United States Government Accountability Office

Washington, DC 20548 

October 7, 2005 

Congressional Requesters

Subject: Childhood Obesity: Most Experts Identified Physical Activity

 and the Use of Best Practices as Key to Successful Programs

In the past 30 years, the number of obese children1

 has increased throughout the 

United States, leading some policy makers to rank childhood obesity as a critical 

public health threat. The rate of childhood obesity has more than tripled for children 

between the ages of 6 and 11 and also increased for children of other ages over the 

same period.2

 According to a 2005 Institute of Medicine (IOM) report, there are 

approximately 9 million children nationwide over the age of 6 who are considered

obese.

3

 An important consequence of childhood obesity is the increasing number of

children experiencing illnesses and other health problems associated with obesity, 

such as hypertension and type II diabetes. The rise in obesity-related health 

conditions also introduces added economic costs. Between 1979 and 1999, obesityassociated hospital costs for children between the ages of 6 and 17 more than tripled, 

from $35 million to $127 million.4

 Moreover, because studies suggest that obese 

children are likely to become overweight or obese adults—particularly if the children 

are obese during adolescence—the increase in the number of obese children may 

 1

In this report, the term “obese” refers to children who are considered both overweight and at risk for 

overweight according to the Centers for Disease Control and Prevention (CDC) standards for childspecific body mass index (BMI) scores, as well as both overweight and obese adults. BMI is an indirect

measure of body fat calculated as the ratio of a person’s body weight in kilograms to the square of a

person’s height in meters. According to CDC’s 2000 growth charts, children are overweight when their

BMI is at or above the 95th

 percentile for their age and gender, while children between the 85th and 95th

percentile are considered at risk of being overweight. BMI for children, also referred to as BMI-for-age, 

is gender and age specific because the percentage of body fat in children changes as they grow and 

because body fat in girls and boys differs. Adults are considered overweight when their BMI is 

between 25.0 and 29.9 and obese when their BMI is 30.0 or above. In addition, in this report, the term

“children” refers to anyone under the age of 18. 2

These data are for children at or above the 95th percentile of BMI for age and gender. Cynthia L.

Ogden, Katherine M. Flegal, Margaret D. Carroll, and Clifford L. Johnson, “Prevalence and Trends in

Overweight Among US Children and Adolescents, 1999-2000,” JAMA, vol. 288, no. 14 (2002) and Allison 

A. Hedley, Cynthia L. Ogden, Clifford L. Johnson, Margaret D. Carroll, Lester R. Curtin, and Katherine 

M. Flegal, “Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 1999-

2002,” JAMA, vol. 291, no. 23 (2004). 3

Institute of Medicine, Preventing Childhood Obesity: Health in the Balance (Washington, D.C.: 

National Academies Press, 2005). 4

These data are in 2001 dollars and reflect the change from 1979-1981 to 1997-1999. Guijing Wang and 

William H. Dietz, “Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979 – 1999,” Pediatrics, 

vol. 109 (2002). 

 GAO-06-127R Childhood Obesity 
also contribute to health care expenditures when they become adults. Obesity-related 

health expenditures are estimated to have accounted for more than 25 percent of the 

growth in health care spending between 1987 and 2001.5

 In 2000, an estimated 

$117 billion was spent for health-related expenditures due to obesity, with direct 

costs accounting for an estimated $61 billion. These direct costs accounted for 

approximately 5 percent of U.S. health expenditures.

6

 Nearly half of all medical 

spending related to adult obesity is financed by the public sector, through Medicaid 

and Medicare.7 Some federal agencies support efforts to target the issue of childhood 

obesity, and legislation introduced in the current Congress also focuses on the issue, 

including the Improved Nutrition and Physical Activity (IMPACT) Act8

 and the 

Childhood Obesity Reduction Act.

9

You asked us to provide information on program strategies and elements experts

have identified as likely to contribute to success in addressing childhood obesity. You 

also asked us to provide information on how those strategies and elements have been 

implemented. In this report we (1) describe the key strategies identified by experts as 

most important to include in programs to prevent or reduce childhood obesity; 

(2) provide examples of how selected programs implemented the key strategies 

identified and challenges these programs faced; (3) describe the program elements 

identified by experts as most important to include in programs to prevent or reduce 

childhood obesity, as well as outcome measures identified as important; and 

(4) provide examples of how selected programs implemented key elements identified 

and the challenges these programs faced, as well as examples of possible roles for the 

federal government. Enclosure I contains the information we provided during our 

September 8, 2005, briefing of your staff. 

The term “program strategy” refers to the issue to be addressed by the program, such 

as improving nutrition choices and eating habits or increasing physical activity. 

Components of the program that can affect its success are referred to as “program 

elements.” For example, conducting a needs assessment prior to implementation, 

using best practice or evidence-based programs, and conducting program evaluation 

are all considered program elements. 

 5

This information is for adults and reflects inflation adjusted per capita spending. Kenneth E. Thorpe, 

Curtis S. Florence, David H. Howard, and Peter Joski, “The Impact of Obesity on Rising Medical

Spending,” Health Affairs, W4-480 (2004). 6

Eileen Salinsky and Wakina Scott, “Obesity in America: A Growing Threat,” (Washington, D.C.: 

National Health Policy Forum, July 2003). 7

Eric A. Finkelstein, Ian C. Fiebelkorn, and Guijing Wang, “National Medical Spending Attributable to

Overweight and Obesity: How Much, and Who’s Paying?” Health Affairs, W3-219 (2003). 8

S. 1325, 109th Cong. (2005). As introduced, it would, among other things, direct the Secretary of the 

Department of Health and Human Services (HHS) to coordinate with appropriate federal agencies as 

well as with leadership within HHS in awarding competitive grants to plan and implement programs

that promote healthy eating behaviors and physical activity to prevent eating disorders, obesity, being 

overweight, and related serious and chronic medical conditions. 9

S. 1324, 109th Cong. (2005). As introduced, it would establish a Congressional Council on Childhood 

Obesity, charged with encouraging elementary and middle schools to develop and implement plans to 

reduce and prevent obesity, promote improved nutritional choices, and promote increased physical

activity among students. The proposed legislation would also establish the National Foundation for the

Prevention and Reduction of Childhood Obesity to support and carry out efforts to prevent and reduce 

childhood obesity through school-based activities. 

2 GAO-06-127R Childhood Obesity
To address these objectives, we conducted a written survey to identify strategies and 

elements that experts believe are most important to include when designing or 

implementing a program to prevent or reduce childhood obesity.10 We chose to

conduct a survey of experts because of the limited availability of information on

evaluated programs that describe successful efforts to address childhood obesity. In 

May 2005, 233 experts in academia and the private sector working in the fields of 

physical activity, nutrition, and childhood obesity and government officials at the 

federal, state, and local levels received the survey. (See enc. III for a copy of this 

survey.) We received 141 completed surveys, 23 survey recipients declined to 

participate, and 6 surveys were excluded, for an overall response rate of 62 percent. 

The survey asked respondents to select from among 9 options related to program 

strategies, 17 options related to program elements, and 7 options related to outcome

measures.11 In addition, respondents were offered the option to choose an “other” 

category for each of these questions, in which they could write in a response. Some 

respondents selected this “other” category and provided information that may have 

overlapped with one of the response options offered in the question. We did not resort responses into different categories. Respondents were also asked to rank the 

three strategies and five elements they considered to be most important to include 

when designing and/or implementing a program to target childhood obesity. We 

analyzed survey responses, calculating weighted frequencies by assigning a numeric 

value to weight the choices respondents’ identified as the three most important

strategies and the five most important elements. We then calculated an aggregated 

score based on the weighted frequencies. We also calculated simple frequencies to 

identify how often experts chose a particular outcome measure as important to the 

determination of a program’s success. 

To obtain examples of how selected programs have implemented the key program 

strategies and elements identified by experts through our survey, we selected four 

programs and conducted telephone interviews with program officials. To select the 

programs, we used specific criteria in order to ensure program variety. These criteria 

included the program’s funding source, program setting, targeted population, and the 

program’s strategy.12 Of the four programs we selected, federal funding was the initial 

funding source for three programs, and one of these programs continues to have 

some federal funding. Two of the programs that initially received federal funding are 

now supported by nonfederal funds, including local funds. One program relies

exclusively on private funding. Two of the four programs were school-based while 

two others were community-based, focusing on communities and including schools.

In addition, one program targeted both children and adults, while the other three 

focused primarily on children. These interviews provided information on the 

approaches used, problems encountered, and challenges overcome when 

implementing the key strategies and elements. In addition, we obtained information

 10In our survey, we defined a “program” as an integrated set of planned or sequential strategies, 

activities, and services that support clearly stated goals. 11The strategies, elements, and outcome measures in the survey were drawn from literature and

interviews we conducted with individuals working at federal agencies and national organizations. 12We selected programs that focused on different strategies using the strategies most frequently 

selected on the survey responses received as of May 20, 2005, although we continued to accept surveys 

through the end of May 2005. 

3 GAO-06-127R Childhood Obesity
on what program officials perceived as possible federal roles targeting childhood 

obesity. The information provided reflects the comments of program officials we 

interviewed and cannot be generalized to all the programs. In addition, the 

information provided by program officials does not reflect all efforts underway to

address childhood obesity or the implementation approaches and challenges faced by 

other programs. (For additional information on our methodology, see enc. II.) 

We did our work from February 2005 through September 2005 in accordance with 

generally accepted government auditing standards. 

Results in Brief 

Experts we surveyed identified several 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.” 

The second-highest-ranked strategy was the “other” category, in which experts wrote 

in a variety of responses. The number and variety of these write-in responses

suggests that, beyond physical activity, there is less consensus on which strategies

should be used to target childhood obesity. The strategy of improving children’s

nutritional intake was identified as third in importance for programs designed to

prevent or reduce childhood obesity by surveyed experts. 

Our interviews with officials at four programs provided different examples of

implementing the key strategies, including the top-ranked strategy, increasing 

physical activity. For example, one school-based program provided children with a 

card that was hole-punched when they walked at recess and which the children could 

redeem when completed for small prizes and incentives. Another program provided

pedometers to encourage walking. Program officials we interviewed also identified 

multiple challenges to implementing key strategies that included policy concerns, 

such as a lack of or inconsistent physical education requirements by school districts,

and infrastructure concerns, such as no sidewalks.

Experts we surveyed identified several key elements to include in the design or 

implementation of a program to prevent or reduce childhood obesity. The program 

element identified as the most important was the use of best practice or evidencebased models. Experts also identified other key elements including the suitability and 

acceptability of the program to the target community, and sufficient financial and 

human resources. Responses from surveyed experts indicate that there is no 

consensus on what outcome measures should be used to determine program success.

Officials we interviewed at four programs provided a variety of examples 

demonstrating how they implemented the top-ranked program element—use of best

practices or evidence-based program models. For example, one program drew best

practices from multiple sources, including clinical treatment programs and programs

aimed at children of other ages, to guide the development of their prevention 

program. Program officials we interviewed also identified challenges to implementing 

key elements that included difficulties in working within school systems and 

communities to obtain program acceptance, and resource constraints. Program 

4 GAO-06-127R Childhood Obesity
officials also identified several possible roles for the federal government related to 

obesity, including supporting and staffing clearinghouses to provide information on

best practices. 

Agency Comments and Our Evaluation 

We received comments on the draft report from the Department of Health and 

Human Services (HHS). These comments are provided in enclosure VI. HHS and the 

Department of Agriculture (USDA) also provided technical comments which we 

incorporated where appropriate. The Department of Education informed us that it

had no comments on the draft report.

In its written comments, HHS stated that our findings were inconsistent with IOM’s

2005 report, which found that preventing obesity involves both regular physical 

activity and healthy eating behaviors. We believe that our findings are consistent with

IOM’s 2005 report. Our survey results show that both physical activity and nutritional 

strategies are important. Although our surveyed experts ranked physical activity as a 

leading strategy for programs that address childhood obesity, it is not the sole 

strategy and our survey results fully support the importance of other strategies, 

including improving children’s nutritional intake. In addition, our report provides

illustrative examples of how program officials have implemented both physical 

activity and nutrition-related strategies. Our title, “Childhood Obesity: Most Experts

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

Programs,” which HHS suggests overstates the importance of physical activity, is an 

accurate reflection of the survey responses. Consistent with the IOM report, we 

provide background on the importance of both sides of the energy balance 

equation—nutrition and physical activity. Our report is also consistent with IOM’s

call for evidence-based best practices that could help in setting priorities to address

childhood obesity, and the rankings from our surveyed experts suggest priorities 

based on their experience. 

HHS (and USDA in its technical comments) also raised questions about our survey 

methods, including how survey respondents were selected, how the response options

offered to respondents were developed, and how analysis of the many “other” 

responses written in by respondents was conducted. As we noted in the draft report,

we selected our survey respondents by using a systematic approach to review 

literature, conference proceedings, and hearings within a defined time frame and by 

developing clear decision rules for selection. Because there is no comprehensive 

national inventory of childhood obesity programs or experts in the field, a 

representative sample is not possible. However, our approach was designed to ensure 

a broad representation across sectors and fields involved in the issue. Both HHS and 

USDA suggested that we provide additional detail on the survey respondents and we 

have modified the report to provide information on the affiliations of our survey 

respondents. As we noted in the draft report, the response categories provided to

respondents in the survey were developed based on a review of the literature and 

interviews, and the survey instrument was reviewed and pretested with each type of 

respondent included in the sample, and was modified multiple times based on input

received before being implemented. HHS (and USDA in its technical comments) 

5 GAO-06-127R Childhood Obesity
suggested that we should have grouped response categories, including those related 

to the program strategies and the “other” responses written in by respondents, into

broader categories. HHS suggested that such grouping would alter the results,

particularly related to the leading program strategy. However, this is not accurate. 

Grouping the response categories provided in the survey to form broader categories

such as physical activity or nutrition would not have changed the results. Physical 

activity would remain as the leading strategy, with nutrition strategies being 

important in the rankings, though ranked lower. Furthermore, as we noted in the 

draft report, we did not re-sort the “other” responses, because respondents

deliberately chose to write a response in the “other” category and re-sorting their 

responses would not have accurately reflected the responses as we received them. 

Furthermore, re-sorting the responses related to program strategies or “other” to

form larger categories would have resulted in a loss of information to the reader 

about the diversity of the respondents’ views; therefore we chose to provide greater 

detail. HHS was concerned that the response categories were incomplete. However, 

the survey made available several areas for respondents to write in responses for an 

individual question as well as generally, so respondents had ample opportunity to

write in additional information. Although HHS stated that we did not mention the use 

of policy as a strategy to shape food and physical activity environments, this issue is 

indeed identified as an “other” response that respondents wrote in. 

HHS commented that the interviews with officials at four programs are anecdotal and 

represent a small fraction of respondents who completed surveys, which 

mischaracterizes our report. HHS’s implication that we selected programs associated 

with survey respondents is inconsistent with our described methodology. The four 

programs were identified through interviews and reviews of documents from multiple 

sources. Furthermore, as the report states, the purpose of the interviews was not to

evaluate these specific programs, but to obtain examples that could illustrate 

concepts in the survey results. As we stated, this was not a generalizable sample. 

Finally, HHS suggested that the report incorporate more recent data on prevalence of 

overweight among children, and provide information on the disparities by 

race/ethnicity. We modified the report to reflect the updated prevalence data; 

however, a detailed discussion on variations in the prevalence of obesity among 

children was not in the scope of our work. 

- - - - - 

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

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

of this letter. At that time, we will send copies of this letter to the Secretaries of 

Health and Human Services, Agriculture, and Education, appropriate congressional 

committees, and other interested parties. In addition, the report will be available at 

no charge on the GAO Web site at http://www.gao.gov. 

6 GAO-06-127R Childhood Obesity
If you or your staff have any questions about this report, please contact me at (202) 

512-7101 or bascettac@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this report. GAO staff

who made major contributions to this report are listed in enclosure VII.

Cynthia A. Bascetta

Director, Health Care 

7 GAO-06-127R Childhood Obesity
List of Requesters 

The Honorable Bill Frist

Majority Leader 

United States Senate 

The Honorable Christopher J. Dodd 

Ranking Minority Member 

Subcommittee on Education and Early Childhood Development

Committee on Health, Education, Labor, and Pensions

United States Senate 

The Honorable Jeff Bingaman 

United States Senate 

The Honorable Mary Bono 

House of Representatives

The Honorable Kay Granger 

House of Representatives

The Honorable Nita M. Lowey 

House of Representatives

8 GAO-06-127R Childhood Obesity 
1

Enclosure I

Childhood Obesity: Most Experts Identified 

Physical Activity and the Use of Best 

Practices as Key to Successful Programs

Briefing for Staff of Congressional Requesters

September 8, 2005

9 GAO-06-127R Childhood Obesity 
2

Enclosure I

Introduction

• In the past 30 years, the number of obese children1 has increased

throughout the United States, leading some policy makers to rank

childhood obesity as a critical public health threat.

• The rate of childhood obesity has more than tripled for children

between the ages of 6 and 11 and also increased for children of 

other ages over that 30-year period.2

• According to a 2005 Institute of Medicine report, nationwide 

approximately 9 million children over the age of 6 are 

considered obese.3

1 In this report, the term “obese” refers to children who are considered both overweight and at risk for overweight according to the Centers for Disease Control and Prevention

(CDC) standards for child-specific body mass index (BMI) scores, as well as both overweight and obese adults. BMI is an indirect measure of body fat calculated as the ratio of a 

person’s body weight in kilograms to the square of a person’s height in meters. According to CDC’s 2000 growth charts, children are overweight when they have a BMI at or 

above the 95th percentile for their age and gender, while children between the 85th and 95th percentile are considered at risk of being overweight. BMI for children, also referred

to as BMI-for-age, is gender and age specific. In addition, in this report, the term “children” refers to anyone under the age of 18.

2 These data are for children at or above the 95th percentile of BMI for age and gender. Cynthia L. Ogden, Katherine M. Flegal, Margaret D. Carroll, and Clifford L. Johnson,

“Prevalence and Trends in Overweight Among US Children and Adolescents, 1999-2000,” JAMA, vol. 288, no. 14 (2002) and Allison A. Hedley, Cynthia L. Ogden, Clifford L.

Johnson, Margaret D. Carroll, Lester R. Curtin, and Katherine M. Flegal, “Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 1999-2002,”

JAMA, vol. 291, no. 23 (2004). 3 Institute of Medicine, Preventing Childhood Obesity: Health in the Balance (Washington, D.C.: National Academies Press, 2005).

10 GAO-06-127R Childhood Obesity
3

Enclosure I

Introduction

• The rise in obesity-related health conditions also introduces added economic costs.

• Between 1979 and 1999, obesity-associated hospital costs for children between the

ages of 6 and 17 more than tripled, from $35 million to $127 million.

4

• Increased numbers of obese children who become obese adults may affect future

health expenditures, including Medicaid and potentially Medicare.

• Obesity-related health expenditures are estimated to have accounted for more than 

25 percent of the growth in health care spending between 1987 and 2001.5

•In 2000, an estimated $117 billion was spent for health-related expenditures due to 

obesity with $61 billion in direct costs. These direct costs accounted for

approximately 5 percent of U.S. health expenditures.

6

• Nearly half of all medical spending related to adult obesity is financed by the public 

sector, through Medicaid and Medicare.

7

• Some federal agencies support efforts to target the issue of childhood obesity. 

Legislation introduced in the current Congress also focuses on the issue, including the

Improved Nutrition and Physical Activity Act and the Childhood Obesity Reduction Act.8

4 The change from 1979-1981 to 1997-1999 in 2001 dollars. Guijing Wang and William H. Dietz, “Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979-1999,” Pediatrics, vol. 109 (2002). 5 This information is for adults and reflects inflation adjusted per capita spending. Kenneth E. Thorpe, Curtis S. Florence, David H. Howard, and Peter Joski, “The Impact of Obesity on Rising Medical

Spending,” Health Affairs, W4-480 (2004). 6 Eileen Salinsky and Wakina Scott, “Obesity in America: A Growing Threat,” (Washington, D.C.: National Health Policy Forum, July 2003). 7 Eric A. Finkelstein, Ian C. Fiebelkorn, and Guijing Wang, “National Medical Spending Attributable to Overweight and Obesity: How much, and Who’s paying?” Health Affairs, W3-219 (2003). 8 S. 1325, 109th Cong. (2005) and S. 1324, 109th Cong. (2005).

11 GAO-06-127R Childhood Obesity
4

Enclosure I

Reporting Objectives

• Describe the key strategies identified by experts as most important 

to include in programs to prevent or reduce childhood obesity.

• Provide examples of how selected programs implemented the key

strategies identified and challenges these programs faced.

• Describe the program elements identified by experts as most

important to include in programs to prevent or reduce childhood 

obesity, as well as outcome measures identified as important.

• Provide examples of how selected programs implemented key

elements identified and the challenges those programs faced, as

well as examples of possible roles for the federal government.

12 GAO-06-127R Childhood Obesity
5

Enclosure I

Scope and Methodology

• In this report, “program strategies” refers to the issue to be addressed

by the program, such as improving nutrition choices and eating habits

or increasing physical activity.

• “Program elements” refers to components of the program that can 

affect its success. For example, conducting a needs assessment

prior to implementation, using best practice or evidence-based

programs, and conducting program evaluation are all considered 

program elements.

13 GAO-06-127R Childhood Obesity
6

Enclosure I

Scope and Methodology

• We surveyed 233 experts in the fields of physical activity, nutrition, and 

childhood obesity to identify the program strategies, elements, and outcome 

measures that are, in their view, important to include when designing and/or

implementing a program to prevent or reduce childhood obesity.9

• Survey respondents were asked to select from among several options 

related to program strategies, elements, and outcome measures, and

were offered the option to choose an “other” category for each of these 

questions in which they could write in a response.

• Some respondents selected the “other” category, providing information

that may have overlapped with one of the response options offered in the 

question, such as physical activity or nutrition intake. Although we 

reviewed the “other” responses for common issues, we did not re-sort

these responses.

9 Of these experts, 141 returned completed and usable surveys. See enc. III for a copy of this survey.

14 GAO-06-127R Childhood Obesity
7

Enclosure I

Scope and Methodology (cont.)

• Survey respondents were also asked to rank the three strategies and five 

elements they considered to be most important to include when designing 

and/or implementing a program to target childhood obesity. 

• Weighted frequencies

• We assigned a numeric value to weight the choices ranked as the

three most important strategies and five most important elements.

• We then calculated an aggregated score based on the weighted 

frequencies.

• Survey respondents were also asked to identify outcome measures they

considered important to the determination of a program’s success.

• Frequencies

• We examined how frequently a particular outcome measure was 

chosen by experts. 

15 GAO-06-127R Childhood Obesity
8

Enclosure I

Scope and Methodology (cont.)

• After surveying experts, we conducted telephone interviews with

officials at four selected programs targeting childhood obesity. To

select the programs, we used specific criteria to ensure program

variety. These criteria included the program’s funding source,

program setting, targeted population, and strategy.

10 We asked 

program officials at each program whether and how they

implemented key strategies and program elements identified by

surveyed experts.

11 Our purpose was to determine the approaches

used, challenges encountered, and obstacles overcome. In

addition, we obtained information from program officials on what

they perceived as possible federal roles related to preventing or

reducing childhood obesity.

10 We selected programs that focused on different strategies using the strategies most frequently selected on the survey responses received as of May 20, 2005, although we

continued to accept surveys through the end of May 2005. 11 Throughout this report, the term “surveyed experts” refers to the people who completed the survey. The term “program officials” refers to the people we interviewed at the

four selected programs.

16 GAO-06-127R Childhood Obesity
9

Enclosure I

Scope and Methodology (cont.)

• Federal funding was the initial funding source for three of the four selected

programs, and one of these programs continues to receive some federal

funding. The two programs that initially received federal funding are now 

supported by other, nonfederal funds, including local and private funds. One

program we selected relies exclusively on private funding.

• Two programs were school-based while two others were community-based, 

focusing on communities and including schools.

• One program targeted both children and adults, while the other three

focused primarily on children.

• Two programs focused on multiple strategies and two focused on a single 

strategy.

17 GAO-06-127R Childhood Obesity
10

Enclosure I

Background

Increase in Childhood Obesity

• Between the early 1970s and 2000, the rate of childhood obesity

has more than tripled for children between the ages of 6 and 11.12

(See fig. 1.)

• During that same time period, the rate of childhood obesity more

than doubled for both children between the ages of 2 and 5 and 

between the ages of 12 and 19.

12 These data are for children at or above the 95th percentile of BMI for age and gender. Ogden et. al., “Prevalence and Trends in Overweight Among US Children and 

Adolescents, 1999-2000,” JAMA, vol. 288, no. 14 (2002) and Hedley et al., “Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 

1999-2002,” JAMA, vol. 291, no. 23 (2004).

18 GAO-06-127R Childhood Obesity
11

Enclosure I

Background (cont.)

Increase in Childhood Obesity (cont.)

Notes: The National Health and Nutrition Examination Survey

(NHANES) is an ongoing cross-sectional, nationally

representative examination survey conducted by the Centers for 

Disease Control and Prevention’s National Center for Health 

Statistics. The survey collects data on the health of U.S.

residents. 

a These data are for children at or above the 95th percentile of 

BMI for age and gender. 

Figure 1: Percent increase in childhood obesity

19 GAO-06-127R Childhood Obesity
12

Enclosure I

Background (cont.) 

Health Consequences of Childhood Obesity

• Children are experiencing illness and other health problems

associated with obesity, including:13

• Type II diabetes

• Hypertension

• In addition, obesity is associated with other physical, social, and 

emotional health consequences, including:

• Sleep apnea

• Orthopedic problems

• Depression

• Negative body image

• Stigma

13 See, for example, Office of the Surgeon General, “The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001,” (Washington,

D.C.: 2001) and Salinsky et al., “Obesity in America: A Growing Threat,” (Washington, D.C.: National Health Policy Forum, July 2003).

20 GAO-06-127R Childhood Obesity
13

Enclosure I

Background (cont.)

Obesity Can Result from an Imbalance in the “Energy Balance

Equation”

14 The energy balance equation is expressed as “energy intake = energy expenditure.” Energy balance is determined by the relationship between energy

intake (food/caloric) and energy expenditure (activity/exercise). See, for example, Institute of Medicine, Preventing Childhood Obesity: Health in the 

Balance (Washington, D.C.: National Academies Press, 2005).

• At the most basic level, obesity results from an imbalance in what

experts refer to as the “energy balance equation.”14

• Obesity can result when increased or

excess energy intake (calories

consumed) is combined with

decreased or unchanged energy

expenditure (insufficient physical

activity). (See fig. 2.)

21 GAO-06-127R Childhood Obesity
14

Enclosure I

Background (cont.) 

Factors Contributing to Childhood Obesity

• Each side of the energy balance equation is affected by the 

complex interaction of social, biological, behavioral, dietary,

environmental, and economic factors.

• For example, children may receive nutrition education and 

healthy foods while in school, but may not have access to

healthy foods in the surrounding community or may lack role 

models who demonstrate healthy lifestyle choices.

• Moreover, changes to diet may be insufficient to reduce 

childhood obesity without a corresponding increase in physical 

activity.

22 GAO-06-127R Childhood Obesity
15

Enclosure I

Background (cont.) 

Federal Agencies and Others are Participating In Efforts to

Prevent and Reduce Childhood Obesity

• At the federal level, the Departments of Health and Human 

Services, Agriculture, and Education have all supported initiatives

that target childhood obesity, in some cases working in partnership 

with private organizations. These initiatives include research and

education, as well as financial and technical support for program 

implementation.

• In addition to federal agencies, a variety of private organizations

and public-private partnerships have also undertaken efforts to 

reduce the effects of factors that contribute to childhood obesity. 

These efforts may target a single issue, such as dietary change,

while others may coordinate activities across multiple issues, such

as both dietary change and physical activity.

23 GAO-06-127R Childhood Obesity
16

Enclosure I

Background (cont.) 

Federal and Private Efforts to Address Childhood Obesity Have 

Not Been Evaluated

• While a variety of efforts are underway in both the federal and

private sectors to address childhood obesity, few programs have

undergone the rigorous evaluations needed to definitively identify

what types of interventions are successful.

• The Institute of Medicine’s 2005 report on childhood obesity noted

that a “robust evidence base” on which interventions have an

impact on reducing or preventing childhood obesity is not yet

available, but because of the magnitude of the problem, there is an 

urgent need to take action.15 The Robert Wood Johnson 

Foundation has funded the Institute of Medicine to continue working 

in this area.

15 Institute of Medicine, Preventing Childhood Obesity: Health in the Balance (Washington, D.C.: National Academies Press, 2005).

24 GAO-06-127R Childhood Obesity
17

Enclosure I

• Experts we surveyed identified several key strategies as important 

to include in programs designed to prevent or reduce childhood 

obesity.

• When responses were weighted by importance, increasing 

physical activity was ranked as the most important strategy.

16

(See fig. 3. See enc. IV for additional data.)

Surveyed Experts Identified Several Key Program 

Strategies, Including Increasing Physical Activity

16 When calculated as straight frequencies, increasing physical activity and "other" were identified most frequently by survey respondents.

25 GAO-06-127R Childhood Obesity
18

Enclosure I

Surveyed Experts Identified Several Key Program 

Strategies, Including Increasing Physical Activity

(cont.)

Figure 3: Strategies Identified by Surveyed Experts

Notes:

Figure is based on weighted data from ranked strategies

identified by experts. (See encs. III and IV for more information

on survey questions and respondent data.)

“Other” refers to answers written in by survey respondents in

the category labeled “other.”

26 GAO-06-127R Childhood Obesity
19

Enclosure I

• The second-highest ranked strategy was the “other” category.

17 The number and 

variety of write-in responses suggests that, beyond physical activity, there is less

consensus on which strategies should be used to target childhood obesity.

• Among the various write-in responses, the most common issues listed were:

• Involving parents18

• General nutrition-related initiatives, such as encouraging water consumption

• Food policy-related initiatives, such as removing high-sugar and high-fat foods

from school vending machines

• Experts also wrote in strategies related to:

• Education

• Physical activity-related initiatives, such as requiring physical activity in schools

at all levels

• Altering child-targeted food marketing/advertising 

• The strategy of improving children's nutritional intake was identified as third in 

importance for programs designed to prevent or reduce childhood obesity by

surveyed experts.

17 “Other” refers to answers written in by survey respondents in the category labeled “other.” 18 By parents, we mean the child’s primary care giver. Parental involvement includes a range of activities such as promoting physical activities for families, 

improving parent’s fitness levels, promoting authoritative parenting practices regarding foods choices, and educating caregivers on portion sizes.

Surveyed Experts Identified Several Key Program Strategies,

Including Increasing Physical Activity (cont.)

27 GAO-06-127R Childhood Obesity
20

Enclosure I

Program Officials Identified Several Examples of and 

Challenges to Implementing Experts’ Key Strategies

Increasing Physical Activity: Examples

• Several program officials we interviewed identified walking as a

means of increasing physical activity.

• At one school, a teacher started an activity to encourage 

children to walk at recess. As an incentive, children were given

cards, and a hole was punched in the card each time the child 

completed the school walking course. Students could then 

redeem the punched cards for small prizes such as colorful 

pencils or erasers. Another school walking program provided

incentives including wrist bands, water bottles, and jump ropes

to encourage children to walk at least 5 miles a week.

28 GAO-06-127R Childhood Obesity
21

Enclosure I

Program Officials Identified Several Examples of and 

Challenges to Implementing Experts’ Key Strategies (cont.)

Increasing Physical Activity: Examples (cont.)

• One program worked with a community to increase children’s

physical activity by developing a program to encourage children 

and parents to walk to school. This type of program is

commonly referred to as a “walking school bus.”

• Another program provided pedometers to children and adults to

encourage walking. In one community involved in this program,

this effort resulted in an increased resident demand for places to

walk, which in turn resulted in an increase in the number of local 

walking paths from one to five.

29 GAO-06-127R Childhood Obesity
22

Enclosure I

Program Officials Identified Several Examples of and 

Challenges to Implementing Experts’ Key Strategies (cont.)

Increasing Physical Activity: Challenges

• Program officials reported that existing community and school 

infrastructures may present challenges to increasing physical activity, such 

as no school bicycle racks, no sidewalks, heavy traffic, and unsafe

neighborhoods. 

• Officials also reported that physical education policy, which varies by state 

and local school districts, may also present challenges. Some states do not 

require physical education for children and others lack physical education 

specifications defining its frequency and duration.

• One program official stated that, while there is a state physical 

education requirement for all schools, schools can receive waivers. In

addition, many schools do not have physical education teachers or

share physical education teachers with multiple other schools.

30 GAO-06-127R Childhood Obesity
23

Enclosure I

Program Officials Identified Several Examples of and 

Challenges to Implementing Experts’ Key Strategies (cont.)

Improving Nutritional Intake: Examples

• One program official we interviewed noted that some schools no

longer involve food in school-sponsored fund raising events. For

example, students could sell Halloween costumes instead of candy

to raise money.

• Another program purchased vending machines that dispense

milk—instead of sweetened beverages—for placement in schools. 

That program also provided coupons for fresh fruits and vegetables

that could be redeemed at local grocery stores.

• Another program provided a salad bar with fresh fruits and 

vegetables purchased from local farmers as a daily lunch option.

31 GAO-06-127R Childhood Obesity
24

Enclosure I

Program Officials Identified Several Examples of and 

Challenges to Implementing Experts’ Key Strategies (cont.)

Improving Nutritional Intake: Challenges

• Program officials from a school-based program noted that children 

received mixed messages, receiving information on healthy lifestyles

through their program while still being offered unhealthy food in the 

school environment.19

• Program officials we interviewed also expressed concern about the 

foods provided through the National School Lunch Program. For 

example, one program official who works for a school district’s Food

and Nutrition Services told us that meats lower in fat should be

available. Another program official with a school-based program noted 

that schools are not currently reimbursed for bottled water that is 

served during after-school programs, though they can be reimbursed

for fruit beverages. 19 For additional information on competitive foods and school meals, see GAO, School Meal Programs: Competitive Foods Are Available in Many

Schools; Actions Taken to Restrict Them Differ by State and Locality, GAO-04-673 (Washington, D.C.: Apr. 23, 2004), GAO, School Lunch Program:

Efforts Needed to Improve Nutrition and Encourage Healthy Eating, GAO-03-506 (Washington, D.C.: May 9, 2003), and GAO, School Meal Programs:

Competitive Foods Are Widely Available and Generate Substantial Revenues for Schools, GAO-05-563 (Washington, D.C.: Aug. 2005).

32 GAO-06-127R Childhood Obesity
25

Enclosure I

Program Officials Identified Several Examples of and 

Challenges to Implementing Experts’ Key Strategies (cont.)

Improving Nutritional Intake: Challenges (cont.)

• One program official told us school district financial staff resisted

altering the bidding process to allow schools to purchase seasonal

produce from local farmers.

• Multiple program officials, including a nutrition specialist employed

by a school district’s Food and Nutrition Services, told us that

preparation of fresh fruits and vegetables is time and labor intensive

and requires schools to have a kitchen located at the school.

• An individual who helped develop a school-based program identified

the need to educate food service staff on the preparation of

nutritious foods.

• One program official said people are often confused by information 

on proper nutrition that seems to change frequently. Because of

this, increasing physical activity was an easier strategy to sustain.

33 GAO-06-127R Childhood Obesity
26

Enclosure I

Surveyed Experts Identified Several Key Program

Elements, Including the Use of Best Practices

• Experts we surveyed identified several key elements as important

to include in programs designed to prevent or reduce childhood 

obesity.

• The use of best practices20 was ranked as the most important 

element by survey respondents when responses were weighted 

by importance.21 (See fig. 4. See enc. IV for additional data.)

20 The survey defined best practices as new lessons learned about effective program activities that have been developed and implemented in the field and 

have been shown to produce positive outcomes. 21 When calculated as straight frequencies, the use of best practices, outcome evaluation, and sufficient financial resources were identified most frequently

by survey respondents.

34 GAO-06-127R Childhood Obesity
27

Enclosure I

Surveyed Experts Identified Several Key Program 

Elements, Including the Use of Best Practices (cont.)

Figure 4: Key Elements Identified by Surveyed Experts

Note:

Figure is based on weighted data from ranked

elements identified by experts. (See encs. III and 

IV for more information on survey questions and

respondent data.)

35 GAO-06-127R Childhood Obesity
28

Enclosure I

Surveyed Experts Identified Several Key Program Elements, 

Including the Use of Best Practices (cont.)

Surveyed Experts Varied on How to Measure Outcomes

• In addition to surveying experts on program elements, we also

asked them to identify outcome measures that should be used to

measure a program’s ability to prevent or reduce childhood 

obesity. (See fig. 5. See enc. IV for additional data.)

• Our survey showed agreement among experts that body mass

index (BMI) and fitness levels can be used as possible outcome 

measures. However, a large number also selected “other.” This

suggests that, while there was agreement among experts on the 

importance of using best practices, there is a lack of consensus

on how best to measure the success of programs designed to

prevent or reduce childhood obesity.

36 GAO-06-127R Childhood Obesity
29

Enclosure I

Surveyed Experts Identified Several Key Program 

Elements, Including the Use of Best Practices (cont.)

Figure 5: Outcome Measures Identified by Surveyed Experts

Note: Figure is based on frequency data from outcome measures identified by experts. (See encs. III and IV for more information on survey questions and

respondent data.) a Body mass index is an indirect measure of body fat calculated as the ratio of a person’s body weight in kilograms to the square of a person’s height in meters. b “Other” refers to answers written in by survey respondents in the category labeled “other.” Examples of “other” measures included waist circumference,

psychological measures (e.g., attitudes, self-esteem), and decreased TV viewing. c Adiposity refers to excessive body fat. d Biomarkers are anatomic, physiologic, biochemical, or molecular parameters associated with the presence and severity of specific disease states. For

example, biomarkers for obesity could include insulin levels.

37 GAO-06-127R Childhood Obesity
30

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements

Use of Best Practices: Examples

• Officials from one community-based program obtained information 

from initiatives in another state and from an international 

conference. Within their own community, they looked to a program

conducted by local police to increase children's physical activity and 

promote neighborhood safety.

• Officials from another community-based program drew on

information from public health programs and a curriculum created

by another program.

38 GAO-06-127R Childhood Obesity
31

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Use of Best Practices: Challenges

• In the absence of best practice models for their targeted population, 

officials from one school-based program reported that they used practices

from obesity programs targeting other age groups. In addition, they used

information collected through clinical treatment of obese children. The 

program also drew on theories of health behavior and learning to create

the framework for the program.

• An official from another school-based program focusing on improving 

children's nutrition told us that, when they started, no best practice 

models that addressed their specific needs were available. Because of 

this, they developed their own model. This program is now

institutionalized throughout its home school district and has developed 

materials to help others develop similar programs.

39 GAO-06-127R Childhood Obesity
32

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Suitability and Acceptability to Community: Examples

• One program developed broad programmatic goals, then worked 

with specific communities to develop objectives that targeted the 

specific needs of those communities.

• Another program created multiple versions of its educational

materials to be sensitive to a community’s religious beliefs.

• A school-based program offered pre-made salads and sold them on

lunch carts so that older students who no longer ate in the cafeteria 

but were still a part of that program’s targeted population would 

participate in the program.

• To address cultural and language diversity, two programs

translated materials into Spanish to reach a broader population.

40 GAO-06-127R Childhood Obesity
33

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Suitability and Acceptability to Community: Challenges

• Program officials noted that working within a school system can

pose challenges because of

• The need for programs to be integrated into existing curricula.

• The need for programs to work within school resource

constraints—for example, be low cost and require no additional

staff.

• The need for programs to have school administrators’ support in 

order to operate.

41 GAO-06-127R Childhood Obesity
34

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Sufficient Human Resources: Examples

• To address human resource needs, some program officials told us

they looked within the program’s community to find people to fill

key paid and volunteer staff positions.

• One program hired neighborhood residents to help implement 

the program. 

• In a school-based program, parents volunteered to clean and

prepare the fresh fruits and vegetables served to children. One 

of these parents was later hired to help facilitate the program at 

a local school.

42 GAO-06-127R Childhood Obesity
35

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Sufficient Human Resources: Challenges

• Some programs identified challenges which, though not specific to

programs targeting childhood obesity, make it difficult to ensure

sufficient human resources.

• Officials from one program stated that staffing instability can 

result from a lack of long-term funding. For example, when paid

positions are dependent on unstable funding, staff may leave 

during the course of the program to accept more secure jobs.

• Officials from another program acknowledged the difficulty of

recruiting volunteers and are trying to work with other

organizations with similar interests to pool resources.

43 GAO-06-127R Childhood Obesity
36

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Sufficient Financial Resources: Examples

• Officials told us that for a program to be implemented in a school 

setting, funds often need to be provided to the schools.

• One program awarded grants to schools to support special 

projects designed to reach program goals, and also provided

reimbursement to schools for data collection activities needed

for the program evaluation. Program officials reported that the

ability to provide these small grants to a community can 

generate enthusiasm for the program in that community.

• Another program official noted the importance of providing funds

for teacher training, as well as a small stipend for a program 

coordinator.

44 GAO-06-127R Childhood Obesity
37

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Sufficient Financial Resources: Examples (cont.)

• Officials stated that financial contributions from communities also

helped provide sufficient resources to support the programs. For

example, in one community, contributions were used to purchase 

walkie-talkies and handheld traffic signs needed by crosswalk

guards for the initiative to promote walking to school.

• Another program official stated that it is important to partner with

organizations in the private sector that will act as “program 

champions.” Such advocates can often raise funds needed as a 

catalyst to implement programs.

45 GAO-06-127R Childhood Obesity
38

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Sufficient Financial Resources: Challenges

• One program official reported that obtaining funding for program

implementation beyond initial research activities can be difficult.

• The uncertainty of future funding was also identified by officials

from one program as a challenge to program continuity. Those

officials also noted that grant funding needs to be flexible and

allow for innovation.

46 GAO-06-127R Childhood Obesity
39

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Specified Program Goals and Objectives: Examples

• Most program officials we spoke with said they developed goals and 

objectives that described program impact or expected changes. For

example, one program developed the following goal, objective, and 

expected impact:22

• Goal—Enhance the well-being of individuals by improving their attitudes

and behaviors related to food, physical activity, and body image, and to

build communities’ capacity to sustain these changes.

• Objective—Create educational and promotional materials, including a

communitywide multimedia campaign, to achieve the program goals.

• Expected Impact—Positive changes in attitudes toward eating, physical 

activity, and body image.

22 This program aimed to reduce obesity by focusing actively on prevention and health—rather than simply on weight—at both the individual and community levels.

47 GAO-06-127R Childhood Obesity
40

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Specified Program Goals and Objectives: Challenges

• Officials from one program stated that it is difficult to attribute 

individual-level change to interventions implemented on a 

communitywide basis.

• Officials from another program noted that measuring the result of

prevention is also difficult, regardless of whether the intervention is

at the individual or community level.

48 GAO-06-127R Childhood Obesity
41

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Outcome Evaluation: Examples

• Program officials we interviewed from one school-based program

used a randomized control trial design.

23

• Because this program had been rigorously evaluated, it was

selected by a private funder for inclusion as part of a larger

program and is currently being disseminated to other schools.

• Program officials we interviewed at other programs had conducted

or planned to conduct an outcome evaluation of their programs,

using both qualitative and quantitative measures.

23 In research communities, randomized control trial design is generally considered to be a rigorous evaluation design.

49 GAO-06-127R Childhood Obesity
42

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Outcome Evaluation: Challenges

• One program official expressed an interest in conducting an 

outcome evaluation, but was unable to find the human and 

financial resources for such an evaluation.

• Officials from one program told us that measuring changes in 

outcomes for individual children during school can be disruptive

and found that extensive evaluation can detract from the 

enthusiasm of participating schools and teachers.

50 GAO-06-127R Childhood Obesity
43

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Outcome Evaluation: Challenges (cont.)

• Program officials at a school-based program noted that schools

may not have the capability or expertise to conduct outcome 

evaluations. However, they noted that schools are better able to

conduct process evaluations, which provide information on how an

intervention is implemented.

• Officials from one program noted that, because extensive 

evaluation is costly and labor intensive, once rigorous evaluation of

an intervention has been conducted, the program should not be

asked frequently to conduct repeated outcome evaluations.

51 GAO-06-127R Childhood Obesity
44

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Program Officials Also Commented on Possible Federal Roles in 

Targeting Childhood Obesity

• In addition to asking officials from four programs about the implementation 

of key program elements, we also asked them what they considered to be 

potential roles for the federal government related to childhood obesity.

• Officials from some programs reported that they believe the federal 

government has a role in developing and staffing clearinghouses to

provide information and materials on programs, and to identify best

practices gleaned from other programs.24 

• Officials from one program expressed concern that seeing the effect of 

a community intervention can take 8 to 10 years, and some current

federal grant structures do not allow time to see a program’s effect on

the targeted population.

24 Some information resources do currently exist, such as Team Nutrition, a Department of Agriculture effort that shares information on school-based 

nutrition programs. Action for Healthy Kids and Shaping America’s Youth, both of which are supported by federal agencies, private organizations, and

professional associations, also provide information on programs targeting childhood obesity.

52 GAO-06-127R Childhood Obesity
45

Enclosure I

Selected Programs Identified Several Examples of and 

Challenges to Implementing Experts’ Key Elements (cont.)

Program Officials Commented on Potential Federal Role in

Targeting Childhood Obesity (cont.)

• Officials from one program told us that the federal government 

should provide communities with information but allow them the 

flexibility to determine what will work in their localities.

• Program officials also noted that they see a role for the federal

government in regulating children’s exposure to food

advertising and marketing.

53 GAO-06-127R Childhood Obesity
46

Enclosure I

Concluding Observations

Our survey indicates that experts consider increasing physical activity as a

leading strategy for programs aimed at preventing or reducing childhood 

obesity. Nutritional intake was also identified as one of the key strategies, 

though experts ranked strategies that targeted physical activity higher than

strategies that targeted nutrition. One possible explanation for this was

offered by a program official who said that increasing physical activity was an 

easier strategy to sustain because people were often confused by information 

on nutritional issues.

Beyond increasing physical activity, the responses from experts were quite

varied and covered many different strategies, although some of these may 

have overlapped with other strategy response categories on the survey. The

number and variety of write-in responses suggests a lack of agreement on

which strategies are important to include in programs addressing childhood 

obesity.

54 GAO-06-127R Childhood Obesity
47

Enclosure I

Concluding Observations (cont.)

With regard to program elements, experts ranked developing best 

practices or evidence-based program models highest—even higher than 

funding support. The need for this element was noted in several ways.

• Our survey revealed little consensus on how to measure program

outcomes. We believe this lack of consensus on outcome

measures may limit the ability to determine best practices. Body

mass index was the outcome measure most often identified by 

experts, but an equal number of experts offered other measures, 

such as psychological measures and decreased television viewing.

• Some program officials noted the lack of program models (models 

in general as well as models for specific age groups) as a barrier 

when initially establishing a program.

55 GAO-06-127R Childhood Obesity
48

Enclosure I

Concluding Observations (cont.)

• Although some information resources exist, some program officials 

suggested that the federal government provide information and 

materials on programs through mechanisms such as the development

of a clearinghouse and the maintenance of a database on best

practices.

56 GAO-06-127R Childhood Obesity
Enclosure II Enclosure II 

Scope and Methodology

To identify strategies and elements that experts believe are most important to include 

when designing and/or implementing a program to prevent or reduce childhood 

obesity, we conducted a written survey of experts in academia and the private sector 

working in the fields of physical activity, nutrition, and childhood obesity. We also

surveyed government officials at the federal, state, and local levels. We chose to 

conduct a survey of experts because of the limited availability of information on

evaluated programs that describe successful efforts to address childhood obesity. 

Because there is no comprehensive inventory of childhood obesity experts, we used a 

systematic approach to identify survey participants. We reviewed both national 

conference proceedings and testimony from congressional hearings focused on

childhood obesity held from January 2004 through February 2005 to identify speakers 

focused on this issue. Using multiple databases, including Medline, BIOSIS, 

Cumulative Index to Nursing and Allied Health Literature, and the Education 

Resources Information Center, we conducted a review of literature published from

January 2003 through February 2005 related to preventing or reducing childhood 

obesity in the United States, identifying primary authors of relevant literature as 

expert contacts for the survey. To identify survey respondents from associations and 

foundations in the private sector, we conducted an internet search to identify

relevant organizations and, when necessary, contacted the organization’s 

communications department or federal affairs office to identify an appropriate

contact. To identify survey respondents at federal agencies, we relied on 

conversations with the Departments of Health and Human Services, Education, and 

Agriculture and also identified respondents from some federal agencies through our 

review of literature and conferences. In addition to these sources, we also identified 

possible respondents from interviews conducted when collecting background 

information and through past GAO work. We compiled a list of 222 experts to receive 

the survey: 95 from academia, 46 from the public sector (federal, state, or local 

government), 38 from foundations and associations, and 43 from the private sector. 

The survey was conducted during May 2005. We pretested the survey with four 

experts representing academia, the public sector, foundations and associations, and 

the private sector, and modified the survey based on their responses. The survey was 

sent via e-mail as both a Microsoft Word document and Acrobat Adobe PDF to

experts, who were given the option to return the survey by e-mail or by fax. For 

surveys that were marked “undeliverable,” correct e-mail addresses were obtained via 

telephone and the survey was sent again. If a correct e-mail address could not be 

obtained, the expert was dropped from our expert pool. Experts who did not respond 

by the deadline were followed up with by both phone and e-mail, up to three times.

The survey was sent to 233 experts—the 222 we identified and an additional 11 

experts to whom the survey was forwarded by the original recipients. Of these, 23 

declined to participate. In addition, 6 survey recipients were excluded because they 

could not be reached or returned unusable surveys. We received 141 completed 

surveys for a 62 percent overall response rate. Of the respondents completing the 

survey, 57 were from academia, 36 were from the public sector (federal, state, or 

local government), 25 were from foundations and associations, and 23 were from the 

57 O-06-127R Childhood Obesity 
Enclosure II Enclosure II

 

private sector. The survey asked respondents to select from among 9 options related 

to program strategies, 17 options related to elements, and 7 options related to

outcome measures.1 (See enc. III for a copy of this survey.) In addition, respondents 

were offered the option to choose an “other” category for each of these questions, in 

which they could write in a response. Some respondents selected this “other” 

category and provided information that may have overlapped with one of the 

response options offered in the question. In order to ensure an accurate reflection of

survey responses, we did not re-sort responses into a different category. 

Respondents were asked to rank the three strategies they considered to be most

important to include when designing and/or implementing a program to target

childhood obesity, as well as the five elements they considered to be most important. 

Respondents were also asked to identify outcome measures they considered 

important to determine program success. In addition to the questions related to

program strategies, elements, and outcome measures, survey respondents were also 

asked to provide information on programs they considered to be successful or have 

shown promise in preventing or reducing childhood obesity and their affiliation, if 

any, with these programs. When completing the survey, respondents represented 

themselves, not the organization or agency they were affiliated with, and were 

allowed the option of remaining anonymous. 

We analyzed survey responses, calculating weighted frequencies of the program 

strategies and elements by assigning a numeric value to weight the choices 

respondents identified as the three most important strategies and the five most

important elements.2

 We then calculated an aggregated score based on the weighted 

frequencies. We also calculated simple frequencies to identify how often experts

chose a particular outcome measure as important to the determination of a program’s

success. We reviewed the information written-in by respondents in the “other” 

category related to program strategies and elements to examine common issues. In 

addition, we used the information provided by survey respondents to compile a list of

programs they considered to be successful or showing promise in preventing or 

reducing childhood obesity. (See enc. V.) 

To illustrate how selected programs have implemented the key program strategies 

and elements identified through our survey, we conducted interviews with officials 

from four selected programs. To select these programs, we developed a list of 

possible programs based on interviews and documents.

3

 We looked for programs that

focused on the strategies most frequently selected from among the strategies listed in 

the survey, based on results received as of May 20, 2005.4

 We sorted programs 

according to program setting, funding source, target population, and whether the 

1

The strategies, elements, and outcome measures in the survey were drawn from literature and

interviews we conducted with individuals working at federal agencies and national organizations. 2

The numeric values assigned to the strategies identified as most, second most, and third most

important were 3 points, 2 points, and 1 point, respectively. The numeric values assigned to the 

elements identified as most, second most, third most, fourth most, and fifth most important were 5

points, 4 points, 3 points, 2 points, and 1 point, respectively. 3

We did not include programs that were focused exclusively on media or educational campaigns. 4

We continued to accept surveys through the end of May 2005. 

58 GAO-06-127R Childhood Obesity
Enclosure II Enclosure II

program targeted one or multiple strategies. We then selected four programs to 

represent variety within these characteristics. Of the four programs selected, federal 

funding was the initial funding source for three programs, and one of these programs

continues to have some federal funding. Two of the programs that initially received 

federal funding are now supported by nonfederal funds, including local funds. One 

program relies exclusively on private funding. Two programs focus exclusively on

one program strategy—one on physical activity, the other on nutrition—while the 

other two programs focus on multiple strategies, including both physical activity and 

nutrition. Two of the four programs were school-based while two others were 

community-based, focusing on communities and including schools. In addition, one 

program targeted both children and adults, while the other three focused primarily on

children. We spoke with multiple individuals connected with each program, including 

one person who served the role of program manager. 

We conducted telephone interviews with program officials from each of the four 

selected programs using a structured protocol. In addition, we reviewed written 

materials on each of the selected programs. We asked program officials for examples 

of how they implemented the key strategies and elements identified through our 

survey and for information on the problems encountered and challenges overcome 

during implementation. In addition, we obtained information on what they perceived 

as possible federal roles related to childhood obesity. The information provided 

reflects the comments of program officials we interviewed and cannot be generalized 

to all programs. In addition, the information provided by program officials does not

reflect all the efforts underway to address childhood obesity or the implementation 

approaches and challenges faced by other programs. 

As part of our review, we also interviewed officials from the Departments of Health

and Human Services, Agriculture, and Education to obtain background information 

about federally funded programs and initiatives, including both current and 

completed programs. In addition, we reviewed documentation provided by these 

agencies regarding their efforts to reduce childhood obesity. We also interviewed 

officials and reviewed documents from the Institute of Medicine and the Robert

Wood Johnson Foundation to obtain background information on childhood obesity

and their efforts to address the issue. 

59 GAO-06-127R Childhood Obesity
Enclosure III Enclosure III 

60 GAO-06-127R Childhood Obesity

Survey on Childhood Obesity
Enclosure III Enclosure III 

61 GAO-06-127R Childhood Obesity
Enclosure III Enclosure III 

62 GAO-06-127R Childhood Obesity
Enclosure III Enclosure III 

63 GAO-06-127R Childhood Obesity
Enclosure III Enclosure III 

64 GAO-06-127R Childhood Obesity
Enclosure III Enclosure III 

65 GAO-06-127R Childhood Obesity
Enclosure III Enclosure III 

66 GAO-06-127R Childhood Obesity
Enclosure IV Enclosure IV 

Data on Program Strategies, Elements, and Outcome Measures Obtained from

GAO Survey on Childhood Obesity

Table 1: Frequencies and Weighted Frequencies of Each Program Strategy

Survey respondent rankings

Possible survey response

Frequency

of each strategy

Weighted

frequency

Reduce sedentary television or screen time 118 116

Promote breastfeeding among expectant mothers 52 13

Promoted increased breastfeeding among nursing

mothers 35 6

Increase physical activity 133 212

Increase financial affordability of nutritious foods 81 50

Increase access to nutritious foods in communities,

homes, etc. 96 52

Improve children's nutritional intake 106 145

Modified buildings, parks, or other spaces created by

people to promote or improve health 101 69

Do not know 2 0

Othera174 170

Source: GAO Survey on Childhood Obesity. 

Note: To determine frequencies, we examined how frequently a particular program strategy was chosen by experts.

To determine the weighted frequencies, we assigned a numeric value to weight the choices ranked as the three most 

important strategies, then calculated an aggregated score based on the weighted frequencies. The numeric value for 

the strategy identified as most, second most, and third most important were 3 points, 2 points, and 1 point, 

respectively.

a

These data include all “other” responses written-in for this question. 

67 GAO-06-127R Childhood Obesity 
Enclosure IV Enclosure IV

Table 2: Frequencies and Weighted Frequencies of Each Program Element 

Survey respondent rankings

Possible survey response

Frequency 

of each element Weighted frequency

Assessment of gathered information to outline need 

for intervention 42 80

Specified target population for the designed 

program 74 94

Specified program goals and objectives that 

describe impact/expected changes 97 186

Use of best practices or substantiated evidence

from other effective programs 105 272

Suitability and acceptability of program to target 

community 100 194

Determination of most appropriate setting for

program to occur 39 9

Integration of program into existing efforts 64 62

Training of staff/volunteers to implement program 71 49

Collaboration with others in community for buy-in 

and ownership 85 110

Presence of program advocate(s) to effect change 52 52

Sufficient financial resources 107 187

Sufficient human resources 103 140

Sufficient program duration to monitor change over

time 93 99

Process evaluation (planned and/or implemented) 78 44

Outcome evaluation (planned and/or implemented) 106 140

Program sustainability 89 122

Do not know 3 4

Othera44 103

Source: GAO Survey on Childhood Obesity. 

Note: To determine frequencies, we examined how frequently a particular element was chosen by experts. To 

determine the weighted frequencies, we assigned a numeric value to weight the choices ranked as the five most 

important elements, then calculated an aggregated score based on the weighted frequencies. The numeric value for 

the element identified as most, second most, third most, fourth most, and fifth most important were 5 points, 4 points, 

3 points, 2 points, and 1 point, respectively. 

a

These data include all “other” responses written-in for this question. 

68 GAO-06-127R Childhood Obesity
Enclosure IV Enclosure IV

Table 3: Frequencies of Outcome Measures 

Survey respondent 

rankings

Possible survey response

Frequency

of each

outcome measure

Body mass index (BMI) 105

Fitness levels (e.g. run-walk times, aerobic capacity) 95

Adiposity 59

Biomarkers (e.g., glucose levels, lipids) 58

Self-reported change in dietary intake 51

Observed change in dietary intake 70

Do not know 2

Othera105

Source: GAO Survey on Childhood Obesity. 

Note: To determine frequencies, we examined how often a particular outcome measure was chosen by experts. 

a

These data include all “other” responses written-in for this question. 

69 GAO-06-127R Childhood Obesity
Enclosure V Enclosure V 

Programs Identified by Surveyed Experts

In a written survey conducted by GAO, experts were asked to provide the names and 

locations of programs they believe have been successful or shown promise in preventing 

or reducing childhood obesity.

1

 GAO did not independently evaluate the programs listed.2

• Action for Healthy Kids, Skokie, Illinois 

• America On the Move, Boston, Massachusetts 

• Apache Healthy Stores Project, New Mexico 

• Balance First, TM Ontario, Canada 

• Be Active North Carolina 

• Bienestar, California 

• Bright Bodies Weight Management, Yale University School of Medicine - New 

Haven, Connecticut 

• Brocodile the Crocodile, New York 

• California Project LEAN (Leaders Encouraging Activity and Nutrition) 

• Cardiovascular Health in Children and Youth Study (CHIC), University of North 

Carolina – Chapel Hill, North Carolina 

• Cartographic Modeling Laboratory, University of Pennsylvania - Philadelphia, 

Pennsylvania 

• *Childhood Weight Control Program, University of Buffalo - Buffalo, New York

• Children's Optimal Weight for Life Program, Children's Hospital Boston, 

Massachusetts

• Color Me Healthy, North Carolina 

• Consortium to Lower Obesity in Chicago Children (CLOCC), Illinois

• Department of Defense’s (DOD) Fresh Produce Program 

• Department of Education’s Carol M. White Physical Education Program 

• Department of Health and Human Services (HHS) - National Institutes of Health’s

(NIH) Coronary Artery Risk Development in Young Adults (CARDIA) study 

• Eat Well & Keep Moving, Baltimore City Public Schools and Harvard School of

Public Health – Boston, Massachusetts 

• Farm Fresh Choice, University of California – Berkeley, California 

• Farm to Schools Program, Occidental College - Los Angeles, California 

• Fitkid Project, Medical College of Georgia – Augusta, Georgia 

• FoodChange, New York, New York 

• Healthy Children Healthy Futures 

• Healthy Living in the Pacific Islands, Honolulu, Hawaii 

• Healthy Start 

• HHS – Centers for Disease Control and Prevention (CDC) School Health Index 

• HHS – CDC’s VERB TM

 1

Program locations are not always included. Programs noted with an asterisk (*) were mentioned by at

least 10 experts. 2

Program names that could not be verified through an internet search were excluded from this list. In

addition, general listings of states, school names, school districts, and hospitals were excluded. 

70 GAO-06-127R Childhood Obesity 
Enclosure V Enclosure V 

• *HHS – NIH’s Child and Adolescent Trial for Cardiovascular Health (CATCH) 

• HHS – NIH’s Girls Health Enrichment Multisite Study (GEMS) 

• HHS – NIH and the National Recreational and Park Association’s Hearts N' Parks

• HHS and Environmental Protection Agency’s National Children's Study 

• HHS’s Head Start 

• HHS’s Steps to a HealthierUS 

• Hip-Hop to Health Program, Chicago, Illinois 

• Ho-Chunk Community Development Corporation, Walthill, Nebraska

• incentaHEALTH Program, Denver, Colorado 

• Kaiser Permanente's Kid Shape®, Oakland, California 

• LEAP: The Live, Eat and Play Study, Royal Children’s Hospital, Melbourne, 

Australia 

• M-SPAN (Middle-School Physical Activity and Nutrition), San Diego State 

University, California 

• New Moves, University of Minnesota – Minneapolis, Minnesota 

• NikeGO / PE2GO, Beaverton, Oregon

• Northwest Schools Obesity Prevention Consortium, University of Washington - 

Seattle, Washington 

• Nutrition and Physical Activity Self Assessment for Child Care (NAP SACC), 

University of North Carolina - Chapel Hill, North Carolina 

• Nutrition Education Aimed at Toddlers (NEAT), Michigan State University - East

Lansing, Michigan 

• Packard Pediatric Weight Control Program, Lucile Packard Children's Hospital at 

Stanford, California 

• Pathways study, University of New Mexico - Albuquerque, New Mexico 

• Physical Best Program, Champaign, Illinois 

• *Planet Health, Harvard Prevention Research Center - Boston, Massachusetts 

• Positive Coaching Alliance, Stanford University, California 

• *Reducing Television Viewing to Prevent Childhood Obesity study, Stanford 

Prevention Research Center 

• Shape Up America! 

• SHAPEDOWN®, University of California – San Francisco, California

• SPARK, San Diego, California 

• Strategies for Metropolitan Atlanta’s Regional Transportation and Air Quality, 

Atlanta, Georgia 

• Student Centered Web-Based Communities: Multi-Disciplinary Approach for 

Adolescent Obesity Prevention, Purdue University - West Lafayette, Indiana 

• TACOS Study, University of Minnesota - Minneapolis, Minnesota

• Take 10!,TM Atlanta, Georgia 

• The California Endowment’s Healthy Eating, Active Communities Initiative 

• The Food Trust, Philadelphia, Pennsylvania 

• The National Black Church Initiative, Washington, D.C. 

• The Nutrition and Fitness for Life Program, Boston Medical Center, 

Massachusetts

71 GAO-06-127R Childhood Obesity 
Enclosure V Enclosure V 

• The Robert Wood Johnson Foundation’s Active Living by Design / Healthy Eating 

by Design, University of North Carolina - Chapel Hill, North Carolina 

• U Move with the Starzz, University of Utah - Salt Lake City, Utah 

• U.S. Department of Transportation’s Safe Routes to School 

• United Way, Alexandria, Virginia 

• Urban Nutrition Initiative (UNI), University of Pennsylvania - Philadelphia, 

Pennsylvania 

• US Department of Agriculture’s (USDA) Breastfeeding Promotion and Support 

• USDA’s Community Supported Agriculture 

• USDA’s Eat Smart. Play Hard.

TM

 

• USDA’s Fit WIC 

• USDA’s Food Stamp Program 

• USDA’s Fruit and Vegetable Pilot Program 

• USDA’s Loving Support Makes Breastfeeding Work 

• USDA’s National School Lunch Program 

• USDA’s Team Nutrition

• Weight Management Program, Louisiana State University - Baton Rouge, 

Louisiana 

• What's for Lunch? program, Brookline, Massachusetts

• WIN the Rockies (Wellness IN the Rockies)

• YMCA Activate America 

72 GAO-06-127R Childhood Obesity 
Enclosure VI Enclosure VI

 Comments from the Department of Health and Human Services 

Now GAO-06-127R. 

73 GAO-06-127R Childhood Obesity
Enclosure VI Enclosure VI

74 GAO-06-127R Childhood Obesity
Enclosure VI Enclosure VI

75 GAO-06-127R Childhood Obesity
Enclosure VII Enclosure VII

GAO Contact and Staff Acknowledgments

GAO Contact 

Cynthia A. Bascetta, (202) 512-7101 or bascettac@gao.gov 

Acknowledgments

In addition to the person named above, Linda T. Kohn, Assistant Director; Jessica Cobert; 

Krister Friday; Emily Gamble Gardiner; Nkeruka Okonmah; and Kimberly A. Scott made key 

contributions to this report.

(290317) 

76 GAO-06-127R Childhood Obesity
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