GAO-07-260R Childhood Obesity and Physical Activity

United States Government Accountability Office

Washington, DC 20548 

December 6, 2006 

The Honorable Bill Frist 

Majority Leader 

United States Senate 

Subject: Childhood Obesity: Factors Affecting Physical Activity 

Dear Senator Frist: 

The latest data show continued increases in rates of childhood obesity.1

 For example, 

obesity rates for children 6 to 11 years old are estimated to have increased from 15.1 

to 18.8 percent between 1999 and 2004.2

 The Department of Health and Human 

Services estimates that 20 percent of children and youth in the United States will be 

obese by 2010. There are numerous negative health outcomes and financial 

consequences related to childhood obesity. Researchers have found that childhood 

obesity is associated with a number of disorders including hypertension, insulin 

resistance, sleep apnea, menstrual abnormalities, and orthopedic problems. 

According to one estimate, insured children treated for obesity are approximately 

three times more expensive for the health system than the average insured child.3

 

Obesity results from an imbalance between the amount of energy consumed and the 

amount of energy expended. While there are many elements that affect the energy 

balance (for example, genetics, growth, and physiology), children and their parents 

can influence both energy consumed through diet and energy expended through 

physical activity. Some researchers have suggested that childhood obesity is largely 

the result of a decline in regular physical activity. In our October 2005 report,4

 we 

 

1

Some experts use the term obesity to refer to children and adolescents who have a body mass index 

(BMI) that is at or above the sex-specific 95th percentile for their age on the BMI charts developed by 

the Centers for Disease Control and Prevention (CDC) in 2000. CDC uses the term overweight, instead 

of obese, to describe children and adolescents with this BMI range. 

2

C.L Ogden, M.D. Carroll, L.R. Curtin, M.A. McDowell, C.J. Tabak, and K.M. Flegal, “Prevalence of 

Overweight and Obesity in the United States, 1999-2004,” JAMA, vol. 295, no. 13 (2006). These data are 

for children at or above the 95th percentile of BMI for age and sex. 

3

Thomson Medstat, Childhood Obesity: Costs, Treatment Patterns, Disparities in Care, and 

Prevalent Medical Conditions, 2006, http://www.medtstat.com/pdfs/childhood_obesity.pdf, 

(downloaded Nov. 3, 2006). Thomson Medstat used medical claims to estimate total health care 

spending for children who receive a diagnosis of obesity. 

4

GAO, Childhood Obesity: Most Experts Identified Physical Activity and the Use of Best Practices as 

Key to Successful Programs, GAO-06-127R (Washington, D.C.: Oct. 7, 2005). 
2 GAO-07-260R Childhood Obesity and Physical Activity

 

surveyed experts on the key strategies to include in the design or implementation of a 

program to prevent or reduce childhood obesity. The program strategy identified by 

experts as most important was “increasing physical activity.” 

You asked us to provide information on the factors affecting physical activity in 

children. Enclosure I contains the information we provided to your staff at our 

November 15, 2006, briefing. 

To carry out our work, we conducted a literature review. We selected 53 articles that 

described work focused on factors affecting rates of physical activity for school-aged 

children, published from 2003 through 2006. Enclosure II is a bibliography of the 

materials we reviewed. To select the articles, we reviewed study abstracts identified 

in your request letter and conducted a literature search of five databases.5

 We focused 

on studies of children and adolescents and excluded studies of infants and preschoolaged children. For purposes of this report, we use the term obese to refer collectively 

to the terms obese and overweight, which were both used by authors. We 

supplemented the studies with information obtained from organizations that recently 

published information on childhood obesity including the Institute of Medicine and 

the Trust for America’s Health. Our literature search was not exhaustive, and for this 

report we did not discuss all of the articles we reviewed, but instead highlighted 

selected articles to provide examples of findings. We conducted our work from 

August 2006 through November 2006 in accordance with generally accepted 

government auditing standards. 

In summary, the articles we reviewed identified a number of factors affecting levels 

of physical activity in children. We categorized the factors presented in the articles 

we reviewed into three groups—demographic factors, cognitive and behavioral 

factors, and community factors. Demographic factors include socioeconomic status 

and race. Cognitive and behavioral factors include attitudes, beliefs, and perceptions 

and sedentary behaviors.6

 Community factors include the built environment7 and 

school-based physical activity. The articles and additional materials we reviewed 

identified additional research needs, such as using objective measures of physical 

activity and sedentary time. The body of research we examined suggests that multiple 

factors that affect physical activity among children may contribute to childhood 

obesity. 

- - - - - 

As we agreed with your office, unless you publicly announce the contents of this 

report earlier, we plan no further distribution until 30 days after the date of this letter. 

5

We also contacted several experts in the field to help us identify relevant literature. 

6

Sedentary behaviors include, for example, television watching, video game playing, and computer use. 

7

The built environment is broadly defined to include land use patterns, the transportation system, and 

design features that together provide opportunities for travel and physical activity. 
3 GAO-07-260R Childhood Obesity and Physical Activity

At that time, this report will be available at no charge on the GAO Web site at 

http://www.gao.gov. Contact points for our Offices of Congressional Relations and 

Public Affairs may be found on the last page of this report. 

If you and your staff have any questions or need additional information, please 

contact me at (202) 512-7101, or bascettac@gao.gov. Major contributors to this report 

were Linda Kohn, Assistant Director; Shannon Slawter; and Julie Thomas. 

Sincerely yours, 

Cynthia A. Bascetta 

Director, Health Care 

Enclosures 
Enclosure I Enclosure I 

4 GAO-07-260R Childhood Obesity and Physical Activity

GAO Congressional Briefing

CHILDHOOD OBESITY: 

Factors Affecting Physical Activity
Enclosure I Enclosure I 

5 GAO-07-260R Childhood Obesity and Physical Activity

Briefing Outline

• Introduction

• Objective, scope, and methodology

• Factors affecting physical activity

• Additional research needs 

• Concluding observations
Enclosure I Enclosure I 

6 GAO-07-260R Childhood Obesity and Physical Activity

Introduction

• The latest data show continued increases in rates of childhood obesity.

1 HHS

estimates that 20% of children and youth in the U.S. will be obese by 2010. 

• There are numerous negative health outcomes and financial consequences

related to childhood obesity. 

• According to one estimate, total health care spending for children who

receive a diagnosis of obesity is approximately $750 million per year.

2

• Obesity results from an imbalance between the amount of energy consumed

and the amount of energy expended.

1Some experts use the term obesity to refer to children and adolescents who have a body mass index

(BMI) for age that is at or above the sex-specific 95th percentile of the BMI charts developed by the Centers

for Disease Control and Prevention in 2000.

2Thomson Medstat used medical claims to estimate total health care spending for children who receive a 

diagnosis of obesity. Children who received a diagnosis of obesity are a small subset of the percentage of 

children who are considered obese. Thomson Medstat estimates that children treated for obesity are 

roughly three times more expensive for the health system than the average insured child.
Enclosure I Enclosure I 

7 GAO-07-260R Childhood Obesity and Physical Activity

Introduction (cont.)

• Children and their parents can influence both energy consumed through diet

and energy expended through physical activity. 

• Some researchers have suggested that childhood obesity is largely the result

of a decline in regular physical activity. 

• For our October 2005 report, Childhood Obesity: Most Experts Identified

Physical Activity and the Use of Best Practices as Key to Successful

Programs (GAO-06-127R), we surveyed experts on the key strategies to

include in the design or implementation of a program to prevent or reduce

childhood obesity. The program strategy identified by experts as most

important was “increasing physical activity.”
Enclosure I Enclosure I 

8 GAO-07-260R Childhood Obesity and Physical Activity

Objective, Scope, and Methodology

• Our objective in this briefing is to summarize the relevant literature about the

factors affecting levels of physical activity among children that may contribute

to childhood obesity.

3 We will also discuss additional research needs

identified in the literature.

• In our review of the literature, we did not examine research that addresses

whether there have been decreases in the physical activity of children over

time, a trend which some researchers dispute.

3For our literature review, we focused on studies of children and adolescents and excluded studies of 

infants and preschool-aged children. For purposes of this briefing, we use the term obese to refer

collectively to obese and overweight children. 
Enclosure I Enclosure I 

9 GAO-07-260R Childhood Obesity and Physical Activity

Objective, Scope, and Methodology

(cont.)

• We reviewed study abstracts identified in the request letter and

conducted a literature search of five databases.

4

• We selected 53 studies that described new work focused on factors

affecting rates of physical activity for children, published from 2003

through 2006.

• We supplemented the studies with information obtained from

organizations such as the Institute of Medicine (IOM), the Trust for

America’s Health, and The Robert Wood Johnson Foundation.

• We conducted our work from August 2006 through November 2006 in

accordance with generally accepted government auditing standards.

4We also contacted several experts in the field to help us identify relevant literature.
Enclosure I Enclosure I 

10 GAO-07-260R Childhood Obesity and Physical Activity

Objective, Scope, and Methodology

(cont.)

• Limitations of our work

• Literature search was not exhaustive.

• We will not discuss all of the articles that we reviewed, but instead

highlight selected articles to provide examples of findings.
Enclosure I Enclosure I 

11 GAO-07-260R Childhood Obesity and Physical Activity

Factors Affecting Physical Activity

• We grouped the factors affecting physical activity into three categories:

• Demographic factors

• Cognitive and behavioral factors

• Community factors 
Enclosure I Enclosure I 

12 GAO-07-260R Childhood Obesity and Physical Activity

Demographic Factors

• Socioeconomic status (SES)

• Studies tied low SES to physical inactivity.

• Race/ethnicity

• While several studies included race/ethnicity as a variable, they focused

on other factors, which we will discuss later.
Enclosure I Enclosure I 

13 GAO-07-260R Childhood Obesity and Physical Activity

Cognitive and Behavioral Factors

• Attitudes, beliefs, and perceptions

• Among other factors, studies identified lack of motivation, selfconsciousness, and concerns about not being good enough as

contributing to reduced physical activity. 

• Studies found some differences between white and African-American

girls in their attitudes and perceptions about physical activity. 

• Studies found that adolescents who were obese perceived more barriers

to physical activity than adolescents who were not.

• Family and social influences

• Studies found that parental and social support for physical activity was

associated with increased physical activity.
Enclosure I Enclosure I 

14 GAO-07-260R Childhood Obesity and Physical Activity

Cognitive and Behavioral Factors (cont.)

• Sedentary behaviors5

• Studies differed in their findings on the relationship between sedentary

behaviors and obesity, but not all of them explained the relationship

between sedentary behaviors and physical activity. 

• Some studies found that increases in sedentary behaviors are

associated with decreases in physical activity. 

• Studies reported differences in sedentary behavior patterns by gender

and the influence of family on children’s television viewing habits.

5Sedentary behaviors include, for example, television watching, video game playing, and computer use.
Enclosure I Enclosure I 

15 GAO-07-260R Childhood Obesity and Physical Activity

Community Factors

• General/safety

• One study found that adolescents in older suburban communities

engage in more physical activity. 

• One study found that adolescents in unsafe neighborhoods engage in

less physical activity.

• Built environment6

• Studies found that environmental characteristics, such as lack of

streetlights and the need to cross busy roads, were negatively related to

children’s physical activity, including walking and biking to school.

6The built environment is broadly defined to include land use patterns, the transportation system, and 

design features that together provide opportunities for travel and physical activity.
Enclosure I Enclosure I 

16 GAO-07-260R Childhood Obesity and Physical Activity

Community Factors (cont.)

• Availability of venues for physical activity

• One study found that lack of venue (e.g., sports areas, swimming pools,

parks) was related to lower rates of physical activity.

• Studies found that areas of low SES and high minority populations had

fewer venues for physical activity.

• School-based physical activity

• School-based physical education policies vary widely by state, school

district, and school.
Enclosure I Enclosure I 

17 GAO-07-260R Childhood Obesity and Physical Activity

Additional Research Needs

• The literature we reviewed contained two commonly suggested themes

for research improvement

• Study design

-longitudinal instead of cross-sectional

-venue affordability, quality, and usage instead of venue

availability only

• Measurement

-objective measures of physical activity and sedentary time

-other measures, such as health status
Enclosure I Enclosure I 

18 GAO-07-260R Childhood Obesity and Physical Activity

Additional Research Needs (cont.)

• IOM and the Transportation Research Board also identified additional

needs, including

• Need for additional evaluations to provide evidence for new or modified

programs or policies

• Built environment:

-need to develop better ways to measure the built environment

-need to connect data on the built environment to data on health

and physical activity
Enclosure I Enclosure I 

19 GAO-07-260R Childhood Obesity and Physical Activity

Concluding Observations

• Reversing trends in childhood obesity requires an understanding of the

factors affecting children’s energy imbalance, including their physical activity levels. 

• The articles we reviewed identified a number of factors affecting levels of

physical activity in children.

• The body of research we examined suggests that multiple factors that affect

physical activity among children may contribute to childhood obesity. 
Enclosure II Enclosure II 

20 GAO-07-260R Childhood Obesity and Physical Activity

Bibliography 

Articles included in GAO’s review 

Arluk, S.L., J.D. Branch, D.P. Swain, and E.A. Dowling. “Childhood obesity’s 

relationship to time spent in sedentary behavior.” Military Medicine, vol. 168, no. 7 

(2003): 583-586. 

Bauer, K.W., Y.W. Yang, S.B. Austin. “‘How can we stay healthy when you’re throwing 

all of this in front of us?’ Findings from focus groups and interviews in middle schools 

on environmental influences on nutrition and physical activity.” Health Education & 

Behavior, vol. 31, no. 1 (2004): 34-46. 

Braza, M., W. Shoemaker, and A. Seeley. “Neighborhood design and rates of walking 

and biking to elementary school in 34 California communities.” American Journal of 

Health Promotion, vol. 19, no. 2 (2004): 128-136. 

Centers for Disease Control and Prevention. “Participation in high school physical 

education--United States, 1991-2003.” Morbidity and Mortality Weekly Report, 

vol. 53, no. 36 (2004): 844-847. 

Cottrell, L., E. Spangler-Murphy, V. Minor, A. Downes, P. Nicholson, and W.A. Neal. 

“A kindergarten cardiovascular risk surveillance study: CARDIAC-Kinder.” American 

Journal of Health Behavior, vol. 29, no. 6 (2005): 595-606. 

Datar, A. and R. Sturm. “Physical education in elementary school and body mass 

index: evidence from the Early Childhood Longitudinal Study.” American Journal of 

Public Health, vol 94, no. 9 (2004): 1501-1506. 

Davison, K.K., L.A. Francis, and L.L. Birch. “Reexamining obesigenic families: parents’ 

obesity-related behaviors predict girls’ change in BMI.” Obesity Research, vol. 13, 

no. 11 (2005): 1980-1990. 

De Bourdeaudhuij, I., J. Lefevre, B. Deforche, K. Wijndaele, L. Matton, and R. 

Philippaerts. “Physical activity and psychosocial correlates in normal weight and 

overweight 11 to 19 year olds.” Obesity Research, vol. 13, no. 6 (2005): 1097-1105. 

Deforche, B.I., I.M. De Bourdeaudhuij, and A.P. Tanghe. “Attitude toward physical 

activity in normal-weight, overweight and obese adolescents.” Journal of Adolescent 

Health, vol. 38, no. 5 (2006): 560-568. 

Dowda, M., R.R. Pate, G.M. Felton, R. Saunders, D.S. Ward, R.K. Dishman, and S.G. 

Trost. “Physical activities and sedentary pursuits in African American and Caucasian 

girls.” Research Quarterly for Exercise and Sport, vol. 75, no. 4 (2004): 352-360. 
Enclosure II Enclosure II 

21 GAO-07-260R Childhood Obesity and Physical Activity

Elgar, F.J., C. Roberts, L. Moore, and C. Tudor-Smith. “Sedentary behaviour, physical 

activity and weight problems in adolescents in Wales.” Public Health, vol. 119, no. 6 

(2005): 518-524. 

Epstein, L.H., J.N. Roemmich, R.A. Paluch, and H.A. Raynor. “Physical activity as a 

substitute for sedentary behavior in youth.” Annals of Behavioral Medicine, vol. 29, 

no. 3 (2005): 200-209. 

Fleming-Moran, M. and K. Thiagarajah. “Behavioral interventions and the role of 

television in the growing epidemic of adolescent obesity - Data from the 2001 Youth 

Risk Behavior Survey.” Methods of Information in Medicine, vol. 44, no. 2 (2005): 

303-309. 

Going, S., J. Thompson, S. Cano, D. Stewart, E. Stone, L. Harnack, C. Hastings, J. 

Norman, and C. Corbin. “The effects of the Pathways Obesity Prevention Program on 

physical activity in American Indian children.” Preventive Medicine, vol. 37, no. 6 

(2003): S62-S69. 

Gómez, J.E., B.A. Johnson, M. Selva, and J.F. Sallis. “Violent crime and outdoor 

physical activity among inner-city youth.” Preventive Medicine, vol. 39, no. 5 (2004): 

876-881. 

Gordon-Larsen, P., P. Griffiths, M.E. Bentley, D.S. Ward, K. Kelsey, K. Shields, and A. 

Ammerman. “Barriers to physical activity - Qualitative data on caregiver-daughter 

perceptions and practices.” American Journal of Preventive Medicine, vol. 27, no. 3 

(2004): 218-223. 

Gordon-Larsen, P., M.C. Nelson, P. Page, and B.M. Popkin. “Inequality in the built 

environment underlies key health disparities in physical activity and obesity.” 

Pediatrics, vol. 117, no. 2 (2006): 417-424. 

Graf, C., B. Koch, S. Dordel, S. Schindler-Marlow, A. Icks, A. Schüller, B. BjarnasonWehrens, W. Tokarski, and H.G. Predel. “Physical activity, leisure habits and obesity 

in first-grade children.” European Journal of Cardiovascular Prevention and 

Rehabilitation, vol. 11, no. 4 (2004): 284-290. 

Hesketh, K., E. Waters, J. Green, L. Salmon, and J. Williams. “Healthy eating, activity 

and obesity prevention: a qualitative study of parent and child perceptions in 

Australia.” Health Promotion International, vol. 20, no. 1 (2005): 19-26. 

Jago, R., T. Baranowski, I. Zakeri, and M. Harris. “Observed environmental features 

and the physical activity of adolescent males.” American Journal of Preventive 

Medicine, vol. 29, no. 2 (2005): 98-104. 
Enclosure II Enclosure II 

22 GAO-07-260R Childhood Obesity and Physical Activity

Janssen, I., W.F. Boyce, K. Simpson, and W. Pickett. “Influence of individual- and 

area-level measures of socioeconomic status on obesity, unhealthy eating, and 

physical inactivity in Canadian adolescents.” American Journal of Clinical 

Nutrition, vol. 83, no. 1 (2006): 139-145. 

Janssen, I., P.T. Katzmarzyk, W.F. Boyce, M.A. King, and W. Pickett. “Overweight and 

obesity in Canadian adolescents and their associations with dietary habits and 

physical activity patterns.” Journal of Adolescent Health, vol. 35, no. 5 (2004): 360-

367. 

Jefferson, A. “Breaking down barriers - examining health promoting behaviour in the 

family. Kellogg’s Family Health Study 2005.” Nutrition Bulletin, vol. 31, no. 1 (2006): 

60-64. 

Kautiainen, S., L. Koivusilta, T. Lintonen, S.M. Virtanen, and A. Rimpelä. “Use of 

information and communication technology and prevalence of overweight and 

obesity among adolescents.” International Journal of Obesity, vol. 29, no. 8 (2005): 

925-933. 

Kelly, L.A., J.J. Reilly, A. Fisher, C. Montgomery, A. Williamson, J.H. McColl, J.Y. 

Paton, and S. Grant. “Effect of socioeconomic status on objectively measured 

physical activity.” Archives of Disease in Childhood, vol. 91, no. 1 (2006): 35-38. 

Kimm, S.Y.S., N.W. Glynn, R.P. McMahon, C.C. Voorhees, R.H. Striegel-Moore, and 

S.R. Daniels. “Self-perceived barriers to activity participation among sedentary 

adolescent girls.” Medicine & Science in Sports & Exercise, vol. 38, no. 3 (2006): 534-

540. 

Mabry, I.R., D.R. Young, L.A. Cooper, T. Meyers, A. Joffe, and A.K. Duggan. “Physical 

activity attitudes of African American and white adolescent girls.” Ambulatory 

Pediatrics, vol. 3, no. 6 (2003): 312-316. 

Miech, R.A., S.K. Kumanyika, N. Stettler, B.G. Link, J.C. Phelan, and V.W. Chang. 

“Trends in the association of poverty with overweight among US adolescents, 1971-

2004.” JAMA, vol. 295, no. 20 (2006): 2385-2393. 

Molnar, B.E., S.L. Gortmaker, F.C. Bull, and S.L. Buka. “Unsafe to play? 

Neighborhood disorder and lack of safety predict reduced physical activity among 

urban children and adolescents.” American Journal of Health Promotion, vol. 18, 

no. 5 (2004): 378-386. 

Mota, J., J. Ribeiro, M.P. Santos, and H. Gomes. “Obesity, physical activity, computer 

use, and TV viewing in Portuguese adolescents.” Pediatric Exercise Science, vol. 17, 

no. 1 (2006): 113-121. 
Enclosure II Enclosure II 

23 GAO-07-260R Childhood Obesity and Physical Activity

Motl, R.W., E. McAuley, A.S. Birnbaum, and L.A. Lytle. “Naturally occurring changes 

in time spent watching television are inversely related to frequency of physical 

activity during early adolescence.” Journal of Adolescence, vol. 29, no. 1 (2006): 19-32. 

Nelson, M.C., P. Gordon-Larsen, Y. Song, and B.M. Popkin. “Built and social 

environments - Associations with adolescent overweight and activity.” American 

Journal of Preventive Medicine, vol. 31, no. 2 (2006): 109-117. 

Neumark-Sztainer, D., M. Story, P. Hannan, T. Tharp, and J. Rex. “Factors associated 

with changes in physical activity - A cohort study of inactive adolescent girls.” 

Archives of Pediatrics & Adolescent Medicine, vol. 157, no. 8 (2003): 803-810. 

Nichols-English, G.J., C.R. Lemmon, M.S. Litaker, S.G. Cartee, Z. Yin, B. Gutin, and P. 

Barbeau. “Relations of black mothers’ and daughters’ body fatness, physical activity 

beliefs and behavior.” Ethnicity & Disease, vol. 16, no. 1 (2006): 172-179. 

Norman, G.J., B.A. Schmid, J.F. Sallis, K.J. Calfas, and K. Patrick. “Psychosocial and 

environmental correlates of adolescent sedentary behaviors.” Pediatrics, vol. 116, 

no. 4 (2005): 908-916. 

Olds, T., K. Ridley, and J. Dollman. “Screenieboppers and extreme screenies: the 

place of screen time in the time budgets of 10-13 year-old Australian children.” 

Australian and New Zealand Journal of Public Health, vol. 30, no. 2 (2006): 137-142. 

Powell, L.M., S. Slater, and F.J. Chaloupka. “The relationship between community 

physical activity settings and race, ethnicity and socioeconomic status.” EvidenceBased Preventive Medicine, vol. 1, no. 2 (2004): 135-144. 

Richmond, T.K., R.A. Hayward, S. Gahagan, A.E. Field, and M. Heisler. “Can school 

income and racial/ethnic composition explain the racial/ethnic disparity in adolescent 

physical activity participation?” Pediatrics, vol. 117, no. 6 (2006): 2158-2166. 

Robbins, L.B., N.J. Pender, and A.S. Kazanis. “Barriers to physical activity perceived 

by adolescent girls.” Journal of Midwifery & Women’s Health, vol. 48, no. 3 (2003): 

206-212. 

Salmon, J., K.J. Campbell, and D.A. Crawford. “Television viewing habits associated 

with obesity risk factors: a survey of Melbourne schoolchildren.” Medical Journal of 

Australia, vol. 184, no. 2 (2006): 64-67. 

Salmon, J., A. Timperio, V. Cleland, and A. Venn. “Trends in children’s physical 

activity and weight status in high and low socio-economic status areas of Melbourne, 

Victoria, 1985-2001.” Australian and New Zealand Journal of Public Health, vol. 29, 

no. 4 (2005): 337-342. 
Enclosure II Enclosure II 

24 GAO-07-260R Childhood Obesity and Physical Activity

Salmon, J., A. Timperio, A. Telford, A. Carver, and D. Crawford. “Association of 

family environment with children’s television viewing and with low level of physical 

activity.” Obesity Research, vol. 13, no. 11 (2005): 1939-1951. 

Santos, M.P., H. Gomes, and J. Mota. “Physical activity and sedentary behaviors in 

adolescents.” Annals of Behavioral Medicine, vol. 30, no. 1 (2005): 21-24. 

Simon, C., A. Wagner, C. Platat, D. Arveiler, B. Schweitzer, J.L. Schlienger, and E. 

Triby. “ICAPS: a multilevel program to improve physical activity in adolescents.” 

Diabetes & Metabolism, vol. 32, no. 1 (2006): 41-49. 

Sirard, J.R., W.F. Riner, K.L. McIver, and R.R. Pate. “Physical activity and active 

commuting to elementary school.” Medicine & Science in Sports & Exercise, vol. 37, 

no. 12 (2005): 2062-2069. 

Stettler, N., T.M. Signer, and P.M. Suter. “Electronic games and environmental factors 

associated with childhood obesity in Switzerland.” Obesity Research, vol. 12, no. 6 

(2004): 896-903. 

Thompson, V.J., T. Baranowski, K.W. Cullen, L. Rittenberry, J. Baranowski, W.C. 

Taylor, and T. Nicklas. “Influences on diet and physical activity among middle-class 

African American 8- to 10-year-old girls at risk of becoming obese.” Journal of 

Nutrition Education and Behavior, vol. 35, no. 3 (2003): 115-123. 

Timperio, A., K. Ball, J. Salmon, R. Roberts, B. Giles-Corti, D. Simmons, L.A. Baur, 

and D. Crawford. “Personal, family, social, and environmental correlates of active 

commuting to school.” American Journal of Preventive Medicine, vol. 30, no. 1 

(2006): 45-51. 

Utter, J., D. Neumark-Sztainer, R. Jeffrey, and M. Story. “Couch potatoes or french 

fries: Are sedentary behaviors associated with body mass index, physical activity, and 

dietary behaviors among adolescents?” Journal of the American Dietetic 

Association, vol. 103, no. 10 (2003): 1298-1305. 

Vandewater, E.A., M. Shim, and A.G. Caplovitz. “Linking obesity and activity level 

with children’s television and video game use.” Journal of Adolescence, vol. 27, no. 1 

(2004): 71-85. 

Ward, D.S., M. Dowda, S.G. Trost, G.M. Felton, R.K. Dishman, and R.P. Pate. “Physical 

activity correlates in adolescent girls who differ by weight status.” Obesity, vol. 14, 

no. 1 (2006): 97-105. 

Welk, G.J., K. Wood, and G. Morss. “Parental influences on physical activity in 

children: an exploration of potential mechanisms.” Pediatric Exercise Science, 

vol. 15, no. 1 (2003): 19-33. 
Enclosure II Enclosure II 

25 GAO-07-260R Childhood Obesity and Physical Activity

Ziviani, J., D. Macdonald, D. Jenkins, S. Rodger, J. Batch, and E. Cerin. “Physical 

activity of young children.” OTJR: Occupation Participation and Health, vol. 26, 

no. 1 (2006): 4-14. 

Other works consulted 

Institute of Medicine of the National Academies. Preventing Childhood Obesity: 

Health in the Balance. Washington, D.C.: The National Academies Press, 2005. 

-----------. Progress in Preventing Childhood Obesity: How Do We Measure Up?

Washington, D.C.: The National Academies Press, 2006. 

Sturm, R. “Childhood Obesity—What We Can Learn from Existing Data on Societal 

Trends, Part 1.” Preventing Chronic Disease, vol. 2, no. 1 (2005): 1-9, 

http://www.cdc.gov/pcd/issues/2005/jan/04_0038.htm, (downloaded Aug. 31, 2006). 

-----------. “Childhood Obesity—What We Can Learn from Existing Data on Societal 

Trends, Part 2.” Preventing Chronic Disease, vol. 2, no. 2 (2005): 1-9, 

http://www.cdc.gov/pcd/issues/2005/apr/04_0039.htm, (downloaded Aug. 31, 2006). 

Transportation Research Board and Institute of Medicine of the National Academies. 

Committee on Physical Activity, Health, Transportation, and Land Use. Does the Built 

Environment Influence Physical Activity? Examining the Evidence. Washington, 

D.C.: Transportation Research Board, 2005. 

Trust for America’s Health. F as in Fat: How Obesity Policies are Failing in 

America. Washington, D.C.: Trust for America’s Health, 2006, 

http://healthyamericans.org/reports/obesity2006/Obesity2006Report.pdf (downloaded 

Oct. 3, 2006). 

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