obesity in preschool and school-age children. Treatment early and 

often may be best. Archives of Pediatric and Adolescent Medicine. 1994;148(12):1257-

61. 

Dietz, WH. Childhood weight affects adult morbidity and mortality. Journal of Nutrition 

1998;128: 411S-414S. 

Falkner MH, Neumark-Sztainer D, Story M, Jeffery RW, Beuhring T, Resnick MD. Social, 

educational and psychological correlates of weight status in adolescents. Obesity 

Research 2001;9:32-42. 

Figueroa-Colon R, Franklin FA, Lee JY, Aldridge R, Alexander L. Prevalence of obesity with 

increased blood pressure in elementary school-aged children. Southern Medical Journal 

1997;90:806-13. 

Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to 

cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. 

Pediatrics 1999;103:1175-82. 

French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: A literature 

review. Obesity Research 1995;3:479-90. 

Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. Social and economic consequences of 

overweight in adolescence and young adulthood. New England Journal of Medicine 

1993;329:1008-12. 

Gunnell DJ, Frankel SJ, Nanchahal K, Peters TJ, Smith GD. Childhood obesity and adult 

cardiovascular mortality: a 57-year follow-up study based on the Boyd Orr cohort. 

American Journal of Clinical Nutrition 1998;67:1111-8. 

Klesges RC, Eck LH, Hanson CL, Haddock CK, Klesges LM. Effects of obesity, social 

interactions, and physical environment on physical activity in preschoolers. Health 

Psychology 1990;9:435-49. 

McGinnis JM, Foege WH. Actual causes of death in the United States. Journal of the American 

Medical Association 1993;270:2207-12. 

Morrison JA, Sprecher DL, Barton BA, Waclawiw MA, Daniels SR. Overweight, fat patterning 

and cardiovascular disease risk factors in black and white girls: The National Heart, Lung 

and Blood Institute Growth and Health Study. Journal of Pediatrics 1999;135;458-64. 
Appendix 

40

Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated 

with overweight and obesity. Journal of the American Medical Association 

1999;282:1523-9. 

Must A, Strauss RS. Risks and consequences of childhood and adolescent obesity. International 

Journal of Obesity and Related Metabolic Disorders 1999;23:S2-S11. 

National Institutes of Health Consensus Development Panel on the Health Implications of 

Obesity. Health implications of obesity: National Institutes of Health Consensus 

Development Conference Statement. Annals of Internal Medicine 1985;103:147-51. 

Pi-Sunyer FX. Medical hazards of obesity. Annals of Internal Medicine 1993;119:655-60. 

Power C, Lake JK, Cole TJ. Measurement and long-term health risks of child and adolescent 

fatness. International Journal of Obesity and Related Metabolic Disorders 1997;21:507-

26. 

Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children 

become obese adults? A review of the literature. Preventative Medicine 1993;22:167-77. 

Strauss RS. Childhood obesity and self-esteem. Pediatrics [serial online] 2000;105 (1):e15. 

http://www.pediatrics.org/cgi/content/full/105/1/e15.

Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young 

adulthood from childhood and parental obesity. New England Journal of Medicine 

1997;37:869-73. 

Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States. 

Obesity Research 1998;6:97-106.
Appendix 

41

Appendix B. Contributors to the Fit WIC Projects 

Fit WIC Project Teams 

Fit WIC California 

Pat Crawford, DrPH, RD 

Principal Investigator 

Social Scientist 

University of California, Berkeley 

Claudia Burnett, RD, MEd 

Project Co-Director 

Department of Health Services WIC Branch 

Sacramento CA 

Wendi Gosliner, MPH, RD 

Project Co-Manager 

University of California, Berkeley 

Poppy Strode, MS, MPH, RD 

Project Co-Manager 

Department of Health Services WIC Branch 

Sacramento, CA 

Yolanda Becerra-Jones 

Intervention Specialist 

University of California, Berkeley 

Cindy Caffery, MPH 

Project Coordinator 

University of California, Berkeley 

Monica Schaeffer, MPH, PhD 

Researcher 

University of California, Berkeley 

Kelly Moore, MS, RD

Research Nutritionist 

University of California, Berkeley 

Fit WIC Inter Tribal Council 

of Arizona (ITCA)

Carol Lujan, PhD 

Social Scientist 

Director of American Indian Studies 

Arizona State University 

Melinda Jossefides-Tomkins, RD 

Project Director 

Inter Tribal Council of Arizona, Inc. 

Susan Kunz, MPH 

Evaluator, Private Consultant 

Tucson, AZ 

Fit WIC Kentucky

Robert C. Whitaker, MD, MPH 

Social Scientist 

Cincinnati Children's Hospital Med. 

Center 

Leigh Ann Chamberlin, RD, MEd 

Project Director 

Cincinnati Children's Hospital Med. 

Center 

Scott W. Powers, PhD 

Researcher 

Cincinnati Children's Hospital Med. 

Center 

Sue Sherman, DPA 

Researcher 

SNS Research 

Cincinnati, Ohio 

Anjali Jain, MD 

Researcher 

University of Chicago 

Fran Hawkins, MS, RD 

Kentucky WIC Director 

Dianna Colson, CN, MS 

WIC Nutrition Education Consultant 

Marshall Co. Health Department 

Fit WIC Vermont

Jean Harvey-Berino, PhD, RD 

Social Scientist 

University of Vermont 

Karen Flynn 

Assistant WIC Director 

Vermont Department of Health 

WIC Program 

Linda Walfield, MS, RD 

Project Co-Director 

Vermont Department of Health 

WIC Program 

Lynne Bortree, MS 

Project Co-Director 

Vermont Department of Health 

WIC Program 

Fit WIC Virginia 

Elizabeth McGarvey, EdD 

Social Scientist 

University of Virginia 

Mena Forrester, MS, RD 

Project Director 

Virginia Department of Health 

Erin Williams, MS, RD 

Project Coordinator 

Virginia Department of Health 

Relana Pinkerton, PhD 

Research Assistant 

University of Virginia

Cindy Shufflebarger, MPH, RD 

Virginia Department of Health 

Alicia H. White, MS, RD 

Virginia Department of Health 
Appendix 

42

Additional contributors

Fit WIC California 

Carol Chase, MS, RD & 

 Erika Trainer, MS, RD 

Dept. of Health Services, WIC Branch 

Sacramento, CA 

Gauri Rao, MS, RD 

Senior Nutritionist 

Public Health Foundation Enterprises 

Marcie Hughes, RD 

Site Supervisor 

Public Health Foundation Enterprises 

Pico Rivera, CA 

Laurie Green, MS, RD 

Dietitian 

Department of Health and Human Services 

Sacramento County 

Kim Frinzell, RD 

Former Site Supervisor 

Department of Health and Human Services Sacramento 

County 

Janet Talsky, MPH, RD 

Site Supervisor 

Department of Health and Human Services 

Sacramento County 

Margie Rose, MPH, RD 

Nutrition Education Coordinator 

Ventura County Health Care Agency 

Melinda Pendleton, RD 

Site Supervisor 

Santa Paula Ventura Co. Health Care Agency 

Lorrene Ritchie, PhD, RD & 

May Wang, DrPH, RD 

Researchers 

University of California, Berkeley 

Karen Tabor, MS, RD 

Data Specialist 

Department of Health Services, WIC Branch 

Sacramento 

Kathy Kennedy-Mason, MS, RD 

Public Health Nutrition Consultant 

Department of Health Services, WIC Branch 

Sacramento 

Sarah Samuels, DrPH, 

Lisa Craypo, MPH, & 

Amy Carroll, MPH 

Consultants 

Samuels and Associates, Oakland, CA 

Mark Hudes, PhD 

Statistician 

University of California, Berkeley 

Carol Barnes, PhD 

Institute for Social Research 

California State University, Sacramento 

Valory J. Logsdon, MA 

Institute for Social Research 

California State University, Sacramento 

Rita Mitchell, RD 

Cooperative Extension 

University of California, Berkeley 

Sheila Stern, MA 

Analyst 

University of California, Berkeley 

Fit WIC ITCA 

Karen Sell, RD 

Health Systems Director 

Inter Tribal Council of Arizona, Inc. 

Donall Hosna, MS, RD 

Local Agency Director 

Native American Community Health Center 

Phoenix, AZ 

Connie Knobloch, RD 

Local Agency Director 

White Mountain Apache Tribe 

Whiteriver, AZ 

Toni Niesen, MS, RD 

Local Agency Director 

Salt River Pima-Maricopa Indian Community 

Scottsdale, AZ 

Doug Taren, Ph.D. 

University of Arizona 

Tucson, AZ 

Fit WIC Vermont 

Jen Woodard, MS, RD 

Project Assistant 

Vermont Department of Health 

WIC Program 

Fit WIC Virginia 

Kathleen R. Heise, MPH, RD 

Nutrition Program Manager 

Virginia Department of Health 

Anna Kanianthra, MS 

Local Coordinator 

Fairfax Health District 

Elva Chowdhury, MS, RD 

Lead Nutritionist 

Falls Church, WIC Branch 

Fairfax County Health Department 

Elizabeth Cummings, RD 

Lead Nutritionist 

Springfield WIC Branch 

Fairfax County Health Department 

Linda Foster, MPH, RD 

Interim Project Director 

Virginia Department of Health 

Anne Wolfe, MS, RD 

Research Assistant/Nutritionist 

University of Virginia 

 M. Norman Oliver, MD 

Department of Family Medicine 

University of Virginia 
Appendix 

43

Staff and participants of the following WIC sites: 

In California: Pico Rivera and 23rd Street, Public Health Foundation Enterprises, Los Angeles; Grand 

Avenue and Florin Road, Sacramento County; Santa Paula and Thousand Oaks, Ventura 

County. 

In Inter Tribal Council of Arizona:Pascua Yaqui Tribe, Native American Community Health Center, Salt 

River Pima-Maricopa Indian Community and White Mountain Apache Tribe. 

In Kentucky: C & Y Project, University of Louisville, Cumberland Valley District, Fayette County, 

FIVCO District, Jefferson County, Marshall County, Northern Kentucky District. 

In Vermont: Middlebury; Rutland; Burlington; and St. Albans. 

In Virginia: Falls Church and Springfield. 

Financial and programmatic support for Fit WIC: 

United States Department of Agriculture, Food and Nutrition Service 

Patricia N. Daniels, MS, RD 

Director, Supplemental Food Programs Division 

Jay Hirschman, MPH, CNS 

Director, Special Nutrition Staff 

Office of Analysis, Nutrition, and Evaluation 

Ed Herzog, MA, MPS 

Fit WIC Project Officer 

Social Science Research Analyst 

Marta Kealey, RD 

Program Analyst, Supplemental Food Programs Division

Centers for Disease Control and Prevention 

Robin Hamre, MPH, RD 

Obesity Prevention Program Team Leader 

Division of Nutrition and Physical Activity 
Appendix 

44

Appendix C. Useful Tools Produced by the Five Fit WIC Project 

Teams 

1. Fit WIC: Programs to Prevent Childhood Overweight In Your Community. The 

Implementation Manual for the Fit WIC Childhood Overweight Prevention Project. 

P.C. Crawford, M.C. Schaeffer and E. Herzog, Editors. United States Dept. of 

Agriculture, Food and Nutrition Service, May 2003. 

The Implementation Manual was prepared by the Fit WIC project teams for use by WIC 

administrators, clinicians, and educators as a step-by-step guide for the implementation of the 

five Fit WIC programs. Background information, some of the results of the qualitative and 

quantitative research done as part of the project, steps to implement the programs, lessons 

learned, recommendations and useful resources are included. The Implementation Manual 

was distributed to all 50 WIC State agencies, along with the tools needed for implementation 

of the programs. The Manual and all forms and tools needed are available through the Fit 

WIC link on the WIC Works website: http://www.nal.usda.gov/wicworks/.

Also, an overview of the 5-State Fit WIC Overweight Prevention Project can be found on 

The Center for Weight and Health’s website, http://www.cnr.berkeley.edu/cwh/activities/fitwic.shtml. 

2. Papers Published by the Five Fit WIC Project Teams 

Burdette HL, Whitaker RC. Neighborhood playgrounds, fast food restaurants, and crime: 

Relationships to overweight in low-income preschool children. Preventive Medicine 

2004;38(1):57-63. 

Burdette HL, Whitaker RC, Daniels SR. Parental report of outdoor playtime as a measure of 

physical activity in preschool-aged children. Archives of Pediatric and Adolescent 

Medicine 2004;158(4):353-357. 

Burdette HL, Whitaker RC, Harvey-Berino J, Kahn RS. Depressive symptoms in lowincome mothers and emotion and social functioning in their preschool children. 

Ambulatory Pediatrics 2004;3(6):288-294. 

Burdette HL, Whitaker RC, Kahn RS, Harvey-Berino J. The association of maternal obesity 

and depressive symptoms with television viewing time in low-income preschool 

children. Archives of Pediatric and Adolescent Medicine 2003;157:894-899. 

Chamberlin LA, Sherman SN, Jain A, Powers SW, Whitaker RC. The challenge of 

preventing and treating obesity in low-income, preschool children: perceptions of WIC 

health professionals. Archives of Pediatric and Adolescent Medicine 2002;156(7):662-

668. 
Appendix 

45

Crawford PB, Gosliner W, Anderson C, Strode P, Bercerra-Jones Y, Samuels S, Carroll AM 

and Ritchie LD. Counseling Latina mothers of preschool children about weight issues. 

Journal of the American Dietetic Association 2004;104(3):387-394. 

Crawford PB, Gosliner W, Strode P, Samuels S, Burnett C, Craypo L and Yancey A. 

Walking the talk: staff wellness improves counseling for childhood obesity. American 

Journal of Public Health 2004;94(9):1480-1485. 

Harvey-Berino J, Geller B, Dorwaldt A, Flynn K, Walfield L. A qualitative data analysis of 

parental attitudes towards preschool physical activity. Annals of Behavioral Medicine 

2001;23:24S. 

Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, Whitaker RC. Why don’t lowincome mothers worry about their preschoolers being overweight? Pediatrics 

2001;107(5):1138-46. 

Jain A, Sherman SN, Chamberlin LA, Whitaker RC. Mothers misunderstand questions on a 

feeding questionnaire. Appetite 2004;42(3):249-254. 

McGarvey EL, Keller A, Forrester M, Williams E, Seward D, Suttle DE. Feasibility and 

benefits of a parent-focused preschool child obesity intervention. American Journal of 

Public Health 2004;94(9):1490-1495. 

Whitaker RC. Obesity prevention in pediatric primary care: Four behaviors to target. 

Archives of Pediatric and Adolescent Medicine 2003;157(8):725-727. 

Whitaker RC, Sherman SN, Chamberlin LA, Powers SW. Altering the perceptions of WIC 

health professionals about childhood obesity using video with facilitated group 

discussion. Journal of the American Dietetic Association 2004;104(3):379-386. 

3. Abstracts Published by the Five Fit WIC Project Teams

Burdette HL, Whitaker RC, Harvey-Berino J. Television viewing and outdoor time in lowincome preschool children: relationship to depression, perceived stress, and BMI in their 

mothers. Obesity Research 2001;9 (suppl. 3):59S (abstract no. O28). 

Burdette HL, Harvey-Berino J, Kahn RS, Whitaker RC. Maternal depression and obesity 

predict television viewing in low-income preschool children. Pediatric Research 

2002;51:203A (abstract no. 1180). 

Burdette HL, Kahn RS, Harvey-Berino J, Whitaker RC. The relationship of well-being in 

low-income mothers to emotional and social functioning (PedsQLTM) in their preschool 

children. Pediatric Research 2002;51:197A (abstract no. 1144).