The State ISSUE REPORT of Obesity: Better Policies for a Healthier America 2017 AUGUST 2017 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and healthcare. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more infor- mation, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook. TFAH would like to thank RWJF for their generous support of this report. TFAH BOARD OF DIRECTORS Gail C. Christopher, DN David Lakey, MD President of the Board, TFAH Chief Medical Officer and Associate Vice President and Founder Chancellor for Population Health Ntianu Center for Healing and Nature The University of Texas System Cynthia M. Harris, PhD, DABT Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA Vice President of the Board, TFAH Executive Director Director and Professor Hogg Foundation for Mental Health at the Institute of Public Health, Florida A&M University University of Texas at Austin Robert T. Harris, MD C. Kent McGuire, PhD Treasurer of the Board, TFAH Program Director of Education Medical Director William & Flora Hewlett Foundation North Carolina Medicaid Support Services Karen Remley, MD, MBA, MPH, FAAP CSC, Inc. CEO/Executive Vice President  Theodore Spencer American Academy of Pediatrics Secretary of the Board, TFAH Eduardo Sanchez, MD, MPH Senior Advocate, Climate Center Chief Medical Officer for Prevention Natural Resources Defense Council American Heart Association David Fleming, MD Umair Shah, MD, MPH Vice President Executive Director and Local Health Authority PATH Harris County Public Health  Stephanie Mayfield Gibson, MD Vince Ventimiglia, JD Senior Physician Adviser and Population Chairman  Health Consultant Leavitt Partners Board of Managers Private Contractor Vice Chairman Leavitt Partners Board of Directors REPORT AUTHORS Laura M. Segal, MA Jack Rayburn, MPH Director of Public Affairs Senior Government Relations Manager Trust for America’s Health Trust for America’s Health Stacy E. Beck, JD Consultant 2 TFAH • RWJF • StateofObesity.org The State of TABLE OF CONTENTS Table of Contents INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . 4 4. chool-Based Physical Activity Programs 49 S Obesity: Obesity Policy a. Physical Education & Physical Activity SECTION 1. The State of Adult Obesity . . . . . 11 Breaks . . . . . . . . . . . . . . . . . . . . . 49 A. Overview . . . . . . . . . . . . . . . . . . . . . . . . 11 b. Recess . . . . . . . . . . . . . . . . . . . . . 50 B. State-by-State Adult Obesity Rates . . . . 16 c. Safe Routes to Schools . . . . . . . . . 51 d. Shared Use . . . . . . . . . . . . . . . . . . 51 series C. National Adult Obesity Rates . . . . . . . . . 17 e. Health Assessments . . . . . . . . . . . 52 D. Inequity and Obesity . . . . . . . . . . . . . . . 20 5. ESSA Implementation . . . . . . . . . . . . . . 52 1. Racial and Ethnic Groups . . . . . . . . . . 20 2. Education and Income . . . . . . . . . . . . 23 6. CDC School-Based Initiatives . . . . . . . . . 53 3. Regional Differences . . . . . . . . . . . . . 24 C. Community Policies & Programs . . . . . . 54 1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . 54 SECTION 2. The State of Childhood Obesity . 26 a. Importance of Place . . . . . . . . . . . . 54 A. Overview . . . . . . . . . . . . . . . . . . . . . . . . 26 b. Food Deserts and Food Swamps . . . 54 B. ational Childhood Obesity Rates N c. Impact of the Environment . . . . . . . 55 (NHANES) . . . . . . . . . . . . . . . . . . . . . . . 29 2. Community-Based Programs . . . . . . . . . 57 C. Early Childhood Obesity Rates (WIC) . . . 31 a. CDC Programs . . . . . . . . . . . . . . . . 58 D. besity Rates in Children Ages 10-17 O b. Fiscal Policies and Innovative (NSCH) . . . . . . . . . . . . . . . . . . . . . . . . . 32 Financing Strategies . . . . . . . . . . 63 E. High School Obesity Rates (YRBSS) . . . . 33 1. Taxes and Subsidies . . . . . . . . . 63 2. Healthy Food Financing Initiative . 64 3. New Markets Tax Credit . . . . . . . 64 SECTION 3. Key Obesity-Prevention Policies . 34 4. Wellness Trusts . . . . . . . . . . . . . 65 A. Early Childhood Policies & Programs . . . 35 5. Pay-for-Performance and Social 1. Nutrition and Physical Activity for Young Impact Bonds . . . . . . . . . . . . . . 66 Children . . . . . . . . . . . . . . . . . . . . . . . . 36 6. Philanthropic Investments . . . . . 66 2. Child and Adult Care Food Program c. HHS, USDA and FDA Obesity-Prevention (CACFP) . . . . . . . . . . . . . . . . . . . . . . . . . 37 and Nutrition Education Initiatives . . 68 3. Child Care and Development Block Grant 1. Dietary Guidelines . . . . . . . . . . . 68 (CCDBG) . . . . . . . . . . . . . . . . . . . . . . . . 38 2. Menu Labeling . . . . . . . . . . . . . 68 4. Head Start . . . . . . . . . . . . . . . . . . . . .39 3. Food Labels . . . . . . . . . . . . . . . 68 5. State Requirements for Early Care and d. Operation Live Well and Healthy Base Education . . . . . . . . . . . . . . . . . . . . . . . 40 Initiative . . . . . . . . . . . . . . . . . . . . 69 6. Every Student Succeeds Act – Early e. Complete Streets . . . . . . . . . . . . . 70 Childhood Education Components . . . . . . 41 f. Nutrition Assistance . . . . . . . . . . . 71 7. WIC . . . . . . . . . . . . . . . . . . . . . . . . . . 42 3. Business Initiatives . . . . . . . . . . . . . . . . . 73 B. School-Based Policies & Programs . . . . . 43 1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . 43 D. Health, Healthcare & Obesity . . . . . . . . . 77 1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . 77 2. Obesity & Academic Achievement . . . . . 43 2. Healthcare Coverage & Programs . . . . . 79 3. School Nutrition . . . . . . . . . . . . . . . . . . . 44 a. Medicare & Medicaid . . . . . . . . . . . 79 a. School Meal Programs . . . . . . . . . . 44 b. Child Obesity-Related Health b. Smart Snacks in Schools . . . . . . . . 46 Provisions . . . . . . . . . . . . . . . . . . 80 c. Summer Food Service Program . . . . 46 c. Healthcare & Hospital Programs . . . 84 d. Water in Schools . . . . . . . . . . . . . . 47 1. Screening Services . . . . . . . . . . . 84 e. Fruit and Vegetable Programs . . . . . 48 2. Fruit, Vegetable and Physical Activity Prescriptions . . . . . . . . . . . . . . . 84 AUGUST 2017 3. Healthy Food Procurement . . . . . 84 4. Community Benefit Programs . . . 85 d. National Diabetes Prevention Program . . . . . . . . . . . . . . . . . . . . . 86 SECTION 4. Recommendations . . . . . . . . . .87 I NT RO D UC TION The State of INTRODUCTIION Introduction Obesity: Obesity is one of the biggest health concerns in communities Obesity Policy across the country, with about 70 percent of county officials Series ranking it as a leading problem where they live. Factors related to obesity are also rated as communities’ priority health issues, including nutrition and physical activity at 58 percent, heart disease and hypertension at 57 percent and diabetes at 44 percent.1 There has been progress to address the Individuals who are obese are at epidemic. After decades of increasing, increased risk for type 2 diabetes, heart the national obesity rate among 2- to disease, some forms of cancer, dementia 19-year-olds has begun to level off and and a number of other health concerns. the rise of obesity among adults has Children who are overweight or obese are slowed over time. Yet obesity remains a at greater risk for high blood pressure, bigger threat to our health and country type 2 diabetes and heart disease. And the now than it was a generation ago. If longer children are overweight or obese, trends continue, children today could the more likely they are to remain so be the first generation to live shorter, into adulthood. At a broader level, high less healthy lives than their parents. obesity rates also have a significant impact on the larger community. Obesity rates vary state-to-state, but remain high nationwide. Across the l besity is a financial issue. The obesity O United States, more than one in three crisis costs our nation more than $150 adults and one in six children (ages billion in healthcare costs annually6 2-19) are obese — and one in 11 young and billions of dollars more in lost children (ages 2-5) are obese.2 Adult productivity.7 The public and officials obesity rates range from a high of 37.7 are rightly concerned about making in West Virginia to a low of 22.3 in sure every taxpayer dollar is spent wisely. Colorado.3 Childhood rates are highest Investing in obesity prevention provides in Mississippi (21.7 percent) and lowest a significant return on investment for in Oregon (9.9 percent).4 Obesity the American taxpayer. Each state and rates also differ from county to county, community is impacted by the cost of and neighborhood to neighborhood. obesity — severe obesity alone costs More than 20 states have counties with state Medicaid programs between $5 adult obesity rates above 40 percent, million in Wyoming and $1.3 billion in including 29 counties in Mississippi California each year.8 Overall obesity- and 14 counties in Alabama. Only two related healthcare costs range from $279 states have counties with adult obesity per person per year in Wyoming to $768 AUGUST 2017 rates below 20 percent: 17 counties in in Oregon.8 Employers want to operate Colorado and one in Massachusetts.5 businesses in places with healthier (Note: County Health Rankings and populations — with a workforce that Roadmaps data are available for every state is more productive and has lower at: http://www.countyhealthrankings.org/.) healthcare costs. l besity is a national security issue. O The obesity crisis also impacts our nation’s military readiness. Being overweight or obese is the leading cause of medical disqualifications, with nearly one-quarter of service applicants rejected for exceeding the weight or body fat standards.9 Obese service members and members of their family who are obese cost the military about $1 billion every year in healthcare costs and lost productivity.9 Mission: Readiness has found that more than 70 percent of today’s youth are not fit to serve in the military due to obesity or being overweight, criminal records, drug misuse or educational deficits.10 l besity is a community safety issue. O With millions of obese and overweight Americans serving as first responders, firefighters, police officers and in other essential community service and protection roles, public safety is at risk. Seventy percent of firefighters are overweight or obese, putting them at risk for cardiovascular events — the leading cause of line-of-duty deaths.11 Police officers have a shorter life expectancy compared with the general population, likely due to their higher- than-average obesity rates.12 l besity is a child development and O l besity is an equity issue. Obesity O academic achievement issue. Obesity- disproportionately affects low-income15 prevention is an investment in our and rural communities16 as well as children’s ability to learn and grow. certain racial and ethnic groups, Childhood obesity is correlated with including Blacks,17 Latinos17 and poor educational performance13 Native Americans.18 Societal inequities and increased risk for bullying and contribute to these disparities. For depression.14 If all kids have the example, in many communities, opportunity to grow up at a healthy children have few safe outdoor spaces weight — a lifestyle that includes to play or accessible routes to walk or nutritious food and plenty of time for bike to school. Their neighborhoods active play — they are more likely to may often be food deserts, having reach their full potential. small food outlets and fast-food TFAH • RWJF • StateofObesity.org 5 restaurants that sell and advertise policies that benefit millions of families unhealthy food and beverages, but and neighborhoods across America. lacking those with fresh and healthy Experts at the Centers for Disease foods at affordable prices. Thus, Control and Prevention (CDC), addressing the obesity epidemic is also National Institutes of Health (NIH), a fight for health equity. U.S. Department of Agriculture (USDA), U.S. Department of Education, l besity is a top national priority. O the Administration for Children Support to Increase Investments to Americans (registered voters) rated and Families (ACF), Food and Drug Improve the Health of Communities by obesity as the top health concern in Administration (FDA), academic Party Affiliation the country in a recent public opinion research centers and state and local survey conducted by the Greenberg, public health agencies across the Quinlan, Rosner Research and country have researched and developed Bellweather Research groups. And 57% 87% top strategies for preventing and nearly three-quarters (73 percent) addressing obesity among children support increasing investments to and adults. These include improving improve the health of communities, Republicans Democrats nutrition standards for the foods and including addressing the obesity crisis beverages offered through the Child and other major health concerns. and Adult Care Food Program (CACFP) Support spans across party lines (57 70% and in schools nationwide. These percent of Republicans, 87 percent agencies also provide the evidence of Democrats and 70 percent of base and technical assistance for every Independents) and regionally across Independents school district in the country to develop the country (75 percent in the effective, strategic, local wellness plans to Northeast, 71 percent in the Midwest, identify “hot spots” where the problems 72 percent in the South and 75 are the most severe, the needs are the percent in the West).19   greatest and where promising efforts Obesity rates have doubled among adults can be most effective. Communities, Signs of Progress in Slowing the and more than tripled among children schools and families around the country Progression of Obesity Rates in Children since the 1980s. In response, health rely on the expert technical assistance, officials have been developing strategies guidance, toolkits and evaluations to counter the trends. There have been demonstrating effective efforts that can signs of progress. Concerted efforts have make a difference to improve health. helped to slow the growth among adults These efforts allow communities to learn (rates remained the same in 45 states and from the best evidence and programs, so Washington, D.C. and declined in one they can build on them for the benefit of 14% of children 5 and under were obese state (Kansas) last year), and childhood their own communities. in 2004 rates have stabilized nationally and even The individual decisions people make declined in some places during the past about eating and activity are not made decade. In fact, obesity rates among in a vacuum. Where families live, children ages 5 and under declined from learn, work and play all have a major nearly 14 percent in 2003-2004 to under impact on the choices they are able to 10 percent in 2013-2014.20 Obesity rates make. Healthy foods are often more among low-income 2- to 4-year-olds have In 2014 the percentage dropped to 10% expensive and less available in some also declined.21 neighborhoods, and finding safe, Federal, state and local agencies play accessible places and having time to a key role in creating and supporting be active can be challenging for many. 6 TFAH • RWJF • StateofObesity.org For instance, most children spend children grow up at a healthy weight significant periods of time in child-care and adults be as healthy as possible at After years of growth, rates and schools where food options may be any weight. While the report focuses on have been stabilizing and beyond the control of their parents. progress and promising policies — it also shows that these approaches have can now move in the right l he most successful approaches T are often comprehensive, localized, not yet received a sufficient level of direction — but only if efforts investment or prioritization to reverse “place-based” efforts — where leaders receive sufficient resources and rates on a large scale. and members of a community build support to move forward. partnerships that bring together public This year’s report shows there is still health and healthcare providers; an urgent need to address the obesity hospitals, schools and universities; crisis — and that the health and child-care providers and centers; financial stakes are too high to allow social service groups; philanthropies; complacency. It also underscores the community-based, faith-based and fact that there is a wide range of efforts community development organizations; that can make a difference. After years and transportation and housing of growth, rates have been stabilizing planners — to assess the priorities and can now move in the right direction within the local area; leverage existing — but only if efforts receive sufficient community resources; and determine resources and support to move forward. the most effective, evidence-based The State of Obesity report series has strategies that can best meet their documented the significant progress needs. Experts have identified a achieved over the past 15 years to reduce range of policies and programs that obesity rates. Evidence-based policies and communities can implement to help practices can make a difference — but make healthy eating and physical they need to be maintained and receive activity part of people’s daily routines, a sufficient level of investment to achieve including improving school nutrition, results. Actions to limit policies and complete streets initiatives, access to reduce funding for obesity-prevention open space, incentives for healthy food efforts will have adverse consequences purchases, food labeling and limits on for the health of Americans. advertising to children. Some key strategies to counter the crisis l he most impactful strategies also T include: typically focus on helping children maintain a healthy weight — since it l S upporting parents, families and is much easier and more effective to caregivers in efforts to offer healthier prevent obesity than to try to reverse food and beverage choices, encourage it later — and to provide adults ample physical activity and serve as with opportunities for improved good examples by spending less time on nutrition and increased physical their screens and more time walking, activity, to be as healthy as possible biking and playing with their children; no matter their weight. l E nsuring healthy food and drink The annual State of Obesity: Better Policies options are available for kids in for a Healthier America report highlights schools and child-care settings — and obesity trends and top strategies, increasing opportunities to be active policies, programs and practices aimed and involved in high-quality physical at reversing the epidemic — to help activity programs; TFAH • RWJF • StateofObesity.org 7 l M aking healthy food options more There are many bright spots to report For example, in New Mexico, the accessible — through efforts like — programs and policies that are nonprofit Healthy Kids, Healthy healthy food financing strategies, making a real difference. For example, nutrition assistance programs, in New Mexico, the nonprofit Healthy Communities (HKHC) partners nutrition education efforts and Kids, Healthy Communities (HKHC) with state and local public farmers’ markets; partners with state and local public health departments, schools and health departments, schools and l P roviding healthcare coverage for obesity other stakeholders to support efforts counseling and services — and strong other stakeholders to support that help children eat well and move preventive healthcare for children; more, serving nearly one in four efforts that help children eat l E ngaging healthcare systems and public elementary school students in well and move more, serving hospitals to support access to services communities with the highest poverty nearly one in four public that promote their patients’ health rates in the state.22 The program beyond doctors’ appointments — such includes supporting Safe Routes to elementary school students in as through ongoing community-based Schools, more high-quality produce communities with the highest programs, coaching and counseling in schools, building physical activity efforts that can reduce healthcare into the school day, making healthier poverty rates in the state. costs and produce better results; foods more available and affordable, especially in rural and remote areas, l E ncouraging smart community and supporting healthier child-care development and design — such settings. The result? An 11.1 percent as land use policies that support decline in overweight and obesity among the development of green space, third-graders and a 15.5 percent decline parks and trails, and Complete among kindergarteners in the state. If Streets initiatives, which hundreds this and other successful efforts were of communities have adopted scaled up, it would dramatically improve nationwide, that promote active living, the health of the nation. including more walkable, mixed-use and recreation-friendly areas; Achieving this goal will require all of society’s institutions — governments, l S upporting the efforts of food and businesses, communities and families beverage companies to produce and — to help. Simply put, communities market healthy, affordable options, all need to work together to invest in and reduce calories, sugar and fat in policies, practices and programs that foods and drinks; and work. Over time, these investments l I ncreasing workplace wellness pay off — in terms of saving lives and programs and employer-involvement healthcare costs. By working together, in supporting community-wide health communities can create a Culture of improvement initiatives, such as Live Health and reduce the obesity epidemic. Well San Diego and NashVitality. 8 TFAH • RWJF • StateofObesity.org NATIONAL OBESITY TRENDS For children and youth: Nationally, childhood obesity rates (ages 2 • 1.4 percent of Latina females 2 to 19) have remained stable for the past and 22.4 percent of Latino males Nationally, childhood obesity decade — at around 17 percent [National are obese. rates have remained stable Health and Nutrition Examination Survey • 20.7 percent of Black females (NHANES), 2011-2014 data].20 for the past decade and 18.4 percent of Black males l S ince 1980, childhood obesity rates are obese. (ages 2 to 19) have tripled — with • 15.1 percent of White females the rates of obese 6- to 11-year-olds and 14.3 percent of White males more than doubling (from 7.0 percent are obese. Obesity Rate for Children Ages 2 to 19 to 17.5 percent) and rates of obese • .3 percent of Asian females and 11.8 5 by Race and Ethnicity teens (ages 12 to 19) quadrupling percent of Asian males are obese. from 5 percent to 20.5 percent.14,23 • mong preschoolers (ages 2 to 5), A [NHANES, 2011-2014 data] Latinos are three times as likely 21.9% 19.5% l O besity rates have also become much (15.6 percent) and Blacks are twice higher starting in earlier ages — 8.9 as likely (10.4 percent) to be obese percent of 2- to 5-year-olds are now than Whites (5.2 percent) and Latinos Blacks obese and approximately 2 percent Asians (5.0 percent). are extremely obese.20 [NHANES, • mong American Indian/Alaska A 2011-2014 data] Native children, 25 percent of 2- to l N early 2 percent of young children 5-year-olds, 31 percent of 6- to 14.7% 8.6% (ages 2 to 5) are extremely obese, 11-year-olds and 31 percent of 12- 4.3 percent of 6- to 11-year olds are to 19-year-olds are obese.24 [Indian Health Service, 2008] Whites Asians extremely obese and 9.1 percent of 12- to 19-year olds are extremely l I n addition, there are also significant obese (body mass index (BMI) at inequities in rates of extreme obesity or above 120 percent of the sex- (BMI at or above 120 percent of the specific 95th percentile on the sex-specific 95th percentile on the CDC BMI-for-age growth charts).20 CDC BMI-for-age growth charts):20 [NHANES, 2011-2014 data] [NHANES, 2011-2014 data] l T here are also significant racial and • lmost 9 percent of Black, 7.6 percent A ethnic inequities. Rates are higher of Latino, 4.4 percent of White and among Latino (21.9 percent) and 1.3 percent of Asian children are Black (19.5 percent) children than extremely obese (ages 2 to 19). among White (14.7 percent) and • mong preschoolers (ages 2 to 5), A Asian (8.6 percent) children (ages Latinos (7.6 percent) and Blacks 2 to 19) — and the rates are higher (8.6 percent) are almost twice as starting at earlier ages and increase likely to be extremely obese than faster.20 [NHANES, 2011-2014 data] Whites (4.4 percent). TFAH • RWJF • StateofObesity.org 9 NATIONAL OBESITY TRENDS For adults: Obesity Rates for Adults by Gender l O besity rates exceeded 35 percent l T here are significant racial and ethnic in five states, 30 percent in 25 inequities. [NHANES, 2013-2014 data] states and 25 percent in 46 states. • besity rates are higher among O 40.4% 35% The lowest rate was 22.3 percent in Blacks (48.4 percent) and Latinos Colorado. [Behavioral Risk Factor (42.6 percent) than among Whites Surveillance System (BRFSS), 2016] (36.4 percent) and Asian Americans Women Men • n 1985, no state had an adult I (12.6 percent).17 obesity rate higher than 15 percent; • he inequities are highest among T Obesity Rates for Adults by Age in 1991, no state was over 20 women: Blacks have a rate of 57.2 percent; in 2000, no state was percent, Latinas of 46.9 percent, over 25 percent; and, in 2006, only Whites of 38.2 percent and Asians Mississippi was above 30 percent. 34.3% 41% of 12.4 percent. For men, Latinos l N ationally, nearly 38 percent of have a rate of 37.9 percent, adults are obese.17 [NHANES, 2013- Blacks of 38.0 percent and Whites 20-39 Years 40-59 Years 2014 data] of 34.7 percent.17 • early 8 percent of adults are N • lack women (16.8 percent) are B extremely obese (BMI greater than or more likely to be extremely obese 38.5% equal to 40.0).17 than White women (9.7 percent).17 • besity rates are higher among O l A nd there are income and/or 60+ Years women (40.4 percent) compared education inequities. to men (35.0 percent).17 Within • early 33 percent of adults who N the last decade (2005 to 2014), Obesity Rates for Adults by Race did not graduate high school the obesity rate among women and Ethnicity were obese compared with 21.5 increased by 5.1 percent, while the percent of those who graduated rate among men only increased by from college or technical college. 1.7 percent. [2008-2010 data] 42.6% 48.4% • omen are also almost twice as W • ore than 33 percent of adults M likely (9.9 percent) to be extremely who earn less than $15,000 per obese compared to men (5.5 Latinos Blacks year are obese compared with percent).17 24.6 percent of those who earned • n addition, rates are the highest I at least $50,000 per year.25 [2008- among middle-age adults (41 2010 data] 36.4% 12.6% percent for 40- to 59-year-olds), compared to 34.3 percent of 20- to 39-year-olds and 38.5 percent of Whites Asians adults ages 60 and older.17 10 TFAH • RWJF • StateofObesity.org SECTI O N 1: The State of SECTION 1: THE STATE OF ADULT OBESITY The State of Adult Obesity Obesity: A. OVERVIEW After years of rapid increases, the growth in America’s adult Obesity Policy obesity rate has started to slow, and even decline, in some series places. On a state level, adult obesity rates increased in four states (Colorado, Minnesota, Washington, and West Virginia), decreased in one state (Kansas), and remained stable in the rest. This supports trends that have shown steadying levels in recent years. Last year was the first time this annual report recorded any declines in adult obesity rates, with four states experiencing declines, and, overtime, growth has started to slow. In 2006, rates increased in 31 states; in 2010, rates increased in 16 states. Yet, obesity remains one of America’s l M ore than 80 percent of Americans most pervasive, expensive and deadly do not eat enough vegetables and health problems. More than one-third more than 70 percent do not eat of U.S. adults are obese (37.9 percent enough fruit.32 as of 2013-2014).23 Obesity increases the l N early half (about 49 percent) risk of developing high blood pressure, of American adults drink a sugar- heart disease, type 2 diabetes, stroke, sweetened beverage on a given day.33 arthritis, liver disease, kidney disease, Alzheimer’s disease, gallbladder disease l M ost Americans exceed the and mental health issues, as well as recommended levels of solid fats, many types of cancer.26 Each year, added sugar and sodium.34 obesity is associated with more than Physical and social environments 100,000 premature deaths.27 Obesity also play a role in the obesity during pregnancy increases the chances epidemic. Communities designed of complications, including gestational for transportation by cars, jobs that diabetes, preeclampsia, cesarean require hours sitting behind a desk, delivery and stillbirth.28,29,30 and entertainment options that revolve The causes of obesity are complex around watching a screen all encourage and include individual, social and a sedentary lifestyle. Meanwhile, environmental factors, but it is clear processed food and sugar-sweetened that most Americans do not eat enough beverages are heavily advertised, and healthy food or get enough physical often less expensive and more readily activity. For example: available than healthier alternatives.35 AUGUST 2017 In many communities, there are no l F ewer than half of American adults grocery stores where residents can buy meet national aerobic guidelines for affordable, nutritious foods. Research physical fitness.31 has shown that there is likely also a genetic susceptibility to obesity, though Indirect costs attributable to obesity also studies have shown that a healthy diet run in the billions due to absenteeism and physical activity can counteract in school and jobs and reduced these risks.36 productivity. One study estimated indirect absenteeism costs to be as much Obesity costs our nation more than $149 as $6.3 billion annually.38 billion in healthcare costs each year.37 WHAT IS OBESITY? Obesity means an amount of body fat that has demonstrated that a high BMI is exceeds the level generally considered strongly correlated with the same negative healthy for a particular height. 39,40 There are health consequences as high body fat, many methods of measuring body fat, some although the association between BMI does of which are expensive and time consuming. vary among ethnic groups. Body mass index, which is inexpensive BMI is a person’s weight in kilograms divided and easy to calculate, is typically used as by his or her height in meters squared. For a proxy. Health officials recommend that measurements in pounds and inches, BMI is individual health assessments should calculated using the following formula: consider other factors as well. Research BMI = ( Weight in pounds (Height in inches) x (Height in inches) ) x 703 Note: In the metric system, BMI is kg / height in meters2 (the 703 is the conversion needed when using pounds and inches.) For adults, BMI levels are associated with the following weight classifications: BMI LEVELS FOR ADULTS AGES 20+ BMI Level Weight Classification Below 18.5 Underweight 18.5-24.9 Normal weight 25.0-29.9 Overweight 30-39.9 Obese 40+ Class 3 obesity* * Also known as severe obesity or morbid obesity. BMI LEVELS FOR CHILDREN AGES 2-19 BMI Level Weight Classification Below 5th percentile Underweight 5th-84.9th percentile Normal weight 85th-94.9th percentile Overweight 95th percentile or above Obese 12 TFAH • RWJF • StateofObesity.org Obesity threatens our military readiness, OBESITY IS COSTLY as well as the number of individuals capable of serving as first responders, The Department of Defense, our nation’s largest employer, spends about firefighters and police officers. In fact, $1.5 billion annually in obesity-related health care costs for current and former service members and their families, as well as costs to replace unfit personnel. being overweight or obese is the leading cause of medical disqualifications, with $ 1.5 23 percent of armed services applicants rejected because of excessive weight or BILLION Lost workdays due to obesity for active military personnel is 658k days per year. 658K DAYS PER YEAR body fat.9 Research has estimated that obese service members cost the Defense In the civilian world, unfit or overweight employees can impact the bottom line. But Department $1.1 billion in medical in our line of work, lives are on the line and our national security is at stake. costs and $105.6 million per year in lost General Richard E. Hawley, U.S. Air Force (Retired) productivity.42 Mission: Readiness — a group consisting of retired admirals and generals — has warned that the obesity IMPROVED NUTRITION AND INCREASED PHYSICAL ACTIVITY CAN BUILD A STRONG NATION crisis threatens the future strength of Healthy eating and physical activity can provide multiple performance our military.10 and health benefits for current and future service members. In the United States, there are two Healthy Eating Benefits • Improved brain function primary instruments at CDC used to • Delayed muscle fatigue If we don’t take steps now to build a track adult obesity rates: • Accelerated recovery from strong, healthy foundation for our young strenuous activity • Improved overall military readiness people, then it will not just be our military 1 he Behavioral Risk Factor T • Sustained health and disease prevention that pays the price -- our nation as a Surveillance System is the source for whole will suffer also. the state-by-state adult obesity data in Physical Activity Benefits Richard R. Jeffries, this report. This survey’s advantages • Improved aerobic and muscular fitness Rear Admiral, U.S. Navy (Retired) and include: (a) it is the largest ongoing • Improved balance and bone health former Medical Officer of the U.S. Marine Corps • Improved joint mobility telephone health survey in the world; • Improved mental health • Reduced risk of falling (b) each state survey is representative • Extended years of active life 277714-B of the population of that state; and May 2017 (c) the survey is conducted annually, so new obesity data are available each year. Downsides of this survey include: FOR MORE INFORMATION PLEASE VISIT: Division of Nutrition, Physical Activity, and Obesity (a) small samples that in some states www.cdc.gov/nccdphp/dnpao prohibit meaningful information collection about particular racial and ethnic groups; and (b) survey NHANES has several advantages: respondents self-report their weight (a) it examines a nationally Nearly 1/4 of armed services and height, which may result in representative sample of Americans reported obesity rates lower than applicants are rejected because ages 2 and older; and (b) it combines actual rates, due to people’s tendency interviews with physical examinations, they are overweight or obese. to underreport their weight and increasing the accuracy of the data. exaggerate their height.43 A downside of the survey is the delay 2 he National Health and Nutrition T between collection and reporting. For Examination Survey is the source for example, the most recent published the national adult obesity data in this obesity rates from the NHANES are report, and also measures childhood from 2013-2014. obesity rates. As a survey instrument, TFAH • RWJF • StateofObesity.org 13 CHART ON OBESITY AND OVERWEIGHT RATES ADULTS Obesity Overweight & Obesity Diabetes Physical Inactivity Hypertension (BRFSS 2016 Data) (BRFSS 2016 Data) (BRFSS 2016 Data) (BRFSS 2016 Data) (BRFSS 2015 Data) Percent of Percent of Adults Precent of Percent of Obese Percent of Adults Overweight and Who are Physically Adults Who have States Adults Ranking Ranking with Diabetes Ranking Ranking Ranking Obese Adults Inactive Hyptertension (95% C.I.) (95% C.I.) (95% C.I.) (95% C.I.) (95% C.I.) Alabama 35.7 (+/- 1.6) 3 69.5 (+/- 1.5) 3 14.6 (+/- 1.0) 2 29.4 (+/- 1.4)** 6 40.4 (+/-1.5) 3 Alaska 31.4 (+/- 2.9) 20 66.7 (+/- 2.9) 20 7.5 (+/- 1.4) 49 19.1 (+/- 2.7) 44 27.5 (+/-2.2) 48 Arizona 29.0 (+/- 1.5) 29 63.2 (+/- 1.7) 38 10.8 (+/- 0.8) 21 23.1 (+/- 1.4) 26 30.8 (+/-1.4) 27 Arkansas 35.7 (+/- 2.4) 3 68.2 (+/- 2.4) 11 13.5 (+/- 1.4) 4 32.5 (+/- 2.3) 1 39.3 (+/-2.2) 4 California 25.0 (+/- 1.1) 47 61.0 (+/- 1.2) 45 10.2 (+/- 0.7) 29 20.5 (+/- 1.0) 36 28.5 (+/-1.0) 46 Colorado 22.3 (+/- 0.9)* 51 58.1 (+/- 1.1) 49 6.6 (+/- 0.4) 51 15.8 (+/- 0.8)** 50 25.7 (+/-1.1) 50 Connecticut 26.0 (+/- 1.2) 42 61.8 (+/- 1.4) 43 9.8 (+/- 0.7) 30 21.3 (+/- 1.1)** 33 30.4 (+/-1.1) 30 Delaware 30.7 (+/- 2.1) 23 68.0 (+/- 2.2) 13 10.6 (+/- 1.2) 23 26.6 (+/- 1.8) 14 34.5 (+/-2.0) 12 D.C. 22.6 (+/- 1.7) 50 53.4 (+/- 2.2) 51 7.7 (+/- 0.8) 48 16.2 (+/- 1.5)** 49 29.4 (+/-2.5) 41 Florida 27.4 (+/- 1.0) 36 63.2 (+/- 1.1) 38 11.8 (+/- 0.7) 11 29.8 (+/- 1.0)* 3 33.5 (+/-1.3) 16 Georgia 31.4 (+/- 1.7) 20 65.8 (+/- 1.8) 24 12.1 (+/- 1.0) 8 29.4 (+/- 1.6) 6 36.2 (+/-1.8) 9 Hawaii 23.8 (+/- 1.4) 48 57.6 (+/- 1.6) 50 10.5 (+/- 0.9)* 25 20.8 (+/- 1.3) 34 32.0 (+/-1.5) 23 Idaho 27.4 (+/- 1.8) 36 64.5 (+/- 2.0) 32 8.9 (+/- 1.0) 40 20.2 (+/- 1.5) 38 31.2 (+/-1.7) 25 Illinois 31.6 (+/- 1.7) 18 65.0 (+/- 1.8) 28 10.4 (+/- 1.0) 27 23.9 (+/- 1.5) 21 30.8 (+/-1.5) 27 Indiana 32.5 (+/- 1.3) 10 67.2 (+/- 1.4) 16 11.5 (+/- 0.7) 13 26.8 (+/- 1.2)** 13 32.4 (+/-1.6) 21 Iowa 32.0 (+/- 1.5) 13 68.7 (+/- 1.5) 7 9.3 (+/- 0.7) 36 22.7 (+/- 1.2)** 30 30.6 (+/-1.4) 29 Kansas 31.2 (+/- 1.1)** 22 66.7 (+/- 1.2) 20 9.4 (+/- 0.6) 34 23.5 (+/- 1.0)** 23 31.6 (+/-0.7) 24 Kentucky 34.2 (+/- 1.5) 7 69.1 (+/- 1.5) 5 13.1 (+/- 0.9) 5 29.8 (+/- 1.4)** 3 39.0 (+/-1.6) 6 Louisiana 35.5 (+/- 2.1) 5 69.2 (+/- 2.1) 4 12.1 (+/- 1.2) 8 29.1 (+/- 2.0)** 8 39.3 (+/-1.8) 4 Maine 29.9 (+/- 1.4) 26 65.2 (+/- 1.5) 27 10.6 (+/- 0.8) 23 20.6 (+/- 1.2)** 35 34.1 (+/-1.3) 14 Maryland 29.9 (+/- 1.1) 26 64.6 (+/- 1.2) 31 10.8 (+/- 0.6) 21 23.1 (+/- 1.0) 26 32.5 (+/-1.6) 19 Massachusetts 23.6 (+/- 1.3) 49 60.2 (+/- 1.6) 48 9.3 (+/- 0.8) 36 20 (+/- 1.2)** 39 29.6 (+/-1.2) 38 Michigan 32.5 (+/- 1.1) 10 67.5 (+/- 1.1) 14 11.2 (+/- 0.7) 17 23.9 (+/- 1.0)** 21 33.1 (+/-1.2) 18 Minnesota 27.8 (+/- 0.8)* 34 64.8 (+/- 0.9)* 30 8.4 (+/- 0.5)* 43 18 (+/- 0.7)** 46 26.3 (+/-0.8) 49 Mississippi 37.3 (+/- 1.9) 2 71.3 (+/- 1.8) 1 13.6 (+/- 1.1) 3 30.3 (+/- 1.7)** 2 42.4 (+/-1.8) 2 Missouri 31.7 (+/- 1.7) 17 67.2 (+/- 1.8) 16 11.5 (+/- 1.0) 13 24.9 (+/- 1.5) 18 34.1 (+/-1.5) 14 Montana 25.5 (+/- 1.6) 44 62.7 (+/- 1.9) 40 8.1 (+/- 0.8) 46 19.9 (+/- 1.4)** 41 29.1 (+/-1.5) 45 Nebraska 32.0 (+/- 1.2) 13 68.5 (+/- 1.3) 9 8.8 (+/- 0.6) 41 22.4 (+/- 1.0)** 31 29.9 (+/-1.0) 34 Nevada 25.8 (+/- 2.0) 43 62.3 (+/- 2.3) 42 11.1 (+/- 1.2) 19 24.7 (+/- 1.9) 19 28.3 (+/-2.4) 47 New Hampshire 26.6 (+/- 1.6) 40 63.5 (+/- 1.9) 36 9.0 (+/- 0.8) 39 19.3 (+/- 1.3)** 43 29.2 (+/-1.4) 44 New Jersey 27.4 (+/- 1.7) 36 63.8 (+/- 1.8) 34 9.2 (+/- 0.9) 38 29.8 (+/- 1.6)* 3 30.9 (+/-1.3) 26 New Mexico 28.3 (+/- 1.8) 33 64.9 (+/- 1.9) 29 11.6 (+/- 1.1) 12 20.3 (+/- 1.5)** 37 30.0 (+/-1.5) 33 New York 25.5 (+/- 1.0) 44 60.8 (+/- 1.2) 46 10.5 (+/- 0.6) 25 26.3 (+/- 1.0)** 15 29.3 (+/-1.0) 43 North Carolina 31.8 (+/- 1.5) 16 66.8 (+/- 1.5) 19 11.3 (+/- 0.9) 15 23.3 (+/- 1.3)** 24 35.2 (+/-1.4) 11 North Dakota 31.9 (+/- 1.6) 15 68.1 (+/- 1.7) 12 8.6 (+/- 0.8) 42 22.2 (+/- 1.4)** 32 30.4 (+/-1.6) 30 Ohio 31.5 (+/- 1.3) 19 66.3 (+/- 1.4) 22 11.1 (+/- 0.7) 19 25.9 (+/- 1.2) 16 34.3 (+/-1.4) 13 Oklahoma 32.8 (+/- 1.6) 9 68.8 (+/- 1.6) 6 12 (+/- 0.9) 10 28.5 (+/- 1.4)** 9 36.2 (+/-1.6) 9 Oregon 28.7 (+/- 1.5) 31 62.6 (+/- 1.6) 41 9.5 (+/- 0.9) 33 17.2 (+/- 1.2) 48 30.1 (+/-1.5) 32 Pennsylvania 30.3 (+/- 1.5) 25 65.4 (+/- 1.6) 26 11.3 (+/- 1.0) 15 22.9 (+/- 1.3)** 29 32.5 (+/-1.6) 19 Rhode Island 26.6 (+/- 1.8) 40 63.7 (+/- 2.0) 35 9.8 (+/- 1.0) 30 24.4 (+/- 1.6)** 20 32.4 (+/-1.6) 21 South Carolina 32.3 (+/- 1.3) 12 67.4 (+/- 1.3) 15 13 (+/- 0.8)* 6 26.9 (+/- 1.2) 12 37.8 (+/-1.2) 8 South Dakota 29.6 (+/- 2.1) 28 66.9 (+/- 2.3) 18 7.9 (+/- 1.0) 47 18.9 (+/- 1.7)** 45 29.9 (+/-1.7) 34 Tennessee 34.8 (+/- 1.8) 6 68.6 (+/- 1.8) 8 12.7 (+/- 1.0) 7 28.4 (+/- 1.6) 11 38.5 (+/-1.8) 7 Texas 33.7 (+/- 1.7) 8 68.4 (+/- 1.7) 10 11.2 (+/- 1.0) 17 25.2 (+/- 1.5)** 17 29.5 (+/-1.3) 40 Utah 25.4 (+/- 1.1) 46 60.4 (+/- 1.3) 47 7.2 (+/- 0.6) 50 15.7 (+/- 0.9)** 51 23.6 (+/-0.9) 51 Vermont 27.1 (+/- 1.6) 39 61.7 (+/- 1.8) 44 8.4 (+/- 0.8) 43 19.5 (+/- 1.3)** 42 29.4 (+/-1.4) 41 Virginia 29.0 (+/- 1.3) 29 65.5 (+/- 1.4) 25 10.4 (+/- 0.7) 27 23.3 (+/- 1.2)** 24 33.2 (+/-1.3) 17 Washington 28.6 (+/- 1.0)* 32 63.5 36 9.4* 34 17.6** 47 29.7 (+/-0.9) 37 West Virginia 37.7 (+/- 1.4)* 1 70.9 (+/- 1.3) 2 15 (+/- 0.9) 1 28.5 (+/- 1.2)** 9 42.7 (+/-1.5) 1 Wisconsin 30.7 (+/- 1.7) 23 66.2 (+/- 1.9) 23 9.8 (+/- 1.0)* 30 20 (+/- 1.5) 39 29.6 (+/-1.5) 38 Wyoming 27.7 (+/- 2.0) 35 64.2 (+/- 2.3) 33 8.3 (+/- 1.0) 45 23.1 (+/- 1.9)** 26 29.9 (+/-1.8) 34 Note: For rankings, 1 = Higest rate and 51 = Lowest rate; Red and * indicates state rate between 2015 and 2016 has significantly increased; Green and ** indicates state rate between 2015 and 2016 has significantly decrease; C.I. = Confidence Intervals. If not referenced, confidence intervals could not be calculated Source: Behavioral Risk Factor Surveillance (BRFSS), CDC 14 TFAH • RWJF • StateofObesity.org AND RELATED HEALTH INDICATORS IN THE STATES CHILDREN AND ADOLESCENTS Young Children Food Insecurity Ages 2 to 4: Children and Teenagers Ages 6 to 17: Obesity and High School Students: Obesity, Overweight, Physical Activity (USDA 2013- Obesity (WIC PC Physical Activity (NSCH 2016 Data) (YRBS 2015 Data) 2015 Data) 2012 Data) Percent of Obese Percent of Obese Percent of Children Ages Percentage of Percentage of Percentage of High School Percent of Low-Income or Overweight Ranking 60 Minutes of Physical Obese High School School Students 6-11 Participating in Overweight High Students Who Were Households with States Children Ages 2-4 Children Ages Students Physically Active At Least Food Insecurity, (95% C.I.) 10-17 Activity Everyday (95% C.I.) (95% C.I.) 60 Minutes on All 7 Days Average Alabama 15.6 (+/- 0.4) 35.5 6 40.0 16.1 (+/- 2.8) 17.5 (+/-2.4) 25.4 (+/- 3.2) 17.7 Alaska 20.6 (+/- 0.9) 26.3 42 31.7 14.0 (+/- 2.3) 16.7 (+/-2.2) 20.9 (+/- 2.3) 13.9 Arizona 14.9 (+/- 0.3) 26.9 40 22.9 10.9 (+/- 2.3) 14.7 (+/-1.8) 26.0 (+/- 3.4) 15.8 Arkansas 14.6 (+/- 0.4) 33.9 9 29.6 18.0 (+/- 2.0) 18.0 (+/-3.0) 28.6 (+/- 3.2) 18.4 California 17.6 (+/- 0.1) 31.2 24 30.5 13.9 (+/- 2.8) 16.5 (+/-3.0) 25.3 (+/- 3.8) 12.5 Colorado 8.9 (+/- 0.3) 27.2 36 28.8 N/A N/A N/A 12.2 Connecticut 16.6 (+/- 0.5) 30.2 29 32.2 12.3 (+/- 2.3) 14.3 (+/-2.0) 25.3 (+/- 2.7) 12.2 Delaware 16.9 (+/- 0.8) 30.9 25 29.5 15.8 (+/- 1.7) 15.8 (+/-2.0) 24.7 (+/- 2.3) 12.1 D.C. 14.4 (+/- 1.0) 33.8 11 23.8 N/A N/A N/A 12.6 Florida 13.7 (+/- 0.2) 36.6 4 32.5 12.3 (+/- 1.1) 14.5 (+/-1.1) 24.1 (+/- 1.6) 15.1 Georgia 13.4 (+/- 0.3) 32.2 18 36.4 N/A N/A N/A 16.2 Hawaii 10.2 (+/- 0.5) 25.5 44 25.1 12.9 (+/- 2.1) 15.3 (+/-1.4) 20.3 (+/- 1.6) 12.8 Idaho 11.8 (+/- 0.5) 26.0 43 30.8 11.1 (+/- 2.2) 15.3 (+/-2.0) 29.6 (+/- 3.2) 14.0 Illinois 15.9 (+/- 0.2) 27.0 39 31.2 12.6 (+/-1.9) 15.4 (+/-1.4) 26.8 (+/- 2.7) 11.7 Indiana 14.7 (+/- 0.3) 33.9 9 36.3 13.6 (+/-1.9) 17.3 (+/-3.0) 25.3 (+/- 2.6) 14.4 Iowa 15.1 (+/- 0.4) 29.9 30 26.0 N/A N/A N/A 12.0 Kansas 13.1 (+/- 0.4) 30.9 25 32.0 N/A N/A N/A 13.2 Kentucky 13.5 (+/- 0.4) 33.5 14 30.2 18.5 (+/-2.2) 17 (+/-2.7) 20.2 (+/- 3.3) 15.8 Louisiana 13.8 (+/- 0.4) 34.0 8 25.4 N/A N/A N/A 16.9 Maine 14.9 (+/- 0.7) 28.2 34 36.0 13.3 (+/-1.5) 14.9 (+/- 0.9) 21.6 (+/- 1.3) 14.8 Maryland 16.2 (+/- 0.4) 33.6 13 27.1 11.5 (+/-0.5) 14.9 (+/- 0.5) 19.5 (+/- 0.5) 11.4 Massachusetts 16.9 (+/- 0.4) 26.6 41 28.1 11.0 (+/-1.7) 15.3 (+/- 1.8) 24.1 (+/- 2.8) 10.3 Michigan 13.9 (+/- 0.2) 32.0 19 32.3 14.3 (+/-1.8) 16.0 (+/- 1.9) 24.6 (+/- 3.8) 15.1 Minnesota 12.2 (+/- 0.3) 27.7 35 32.6 N/A N/A N/A 9.9 Mississippi 14.8 (+/- 0.4) 37.0 3 34.3 18.9 (+/-2) 17.1 (+/- 1.4) 21.2 (+/- 2.7) 21.5 Missouri 13.5 (+/- 0.3) 29.4 32 29.6 13.1 (+/- 3.6) 13.3 (+/- 2.3) 26.0 (+/- 4.2) 15.6 Montana 11.3 (+/- 0.7) 23.2 48 30.3 10.3 (+/- 1.2) 15.0 (+/- 0.9) 28.7 (+/- 1.7) 13.0 Nebraska 17.2 (+/- 0.6) 29.2 33 36.4 13.0 (+/- 2.1) 16.9 (+/-1.9) 29.7 (+/- 2.9) 12.3 Nevada 12.9 (+/- 0.4) 30.5 28 31.0 12.2 (+/- 2.1) 15.0 (+/- 2.4) 28.6 (+/- 2.9) 13.7 New Hampshire 14.8 (+/- 0.9) 23.8 47 30.1 12.2 (+/- 2.5) 14.5 (+/- 1.1) 22.3 (+/- 1.1) 9.7 New Jersey 16.8 (+/- 0.3) 31.7 21 24.7 N/A N/A N/A 10.8 New Mexico 13.5 (+/- 0.5) 24.9 46 31.8 15.6 (+/- 0.9) 16.2 (+/- 1.1) 30.9 (+/- 1.8) 16.0 New York 15.1 (+/- 0.2 31.8 20 22.9 13.1 (+/- 1.6) 13.9 (+/- 1.5) 23.3 (+/- 2.5) 12.6 North Carolina 13.5 (+/- 0.3) 30.9 25 32.5 16.4 (+/- 2.9) 15.9 (+/- 2.7) 24.3 (+/- 1.5) 16.5 North Dakota 14.0 (+/- 1.0) 37.1 2 34.8 14.0 (+/- 2.0) 14.7 (+/- 1.6) 25.4 (+/- 2.5) 7.7 Ohio 13.0 (+/- 0.2) 33.1 16 34.9 N/A N/A N/A 16.0 Oklahoma 15.0 (+/- 0.4) 33.8 11 30.8 17.3 (+/- 3.1) 15.3 (+/- 2.3) 32.2 (+/- 2.9) 16.2 Oregon 15.9 (+/- 0.4) 20.3 50 29.7 N/A N/A N/A 14.2 Pennsylvania 13.1 (+/- 0.3) 31.7 21 30.8 14.0 (+/- 1.8) 15.8 (+/- 1.6) 24.8 (+/- 2.5) 13.1 Rhode Island 16.7 (+/- 0.8) 36.3 5 28.2 12.0 (+/- 2.4) 14.7 (+/- 1.8) 20.3 (+/- 2.5) 12.5 South Carolina 12.6 (+/- 0.3) 32.9 17 31.3 16.3 (+/- 1.9) 18.2 (+/- 1.1) 23.6 (+/- 3.6) 15.3 South Dakota 14.8 (+/- 0.8) 31.4 23 31.9 14.7 (+/- 2.7) 14.5 (+/- 2.7) 28.1 (+/- 3.9) 12.1 Tennessee 15.3 (+/- 0.3) 37.7 1 29.6 18.6 (+/- 2.0) 17.1 (+/- 1.2) 25.9 (+/- 1.8) 15.4 Texas 15.9 (+/- 0.1) 33.3 15 23.8 N/A N/A N/A 15.7 Utah 8.7 (+/- 0.4) 19.2 51 21.9 N/A N/A N/A 13.1 Vermont 13.7 (+/- 0.9) 22.2 49 39.7 12.4 (+/- 0.5) 14.0 (+/- 0.5) 23.1 (+/- 0.6) 11.9 Virginia 20.1 (+/- 0.4) 27.2 36 29.9 13.0 (+/- 1.8) 15.1 (+/- 1.6) 25.1 (+/- 2.3) 11.2 Washington 14.3 (+/- 0.3) 25.5 44 33.7 N/A N/A N/A 12.8 West Virginia 14.1 (+/- 0.6) 35.1 7 32.1 17.9 (+/- 3.1) 17.0 (+/- 2.1) 25.8 (+/- 2.7) 14.9 Wisconsin 15.2 (+/- 0.3) 29.5 31 32.5 N/A N/A N/A 11.0 Wyoming 10.6 (+/- 0.9) 27.1 38 29.2 11.0 (+/- 1.6) 14.6 (+/- 1.6) 27.1 (+/- 2.4) 12.3 Note: C.I. = Confidence Note: For ranking, 1 = Highest rate and 51 = Lowest rate. Note: C.I. = Confidence Intervals. Source: Calculated by USDA, Intervals Source: National Survey of Children’s Health (NSCH), 2016 data. Confi- Source: Youth Risk Behavior Survey (YRBS) 2015, CDC. YRBS data are collected every 2 Economic Research Service Source: USDA, Women, dence intervals and additional information can be found online: http:// years. Percentages are as reported on the CDC website and can be found at: http://www. using data from the Current Infants, and Children www.childhealthdata.org/browse/survey/allstates?q=4568; http:// cdc.gov/HealthyYouth/yrbs/index.htm. Population Survey Food Security Participant and Program childhealthdata.org/browse/survey/allstates?q=4551 Supplement. Characteristics (WIC PC), 2012. TFAH • RWJF • StateofObesity.org 15 B. STATE-BY-STATE ADULT OBESITY RATES The two maps below illustrate the major to the survey in 2011, which do not allow growth in state obesity rates between 1993, for direct comparisons. However, these when the BRFSS became a nationwide maps reflect trends confirmed by other surveillance system, and 2017. Note that surveys, which all show large increases in CDC made some methodological changes obesity rates over the past 25 years. TRENDS IN OBESITY AMONG U.S. ADULTS BMI >30 = Obese, or about 30lbs overweight for 5’4” person Interactive maps and timelines for all years are available at stateofobesity.org 1993–1995 Combined Data WA MT ND MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA n No Data n <10% FL AK n >10% & <15% HI n >15% & <20% n >20% <25% n >25% <30% n >30% 2016 Adult Obesity Rates WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD CA DC OK TN NC NM AR AZ SC MS AL GA TX LA n >20% to <25% FL n >25% to <30% AK n >30% to <35% HI n >35% to <40% Territory Obesity Rate Guam 28.3 Source: CDC, BRFSS Puerto Rico 30.7 16 TFAH • RWJF • StateofObesity.org C. NATIONAL ADULT OBESITY RATES Nationally, 37.9 percent of American Obesity rates vary by sex, age and adults were obese in 2013-14 (NHANES).17 other characteristics. The obesity More than 70% of American Rates of extreme or severe obesity are 7.7 rate is higher among women (40.4 adults are obese or overweight. percent, and more than 70 percent are percent) than men (35.0 percent); overweight or obese. women also have higher rates of class 3 obesity (9.9 percent vs. 5.5 percent After decades of increases, rates stabilized for men).17 In 2011-2014, middle- during the time period between 2003-2004 aged Americans (ages 40-59) had the and 2011-12, and grew slightly among highest obesity rate of any age group women from 2011-12 to 2013-14 (using at 41.0 percent, followed by seniors measures of statistical significance).17 (ages 60 and older) at 38.5 percent, Obesity rates had nearly tripled since CDC and then young adults (ages 20-39) at first began tracking them in 1960, and 34.3 percent. have doubled since the 1980s.44 Trends in obesity prevalence among adults aged 20 and over (age-adjusted) and youth aged 2–19 years: United States, 1999–2000 through 2013–2014 40 37.7 Adults1 35.7 34.9 34.3 33.7 30 32.2 30.5 30.5 Percent 20 Youth1,2 17.1 16.8 16.9 16.9 17.2 15.4 15.4 13.9 10 0 1999–2000 2001–2002 2003–2004 2005–2006 2007–2008 2009–2010 2011–2012 2013–2014 Survey years 1 Significant increasing linear trend from 1999–2000 through 2013–2014. 2 Test for linear trend for 2003–2004 through 2013–2014 not significant (p>0.05) NOTE: All adult estimates are age-adjusted by the direct method to the 2000 U.S. census population using the age groups 20–39, 40–59, and 60 and over. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey. TFAH • RWJF • StateofObesity.org 17 WHY ARE REPORTED NATIONAL OBESITY RATES HIGHER THAN STATE-BY-STATE RATES? How is it that only five states have are more likely to misreport their weight obesity rates exceeding 35 percent, and/or height. For example, one study yet the national obesity rate is 37.7 found rural Blacks are more likely percent? This paradox is explained than rural Whites to misperceive their by the fact that people do not always weight.46 Another study of adolescents accurately report their height and weight. found that females underreported their weight more than males, and overweight State obesity rates are collected individuals underestimated their weight by the BRFSS, which relies on self- more than non-overweight individuals.47 reported height and weight. Research has demonstrated that respondents The NHANES survey, from which tend to overestimate their height the national obesity rate is derived, and underestimate their weight.43 calculates its obesity rate based on In fact, one study found that, due to physical examinations of respondents. this phenomenon, the BRFSS may Accordingly, the higher rates reflected underestimate obesity rates by nearly by the NHANES survey are likely a more 10 percent.45 There is also research accurate reflection of the true extent of indicating that certain groups of people the obesity epidemic. 18 TFAH • RWJF • StateofObesity.org ADULT OBESITY RATES BY AGE RANGE Obesity Rates for Young Adults (18- to 24-year-olds) BRFSS 2016 WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC Obesity Rates for Baby Boomers (45- to 64-year-olds) BRFSS 2016 NM AR AZ SC MS AL GA WA ND MT TX LA MN VT ME SD WI OR ID NH FL WY MI NY AK IA MA NE PA RI HI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA FL AK HI Obesity Rates for Seniors (65+ year-olds) BRFSS 2016 WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD CA DC n >10% to <15% n >25% to <30% n >40% <45% OK TN NC AZ NM AR SC n >15% to <20% n >30% to <35% n Data not available MS AL GA TX LA n >20% to <25% n >35% to <40% FL AK HI 50 20 and over 20–39 40–59 60 and over Prevalence of obesity among adults 44.6 ages 20 and over, by sex and age: 41.0 40.4 United States, 2013–2014 40 39.4 37.7 38.5 37.2 37.5 37.0 34.3 35.0 31.6 30 Percent 20 NOTES: Totals were age-adjusted by the direct method to the 2000 U.S. census population using the age groups 10 20–39, 40–59, and 60 and over. Crude estimates are 37.9% for all, 35.2% for men, and 40.5% for women. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2013–2014. 0 All Men Women TFAH • RWJF • StateofObesity.org 19 D. INEQUITY AND OBESITY Obesity disproportionately OBESITY BY RACE/ETHNICITY — 2013-2014 DATA17 affects different communities Race/Ethnicity Obesity Rate Asian* 12.6% — including communities of Black* 48.4% color, communities with high Latino** 42.6% levels of poverty, and adults White* 36.4% with lower education levels. * Black, White and Asian rates are for non-Hispanic members of each race. ** Persons of Hispanic origin may be of any race. 1. Racial and Ethnic Groups Obesity rates vary widely among Broken down by sex and race/ethnicity, racial/ethnic groups, with Latinos and Black women have the highest obesity Blacks having significantly higher rates rates at 57.2 percent, while than Whites and Asians. According to the Asian-American women have the lowest most recent national data (2013-2014, rates at 12.4 percent. Below are obesity age adjusted), obesity rates are:17 rates by sex and race/ethnic origin. l Asian — 12.6 percent l Black — 48.4 percent l Latino — 42.6 percent l White — 36.4 percent Obesity and Extreme Obesity Rates for Adults, National Health and Nutrition Examination Survey (NHANES), 2013-201417 (with Native American/Alaska Native Rates per 2014 National Health Interview Survey48) Both Genders Men Women 80 70 60 57.2% 50 48.4% 46.9% 42.3% 7.1% 40 38.0% 37.9% 38.2% 36.4% 34.7% 30 20 16.8% 12.6% 12.4% 12.6 12.4% 10 8.7% 9.7% 7.1% ■ 7.6% 7.2% ■ N/A Unknown ■ N/A 5.4% 5.6% ■ N/A 0 Asian* Black* Hispanic** Native White* Asian* Black* Hispanic** White* Asian* Black* Hispanic** White* American/ ■ Obese ■ Extreme Obese Alaska Native ■ Obese ■ Extreme Obese ■ Obese ■ Extreme Obese * Black, White and Asian rates are for non-Hispanic members of each race. N/A data only included 2 participants. ** Persons of Hispanic origin may be of any race. 20 TFAH • RWJF • StateofObesity.org RACIAL AND ETHNIC INEQUITIES AND OBESITY OBESITY RATES BY AGE AND ETHNICITY Obesity Rates by Age — BRFSS 2016 Obesity Rates by Ethnicity — BRFSS 2016 Obesity Among Obesity Among 18-24 Year Olds 25-44 Year Olds 45-64 Year Olds 65+ Year Olds Obesity Among Blacks Latinos Whites Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank Percent Obese, Rank 2016 (95% C.I.) 2016 (95% C.I.) 2016 (95% C.I.) 2016 (95% C.I.) 2016 (95% C.I.) 2016 (95% C.I.) 2016 (95% C.I.) Alabama 22.6 6 38.2 3 42.1 (+/- 2.5) 3 29.6 (+/- 2.5) 20 44.1 (+/- 1.9) 5 28.1 38 32.4 (+/- 1) 5 Alaska 15.1 36 35.4 (+/- 5.6) 8 32.5 (+/- 4.1) 36 35.3 (+/- 7.2) 1 43.6 6 27.9 40 28.7 (+/- 1.5) 27 Arizona 14.4 42 31.3 24 35.1 (+/- 2.4) 23 25.9 (+/- 1.8) 36 33.1 34 35.0 (+/- 2.2) 9 26.0 (+/- 0.9) 37 Arkansas 28.6 (+/- 9.8) 1 38.4 (+/- 5) 2 41.1 (+/- 3.5) 3 27.6 (+/- 2.8) 32 44.2 (+/- 4) 4 32.4 (+/- 7.6) 15 34.0 (+/- 1.4) 2 California 14.5 (+/- 2.5) 40 25.4 (+/- 1.9) 45 29.6 (+/- 1.9) 47 23.5 (+/- 2.4) 49 31.0 (+/- 2.9) 39 32.3 (+/- 1.2) 17 22.7 (+/- 0.8) 48 Colorado 12.8 48 21.9 49 26.9 (+/- 1.5) 51 21.0 (+/- 1.4) 50 29.1 45 27.1 42 19.8 (+/- 0.6) 49 Connecticut 13.4 (+/- 3.7) 46 27.0 (+/- 2.7) 39 30.3 (+/- 1.8) 43 24.9 (+/- 1.7) 44 37.7 (+/- 3) 19 30.3 (+/- 2.4) 31 24.3 (+/- 0.8) 45 Delaware 19.3 14 30.9 (+/- 4.2) 27 34.8 (+/- 3.4) 27 30.4 (+/- 3.2) 14 36.5 (+/- 3.2) 27 32.1 (+/- 4.8) 19 29.4 (+/- 1.4) 21 D.C. 11.6 (+/- 5.1) 50 21.1 (+/- 2.8) 51 29.1 (+/- 2.7) 48 24.0 (+/- 3.4) 47 35.5 (+/- 2.1) 29 20.0 (+/- 5.6) 49 9.7 (+/- 1.4) 51 Florida 14.9 38 28.3 33 32.1 (+/- 1.8) 38 25.8 (+/- 1.7) 38 35.2 30 26.8 43 25.7 (+/- 0.8) 39 Georgia 17.3 24 31.7 22 37.1 (+/- 2.8) 16 31.0 (+/- 2.7) 7 37.7 (+/- 2.1) 20 28.4 36 28.9 (+/- 1.2) 25 Hawaii 13.9 44 27.9 35 28.3 (+/- 2.2) 49 16.0 (+/- 2) 51 31.3 38 31.4 (+/- 3.1) 21 17.6 (+/- 1.4) 50 Idaho 21.4 9 25.9 (+/- 3.5) 42 32.8 (+/- 3.0) 34 25.2 (+/- 2.6) 41 N/A N/A 33.6 (+/- 4.5) 11 27.6 (+/- 1.1) 32 Illinois 17.3 24 31.4 (+/- 3.3) 23 37.5 (+/- 2.8) 13 30.8 (+/- 2.9) 11 41.3 (+/- 3.1) 13 36.3 (+/- 3.2) 7 29.2 (+/- 1.1) 22 Indiana 17.6 21 33.7 (+/- 2.7) 12 38.4 (+/- 2.0) 10 30.6 (+/- 1.8) 12 41.7 11 28.7 35 31.8 (+/- 0.9) 9 Iowa 18.4 16 33.4 (+/- 3) 14 37.1 (+/- 2.3) 16 30.9 10 32.1 35 29.9 32 31.9 (+/- 0.9) 7 Kansas 19.8 13 32.3 19 36.4 (+/- 1.8) 19 28.9 (+/- 1.7) 22 43.1 (+/- 3.2) 7 35.2 (+/- 2.4) 8 31.5 (+/- 0.6) 10 Kentucky 20.2 11 37.1 6 38.4 (+/- 2.3) 10 31.0 (+/- 2.5) 7 42.4 9 25.0 45 33.4 3 Louisiana 25.9 3 36.4 7 38.5 (+/- 3.1) 8 35.3 (+/- 3.1) 1 42.9 8 32.2 18 32.6 (+/- 1.2) 4 Maine 20.7 10 27.8 36 35.0 (+/- 2.2) 25 28.7 (+/- 2) 23 34.3 32 30.5 30 29.5 (+/- 0.8) 18 Maryland 16.3 (+/- 3.4) 31 29.9 (+/- 2.2) 28 35.0 (+/- 1.6) 25 29.2 (+/- 1.6) 21 38.1 (+/- 1.8) 18 25.4 (+/- 3.9) 44 27.8 (+/- 1) 31 Massachusetts 14.5 40 21.8 (+/- 2.4) 50 27.7 (+/- 2.2) 50 25.1 (+/- 2.6) 43 36.6 25 31.4 (+/- 2.7) 21 22.9 (+/- 0.8) 47 Michigan 21.7 8 33.4 14 35.7 (+/- 1.7) 21 32.2 (+/- 1.9) 5 37.4 22 38.4 2 30.7 (+/- 0.8) 15 Minnesota 16.1 32 26.5 (+/- 1.6) 40 32.7 (+/- 1.4) 35 28.6 (+/- 1.6) 25 30.4 (+/- 3) 41 33.1 (+/- 3.2) 12 27.3 (+/- 0.5) 33 Mississippi 19.9 12 42.9 1 42.6 2 31.0 (+/- 2.9) 7 44.6 (+/- 1.9) 2 22.3 48 31.9 (+/- 1.4) 7 Missouri 17.7 18 31.2 (+/- 3.6) 26 38.5 (+/- 2.8) 8 30.0 (+/- 2.5) 16 38.6 (+/- 3.4) 17 32.7 14 30.7 (+/- 1) 15 Montana 15.3 35 25.2 (+/- 3.4) 46 30.3 (+/- 2.7) 43 24.3 (+/- 2.5) 46 N/A N/A 24.8 (+/- 6.4) 46 24.4 (+/- 1) 44 Nebraska 17.2 26 32.9 17 38.6 (+/- 2) 7 29.9 (+/- 1.8) 18 37.2 23 31.8 20 30.8 (+/- 0.7) 13 Nevada 16.9 (+/- 5.4) 27 24.8 (+/- 3.5) 48 30.0 (+/- 3.4) 45 25.7 (+/- 3.7) 40 30.8 40 30.6 (+/- 3.4) 28 26.2 (+/- 1.6) 36 New Hampshire 13.7 45 28.0 (+/- 3.7) 34 29.9 (+/- 2.3) 46 26.5 (+/- 2.2) 35 30.3 42 24.7 47 27.2 (+/- 0.9) 35 New Jersey 14.2 43 25.6 (+/- 3.3) 44 32.9 (+/- 2.7) 33 27.9 (+/- 3) 29 37.2 (+/- 2.6) 24 31.4 (+/- 2.3) 21 25.4 (+/- 1) 41 New Mexico 17.6 21 32.6 (+/- 3.6) 18 31.3 (+/- 2.7) 41 24.0 (+/- 2.6) 47 34.4 (+/- 9) 31 31.3 (+/- 1.7) 24 23.9 (+/- 1.2) 46 New York 12.7 49 24.9 47 31.4 (+/- 1.7) 40 24.6 (+/- 1.9) 45 32.1 36 30.6 28 25.1 (+/- 0.8) 42 North Carolina 17.7 18 33.4 (+/- 2.7) 14 37.3 (+/- 2.5) 14 28.6 (+/- 2.6) 25 40.2 (+/- 2) 14 31.2 25 28.1 (+/- 1) 29 North Dakota 17.7 (+/- 5.2) 18 33.6 (+/- 3.1) 13 37.1 (+/- 2.4) 16 32.1 (+/- 2.4) 6 15.9 46 37.2 5 31.5 (+/- 1) 10 Ohio 16.6 29 32.1 (+/- 2.7) 20 37.3 (+/- 2.1) 14 29.7 (+/- 2) 19 37.6 21 27.8 41 30.8 (+/- 0.9) 13 Oklahoma 22.9 5 34.4 (+/- 3.1) 10 36.3 (+/- 2.4) 20 30.4 (+/- 2.2) 14 36.6 (+/- 3.7) 26 36.7 6 32.3 (+/- 1) 6 Oregon 17.4 (+/- 4.6) 23 28.9 (+/- 2.9) 32 33.1 (+/- 2.5) 30 27.7 (+/- 2.5) 31 30.2 (+/- 9.9) 43 32.4 (+/- 4) 15 29.0 (+/- 1) 24 Pennsylvania 15.9 34 29.9 (+/- 2.9) 28 35.4 (+/- 2.4) 22 30.5 (+/- 2.9) 13 36.4 28 39.5 1 29.5 (+/- 0.9) 18 Rhode Island 13.1 47 26.4 (+/- 3.8) 41 33.1 (+/- 2.6) 30 25.2 (+/- 2.6) 41 31.9 37 30.8 (+/- 3.5) 27 26.0 (+/- 1.1) 37 South Carolina 16.8 28 34.6 (+/- 2.6) 9 38.0 (+/- 2) 12 28.7 (+/- 1.8) 23 41.7 (+/- 1.5) 12 28.2 37 28.9 (+/- 0.8) 25 South Dakota 15.0 37 32 21 34.5 28 27.3 (+/- 3.4) 33 N/A N/A 29.5 34 29.5 (+/- 1.2) 18 Tennessee 22.5 7 38.0 (+/- 3.8) 5 40.0 (+/- 2.9) 5 28.6 (+/- 2.7) 25 45.1 1 33.0 13 31.3 (+/- 1.1) 12 Texas 23.9 4 34.2 (+/- 3) 11 38.9 (+/- 3) 6 30.0 (+/- 3.3) 16 42.4 10 37.4 (+/- 1.7) 4 29.2 (+/- 1.1) 22 Utah 8.9 51 25.9 (+/- 2) 42 33.0 (+/- 2.1) 32 26.8 (+/- 2.2) 34 30.1 44 28.1 38 24.9 (+/- 0.6) 43 Vermont 18.7 15 27.6 37 30.5 (+/- 2.3) 42 25.9 (+/- 2.5) 36 N/A N/A N/A N/A 25.7 (+/- 0.9) 39 Virginia 18.2 17 27.5 38 35.1 23 27.8 30 39.4 16 29.6 33 27.3 (+/- 0.8) 33 Washington 16.4 30 29.6 30 32.1 38 28.3 28 34.2 33 34.4 10 28.2 (+/- 0.7) 28 West Virginia 26.0 (+/- 5.3) 2 38.2 (+/- 2.7) 3 44.7 (+/- 2.1) 1 32.4 (+/- 2.3) 4 44.6 (+/- 5.4) 3 37.7 (+/- 9.7) 3 36.0 (+/- 0.9) 1 Wisconsin 14.8 39 31.3 24 33.6 29 34.6 (+/- 3) 3 39.9 15 31.2 25 30.5 (+/- 1) 17 Wyoming 16.0 (+/- 6.9) 33 29 (+/- 4.1) 31 32.3 (+/- 3.1) 37 25.8 (+/- 2.9) 38 N/A N/A N/A N/A 27.9 (+/- 1.2) 30 Note: For ranking, 1 = Highest rate and 51 = Lowest rate; If not referenced, confidence intervals could not be calculated; C.I. = Confidence Intervals. Source: Behavior Risk Factor Surveillance System (BRFSS), CDC TFAH • RWJF • StateofObesity.org 21 LIMITED DATA FOR RACIAL AND AMERICAN INDIAN/ALASKA NATIVES OBESITY STATE-DATA ETHNIC POPULATIONS According to an analysis by the Kaiser analyzed had adult overweight and The total sample sizes for BRFSS in states Family Foundation (KFF) of 2014 BRFSS obesity rates above 70 percent. Ohio is often 600-800 people. Many states surveys in states with reportable data had the highest adult rate at 93.9 do not have large enough populations for American Indian/Alaska Native percent and North Carolina had the of Asian/Pacific Islanders and American populations, 14 of the 24 states lowest at 60.9 percent.49 Indian/Alaska Natives to be reflected in the survey findings. For some states, the sample sizes for Black and Latino Overweight and Obesity Rates for American Indian/Alaska Native Adults populations are too small to be reported. 2014 BRFSS Data Increasing sample sizes for each state Wyoming Wisconsin (requiring additional funding) would provide Washington an opportunity to collect more meaningful Utah Texas information about different racial and South Dakota ethnic groups in each state. South Carolina Oklahoma Ohio North Dakota North Carolina New Mexico States Nebraska Montana Minnesota Maryland Maine Kentucky Kansas Indiana Colorado Arizona Alaska Alabama 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent Rates Source: Kaiser Family Foundation. Confidence intervals not reported. PROFILE: Promoting Healthy Weight in American Indian/Alaska Native Children What began as a golf program for American Indian/Alaska Native education and community garden projects. The Foundation has youth in Albuquerque in 2005 has expanded into a national improved the lives of 24,000 American Indian/Alaska Native in effort to prevent childhood obesity and type 2 diabetes in Native 59 different communities.51 children. Founded by former PGA golfer Notah Begay III, the In 2013, NB3F launched Native Strong: Healthy Kids, Healthy NB3 Foundation (NB3F) works to reduce the staggering rates Futures, a national initiative that supports Native communities’ of obesity in Native communities where childhood obesity rates obesity-prevention efforts through grants, technical assistance, often exceed 50 percent.50 research and advocacy.50 The program supports community efforts NB3F has invested $2.3 million in grants and $7 million in that promote physical activity, nutrition education and eating healthy direct spending on evidence-based obesity-prevention programs, foods. Native Strong is aimed at building the capacity in Native including sports programs, culturally appropriate nutrition communities to help their children lead longer and healthier lives. 22 TFAH • RWJF • StateofObesity.org OBESITY AND ASIANS Asian-Americans have dramatically lower false sense of health security. Research level of body fat than Whites with the obesity rates than other U.S. racial and shows that a substantial number of Asians same BMI, it determined there is not ethnic groups. This is consistent with world with weights in the “normal” BMI range enough scientific data to suggest a trends: in general, Asian populations have (i.e., below 25) have an elevated risk for clear cut-off point for all Asians for median BMIs lower than other population obesity-related health problems, including obesity. However, Asian-Americans — groups. While the reasons for this 52 type 2 diabetes and heart disease. 52 particularly those with Indonesian, disparity are not fully understood, research Hong Kong Chinese or Singaporean A World Health Organization expert has shown that foreign-born Asian- ancestry — should recognize that BMI consultation met in 2002 to determine Americans have lower rates of obesity represents a continuum of risk and whether there should be a unique than those born in the United States, and their risk of developing obesity-related population-specific BMI cut-off point obesity increases with more years in the disease could be elevated at BMIs as for Asians. While the group found country. In addition, low obesity rates 53 low as 23.52 that Asians generally have a higher among Asian-Americans could create a 2. Education and Income Obesity rates also vary by income levels. Poverty Level & Obesity Obesity rates are generally inversely 2011–2014 data54 correlated with income, with low-income 50% individuals far more likely to be obese than higher-income individuals. There was one aberration to this rule in the 40% 42.6% 39.2% 38.8% most recent national survey: the very Obesity Rate poor (those living below 100 percent of 30% the poverty level) had lower obesity rates 29.7% (39.2 percent) than those with incomes 20% between 100 percent to 199 percent of the poverty level, who had a rate of 42.6 10% percent.54 But both groups had far higher obesity levels than those with incomes at 0% 400 percent or more of the poverty level, Below 100% 100%-199% 200%-399% 400% or more whose obesity rate was 29.7 percent. Percent of Poverty Level Children from low-income families are also more likely to be obese. In of those with less than a high school 2007, 27.4 percent of children living in education were obese compared to households below the federal household 21.7 percent among college graduates poverty level were obese, compared to (BRFSS analysis).56 An analysis of the only 10 percent of children living in 2007 National Survey of Children’s households exceeding 400 percent of Health found that children of parents the federal poverty level.55 with less than 12 years of education had Individuals with lower education levels an obesity rate 3.1 times higher (30.4 are also disproportionately more likely percent) than those whose parents have to be obese. In 2015, 34.0 percent a college degree (9.5 percent).57 TFAH • RWJF • StateofObesity.org 23 3. Regional Differences Rural, suburban and urban communities Rural counties have higher rates all have different environmental factors of obesity than urban or suburban impacting their residents’ health. Urban counties, with the highest adult obesity residents also face different challenges rates in the United States found in rural that vary according to the size of the city counties of Mississippi and Alabama.58 in which they live. Obesity Rate, 2013 0–19.9 20.0–24.1 24.2–27.2 27.3–30.8 30.9+ No Data Source: CDC58 Children Ages 10-17 Who are Obesity Rate by Level of Urbanization, 2012 Overweight of Obese, by Location (County Health Rankings Report, 2016)58 50 Key Health Factors by Level of Urbanization Large Urban Large Suburban Smaller Metro Rural 40 38.2 35.5 31.3 Health Behaviors — Adult Obesity Percent of Children 30.1 30 BEST WORST 25% 26% 27% 28% 29% 30% 31% 32% 20 Source:  The 2016 County Health Rankings Key Findings Report 10 Total Urban Large Small Source:  The Health and Well-Being of Children in Rural Areas: A Portrait of States and the Nation 2011-201259 24 TFAH • RWJF • StateofObesity.org Low-income neighborhoods are 4.5 times more likely not to have pools, tracks, tennis courts, sports fields and other recreational facilities. Rural communities face different counterparts. One reason may be the pools, tracks, tennis courts and sports challenges than their urban and lower rates of physical activity among fields.66 A New England Journal of Medicine suburban counterparts. Fewer children urban residents compared to suburban study found that when low-income in rural areas walk to school, and the dwellers. This disparity may be caused by families were provided housing vouchers populace relies heavily on automobiles the fact that there are often fewer safe that allowed them to move out of a for transportation. Lifestyle differences places to play and be physically active in high-poverty neighborhood, adults may also contribute, including higher urban environments, along with fewer experienced lower rates of extreme rates of television watching, higher venues selling healthy, affordable foods. obesity and diabetes than adults who calorie consumption and lower rates received vouchers for housing within the Researchers are still trying to understand of exercise in rural areas.60 There high-poverty neighborhood or adults who aspects of small cities that may be are also likely structural differences received no housing vouchers at all.67 different from larger urban areas. One at play, which may include lack of study found that low-income women in Living in a predominantly racial/ethnic nutrition education, fewer nutrition small cities (less than 40,000) had a higher minority community also correlates with services, fewer sidewalks and reduced risk of obesity, which actually increased certain environmental factors that may access to facilities that foster healthy if they lived within a one-mile radius of a contribute to obesity. For example, one behavior, such as recreation centers supermarket.63 This study contrasts with study found that fast-food establishments and supermarkets that sell healthy, other research that revealed that living were more prevalent in both high-income affordable food.60,61 Some strategies close to a supermarket has been shown to and low-income Black communities to improve diet and physical activity lower the risk of obesity.64 than in White communities.68 Another that have been effective in rural areas found that minority neighborhoods include farmers’ markets, farm-to-school Low-income communities face their own were significantly less likely to have programs, activity programs for older unique challenges. Numerous studies recreational facilities than White adults, and increasing access to new or have found that healthy foods are less neighborhoods.66 A study of food stores existing facilities for physical activity.62 available in low-income communities.65 found four times more supermarkets One study found that low-income While urban communities have lower located in White neighborhoods than neighborhoods were 4.5 times more rates of obesity than rural communities, Black neighborhoods.69 likely than high-income neighborhoods inner-city residents have higher to lack recreational facilities such as rates of obesity than their suburban TFAH • RWJF • StateofObesity.org 25 S EC T I ON 2 : The State of SECTION 2: THE STATE OF CHILDHOOD OBESITY The State of Childhood Obesity Obesity: A. OVERVIEW Obesity Policy Recent national data show that childhood obesity rates have Series stabilized at 17 percent over the past decade. Rates are declining among 2- to 5-year-olds, stable among 6- to 11-year-olds, and increasing among 12- to 19-year-olds. This shows signs of positive progress following a long period where rates had grown significantly among youth ages 2-19 when they more than tripled between the early 1970s and 2005 (from 5 percent to 17 percent).70 There are even signs that childhood has also declined from a high of 15.9 obesity rates are starting to decline, percent in 2010 to 14.5 percent in 2014, particularly among young children the most recent year for which data are and in communities that have taken available.21 There are increasing examples comprehensive obesity-prevention of signs of progress — where areas have approaches. Between 2010 and 2014, implemented a wide range of strategies 31 states and three territories reported to make healthy foods and beverages declines in obesity rates among toddlers available in schools and communities, (ages 2 to 4) whose families participate and have integrated physical activity into in the Special Supplemental Nutrition daily life — ranging from a 24.1 percent Program (SNAP) for Women, Infants, and decline in obesity for children under 6 in Children (WIC) nutrition program for Eastern Massachusetts to a 13.4 percent low-income families. The national obesity decline among kindergarten to fifth- rate among children in the WIC program graders in Kearney, Nebraska.71 NCHS Health E-Stats July 2016 AUGUST 2017 Despite these positive trends, childhood l 9 1 percent of American children have obesity remains an American epidemic. poor diets and less than half get the One-quarter of American high More than 12 million U.S. children are recommended 60 minutes of daily school students watch three obese — one out of every six children.72 physical activity.76 Obese children have an increased risk of or more hours of TV on an l A lmost two-thirds of American youth developing a range of health problems, consume a sugary beverage on any average school day. including high blood pressure and high given day.77 cholesterol, which are both risk factors for heart disease.72 Obesity can also cause l A quarter of American high school sleep apnea, bone and joint problems, students (24.7 percent) watch three or and chronic health conditions such as more hours of television on an average asthma and type 2 diabetes.72 Obese school day.78 children are at increased risk of being l S chools have reduced recess time bullied and suffering from depression, in favor of academic instruction, while a healthy diet and physical activity particularly among older children.79 in childhood is associated with better mental health.72 More than 200,000 As with adults, environmental factors youth under the age of 20 have type 2 also play a role in childhood obesity. diabetes, and many more are at risk for Some children have limited access to developing diabetes.73 Obese children safe places to play, while others live are also likely to grow up to be obese in food deserts where there are few adults,74 at risk for all health problems nearby places for their parents to buy associated with obesity. affordable, healthy foods to serve their families. One study found that the odds of a child being obese or overweight More than 90% of American increases by 20 percent to 60 percent if children have poor diets. he or she lives in a neighborhood with unfavorable conditions such as poor housing, unsafe surroundings and/or Socioeconomic factors are also strongly limited access to sidewalks, parks and correlated with childhood obesity. In fact, recreation centers.80 Unhealthy foods are one recent study found that family income heavily marketed to children, with Black plays a larger role than race or ethnicity youth exposed to a greater amount of in predicting childhood obesity, and that unhealthy food marketing than White One study found that the the relationship between Black and Latino youth.81 Accordingly, efforts to prevent odds of a child being obese or children and obesity disappeared after childhood obesity must address all of overweight increases by 20% controlling for income.75 these factors. to 60% if he or she lives in a There are multiple factors that may Because kids are still growing, obesity is explain why the United States has measured differently among children neighborhood with unfavorable significant numbers of overweight than adults. Instead of a simple BMI conditions such as poor and obese children. Like their adult measurement, a child’s BMI is compared counterparts, most children in the United to others of the same age and sex. housing, unsafe surroundings States are not eating enough nutritious Children with BMIs at the 95th percentile and/or limited access to foods or getting sufficient physical or above are considered obese, and those sidewalks, parks and recreation activity: family and environmental factors with a BMI between the 85th and 95th are key. For example: percentiles are considered overweight. centers. TFAH • RWJF • StateofObesity.org 27 As with adult obesity rates, this report relies on multiple survey instruments to paint a complete picture of childhood obesity in America: 1 he National Health and Nutrition T Examination Survey at CDC measures obesity rates among Americans ages two and older and is the primary source for national obesity data in this report of children ages 2 to 19. NHANES is particularly valuable in that it combines interviews with physical examinations and covers a wide age range of Americans. However, due to the delay between collection and reporting, the timeliness of its data can lag. The most recent NHANES obesity rates are from the 2013-2014 survey. 2 he WIC Participant and Program T Characteristics (WIC PC), a USDA survey analyzed for obesity trends by CDC, is a report of the Special Supplemental Nutrition Program for Women, Infants, and Children on the results of its biennial census of families served by the program. The data it collects include height and weight information. Because the program provides assistance only to low-income mothers and children under the age of 5, this dataset is aspects of their children’s health. in grades 9-12, including unhealthy limited. However, because obesity An advantage of this survey is that it dietary behavior and physical disproportionately affects the poor, includes both national and state-by- inactivity. The survey also measures and early childhood is a critical time state data, so obesity rates between the prevalence of obesity by asking for obesity prevention, the dataset states can be compared. The latest respondents about their height and provides valuable information survey was conducted in 2016 and weight. As in other surveys that use for evaluating the effectiveness of published in 2017. In addition, self-reported data to measure obesity programs aimed at reducing obesity obesity rates are calculated based on rates, this survey likely underreports rates and health disparities. parent-reported height and weight. the true rates. The survey is conducted in odd-numbered years. 3 he National Survey of Children’s T 4 The Youth Risk Behavior Surveillance The most recent public YRBSS obesity Health (NSCH) surveys parents System (YRBSS) tracks high-risk data are from the 2015 survey. of children ages 0 to 17 about all health behaviors among students 28 TFAH • RWJF • StateofObesity.org B. NATIONAL CHILDHOOD OBESITY RATES (NHANES) Nationally, the childhood obesity rate obesity rates have stabilized at 17 is 17 percent. The rate varies among percent over the past decade. Rates are different age groups, with rates rising declining among 2- to 5-year-olds, stable along with age. This same pattern is among 6- to 11-year-olds and increasing seen in both boys and girls. Recent among 12- to 19-year-olds. national data show that childhood CHILDHOOD OBESITY RATES — 2011-2014 DATA23 Age Group Obesity Rate Ages 2-5 8.9% Ages 6-11 17.5% Ages 12-19 20.5% All youth (ages 2-19) 17.0% Prevalence of obesity among youth ages 2–19 years, by sex and age: United States, 2011–2014 30 2–19 years 2–5 years 6–11 years 12–19 years 25 1 20.5 1 21.0 1 20.1 20 17.0 1 17.5 1 17.6 17.1 1 17.5 16.9 Percent 15 10 8.9 9.2 8.6 5 0 All Males Females 1 Significantly different from those aged 2–5 years. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2014. TFAH • RWJF • StateofObesity.org 29 Prevalence of obesity among youth aged 2–19 years, by sex and race and Hispanic origin: United States, 2011–2014 30 Non-Hispanic White Non-Hispanic Black Non-Hispanic Asian Hispanic 25 21.9 1,2 22.4 1,2,4 1,2 21.4 1 20.7 20 1,2 19.5 1,2 18.4 Percent 1 14.7 1 15.1 15 14.3 11.8 3 10 8.6 5.3 5 0 All Males Females 1 Significantly different from non-Hispanic Asian persons. 2 Significantly different from non-Hispanic White persons. 3 Significantly different from females of the same race and Hispanic origin. 4 Significantly different from non-Hispanic Black persons. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2014. As with adults, obesity rates vary by race and ethnicity, with Latino and Black children having higher obesity rates than White and Asian children.23 Childhood Obesity Rates20 2011-2014 Data 25% 20% 21.9% 19.5% Obesity Rate 15% 14.7% 10% 8.6% 5% 0% Asian Black Hispanic White Race/Ethnicity 30 TFAH • RWJF • StateofObesity.org C. EARLY CHILDHOOD OBESITY RATES (WIC) Research has demonstrated that creating healthy eating patterns early on can help establish lifelong food preferences and habits.82 Given that more than one in 11 of all low-income children ages 2-5 are already overweight or obese,21 forming good eating behaviors at an early age is critical.83 Early childhood obesity rates have begun to level off and even decline. Nationally, the obesity rate among low-income 2- to 5-year-old children enrolled in the WIC program declined from 15.9 percent in 2010 to 14.5 percent in 2014.21 Among these children, a majority of states and all major racial/ethnic groups saw a reduction between 2010 and 2014 in the obesity rates. l n a state level, rates ranged from a O low of 8.2 percent in Utah to a high of 20.0 percent in Virginia. Rates Prevalence of obesity among WIC participants aged 2–4 years, overall and by decreased significantly in 31 states and race/ethnicity — United States, 2000–2014 increased significantly in only four states between 2010 and 2014.21 l acial and ethnic differences remain R significant: 18 percent of American Indian/Alaska Natives, 17.3 percent of Latinos, 12.2 percent of Whites, 11.9 percent of Blacks, and 11.1 percent of Asians/Pacific Islanders in 2014.21 CDC analyses cite that a set of initiatives have contributed to the recent reduction in obesity rates, including revisions to the WIC program’s food package, providing WIC recipients with more healthy food options, and WIC efforts to promote and support breastfeeding. TFAH • RWJF • StateofObesity.org 31 D. OBESITY RATES IN CHILDREN AGES 10-17 (NSCH) In 2016, nearly one-third (31.2 percent) NSCH is based on a survey of parents in of children ages 10-17 were either each state. The data are from parental overweight or obese, according to the reports, so they are not as reliable as National Survey of Children’s Health.84 At measured data, but they are the only a state level, Utah had the lowest rate of source of comparative state-by-state overweight or obese children in this age data for children in this age group. group at 19.2 percent, while Tennessee NSCH has typically been conducted and had the highest rate at 37.7 percent.84 released every four years. Percentage of Children Ages 10 to 17 Classified as Obese and Overweight by State, 2016 National Survey of Children’s Health (NSCH) WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA ≥15% to <20% ≥20% to <25% TX LA ≥25% to <30% ≥30% to <35% FL ≥35% to <40% AK HI An interactive map and timeline of these data are available at stateofobesity.org Source: National Survey of Children’s Health, 2016 32 TFAH • RWJF • StateofObesity.org E. HIGH SCHOOL OBESITY RATES (YRBSS) According to the Youth Risk Behavior Surveillance System, 13.9 percent Percentage of High School Students Classified as Obese by State, 2015 YRBSS of high school students were obese, and an additional 16.0 percent were WA MT ME overweight in 2015. There was a ND VT OR MN significant increase in high school ID NH SD WI NY MA obesity rates between 1999 and 2015 WY MI CT RI (from 10.6 percent to 13.9 percent), NV NE IA PA NJ OH DE but no significant change between UT IL IN CA MD CO WV MO VA 2013 and 2015.85 KS KY DC NC State obesity rates among high school AZ TN OK NM AR SC students in 2015 ranged from a low GA No Data MS AL of 10.3 percent in Montana to a ≥10% to <15% TX LA ≥15% to <20% high of 18.9 percent in Mississippi, FL with a median of 13.3 percent.85 The AK information from YRBSS is based on a HI survey of participating states and uses self-reported information. Male students had higher obesity Note: Data not available for Colorado, District of Columbia, Georgia, Iowa, Kansas, Louisiana, Minne- rates than female students (16.8 sota, New Jersey, Ohio, Oregon, Texas, Utah, Washington and Wisconsin. Source: CDC, Youth Risk Behavior Surveillance System percent vs. 10.8 percent). An interactive map is available at stateofobesity.org American Indian/Alaska Native, Black and Hispanic students had higher rates than White and Asian students, as seen in the chart below. Obesity Rates for High School Students by Race/Ethnicity and Gender, YRBSS 1999 to 2015 1999 2001 2003 2005 2007 2009 2011 2013 2015 TOTAL 10.6% 10.5% 12.0% 13% 12.8% 11.8% 13% 13.7% 13.9% BY RACE/ETHNICITY American Indian/ Alaska Native§ N/A 17.2% 17.5% 13% 19.5% 8.2% 17.5% 9.10% 15.9% Asian§ 3.6% 6.7% 6.8% 5.4% 7.2% 7.2% 9.8% 5.6% 5.5% Black § 12.3% 16.0% 16.1% 15.9% 18.3% 15.0% 18.2% 15.7% 16.8% Latino 13.2% 15.1% 16.2% 16.7% 16.3% 14.9% 14.1% 15.2% 16.4% Native Hawaiian/ Other Pacific Islander § 12.5% 7.5% N/A N/A N/A 20.1% 21.4% 7.5% N/A White§ 10.0% 8.8% 10.3% 11.7% 10.6% 10.2% 11.5% 13.1% 12.4% Multiple Race§ 11.2% 9.2% 9.6% 13.5% 13.5% 13.4% 13.6% 15.2% 17.5% BY GENDER Female 7.4% 6.9% 8.1% 9.9% 9.4% 8.1% 9.8% 10.9% 10.8% Male 13.7% 14.2% 15.7% 15.9% 16.2% 15.2% 16.1% 16.6% 16.8% Note: The CDC uses the term Hispanic in analysis. § = non-Hispanic TFAH • RWJF • StateofObesity.org 33 S EC T I ON 3 : The State of SECTION 3: KEY OBESITY-PREVENTION POLICIES Key Obesity-Prevention Policies Obesity: A range of strategies can help support opportunities for healthy Obesity Policy eating and increased physical activity. They focus on making Series healthier choices easier in people’s daily lives. This section reviews a range of recent government services, and a range policy trends and changes that can of community and philanthropic promote healthy weight in children and organizations have helped develop, healthy lives for all adults. CDC, NIH, evaluate and advance top strategies that FDA, HHS, USDA, the U.S. Department communities around the country can of Education, U.S. Department of use to help prevent obesity and improve Transportation, state and local public health in their areas. health agencies, other state and local A. EARLY CHILDHOOD POLICIES & PROGRAMS A number of federal, state and young children at home, in child-care community policies and programs settings, in their local communities and focus on improving nutrition, activity through healthcare services. and health for infants, toddlers and State has regulations requiring licensed Early Care and Education programs to provide meals and snacks that meet USDA standards AUGUST 2017 Yes No Budgets for Some Key Federal Enacted Budget Enacted Budget Numbers Served by Child Care and Obesity-Related FY 2017 FY 2016 Program Programs86, 87, 88, 89, 90 Child and Adult Care Food 4.2 million children *$3.491 billion $3.340 billion Program (USDA) and 130,000 adults Child Care and Development Around 1.4 million $2.856 billion $2.761 billion Block Grant children every month More than 1 million Head Start $9.253 billion $9.168 billion children under 5 8.1 million women, WIC (USDA) $6.35 billion $6.35 billion infants and children monthly participation *Estimated (vs. enacted) HELPING YOUNG C CHILDREN THRIVE A B D HEALTHY PRACTICES IN THE EARLY CARE AND EDUCATION (ECE) SETTING CHILDHOOD OBESITY IS A MAJOR THREAT TO THE UNITED STATES 14 IN Nearly 1 in 4 children Obesity puts children at risk for Type 2 diabetes, asthma, anxiety and $ depression, and low Obesity costs the US (aged 2 to 5) are health care system self-esteem. overweight or have $147 billion a year. obesity. WE MUST ACT EARLY It’s easier to influence children's food and physical activity choices when they are young, before habits are formed. Establishing healthy Both a healthy diet and Young children who habits for physical physical activity are are overweight in activity in early positively associated with kindergarten are 4 childhood influences some measures of times more likely to activity levels as cognitive development. have obesity by 8th children grow. grade than those not overweight. ECE FACILITIES ARE IDEAL PLACES TO ENCOURAGE GOOD NUTRITION AND PHYSICAL ACTIVITY 60%OF 3-TO 5-YEAR-OLDS are cared for in an ECE facility at least once a week.* PRE-K PRESCHOOL CHILD CARE CENTER The ECE setting can directly influence what children eat and drink and how active they are, and build a foundation for healthy habits. * These facilities include childcare centers, family care homes, Head Start programs, preschool, and pre-kindergarten programs. TFAH • RWJF • StateofObesity.org 35 1. Nutrition and Physical Activity for Young Children Engaging in physical activity and eating Federal, state and local governments nutritious foods beginning in early fund a number of programs that help childhood establishes healthy habits infants and toddlers grow up at a that can last a lifetime. It is also much healthy weight, including programs easier and more effective to prevent that provide direct nutritional support obesity during early childhood than and others that encourage healthy to reverse trends later in life. Early eating and active play at home and in childhood is also a critical window child-care settings. Many of the national for obesity-prevention interventions, programs are in the form of block as children who are obese entering grants, with the federal government kindergarten are four times more likely providing the funding and states to be obese in eighth grade.91 administering the programs. PRENATAL AND MATERNAL HEALTH Pre-pregnancy obesity can lead to a host Percentage change in pre-pregnancy obesity between 2011 and 2014, by reporting of health problems for babies, including area: 36 states and the District of Columbia congenital heart defects and stillbirth. If all pregnant women were at a healthy weight WA before becoming pregnant, it would prevent NH ME MT ND VT nearly 7,000 fetal deaths in the United OR MN States per year.92 In mothers, obesity ID MA SD WI NY RI is associated with an increased risk of WY MI CT IA PA gestational diabetes, caesarean delivery NE NJ NV OH IL IN DE and preeclampsia. 30,93,94 CA UT CO WV MD KS MO VA KY Approximately half of U.S. women who DC NC gave birth in 2014 were overweight TN AZ OK NM AR SC (25.6 percent) or obese (24.8 percent) MS AL GA pre-pregnancy, based on information from TX LA states that includes maternal pre-pregnancy height and weight on birth certificates (96 FL AK percent of all U.S. births). Pre-pregnancy 95 obesity rates ranged from a low of 19.2 Greater than 10% increase percent in Massachusetts to a high of 6%–10% increase 32.1 percent in Mississippi. Of the 37 1%–5% increase states or territories that also collected this HI No change information in 2011, 30 saw increases in 1989 U.S. Standard Certificate of Live Birth SOURCE: NCHS, National Vital Statistics System. data not available as of January 1, 2011 obesity rates between 2011 and 2014 and seven had no significant change. Prenatal behavior by mothers can also affect their children’s future eating habits. Research has shown that children of mothers who ate fruits and vegetables during their pregnancy were more likely to eat those foods.82 36 TFAH • RWJF • StateofObesity.org 2. Child and Adult Care Food Program (CACFP) The Child and Adult Food Care Program provides federal funding to states to Enhanced CACFP reimburse providers for the cost of Nutrition Standards providing nutritious meals and snacks State encourages to children and adults in their care. The early care and program, which helps feed 4.2 million education providers children and 130,000 adults each year, participating in sets minimum nutritional standards CACFP to meet that providers must meet to receive nutrition standards reimbursement.96 These standards that exceed the were recently updated to require more federal requirements. whole grains, a wider variety of fruits and vegetables, and less added sugar and saturated fat. The new standards Yes No are slated to go into effect on October 1, 2017.96 Initial results from a health impact assessment conducted by the Kids’ Safe CACFP Promotes and Healthful Foods Project suggest that Obesity Prevention the updated CACFP nutrition standards State promotes will have a positive effect on children’s or provides a health by increasing the likelihood that specific early care children will eat more vegetables and and education whole grains, and consume fewer whole obesity prevention grain-based desserts, such as cakes, pies intervention to and cookies.97 The Food and Nutrition providers who Service recently announced a transition participate in CACFP. period through September 30, 2018, during which violations of the new Yes No standards will result in technical assistance instead of fiscal action.98 Some states have gone even further CACFP Trainings than the new federal standards require. State includes For example, the federal standards obesity prevention require only unflavored milk be served topics, such to children under age 2, while New York as nutrition, state requires all children under age 5 physical activity be served unflavored milk as part of its or breastfeeding Healthy Infant and Healthy Child Meal support into CACFP Pattern initiative.99 In 2016, CDC found trainings. that 29 states had implemented enhanced nutritional standards, and that 23 states include some type of obesity-prevention information in their CACFP training.99 Yes No TFAH • RWJF • StateofObesity.org 37 HEALTHY EATING RESEARCH: FEEDING INFANTS & TODDLERS The first 1,000 days of life serve as a critical developmental The panel also recommends: period in a person’s life. However, there are currently no l h ealthy eating by mothers during pregnancy and breastfeeding; federal nutritional guidelines for children under the age of 2. To address this gap, the Robert Wood Johnson Foundation’s l b reastfeeding infants; (RWJF’s) Healthy Eating Project assembled an expert panel to l r epeatedly exposing children to healthy foods, so they learn to develop guidelines on healthy feeding of infants and toddlers.82 like them; and The panel’s overriding piece of advice: listen to your child. In l a voiding foods high in added sugars, sodium and saturated fat. other words, practice “responsive parenting,” which is based on the theory that very young children will eat until they are full. 3. Child Care and Development Block Grant (CCDBG) The Child Care and Development requirements, and states are encouraged Communities program, Child Care Block Grant provides federal dollars to to include nutrition and physical Aware of America — supported by RWJF states to assist low-income families with activity requirements. To apply for grant funding — is working with six child care, benefitting approximately funding, states must submit plans that states on their plans to enhance health 1.4 million children every month. To describe their program and the services and wellness components of their plans, participate in the program, child-care available to eligible families. Through including requiring health and nutrition providers must meet health and safety their Healthy Child Care, Healthy training for child-care staff.100 STATE PROFILE: South Carolina South Carolina has above-average obesity rates. It is ranked l I ncreasing the number of active diabetes prevention programs 12th in the nation for adult obesity, second for school-aged in the state from two to 40; and childhood obesity (ages 10 to 17) and eighth for obesity among l I ncreasing the number of schools participating in Farm-to- high school students. The state also has high rates of diabetes School programs from 124 to 194.102 and hypertension, ranking eighth in the nation for both of these chronic conditions. New research demonstrates that South Carolina’s policy changes are making a difference. In October 2016, the South Carolina is working to bring down its obesity rates. Its American Journal of Public Health published the results of a SCaledown.org website helps engage and educate partners study of physical activity practices in South Carolina child-care about obesity and how to “make the healthy choice the easy centers after new state standards went into effect in 2012. choice for South Carolinians.”101 The state also developed Compared with another state that lacked such standards, the South Carolina Obesity Action Plan in 2014 to promote the South Carolina child-care centers significantly improved environmental and policy changes to prevent and reduce their physical activity practices by providing a wide variety of obesity. Successes from 2016 include: playground equipment, and more physical activity training and l I dentifying 116 farmers’ markets in South Carolina that education for children, staff and parents.103 accept SNAP benefits; 38 TFAH • RWJF • StateofObesity.org 4. Head Start Head Start is a comprehensive early percent identified obesity among adult childhood education program that family members as a major concern.104 helps prepare more than one million The vast majority (88 percent) of low-income children under the age programs that identified obesity as a of 5 for school every year. It began major concern have policies in place as a program for preschoolers in the requiring physical activity and nearly 1960s and was expanded in the 1990s all (99 percent) provide obesity-related with the creation of Early Head Start, services to their families, including which serves pregnant women, infants programs focused on nutrition, physical and toddlers. The federal government activity and/or weight management. provides funding and oversight to local The ACF, which oversees the Head Start agencies that administer the program. program, sets minimum standards that Head Start and Early Head Start programs must meet with respect to programs participate in either CACFP nutrition and outdoor active play. In or the federal School Meals Program. November 2016, updated regulations Obesity is a major health challenge went into effect, the first major for Head Start participants and their rewrite since they were first issued in families. In a 2016 survey of Head Start the 1970s.105 The revised standards program directors and health managers, require Head Start programs to actively 86 percent of health managers identified engage in obesity prevention both in obesity among children as a major health the classroom and through its family concern for the program, while 82 partnership process.106 TFAH • RWJF • StateofObesity.org 39 5. State Requirements for Early Care and Education (ECE) Investing in high quality early Beyond different federal requirements, It found that: childhood programs can provide states set standards for day-care centers, l S ince 2010, 25 states had updated preschools and other early child-care a 13% return on investment ECE licensing regulations to better settings. By designing standards for and reduce obesity incorporate nationally-recommended early care and education settings that obesity-prevention standards; encourage healthy eating and abundant physical activity, states can help young l 2 9 states had incorporated obesity children get a healthy start in life. prevention into their Quality Rating Investing in quality ECE programs pays and Improvement Systems (QRIS) off. Research conducted by Nobel Prize standards, which measure the quality winning economist James J. Heckman of ECE programs (39 states had QRIS shows that investing in high-quality early ratings); and childhood programs for disadvantaged l 4 2 states offered training to ECE children can provide a 13 percent per providers in obesity prevention.99 year return on investment, including reduced rates of obesity and chronic These findings illustrate that most states health conditions such as heart disease are implementing changes aimed at and diabetes.107 reducing obesity in early childhood facilities. At the same time, out of 47 To help support states in reducing obesity, practices that experts have identified CDC designed a framework to guide states as having the most impact on reducing in assisting ECE providers in improving obesity in early childhood settings, the nutrition, breastfeeding support and most any state had fully incorporated physical activity and reducing screen time. into their licensing regulations was 15 CDC issued a report in 2016 evaluating (by Mississippi). states’ success on this score. Professional Development State allows early care and education providers to meet professional development requirements through online training. States can include requirements for ongoing training for early care and education providers in their licensing regulations or QRIS. Yes No 40 TFAH • RWJF • StateofObesity.org 6. very Student Succeeds Act — Early Childhood Education Components E The Every Student Succeeds Act l U se of Title II funds, which are for (ESSA) became law in December 2015 teacher and principal training, for to reauthorize federal elementary early learning capacity building;108 and and secondary education programs, l A uthorizing the Full-Service included many provisions related Community School program and the to healthy schools and physical Promise Neighborhood program, education and several provisions both of which aim to improve affecting early childhood education, educational outcomes for children health and well-being: in distressed communities and which l E stablishment of a Preschool have early education components.109 Development Grant program aimed Organizations serving disadvantaged at improving early education for low- populations, which can include those income children; with high rates of childhood obesity, are eligible for Promise Neighborhood l U se of Title I funds, which are for grants to help provide social, health, low-income schools, to support early nutrition and mental health services.110 education programs; TFAH • RWJF • StateofObesity.org 41 7. WIC The Special Supplemental Nutrition l P roviding healthy foods and nutrition Program for Women, Infants, and education; Children is a federal grant program l P romoting breastfeeding and that funds state nutrition and education supporting nursing mothers; and services for low-income pregnant, postpartum and breastfeeding women l P roviding healthcare and social service and their children under the age of referrals. 5. WIC is one of the largest federal Research has demonstrated the success nutrition programs, with an average of WIC efforts.112 For example, more monthly participation of 8.1 million than 30 percent of WIC recipients women, infants and children.111 initiate breastfeeding and WIC The WIC program, which is recipients who received postpartum administered by state agencies, helps its benefits were less likely to be obese at recipients achieve a healthy weight in the onset of their next pregnancy,113 several ways, including by: reducing their chance of delivering a stillborn baby or one with birth defects. BREASTFEEDING Breastmilk is the healthiest food for in- Rates of breastfeeding in the United Breastfeeding rates also vary widely be- fants. The American Academy of Pediatrics States have increased in recent years. Of tween states. Mississippi has the lowest (AAP) recommends exclusive breastfeed- babies born in 2013, 81.1 percent were rates, with only 52.0 percent of babies ing for the first six months of life and con- breastfed at birth, more than half (51.8 born in 2013 ever breastfed and 9.3 per- tinuing to breastfeed through the first year percent) were still breastfeeding at six cent breastfed exclusively at six months.120 of life. Breastfeeding is associated with a months, and nearly a third (30.7 percent) Idaho has the highest rate of ever breast- number of long-term medical benefits for were breastfeeding at one year. 120 But, fed at 92.9 percent, and Montana has the babies, including reduced risk of respira- only 22.3 percent of babies were exclu- highest rate of babies being breastfed ex- tory tract infections, gastrointestinal tract sively breastfed at six months. clusively at six months at 33.8 percent. infections and diabetes.114 Breastfeeding is also associated with a sig- nificantly reduced risk of childhood obesity, according to a 2014 meta-analysis of 25 studies,115 although there is debate about whether breastfeeding actually prevents obesity or if other socioeconomic and cul- tural factors are key factors.116 There also may be weight-related benefits for mothers who breastfeed: some studies have found they lose more weight postpartum than mothers who do not breastfeed and are more likely to return to their pre-pregnancy weight,117,118 although other studies found little or no relationship between breastfeed- ing and weight change.118,119 42 TFAH • RWJF • StateofObesity.org B. SCHOOL-BASED POLICIES & PROGRAMS 1. Overview Given that children spend significant Budgets for Some Key Federal School-Based Enacted Budget Enacted Budget FY 2016 portions of their day in school, where Obesity-Related Programs111,123,124,125,126,127,128,129,130 FY 2017 they consume nearly half their calories,121 National School Lunch Program (USDA) *$12.340 billion $12.528 billion school-based obesity-prevention School Breakfast Program (USDA) *$4.470 billion $4.339 billion programs are an excellent way to reach large numbers of children. Research Student Support and Academic Enrichment Grants [these are new grants $400 million authorized in late 2015 has demonstrated that school programs (U.S. Department of Education) as a component of ESSA] are effective in preventing childhood Farm-to-School Program (USDA) $8.4 million $9.1 million obesity, encouraging healthier diets and fostering more physical activity.122 And Transportation Alternatives Set-Aside (may include Safe Routes to School) (Department of $835 million $835 million because preventing childhood obesity is Transportation) much easier than helping obese adults Division of Population Health, Healthy Schools (CDC) $15.4 million $15.4 million lose weight, investing in the programs below make sense for both fiscal and *Estimated (vs. enacted) public health reasons. Research has also repeatedly shown level, blood pressure, blood glucose that American children are not getting and smoking status. It found that Fewer than half of American enough activity or eating enough very few children meet all measures children get the recommended nutritious foods. In 2016, the American of a healthy heart. For example, 91 Heart Association released a scientific percent of American children have amount of daily aerobic statement outlining seven measures of poor diets and less than half get the physical activity. cardiovascular health, which include recommended 60 minutes of daily physical activity, diet, BMI, cholesterol aerobic physical activity.76 2. Obesity & Academic Achievement School children are healthier and likely to watch TV or play video games perform better in school when they for three or more hours a day. Students are eating nutritious food and getting with higher grades are also more likely to plenty of physical activity. A CDC have healthy dietary behaviors, including review of 50 studies found substantial eating breakfast, eating fruits and evidence that physical activity not only vegetables, and avoiding soda.132 provides significant health benefits, Meanwhile, obesity is associated with but can also help improve academic poorer educational outcomes, including achievement, concentration and more school absences, parents more classroom behavior, as well.131 frequently contacted by the school Students with better academic grades about problems, and lower educational have healthier behaviors. According to engagement.13,133,134 Studies have also data from the 2015 National Youth Risk found that obese students have more Behavior Surveillance System, students behavioral problems, are more likely with higher grades are more likely than to repeat a grade, have lower grade students with lower grades to be physically point averages and reading scores, and active and play on a sports team, and less demonstrate lower academic effort.135,136,137 TFAH • RWJF • StateofObesity.org 43 3. School Nutrition a. School Meal Programs Kids Act of 2010 (HHFKA), which More than 30 million American children allows any school district with at least participate in the National School Lunch 40 percent or more of children eligible and School Breakfast Programs, which for school lunch to provide free meals provide federally-funded low-cost or free for all (which now covers more than meals and snacks to students in more 6 million children); (2) via Provision than 100,000 public schools, private 2 of the National School Lunch Act, schools and child-care centers across which allows schools to reduce its the United States.134,138 Participating administrative burdens by basing four schools receive subsidies from the federal years of reimbursements off of one year government for each meal they serve of submissions, provided the schools and, in return, they must serve meals that serve free meals to all students; or (3) meet federal standards at a reduced cost via “nonpricing,” where schools simply or no cost to eligible students. Children do not charge any students for meals but from families that earn 130 percent receive federal reimbursements based of the federal poverty level or less are on the number of meal applications eligible for free meals, and children submitted.139 Administrative savings help from families that earn between 130-185 offset the costs of offering meals to all, percent of the poverty level are eligible and help remove stigma associated with for reduced-price meals.134 participating in the program. Some children experience social stigma As required by HHFKA, updated for taking part in the school meals nutrition standards for the school programs, but making breakfast and meals programs were issued in 2012. lunch free to all students can reduce The updated rules require increased the problem. This can be done in three availability of whole grains, fruits and ways: (1) via the Community Eligibility vegetables, fat-free and low-fat milk, and Provision of the Healthy, Hunger-Free decreased levels of sodium, saturated 44 TFAH • RWJF • StateofObesity.org fats and trans fats. The changes are Percentage of Eligible School Districts Adopting Community Eligibility being phased in over several years.140 Research has demonstrated that the healthier school lunches are popular among students141 and parents,142 and they have succeeded in increasing students’ fruit and vegetable intake.143 In 2017, U.S. Agriculture Secretary Sonny Perdue announced that the Agriculture Department would be taking regulatory action with respect to the whole grain, sodium and milk requirements. He authorized states to grant exemptions to schools on the whole grain requirements, deemed schools that meet the first of three phased-in sodium requirements to be compliant, and directed USDA to begin n 0 – 24.9% n 25 – 49.9% n 50 – 74.9% n 75 – 100% the regulatory process to permit schools The Community Eligibility Provision (CEP) allows schools in high-poverty areas to serve free to serve one percent flavored milk.144 breakfast and lunch to all students. The percentage of eligible schools in each state that Passage of the HHFKA in 2010 was have adopted CEP ranges from 10 percent in New Hampshire to 95.6 percent in Ohio. the last congressional authorization of child nutrition programs, which are Children who eat breakfast at school are less likely to be overweight supposed to be reauthorized every five years. While reauthorization efforts have than those who skip breakfast. stalled in Congress, the vast majority of program operations will continue as a recent study found that middle school schools also enjoyed ancillary benefits long as Congress keeps funding them students who regularly skipped breakfast including fewer visits to the school through annual appropriations laws.145 were twice as likely to be overweight nurse, increased attentiveness and Although more than 90 percent of or obese than those who ate breakfast fewer discipline programs. Some even schools that offer a School Lunch either at home or school.148 A number experienced improved reading and Program also offer the School Breakfast of studies have indicated that eating math scores.152 Program, student participation lags a healthy breakfast is correlated with Participation in the breakfast program behind for breakfast.146 Only about increased school attendance.149,150,151 has been increasing over the past several half of the students (56 percent) who New “breakfast after the bell” decades. The 56 percent of children who participate in the lunch program take programs are tackling some of these participate in both the lunch program advantage of the breakfast program,147 barriers. Three models include: (1) and breakfast program is up from 31.5 likely due to barriers such as social providing breakfast in classrooms after percent in the 1990-91 school year. stigma and the logistical and timing school starts; (2) offering breakfast The Food Research and Action Center, challenges posed by having to arrive during a mid-morning break; and/ which tracks breakfast participation at school early enough to eat breakfast or (3) making “grab & go” breakfast rates, announced a 3.7 percent increase before school starts. options available. In a 2016 survey in breakfast participation during the Yet some research demonstrates that of high school principals that had 2015-16 school year compared with the children who eat breakfast at school implemented one or more of these prior school year. This translates into an are less likely to be overweight or obese models, 82 percent reported increased additional 433,000 children receiving a than students who skip breakfast. In fact, program participation.152 Many healthy breakfast.147 TFAH • RWJF • StateofObesity.org 45 United States Department of Agriculture b. Smart Snacks in Schools SMART The Healthy, Hunger-Free Kids Act of 2010 requires USDA to establish The Smart Snacks in School rule nutrition standards for all foods sold in schools — beyond the federally- supported meals programs. This new rule carefully balances science-based SNACKS requires all food sold at schools nutrition guidelines with practical and flexible solutions to promote during school hours to meet federal healthier eating on campus. The rule draws on recommendations from the Institute of Medicine, existing voluntary standards already implemented by nutrition standards,153 although states thousands of schools around the country, and healthy food and beverage are permitted to exempt certain school IN SCHOOL offerings already available in the marketplace. Equals 1 calorie Shows empty calories* fundraisers from the standards.154 A review by the Institute for Health Before the New Standards After the New Standards Research and Policy at the University of Chicago found that, as of March 2017, 21 states and Washington, D.C., have 286 249 242 235 136 170 161 118 95 68 0 TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL policies requiring zero exemptions to CALORIES Chocolate CALORIES Fruit CALORIES Donut CALORIES Chocolate CALORIES Regular CALORIES Peanuts CALORIES Light CALORIES Low-Fat CALORIES Granola CALORIES Fruit Cup CALORIES No-Calorie Sandwich Flavored Bar Cola Popcorn Tortilla Bar (oats, (w/100% flavored the rule—meaning all foods sold at Cookies Candies (1 large) (1 bar-1.6 oz.) (12 fl. oz.) (1 oz.) (Snack bag) Chips fruit, nuts) Juice) Water (6 medium) (2.2 oz. pkg.) (1 oz.) (1 bar-.8 oz.) (Snack cup (12 fl. oz.) school, even for fundraising efforts, 182 177 147 112 126 0 17 0 32 4 oz.) 0 0 must comply with the USDA’s Smart Empty Calories Empty Calories Empty Calories Empty Calories Empty Calories Empty Calories Empty Calories Empty Calories Empty Calories Empty Calories Empty Calories Snacks nutrition standards: Alaska, California, Connecticut, Delaware, Hawaii, Iowa, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New York, North Carolina, Oregon, Rhode Island and Washington.155 All fundraising efforts that take place outside of school hours are exempt from the federal Smart Snacks in School *Calories from food components such as added sugars and solid fats that provide little nutritional value. Empty calories are standards.154 The standards also do not part of total calories. apply to food that is not being sold—for example, cupcakes brought in for a student’s birthday or other celebration. But a review of school snack policies by Voices for Healthy Kids (VFHK) found that, in the fall of 2014, seven states and USDA is an equal opportunity provider and employer. Washington, D.C., had standards for c. Summer Food Service Program school snacks that align with USDA’s The Summer Food Service Program the program. Sponsors include schools, Smart Snack in School nutrition (SFSP) ensures that low-income camps, community centers or other standards and also included standards children can continue to receive nonprofit organizations that have the for programs and events beyond school nutritious meals during summer ability to run a food service program.157 hours and/or for school celebrations. vacation from school. Like the other In summer 2017, the program aims to These states were Hawaii, Maine, school meal programs, SFSP is federally serve 200 million free meals to children Mississippi, Oregon, Rhode Island, funded but administered by the states, around the country.158 Washington and West Virginia.156 which contracts with sponsors to run 46 TFAH • RWJF • StateofObesity.org d. Water in Schools Federal law requires schools participating Water quality issues unfortunately affect in the National School Lunch or the availability of clean drinking water at School Breakfast programs to make schools. While 8,000 schools and child- free water available to children during care centers maintain their own water meals. Drinking water helps children supply and are thus regulated by the U.S. stay hydrated, provides an alternative Environmental Protection Agency (EPA), to sugary drinks and may improve more than 100,000 additional schools children’s concentration. However, not and centers are unregulated by the EPA all schools meet the requirements: one and may or may not be conducting study found that 10 percent of middle their own water quality testing for lead and high schools and nearly 15 percent or other unhealthy contaminants.161 of elementary schools did not meet the A recent study found that nearly one- drinking water requirements during the quarter of Americans drink water that is 2011-12 school year.159 For schools that either unsafe to drink or has not been need help meeting the drinking water properly tested for contaminants.162 EPA requirements, CDC has created the Water has developed a toolkit, 3Ts for Reducing Access in Schools toolkit to guide schools Lead in Drinking Water in Schools, through the process of evaluating their which can help schools reduce lead in current policies and creating action plans drinking water.163 to increase access to drinking water.160 TFAH • RWJF • StateofObesity.org 47 e. Fruit and Vegetable Programs The Fresh Fruit and Vegetable Program (FFVP), which started as a pilot program in 2002, has now expanded to elementary schools nationwide. It provides free fresh fruits and vegetables to schools with high percentages of students who qualify for free or reduced-price lunch.164 The produce must be served outside the lunch and breakfast hours. An evaluation of the program published in 2013 found “strong evidence” that the program increased fruit and vegetable consumption in participating schools.165 In addition, farm-to-school programs help bring fresh, local food into schools and provide hands-on learning activities including school gardens, farm visits and cooking classes. The Healthy Hunger-Free Kids Act of 2010 formally established the USDA’s Farm-to-School program, which helps incorporate local foods into school nutrition programs.166 During the 2013-14 school year, farm-to-school programs served more than 42 percent of schools and 23.6 million children. In addition, more than 7,000 schools reported having school gardens. During the 2013-14 school year, school districts purchased Research has shown that farm-to-school nearly $800 million in local food from programs can encourage healthy eating More than 7,000 schools in the farmers, ranchers, fishermen, and habits in students, and participants U.S. have school gardens. food processors and manufacturers—a are more likely to try and like fruits 105 percent increase over the $386 and vegetables as a result.168,169 These million purchased during the programs also enhance academic 2011-2012 school year.167 performance and dietary outcomes.170 48 TFAH • RWJF • StateofObesity.org 4. School-Based Physical Activity Programs a. hysical Education & Physical Activity Breaks P Physical education (PE) provides important benefits for children, including delivering dedicated time for physical activity, teaching the rules of sports and games, allowing practice of gross motor skills, and helping cultivate a lifelong interest in exercise. School-Based Programs to Increase Physical Activity is an umbrella name that CDC has termed for programs implemented by states or school districts that expand physical education or incorporate physical activity into the classroom.171 This collection of programs is one of number of PE minutes per week. Only Oregon and CDC’s HI-5 Initiatives, a collection of cost-effective community- Washington, D.C., require the time necessary to meet based health interventions that research shows should make the national standards for physical education at both a positive health impact in five years or less.172 Research has the elementary and middle school levels.175 Even where demonstrated the cost-effectiveness of such programs and standards are in place, however, schools are not necessarily their efficacy in preventing childhood obesity.173,174 in compliance. A 2016 Washington Post investigation Despite the documented benefits of PE, there are no found that only 10 of Washington, D.C.’s, more than 200 federal requirements for PE, not all states require students public and charter schools were meeting the law’s physical to participate in PE, and few states require a minimum education requirements.176 State Requires Physical Education for Elementary, Middle and High Schools WA§ MT ME§ ND VT§ OR* MN ID NH§ SD WI§ NY MA WY MI § CT§RI NE IA PA§ NJ§ NV OH§ DE§ UT IL IN CA§ MD CO§ WV§ State has minimum time requirements for elementary, KS MO VA§ DC§ KY middle and high schools NC§ State has minimum time requirements for elementary AZ TN§ § OK and middle schools NM AR SC§ GA§ State has minimum time requirements for elementary MS§ AL§ and high schools TX§ LA State has minimum time requirements for elementary, middle or high schools § FL AK State has no minimum requirements HI § State has student assessment in physical education or of physical fitness * State met national recommendations for weekly time in Source: SHAPE America and AHA Voices for Healthy Kids physical education TFAH • RWJF • StateofObesity.org 49 b. Recess State Requires Recess in Elementary Schools. Research has demonstrated that children benefit in numerous ways from having time to be physically active during the school day. In addition to increasing physical activity, recess helps students by increasing their attention in the classroom, reducing disruptive behavior, and providing opportunities for social and emotional development.177 The American Academy of Pediatrics describes recess as “a crucial and necessary component of a child’s development” and explains that “recess is unique from, and a complement to, physical education — not a substitute for it.”79 AAP specifically Yes No credits recess with helping students meet their recommended 60 minutes of daily physical activity, and thus lowering even in those states that require recess indoor recess, providing planned recess rates of obesity.79 time, sufficient free play time is not activities, involving students in planning necessarily guaranteed. and leading recess, and tracking Primary school recess requirements physical activity during recess.177 State are set at the state level, and only a In 2017, CDC, in partnership with and local policymakers and educators handful of states require schools to SHAPE America (Society of Health and can use these recommendations to help provide recess specifically, as opposed Physical Educators), released a report support recess in their local schools. to physical education or unspecified recommending strategies for planning Five states (Connecticut, Indiana, physical activity.175,178 In addition, many and providing recess in schools, Missouri, Rhode Island and Virginia) state laws group together requirements including documenting recess policies, have recess requirements. for recess and physical education, so designating spaces for outdoor and STATE PROFILE: Alaska The Alaska Department of Health and Social Services helps young Alaskans stay healthy through its Obesity Prevention and Control program. Initiatives include: l T he Play Every Day! Campaign, which l T he Healthy Futures Challenge, which l S upporting Alaskan schools by encourages children to engage in encourages kids to participate in school- providing physical education training to active play by educating parents about based physical fitness challenges, staff and teachers, assisting schools in the benefits of physical exercise and promotes physically active Alaskan developing and implementing wellness encouraging them to serve fewer role models, and supports low-cost policies, and supporting the serving of sugary drinks to their kids; community physical activity events; and local foods in Alaskan schools.179 50 TFAH • RWJF • StateofObesity.org c. Safe Routes to Schools In 1969, nearly half of American school children (47.7 percent) usually walked or biked to school. By 2009, that number had fallen to 12.7 percent.180 Safe Routes to School (SRTS), another of CDC’s HI-5 initiatives, promotes walking and biking to school by educating students and families about its benefits and ensuring that the school environment allows kids to do so safely. To implement an SRTS initiative, states, localities and school districts can compete for federal funding, which is available via a transportation alternatives set-aside funding under the Fixing America’s Surface Transportation (FAST) Act.181 SRTS programs have resulted in signif- icant improvements in active transpor- tation to school. One national review of SRTS programs found that three high-per- forming/achieving schools that adopted the program doubled the number of students walking and biking to school over In 2016, the Safe Routes to School a three year period — with walking rates National Partnership issued a report Nearly half of American school at 15 percent and biking at 2 percent as of card assessing states on how well they children walked or biked to 2012.182 Another review of SRTS programs support walking, biking, and active kids in Florida, Mississippi, Washington and and communities.184 Only three states — school in 1969, compared to Wisconsin found a significant increase in California, Minnesota and Washington only 12.7% in 2009. walking and biking rates in schools that — were awarded the top grade and had adopted the program, with walking to found to have “made a significant school increasing from 9.8 percent to 14.2 commitment to support walking, percent, and bicycling from 2.5 percent to bicycling, and physical activity and [are] 3.0 percent (as of 2014).183 providing support in multiple ways.”184 d. Shared Use One strategy for promoting physical can help reduce barriers to use by laying Kansas, Ohio, Oklahoma and Utah activity is the shared use of recreational out clear rights and responsibilities on go further and require shared use.184 facilities. For example, schools can make issues such as liability, maintenance, States can encourage shared use by their gymnasiums, tracks, fields and safety and scheduling.185 providing funding or other incentives playgrounds available for community to schools that share their facilities, Thirty states and Washington, D.C., use before and after school times and but Arkansas and Washington are the have laws encouraging schools to on weekends. This can be particularly only states to do this.184 In addition, make facilities available for use by helpful in low-income communities 42 percent of U.S. municipalities have the community through shared-use where there is less access to recreational shared use agreements.186 agreements, while Georgia, Maryland, opportunities. Shared use agreements TFAH • RWJF • StateofObesity.org 51 e. Health Assessments In order to monitor levels of childhood assessment programs in schools, but does obesity, a number of states have put in offer guidance on how to implement place school-based BMI measurement a program that provides appropriate programs. These can be used for safeguards for students.187 Fewer than half surveillance of population trends or of the states either require or encourage screening of individual patients for the collection of BMI data or have a purposes of intervention. CDC does not program in place to collect either BMI or make a recommendation regarding BMI height and weight information.175,188 5. ESSA Implementation In addition to its early childhood via formula and instead giving them components, the Every Student the option to award their funding Succeeds Act has elementary and competitively (where no school may secondary school provisions that can receive less than $10,000).190 help students maintain a healthy weight The law also authorizes a Promise by improving their nutrition and Neighborhood program to provide increasing their physical activity levels. “pipeline services” to low-income ESSA’s new Student Support and communities suffering one or more Academic Enrichment Grants can be signs of distress, which can include high used for health and physical education. rates of childhood obesity. ESSA’s Full- Districts receiving grants larger Service Community Schools Program than $30,000 must conduct a needs supports local school districts partnering assessment — which could include how with community-based organizations the school environment helps support to provide coordinated academic, nutrition and physical activity — and social and health services to improve must spend 20 percent of its grant on educational outcomes for children in safe and healthy school activities.189 neighborhoods facing high rates of Block grants will be distributed to states obesity and other challenges.110 under the Safe and Healthy Students ESSA allows schools the flexibility to program. School districts and schools choose how portions of their Title II can apply to their state department of professional development money is education for funding for a wide range allocated, which can include support for of safety, health and school-climate promoting health and wellness priorities, programs that include health education providing for additional school health and physical education. While the professionals, or educators and staff program is authorized at $1.6 billion training to support improving health.110 under ESSA, Congress provided only $400 million for Student Support State education agencies must also and Academic Enrichment Grants develop state accountability systems, which in fiscal year 2017 — necessitating must include at least one non-academic one year exemptions to several of the performance measure. For instance, requirements of the grant program, Connecticut’s system assesses physical including that States award their funds activity and chronic absenteeism.191 52 TFAH • RWJF • StateofObesity.org 6. CDC School-Based Initiatives CDC provides a number of resources to a wellness policy — which includes support schools in obesity-prevention supportive school nutrition and efforts. Some examples include: physical activity environments — if they participate in federal Child l A Virtual Healthy School (VHS), a Nutrition Programs.193 CDC has tool that allows school administrators developed profiles of 11 schools’ and policymakers to see policies wellness policy efforts.194 that can improve student health in (virtual) action. These include a l chool Health Index to allow schools to S virtual cafeteria offering healthy food conduct a self-assessment and plan choices and a virtual playground that school health initiatives.195 promotes physical activity. VHS is CDC also funds state-based school part of CDC’s Whole School, Whole obesity-prevention efforts. For example, Community, Whole Child model. every state is provided with federal l S chool Health Guidelines to Promote funding to support efforts to prevent and Healthy Eating and Physical Activity control obesity, heart disease and stroke, — a compendium of top strategies, known as State Public Health Actions or goals, best practices and resources for DP-13-1305 funding.196 The program’s schools and communities around the goal is to make it easy for Americans country to meet the needs of their to live healthy lives, and it focuses on students and utilize existing resources creating healthy environments in local within their local areas.192 institutions, including schools. School- based strategies to accomplish this l L ocal School Wellness Policy include adopting food service nutrition guidelines and support. Each local standards and promoting physical education agency or school district is education and activity in schools.197 required to develop and implement PROFILE: Whole School, Whole Community, Whole Child Model CDC’s Whole School, Whole Community, Whole Child coordination needed between school, health (WSCC) model is a collaborative approach to and community sectors as they develop learning and health. Recognizing a child’s policies that affect children. The blue health is linked to his or her academic section indicates the multiple school achievement, the model encourages components representing the full range communities, schools and families to of learning and health supports that work together to address children’s surround a child. Finally, the yellow educational and health needs. represents the community that exists around the school environment and This approach places the child at the provides needed resources and input.198 center, focusing on ways to help children be healthy, safe, engaged, challenged and supported. The white band indicates the Source: U.S. Centers for Disease Control and Prevention TFAH • RWJF • StateofObesity.org 53 C. COMMUNITY POLICIES & PROGRAMS Budgets for Some Key Federal Enacted Budget FY Enacted Budget FY Community-Based Obesity-Related Programs 2017 2016 Division of Nutrition, Physical Activity and $49.920 million199 $49.920 million129 Obesity (CDC) Chronic Disease Programs at CDC Including the Division of Nutrition, Physical Activity and $1.116 billion128 $1.177 billion129 Obesity and School Health Programs Healthy Food Financing Initiative $22 million200 $22 million200 $3.5 billion (for $7 billion (2015-2016 New Markets Tax Credits Calendar Year 2017)201 combined funding)202 SNAP (USDA) *$78.488 billion203 $80.839 billion203 *Estimated (vs. enacted) 1. Overview a. Importance of Place b. Food Deserts and Food Swamps While the causes of the obesity crisis Food deserts are areas where residents are complex, public health experts have little or no access to affordable, have become increasingly aware of the healthy food. Food deserts typically lack role that environmental factors play in nearby grocery stores and residents are obesity. For example, the place a person forced to rely on processed food from lives will help determine whether: convenience stores or fast-food retailers to feed their families. l P ublic transportation is available for commuting to work; The U.S. Department of Agriculture estimates that more than 23 million l T here are nearby supermarkets that Americans live in a low-income area that sell affordable, healthy foods; is more than a mile from the nearest l T here are sidewalks allowing children supermarket in urban areas and more to safely walk or bike to school; than 10 miles away in rural areas.204 About half of the people who live in l T here are nearby parks in which to such food deserts earn less than 200 play and exercise; percent of the poverty level.205 l L ocal schools provide free meals for Some communities can also be classified all students; as food swamps — areas that have an l T here is easy access to fresh, local overabundance of unhealthy food produce from a farmer’s market; options, such as fast-food and convenience stores, while having limited availability l L ocal roads include bike lanes; and of healthy options and fresh foods. For l P urchases of sugar-sweetened beverages instance, many low-income communities are discouraged through taxation. have nearly twice the number of fast-food restaurants and convenience stores as higher-income areas.206, 207, 208 The high availability of inexpensive and unhealthy options influence the choices that families in those neighborhoods make. 54 TFAH • RWJF • StateofObesity.org c. Impact of the Environment The term “built environment” means all The Community Preventive Services the physical aspects of the places where we Task Force, a group of public health live, work and go to school. The way our and prevention experts appointed by environments are built can help determine CDC’s director, has recommended our level of physical activity and influence built environment approaches that obesity rates. One simple example is stairs. combine transportation system When an apartment building or office interventions with land use and building has a centrally located, well-lit environmental design.210 In other elevator bank and a dark stairwell stuck in words, as communities update or plan a corner, people tend to take the elevator. new transportation systems, they should But when stairwells are clean, safe, well- do so in conjunction with land use lit and centrally located, research shows decisions in ways that make physical they are used more frequently.209 Research activity easier and more accessible. has unsurprisingly found a link between For example, if a town decides to built environments and obesity, with the build a bike path, it might build it so it odds of a child being obese or overweight connects a neighborhood to a nearby increasing by 20 percent to 60 percent park, encouraging families to bike if he or she lives in a neighborhood with instead of drive. Or it might install a unfavorable environmental aspects, sidewalk that allows people to walk to a such as poor housing, unsafe conditions light rail station, making it easier both and/or no access to sidewalks, parks and to walk and use public transportation. recreation centers.80 Access to Parks and/or Recreation Facilities Source:  Development of a Nationally Representative Built Environment Measure of Access to Exercise Opportunities, Preventing Chronic Disease, Vol 12211 TFAH • RWJF • StateofObesity.org 55 STATE PROFILE: Arizona In Arizona, the Department of Health nearly two-thirds (62 percent) of Services has engaged in a thoughtful Arizonans were overweight or obese, and methodical assessment of the plan included obesity prevention the state’s health needs and has as one of 10 public health priorities developed a plan to improve Arizona’s for the state. The plan describes how public health. It started by conducting the health department will work with a statewide assessment of the local communities to implement three state’s 15 counties and analyzing strategies: (1) enhancing the state’s quantitative and qualitative data to built environment to improve health; thoroughly understand the state’s (2) encouraging employers to adopt public health status.212 In 2016, the worksite wellness programs; and (3) Department presented a statewide supporting schools in promoting the Health Improvement Plan, based on health and safety of their students.213 the assessment. Recognizing that PROFILE: Encouraging Youth Sports Participation Organized sports programs provide a host of benefits for children. In addition to regularly scheduled physical activity, sports also provide children with the opportunity to build motor skills, develop self- confidence, and practice cooperation and teamwork. However, for many low-income families, program costs may prevent their children from joining. One study found that nearly one in five low-income parents reported a decrease in their child’s sports participation due to cost.214 Although fee waivers and scholarships are sometimes available, embarrassment at requesting aid and/or requirements to produce evidence of need may deter qualifying families from accessing aid. Maryland, made it easy to obtain a by 78 percent.215 When funding is A recent study demonstrated that waiver for sports registration fees — available to cover program costs, this removing cost barriers in a simple city residents simply had to click a box successful experiment easily could be way can dramatically increase youth to qualify — waivers increased 1,200 replicated to boost organized sports sports participation. When a city percent and program participation participation rates in other low-income youth sports program in Gaithersburg, in low-income schools increased communities. 56 TFAH • RWJF • StateofObesity.org 2. Community-Based Programs Schools and federal, state and local per person per year, as of FY 2017), while l C ommunity Development Financial governments support a number of more than 80 percent of the annual Institutions (CDFI) Fund, tax credits, community-based programs to help nearly $3 trillion in healthcare spending revolving loan funds, program-related address the obesity epidemic. Strategies is spent on individuals with one or more investments, social impact bonds and underlying these programs include chronic conditions (about $8,000 per pay-for-performance initiatives; and making healthy foods more available person per year for chronic disease).216 l A Wellness Trust or other formal and appealing, educating consumers Optimally, revenue sources, programs and structure where there is direct about healthy eating and food goals can be coordinated and leveraged community investment, from ingredients, supporting projects that for greater effect. For instance, partners in government support, tax revenue or bring grocery stores into food deserts, a community form a collaborative, where other ongoing sources. providing places for physical activity, one organization can take a lead partner and expanding public transportation. or “integrator” role, helping to manage Effective, evidence-based obesity- the program and use of resources for prevention and health improvement Community-based efforts are designed to strategies can lower healthcare costs and maximum effect and accountability. be flexible enough to address the needs improve the vitality of neighborhoods. of specific local areas — matching their Some additional potential financial For example, evidence-based community priorities and leveraging existing resources. partners and funding sources include: prevention programs that increase physical The most successful strategies bring key l T he healthcare system, including public activity, improve nutrition and prevent partners and assets together and take a and private providers and insurers, smoking could save the country more than comprehensive approach to maximize hospitals and community benefit funds $16 billion annually within five years — a impact. Multi-sector collaborations can (see discussion in Section D); $5.60 return for every $1 spent.217 include public health agencies, healthcare l S ocial service, housing, agriculture, A strong focus should be placed on early providers and payers, social services, transportation and/or environmental childhood policies and programs — private businesses, philanthropies, schools agencies via cross-sector opportunities; which can have the highest impact for and community groups — all of which have a vested interest and different l Businesses; setting the course for lifelong health — as expertise for improving the health and l C ommunity and philanthropic well as continued support through every vitality of a community. organizations; stage of life. For instance, working together, cross-sector partnerships can better address key issues, such as affordable Potential Sources for Funding for Local Obesity-Prevention and Health housing, quality education, income, Improvement Initiatives transportation, the availability of affordable, nutritious food, safe places Level 1: Traditional Grants Increasing Flexibility and Scalability to be physically active and other healthy Increasing Need for Coordination • Government Dedicated Revenue Streams conditions in neighborhoods. • Philanthropic There are a range of additional sources that can help provide investments and Level 2: Non-Traditional Funding resources for obesity-prevention efforts • Community Hospital Benefits • Medicaid and Commericial Health Insurance along with federal, state and local grants. Reimbursement It is essential to engage a broader set of private and public resources to be able Level 3: Innovative Financing Mechanisms to scale effective, evidence-based efforts • CDFI Community Development more broadly. The entire federal budget • Pay for Success for all chronic disease prevention activities at CDC is around $1.2 billion (about $4 TFAH • RWJF • StateofObesity.org 57 a. CDC Programs CDC supports a range of obesity- prevent and manage heart disease, l rograms to Reduce Obesity in High P prevention programs in communities diabetes and associated risk factors Obesity Areas (CDC-RFA-DP14-1416 around the country. The National in American Indian tribes and Alaska funding or High Obesity Program): Center for Chronic Disease Prevention Native villages.219 This three-year program, now in its and Health Promotion (NCCDPHP) final year, is a pilot program that funds l artnership to Improve Community P — including the Division of Nutrition, land grant colleges and universities in Health (PICH): Provided $220 million Physical Activity and Obesity (DNPAO) counties where the obesity rate exceeds from FY 2014 to FY 2016 to support — is the lead center working on 40 percent to conduct interventions evidence-based strategies to improve obesity prevention and control. at the county level.224 The agency has the health of communities and reduce NCCDPHP works in partnership with funded work in 49 counties, across 11 the prevalence of chronic diseases by other parts of CDC, including: states, reaching more than 1.8 million addressing tobacco use and obesity.220 l S chool Health Branch of the Division people. By identifying and addressing of Population Health; l acial and Ethnic Approaches to R risk factors — such as having less access Community Health (REACH): A to healthy foods and fewer opportunities l D ivision of Heart Disease and Stroke; and national program to reduce health to be physically active — the program l D ivision of Diabetes Translation. disparities, which provides funds to helps improve the long-term health of Some major CDC obesity-prevention community organizations, tribes, residents in these counties. Grantees programs include: universities, and state and local health collaborate with existing cooperative departments to implement culturally- extension and outreach services at the l tate Public Health Actions to Prevent S appropriate programs, including county level in their states to develop and Control Diabetes, Heart Disease, obesity-prevention efforts.221 obesity solutions. They put into action Obesity and Associated Risk Factors a set of evidence-based strategies in and Promote School Health (“DP13- l illion Hearts Campaign: A five-year M early care and education centers or the 1305 funding”): These grants fund national initiative, co-led by CDC and community setting. Activities include: state initiatives to coordinate the care the Centers for Medicare & Medicaid convening partners to assess community and prevention of these diseases across Services (CMS), aimed at preventing assets and needs and leverage resources; multiple community institutions, one million heart attacks and strokes providing training, technical assistance including schools, early childhood by 2022. The program estimates that and support for program development, centers, worksites and health systems.196 it prevented as many as 500,000 heart implementation and evaluation; events during the first five years of the l tate and Local Public Health Actions S evaluating and monitoring progress on program, 2012-2016.222 to Prevent Obesity, Diabetes and program implementation and assessing Heart Disease and Stroke (“1422” l reventive Health and Health P program effectiveness; and translating awards): This program helps state and Services (PHHS) Block Grant: This and communicating evaluation results local health departments implement program provides every state with for stakeholders, decision-makers, community-based obesity-prevention flexible support to address what they partners, funders and the public. The activities that complement activities determine to be their most important first round of grant recipients included receiving DP13-1305 funding.218 health needs. In FY 2016, nutrition colleges and universities in Alabama, and weight status was a top funded Arkansas, Georgia, Indiana, Kentucky, l ood Health and Wellness in Indian G health topic area, receiving more than Louisiana, North Carolina, South Dakota, Country (DP14-1421PPHF14): $10 million of PHHS grant funds.223 Tennessee, Texas and West Virginia.225 A five-year, $16 million program to 58 TFAH • RWJF • StateofObesity.org PROFILE OF HIGH OBESITY AREAS IN: ARKANSAS Estimated Adult Obesity Prevalence Poverty Levels ■ The estimated adult obesity prevalence in these counties ranges from Poverty levels are significant social determinants of health. 40.4 percent to 47.4 percent. The overall state adult obesity ■ Chicot, Jefferson, and Monroe counties are classified as “persistent prevalence is 34.5 percent. These 4 counties are between 30.9% and poverty” and “persistent-child-poverty” counties. 69 percent rural. County adult obesity % Population living % County population below % Children below County County population1 County prevalence2 in rural areas3 poverty line5 poverty line5 Chicot 11,800 47.4% 54.3% Chicot 32.4% 45.0% Craighead 96,443 40.4% 32.2% Craighead 21.5% 31.5% Jefferson 77,435 40.9% 30.9% Jefferson 24.5% 37.3% Monroe 8,149 42.5% 69.0% Monroe 30.2% 46.8% Selected Racial/Ethnic Demographics in High Obesity Counties High Obesity Counties of Arkansas in Arkansas 100 80 60 40 20 0 Chicot Craighead Jefferson Monroe Craighead ■ Percent White (non-Hispanic/Latino) ■ Percent Black Monroe Jefferson Chicot TFAH • RWJF • StateofObesity.org 59 PROFILE OF HIGH OBESITY AREAS IN: ALABAMA Estimated Adult Obesity Prevalence Poverty Levels ■ Ranges from 40.2 percent to 48.9 percent. The overall state adult Poverty levels are significant social determinants of health. obesity prevalence is 33.8 percent. ■ Nine of these counties are classified as “persistent poverty” counties ■ Children in rural areas are 25 percent more likely to be overweight or by the US Census Bureau. obese than children in metropolitan areas. ■ All but Coosa and Cullman counties are classified as “persistent child-poverty counties” by the US Census Bureau. ■ All but Chambers County are between 51 percent and 100 percent rural. County adult obesity % Population living % County population below % Children below County County population1 County prevalence2 in rural areas3 poverty line5 poverty line5 Barbour 27,457 40.5% 67.8% Barbour 26.7% 44.1% Bibb 22,915 41.4% 68.4% Bibb 18.1% 30.8% Bullock 10,914 48.5% 51.4% Bullock 21.6% 31.9% Chambers 34,215 41.4% 49.1% Chambers 24.1% 42.1% Coosa 11,539 41.7% 100.0% Coosa 20.9% 30.4% Crenshaw 13,906 44.8% 100.0% Crenshaw 19.1% 24.8% Cullman 80,406 40.3% 73.2% Cullman 18.8% 25.8% Escambia 38,319 44.7% 63.5% Escambia 25.4% 37.4% Greene 9,045 47.4% 100.0% Greene 32.9% 56.0% Lowndes 11,299 42.5% 100.0% Lowndes 26.7% 37.6% Macon 21,452 40.2% 55.5% Macon 27.3% 43.5% Pickens 19,746 41.7% 100.0% Pickens 27.2% 36.7% Sumter 13,763 45.0% 100.0% Sumter 38.0% 46.9% Wilcox 11,670 48.9% 100.0% Wilcox 39.2% 50.3% Selected Racial/Ethnic Demographics in High Obesity Counties High Obesity Counties of Alabama in Alabama Bullock, Greene, Lowndes, Macon, Sumter and Wilcox are located in the mid-section of Alabama known as the “Black Belt.” These are counties that, historically, have majority Black populations. Cullman 100 80 Pickens 60 Bibb Chambers Coosa 40 Greene 20 Sumter Macon Lowndes 0 Bullock Barbour Bibb Bullock Chambers Coosa Crenshaw Cullman Escambia Greene Lowndes Macon Pickens Sumter Wilcox Wilcox Barbour Crenshaw ■ Percent White (non-Hispanic/Latino) ■ Percent Black Escambia 60 TFAH • RWJF • StateofObesity.org STATE PROFILE: Alabama Alabama — which has had one of the highest obesity rates in them easier to identify with a “good choice” sticker.231 These the country — is working to address the epidemic. It has created changes have reached nearly 30,000 people in Alabama.232 a state Obesity Task Force to support programs, advocacy In addition, Auburn University, with funding from CDC’s and environmental changes, including by: High Obesity Program, has collaborated with the l D eveloping a guide to assist Alabama employers university’s extension program and other community in creating workplace wellness programs;229 partners to form ALProHealth: Alabama Preventing and Reducing Obesity: Helping to Engage l elping launch Get Moving Alabama, a public H Alabamians for Long-Term Health. This initiative awareness campaign to increase physical is helping create obesity-prevention and control activity and promote a healthy lifestyle throughout activities in 14 Alabama counties with rates of Alabama; and230 obesity exceeding 40 percent, including: l C reating the Alabama Healthy Vending Machine Program, l C ommunity and school gardens; in partnership with Auburn University and the Supplemental Nutrition Assistance Program Education (SNAP-Ed), to educate l H ealthy vending and concessions; employers about the benefits of healthy vending options. l F armers’ markets and other healthy retail options; and The program has increased the number of healthy items in vending machines at 13 worksites across the state and made l S afer and more trails for walking.233 STATE PROFILE: Mississippi The state of Mississippi has one of implementing several obesity-prevention l W orking with the Mississippi the highest rates of obesity in the initiatives, including: Department of Education to implement United States. It has one of the highest physical activity and nutrition policies; l P roviding assistance to state hospitals to adult rates in the country and has the help improve their breastfeeding rates; l C ollaborating with Blue Cross and Blue highest childhood obesity rate in the Shield State and School Employees’ nation among children ages 10 to 17 l D eveloping a healthy catering policy for Health Insurance Plan to implement a (21.7 percent) and among high school foods and beverages served at state wellness plan for state employees; and students (18.9 percent).226 health department events and meetings; l P artnering with the Mississippi Mississippi also has high rates of l H elping early childhood centers increase Department of Rehabilitation obesity-related health problems. It children’s physical activity levels; and Services to establish a healthy has a higher rate of diabetes than l C onducting and evaluating an eight- catering and vending initiative. Since any other state (14.7 percent) and its week fitness pilot program, which implementation of this program, hypertension rate (42.4 percent) ranks resulted in a 3 percent decrease in more than 95 percent of state second.226 Mississippi also has the weight and a 4 percent decrease in agency vending machines include Fit lowest breastfeeding rates in the nation, blood pressure among participants.227 Pick snack selections, which help with only 52.0 percent of babies born consumers make healthier choices.228 in 2013 ever breastfed and 9.3 percent The Mississippi Department of Health breastfed exclusively at 6 months.120 has also collaborated with other With these programs, the state health state government offices and external department is working hard to increase With State Public Health Actions organizations to implement obesity control the number of Mississippians living at a funding from CDC, Mississippi has been and prevention initiatives, such as: healthy weight. TFAH • RWJF • StateofObesity.org 61 EXAMPLES OF PROGRAMS TO REDUCE OBESITY IN HIGH-OBESITY AREAS l T he University of Arkansas l L ouisiana State University (LSU) and Cooperative Extension Service works their agriculture extension partners, with four County Extension Offices to including the LSU AgCenter and the promote and increase access to healthy Southern University AgCenter, as food and more active lifestyles. The well as the Louisiana Department Extensions and their partners promote of Health and Hospitals, work with acceptance of Supplemental Nutrition three parishes to implement the Assistance Program Women, Infants Healthy ABCs program. Community and Children benefits at food retailers assessments serve to tailor each and work with retailers and farmers’ program to increase access to markets to promote programs such healthy food and physical activity as Cooking Matters at the Store and opportunities. The Healthy ABCs Faithful Families Eating Smart and program provides training and Moving More. The Extensions are also technical assistance on interventions working with faith-based groups and city such as the Louisiana Department government planners and programs, of Health and Hospital’s Well Ahead such as Kids Walk Across Arkansas and program, Let’s Eat for the Health of Yoga for Kids to create and enhance It, Dining with Diabetes, Organwise safe places for physical activity.234 Guys, Smart Portions, Family Nutrition Night, SNAP-Ed C.H.E.F camp and l T he University of Kentucky community garden work. Communities Cooperative Extension Service is will create promotional campaigns to convening multi-sector community encourage physical activity, using the partners to promote healthier Let’s Move! Faith and Communities food options at local retail stores, toolkit to identify physical activities provide incentives to buy fruits and for their communities and joint-use vegetables at farmers’ markets, agreements to increase access to enhance existing park and recreation more locations for physical activity.236 amenities, and plan and implement Source: CDC more walking and biking trails.235 62 TFAH • RWJF • StateofObesity.org b. Fiscal Policies and Innovative Financing Strategies 1. Taxes and Subsidies California implemented a penny-per- Sugar-sweetened beverages account for ounce excise tax on sugar-sweetened Every 10% decrease in the approximately 40 percent to 50 percent beverages in 2015. Four months after cost of fruits and vegetables of the excess sugar in Americans’ diets, implementation, consumption of these beverages in low-income Berkeley increases their purchase by 14%. so reducing their consumption could have a significant effect on public neighborhoods had decreased by 21 health.33 One study found that, if every percent, while water consumption had percent reduction in the cost of other American reduced their sugar-sweetened increased 63 percent.241 One year after healthy foods increased their purchase beverage consumption by three 12-ounce implementation, sales of taxed sugar- by 16 percent. Moreover, subsidizing drinks per month, there would be 2.6 sweetened beverages had fallen by 9.6 the cost of fruits and vegetables was million fewer obese Americans, saving percent while sales of untaxed beverages shown to effectively reduce BMI, with the country more than $25 billion in rose 3.5 percent (driven by a 15.6 a reduction of 0.04kg/m2 for every 10 healthcare costs over the next 15 years.237 percent rise in sales of water). In relation percent decrease in price.239 Soda sales in the United States have to comparison cities without such a tax, declined for the past 12 years in a row.238 Berkeley did not see a decrease in stores’ Double Up Bucks, a SNAP-doubling revenue or an increase in consumers’ program, utilizes the proven theory Providing consumers with financial average grocery bill.242 The Berkeley that healthy food purchases can be incentives to make healthier food tax revenue has helped fund cooking, incentivized.244 The program is simple: it choices has proven effective. A 2017 gardening and nutrition programs in doubles the value of SNAP benefits when review of 30 studies measuring the public schools and health promotion they are spent on fruit and vegetables at effect of food subsidies and taxes found programs sponsored by community participating grocery stores and farmers’ that a 10 percent tax increase on sugar- groups, including Healthy Black Families markets.245 The program helps stimulate sweetened beverages reduced their and the YMCA.  the bottom lines of participating retailers sale by 7 percent.239 The same review while improving the public health of the found that raising taxes on unhealthful Other jurisdictions that have surrounding communities. food generally (such as fast food) has implemented volume-based taxes on also proven successful, with every 10 sugar-sweetened beverages include Alameda County in East Oakland, percent price increase reducing sales Philadelphia, Pennsylvania (1.5 cents per California has a Measure A Essential by 6 percent.239 ounce), Boulder, Colorado (two cents per Health Care Services Tax — a half-cent ounce), Cook County, Illinois (one cent sales tax passed by California voters in 2004 Many taxes on unhealthy food and per ounce), Seattle (1.75 per ounce) and to support public health efforts, emergency beverages are too small to have a three additional cities in the California medical, hospital inpatient and outpatient, significant effect on purchasing behavior. Bay Area: San Francisco, Oakland and and mental health and substance use However, two recent jurisdictions that Albany (one cent per ounce).243 services for low-income individuals in the implemented volume-based excise country.246 The revenue from the tax helps taxes on sugar-sweetened beverages In addition to discouraging consumers support the ability of the Alameda County experienced significant behavioral from purchasing unhealthy foods, fiscal Public Health Department to serve as a changes. Mexico implemented a policies can also incentivize healthy Host Hub of the California Endowment’s peso-per-liter tax on sugar-sweetened choices by lowering the cost of nutritious Building Healthy Communities initiative beverages in 2014, which was followed foods. Research has demonstrated that — part of a 10-year, $1 billion place-based by a 7.6 percent reduction in the every 10 percent decrease in the cost initiative supported by the California purchase of these drinks over the of fruits and vegetables increased their Endowment (See more in philanthropic following two years.240 Berkeley, purchase by 14 percent, while a 10 investments section below).247 TFAH • RWJF • StateofObesity.org 63 2. Healthy Food Financing Initiative The Healthy Food Financing Initiative (HFFI) works to bring State awarded Healthy Food Financing Initiative grants, grocery stores to urban and rural communities that lack access from 2011 to 2016 to affordable, healthy food. It also assists retailers in selling healthy food in these communities. Three federal agencies — HHS, USDA and the Treasury Department — make funding available for these projects. HHS awards competitive Community Economic Development grants that serve the dual purposes of stimulating job and business development in low-income communities and helping ameliorate food deserts. USDA provides financial and technical assistance to food retailers to increase the availability of local foods and to help stimulate demand for healthy foods. The Treasury Department’s Community Development Financial Institutions Fund provides funding and technical assistance to CDFIs that invest in businesses that sell healthy foods.248 Yes No LOCAL PROFILE: Jim’s Local Market — Newport News, Virginia A 2014 study by Virginia Tech and Virginia State University financial institution Virginia Community Capital.250 Jim’s Local found that the cities of Newport News and Hampton, Virginia, Market is a source of affordable and healthy food for an have higher rates of food insecurity than the rest of the state underserved neighborhood and has created 26 full-time jobs, (17 percent versus 12.7 percent). The southeast section of most of which have been filled by local residents.249 Newport News has also been a food desert since the only area The market has also provided services to help revitalize grocery store closed in 2014. The nearest supermarket was a the neighborhood, including a community room for local Walmart five miles away and separated from the neighborhood organizations to use and a branch of Bayport Credit Union right by an eight-lane road.249 in the market. Thanks to a partnership with nonprofit health That all changed in May 2016, when experienced grocer Jim system Bon Secours, the store also hosts healthy eating Scanlon opened a new full-service grocery story in southeast courses in its community room and financial literacy training Newport News with help from the community development offered by Bayport.250 3. New Markets Tax Credit The New Markets Tax Credit (NMTC) lack access to affordable, healthy food helped finance 49 grocery stores and is designed to encourage investment and safe places to play and exercise, seven fitness or recreation facilities in low-income communities. By this program can help remove some nationwide.251 Between 2003 and incentivizing companies to build of the barriers to a healthy life that 2015, $42 billion in direct NMTC projects such as supermarkets or exist in low-income communities. investments were made in low-income fitness facilities in communities that Between 2003 and 2010, the NMTC communities.252 64 TFAH • RWJF • StateofObesity.org 4. Wellness Trusts A number of groups have proposed Once community prevention efforts the model of establishing a Wellness demonstrate savings, some models or Health Trust — a pool of funds set suggest that a portion of savings could be aside to finance evidence-informed reinvested in the Wellness Trust, providing community prevention in a strategic one source of funding. Having multiple and coordinated way — that does not funding streams can increase participation rely on federal grants or state general and flexibility, and reduce vulnerability to revenue, but rather provides a steady, the loss of any single funding stream. Other predictable source of funding.253, 254, 255 considerations in establishing Wellness Funds for proposed Wellness Trusts can Trusts include administrative oversight and be raised in different ways from various transparency; community engagement; public and private sources, including deciding on priority activities and how taxes or fees on products with known funds will be distributed; ultimately health risks (such as tobacco), private or creating a balanced portfolio of prevention corporate philanthropy, fees charged to investments that include interventions with health insurers or hospitals, community short-, medium- and long-term returns benefit funds from hospitals, voluntary on investment; assessing process and contributions or purchases, and legal outcomes; and capturing and reinvesting penalties or settlements. savings in community prevention.254, 255 LOCAL PROFILE: Massachusetts Prevention and Wellness Trust The Massachusetts Prevention and evaluation. The Department of Public Wellness Trust Fund was the first Health oversees the fund, in consultation established state-based trust — a with an Advisory Board established four-year, $60 million commitment to specifically for the Trust. Public comment community prevention and wellness meetings were also held to facilitate efforts, financed via a one-time public participation.256 Through a assessment on the state’s large insurers competitive application process, four- and hospitals. The Trust was established year grants from the Trust were awarded by the passage of new healthcare cost to nine community partnerships in containment legislation in 2012, and thus January 2014, in the amount of up to did not require annual approval through an $250,000 for the first phase and a appropriations process. Identified health potential additional $1.5 million for each priorities for the Trust included tobacco of the following three years. Applicants use, childhood asthma, hypertension and were required to demonstrate robust elder fall prevention. At least 75 percent community-clinical linkages as well as of the funds were awarded in grants to outline their plans to improve health local communitywide initiatives, up to 10 outcomes and reduce costs related to percent was used for workplace wellness at least two of the four priority health efforts, and up to 15 percent was conditions: to reduce health disparities spent on grant administration, including and to sustain their efforts.257 TFAH • RWJF • StateofObesity.org 65 5. Pay-for-Performance and Social Impact Bonds Pay-for-performance models are this mechanism, the government the government pays the bond-issuing innovative mechanisms for addressing identifies a challenge and contracts with organization back based on whether social challenges — where through a private-sector financing intermediary established performance targets are contracts or loans, the government pays to issue a bond to obtain social services met — and the investors are repaid with for the delivery of certain services based to address the challenge.260, 261 The a certain rate of return for taking on on positive, measured performance social service might be a local program the risk.260, 261 The goal is for successful outcomes.258, 259 There are not any current that has demonstrated success and can programs to allow investors to get their pay-for-performance programs that focus be expanded, or one that has worked money back and earn a return, for the on obesity, but it is one mechanism being elsewhere and can be replicated.260 government to address a policy priority explored for potential investments. The bond-issuing organization then and possibly achieve long-term savings, raises the funds to finance costs of the and for the larger community to benefit Social impact bonds are one form of a program from private investors. Finally, from improved social outcomes.260 pay-for-performance approach. Through LOCAL PROFILE: South Carolina Nurse-Family Partnership The South Carolina Department of results are found, South Carolina (state in the state) and a consortium of private Health and Human Services launched government) will make up to $7.5 million funders, along with technical assistance a pay-for-success initiative in February in success payments to sustain Nurse- from the Government Performance Lab at 2016 to improve health for mothers and Family Partnership’s services.263 Funding the Harvard School of Government and children living in poverty262 by sending sources include a 1915 (b) Medicaid a randomized control trial evaluation by trained nurses to conduct home visits waiver that will contribute approximately Massachusetts Institute of Technology. with vulnerable, first-time mothers $13 million and a combined $17 Evaluation metrics will include: from early pregnancy through a child’s million from the BlueCross BlueShield reduction in preterm births; reduction second birthday. Over six years, they will of South Carolina Foundation, the Duke in child hospitalization and emergency expand the evidence-based Nurse-Family Endowment, Greenville First Steps, department use due to injury; increase Partnership to an additional 3,200 low- Children’s Trust Fund of South Carolina, in healthy spacing between births; and income mothers. The project is mobilizing Laura and John Arnold Foundation, the increase in first-time mothers living in $30 million in funds, and, if positive Boeing Company (which manufactures poverty who are served by the program. 6. Philanthropic Investments A number of national and regional for more than a decade, RWJF made and business leaders, the foundation is philanthropic institutions also invest investments to build initiatives and working to advance changes in public in state and local efforts to prevent strategic partnerships to ensure that all policy, community environments and and reduce obesity — and the factors children grow up at a healthy weight. In industry practices that can help children that contribute to it. For instance, alliance with a growing coalition of civic have a healthy start in life. 66 TFAH • RWJF • StateofObesity.org EXAMPLES OF PHILANTHROPIC INITIATIVES TO SUPPORT LOCAL HEALTH IMPROVEMENT EFFORTS Building Healthy Communities (BHC) is a 10-year, $1 billion These teams each have two coaches to guide, support and place-based initiative of The California Endowment working in 14 facilitate the team through its process, including a coach from California communities to promote prevention policy, system and YMCA, as well as one of the partnering institutions. There are environmental changes through cross-sector collaborations and currently 129 communities participating in PHC. community engagement. Launched in 2010, BHC aims to reduce The Blue Zones Project is a community improvement initiative health inequities through improvements in neighborhood safety, that brings together community leaders and citizens to impact unhealthy environmental conditions, access to healthy foods, the environment, policy and social networks to help make healthy education, housing and employment opportunities. Each BHC choices easier.269 Each certified Blue Zones Community implements appoints a BHC Hub Host to act as the central coordinator for long-term, evidence-based policies and interventions to improve the implementation of health improvement initiatives.247 A five-year built environment; create and enforce health-promoting municipal review of BHC found some key achievements: improved coverage policies and ordinances; form and nurture social groups that support for the underserved; strengthened health coverage policy for the healthy habits; and build healthier options in schools, grocery stores undocumented; school climate, wellness and equity improvements; and workplaces. Current project sites include California, Florida, prevention and reform support in the justice system; public-private Hawaii, Iowa, Minnesota, Oregon, Texas and Wisconsin. investments and policy changes for boys and young men of color; and local and regional progress in “health in all policies.”264 Voices for Healthy Kids works with communities across the country to make it easy and enjoyable for children to eat healthy foods and be Invest Health, a collaboration between Reinvestment Fund and active where they live, learn and play. VFHK supports policy changes RWJF, incorporates health into community development by providing and provides technical assistance, capacity-building and public $60,000 grants, technical assistance and other support to new education. A 2016 study found that VFHK financial and technical multi-sector partnerships in 50 mid-sized cities across the country. support could increase the chances of passing state policies to The goal is to increase and leverage private and public investment improve the nutrition and physical activity environment by 50 percent. in neighborhoods facing the biggest barrier to health, particularly Recent state and local policies passed with VFHK support include by helping these cities attract capital to advance systems-focused securing $3.5 million in funding for Safe Routes to School in Oregon, strategies, and by helping them use data as a driver for change. prioritizing investments in walking and biking in the Los Angeles Grantees will bring together multiple sectors over 18 months to County Transportation Improvement Plan, and requiring healthy collect data, test solutions and advance strategies that address offerings in vending machines on Baltimore city property. VFHK is a factors that drive health in low-income neighborhoods, including joint initiative of RWJF and the American Heart Association.270 a lack of quality jobs, affordable housing and nutritious food, high crime rates and unhealthy environmental conditions.265 At the end The Alliance for a Healthier Generation’s Healthy Schools of the grant period, the cities are expected to have investment plans Program provides schools with wellness modules that combine and interested investors. Reinvestment Fund, one component of the latest research on childhood health with the most effective the project, is a Community Development Financial Institution that school policies, giving schools an action framework to create manages $946 million from over 850 investors to support low- and sustain healthy environments and improve the health of income communities through investments, real estate development, their students. The program is being used by more than 31,000 data analysis and advocacy.266 Reinvestment Fund’s investments schools nationwide,271 and a 2015 study found that the more have generated 71,550 jobs; 17 million square feet of commercial schools engaged with the program, and the longer they engaged, space; and 163 supermarkets, grocery stores and fresh food retail.267 the greater reductions they saw in student rates of obesity.272 Pioneering Healthier Communities (PHC) initiative uses funding The Kids’ Safe and Healthful Foods project provides nonpartisan from CDC and corporate and foundation donors to support a analysis and evidence-based recommendations to ensure that all collaborative community process to develop policy, system and foods sold in schools are safe and healthy and that the USDA adopts environmental changes that promote healthy living.268 Launched rigorous school food safety policies and science-based nutrition in 2004, PHC empowers communities with strategies and mod- standards. The project also helps give schools the resources they els to support sustainable change in their communities. Partic- need to train cafeteria employees and replace outdated and broken ipating YMCAs, as major partners, bring together a cross-sector kitchen equipment. The Kids’ Safe and Healthful Foods project is a team of leaders from the private, public and nonprofit sectors. joint initiative of RWJF and The Pew Charitable Trusts.273 TFAH • RWJF • StateofObesity.org 67 c. HHS, USDA and FDA Obesity-Prevention and Nutrition Education Initiatives 1. Dietary Guidelines date of the rule has been delayed. In 2015, HHS and USDA jointly released In May 2017, just before the rule was the eighth edition of the Dietary scheduled to start being enforced, the Guidelines for Americans (DGA). FDA announced it would push back Nutrition Facts Guidelines are revised every five years the effective date of the menu labeling 8 servings per container Serving size 2/3 cup (55g) to reflect the latest assessments of requirements until May 7, 2018, in Amount per serving Calories 230 nutrition science. The 2015-2020 edition order “to consider how we might further Total Fat 8g % Daily Value* 10% Saturated Fat 1g 5% emphasizes the idea that Americans reduce the regulatory burden or increase Trans Fat 0g Cholesterol 0mg 0% Sodium 160mg 7% should shift food choices toward more flexibility” of the rule.276 Total Carbohydrate 37g Dietary Fiber 4g 13% 14% Total Sugars 12g nutrient-dense foods and beverages in Recent studies on consumers’ support Includes 10g Added Sugars Protein 3g 20% place of less healthy choices.32 for providing nutrition information Vitamin D 2mcg Calcium 260mg 10% 20% Iron 8mg 45% Potassium 235mg 6% Most federal food programs are required at the point of purchase, awareness * The % Daily Value (DV) tells you how much a nutrient in a serving of food contributes to a daily diet. 2,000 calories a day is used for general nutrition advice. by law to have nutrition standards that of nutritional information, purchase meet the DGA, including CACFP, the intentions and actual purchases find:277 National School Meals Program and l M ost customers and the majority of WIC. The guidelines also highlight the general public want restaurants Source: FDA the importance that all sectors play in and cafeterias to have menu labeling; helping Americans meet healthy eating l C ustomers rarely seek out nutrition requirements for packaged food in and physical activity recommendations. information from sources not available 2016.278 Though originally scheduled to In December 2015, Congress directed at the point of purchase, such as take effect for most products in July 2018, the National Academy of Medicine (then websites or brochures, but they do see the FDA announced in June 2017 that the Institute of Medicine) to conduct a menu labels at the point of purchase the deadline would be delayed and no review of the process by which HHS and and those labels increase their new timing has been announced.279 The USDA develop the Dietary Guidelines.274 awareness of nutritional information; changes to the nutrition label include: The Committee to Review the Process E vidence from surveys and simulation l D esigning changes to make it easier to to Update the Dietary Guidelines for l studies suggests menu labeling reduces identify calorie count and serving size; Americans is conducting an 18-month review study that began in late 2016. calories purchased or consumed, but l R equiring “added sugars” (sugars and evidence from real-world cafeteria and syrups added to foods or beverages 2. Menu Labeling restaurant studies regarding calories when they are processed or prepared, purchased or menu items selected is not including naturally occurring Recognizing that many consumers do not mixed; and sugar) to be listed; know — or underestimate — the calories in foods, and to enable consumers l T he impact of menu labeling is not l M odifying the list of required to make informed and healthy food uniform. Research has found it may nutrients (adding Vitamin D and choices, the Affordable Care Act’s (ACA) have a greater effect on women than potassium, making Vitamin A and nutrition labeling provisions require men, on higher-calorie items and among C voluntary) to reflect the latest large chain restaurants, convenience certain types of restaurant chains. nutrition science; and stores and grocery stores to list the calorie count of ready-to-eat items sold 3. Food Labels l U pdating serving size requirements.278 on the premises.275 While the FDA To better reflect the latest scientific These new requirements represent the first published a rule implementing this knowledge about healthy eating, the comprehensive update to the nutrition requirement in 2014, the compliance FDA updated the Nutrition Facts label label in more than two decades.278 68 TFAH • RWJF • StateofObesity.org d. Operation Live Well and Healthy Base Initiative Operation Live Well (OLW) is the places of worship and morale, welfare measured results and provided lessons Department of Defense’s (DoD) and recreation programs.280 and recommendations for OLW.281 In a prevention initiative to promote health, survey of more than 600 employees at one The initiative includes demonstration well-being, and readiness among service of the HBI sites (the Defense Logistics projects such as the Healthy Base Initiative members and in military communities. Agency (DLA)), 93 percent of employees (HBI), which was implemented at 14 DoD OLW brings together the resources and said the initiative helped change their sites worldwide. The initiative assessed capabilities of local military communities, behaviors, including eating habits and health and wellness status in the selected including commanders, health and physical activity, while 83 percent used sites, tested evidence-based initiatives medical experts, commissaries and the farmers’ market(s) and 65 percent (to reduce obesity and tobacco use and dining facilities, education resources, participated in the stairwells program.280 improve fitness, readiness and resilience), OBESITY AND MILITARY READINESS Mission: Readiness — a set of retired admirals and generals — has warned that the obesity crisis threatens the future UNFIT TO SERVE strength of our military and that more OBE SI T Y than 70 percent of today’s youth are IS IMPACTING NATIONAL SECURITY not fit to serve in the military.10 Indeed, THE PROBLEM being overweight or obese is the leading cause of medical disqualifications from Almost 1 in 5 children Only half of adults Nearly 1 in 4 and more than and about one young adults are the military, with 23 percent of armed 1 in 3 adults quarter of youth too heavy to serve in the U.S. struggle get recommended in our military. services applicants rejected because with obesity. amounts of aerobic physical activity. of excessive weight or body fat.9 The number of overweight and obese active duty service members increased by Over the last decade, we have experienced increasing difficulty in recruiting soldiers due to the 61 percent between 2002 and 2011, decline in the health of our nation’s youth. Unless we see significant change in physical activity and threatening our military’s ability to nutrition in America our national security will be affected. deploy.282 Research has estimated that Mark Hertling, Lieutenant General, U.S. Army (Retired) overweight and obese service members cost the armed services $1.1 billion in INELIGIBLE TO SERVE medical costs and $105.6 million per 71% year in lost productivity.42 Obesity causes 3 most common reasons young people are ineligible. 658,000 lost workdays per year for active duty personnel.282 The authors of “Too Fat To Fight,” a 2010 letter from a group of retired admirals 71% of young people in the U.S. would not be able to Overweight or Educational Criminal or drug and generals warning that the obesity join the military if they wanted to. obesity (31%) deficits abuse record crisis threatens the future strength of our military, reminded readers that National School Lunch Act, because security. They conclude that the ability OBESITY IMPACTS MILITARY READINESS military concerns about good nutrition he understoodamong providingservice members has Obesity that active duty American of the military to recruit fit and strong risen 61% between 2002 and 2011. are not new. In the 1940s, the letter children with healthy, nutritious to be medically These individuals are less likely meals young men and women to serve requires explains, General Lewis Hershey was 61% would increase theirready to deploy. weight height and addressing the obesity crisis.283 a leading advocate of the original and therefore help ensure our national Both obesity and low levels of physical fitness increase the risk for injury among active military personnel. TFAH • RWJF • StateofObesity.org 69 e. Complete Streets Walking and biking to work or school can be an easy way to Complete Streets, State has adopted a complete incorporate more physical activity into a person’s life. However, streets policy. many communities were designed around the automobile, making safely walking or biking a challenge. Complete Streets is a transportation and design approach that focuses on making streets accessible to all, so that not just drivers, but also walkers, bikers and people in wheelchairs can safely travel through their communities. Congress recognized the value of this approach by including Complete Streets language in the Fixing America’s Surface Transportation Act, a $305 billion transportation bill passed in 2015. The bill requires the National Highway System to take all types of transportation into account when designing new roads, which will make our nation’s transportation systems safer for people walking, biking and using wheelchairs.284 Yes No LOCAL PROFILE: Making Phoenix Safer for HIGH IMPACT INITIATIVE: EXPANDING PUBLIC Walking & Biking TRANSPORTATION Recognizing that making streets safer and more accessible increases physical activity and fosters community engagement, Vitalyst Health Foundation supports efforts to build Complete Streets in Phoenix and throughout the state of Arizona.285 Their work has included: Introducing or expanding public l H elping pass two city ordinances that require the city to transportation has been shown Taking public use Complete Streets principles in designing transportation to increase physical activity, improvements, including street lighting and other transportation can and is one of the high-priority pedestrian and bicycle safety measures; lead to 33 minutes of HI-5 CDC community prevention l W orking with the newly created Complete Streets Advisory programs. 287 Research has extra walking per day. Board to implement these improvements; and found that people using public transportation often walk or l D eveloping a Complete Streets policy guide to help bike at either end of the trip — building more physical activity educate stakeholders and the public about the benefits into their daily routine. A review of 10 years of studies of the of Complete Streets.286 relationship between public transportation and physical activity With these efforts, Vitalyst hopes to make Phoenix a found that using public transportation results in 8 to 33 minutes healthier city for its residents to live, work and play. of additional walking per day.288 Public transportation is typically a local or regional responsibility, but is often supported by state and/or federal funding. 70 TFAH • RWJF • StateofObesity.org f. Nutrition Assistance The Supplemental Nutrition Assistance Program, formerly known as the Food Stamp Program, is our nation’s largest nutrition assistance effort, helping feed more than 42 million low-income Americans each month.289 The federal government funds the benefits and splits the cost of administering the program with the states.290 SNAP serves as a safety net and ensures millions of Americans have access to and can afford nutritious food.289 Approximately three-quarters of SNAP benefits go to families with children. SNAP kept around 8.4 million people out of poverty — including 3.8 million children — in 2014 (most recent available year), according to an analysis by the Center on Budget and Policy Priorities.291 From 2008 to 2012, 14.6 percent of rural households received SNAP benefits.292 That is a higher percentage than households receiving SNAP in both metropolitan and small l P roviding SNAP benefits to students city areas. Studies have found that: eligible for free or reduced-price school l S NAP benefits can reduce food meals cut very low food security among insecurity — allowing low-income these children by nearly one-third; families to be able to spend more on l Y oung children in food insecure food. One study found that SNAP households receiving SNAP benefits are reduced households’ food insecurity less likely to be in poor or fair health, by 5 to 10 percentage points and very overweight or at developmental risk low food security (skipping meals due than children in food insecure homes to inability to purchase food) by 5 to not receiving SNAP benefits;293,294 6 percentage points. Another study found SNAP helped reduce food l C hildren who had access to food insecurity among high-risk children by assistance in early childhood and 20 percent and improve their overall whose mothers had access during self-sufficiency (as measured by a health status by 35 percent; their pregnancy were more likely to combination of employment, income, graduate from high school;295,296 and l A dults who had access to SNAP as young poverty status, high school graduation children reported better health and had and program participation), according l M others in food insecure households lower rates of “metabolic syndrome” to an analysis by the Center on Budget that receive SNAP benefits are less (a combined measure of the incidence and Policy Priorities;291 likely to experience symptoms of of obesity, high blood pressure, heart maternal depression and are less l S mall incentives via the SNAP program disease and diabetes), and women who likely to be in poor or fair health than (an extra 30 cents on the dollar spent had access to food stamps as young mothers in food insecure households on produce) increased fruit and children reported improved economic not receiving SNAP benefits.293 vegetable consumption by 26 percent; TFAH • RWJF • StateofObesity.org 71 Additionally, all states participate The Agricultural Act (“Farm Bill”) of 2014 More than 3,500 farmers’ in SNAP-Ed, which is the nutrition also directed USDA to create the Food markets in the United States education and obesity-prevention Insecurity Nutrition Incentive (FINI) component of the program.290 SNAP-Ed grant program, which is funding three accept SNAP benefits. includes educational campaigns to different categories of grantees to pilot encourage recipients to make healthy innovative approaches to increase the food choices. In addition, USDA works purchase of fruits and vegetables among to make farmers’ markets and other SNAP participants. Funded projects vary sources of fresh, local produce available in length and scale (not to exceed four to SNAP recipients. More than 3,500 years) and are expected to document and farmers’ markets nationwide accept evaluate their performance in meeting SNAP benefits.297 program goals.298 18% of the total cost to raise a child goes towards food USDA,Center for Nutrition Policy and Promotion Source: Expenditures on Children by Families, 2015 United States Department of Agriculture The Cost of Raising a Child: $233,610 Where does the money go? 18% 29% 15% 9% 6% 16% 7% Food Housing Transportation Health Care Clothing Child Care Misc. & Education Not including the annual cost Annual Housing Cost Annual Food Costs by Age Cost by Region per Child of college! $2,680 $2,780 $2,790 Urban Northeast $264,090 $45,370 $2,280 Urban Midwest Private $227,400 Urban West Urban $245,460 $20,090 $3,900 Urban South Public $1,690 $232,050 $1,580 *Includes room and board. VS VS Rural Areas Rural $193,020 $233,610 $2,400 0-2 3-5 6-8 9-11 12-14 15-17 Age in years *U.S. average for middle-income, married-couple families. Total costs are from birth through age 17. January 2017 Source: Expenditures on Children by Families, 2015. Revised March 2017 U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. Misc. Pub. No. 1528-2015. USDA is an equal opportunity provider, employer, and lender. 72 TFAH • RWJF • StateofObesity.org WHAT IS FOOD INSECURITY? Food insecurity means limited access to adequate healthy food because of a lack of money or other resources. It impacted 15.8 million (12.7 percent) American households in 2015.299 In addition, 6.3 million of these households (5 percent of U.S. households) had very low food security, which means food intake was reduced and normal eating habits were disrupted for at least some members of the household. After a steep increase during the 2008 recession, food insecurity has recently declined, with a significant decline between 2014 and 2015. Very low food security has followed a similar path and declined significantly between 2014 (5.6 percent) and 2015 (5 percent). The rate of food insecurity varies widely between states, ranging from a low in Montana of 8.5 percent to a high in Mississippi of 20.8 percent in the years 2013 to 2015299 (three years of data Among women, food insecurity is associated with obesity, while were combined to produce more accurate state numbers). the results are mixed with respect to men and children. This Food insecurity rates are higher than the national average (12.7 is likely due to several behavioral factors by women in food percent) in households: insecure households, including: l W ith incomes below 185 percent of the poverty threshold l E ating more high-calorie, energy-dense foods, which are the (32.8 percent); least expensive and easy to overconsume; l H eaded by a single woman (30.3 percent) or single man l E ating fewer fruits and vegetables; and (22.4 percent); l S uffering psychological effects of food insecurity, such as l H eaded by Blacks (21.5 percent) or Latinos (19.1 percent); depression and stress, which are associated with obesity.300 l W ith children (16.6 percent); and Pregnant women in food insecure households tend to gain more l L ocated in rural areas (15.4 percent) and the South weight during their pregnancies and are more likely to suffer (13.3 percent). from pregnancy complications, such as gestational diabetes.301 TFAH • RWJF • StateofObesity.org 73 PROFILE: Center for Healthy Food Access Recognizing the need for diverse l C reating jobs and economic food more affordable for those on stakeholders to work together to increase development by bringing grocery food stamps; access to nutritious foods, the Food Trust, stores and other healthy food l P romoting the Healthy Food a national nonprofit, launched the Center businesses to underserved areas; Access Portal so organizations and for Healthy Food Access in January 2017, l C ollaborating with hospitals and businesses can share successes with with support from RWJF. The new national healthcare systems to prevent one another; and collaborative will focus on healthy food diet-related disease in low-income access in underserved rural and urban l P roviding $1 million in grants to communities; communities, including by: more than 15 organizations across l P artnering with businesses to focus the country. 302 l S trengthening federal nutrition programs, marketing efforts on healthier choices; including SNAP, WIC and SNAP-Ed; The goal of the initiative is to ensure l E xpanding SNAP-incentive programs that every child in America has equal l I mproving food and water quality in that provide support to make healthier access to affordable, healthy food. schools; 3. Business Initiatives Research demonstrates that multi- to plan and build communities that component workplace wellness Workplace wellness programs encourage walking, biking and taking programs can be an important strategy boost employee health and public transportation; and engaging the in preventing and reducing obesity. A healthcare industry to support a broad number of reviews have found these productivity and reduce range of community programs. initiatives can pay for themselves by absenteeism. State governments — as employers and increasing productivity and reducing contractors — can establish policies and absenteeism.303 They also have been based healthcare can make sure their serve as a role model by setting nutrition shown to reduce weight, body fat and plans cover obesity-prevention services standards for food sold in government BMI, and increase physical activity.306 including BMI screening, and nutrition office buildings and other state-run Many state health departments have and physical activity counseling. facilities. Reviews of state efforts, developed resources to assist employers however, reveal that only a small number in creating effective wellness programs, Business investments are also needed of states are taking full advantage of this such as the Work Well Texas program to create healthier communities. There authority. A 2013 CDC review of state discussed in a subsequent section. need to be increased investments and public health policies assessed whether Worksite nutritional programs have incentives for the food industry to states had implemented a nutrition similarly positive effects, boosting build supermarkets and set up farmers’ standards policy for the sale of food and employee health and productivity markets in low-income communities. beverages on state executive branch and reducing absenteeism.306 Like Examples of business initiatives include policy. Only two states earned the highest governments, businesses can require incentivizing fitness companies to score (green), two states earned yellow, that all food sold on its premises — develop gyms and other recreation and 47 states earned the lowest score in workplace cafeterias and vending facilities in underserved neighborhoods; (red), because they either had no policy machines — meet established nutritional supporting transportation initiatives at all or it did not meet CDC’s criteria.304 standards. Businesses that offer employer- to work with government on all levels 74 TFAH • RWJF • StateofObesity.org STATE PROFILE: Missouri In 2014, Missouri’s adult obesity in these areas, and encourage residents rate was 30.2 percent. 305 Full service to eat fresh fruits and vegetables. grocery stores that offer fresh fruit With the support of SHSH, about 22 and vegetables can be up to 30 miles corner stores across Missouri are now away in some of its rural communities. considered healthy corner stores. That Such distances can make it difficult for means that nearly 319,000 residents residents to get recommended foods — spanning 11 rural and 11 urban like fruits, whole grains and vegetables. neighborhoods — can buy fresh fruits The University of Missouri Extension and vegetables close to home. Almost partnered with the Missouri Department 30 community partners, including of Health and Senior Services to expand hospitals and schools, worked together Stock Healthy, Shop Healthy (SHSH) pro- to provide store owners educational grams to expand the availability of fresh information and other resources on the produce at corner stores in rural and benefits of healthy corner stores. Also, low-income areas across the state. SHSH more than 40 in-store improvements provides webinar trainings and two SHSH were made. Examples include updates toolkits: one for retailers and one for to food displays, painting walls to attract communities. The Retailer Toolkit provides customers to healthy food choices, healthier foods information, safe handling and repositioning produce to make it and storing guidelines for produce, product easier for residents to choose healthier placement and marketing suggestions. foods. With these improvements, early The Community Toolkit guides community evaluation data showed that corner partners in working with stores and build- stores now dedicate 8.7 percent more ing demand for healthy foods. This effort shelf space to healthier food selections. aims to increase sales for corner stores, Source: CDC improve the availability of healthier foods HIGH IMPACT INITIATIVE: Workplace Obesity Programs CDC has identified Multi-Component a positive effect for reducing weight, Worksite Obesity Prevention as body fat and BMI and increasing one of its HI-5 initiatives. Private physical activity. A number of these or public employers can implement worksite nutritional programs have also these programs, which incentivize been found to be associated with an employees to make healthy choices. increase in employees’ overall health A review of evidence-based studies and productivity, and a reduction in by CDC found some programs have absenteeism.306 TFAH • RWJF • StateofObesity.org 75 STATE PROFILES: Indiana, Texas and Colorado INShape Indiana is the state’s program employers create healthier worksites. to help Hoosiers eat healthier, increase The program educates employers physical activity and stop using tobacco about the business benefits of products. The initiative promotes these reducing obesity, provides tools to help healthy lifestyle changes in a variety employers create wellness programs, of ways. Its Walk Indiana program and serves as a resource on topics promotes walking as an easy way to such as healthy eating, breastfeeding, stay physically active. The INShape physical activity, health screenings and Indiana website has a Community stress management.309,310 Corner to help residents find parks, Other state obesity-prevention initiatives trails, farmers’ markets and other local include working with vendors to make resources to help them live healthier food service changes across state lives. The program also provides agencies and strengthening state resources for the business community. nutrition and physical activity standards For example, it has designed a toolkit for early child-care centers.310 to help small businesses increase opportunities for their employees to Live Well Colorado is a nonprofit engage in healthy eating and physical organization that promotes equal access activity. Finally, the program helps to healthy eating and active living and families by providing tips for parents on works to advance health equity among healthy eating and resources on how to Colorado’s most vulnerable populations. incorporate more physical activity into The organization partners with other Indiana schools.307 local groups on projects such as: In 2013, the Texas Department of State l R enovating outdated recreation Health Services created its Obesity centers into community hubs where Prevention Program with a goal of making youth can learn about healthy eating it easier for Texans to make healthy and active living, resulting in 92 choices where they live, work and play. The percent of participants eating more program supports projects that aim to: vegetables, 85 percent cutting back on screen time and 70 percent l R educe obesity; cooking meals with their families;311 l L ower consumption of added sugars l T eaming up with nearly 50 other and high-calorie, low-nutrient food; organizations to create the Colorado l I ncrease consumption of water, fruits Double Up Food Bucks program, and vegetables; which promotes fruit and vegetable consumption by providing coupons l P romote breastfeeding; and to SNAP recipients to spend on fresh l E ncourage physical activity.308 produce;311 and With funding from CDC, the Texas l T raining food service providers from Department of State Health Services Colorado school districts on how to created Work Well Texas, a statewide prepare fresh meals that both taste resource to help public and private good and are good for students.312 76 TFAH • RWJF • StateofObesity.org D. HEALTH, HEALTHCARE & OBESITY 1. Overview Obesity is one of America’s most costly and devastating health problems. It increases risk for a host of chronic and life-threatening conditions, including high blood pressure, heart disease, type 2 diabetes, stroke, arthritis, liver disease, kidney disease, dementia, gallbladder disease, mental health issues and some forms of cancer.26 Each year, obesity contributes to more than 100,000 premature deaths,27 and during pregnancy it increases the chances of complications, including gestational diabetes, preeclampsia, cesarean delivery and stillbirth.28,29,30 Obesity-related healthcare costs exceed $150 billion a year, based on a meta-analysis of 12 recent studies.37 Another study found that overweight and obese service members alone cost the armed services $1.1 billion in Obesity costs our nation $150 billion in health care costs every year. annual medical costs.42 Each state and community is impacted Per Capita Obesity-Related Healthcare Expenditures, 2013 by the cost of obesity, with obesity-related healthcare costs ranging from $768 per Per capita obesity cost ($) person in Oregon to $279 per person l 575-657 l 475-571 in Wyoming. Across the country, obesity l 398-472 costs an average of $558 per person.8 l 279-366 The healthcare system can play a vital role in our battle against obesity — and can work in concert with community health and other sector initiatives for even stronger reinforcing impact. Healthcare providers are on the front lines of the obesity epidemic and can help implement prevention strategies, including obesity screening and nutrition and exercise counseling. Health insurance plans can also play an important role by providing coverage for obesity-related disease and incentivizing its healthcare facilities Source: Wang YC, Pamplin J, Long MW, Ward, ZJ, Gortmaker SL. and Andreyeva T. 2015. Severe obesity in and providers to implement obesity- adults cost state Medicaid programs nearly $8 billion in 2013. Health Affairs, 2015;34(11):1923-1931. prevention interventions. TFAH • RWJF • StateofObesity.org 77 MAJOR OBESITY-RELATED HEALTH CONCERNS l Type 2 Diabetes: • mong Latinos, rates are 12.0 A • recent review published in the Journal A • iabetes rates have nearly doubled D percent for Puerto Ricans, 13.8 of the American Medical Association in the past 20 years — from 5.5 percent for Mexican-Americans, 9.0 found that adults who exercised the percent in 1988 to 1994 to 9.3 percent for Cubans and 8.5 percent most decreased their risk of having percent in 2005 to 2012. 313, 314 for Central and South Americans. 13 types of cancer — 42 percent less • ore than 30 million American adults M risk of esophageal cancer; 20 percent l Heart Disease and Hypertension: have diabetes and another 84 million or more less risk of liver, lung, kidney, • ne in four Americans has some O have prediabetes. 315 CDC projects stomach, endometrial or myeloid form of cardiovascular disease. Heart that one in three adults could have leukemia cancer; and 10 to 17 percent disease is the leading cause of death diabetes by 2050. 316 less risk of myeloma, colon, head and in the United States — responsible neck, rectal, bladder or breast cancer.327 • More than one-quarter of seniors for one in three deaths.318 (ages 65 and older) have diabetes l Arthritis: Almost 70 percent of • t least one out of every five teens A (25.2 percent or 11 million has abnormal cholesterol, a major individuals diagnosed with arthritis are seniors).315 risk factor for heart disease; among overweight or obese.328 • iabetes is the seventh leading cause D obese teens, 43 percent have l Nonalcoholic Fatty Liver Disease: of death in the United States, and abnormal cholesterol.319 Up to 25 percent of adults have costs the country around $245 billion • ne in three adults has high blood O nonalcoholic fatty liver disease (NFLD), in medical costs and lost productivity pressure, a leading cause of stroke.320 which can lead to liver damage each year.315 Average medical Approximately 30 percent of cases of (cirrhosis) or the need for transplants.329 expenditures are around 2.3 times hypertension may be attributable to l Kidney Disease: An estimated 24.2 higher among people with diagnosed obesity, and the figure may be as high diabetes than what expenditures percent of kidney disease cases as 60 percent in men under age 45.321 would be absent diabetes. among men and 33.9 percent of • eople who are overweight are more P cases among women are related to • ore than 80 percent of people with M likely to have high blood pressure, high overweight and obesity.330 diabetes are overweight or obese. levels of blood fats and high LDL (bad l Alzheimer’s/Dementia: Both • pproximately 193,000 children A cholesterol), which are all risk factors (ages 2 to 20) have diabetes and 2 for heart disease and stroke. 322 overweight and obesity at midlife million teens (ages 12 to 19) have independently increase the risk of • eaths from heart disease and D prediabetes. 315 For children and dementia, Alzheimer’s disease and stroke are almost twice as high youth (ages 0 to 19), type 2 diabetes vascular dementia.331, 332 among Blacks than among Whites.323 rates have increased by more than l Mental Health: Studies have shown an • atinos are more likely to suffer a L 30 percent since 2001.317 association between anxiety and obesity, stroke than are other ethnic groups. • iabetes rates are higher among D Specifically, Mexican-Americans and that this association is true for both American Indians/Alaska Natives are 43 percent more likely to have men and women.333,334,335 The direction of (15.1 percent), Blacks (12.7 percent) a stroke — the leading cause of the association can seem to be related and Latinos (12.1 percent) than disability and the third-leading cause to both cause and effect. Obese adults Asian-Americans (8.0 percent) and of death — than Whites.324 are more likely to have depression, Whites (7.4 percent).315 anxiety and other mental health condi- l Cancer: Up to 40 percent of some • mong Asian-Americans, rates are A tions.336,337,338 One study of women ages forms of cancers are attributable to 40 to 65 found that one-quarter of obese 11.2 percent for Asian Indians, 8.9 obesity.325 Approximately 20 percent of women had moderate to severe depres- percent for Filipinos, 4.3 percent for cancer deaths in women and 15 percent sion — with rates four times greater than Chinese and 8.5 percent for other of cancer deaths in men are attributable non-obese and non-overweight women.339 Asian-Americans. to overweight and obesity.326 78 TFAH • RWJF • StateofObesity.org 2. Healthcare Coverage & Programs a. Medicare & Medicaid Obesity imposes high costs on Medicare, who are obese lose weight.340 Medicare the federal healthcare program for also covers bariatric surgery in some Without obesity, Medicare and Americans aged 65 and older, and situations.341 States can choose which Medicaid costs would be up to Medicaid, the government healthcare obesity services to cover for adult program for low-income and disabled Medicaid recipients, with most states 10% lower. Americans. One study found that covering at least one. For children, Medicare and Medicaid costs would be as states are required to cover all medically much as 10.7 percent lower in the absence necessary services, which can include of obesity.38 Another study found that obesity services. States also get an severe obesity alone costs state Medicaid enhanced federal match for providing programs almost $8 billion a year.8 obesity screening and counseling, because these services have received Both Medicare and Medicaid provide a “B” grade from the U.S. Preventive a variety of obesity services. Medicare Services Task Force, meaning they are covers BMI screenings and behavioral recommended preventive services.342,343 counseling to help Medicare recipients PROFILE: Engaging Medicaid Families in Fighting Obesity Join for Me is a weight management program for children, teens and their families offered by UnitedHealth Group, a Medicaid managed care organization. It was first developed in Rhode Island in partnership with the YMCA of the USA and the YMCA of Greater Providence.344 Pediatricians and other healthcare providers refer patients with high BMIs to the program, which involves a series Since 2012, more than 200 children of weekly group sessions at local and their parents or caregivers have community centers, including YMCAs completed the program. At the end and health centers. At the meetings, of four months, children and teens children and their parents learn about experienced an average 4.5 percent healthy eating and increasing physical reduction in their level of being activity, including the importance overweight.345 The participants that of reducing processed foods and attended the most sessions lost the sugary drinks, eating more fruits and most weight.346 Their parents often lost vegetables, getting sufficient sleep, weight as well.344 Join for Me illustrates reducing screen time and getting daily the power of engaging an entire family physical activity. 345 in the process of weight management. TFAH • RWJF • StateofObesity.org 79 CENTER FOR MEDICARE & MEDICAID INNOVATION INITIATIVES The Affordable Care Act created a new of each PIP varied across states and Innovation Center within the Centers managed care organizations, most of for Medicare & Medicaid Services with the programs included improving BMI a mission of finding better and more documentation, nutrition counseling and coordinated ways to deliver healthcare physical activity counseling.348 while improving payment systems. Its l M edicare Diabetes Prevention focus areas include Community Care Program: The National Diabetes models, which aim to make communities Prevention Program (National DPP) healthier by addressing grave public supports a successful lifestyle change health problems such as obesity.347 approach aimed at preventing those Examples of obesity-related Innovation with prediabetes or at high risk of Center initiatives include: type 2 diabetes from developing type 2 diabetes. In November 2016, after l C hildhood Obesity Performance finding that the program reduced net Improvement Projects: The federal Medicare spending, CMS issued a rule government mandates that states expanding the Medicare DPP model implementing a Medicaid managed care test starting January 1, 2018.349 The program must require health plans to Medicare DPP will now be covered as an complete performance improvement additional preventive service, marking projects (PIPs). Thirteen states reported the first time that an Innovation Center a combined total of 26 PIPs that prevention model has been expanded to targeted childhood obesity in 2014- all eligible beneficiaries.342 2015. While specific interventions b. Child Obesity-Related Health Provisions A number of early childhood provisions The ACA also created the Maternal, of the Affordable Care Act help prevent Infant, and Early Childhood Home obesity, including: Visiting (MIECHV) Program,351 discussed in more detail below. l P roviding financial incentives to states In addition, the ACA supports that cover certain preventive services, breastfeeding by requiring coverage including obesity screening and of breastfeeding supplies and counseling for children; support ser vices and employers with l P romoting state public education 50 or more employees to provide campaigns about the obesity- break time and a private place for prevention services available to employees to express milk during Medicaid recipients; and their first year postpartum.352 l P roviding funding for the Childhood Obesity Demonstration Project.350 80 TFAH • RWJF • StateofObesity.org HOME VISITING PROGRAMS Home visiting programs are an effective, evidence-based strategy for helping children at risk of obesity and other physical, behavioral and mental health concerns. The ACA expanded home visiting programs by creating MIECHV, which supports home visits for at-risk pregnant women and parents of young children.353 The voluntary visits are made by a social worker, nurse or other trained professional, who evaluates a family’s needs and provide services, such as: l eaching parenting skills; T l roviding education about nutrition, P breastfeeding, safe sleep practices and injury prevention; A July 2017 Home Visiting Year Book l hrough MIECHV, the federal T l romoting early learning in the home; P issued by the National Home Visiting government has bolstered evidence- l onducting screenings and providing C Resource Center found that: 354 based home visiting since 2010, referrals for postpartum depression, l ore than 18 million pregnant women M investing $1.85 billion for services, substance misuse and family and families (including more than 23 research and local infrastructure to violence; and million children) could benefit from develop early childhood systems; l creening children for developmental S home visiting; l vidence-based home visiting is E delays. l ore than a quarter of a million M now implemented in all 50 states, families received evidence-based home Washington, D.C., five territories, States conduct community needs visiting services in 2015; and 25 tribal communities. About 40 assessments to determine the percent of all counties have at least specific characteristics of their at-risk l tates have long supported home visiting S one local agency offering evidence- populations, such as disproportionately services by pooling limited resources. based home visiting; and high rates of teen parents, first-time They allocate federal dollars and state mothers, low-income parents and funds from tobacco settlements and l he field is moving toward T children exhibiting developmental taxes, lotteries, and budget line items. professionalization of the home visiting concerns. The most effective home Some foundations provide additional workforce to standardize and support visiting programs are integrated with funding. Home visiting is provided at no the knowledge and skills needed to other programs and supports. cost to recipients; serve families successfully. TFAH • RWJF • StateofObesity.org 81 IDENTIFYING AT-RISK CHILDREN Doctors and other medical professionals can play a critical Research has also demonstrated a link between ACEs and role in obesity prevention by identifying children at risk for obesity. A landmark study on the impact of ACEs found that the obesity and helping connect them with support services when prevalence and risk of severe obesity (BMI = 35+) grew as the needed. The U.S. Preventive Services Task Force recommends number of ACEs increased.357 A 2002 study found childhood that healthcare providers screen children ages 6 and older physical and verbal abuse to be associated with adult obesity.358 for obesity.355 The American Academy of Pediatrics has also One study found that men who had suffered from childhood developed screening tools to identify toxic stress and adverse sexual abuse were more likely to be obese; however, the same childhood experiences (ACEs) (see box below), which are risk relationship was not found with women in the study.359 factors for obesity. Once a healthcare provider has identified an The long-lasting effects of ACEs on children underscores an at-risk child, he or she can refer them to community programs important reality: if helping all children to grow up at a healthy and services, such as healthy weight programs. Home visiting weight is a priority, it is important to invest in wrap-around programs have also proven to be effective at assisting children services, including programs that support entire families and at risk of obesity and other health problems. abuse and violence prevention strategies. Adverse Childhood Experiences & Toxic Stress Adverse childhood experiences are events that cause Death repeated or toxic stress to a child, and raise their risk of developing long-term health and emotional problems, Early Death including obesity, alcoholism, drug abuse, depression and Disease, suicide attempts. Disability and Social Problems Scientific ACEs include: Adoption of gaps Health-risk Behaviors l hysical abuse; P l ubstance misuse within S Social, Emotional, and l exual abuse; S household; Cognitive Impairment l motional abuse; E l ousehold mental illness; H Disrupted Neurodevelopment l hysical neglect; P l arental separation or P Adverse Childhood Experiences divorce; and Conception l motional neglect; E Mechanisms by Which Adverse Childhod Experiences l ncarcerated household I Influence Health and Well-being Throughout the Lifespan l other treated violently; M member.356 CHILD OBESITY RESEARCH DEMONSTRATION PROJECT When the Children’s Health Insurance Program (CHIP) was with local institutions, such as schools, child-care centers reauthorized in 2009, it provided funding for Childhood and healthcare settings.360,361 Building on lessons learned Obesity Research Demonstration (CORD) projects. Beginning from CORD 1.0, a new set of projects (CORD 2.0) focuses on in 2011, CDC funded four-year projects in rural and urban reducing and preventing childhood obesity by strengthening communities in California, Texas and Massachusetts with a clinical and community relationships. The projects, located in high proportion of children from low-income families (CORD Massachusetts and Arizona, increase obesity screening and 1.0). The aim of the projects was to reduce obesity by both counseling services and refer children to local pediatric weight providing behavioral support for individuals and intervening management programs.360 82 TFAH • RWJF • StateofObesity.org SCHOOL HEALTH SERVICES Because healthy kids are better able to learn, increasing health services in schools is an important way to support student health and learning. In partnership with the Healthy Schools Campaign, the Trust for America’s Health (TFAH) formed the National Collaborative on Education and Health in 2014 to bring together stakeholders from the health and education sectors to work together to support health and learning.362 Cost and healthcare service and delivery structures have long created barriers to providing health services in school. For years, the federal free care policy prohibited healthcare providers — including schools — from seeking Medicaid reimbursement for services they provided to other patients free-of- charge. However, in 2014, the Centers for Medicare & Medicaid Services issued Schools Campaign has developed toolkits is a key strategy for improving access guidance clarifying that Medicaid can pay and resources to assist states in this to quality healthcare for underserved for covered services provided to Medicaid process or to learn other mechanisms for children. The Learning Collaborative is beneficiaries, regardless of whether the expanding student health services.205 currently comprised of 14 teams from service was provided at no cost to other California, Colorado, District of Columbia, non-Medicaid-eligible patients.363 Schools In response to the free care policy Illinois, Massachusetts, Minnesota, can now seek Medicaid reimbursement change, TFAH, in partnership with the Mississippi, New Jersey, New York, Ohio, for Medicaid-covered services provided to Healthy Schools Campaign, launched South Carolina, Tennessee, Virginia any Medicaid-enrolled child.364 In some the Healthy Students, Promising and Washington. To participate, state states, changes to the state Medicaid plan Futures Learning Collaborative (the teams must include representatives of need to be made before schools can take Learning Collaborative) in July 2016 to state Departments of Education, state advantage of this change. In 13 states, support states in expanding Medicaid Medicaid agencies and two school however, no plan changes are needed: services in schools, including physical districts, and may also include state-level Alaska, Arizona, Arkansas, California, and behavioral health services. advocates. State teams receive technical Delaware, Illinois, Iowa, Mississippi, The Learning Collaborative was assistance on the options for delivering Nebraska, South Carolina, South Dakota, established with support from the health services in schools, Medicaid Tennessee and Wyoming.363 In other U.S. Departments of Education and reimbursement and existing federal and cases, there may be other state laws that Health and Human Services out of state policy opportunities — including pose a barrier to seeking reimbursement. the growing recognition that healthy policies beyond free care such as those For those states that may require an students are better learners, and that within the Every Student Succeeds Act. amendment to their state plan, the Healthy delivering health services in schools TFAH • RWJF • StateofObesity.org 83 c. Healthcare & Hospital Programs Healthcare providers and facilities can play key roles in obesity prevention and reduction by implementing evidence-based initiatives and programs. 1. Screening Services Healthcare providers can screen their low-income patients with nutrition patients for obesity and refer obese assistance programs such as SNAP, WIC patients to counseling. As noted and the school meal programs. In fact, above, both are preventive services the American Academy of Pediatrics recommended by the U.S. Preventive recommends that pediatricians screen Services Task Force.343 Healthcare their patients for food insecurity and providers can also screen their patients know how to refer eligible families for for food insecurity and help connect services.365 A New York City fruit and 2. Fruit, Vegetable and Physical Activity Prescriptions vegetable prescription program Wholesome Wave, a nonprofit and/or by referring patients to certified organization, has partnered with doctors trainers or exercise programs. In a reduced the BMIs of 42% of to enable low-income families to buy pilot program at four Kaiser Northern participants more produce via its Fruit and Vegetable California centers, a physical activity Prescription (FVRx) program. Doctors prescription program was associated with write fruit and vegetable prescriptions weight loss in overweight patients and for patients at risk of obesity, providing improved blood sugar control for patients them coupons for free produce with diabetes.367 Kaiser Permanente was redeemable at participating stores and the first major health plan to ask patients farmers’ markets. Between 2012 and about their physical activity levels and 2015, Wholesome Wave’s FVRx program record the information in their electronic in New York City helped increase fruit medical records. In 2016, Kaiser and vegetable consumption for nearly Permanente and the American College of 3,000 people, resulting in reduced BMIs Sports Medicine issued a call to action to for 42 percent of participants.366 the medical community to make physical activity assessment a standard of care Similarly, doctors can prescribe physical that is obtained and recorded at every activity for their patients by suggesting medical visit.368 a recommended amount of exercise 3. Healthy Food Procurement Healthcare facilities — particularly large staff and visitors — can provide healthier institutions like hospitals — can require options and help model healthy choices. their food service providers to serve food A national program, the Healthy Food in that conforms to nutritional guidelines. Health Care Pledge, assists the healthcare The healthcare sector spends $12 billion system in leveraging its purchasing power annually on food and beverages. Changes and expertise to increase access to healthy in food service policies — what foods they food and build a healthier food system, purchase and make available to patients, 84 TFAH • RWJF • StateofObesity.org beginning with the food procured and 500 hospitals and food service providers served by hospitals. Changes made by in the United States and Canada have hospitals include purchasing healthier signed the pledge demonstrating their beverages, increasing access to public commitment to these and other strategies drinking water, reducing meat options, to provide local, nutritious and sustainable purchasing meats raised without food.369 CDC has also developed a hospital antibiotics, and purchasing local and environment assessment tool to help sustainably-grown produce. More than evaluate and support improvements. 4. Community Benefit Programs Percent of American Association of Medical Colleges’ Member Hospitals The majority of hospitals in the need in many hospital assessments. that Identified Obesity as a Priority United States are run as nonprofit For example, more than half of the Health Need. organizations.370 In order to Catholic Health Association’s 203 demonstrate they are being operated member hospitals included childhood for charitable purposes and thus obesity in their assessments,372 while qualify for tax-exemption, nonprofit 70 percent of American Association 70% hospitals have long been required to of Medical Colleges’ 238 member demonstrate that their primary purpose hospitals identified obesity as a priority is to benefit the community.371 The health need.373 ACA imposed additional community Nonprofit hospitals reported spending benefit mandates upon nonprofit $62.4 billion on community benefit hospitals, including requiring that programs in 2011,374 which include they assess and implement strategies to nutrition programs, physical activity address their local community’s health programs, school-based programs and needs.370 Not surprisingly, childhood public awareness campaigns.372 obesity has emerged as a priority health PROFILE: Montana’s Healthy By Design In 1994, two hospitals and a health Healthy by Design promotes a healthy improve worksite wellness and address clinic in Billings, Montana, decided to lifestyle by spreading the 5-2-1-0 gender barriers to physical activity. work together to promote and improve message, which recommends that, One particularly successful initiative is health in their community. In 2006, every day, individuals have: their Gardener’s Market. The market is RiverStone Health, St. Vincent l 5 servings of fruits or vegetables; designed to bring healthy, fresh, local Healthcare and Billings Clinic l 2 hours or less of screen time; and affordable fruits and vegetables into conducted their first community l 1 hour of physical activity; and the community and offers an educational health assessment and created a course to help shoppers cook easy meals program called Healthy By Design l 0 sugary drinks.376 using fruits and vegetables. Another to address community-wide health The program also works with partners unique feature of the market is that it issues. One of the primary goals of across various sectors in the Billings does not charge farmers and backyard the program is to help community community to increase the availability gardeners a fee to sell their produce, members achieve a healthy weight and affordability of nutritious food, making their fruits and vegetables more through increased physical activity foster community connectedness, affordable for all shoppers. The farmers and improved nutrition. 375 promote safety through a functional, are also encouraged to accept SNAP and interconnected transportation system, WIC Farm Direct benefits at the market.377 TFAH • RWJF • StateofObesity.org 85 d. National Diabetes Prevention Program In addition to the 29 million Americans change intervention cut participants’ Diabetes Prevention Programs that suffer from diabetes, an additional risk for developing type 2 diabetes by 58 can reduce the risk of seniors 86 million American adults have percent. Results were particularly highest prediabetes, a condition where a patient among people ages 60 or older — their developing diabetes by as has glucose levels that are elevated, risk was reduced by 71 percent.379 The much as 71%. but not high enough for a diagnosis program focuses on supporting people of diabetes. Without changes to their with prediabetes through a combination lifestyle, such as losing weight and of doctor’s care and counseling/lifestyle increasing their activity levels, as many as coaching to make modest behavior 30 percent of the people with prediabetes changes. CMS recently expanded the will go on to develop type 2 diabetes.378 Medicare DPP to all eligible beneficiaries effective January 2018.349 The CDC-led National Diabetes Prevention Program is a public-private Community health workers — frontline initiative that offers evidence-based public health workers that are typically interventions to help prevent diabetes. members of the community being There are more than 1,500 DPP served — can play a key role in DPP programs offered around the country by programs by serving as a bridge a wide range of organizations, including between underserved communities and private insurers, employers, community healthcare systems. In August 2016, the organizations, healthcare organizations, Community Preventive Services Task faith-based organizations and Force issued a finding that these workers government agencies.378 An evaluation can improve outcomes for people at risk of the program found that DPP’s lifestyle for type 2 diabetes.380 86 TFAH • RWJF • StateofObesity.org SECTI O N 4: The State of SECTION 4: RECOMMENDATIONS Recommendations Obesity: The State of Obesity reports have documented how, over the past 15 years, significant progress has been made toward preventing Obesity Policy obesity and stabilizing obesity rates, especially among children, series by promoting better nutrition and increased physical activity through local, state and federal programs and policy changes, and collaborations between the public and private sectors.381, 382 Long-term investments and policy changes Top recommendations for maintaining in early childhood settings, schools, and building on this progress include: communities, and the healthcare system l I nvest Prevention, Evidenced-based have begun to pay off, but the next Policies and Programs to Improve few years will be pivotal for the obesity Nutrition and Increase Physical epidemic to ensure that progress continues Activity at the Federal, State and and accomplishments are not eroded. Local Level. Proposals to cut funding for obesity prevention programs, weaken school n F ederal programs need sufficient nutrition regulations, and delay updates resources to develop and support to important education tools like the innovative, evidence-based Nutrition Facts label could contribute to approaches to address obesity and higher obesity rates, reversing hard-fought improve nutrition and physical progress and harming the nation’s health. activity. Examples include: the National Center for Chronic Disease An analysis in 2012 found that 39 states Prevention and Health Promotion would have adult obesity rates at or above and the Division of Nutrition, 50 percent by 2030 if rates continued rising Physical Activity and Obesity, the at then-current projections.383 However, Prevention and Public Health Fund, this year, adult obesity rates increased in the Division of Adolescent and only four states (2016 data) and declined School Health (DASH) and the in one; and in 2015, only two states Office of Safe and Healthy Schools at experienced an increase. In contrast, the Department of Education. 16 states had increases in 2011; 37 had increases in 2010; and 49 had increases s S tate and local governments should in 2005. A similar story has emerged with expand resources for comprehensive respect to children. A 2008 study estimated approaches to obesity — including that childhood obesity rates would reach supporting obesity, nutrition and 30 percent if they continued increasing physical activity programs. at rates from the 1980s and 1990s, but childhood rates stabilized over the past • ther sectors beyond government O AUGUST 2017 decade, and have even declined in some should invest in efforts to address the areas of the country.381, 384, 385 Between 2010 obesity crisis, including the hospitals, and 2014, 31 states and three territories health insurers, employers and reported obesity rate declines among low- businesses, social services, community income 2- to 4-year-old children receiving organizations and philanthropies. WIC benefits.21 l P rioritize Early Childhood Policies n F ederal program need sufficient and Programs. resources to support physical n H HS, USDA and the Department education and physical activity of Education should issue regular throughout the school day guidance covering programs such as and healthier school initiatives Head Start, the Child and Adult Care (including, but not limited to ESSA Food Program and early childhood Title I and Title IV and programs programs supported through ESSA supported by DASH and DNPAO). that encourage healthier meals, opportunities for physical activity, limits F ederal, state and local programs on screen time and other supports that should be expanded to eliminate promote health. And policies should lead from water in schools and to support strong preconception and make safe, free water available to all prenatal health support. students. s S tates should follow expert guidance s S tates should continue to meet or by adopting and implementing best exceed current federal nutrition practices—including by making standards for school meals and investments in Quality Improvement snacks. School districts should Rating Systems—for nutrition, activity continue to support local wellness and screen time requirements and plan implementation to ensure regulations covering child-care and students have healthy learning day-care settings. States also should environments conducive to support targeted home visiting improved school performance. programs that provide at-risk families School districts should also with parenting education resources continue and expand flexible and connections to nutrition breakfast programs, such as second- programs and other services. chance breakfasts, breakfast on- the-go and breakfasts in classrooms. l M aintain Progress on School-Based s S tate and local education agencies Policies and Programs. should maintain and enforce n U SDA should maintain: standards for physical education • urrent nutrition standards C and physical activity throughout covering school meals and snacks. the school day. • he Community Eligibility Provision T s S tate and local policymakers should that allows schools in high-poverty identify opportunities to further areas to reduce bureaucracy, integrate education and health improve efficiency, save costs and through the implementation of decrease childhood hunger; and ESSA, including incorporating • chool wellness research, technical S indicators of student health as assistance and programs should education accountability measures. be maintained at CDC and the Department of Education. 88 TFAH • RWJF • StateofObesity.org l I nvest in Community-Based Policies and Programs to Improve Nutrition and Increase Physical Activity. n F DA should move forward with guidelines, requirements and implementation of menu labeling rules and the updated Nutrition Facts label to help Americans make more informed choices about what they eat and drink. F ederal, state and local governments should provide sufficient resources to support policies and programs that support healthy communities, including obesity and chronic disease prevention programs; transportation, housing and l E xpand Obesity-Prevention Healthcare Coverage and Care. community development policies • ll public and private health plans A and physically active lifestyles. that support active living; and should cover the full range of Programs that are effective in nutrition assistance programs such obesity prevention, treatment and terms of costs and performance, as SNAP and healthy food financing management services, including such as the Diabetes Prevention initiatives (including public-private nutritional counseling, medications Program and community health partnerships) that reduce food and behavioral health consultation. worker-clinical coordination insecurity and help ensure all Medicaid programs should cover models, should be extended. CMS Americans have access to affordable, and encourage use of obesity-related is finalizing a payment structure healthy food options. preventive services. Medicare should for DPP coverage under Medicare, encourage eligible beneficiaries expected to go into effect in 2018. s S tate and local governments should to enroll in obesity counseling, a prioritize health in transportation covered benefit, and evaluate its use s S tates should promote innovative and community design planning, and effectiveness. solutions that help people ensuring residents have access to maintain healthy diets and physical walking, biking, transit and other • ealth plans and health systems H activity by, for example, including forms of active transportation, should seek innovative solutions coverage of DPP and diabetes self- parks and recreation centers and for linking clinical treatment and management education in their other safe, accessible places to be counseling services with public state employee health plan and in physically active. health strategies to help people their Medicaid program. develop and maintain healthy diets TFAH • RWJF • StateofObesity.org 89 A P P END IC E S The State of APPENDICES APPENDIX A: Methodology for Behavioral Obesity: Risk Factor Surveillance System for Obesity, Obesity Policy Physical Activity and Fruit and Vegetable Consumption Rates Series Methodology for Obesity and Other Rates Using BRFSS ANNUAL DATA Data for this analysis was obtained from for Whites, Blacks and Latinos — and the Behavioral Risk Factor Surveillance gender. Another variable, ‘overweight’ System dataset (publicly available on was created to capture the percentage of the web at www.cdc.gov/brfss). The adults in a given state who were either data were reviewed and analyzed for overweight or obese. An overweight TFAH and RWJF by Sarah Ketchen adult was defined as one with a BMI Lipson, PhD. greater than or equal to 25 but less than 30. For the physical inactivity variable a BRFSS is an annual cross-sectional binary indicator equal to one was created survey designed to measure behavioral for adults who reported not engaging risk factors in the adult population in physical activity or exercise during (18 years of age or older) living in the previous thirty days other than their households. Data are collected from regular job. For diabetes, researchers a random sample of adults (one per created a binary variable equal to one if household) through a telephone the respondent reported ever being told survey. The BRFSS currently includes by a doctor that he/she had diabetes. data from 50 states, the District of Researchers excluded all cases of Columbia, Puerto Rico, Guam and the gestational and borderline diabetes as Virgin Islands. well as all cases where the individual was Variables of interest included BMI, either unsure, or refused to answer. physical inactivity, diabetes, hypertension To calculate prevalence rates for and consumption of fruits and hypertension, researchers created a vegetables five or more times a day. BMI dummy variable equal to one if the was calculated by dividing self-reported respondent answered “Yes” to the weight in kilograms by the square of self- following question: “Have you ever been told reported height in meters. The variable by a doctor, nurse or other health professional ‘obesity’ is the percentage of all adults in that you have high blood pressure?” This a given state who were classified as obese definition excludes respondents (where obesity is defined as BMI greater classified as borderline hypertensive and than or equal to 30). Researchers also women who reported being diagnosed provide results broken down by race/ with hypertension while pregnant. AUGUST 2017 ethnicity — researchers report results Appendix B: STATE POLICY REVIEW ON OBESITY PREVENTION: EARLY CHILDHOOD EDUCATION Early Childhood Education (Ages 0 to 5)* Physical Activity (PA) Screen Time (ST) Defined PA: Mixture of Screen Time Screen Time Limits Child and Infant Screen Time State defines PA Activities: State Infant Varied Defined: State for Children Under Adult Care Outdoor PA: Tummy Time: Limits for as moderate or requires mixture Activity: State defines screen- the Age of Two: Food Program State requires State requires Children Under vigorous for at of moderate requires indoor time to include State limits screen (CACFP): State active play daily tummy the Age of Two: least: 60 mins/ and vigorous and outdoor T.V., movies, cell time to 1 hour/ has licensing laws outdoors time for State eliminates day for full-day activities, activities phones, video day for full-day linked to CACFP whenever infants screen time for and 30 mins/ including bone- under adult games, computer, programs and 30 that automatically possible less than 6 children under day for part-day and muscle- supervision and other digital mins/day for part- update months of age the age of two programs strengthening devices day programs Alabama √ C,F √ C,F √ C,F √ C,F Alaska √A Arizona √C √C √C √C √C Arkansas √D,F √C √C √C √C √C California √C Colorado √C √C √C √C,F √C,F √C,F √C,F √C √C Connecticut √D √C √C Delaware √C,F √C,F √F √F D.C. √A √A √A √A √A √A Florida √C,F √C √C √C √C Georgia √L √C √C √C √C √C √C Hawaii √D,G,F √C,F Idaho √C Illinois √F √F √F Indiana √C,F √C,F √C,F Iowa √D,V √C Kansas √C √C Kentucky √C,F Louisiana √A √C √C Maine √C √C √C Maryland √D,G,F √C √C √C √C √C Massachusetts Michigan √C,F √C √C Minnesota √D √C Mississippi √A √A √A √A √A √A Missouri √C,F √C,F Montana √D,F Nebraska √C,F √C,F Nevada √A √A New Hampshire New Jersey √D,F √C,F √C,F √C,F √C,F New Mexico √D,F √C,F √C,F √C,F New York √D North Carolina √D,F √C,F √C,F √C,F √C √C,F √C,F √C,F √C,F North Dakota √C,F Ohio √C √C Oklahoma √C,F √C Oregon √C √C √C Pennsylvania √D Rhode Island √D,F √C √C √C √C √C √C √C South Carolina √D √C South Dakota Tennessee √C,F √C,F √C,F Texas √C,F √C,F √C,F √C Utah √D,F √C,F √C Vermont √C,F √C,F √C,F √C,F √C,F √C,F √C,F √C,F Virginia √C √C √C √C √C Washington √F √C,F √C,F √C,F West Virginia √D √C √C √C,F √F √C,F √C √C √C Wisconsin √D,F √F √F √F √F Wyoming √C,F Total States 20 States + D.C. 8 States 23 States 32 States 27 States 13 States 10 States 12 States 7 States Note: *Applies to Child Care Centers or Child Care Family Care Homes only. √ = State has a law, statute or both. A = All Child Care Facilities; C = Child Care Centers; D = Child Day Care Centers; G = Child Care Group Homes; F = Child Care Family Homes; L = Child Learning Centers; V = Child Development Centers TFAH • RWJF • StateofObesity.org 91 Appendix B: NEMOURS STATE POLICY REVIEW ON OBESITY PREVENTION: EARLY CHILDHOOD EDCUATION State Early Childhood Education (ECE) Licensing Regulations/Quality Rating and Improvement System (QRIS) Standards to Prevent Obesity (Ages 0 to 5) Private Screen Time: Nutritional USDA Breastfeeding: Breastfeeding Drinking Healthy Eating: Physical State has Standards: State State has Space: State Water: State CACFP: State State has Activity: State regulations has regulations regulations has regulations has regulations has regulations regulations has regulations requiring licensed requiring licensed requiring licensed requiring licensed requiring licensed requiring licensed requiring licensed requiring licensed ECE programs that ECE programs ECE programs ECE programs to ECE programs to ECE programs to ECE programs ECE programs to either prohibit to provide food to allow/ have a private make drinking meet CACFP for to have healthy have time for daily screen time for (meals and encourage onsite space available water available to meals and snacks eating policies physical activity children under age snacks) that meet breastfeeding for mothers to children 2 or sets limits USDA standards breastfeed infants Alabama √L √L √L √L √L √L Alaska √L √L √L √L √L Arizona √L √L √L √L √L Arkansas √L,Q √L √L,Q √L √L √L California √L √L √L √L Colorado √L,Q √L,Q Connecticut √L √L √L Delaware √L,Q √L √L,Q √L √L D.C. √L √L √L √L √L Florida √L √L √L √L √L Georgia √L,Q √L √L,Q √L √L √L Hawaii √L √L √L √L Idaho √Q √Q Illinois √L √L √L √L Indiana √L,Q √L √L,Q √L,Q √L Iowa √L,Q √L √L √L Kansas √L √L √L Kentucky √L √L √L √L Louisiana √L √L √L √L Maine √L √L,Q √L √L Maryland √L,Q √L,Q √Q √L √L √Q Massachusetts √L,Q √L,Q √L √L Michigan √L,Q √L √L,Q √L √L √L √Q Minnesota √L,Q √L,Q √L √L Mississippi √L √L √L √L √L √L √L Missouri √L √L √L Montana √L,Q √L,Q √L √L √Q Nebraska √L,Q √Q √L,Q √Q √L √Q Nevada √L,Q √L,Q √L,Q √L √Q New Hampshire √L √L √L New Jersey √L,Q √Q √L,Q √L √L √L New Mexico √L,Q √L,Q √L,Q √L √L New York √L,Q √L,Q √L,Q √L,Q √L √L,Q North Carolina √L √L √L √L √L √L √L North Dakota √L,Q √L √L,Q √L √L Ohio √L √L √L √L √L Oklahoma √L √L,Q √Q √L Oregon √L,Q √L,Q √L,Q √L Pennsylvania √L,Q √L,Q √L Rhode Island √L √L,Q √L √L South Carolina √L,Q √L,Q √L,Q √L √L,Q South Dakota √L √L Tennessee √L √L √L √L √L Texas √L,Q √L √L √L √L √L Utah √L,Q √Q √Q √L,Q √Q √Q √L Vermont √L √L √L √L √L Virginia √L √L √L √L √L Washington √L,Q √L,Q West Virginia √L √L √L √L √L Wisconsin √ L,Q √L,Q √L √L Wyoming √L √L Total States 50 States + D.C. 22 States + D.C. 4 States + D.C. 50 States + D.C. 28 States 43 States 26 States + D.C. 5 States Note: √ = State has either licensing regulations, QRIS Stanadards or both. L= licensing regulations; Q = QRIS Standards 92 TFAH • RWJF • StateofObesity.org STATE POLICY UPDATE SCHOOL NUTRITION Percentage of eligible Low-Income Student School Participation in State fundraising exemption Percent of School Food districts adopting the Participation in School Lunch School Lunch (NSLP) and Indicator policies (with zero-exemption Authorities (SFAs) Certified community eligibility (NSLP) and School Breakfast School Breakfast (SBP) vs. exemption) (2016) (2016) provision take-up (2016) (SBP) (2015-2016) (2015-2016) Yes = olicy allows >1 P Additional exemption details about No = olicy allows 0 P indicator exemptions NS = Not Specified Alabama 31.7 Yes 100% 57.9 97.7 Alaska 78.8 NS 93.80% 54.9 87.4 Arizona 32.2 Yes 99.80% 53.9 94.1 Arkansas 25 Yes 98.00% 63.5 100 California 15.1 No 99% 55.6 89.9 Colorado 28.6 Yes 100% 60.1 83.6 Connecticut 45.7 No 99% 51.4 81.8 Delaware 76.5 No 98.10% 61.5 98.5 D.C. 83 No 94% 67.4 99.1 Florida 65.1 NS 100% 50.5 97.9 Georgia 64.1 Yes 97.90% 58.9 97.1 Hawaii 70.6 No 100% 43 99.7 Idaho 46.8 Yes 100% 59.4 95.5 Illinois 54 NS 100% 47.7 82.2 Indiana 30 Yes 100% 50.7 90.7 Iowa 30.8 No 99.60% 44 100.1 Kansas 12.7 Yes 99.80% 49.3 93.9 Kentucky 88.3 No 100% 64.2 100 Louisiana 78 No 99% 57.7 96.5 Maine 27.5 No 96.70% 59.3 95.9 Maryland 45.2 No 100% 64.2 98.5 Massachusetts 36.9 No Policy 99.60% 49.4 82.4 Michigan 48.1 Yes 100% 58.1 90.2 Minnesota 40.4 No 99% 53.1 86.9 Mississippi 36.9 No 100% 58.7 94.3 Missouri 35.6 Yes 100% 59.3 92.7 Montana 72.5 No 100% 53 88.6 Nebraska 27.6 No 100% 43 83.5 Nevada 71.4 No 100% 56.1 95.7 New Hampshire 20 Yes 99% 40.9 91.4 New Jersey 40.8 No 99.20% 58.6 80 New Mexico 75.2 Yes 97.40% 72.9 93.1 New York 55.4 No 100% 49 93.2 North Carolina 62.8 No 100% 57.4 98.7 North Dakota 85.7 Yes 100% 49.1 89.2 Ohio 92.2 No Policy 100% 55.7 87.1 Oklahoma 26.9 Yes 100% 58.7 97.5 Oregon 64.5 No 99% 53.4 94.9 Pennsylvania 46.6 Yes 93.50% 49.5 87.1 Rhode Island 12 No 90.40% 51.3 97.5 South Carolina 51.6 Yes 100% 62.3 99.5 South Dakota 57.7 Yes 100% 46.1 85.7 Tennessee 60.3 NS 100% 64.5 98.3 Texas 31.6 NS 98% 63.1 100.2 Utah 38.9 Yes 97% 38.1 88.6 Vermont 63.6 No 94% 62.7 97.6 Virginia 42.2 Yes 100% 56.2 98.8 Washington 36.1 No 100% 45.1 93 West Virginia 87.3 No Policy 100% 83.9 98.9 Wisconsin 52.7 Yes 100% 51.1 79.9 Wyoming 71.4 Yes 98.50% 42.7 91.1 Source: USDA Source: National Wellness Source: USDA Source: USDA Source: USDA Policy Study TFAH • RWJF • StateofObesity.org 93 APPENDIX B: STATE POLICY UPDATE SCHOOL PHYSICAL ACTIVITY State requires physical education for elementary, State requires physical education for elementary, middle and high schools — requirements middle and high schools — minimum time (2015-2016) requirements (2015-2016) Recess/General Activity Requirements (2016) Requires Requires Middle Requires High Minimum Time Minimum Time Minimum Time Elementary Elementary Middle School High School State State has School Students School Students State has recess Students Students Students Students recommends general activity Participate in Participate in requirements Participate in Participate in Participate in Participate in recess requirements P.E. P.E. P.E. P.E. P.E. P.E. Alabama Yes Yes Yes Yes Yes Alaska Arizona Arkansas Yes Yes Yes Yes Yes √ √ California Yes Yes Yes Yes Yes Yes √ Colorado √ Connecticut Yes Yes Yes √ Delaware Yes Yes Yes D.C. Yes Yes Yes Yes Yes Florida Yes Yes Yes Yes Georgia Yes Yes Yes Hawaii Yes Yes Yes Yes Idaho Yes Yes Illinois Yes Yes Yes Indiana Yes Yes Yes √ Iowa Yes Yes Yes Yes √ √ Kansas Yes √ Kentucky Louisiana Yes Yes Yes Yes Yes √ Maine Yes Yes Yes Maryland Yes Yes Yes Massachusetts Yes Yes Yes Michigan Yes √ Minnesota Yes Yes Yes Mississippi Yes Yes Yes Yes Yes Missouri Yes Yes Yes Yes Yes √ Montana Yes Yes Yes Yes Nebraska Yes Yes Nevada Yes √ New Hampshire Yes Yes Yes √ New Jersey Yes Yes Yes Yes Yes Yes New Mexico Yes √ New York Yes Yes Yes Yes Yes Yes North Carolina Yes √ North Dakota Yes Yes Yes Yes Yes Ohio Yes Oklahoma Yes Yes √ Oregon Yes Yes Yes Yes Yes Pennsylvania Yes Yes Yes Rhode Island Yes Yes Yes Yes Yes Yes √ South Carolina Yes Yes Yes Yes √ √ South Dakota Yes Tennessee Yes Yes Yes √ Texas Yes Yes Yes √ Utah Yes Yes Vermont Yes Yes Yes √ Virginia Yes Yes Yes √ Washington Yes Yes Yes Yes Yes West Virginia Yes Yes Yes Yes Yes Wisconsin Yes Yes Yes Wyoming Yes Yes Source: SHAPE America, VHK 94 TFAH • RWJF • StateofObesity.org STATE POLICY UPDATE ACTIVE LIVING Healthy Food Percent Sales State Requires BMI Financing Initiative, Tax on Regular Screening or Weight- Grants Distributed Soda in Food State has Shared-Use Related Assessments in from 2011 to 2016 Stores by Agreements (2016) Complete Street Policies and Intent for Action by State Schools by State State (2014) State has adopted shared use State adopted State State adopted legislation that either require CS Policy and State adopted requires State Awarded CS Policy and State or recommend cooperation has mandatory CS Policy, State has not weight- Healthy Food has mandatory requires between schools and requirements, but does adopted a related Financint Intiative requirements BMI commmunites to access to but has no not have any CS Policy assessments (HFFI) Grants, from with clear action screening school’s recreational facilites clear action and requirement other than 2011 to 2016 and intent outside of school hours intent BMI Alabama Yes √ √ Yes 4 Alaska No √ No Arizona Yes √ Yes Arkansas Yes √ √ No 1.5 California Yes √ √ Yes 6.5 Colorado Yes √ No 2.9 Connecticut No √ √ Yes 6.4 Delaware Yes √ √ No D.C. Yes √ √ No 5.8 Florida No √ √ Yes 6 Georgia Yes √ √ No Hawaii Yes √ No 4 Idaho No √ No 6 Illinois Yes √ √ Yes 6.3 Indiana Yes √ Yes 7 Iowa Yes √ √ Yes 6 Kansas Yes √ Yes 6.2 Kentucky Yes √ √ Yes 6 Louisiana Yes √ √ No Maine No √ √ Yes 5.5 Maryland Yes √ Yes 6 Massachusetts No √ √ Yes Michigan Yes √ Yes Minnesota Yes √ Yes 6.9 Mississippi Yes √ √ No 7 Missouri Yes √ √ No 1.2 Montana Yes √ Yes Nebraska No √ √ Yes Nevada Yes √ √ No New Hampshire No √ No New Jersey Yes √ √ No 7 New Mexico Yes √ √ Yes New York Yes √ √ Yes 4 North Carolina Yes √ √ Yes 4.8 North Dakota No √ No 5 Ohio Yes √ √ Yes 5.8 Oklahoma Yes √ √ No 4.5 Oregon Yes √ Yes Pennsylvania Yes √ √ Yes 6 Rhode Island No √ Yes 7 South Carolina No √ √ Yes South Dakota No √ No 4 Tennessee Yes √ √ Yes 5 Texas Yes √ √ Yes 6.3 Utah Yes √ No 1.8 Vermont No √ √ No Virginia No √ Yes 1.5 Washington Yes √ No 6.5 West Virginia Yes √ √ Yes 6 Wisconsin Yes √ Yes 5 Wyoming Yes √ No Source: Safe Routes to Source: Safe Routes to School Source: Shape America, Source: ACF Source: Bridging School VHK the Gap TFAH • RWJF • StateofObesity.org 95 Endnotes 1 lberti P, Sutton K, Baer I. Community Health A 12 iolanti JM, Fekedulegn D, Hartley TA, An- V 23 Ogden CL, Carroll MD, Fryar CD, Flegal Needs Assessments: Engaging Community drew ME, Gu JK, Burchfiel CM. Life expec- KM. Prevalence of obesity among adults and Partners to Improve Health. Association of tancy in police officers: a comparison with youth: United States, 2011–2014. NCHS data American Medical Colleges. Analysis in Brief. the U.S. general population. Int J Emerg Ment brief, no 219. Hyattsville, MD: National Cen- 2014;14(11). https://www.aamc.org/down- Health. 2013;15:217–228. ter for Health Statistics. 2015. load/419276/data/dec2014communityhealth. 13 arey FR, Singh GK, Brown HS, Wilkinson C 24 ndian Health Service. Healthy Weight for Life: I pdf. Accessed July 18, 2017. AV. Educational outcomes associated with A Vision for Healthy Weight Across the Lifes- 2 ational Center for Health Statistics. 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