Cailyn Lingwall, Final Thesis

PRE-K COUNTS EXERCISE

Name: Cailyn A. Lingwall Date: Spring, 2015Major: Global Health StudiesThesis Committee: Dr. Caryl Waggett, Ms. Kirsten Peterson

Title: An Evaluation of Physical Activity among Preschoolers at an Income-Eligible “Pre-K Counts” Program in a Rural Northwest Pennsylvania Community

Childhood obesity is a national epidemic, impacting health, productivity, and economics. Obesity and overweight impact lifelong mental and physical health. Childhood obesity accounts for $14.1 billion in direct health care costs nationally. While obesity rates among preschoolers declined in 19 of 43 states, rates continue to rise in Pennsylvania. Obesity and poverty are tightly correlated, and rural Pennsylvania faces high poverty rates. In 2013, 22.6% of Crawford County children (0-17) lived below the federal poverty level. During 2009-11, 12.9% of Crawford County preschoolers were obese. To mitigate the double regional impact of poverty and early obesity, this study focuses on the preschool environment. Pre-K programs help children develop attention, behavioral, social, and academic skills for kindergarten. Preschoolers require more physical activity than elementary children. Achieving recommended daily levels, however, is difficult in childcare settings. Preschoolers require one structured and several unstructured hours of physical activity each day. Assessing the gap between actual and recommended activity is critical. I evaluated the activity deficit in an income-eligible 4-STARS Pre-K Counts program, and am conducting interventions to help meet the daily gap. Helping Pre-K programs meet recommended physical activity can counteract long-term health issues while developing motor skills, social and problem solving skills, and improving learning. Pre-intervention, children took one-quarter of the total recommended steps. Post-intervention, children took about one-third of the total recommended steps. The study concludes that preschool children are insufficiently active.

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Preschool Exercise Senior Comprehensive Project Table of Contents

Chapter 1: Background InformationMeadville, PA: Demographics…………………………………………………………………………………………………………..4-5Meadville Area Children’s Center (MCC)………………..…………….………………………………………………………….6-7

Chapter 2: Study design and resultsIntroduction……………………………………………………………………………………………………………………………………..8-9Methods…………………………………………………………………………………………………………………………………………..10-12Results ………………………………………………………………………………….…………………………………………………………13-16Discussion………………………………………………………………………………………..………………………………………….…..17-23

Chapter 3: Ethics and Social Philosophy…………………………………………………………………………………………24-27

Chapter 4: Policy, Poverty, and Economics…………………......................................................................28-34

Chapter 5: Science, Health, and the Environment………………………………………………………………………….35-40

Chapter 6: Culture and Societies…………………………………………………………………………………………………….41-44

References………………………………………………………………………………………………………………………………………45-55

Appendices…………………………………………………………………………………………………………………………………….56-70

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Acknowledgements:

I am proud to be among the first graduating class of Global Health Studies majors at Allegheny College. This major has provided me with a solid foundation in community health knowledge and experiences to prepare me for a career in public health. I would like to thank my senior project advisor Professor Caryl Waggett for her steadfast guidance and support throughout this study, as well as my four years at Allegheny. Also, I would like to thank my second reader Professor Kirsten Peterson for offering her critiques and advice during this project. Finally, I would like to thank my community partner, the Meadville Children’s Center. It was truly a rewarding experience working with such committed teachers and engaging students. I hope that this work will positively contribute to future research in preschool physical activity and early childhood health.

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Chapter 1: Background Information

Study Area Demographics: Meadville, Pennsylvania

Located in Northwestern Pennsylvania, Meadville is the county seat of Crawford County. According to the Pennsylvania Department of Community and Economic Development, Meadville is classified as a third-class city, which is the smallest designation for Pennsylvania cities (2013). Meadville is a mostly rural city located 45 minutes south of Erie, Pennsylvania and 1.5 hours south of Pittsburgh, Pennsylvania. While Meadville is classified as rural, the city is not rural by the traditional definition in that it is not comprised of strictly farmland. The density of housing in the town center is similar to that of another urban area. A once economically thriving area, Meadville has become part of the “rust belt” facing economic decline and loss of industry.

Figure 1: Pennsylvania State map showing the location of Meadville in relation to major cities (Meadville, PA, n.d.).

Figure 2: The chart below depicts Crawford County in comparison to Pennsylvania State: (U.S. Census Bureau, American Community Survey, 2013)

Key Variable Crawford County

Pennsylvania State

Population, 2009-2013 88,173 12,773,801White alone, 2009-2013 95.5% 81.9%Mean household income, 2009-2013 $53,953 $71,088Unemployment rate, February 2015 (Bureau of Labor Statistics, 2015a, 2015b)

5.6% 5.1%

Persons below poverty level, 2009-2013 15.9% 13.3%Persons under age 18 below the poverty level, 2009-2013

25% 18.8%

SNAP/Food Stamp benefits within the past 12 months, % of persons

15.3% 11.8%

High school graduate or higher, % of persons age 25+, 2009-2013

86.8% 88.7%

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Meadville is an interconnected community with many valuable assets. For instance, Meadville offers significant opportunities for youth education as well as physical activity. The city has one Head Start program and one Pre-K Counts program, in addition to five public elementary schools served by Crawford Central School District (PA Head Start, 2015; Crawford Central School District, 2015). Community partners such as the YMCA and the MARC (Meadville Area Recreation Complex) also offer great opportunity for youth development. For instance, the YMCA provides before and after-school programs for school-aged children in addition to the Early Learning Academy, a Keystone STARS accredited preschool program for infants through Pre-Kindergarten children. The YMCA also offers a variety of youth summer camps and sports leagues for children of all ages (Meadville YMCA, 2015). The MARC provides a wide range of activities including hockey, ice skating, and swimming. Most recently, the MARC sponsored the “Spring into Health Fair” for young children and their families in partnership with Allegheny College, the YMCA, the Meadville Medical Center, and Crawford Central School District, among others (Meadville Area Recreation Complex, 2015). In addition, the Meadville Medical Center recently launched the Children’s Health Network, the first long-term chronic disease management project exclusively serving community youth. Significantly, the aim of the Children’s Health Network is prevention of future illness and hospital visits by educating and assisting families in caring for their young children with chronic illnesses (Meadville Medical Center, 2015).

While the Meadville community undoubtedly has clear assets and social support, area youth face significant disadvantages related to both poverty and obesity. Poverty is a key issue impacting high overweight and obesity rates. As noted in Figure 2, 25% of persons in Crawford County under the age of 18 lived below the poverty level during 2009-2013, which is higher than the Pennsylvania state average. The Crawford Central School District also reports that about 38% of children in grades K-6 were overweight or obese during the 2011-2012 school year (PA Department of Education). Food insecurity is another prevalent issue impacting youth. The double burden of poverty and food insecurity is especially evident in area schools. Significantly, the Annie E. Casey Foundation notes that during the 2013-14 school year, 46.4% of students enrolled in Crawford Central School District were eligible for free or reduced lunch. The 2013 Seventh Grade Wellness Survey conducted by Allegheny College in partnership with the Meadville Area Middle School also found that a large portion of area families lacked proper cooking facilities such as an oven (Allegheny College, 2013). Additionally, a portion of Meadville youth lack access to safe physical activity opportunities during all seasons. While there is great opportunity for activity indoors, there are still barriers for the highest risk children. As a result, there are many kids who want to participate in after-school sports, summer camps, and similar activities but are unable to afford the costs, cannot find transportation, or lack parental guidance. Finally, asthma is a prevalent health problem among Crawford County Youth. The prevalence of asthma among school-aged children increased from 5.9% during the 2003-2004 school year to 6.8% during the 2008-2009 school year (Pennsylvania Department of Health, 2012). Despite major challenges, Meadville has strong potential to capitalize on existing resources and make meaningful progress toward preventing childhood obesity.

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Image Source: Meadville Children’s Center (2015)

Study Location: Meadville Children’s Center

The Meadville Children’s Center (MCC) is an accredited 4 STARS facility offering full-day preschool and child care on the Allegheny College Campus. The mission statement of the MCC is to “stimulate the development of young children through age-appropriate, individualized care in a warm, loving environment.” The Meadville Children’s Center has partnered with the STARS program since 2007 to work toward a complete 4 STARS accreditation. Keystone STARS is an accreditation program sponsored by the Office of Child Development and Early Learning that partners with early learning programs across the state to continuously improve facilities and learning programs (Meadville Children’s Center, 2015). STARS are classified by 4 designations: Standards, Training/Professional Development, Assistance, Resources, and Support (PA Keys, 2009).

This image shows the Keystone STARS Designation.Image source: Meadville Children’s Center (2015)

In addition, the MCC offers a full-day Pre-K Counts (PKC) program with 32 total seats. The Pre-K Counts program is an approved Pennsylvania provider and is free of cost to families. The program consists of classrooms of about 15 students each, as well as two full-time teachers with degrees in early childhood education. Pre-K Counts begins each day at 8:15 a.m. and ends at 2:15 p.m., and includes both breakfast and lunch in compliance with Head Start nutritional guidelines (Meadville Children’s Center, 2015).

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This image shows the primary outside play space for preschool-aged children.


.

The aim of Pre-K Counts is to prepare 3-4 year-old children for Kindergarten and beyond; these children face economic, cultural, or learning disadvantages that put them most at risk for academic failure. Economically “at risk” is defined as children living in families with a household income less than 300% of the Federal Poverty Guidelines (PA Keys, 2009). As of March 2013, 67% of children enrolled in Pre-K Counts programs across Pennsylvania were affected by at least one or more risk factors in addition to income (PA Keys, 2009). All Pre-K Counts programs adhere to academic guidelines approved by the Pennsylvania State Board of Education. Pre-K Counts provides children with the opportunity to develop social, fine, and gross motor skills as well as the necessary academic foundation for Kindergarten (Meadville Children’s Center, 2015). Additionally, Pre-K Counts provides vital opportunities to develop social skills, verbal comprehension, paying attention, and following directions. The 2012-2013 Pennsylvania Pre-K Counts Report notes that after participating in Pre-K Counts programs during the 2012-2013 year, the percentage of 4-year-olds with proficient social and academic skills tripled to 82% (PA Keys, 2009). In total, Pennsylvania Pre-K Counts programs served 11,350 preschool-aged children in 2009 (PA Keys, 2009).

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This image shows the second of the two Pre-K Counts classrooms.This image shows the first of the two Pre-K Counts

classrooms.


Chapter 2: Study Design and Results

Introduction:

Prior to the AMA’s (American Medical Association) declaration of obesity as a disease, obesity was merely viewed as a risk factor for chronic disease. In 2012, however, the AMA declared obesity as a disease with significant lifelong physical and mental health consequences (American Medical Association, 2013). The current obesity epidemic impacts national health, productivity, and rising healthcare costs. In the past 30 years, childhood obesity in the United States has more than doubled. Nationally, more than one-third of children and adolescents were overweight and obese in 2012. Overweight and obesity also poses a serious public health crisis among preschool-aged children. Currently, one in eight preschoolers is obese (Centers for Disease Control and Prevention, 2013). The established relationship between obesity and poverty also plays a significant role in childhood overweight and obesity. Given the double regional impact of poverty and obesity in rural, Northwest Pennsylvania, this relationship is especially evident.

Current public health recommendations closely follow the neoliberal model, which impacts government deregulation of environmental and economic factors influencing health. With that, “neo-liberalism” advocates for increased personal responsibility for health decisions. Based entirely at the individual level of decision making, the Health Belief Model also plays a role in delegating “responsibility” for behavior. The model states that health behavior is dependent upon four key factors: costs or severity of potential illness, likelihood of developing illness, benefits of preventive actions, and barriers to preventative actions. Commonly cited to explain health behaviors in physical activity and obesity research, the theory focuses on the significance of repeated personal behaviors as key elements to forming habits (Boston University School of Public Health, 2013). The great public health emphasis on individual responsibility versus collective responsibility informs the current guidelines promoting individual obligation to take preventive action against obesity.

The National Association for Sports and Physical Education recommends an increase in physical activity among preschoolers as one avenue to prevent lifelong overweight and obesity, as well as aid in the development of motor skills (2014). The current physical activity guideline for children ages 2-5 is 60 minutes of structured physical activity, in addition to up to several hours of unstructured physical activity per day (2014). The clear relationship between physical activity, health benefits, and greater learning outcomes is cited as a key reason to increase physical activity (U.S. Department of Health and Human Services, 2008). Generally, young children naturally enjoy being active, yet are frequently constrained to be inactive in childcare settings (Copeland, et al., 2011). Significantly, 42% of children ages 0-6 spend 35 hours per week or more in childcare settings (American Alliance for Health, Physical Education, Recreation, & Dance, 2012). In many instances, the physical activity as a part of Pre-K programs is the only regular daily physical activity opportunity for young children. After parent pick-up, children are more likely to engage in sedentary activities for the remainder of the day such as watching TV, playing with video games or other toys, or reading (Copeland, et al., 2011).

The National Head Start Association is a federally funded preschool program serving low-income children across the country (PA Keys, 2009). Head Start requires that facilities have "sufficient time, indoor and outdoor space, equipment, materials and adult guidance... [to] support the development of gross motor skills” (Office of Head Start National Centers, 2012). The duration, intensity, and frequency of activity are not specified. As a result, the amount of physical activity across individual facilities varies greatly according to weather-related play policies, size of indoor play space, and discretion of individual teachers (Copeland, et al., 2011). In rural Northwest Pennsylvania, weather poses a major barrier to physical activity for a significant portion of the year. Many Pre-K Counts programs are unable to go outside when the weather is below freezing

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(≤32°F), which is typically December through March. Smaller childcare facilities in low-income communities also commonly lack expansive indoor classroom space for structured and unstructured free play.

The number of steps taken per day is one common metric used by public health educators to identify and communicate recommended daily amount of physical activity to the public. Recently, pedometers have been gaining popularity in public health research as an approximation of average amount of physical activity (Locke, et al., 2008). In comparison to accelerometers, pedometers are relatively low-cost, accessible to the general public, and the results are easily interpreted. Given the childhood obesity epidemic, current literature emphasizes the need for increased study of physical activity guidelines for children (ages 6-11), and adolescents (ages 12-19). Locke, et al., (2008) note that there is also growing interest in providing more concrete guidelines for preschool-aged children. As physical activity guidelines vary among different age groups, there is no single number of steps per day that serves all age groups.

Current studies using pedometers to measure physical activity among preschool children do not recommend with certainty an ideal target number of steps per day. Limited evidence suggests that a range of 9,000 to 14,000 steps per day is ideal (Locke, et al., 2008 & Kambus, et al., 2014). However, there is no standard “ideal” step estimate that translates exactly to the current recommendation of one hour of structured activity and up to several hours of unstructured activity each day. As a result, it is difficult to quantify exactly how much physical activity preschool-aged children in childcare settings should receive. Unfortunately, preschool children clearly fall below the recommended guidelines for daily physical activity. The Children’s Activity and Movement in Preschools Study suggests that preschool-aged children are sedentary for the majority of their monitored hours (Williams, et al., 2008).

The established relationships between obesity and poverty, as well as location and poverty (Drewnowski & Specter, 2004) are significant factors in the amount of physical activity preschoolers currently receive. In this study, physical activity interventions are specifically targeted to benefit the population with the greatest likelihood of lifelong overweight and obesity: the rural poor. To better understand how many steps per day preschoolers do take in an average day, this study assesses the current gap in physical activity. Since weather and amount of indoor play space impact the average daily physical activity (Copeland et al., 2011), this study predicts that low-income preschoolers are not sufficiently active.

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Methods:

Project Summary:This six-week study used pedometers to collect approximate daily step counts for preschoolers enrolled in an income-eligible Pre-K Counts program. A baseline estimate of the number of steps taken per day was collected, and the predicted physical activity deficit was identified. Interventions consisting of short, structured bursts of physical activity were then developed in an attempt to meet the identified deficit. Finally, the results and activities will be shared with the other Crawford County area Head Start program.

Sample: The study population consisted of 32 preschoolers enrolled in an income-eligible Pre-K Counts program at the Meadville Children’s Center. The Pre-K Counts program is divided into two separate classes (Pre-K Counts A and Pre-K Counts B) of approximately 15 students each. Class rosters were obtained from Carrie Dinsmore, Director of the MCC. The study population was intended to be representative of a larger population of preschoolers enrolled in Pre-K Counts programs in low-income, rural areas in the United States also facing inclement winter weather climates. There are, however, differences in terms of childcare facility size and indoor gross motor space among different centers which may not be representative of a larger population.

Measures:Data were collected using SM2000 digital step pedometers. Pedometers were chosen due to the limited study budget and easy interpretation of results (Locke, et al., 2008). Contextual information was collected using the following two methods:

Informal observation including written, decoded notes of classroom management styles, dynamics, challenges and successes, as well as activity preferences and execution.

Three structured 15-minute discussions with the two Pre-K Counts A teachers, the two Pre-K Counts B teachers, and Carrie Dinsmore. These discussions were used to elicit specific feedback about the project including: strengths, weaknesses, and major barriers to increased physical activity from the perspective of child care providers.

Key terms: The following terms were used to operationalize and describe step estimates: “optimal physical activity” and “physical activity deficient” (Kambuas, et al., 2014).

“Optimal physical activity”= >10,000 steps daily (~3 hours of physical activity) “Physical activity deficient” = <10,000 steps per day Physical activity deficit (10,000 - average # of steps from weeks 1-3

Procedures and confidentiality: During weeks 1-3, a baseline number of steps taken per day was collected. The predicted gap in physical activity was then assessed. During weeks 4-6, several 10-15 minute physical activity bursts were planned throughout the day to help meet the predicted physical activity gap. Data was collected and recorded for approximately 32 students. Data was stored using each student’s first name and last initial. This identification was necessary to assign pedometers to each student. All consent forms as well as data were stored and locked in the principal investigator’s office. In the final written product, data for both classrooms were combined to obtain an average during the baseline period and an average during the intervention period. Additionally, no names or identifiable information from the focus groups with both PKC-A and PKC-B students were collected or included in the final product.

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IRB approval procedures: During December 2014, the IRB approval form was submitted which included the researcher’s discussion of the project aims, methods, and study timeline. The parent/guardian study consent form was attached as an appendix. These forms were comprised of the researcher’s explanation to the project in addition to a discussion of privacy, potential risks, and benefits. Verbal scripts of student assent forms explaining that wearing a pedometer each day was not mandatory and could be removed during the school day if necessary was attached as an appendix.

In addition, written agreement expressing a desire to partner was obtained from Carrie Dinsmore, Executive Director of the MCC during December 2014 and was attached as an IRB appendix. Verbal consent and initial project discussions with the four Pre-K Counts teachers also occurred during December 2014. The approval process from the Meadville Children’s Center was aided by prior work experience of the researcher with the full-day preschool program during the summer of 2014. The principal investigator of the study had a prior relationship with the MCC as well that extended several years before the study. The long-standing cooperative relationship between the MCC and Allegheny College also played a significant role in establishing trust, as well as in aiding the IRB approval process. In addition, the researcher had current Pennsylvania Child Abuse Clearance forms from prior summer employment. In February 2015, the IRB approval process was complete. Parent/guardian photo release forms for the purposes of the study were also drafted and approved by the IRB during February 2015.

Study procedure: During the end of February 2015, consent forms and photo release forms were disseminated and explained to parents of preschoolers at the Meadville Children’s Center. Once approval was obtained, the documents were locked and stored in the principal investigator’s office.

Data were recorded using each child’s first name and last initial. Within the results of the final written product, data were recorded using unique participant ID numbers. Each participant was randomly assigned a unique identification number, which was matched with the number on the pedometer. Each day for 3 weeks, pedometers were zeroed and put on PKC students. After putting pedometers on at 9:20 a.m. during the first week of the study, the decision was made to wait until after the first bathroom break at 9:45 a.m. to put pedometers on for the PKC-A class, as advised by PKC-A teachers. It was found that the PKC-A class was significantly less likely to take the pedometers off early if put on at this time. There was no difference in the PKC-B class, and pedometers were put on students at 9:20 a.m. In each classroom, pedometers were removed at 1:40 p.m. to allow adequate time for parent pickup beginning at approximately 2:00 p.m. The number of steps was recorded and the pedometer was zeroed.

Pedometer placement:Pedometers were attached to the right hip. To account for variation in clothing such as dresses or skirts, belts were available. It was impractical to place pedometers on shoes because some of the children wore boots during the winter months or changed into boots before going outside to play. The four full-time Pre-K Counts teachers assisted in placing pedometers on children as well as recording the number of steps when necessary.

Data collection and analysis: Results from weeks 1-3 were compared to the baseline recommendation of 10,000 steps per day for preschool-aged children to determine the physical activity deficit. This recommendation was chosen because Kambuas et al. (2014) found that 10,000 steps roughly equals one hour of structured physical activity and up to several hours of unstructured activity. This is the current physical activity recommendation for preschoolers by

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the National Association for Sports and Physical Activity. The activity deficit was calculated by subtracting the average from weeks 1-3 from 10,000.

During weeks 4-6, two ten-to-fifteen minute physical activity bursts were conducted in both classes each day for 3 weeks. When possible, one physical activity burst was conducted in the mid-morning (10:30-11:00 a.m.), as well as in the afternoon (1:30-2:00 p.m.). The pedometers were zeroed and placed on the PKC-B class at 9:20 a.m., and the PKC-A class at 9:45 a.m. The pedometers were taken off at 1:40 p.m. to record the number of steps. Once data was recorded, the pedometers were zeroed. Finally, the results were compiled and shared with another Meadville Area Head Start program also serving income-eligible preschoolers.

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Results:

The six-week pedometer study found that preschool children took less than half of the recommended number of steps per day. The number of steps taken increased by close to one-third following the interventions in weeks 4-6, but interventions alone were not enough to meet the large baseline step deficit. Daily interventions took a rigid approach in both structure and time of day in the PKC-A classroom, while interventions were more flexible in terms of time of day and structure in the PKC-B classroom. In consultation with the PKC teachers, it was decided that a difference in approach to the interventions between the two classrooms would be most effective. Interventions, therefore, were conducted separately in each classroom. Additionally, the study found that there are challenges associated with using pedometers to determine physical activity among a preschool-aged group. One, the pedometer placement was easily accessible to the children, meaning that they were somewhat prone to remove or lose them during the day. The pedometers that were taken off early and excluded a large portion of the active day were excluded from the baseline data and final step calculations. To account for absences, there were about 26 days of data collection.

The study found that there is no single most effective way to conduct physical activity interventions, as the classroom dynamics and teacher management styles greatly impact approaches to increasing physical activity. Some children were more active than others during the study and reached or exceeded the halfway point during weeks 4-6. Four students or 13% of children were outliers meaning that they took at least 5,000 steps during weeks 4-6. The higher than average step count among this group of students had several unintended effects. One, these four students had some concept that increased physical activity yields higher step counts. For instance, they mentioned that they “ran around a lot to get a big number” and clearly recognized the concept of goal setting. These four students were also consistently very active during interventions and would often run, jump, hop, skip, etc. for a longer duration of time than designated in the activity. Yet, the step averages of these students were clear outliers and the impacts of a few were not enough to significantly increase the total average step count. A final unintended result was the use of pedometers as an educational tool. The majority of students took significant interest in learning to read the pedometers at the end of each day, and appeared to enjoy partaking in “real scientific research.”

In summary, pre-intervention, students took one quarter of the total recommended amount of steps per day. Post-intervention, students took nearly one-third of the total recommended amount of steps per day. The unintended educational benefits and greater conception of physical activity among a preschool aged group is significant. The study concludes that there is clear lack of physical activity among preschoolers enrolled in an income-eligible Pre-K Counts program in rural Northwest Pennsylvania.

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Figure 1:

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2,410

2,662

2,473 Week 1Week 2Week 3

Average Baseline Steps: Weeks 1-3

Figure 2:

0100020003000400050006000700080009000

10000

2,515

Step Deficit

Baseline Average

Figure 2 shows a step deficit of 7,485 steps per day during weeks 1-3.

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Baseline Average vs. Optimal Step Count

Figure 1 shows that preschool children took less than one-quarter of the recommended number of steps during weeks 1 and 3, and over one-quarter during week 2. The weather permitted outside play for several days during week 2, which partially explains the small step increase.


Figure 3:

0500

1000150020002500300035004000

2,819

3,416 3,746

Week 4Week 5Week 6

Intervention Steps: Weeks 4-6

Figure 4:

0100020003000400050006000700080009000

10000

3327

Final Step deficitIntervention

Intervention Avgerage vs. Optimal Step Count

Figure 4 shows a step deficit of 6,673 steps per day during weeks 4-6.

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Figure 3: shows that preschool children took less than one-third of the recommended number of steps per day during week 4, and over one-third during weeks 5 and 6. In addition to the interventions, the weather permitted more frequent outside play, which partially explains the step increases from weeks 4-6.


Figure 5:

0

500

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2,410 2,662 2,473

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Week 1Week 2Week 3Week 4Week 5Week 6

Figure 5 shows a comparison between averages for weeks 1-3 and averages for weeks 4-6.

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Average Number of Steps


Discussion:

This study found that preschool-aged children in a low-income area are insufficiently active, and face a large activity deficit. The findings of this study are generally consistent with current literature finding that preschool-aged children are not active enough during the school day. While the Children’s Activity and Movement in Preschools Study (CHAMPS) examined physical activity through motion sensors (accelerometers) and observation of 24 centers including preschool, Head Start, and faith-based programs in urban South Carolina, the findings are indicative of the larger picture of physical activity. CHAMPS determined that three-to-five-year-olds spend 76-79% of their monitored hours participating in sedentary activities (Williams, et al., 2008). Additionally, CHAMPS found preschoolers were engaged in moderate-to-vigorous physical activity for less than 5% of the total school day. The CHAMPS study observations note that time spent inside is one contributing factor to lack of physical activity because most of the activities in a typical day are sedentary in nature. The study lists that the five most common indoor scenarios were: nap/quiet time, large group, indoor transition, snack/meal time, and manipulatives (Brown, et al., 2009).

Kambas et al. used pedometers to measure physical activity among preschool-aged children in Northern Greece. Although pedometers were placed on the children for the duration of the day as opposed to just the school day, Kambas et al. suggests that preschool children were still not meeting the recommended 10,000 steps per day guideline (2014). Specifically, Kambas et al. found that 31.6% of preschoolers reached the optimal 10,000 steps per day guideline, which includes activity before, during, and after school. Additionally, Greek preschools do not have regular physical activity classes so it is likely that the majority of the physical activity took place at home. While Kambas et al., and Tudor-Locke et al. (2011) note that there is limited research on exact step recommendations for preschool children, the clear gap between current and optimal physical activity suggests that there are not enough opportunities for physical activity during the normal day (Kambas et al., 2014).

Physical activity approaches:While children are generally more likely to engage in physical activity outside, CHAMPS notes that teacher-arranged physical activity inside is associated with higher activity levels. Through focus groups with the four PKC teachers, this study found that several of the teachers echoed similar strategies to increase physical activity indoors. One PKC-A teacher noted that she incorporates 10-15 movement breaks during the day (such as stretching or dancing) when the kids are unfocused. “We see that the kids come back much more focused. This group needs gross motor (activities) each day,” she says. The other PKC-A teacher also noted that although the infant room directly across the hall poses a barrier to group physical activity in the afternoon, they have adapted to quieter forms of activity if they can’t go outside such as silent ball. This teacher explicitly commented on using the need to be quiet during physical activity as a creative mechanism to more actively engage the class in different type of activity. In contrast, other teachers noted that although teacher-led structured activity is effective with some classes, a more flexible approach is also important. One PKC-B teacher mentioned that a flexible schedule has been most effective to provide opportunity for activity in her class: “There is not a single most effective method to increase physical activity. The structure and type of physical activity varies according to classroom dynamics. In our class, we have to be flexible with our gross motor (activities).”

This study elicited feedback from each of the PKC classrooms about the types of physical activities performed as well as how those activities made the participants feel. Each of the classrooms generally preferred the less structured movement activities in comparison to the more structured activities. Both the PKC-A class and the PKC-B class mentioned that they enjoyed activities with the beach ball and the parachute most as indoor activities. Although outside activities were limited due to weather, the PKC-A class agreed that the few times

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they played large-group games of “red light-green light” and “duck-duck-goose” on the playground were most enjoyable. The PKC-B students also said that “duck-duck-goose” was a clear favorite, as it was requested as much as several times per week due to the larger classroom space.

These images demonstrate favorite inside activities planned to account for space, noise levels, as well as inclement weather.

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These images represent favorite outdoor activities. Although regular outdoor activity during the study was not possible, the children loved playing games outside.

When asked about which activities were their least favorite, the PKC-A class mentioned that they generally didn’t enjoy games with pictures instructing them to emulate the picture in movement (ex: dance in the rain, fly like a bird, etc.). Additionally, they didn’t enjoy games involving less movement such as walking around in a circle to music with short bursts of movement (ex: 10 jumping jacks, running in place for 10 seconds., etc.). The PKC-B class also didn’t enjoy games with greater structure such as “Simon Says” or freeze tag on the playground. When asked how the activities made them feel, the overwhelming majority of PKC-A and PKC-B students mentioned “happy,” while others mentioned “tired.” Several students expressed different comments regarding the activities. Those students mentioned that the daily activities were “fun” while another mentioned that the activities should have been longer (as opposed to 10-15 minutes). Also, one student commented that she wanted “more exercise from the activities.” Finally, when asked about activities not included in the interventions but that the kids wanted to play, the majority of students in both PKC-A and PKC-B responded with activities typically requiring extensive space. For example, students mentioned games such as “football, soccer, more red light-green light, hide-and-seek”, as well as interpretative games such as “zebra tag” or “Frozen.”

Benefit of physical activity: Despite the gap in physical activity, each of the four teachers expressed a clear desire to increase physical activity opportunities for their classes and noted the benefits. “An active body stimulates the brain,” noted one PKC-B teacher. These opinions were also echoed during focus groups of Head Start teachers in Eastern Pennsylvania (Gehris, Gooze, & Whitaker, 2014). The teachers discussed that “children have an innate need to move,” expressing the significance of planning physical activities to meet this need. Taking walks during the day to refocus was another reoccurring theme between focus groups in this 6-week pedometer study as well as in the Gehris, Gooze, and Whitaker study. “On the days when the kids are unfocused, we get up and go for a walk if we can. The kids are much more focused. Better behavior is clear,” one PKC-B teacher mentioned. Another PKC-B teacher said that perhaps a best practice for elementary school is also applicable to preschool:

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“Where I used to teach, we had a 10-15 minute walk every morning. It made a big difference.” Gehris, Gooze and Whitaker discuss the significance of physical activity in the community as one mechanism to increase learning as well as exercise. For instance, helping children connect with their community by walking through neighborhoods and talking about the sights, sounds, and smells of the area was cited as a best practice (2014). In a different way, one PKC-B teacher expressed similar sentiments regarding the significance of community interaction to increase physical activity: “The community is doing a lot that not everyone is aware of. A lot of activities cost money. I know some places offer reduced membership fees.” In addition, Gehris, Gooze and Whitaker discussed the significance of physical activity in teaching children social, behavior, and spatial awareness skills. Specifically, the focus group of Head Start teachers cited indoor physical activity as one strategy to increase spatial awareness skills due to the limited space in classrooms (Gehris, Gooze, & Whitaker, 2014). There are several notable observations during the intervention period of the pedometer study. For instance, during large-group activities such as parachute games, the children applauded each other’s efforts and showed a collaborative spirit. It was clear that the group interventions encouraged children to demonstrate positive behaviors of teamwork, respect for others’ space, as well as healthy social interactions. In summary, each of the four PKC teachers clearly expressed the significance of gross motor time for physical activity as well as development although they shared differing opinions about which method is most effective.

Challenges to physical activity: Barriers to regular physical activity were a common theme mentioned by the MCC director as well as the four PKC teachers. The barriers elicited through focus groups are also generally consistent with those cited in childcare physical activity literature. The study found that the major daily challenges to physical activity discussed in the focus groups as well as in childcare physical activity literature provide major explanations for the inadequate step count over the 6-week period. The MCC director in addition to the four PKC teachers unanimously agreed that the lack of indoor gross motor space is a key challenge. Copeland et al., (2011) found that only half of the childcare centers studied in Hamilton, Ohio had sufficient indoor gross motor spaces such as a gym for inclement weather. Additionally, nearly all of the centers without exclusive indoor gross motor space noted that they commonly use available classroom or hallway space for physical activity (Copeland, et al., 2011). When asked about challenges to increasing physical activity, the MCC director responded that “The space we have is not conducive to physical activity.” She explained that the MCC received a grant a number of years ago in partnership with Allegheny College to build gross motor space. At that time, however, enrollment was not nearly as high as today. To accommodate growing enrollment, the gross motor space had to be converted into classroom space. The MCC director said that from an economic standpoint, it was more profitable to increase enrollment to help subsidize the high costs of building rental. She described the double bind that other Head Start providers face: “A lot of other centers in communities similar to Meadville face the same challenges. Facilities are often housed in church basements or school buildings. Rental of space is an issue so programs want to get as much enrollment as possible to cover costs, but gross motor space indoors is cut to increase numbers.”

Both of the PKC-A teachers expressed concern over the lack of space. “There is no indoor gym on days outside play is not possible, and the playground outside isn’t that large.” Additionally, the PKC-A teachers discussed the length of the room as a challenge because it limits the types of activities possible. As a result, the planned interventions during the 6-week study consisted mostly of variations of dancing, and circle games with a parachute or beach ball to correspond with the weekly theme. The PKC-B teachers mentioned noise as an additional concern limiting physical activity. “I know this room seems large but there’s only a divider between the other preschool room and our PKC room so we can’t do anything extremely loud if they are doing a lesson or napping.” The planned interventions in PKC-B were primarily more active in the morning (ex: duck-duck-goose or dancing), and quieter during the afternoon hours when the other preschool class was napping (ex: silent ball, or parachute games).

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Weather arguably poses the second-largest barrier to physical activity, specifically in Northwestern, Pennsylvania. Each of the 4 PKC teachers also noted weather as a major barrier to outside play. Copeland et al. mentioned that stringent weather-related play policies when the temperature is below 32 degrees make it especially difficult for centers located in colder climates. For example, in the study area of Hamilton, Ohio, Copeland et al. found that the typical weather-related play policies would restrict outdoor physical activity for about 46% or 179 days of the entire school year.

This image shows the MCC outside playground. This photo was taken on March 31, 2015, during the 5th week of the 6 -week study.

One PKC-A teacher discussed how her class struggled to focus during the winter months, which consisted of the majority of the 6-week study period, and had a clear impact on the step deficit. For instance, the study results show a considerable increase in physical activity (597 steps) from week 4 to 5, which also coincided with an increase in outdoor temperature. Although the weather was not formidable for outside play all of the days, outside play was significantly more regular during this time. “The winter time was especially hard for us,” she said. “We couldn’t go outside for days on end. Then it rained for days on end. The kids were ‘stir crazy’ and couldn’t focus, which was difficult.” Each of the PKC-B teachers also expressed similar frustrations: “There are weeks on end in the middle of the winter where we couldn’t go outside.” One of the PKC-B teachers mentioned during informal conversation one day that she worked in a childcare facility in the past that had an

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This image demonstrates yoga as one approach to “quiet physical activity” when outside play was not possible.


indoor gym, and was used to taking the kids there for hours during the winter time. She also noted that she doesn’t mind the kids running around the room a bit during unstructured free play because they will never sit still if they don’t get any activity. Both of the PKC-B teachers mentioned that “contained gross motor” activities within the classroom during the winter months are their goals. “It would be easier if we had a space where they could run. We stress activity but also self-control.” All of the teachers mentioned that even on days when the temperature was above 32 degrees, the weather was so unpleasant that they could only stay outside for 15 minutes by the time they helped their classes put on snow clothing. Additionally, on days when the temperature was above 32 degrees, a lack of proper snow clothing inhibited outside play. One of the PKC-B teachers said, “It’s hard when one person doesn’t have clothing and no one can go outside or the child has to stand there. I know some of the teachers donate their children’s old snow clothes to the center because it’s a problem.”

Barriers to physical activity have disproportionate implications for the most at-risk group of kids because physical activity during the school day is usually their total amount for the entire day (Copeland, et al., 2011). The larger community and family, therefore, have significant implications for the amount of physical activity preschoolers get during an average day. The MCC director noted that, “Most parents of PKC kids work full-time. It’s not that the parents don’t want to play with their kids; they work full-time and can’t.” One of the PKC-B teachers echoed these feelings, adding that a lot of kids also go between mom and dad’s house, posing additional challenges to activity outside of the normal school day. For instance, one of the PKC-B teachers told a story that elucidated the inadequate physical activity picture. “One day I asked the kids if they went sledding or played in the snow in the winter. Most responded that they watched TV and played video games. So I know the kids generally are not very active at home.” Awareness of community resources was also mentioned by one of the PKC-B teachers. “The community is doing a lot (in terms of youth physical activity opportunities). Yet, a lot of activities (youth sports leagues, YMCA memberships, etc.) cost money. At the same time, I know some places offer reduced fees.” While outside factors such as the community and families did not have a direct influence on the physical activity deficit identified in this study, it signifies that perhaps the physical activity deficit is also present during the after-school hours.

Study limitations:This study had several reoccurring limitations throughout the entire 6-week period. First, full-day attendance varied due to illness, vacation, late arrivals, and early pick-up times. All step data that excluded significant portions of the “active” day were not included in the class step averages. For this reason, it would have been nearly impossible to track individual step data over the 6- week period. Second, not all of the children wanted to wear a pedometer each day, and others wanted theirs removed after wearing it for a few hours. On an average day, about half of the students wore pedometers due to inconsistencies in attendance as well as those who chose not to participate. Third, pedometers were removed before outside play at the end of the day on several occasions because removal of pedometers was difficult when students were wearing heavy snow pants covering nearly the child’s entire torso. Fourth, the findings and results from focus groups are representative of one Pre-K Counts program and may not be representative of other early childhood programs in different geographic regions.

Future recommendations and efforts: Significant opportunity exists at the local, state, and national levels for increased focus on physical activity by Head Start Programs. From a policy perspective, federal, state, and local policies are largely outdated and do not elucidate the need for greater moderate-to-vigorous physical activity. At the state level, one key step is to incorporate physical activity into the Head Start Program’s goal of school readiness and the Early Learning curriculum framework. Specifically, in Pennsylvania, revision of the Keystone STARS accreditation and the Department of Health and Human Services framework to require greater gross motor space, as well as funding

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opportunities for expanding indoor space in childcare centers is one plausible recommendation. Currently, there are no federal Head Start Program guidelines specifying the amount, frequency, and type of physical activity (Story, Kaphingst, French, 2006). Strong localized physical activity polices are, therefore, significant. One PKC-B teacher noted that since each Head Start providers vary so greatly in terms of location, facility space and layout, funding, enrollment, and management styles perhaps it would be more effective for each child care facility to set their own tailored physical activity policies. Although there may still be a step deficit, this PKC-B teacher believes that this policy could be one potential avenue to ensure that preschoolers have regular opportunities for physical activity each day.

Additionally, the American Alliance for Health, Physical Education, Recreation and Dance (2012) notes that increased time available outside of the classroom for teacher training and building greater community partnerships is one strategy. For instance, greater community partnerships are significant in securing joint use agreements for parks and other recreational areas in addition to greater funding sources to upgrade gross motor equipment and spaces. Gehris, Gooze, and Whitaker (2014) echo this strategy, discussing that additional training of teachers in gross motor development and children’s movement could be beneficial for more effectively incorporating regular physical activity into academic lessons. Once greater activity is implemented, regular teacher participation in physical activity with the children both in and outside of the classroom is a key recommendation to improve children’s learning as well as sustain participation in gross motor activities (Gehris, Gooze, & Whitaker, 2014).

Ultimately, Pre-K Counts programs matter in Crawford County and in every community because they serve the kids at the greatest risk for academic failure. Physical activity interventions in Pre-K Counts programs, however, represent one potential avenue to increase physical activity among preschoolers. Further research is necessary to clearly define physical activity recommendations for preschool-aged children (Tudor-Locke et al., 2011), as well as determine which methods are most effective in increasing moderate to vigorous physical activity (American Alliance for Health, Physical Education, Recreation & Dance, 2012). Greater research efforts to assess physical activity among low-income children in the home environment can also help inform physical activity policy efforts in child care settings. Sustainable physical activity initiatives must encompass not only a commitment from key policy stakeholders at the local, state, and national levels, but also individual childcare providers. Although interventions and some increases in outside play are not enough to increase physical activity enough to meet the daily guidelines, increased regular gross motor time is one significant part of promoting greater early childhood health.

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Chapter 3: Ethics and Social Philosophy

While obesity is typically defined clinically as a “disease of excess,” obesity is also a social issue given the emerging relationship between obesity and poverty. The highest rate of obesity occurs among populations with the least amount of money and the least amount of education. Low-income individuals are especially vulnerable to obesity for a number of reasons including food insecurity, increased stress, as well as decreased access to physical activity, nutritious food, and health care facilities (Drewnowski & Specter, 2004). Stress is one factor magnifying the relationship between obesity and poverty. Low-wage jobs, unsafe neighborhoods, poor housing conditions, and increased financial burden all contribute to poor physical health. Stress also triggers poor health behaviors such as unhealthy eating or being sedentary, while long-term stress impacts mental health (Food Research and Action Center, 2010). Despite the multitude of external factors influencing obesity, self-management is still the current primary preventative strategy. The focus on individual versus collective responsibility is significant, as children are taught from a young age that they have complete control over their health behaviors. The constraints of poverty make positive health behaviors such as purchasing nutritious food, regular wellness visits, or seeking physical activity opportunities difficult. Nonetheless, our society still blames individuals for unhealthful choices (Purcell, 2010).

Many of these constraints are policy driven as the government traditionally plays little role in greater regulation of the economy and built environment (Purcell, 2010). Public policy is one major driving force of poverty and obesity, because it has the most significant impacts on those with the fewest resources and lowest incomes. A number of policies impact poverty and obesity rates. The economic and health impacts of the policies listed below will be discussed in greater detail in Chapter 4:

Welfare policy (Supplemental Nutrition Assistance Policy; Women, Infants, and Children) School nutrition assistance programs (National School Lunch and Breakfast Program) School physical activity curriculum and policy Built environment (sprawl, zoning, and tax codes)

Obesity disproportionately impacts the poor, racial minorities, and those of low socioeconomic status (SES) (Drewnowski & Specter, 2004). There are a number of other reasons for the apparent health disparity including genetic predisposition, disparities in the built environment, access to care, and public policy. Scholars have also cited racial or ethnic discrimination as potentially negatively impacting mental health, increased stress, and low SES (Caprio, et al., 2008). In the National Health and Nutrition Examination Survey, the CDC notes that non-Hispanic white children living in households where the head of the household has a college degree are generally less likely to be obese compared to those in households with lower education (Ogden, Lamb, Carroll, & Flegal, 2010). Generally, non-Hispanic white children from low-income parents are more prone to overweight or obesity, which reduces that child’s future earning potential (Jo, 2014). Obesity, therefore, can serve as one mechanism in which economic status is transmitted from parents to children. Ultimately, the clear racial and socioeconomic disparity in obesity should prompt public health professionals to more effectively target prevention strategies to benefit those at the greatest risk of overweight and obesity (Caprio, et al., 2008).

The rates of obesity differ dramatically by income level. With the recent economic downturn, forty-six million people in the United States currently live in poverty, the highest rate in more than fifty years (Levine, 2011). In 2007, 45% of children living in poverty were overweight or obese compared to 22% of children living in households with incomes four times more than the poverty line (Levi, Vinter, Laurent, & Segal, 2010). In

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Pennsylvania, 36.1% of children living in households with incomes 100% of the poverty level are overweight or obese (in 2007, the poverty level was $20,650 for a family of four) (The Child and Adolescent Health Measurement Initiative, 2012). The 2008 Pediatric Nutrition Surveillance System found that among low-income families participating in Women, Infants, and Children (WIC) supplemental nutrition assistance program, 25.8% of preschool children aged two to five in Pennsylvania were overweight or obese (The Child and Adolescent Health Measurement Initiative, 2012). Rural, northwest Pennsylvania also faces higher poverty rates than the state average. According to the 2009-2013 American Community Survey, in Crawford County 25% of persons under the age of 18 live below the poverty level. In Pennsylvania, 18.8% of persons under the age of 18 live below the poverty line (U.S. Census Bureau, 2013). Household income, however, is just one factor influencing childhood obesity rates.

Levine notes that the poorest counties have the greatest sedentariness and highest obesity rates. The term “sedentary” is defined as movement for two hours less than active individuals. In a study of 3,139 U.S. counties, “the wealthiest quintile” is defined as a mean poverty rate of 8.2% and a median household income of $56,259, while “the poorest quintile” is defined as a mean poverty rate of 25% and a median household income of $32,671. In comparison to “the wealthiest quintile”, Levine finds that the “poorest quintile” has the greatest sedentariness as well as the highest obesity rates. Inequalities in the built environment, as well as economic disparities are cited as promoting a sedentary lifestyle in poorer counties (Levine, 2011). Environmental and economic policies contributing to obesity will be discussed in greater detail in Chapter 4.

Hunger and lack of access to proper nutrition are additional driving forces of obesity and poverty. According to the United States Department of Agriculture (USDA), 43% of households with incomes below the poverty line of $21,756 are also food-insecure, meaning that they are unable to obtain a sufficient and consistent food supply (Levine, 2011). Evidence suggests that there is an association between childhood food insecurity and overweight and obesity. In a national sample of about 7,000 children, Casey et al. found that childhood food insecurity is associated with overweight after controlling for age, race, gender, and family poverty index (Food Research and Action Center, 2011). To complicate the issue, aggressive fast food marketing strategies bombard consumers with messages promoting unhealthful foods. Food consumers are faced with a dilemma of persistent advertising encouraging them to choose foods high in sugar and fat instead of fruits and vegetables. Such messages have serious health consequences, specifically for low-income, food-insecure consumers. Coupled with low education in a poverty-dense region, low-income consumers can be targets for direct fast food marketing. Drewnowski and Specter (2004) note that, “limited economic resources may shift dietary choices toward an energy-dense, highly palatable diet that provides maximum calories per the least volume and the least cost” (p. 14). Food-insecure people are disproportionately likely to rely upon “obesity promoting foods” that are lowest in cost, largest in quantity, and provide the highest dietary energy (Drewnowski & Specter, 2004, p. 9). The home environment and employment intensity of caregivers have also been cited as factors potentially influencing obesity (Jo, 2014). Anderson (2012) found that family routines vary with the intensity and daily time commitment of caregivers’ employment. Given increased economic pressures, children are increasingly likely to come from dual-career households or from single-parent households where the primary caregiver works full-time. As a result, families are likely to use childcare services before and after school, or both. Caregivers are, therefore, likely not always present for the enforcement of normal family routines such as meal times or physical activity. Single-parent households face additional economic and time constraints, which makes preparing a nutritious meal or engaging in regular family physical activity difficult. Clearly, not all children face the same risk of obesity, and children from low-income families are more prone to obesity (Anderson, 2012).

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For instance, the constraint of a normal work schedule allows caregivers little to no time to shop for and prepare meals. Therefore, an average dinner for working families may consist of fast food and other “convenience foods” (Anderson, 2012). According to Appelhans et al., (2014), intense employment schedules are negatively correlated with healthy family routines such as eating regular family meals, and enforcement of screen time rules or bedtime. Sleep duration and screen time are also important influences on childhood obesity in low-income households. For example, Burt, Dube, Thibault, & Gruber (2013) note an association between poor sleep quality and increased food intake in young children. Children that sleep less are more likely to consume food as a result of increased sensory susceptibility to smell and taste. Decreased self-control makes it difficult for children to resist temptation in the presence of food. Since decreased sleep time and poor sleep quality are associated with greater food intake even among non-overweight children, the mechanism(s) impacting sleep and diet has great implications for adult obesity. Decreased sleep also triggers an external emotional response in children, promoting greater food intake, which also has implications for both physical and mental health. Reducing chaos or disruption in the household, enforcement of a strict bedtime routine, and monitoring screen time are all important weight management measures (Appelhans et al., 2014). Employment intensity of caregivers and routine are merely two factors impacting obesity and do not explain the mechanism behind employment and obesity (Anderson, 2012). These weight management strategies, however, largely advocate for increased responsibility at the family level versus a collective responsibility to more closely examine larger social factors underlying obesity.

While it is important to examine the impact of health behaviors on obesity at an individual or family level, there are numerous other factors exacerbating the childhood obesity epidemic. One issue with the current obesity rhetoric is that it almost entirely places the blame for weight status on the individual or family. The North American belief system dictating that our food and exercise habits are exclusively our own decisions also influences this narrative. Tommy Thompson, former secretary of the U.S. Department of Health and Human Services, echoes this belief: “We must continue to work hard to spread the gospel of personal responsibility. Each of us has to take responsibility for making the right choices when it comes to diet and exercise “(Purcell, 2010, p. 437). This narrative argues that parents have sole responsibility for modeling healthy behaviors for their children.

Short-term health promotion interventions targeting children have ignored the unique social and economic circumstances underlying obesity. Most of the current obesity-related strategies almost exclusively focus on “self-management” and preventative action at the micro level. These educational efforts are, in reality, quite limited by election cycles, funding, and usually do not consider the long-term issue of obesity. Historically, state polices have promoted individual reliance, consumer sovereignty, and freedom to change health behaviors. Primarily well-educated groups will, however, benefit most from health information as they are able to more effectively apply health knowledge in comparison to low-income groups. Unintentionally, uneven distribution of health education can widen the existing gap in health disparities. Although some public health researchers argue that increased government intervention and regulation are key to reducing childhood obesity, such efforts are rarely widely supported and often discussed as an infringement on personal liberties (Purcell, 2010).

Deregulation of the advertising industry and the immense social influence of food advertisements also contribute to a “toxic environment,” complicating individual choice (Purcell, 2010, p. 434). For example, Purcell (2010) mentions that most parents recognize that “dinner served from a bag” is not nutritious for their children, leaving working parents are left with few options when their children’s food preferences are so heavily shaped by advertising, family income, and time for meal preparation (p. 433). Although researchers have advocated reducing commercial access to children to decrease consumption of high calorie and high sugar foods, the advertising industry in North America is relatively unregulated. Each year, $10 billion is spent

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on food advertising promoting unhealthy foods and portion sizes to children (Purcell, 2010, p. 434). As cited in Purcell (2010), Schor (2004) argues that, “Food advertisers have become sophisticated anthropologists. Their ads build on basic social relationships and connections of food to those relationships…” (p. 438). As a result, it is difficult for children to acquire their own taste preferences, and make unique food choices when their decisions are inundated by an aggressive advertising industry (Purcell, 2010).

Given the push from food advertisers to target marketing to low-income populations, we must counter by not only strengthening individual will power but also broad social preventative efforts. Likely, preventing pediatric obesity is one of the few promising strategies to combat the obesity epidemic. Ells et al. (2005) recommends obesity interventions at the local level targeting children and families in addition to greater regional and national level efforts. There are two common childhood obesity prevention approaches at the population level. One, some scholars argue that tailored interventions are most effective to target the population “most at risk” for developing obesity. Ells et al. (2005), however, notes that further research is necessary to prove the effectiveness of obesity prevention by targeting vulnerable groups. In contrast, others recommend a much broader population approach because all children will benefit from the development of healthy physical activity and nutrition habits. Further research on preventative strategy is recommended to determine greater generalizable conclusions and more accurately determine effective intervention approaches (Ells et al., 2005).

The increase in childhood obesity in the midst of social challenges such as poverty, political gridlock, and a healthcare system promoting reactive care instead of preventative care should prompt national action. Clear opportunities exist for intervention; yet, debates over which actors or policies are responsible for the obesity epidemic confuse the ultimate goal of obesity prevention rather than lifelong treatment. While there is merit to the current public health focus on family-based interventions as agents of preventative change for young children, many individual efforts are undermined by a much broader obesogenic environment. On a broader scale, Ells et al. (2005) suggests that a variety of childhood obesity intervention points such as homes, schools, communities, and national policy are most likely to yield significant progress.

Although it is politically convenient to debate responsibility, obesity is a global epidemic with both immediate and future implications. We, therefore, share a collective responsibility for the declining state of American public health. This prompts a clear moral obligation to continuously seek new intervention approaches, partnerships, and opportunities for greater collective action on childhood obesity prevention. Ultimately, public health professionals, researchers, and physicians must use their resources and knowledge to advocate for the children most vulnerable to obesity.

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Chapter 4: Policy, Poverty, and Economics

In 2012, more than one-third of children, adolescents, and adults in the United States were obese (CDC). The Robert Wood Johnson Foundation estimates that by 2040, about one-half of all adults in the United States could be obese (Brill, 2013). Yet, the United States spends more money on healthcare costs annually than any other advanced nation (Robert Wood Johnson Foundation, 2012). The lifetime healthcare costs for treating chronic conditions are rising. Childhood obesity alone accounted for $14.1 billion in direct national health care costs in 2009 (Robert Wood Johnson Foundation, 2015a). Cawley and Meyerhoefer estimate that as of 2012, annual medical costs for lifetime obesity-related illnesses were $190.2 billion or 21% of annual medical spending in the United States (as cited in National League of Cities, n.d.). Finkelstein et al. (2012) project that if obesity trends continue at the 2010 levels, healthcare expenditures for treatment of preventable obesity-related conditions are expected to reach $549.5 billion over the next two decades (as cited in National League of Cities, n.d.). Cawley (2007) found that nonmedical costs of obesity including loss of productivity, employee absenteeism, and disability also stifle business growth. Currently, obesity-related employee absenteeism costs businesses $4.3 billion per year. The nonmedical costs of obesity on employers are expected to rise (as cited in National League of Cities, n.d.).

Current healthcare and social welfare policies are largely short-sighted and primarily emphasize reactive treatment over lifetime preventative care. The Robert Wood Johnson Foundation notes that the Congressional Budget Office only evaluates healthcare policies by considering the impact and costs over a ten-year “window” although it takes much longer to project policy outcomes for diseases such as obesity and related chronic conditions. Most costly complications of obesity take at least ten years to fully develop, meaning that it is difficult to create effective policy without considering costs over the entire course of the disease. It is also nearly impossible to distinguish ineffective preventative policies from effective policies with the same initial starting costs within a ten-year window. It is recommended that the Congressional Budget Office estimate obesity costs over a lifetime (75-year) time frame to accurately capture long-term savings (Brill, 2013). Additionally, The American Public Health Association (APHA), recommends institutionalizing Health in All Policies (HiAP) when evaluating potential health, education, and environmental policies at all levels of government. HiAP promotes a community based, holistic understanding of health policy over the long term, as opposed to the current short-term views of policy. This model views health as the “ultimate outcome of political, social, and economic conditions,” and advocates for health to be of equal concern as other factors such as cost in policy decisions (American Public Health Association, 2012).

Given the current focus on fiscal conservatism and national debt, federally funded obesity prevention programs would actually reduce long-term costs by lowering chronic disease rates (O’Grady, M., & Carpetta, J., 2012). In 2010, the passage of the Affordable Care Act (ACA) attempted to control rising national costs through greater focus on preventative health services. For example, screening tests such as cholesterol, diabetes, blood pressure, mammograms, and colonoscopies are now free of cost. Counseling services including weight loss, nutrition, mental health, tobacco cessation, and alcohol reduction are also covered under preventative care. Key benefits for children include preventative services such as well-baby and child checkups from birth to age twenty-one and the end of preexisting condition exclusions for children under the age of nineteen. The ACA also aims to address the apparent gap in quality of care between the insured and uninsured. For example, components such as the elimination of lifetime limits on patient care, expansion of coverage to individuals with preexisting conditions, or increased funding for preventative health services were largely aimed to benefit low-income individuals without private insurance. Despite increased access to health services, the long-term cost savings and potential benefits of the ACA are largely unseen (Jacobs and Skocpol, 2012).

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Nutrition Policy: Current welfare and health policy are not entirely beneficial to improving obesity and poverty rates. In 2013, the USDA noted that 9.9% of children and adults nationwide lived in food-insecure households. Significantly, 62% of all food-insecure households participated in at least one of the three largest food assistance programs during the month prior to the 2013 survey. While there are a number of food assistance policies aimed at families with young children, such programs frequently face pressures of shrinking budgets and resources (Coleman-Jensen, Gregory, & Singh, 2014).

The recent Farm Bill is one example of an effort to control rising national expenditures and improve access to nutritious foods for low-income families. President Obama signed the $956 billion Farm Bill in February 2014. Thus far, the policy impacts are uncertain as it is lauded for some anti-obesity initiatives yet heavily criticized for significant cuts to the food stamp program. The Robert Wood Johnson Foundation (2014) cites several key components designed to address obesity:

requiring SNAP retailers to carry at least seven items in each of the four food groups increasing SNAP eligibility at community-supported agriculture retailers inclusion of physical activity in all state-sponsored SNAP nutrition education and obesity prevention

programs $125 million in funding for the Healthy Food Financing Initiative, encouraging food retailers to relocate

to low-income communities

The bill is also widely criticized by food stamp advocates for cutting $8.55 billion in funding when many families are already economically vulnerable. The Center for Budget and Policy estimates that 850,000 food stamp recipients may see their benefits fall by $90 per month. Although $8.55 billion in cuts is more palatable than the $40 billion that was originally proposed, recent food stamp cuts put increasing pressure on public charities and food banks. Unemployment and underemployment are also driving need for increased SNAP assistance (Grovum, 2014). The Food Research and Action Center notes that in January 2015, about one in seven people in the United States received SNAP benefits and one in nine was unemployed or underemployed. Most significantly, SNAP benefits are vital to decreasing poverty as well as improving children’s health through ensuring that they receive the proper nutrients for development.

For school-aged children, food assistance programs such as the School Breakfast Program/ National School Lunch Program are important to prevent food insecurity. For children from low-income families, breakfast may not be unavailable at home or lack nutritional quality, placing them at great risk for hunger. Additionally, some children face long commutes to school, meaning that they begin their academic day hungry. The availability of school breakfast at no cost creates an environment conducive to learning, and long-term academic success. Notably, the School Breakfast Program is vital to improved learning outcomes and retention. Studies show that students who ate school breakfast performed better on math and reading tests as well as cognitive tests. Students who ate breakfast also had fewer disciplinary problems, absent or tardy days and visits to the school nurse. The Food Research and Action Center recommends several significant policy changes to increase participation in the current program. One, breakfast should be a designated part of the school day. This can be accomplished through delivering breakfast on carts directly to classrooms at the start of the day, increasing the amount of time in the morning breakfast is offered, or providing “on-the-go” breakfast. Two, breakfast should be provided free to all kids regardless of income. This strategy would increase broader participation, improve nutrition for all children, and eliminate the stigma that “free breakfast is only for the poor kids.” During the 2013-14 school year an estimated 11.2 million low-income children ate a school breakfast each day. The school breakfast program, therefore, has a meaningful impact on improved

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nutrition and greater diversity of foods and academic success, as well as overweight and obesity (Food Research and Action Center, n.d.).

The National School Lunch Program (NSLP) also has important implications for improved nutritional status and classroom performance. During the 2013-14 school year, 30.7 million children and over 98,433 schools and registered childcare facilities participated in the NSLP on a typical day. The federal government mandates that each school participating in NSLP or other federally funded childhood nutrition programs must also enact school wellness policies to increase the health of low-income students. School wellness programs are designed to target schools serving large numbers of low-income students. The programs aim to reduce childhood obesity by involving diverse interests such as parents, community members, local business, and medical professionals to enact broad district-wide policy change. For example, wellness policies include: NSLP-approved snacks for after-school care or enrichment programs, walking clubs before and after school, regulations on food available in vending machines, farm-to-school programs, or cooking classes. Yet, the schools with the greatest number of low-income children that are also most at risk for obesity face extremely limited resources and funding. While it is the responsibility of low-income schools to provide nutritious food and regular physical activity opportunities that are otherwise not available at home, the efforts are limited. Shrinking education budgets on a national and state level, lack of available time for school administrators to effectively address wellness, high staff turnover, limited parental involvement, and increased academic pressure driven by low test scores largely inhibit significant progress (Food Research and Action Network, n.d.). Ultimately, the children most impacted by NSLP are at greatest risk for obesity and lack access to both nutritious food and adequate opportunity.

WIC (Women, Infants, and Children) is another food assistance program that greatly impacts the nutritional status of many young children. Income-eligible mothers with children up to age five are eligible for WIC benefits, suggesting that the availability of WIC benefits plays a key role in determining young children’s nutritional status, development, and likelihood of overweight and obesity. In 2007, significant changes were made to WIC to align eligible food with the latest nutrition standards. These changes have broader implications for improving neighborhood food environments, dietary intake, breast feeding standards, and childhood obesity. The USDA notes that obesity rates among WIC participants have begun to decline between 2008 and 2012. Among children ages two to four, 14.7% were obese in 2008. In comparison, 14.0% of children ages two to four were obese in 2012 (2013). The Food Research and Action Center notes that in 2012, more than 8.9 million women, infants, and children relied on WIC benefits every month. In total, the WIC program provides food assistance to 2.1 million women, 2 million infants, and 4.7 million children (Food Research and Action Center, n.d.).

The Child and Adult Food Care Program (CAFCP) provides nutritious meals as well as snacks to childcare settings and Head Start programs. Centers are reimbursed for the food served to enrolled children, allowing childcare facilities to help meet the nutritional needs of low-income children (USDA, 2014). Meals eaten at Head Start programs in childcare facilities consist of up to 50-100% of preschoolers’ daily calorie intake (American Alliance for Health, Physical Education, Recreation, & Dance, 2012). Although there are published federal nutritional guidelines for breakfast, lunch, and snacks, there have not been major changes to the CAFCP meal guidelines since the program’s creation in 1968 (USDA, 2014). There was, however, a new rule proposed in January 2015 to significantly update CAFCP meal patterns. The proposed changes aim to significantly increase the amount of fruits and vegetables and whole grains served, while decreasing the amount of sugar and fat. Additionally, the USDA notes that these changes do not alter costs to childcare providers (2014). The Head Start, Body Start 2012 policy recommendations cite a number of barriers to providing nutritious meals. For example, some childcare providers lack knowledge about which foods constitute a nutritious meal as well as the additional time and resources to plan and implement significant

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improvements for their facility. In some instances, households struggle to afford nutritious food or children and families already have a preference for many of the foods eaten at home regardless of their nutritional value. At the federal level, greater accountability and attention to Head Start’s school readiness goals in relation to the physical health components of the Early Learning Framework is a necessary step for nutrition education (American Alliance for Health, Physical Education, Recreation, & Dance, 2012).

Physical activity policy:The federal Head Start Program requires that centers provide adequate opportunities for fine and gross motor skill development both indoors and outdoors. Yet, there are no federal Head Start Program guidelines specifying the amount, frequency, and type of physical activity (Story, Kaphingst, French, 2006). As a result, the amount and intensity of physical activity are largely up to the discretion of individual child care facilities. Despite benefits such as motor skill development, self-confidence from skill mastery, and improved mood, physical activity levels vary according to both policy and individual practices (Copeland, et al., 2011). One study of Ohio child care centers found that differing weather-related outdoor play polices greatly impacted physical activity opportunities. Copeland, et al., (2011) found that only 20% of centers reported allowing children to play outside in temperatures below thirty-two degrees while 43% allowed children to play outside in light rain. Among centers that didn’t allow children to go outside in sub-freezing temperatures or rain, some indicated that they had expansive indoor gross motor facilities. Nevertheless, centers that lack indoor gross motor facilities and have strict weather-related or clothing play policies pose major barriers to physical activity. The study concludes that children are more active in childcare settings offering opportunities for outdoor play, as well as increased total allotted time for play. Therefore, perhaps policy change mandating physical activity requirements as well as increased teacher education is necessary to ensure regular and adequate physical activity (Copeland, et al., 2011). Additionally, even if physical activity is a scheduled part of each day, enforcement varies according to the preferences of individual teachers. For example, teachers may decide against outside play for a number of reasons including:

the weather is not “good enough” for outside play the preparation of going outside managing large groups in a noisy environment attitudes and beliefs about physical activity (facilitation of play versus supervision only)

Ultimately, the amount and regularity of physical activity can differ greatly among children within the same childcare center due to teacher beliefs (Copeland, Kendeigh, Saelens, Kalkwarf, Sherman, 2011).

The amount and regularity of physical activity opportunities for school-aged children also vary greatly. Currently, there is no federal policy requiring physical activity education for school-aged children, leaving program design and enforcement to state discretion. There are also no direct incentives for states or schools to mandate regular physical activity. The National Coalition for Promoting Physical Activity (n.d.) notes that the amount of recess time has declined steadily since 1989. While 90% of schools used to have some form of recess, 40% of elementary schools have since reduced, eliminated, or are considering eliminating recess. The barriers to greater activity in schools are similar to those inhibiting greater action on NSLP-related school wellness policies. For example, decreased state and national funding, and increased focus on test scores, largely driven by No Child Left Behind (NCLB) impact decreasing physical activity opportunities. Although NCLB required increased instruction time on core standardized testing subjects such as math and reading, decreased emphasis on and time for physical activity education or recess was a significant yet unintended consequence (National Coalition for Promoting Physical Activity, n.d.). In addition to lack of proper staffing and budget cuts, withholding recess as a penalty for poor behavior or unfinished work poses barriers to physical activity. In a survey of 1,900 principals across the United States, 77% reported withholding recess as a punishment (Chierici, Powell, & Manes, n.d.). The 2012 School Health Policies and Programs Study found that 58.9% of school

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districts required that elementary schools provide a regular recess time for all grades, while 34.2% of schools only recommended a scheduled recess time. Out of the 58.9% of school districts mandating recess, only 30.2% mandated that students participate in the recommended sixty minutes per day of physical activity (Lee, Nihiser, Fulton, Borgogna, & Zavacky, 2012). Despite national guidelines for school aged children, many of the physical activity programs are still limited in enforcement and frequency.

Built environment policy: Ecological models are frequently used to further examine the relationship between the environment, behavioral, and biological determinants of obesity (Swinburn, Egger, & Raza, 1999). Swinburn, Egger, and Raza define the term “obesogenic environment:” “the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations” (p. 564). Conversely, the term “leptogenic environment” describes “[an environment that] promotes healthy food choices and encourages physical activity” (Swinburn, Egger, & Raza, 1999, p. 564). The ANGELO (Analysis Grid for Environments Linked to Obesity) framework was developed to more accurately understand obesogenic environments and direct public policy influences. The framework divides environments by size into “micro” (homes, churches, schools, neighborhoods, etc.) or “macro” (public transportation systems, entire cities, food marketing, etc.). The criteria are: “physical” barriers or facilitators to health; “economic”- costs associated with the physical environment; “political”- zoning ordinances or other laws and influential decision makers; and “sociocultural”- the attitudes or beliefs about health (Swinburn, Egger, & Raza, 1999, pp. 564-567). Obesogenic physical environments at the micro level greatly impact health disparity as well as overweight and obesity. The physical environment is one important aspect of Swinburn, Egger, and Raza’s ANGELO criteria. In a scientific literature review of studies about health disparities in obesogenic environments, low-income individuals reported that they perceive that they have less access to indoor and outdoor physical activity opportunities (Lovasi, Hutson, Guerra, & Neckerman, 2009). When self-perceptions were compared to a national study by Gordon et al. (2006), low SES neighborhoods and African-American neighborhoods lacked access to public, private, indoor, and outdoor physical activity opportunities. Lovasi, Hutson, Guerra, and Neckerman (2009) evidence that disadvantaged groups (low-income African-Americans and Hispanics) were more likely to live in areas with higher traffic and crime concerns as well as fewer parks and recreation spaces. Wilson et al. adds that low-income African- Americans reported lower ease of walking in their neighborhoods, citing problems such as noise and stray dogs (as cited in Lovasi, Hutson, Guerra, & Neckerman, 2009). Similarly, Wilson et al. found that in comparison to higher-income respondents, low-income respondents have higher perceptions of neighborhood crime and traffic, as well as “aesthetic problems” (as cited in Lovasi, Hutson, Guerra, & Neckerman, 2009, p. 15). Significantly, appealing aesthetics and green space for physical activity have been linked to lower obesity risk and health disparities specifically in children. Given the concern of obesity, increasing aesthetically pleasing spaces to exercise safely as well as access to supermarkets are several promising strategies to create leptogenic environments in low-income, minority areas (Lovasi, Hutson, Guerra, & Neckerman, 2009).

Urban design and politics: According to the ANGELO criteria, the built environment also includes political decisions such as zoning restrictions and other city tax codes, which impact overweight and obesity. Regional policies regarding city design in part determine neighborhood walkability and overall health status. Lathey, Guhathakurta, & Aggarwal (2009) cite neighborhood socioeconomic status as a strong indicator of clustering of chronic disease, namely, diabetes. The “sprawl” of a neighborhood is also cited as influencing chronic disease prevalence. Sprawl is defined as “a complex pattern of land use, transportation, and social and economic development” (Centers for Disease Control and Prevention, 2009). Key characteristics of sprawl include: zoning policies segregating business, schools, residential development, and parks; disappearance of open farmland or fields;

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sporadic development between large spaces of open lot; and poor air quality due to increased traffic congestion (Centers for Disease Control and Prevention, 2009). The walkability index (within one mile) to mixed use spaces such as “social interaction places” is another significant predictor of chronic disease status. For example, people living in neighborhoods located within reasonable distance from “social interaction places” such as a park, church, or community center may be more inclined to walk or bike if it is more convenient than driving. While it is difficult to implement neighborhood walkability policies at a regional level, zoning regulations encouraging “social interaction places” in neighborhood design has significant positive public health implications (Lathey, Guhathakurta, & Aggarwal, 2009, p. 137). At a city level, policies promoting mixed use spaces are one promising strategy to mitigate health impacts of sprawl. For example, a mixed use space includes a portion of developed land such as commercial, office buildings, or neighborhoods and undeveloped land for community parks or recreational spaces. In summary, implementing urban design policies at a micro level is perhaps more significant than at a macro level because many design features within neighborhoods are often overlooked by broader regional policies (Lathey, Guhathakurta, & Aggarwal, 2009).

Food access and insecurity: Urban and rural food deserts are also cited as obesogenic environmental factors at the macro level. The USDA defines a food desert as “urban and rural towns without access to fresh, healthy, and affordable food” (n.d.). Currently, 23.5 million people live in food deserts and approximately half, 13.5 million, are low-income (United States Department of Agriculture, n.d.). Swinburn, Egger, & Raza (1999) cite politics as one of the ANGELO criteria, including the impacts of city zoning regulations. Such policies can be manifested through disproportionate numbers of convenience stores, liquor stores, and fast-food restaurants compared to full-size supermarkets (United States Department of Agriculture, n.d.). Unfortunately, fast food restaurants or convenience stores are often the least expensive and most accessible options for low-income minorities. Lack of access to nutritious food has significant implications for chronic nutrition deficiencies, obesity, and food insecurity. Food deserts in urban and rural communities vary. Each community poses different health-related challenges as each involves a larger set of economic, political, and physical challenges (Michimi & Wimberly, 2010).

Throughout the past thirty years, individually-owned full-service grocery stores that were once thriving in rural communities are being replaced by fewer national chain grocers. As a result, rural residents must drive longer distances to fewer chain grocers that carry nutritious food. Food consumption patterns are also associated with poverty levels in rural areas, meaning that diet quality is lower among low-income adults. These low-income households are also likely to frequent nearby convenience stores and other small grocery stores that offer nutritious food at a much higher price compared to full-service grocery stores (Michimi & Wimberly, 2010). Crawford County, Pennsylvania faces many of the economic and health issues associated with lack of access to nutritious foods. According to the USDA’s Food Environment Atlas, 1,633.80 Crawford County households had no car or access to a grocery store in 2010 (2013). Yet, obesity rates are not necessarily higher in all rural areas and lower in all urban areas because food deserts are embedded in a much larger set of social, cultural, and economic factors (Michimi & Wimberly, 2010).

Access to nutritious food has great implications for food insecurity, because in the United States, food security requires physical access as well as sufficient funds (Cook & Jeng n.d.). The USDA defines food insecurity as “limited or uncertain availability of nutritionally adequate or safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways” (Cook & Jeng, n.d., p. 9). Hunger is a potential consequence of food insecurity, and over time, may develop into malnutrition (Cook & Jeng, n.d.). Low-income, younger residents are particularly at greater risk of food insecurity compared to other rural populations (Michimi & Wimberly, 2010). Children from food-insecure families are more likely to develop overweight or obesity. Toddlers who experience food insufficiency, a measure of food insecurity, at any point

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during their toddler years are 3.5 times more likely to be obese by age four and a half. Although the specific pathways are undetermined, the quality and quantity of food, as well as health behavior and depression status of caretakers play a role in the association between food insecurity and obesity (Cook & Jeng, n.d.).

In Crawford County, the childhood food insecurity rate rose from 7.20% of households during 2001-2007 to 7.90% of households during 2003-2011 (United States Department of Agriculture, 2013). In addition to increased likelihood of overweight and obesity, food-insecure children are likely to face intellectual, physical, and emotional development impairments. Child hunger is also an economic issue as food-insecure children get sick more often requiring additional costs for pediatric visits or hospitalization, which are likely then passed on to the business community, insurance companies, and taxpayers. For example, iron deficiency anemia is common among the most at-risk children, and in severe cases requires hospitalization at an average cost in 2003 of $5,573 per child. In children ages 0-3, school readiness is built on “growth, development, and experiences” (Cook & Jeng, n.d., p. 10). This stage is the most important developmental period of a child’s life because improper nutrition can harm cognitive development during this period of critical brain growth, permanently altering the neurological architecture of the brain and central nervous system. In school-aged children, chronic hunger impairs ability to focus during school and as a result, academic achievement. In the long term, the lack of education and technical skills could greatly inhibit human capital by creating a less competitive workforce without the necessary physical, emotional, or social skills (Cook & Jeng, n.d).

Walls, Peeters, Proietto, & McNeil, (2011) describe public policy as “one of society’s more powerful mechanisms for change” (as cited in Harvard School of Public Health, 2015). Similar to successful anti-tobacco policies banning smoking in public places or increasing tobacco prices, public policy is a key mechanism to influence social behaviors and attitudes about health. Although there is not a single “target” in the obesity epidemic compared to anti-tobacco campaigns, health policies greatly influence the environments in which we live, work, play, and attend school. To transform obesogenic environments into leptogenic environments, policy reforms on welfare, nutrition, physical activity, schools, and the built environment are necessary at all levels of government. Concerns about sustainability and long-term impacts of policies, however, have prompted us to delay multifaceted solutions. As cited by Harvard School of Public Health’s Obesity Prevention Source Web, Swinburn et al. (2011) and the Institute of Medicine (2010) found that policy approaches are easier to sustain with greater return on investment compared to health promotion or clinical programs. Ultimately, both individual and family-level policy solutions, in addition to broad federal level reforms, are crucial to obesity prevention (Harvard School of Public Health, 2015).

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Chapter 5: Science, Health, and the Environment

Obesity: According to the World Health Organization (WHO), obesity is defined as having an excessive accumulation of body fat (2014). Overweight is defined as having an excess of body weight for a particular height. Classification of overweight, however, is not always due to fat and could also be impacted by muscle, bone density, and water intake. Among environmental, genetic, and socioeconomic factors, overweight and obesity are generally caused by a caloric imbalance (Centers for Disease Control and Prevention, 2014a). Obesity is a “vicious cycle” or in clinical terms, a self-reinforcing feedback loop. Obesity itself is found to increase susceptibility to risk factors such as diet, physical inactivity, and genetics that promote weight gain. Children are increasingly exposed to chemicals or obesogenic agents in the environment (ex: plastics, pesticides, food additives), which make self-reinforcing feedback loops more common, especially in those who are already genetically predisposed to weight gain or diabetes. These obesogens in the environment alter hormone signals from the body to the brain, promoting fat storage or increased glucose levels. Obesity is a significant part of the obesogenic environment, perpetuated by weight gain and increased sensitivity to obesity-related risk factors (Diabesity Research Foundation, 2015). Nonetheless, childhood obesity is a complex issue with diverse contributing factors.

In 2013, the American Medical Association (AMA) officially recognized obesity as a disease. The AMA argues that obesity fits some of the criteria for a “disease” because it impairs the function of the body and is not solely brought on by a chosen unhealthy lifestyle (2013). Obesity, therefore, is a significant cause of chronic disease. According to the American Heart Association (AHA), heart disease is currently the number-one killer in the United States, while stroke is number five. New guidelines released by the AHA, American College of Cardiology, and The Obesity Society suggest that the classification of disease implores increased attention by medical providers to take preemptive weight management actions and prevent onset of chronic diseases. In November 2013, new guidelines released by the three agencies prompted physicians to “own the problem of weight management.” It is recommended that physicians enroll eligible patients in a medically based weight loss program two to three times per month for a total of six months. Patients are enrolled based upon Body Mass Index result. For example, some of the programs include behavioral interventions such as food journaling, telephonic/online coaching, or meeting with a dietitian or psychologist to establish a meal plan and discuss potential barriers to adhering to a weight loss program. Finally, for severely obese patients with one or more obesity-related health problems (diabetes, high blood pressure, sleep apnea or other respiratory issues) weight loss surgery such as bariatric surgery is an option (American Heart Association, 2013b).

Body Mass Index:In children ages 2 to 19 years, BMI (Body Mass Index) is used to determine overweight and obesity as well as risk of subsequent physical and mental health effects. BMI is a measure of weight relative to height and a method of screening used to determine weight categories. Freedman, Bettylou, and Sherry (2009) suggest that children with high BMI relative to their age and gender are more likely to have excess body fat. BMI, however, cannot distinguish between body weight, skeletal muscle, muscle mass, and body fatness, which results in misclassification. BMI is a more accurate predictor of obesity in children who have excess body fat in comparison to thinner children due to differences in BMI from fat-free body mass among thinner children. Additionally, major growth spurts occurring during ages 5-18 can also falsely increase BMI readings, making the interpretation of results difficult for children and adolescents. To most accurately predict chronic disease risk, several screenings are recommended because adult obesity is a significant factor in disease outcome for obese children. The WHO notes that among adults, however, there is currently no consensus on the exact BMI cut-off points for body fat percentages classifying overweight versus obesity (Freedman, Bettylou, & Sherry, 2009).

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(Spear, et al., 2007).

Childhood obesity trends: Although obesity was once considered a “disease of wealth” and mainly an issue in the global North, obesity is increasingly becoming a problem in developing nations with emerging economies. Globally, the prevalence of overweight and obesity in infants and children under age five has increased from 31 million to 44 million during the years 1992-2012 (World Health Organization, 2013). In 2013, 42 million children under the age of five were overweight or obese. In young children, micronutrient deficiencies are especially common because processed foods high in salt and sugar are more affordable. It is not uncommon, therefore, for a child to be both malnourished and obese. This increase is in part due to the global availability of energy-dense, high-calorie foods, and a global shift to a sedentary lifestyle, which includes changing methods of transportation, and urbanization. Furthermore, obesity rates are also impacted by countries with emerging economies and lack of funding for health and nutrition education programs, and more effective urban planning. The rise of large-scale agriculture and crop subsidies plays a key role in obesity as well (World Health Organization, 2014). Since the late 1970’s, the United States has also seen an increase in childhood obesity among all socio-economic classes and races throughout the country (Ludwig, 2007). According to the American Heart Association (AHA), childhood obesity rates in the United States have nearly tripled since 1963 (2013a). In 2009-2010, 16.9% of children aged 2-19 years were obese (Ogden, Carroll, Kit, Flegal, 2012). Former U.S. Surgeon General Richard Carmona described the prevalence of childhood obesity in the United States as an epidemic: “Because of the increasing rates of obesity, unhealthy eating habits and physical inactivity, we may see the first

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BMI equation: weight (kg) / [height (m)] 2

Weight status in children is determined using sex and age-specific percentiles for BMI rather than BMI categories used for older children and adults.

Childhood overweight: BMI ≥91% for children of the same age and sex (Cole, Bellizzi, Flegal, & Dietz, 2000)

Childhood obesity: BMI ≥99% for children of the same age and sex (Cole, Bellizzi, Flegal, & Dietz, 2000)

Weight-for-stature charts: (Spear, et al., 2007) Alternative to BMI for preschool-aged children (2-5) Only assesses growth during preschool years Three recommended obesity treatment strategies by the Journal of Pediatrics for

children aged 2-5:1.) 84th to 94th percentile (overweight children): prevention plus healthy lifestyle changes to maintain a healthy weight for height2.) 95th to 98th percentile (obese children): prevention plus a structured weight management plan by the pediatrician 3.) ≥ 99th percentile (obese children): Comprehensive multidisciplinary intervention. This plan is only necessary if there is no improvement after three-to-six months of prevention in addition to a structured weight management plan.

o Parent/caregiver training o Strict dietary and physical activity guidelines


generation that will be less healthy and have a shorter life expectancy than their parents” (American Heart Association, 2013a).

Nationally, obesity among low-income preschoolers has started to decline during the time period of 2008-2011, as evidenced by a decrease in nineteen out of forty-three U.S. states and territories. The Centers for Disease Control and Prevention (CDC) note that obesity in children ages 2-5 fell from 14% in 2003-2004 to slightly over 8% in 2011-2012 (2014a). The causes for the drop in obesity rates are uncertain, although some public health experts point to increases in nutritious food and physical activity in childcare settings, as well as improved breast feeding rates. Obesity rates are, however, rising in three states: Colorado, Pennsylvania, and Tennessee. Currently, one in eight preschoolers in the United States is obese (Centers for Disease Control and Prevention, 2013b). Among preschool-aged children, it is a common misconception that obese or overweight kids will “grow out of it” (National Academy of the Sciences, 2011). A study referenced by the CDC, however, found that overweight and obese preschoolers are five times more likely to stay overweight or obese in their adult lives as their non-obese peers (Whitaker, Wright, Pepe, Seidel, & Dietz, 1997).

Childhood obesity rates are on the rise in Pennsylvania (Centers for Disease Control and Prevention, 2013). In 2011, 12% of low-income children ages 2-4 years were obese within the state (Robert Wood Johnson Foundation, 2015b). During the 2010-2011 school year, 32.6% of children in grades K-6 were overweight or obese (Pennsylvania Department of Health, 2015). Childhood obesity rates in Northwest Pennsylvania are higher than the state as a whole. Locally, the low-income preschool obesity rate in Crawford County during 2006-2008 was 11.30%, and increased by 1.60% during 2009-2011 to 12.90% (United States Department of Agriculture, 2013). According to the Pennsylvania Department of Education, 38% of children in grades K-6 are overweight or obese during the 2011-2012 school year.

Physical health implications: Obesity-related diseases are a major cause of morbidity and mortality worldwide, impacting every major organ system (Raj, 2012). The AHA notes that obesity is linked to more than 20 chronic diseases, which is more than smoking, drinking, and poverty (2015). Overweight and obese children are more likely to develop early onset of chronic disease risk factors and are at a high risk for adult obesity (Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007). The physical health outcomes of childhood obesity are cumulative, with health impacts such as hypertension, atherosclerosis, and diabetes beginning to emerge in young children (Bridger, 2009). Obese children are also more likely to possess early risk factors for adult metabolic syndrome, such as hypertension, abnormal glucose tolerance, and dyslipidemia, which includes high triglyceride levels and low HDL (high density lipoprotein) cholesterol levels (Bridger, 2009). Broadly, childhood obesity has great health implications for Type 2 Diabetes, heart problems, sleep apnea and asthma, as well as bone and joint problems, which are discussed in greater detail below.

Type 2 diabetes, previously known as “adult-onset diabetes” is another physical health implication of overweight and obesity, with early indicators such as insulin resistance developing in children (Bridger, 2009). Often referred to as “impaired glucose tolerance”, prediabetes, a condition in which blood glucose levels are higher than normal yet not high enough for diabetes, is becoming increasingly prevalent in younger children and teens (American Diabetes Association, 2015). Prediabetes is a risk factor for Type 2 diabetes, as well as stroke and heart disease. Among a population aged 5 to 9 years, waist circumference was the strongest modifiable predictor of early-onset Type 2 diabetes (Franks, et al., 2007). The American Diabetes Association estimates that by 2050, one in three people will have diabetes (2015). Childhood obesity, therefore, is a significant risk factor for Type 2 diabetes, as well as cardiovascular disease (CVD), demonstrating the urgent need to address long-term health concerns (Franks, et al., 2007).

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Childhood obesity is one of the strongest predictors of adult heart disease (Raj, 2012). The AHA notes that children who are obese by the age of three demonstrate early indicators of developing heart disease later in life (2013a). In older children and adolescents, the CDC recognizes high blood pressure and high cholesterol as two immediate and prominent risk factors of heart disease, posing serious health issues before adulthood. According to the AHA, obese teens with high triglyceride levels have arteries that resemble that of a 45-year old (2013a).

Bridger (2009) found that obese children already demonstrate risk factors for CVD, such as high cholesterol or high blood pressure. Atherosclerosis, the formation of fatty plaque in the arteries, is one early risk factor for later onset of heart disease in children. The extent of the atherosclerotic process in children, however, depends on the number and severity of risk factors present (Bridger, 2009). Freedman et al. (2007) found that 70% of obese children had at least one CVD risk factor, and 39% had two or more. The American Association of Pediatrics predicts that the current rate of childhood obesity has great implications for early adult morbidity and mortality. If this trend continues, some predict that in 2020, heart disease prevalence will be 16% and will account for 19% of deaths in adults aged 35 to 50 years (Bridger, 2009).

Additionally, obesity impairs lung function in children and adolescents, increasing the risk for developing Obstructive Sleep Apnea Syndrome (OSAS) and potentially, asthma. Redline et al. found that each additional unit of BMI above the average increases the risk of developing OSAS by 12%. OSAS and chronic respiratory issues during childhood are also major risk factors for cardiovascular-related diseases in adulthood (as cited in Raj, 2012). Childhood asthma is cited as one potential physical health outcome of obesity, although further research is necessary to prove causation. In a literature review of epidemiologic studies, Mebrahtu, Feltbower, Greenwood, and Parslow found that there is an association between childhood overweight and obesity and increased risk of asthma (2014). Tai, Volkmer, and Burton (2009) also note that despite little research on asthma symptoms and obesity in preschool-aged children, there is an association for both males and females. Specifically, 23.7% of preschool children experienced wheezing symptoms within the past 12 months. Within the cohort of children in the study, 13.7% were classified as overweight while 5.7% of children were classified as obese according to the International Obesity Task Force definitions (Tai, Volkmer, & Burton, 2009).

Childhood obesity also impacts the proper formation of growth plates and cartilage tissue at the end of long bones such as arms and legs, which regulates size and shape at full maturity. Increased stress and tension on bones from excess weight could potentially lead to bone and joint problems as well as impaired bone growth. Morbidly obese older children (BMI of 40 or above), are at risk of developing Developmental Coordination Disorder (DCD). DCD impairs gross motor skills such as hopping, skipping, or jumping, as well as fine motor skills such as using scissors or tying shoelaces. As a result, most children with DCD are nearly physically unable to exercise or greatly impaired, and must seek physical and occupational therapy services to prevent more weight gain. Excess weight over a prolonged period stresses these growth plates, increasing vulnerability to broken bones, as well as early onset of arthritis. Therefore, untreated obesity in adulthood is likely to greatly impair mobility, and inhibit quality of life (American Academy of Orthopedic Surgeons, 2014).

In the long term, overweight and obesity increase risk for chronic disease such as Type 2 Diabetes, heart disease, and stroke. Overweight and obesity is also a risk factor for some forms of cancer such as kidney, colon, breast, and pancreatic. Ultimately, if childhood obesity persists, obesity in adulthood is more likely to be severe, which has both serious physical and mental health consequences (Center for Disease Control, 2013b).

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Mental health implications: Childhood overweight and obesity is associated with serious psychological and social health effects. Weight-related discrimination, depression, poor performance during school, bullying from peers, poor body image, and low self-esteem are among the most prominent psychological and social consequences of obesity. Latzer (2013) notes that children diagnosed as “clinically overweight” show elevated levels of anxiety, depression, behavioral problems such as ADHD, and increased likelihood of developing eating disorders (p. 1). Although there is not a causal link between childhood overweight and obesity and poor self-esteem, evidence suggests that overweight children have poor body-related attitudes and self-esteem in comparison to their normal weight peers. This trend is particularly salient for overweight females, as they are at great risk of suffering from low self-esteem. According to Latzer (2013), children as young as age five perceive their own weight and therefore have some concepts of body image, self-esteem, and social competence. However, the extent to which overweight and obesity provoke low self-esteem in young children is highly complex as there are many social and societal factors that play a role in socialization (Latzer, 2013).

As children age, the mental health implications of overweight and obesity intensify. In comparison to other children aged 5 to 18 with other chronic health conditions, children diagnosed with obesity had higher rates of internalizing and externalizing mental health conditions. Internalizing and externalizing disorders present significant barriers to a healthy lifestyle such as overeating, emotional eating, and sedentary activities that are likely to continue the cycle of weight gain (Janicke, Harman, Kelleher, & Zhang, 2008). A study by the International Journal of Eating Disorders examining clinical samples of overweight and obese adolescents found that 30 to 50% demonstrated moderate-to-severe levels of depression, while one-third had high anxiety levels. Obese adolescents, therefore, are at a greater risk of developing long-term psychological issues compared to their non-obese peers, considerably reducing their quality of life (Latzer, 2013). Psychological problems associated with overweight and obesity also impact the academic performance of school-aged children. Significantly, Latzer (2013) found that obese children are more likely to be absent from school than their non-obese peers.

Many of the psychological issues associated with obesity such as poor body image, teasing from peers, anxiety, and depression can also be precursors to eating disorders. Additionally, obesity within the context of poor family relationships, lack of social support, and existing mental health issues increases risk for development of destructive eating habits, such as binge eating disorder (Latzer, 2013). Binge eating disorder is defined as “uncontrolled eating episodes that occur at least twice per week for a period of no less than three consecutive months, with no evidence of weight-reduction behaviors” (p. 6). Morgan et al. (2002) found that while binge eating exists among 20 to 40% of severely obese adults and adolescents, 5.3% of overweight children aged 6-11 exhibit signs of binge eating disorder (as cited in Latzer, 2013). Haines and Neumark-Sztainer (2006) also note that similar psychological risk factors influencing obesity also influence eating disorders. The Youth Risk Behavioral and Surveillance System found that ≥ 11% of girls and 7% of high school boys in the United States reported using diet pills, liquids, or powders to lose weight. Furthermore, about 8% of girls and 4% of boys reported vomiting or taking laxatives to lose weight (Haines & Neumark-Sztainer, 2006).

Broadly, childhood psychological disorders are associated with overeating, food addiction, and lack of physical activity which can contribute to adult obesity. Additionally, Sanchez-Villages (2013) found that a number of other factors such as socioeconomic status, social isolation, dietary patterns, and physical activity level also influence the link between childhood obesity and adult depression. Ultimately, childhood obesity and adverse mental health have lifelong psychological implications for both young children and adults (Sanchez-Villages, 2013). Physical activity guidelines:

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One prominent recommendation emerging from the childhood obesity epidemic and subsequent health complications is to increase opportunities for physical activity in children (US Department of Health and Human Services, 2013). The AHA notes that birth to age 5 is a key developmental time to set positive patterns and habits for children (2013a). The 2008 Physical Activity Guidelines for Americans cite the substantial health benefits of physical activity for children including a more favorable body composition, reduced symptoms of depression, reduced cardiovascular disease risk factors, as well as improved bone health (US Department of Health and Human Services, 2008).

There are also significant developmental and academic benefits of physical activity. The National Head Start Program curriculum highlights improved health knowledge and practice, gross motor skills, and fine motor skills as major benefits of movement. For instance, gross motor skills are developed through activities such as throwing a ball, doing a summersault, or hopping. Physical activity also aids in development of social and emotional skills. For example, group physical activities help preschoolers express their “sense of self” in addition to taking turns and interacting with others. From an academic standpoint, movement helps preschoolers understand fundamental concepts such as trial and error, maintaining concentration during tasks, and problem solving (Go Smart, 2014). In older children, physical activity is associated with fewer behavioral problems and absences, as well as increased self-esteem and academic performance (American Heart Association, 2013a).

Development of motor skills in relation to physical activity has received relatively little attention in the past as many believe that preschoolers are very active during the day. Although the relationship between physical activity and motor skills is not well understood, the amount of physical activity does impact motor skill performance. Children with poorer motor skills were less active than children with more developed motor skills, meaning physical activity in preschool programs is crucial for both skill development as well as obesity prevention (Williams, et al., 2008). In fact, preschool kids require more physical activity than elementary school-aged children. The established relationship between physical activity, health benefits, and increased learning outcomes is one major reason for increased physical activity among preschoolers (U.S. Department of Health and Human Services, 2008). The National Association for Sports and Physical Education (N.A.S.P.E) recommends 60 minutes of structured physical activity, as well as up to several hours of unstructured physical activity each day for children ages 2 to 5. According to N.A.S.P.E, children should not be sedentary for more than 60 minutes except when sleeping (Society of Health and Physical Educators, 2014).

While the physical impacts of childhood overweight and obesity indicate a clear public health crisis, the rise in mental health issues such as eating disorders also signifies a much larger conversation about multifaceted public health interventions. Obesity prevention programs that address both physical and mental health issues such as unsafe dieting, body dissatisfaction, or bullying may be most effective. For example, physical activity and nutrition intervention programs can also address eating disorders, unhealthy ideals of weight in the media, or safe ways to make lifestyle changes. Ultimately, obesity is a disease with serious physical as well as psychological and psychosocial issues that must be addressed in all avenues of childhood obesity prevention (Haines & Neumark-Sztainer, 2006).

Chapter 6: Culture and Societies

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Obesity has historically been perceived as a status symbol that many women in poor countries strive to attain (Dinsa, Goryakin, Fumagalli, & Suhrcke, 2012). Obesity in women was also viewed as a symbol of status and health during food-insecure periods (Saguy, Gruys, & Gong, 2010, p. 590). Specifically, young girls of high SES were encouraged to “fatten up” for sexual desirability in marriage. In higher-income countries, childhood obesity is more prevalent among lower socioeconomic (SES) classes. This is largely because low SES classes are more likely to lack the health education and resources necessary to maintain a healthy weight (Dinsa, Goryakin, Fumagalli, & Suhrcke, 2012). Conversely, higher SES classes can “shield themselves from obesity” by virtue of having the time and disposable income for nutritious food and opportunity for physical activity (Dinsa, Goryakin, Fumagalli, & Suhrcke, 2012, p. 1076). Rhetoric of “thinness as beauty” and “fat shaming” has become more prevalent among wealthy nations. Public perceptions of body size dictate that weight status is an individual choice of unhealthy behaviors such as smoking or drinking, rather than an “ascribed characteristic” such as genetics or race (Saguy, Gruys, & Gong, 2010, p. 586). As a result, overweight and obesity in the West are characterized as a sign of “laziness, ill health, or ugliness” (Saguy & Ward, p. 55). American ideals of neo-liberalism and the theory of the Health Belief Model have also made it easier for obese individuals to be blamed for poor health habits or poverty.

The broad agenda-shaping role of the news media in part shapes how obesity is framed as an “aesthetic issue” instead of just a health issue (Saguy, Gruys, & Gong, 2010, p. 587). For instance, international media in wealthy countries such as France have also leveraged the current “aesthetic” and public health crisis of American obesity to motivate citizens toward healthier behaviors. For example, to prevent both “medical and social contamination,” French media has warned citizens against the American lures of fast food and inferior lifestyle habits (Saguy, Gruys, & Gong, 2010, p. 589). In comparison to the United States, French rhetoric is also more likely to discuss obesity in terms of obesogenic environments and diverse factors, namely SES. French discourse, therefore, is less likely to blame the individual for obesity, rather attributing weight to larger social inequalities causing poor health habits (Saguy, Gruys, & Gong, 2010). In addition, the fashion industry plays a central role in suggesting that thinness should be a central part of American beauty because the industry largely features thin models. While plus-sized modeling has become more popular in the recent decade, many argue that the message of “big is beautiful” is largely overpowered by economic interests predominately supporting slenderness (Saguy & Ward, 2010).

Cultural perceptions of beauty also partly define discourses about weight. While values that “thin is beautiful” are portrayed as the dominant narrative in the United States, different cultures use diverse ideas of beauty as a means of empowerment. For instance, scholars note that in comparison to Caucasians, the African-American community is more of accepting of “a wide range of body weights” (Webb, Looby, & McMurtery, p. 371, 2004). This has great implications for overweight and obese individuals, as they are generally more accepted in their communities. The role of the African-American community and family structure has also been described as “protective factors” against eating disorders and unhealthy weight loss behaviors. Traditionally, men have played a key role in this culture by perpetuating appreciation of varying body shapes. Webb, Looby, & McMurtery (2004) note that African- American culture has worked to change ideas of overweight people as lazy or incompetent because curvier women have historically been perceived as attractive, employed, and “rulers of their households” (372).

In comparison to Caucasian and African-American women, research on perceptions of beauty among Hispanic women is relatively inconclusive. For instance, some scholars note that while Latina women are more accepting of “curvy” body shapes and healthy looking figures, they also concur with Caucasian females that thinness is an acceptable social standard. In contrast, others found that Latina females have heavier figures because they are generally less concerned with conforming to Caucasian norms of beauty, and believe that

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Caucasian females are too preoccupied with weight loss. In fact, only 4.7% of models featured in non-Latina magazines are Hispanic, meaning that Latina girls in the United States are primarily subjected to media messages promoting “thinness as healthy.” Pompper & Koenig (2004) note that in focus groups and telephone interviews, young Hispanic women aged 18 to 35 reported a “preoccupation with body image and weight,” as well as unhealthy dieting and exercise habits (p. 96). Culture, including family and food, was also highlighted as a significant factor influencing perception of ideal body shape. For example, one participant mentioned the significance of food as a cultural symbol, and that it is considered “rude” not to eat at family gatherings (p. 98). Family values was discussed as both a positive and negative factor impacting body image, as many women mentioned that their mothers influenced their current perceptions of beauty. The double bind of a struggle to maintain a culture heavily focused on food as a social event, while adhering to stereotypical American standards of beauty creates complex body image and identity issues for Latinas living in the United States (Pompper & Koenig, 2004).

Despite diverse views of beauty in other cultures, thinness is heavily tied to civic ideals in America. The notion of the deserving citizen portrayed in American values likens maintaining good health to a moral duty. Proper care of our bodies is considered a civic responsibility in the United States and central to good character and willpower (Kirkland, 2008). Influential economic interests in public health campaigns have also promoted similar messages blaming individuals for weight in an attempt to spread awareness about the obesity epidemic. While it may appear that “fat shaming” and discrimination are common among overweight and obese adults, children are no exception to this trend.

Fat shaming messages aiming to “shock families into realizing [that] obesity is a problem” were exemplified in a costly Georgia public health campaign. Prompted by rising childhood obesity rates, the Children’s Hospital of Atlanta unveiled the 25 billion dollar “Strong 4 Life Campaign” in 2012. In addition, the state faces the sixth-highest childhood poverty rate in the nation (Johnson, 2013), making the focus on familial responsibility for obesity problematic as it ignores poverty as an underlying factor in health status. The campaign includes public billboard and television advertisements featuring overweight children with taglines such as: “Warning: it’s hard to be a little girl if you are not,” or “My doctor says I have something called hypertension, and I am really scared” (Lohr, 2012). The tactic of “shock” as a mechanism to rally greater public action was modeled from anti-smoking and anti-drug public health campaigns. The Vice President of Children’s Hospital of Atlanta justified the tactics, explaining that, "It has to be harsh. If it's not, nobody's going to listen" (Lohr, 2012). The campaign has faced great criticism for the overwhelmingly negative tone and stigmatization of young children. While the campaign has since pulled the overt “fat shaming advertisements,” it is still criticized for its focus on the individual choice to make time for exercise, purchase healthy food options, and teach kids healthy lifestyles. The messages of the campaign, however, are likely to have the opposite effect on children. For example, research says that children who are embarrassed by virtue of their weight are potentially more likely to face low self-esteem and depression. As a result, overweight and obese children are actually less likely to exercise to avoid potential shaming. The “fat shaming” rhetoric exemplified in “Strong 4 Life” is not uncommon and has lifelong impacts. Public perceptions of weight demonstrate that “[weight discrimination] can be much more limiting on that person’s life than the excess weight itself. Yet, weight discrimination remains one of the most socially acceptable forms of discrimination” (Wang, p. 1902, 2008).

In adults, fat shaming in the professional sphere creates major barriers to entry into the workplace as well as advancement. Wang (2008) notes that overweight job candidates with the same credentials are less likely to be hired than a thin applicant, and are perceived as “less competent, productive, industrious, organized, decisive, and successful.” Once people are employed, weight-based discrimination still exists in the form of negative treatment. Weight discrimination is also an issue in healthcare, and is often perpetuated through the physician-patient relationship. In theory, physicians are supposed to work with patients to improve their

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physical and mental well-being. While physicians want to help patients lose weight, failure to follow up with patients about weight management routines or failure to recommend other treatment options reinforces the idea that weight is solely an issue of personal responsibility. Additionally, discrimination is commonly manifested through partiality, meaning that overweight and obese patients receive less time with physicians than thinner patients. “Obesity [does not receive] the attention it deserves from primary care practitioners,” creating a larger failure to treat the underlying cause of disease (Wang, p. 1912, 2008). Discrimination is also indirectly manifested through quality and cost of health insurance based on weight status. Prior to the passage of the Affordable Care Act, overweight people could be denied both insurance coverage and coverage for obesity-related surgeries because obesity was classified as a “preexisting condition.” Today, overweight and obese people are still forced to pay more out-of-pocket for services, which make them less likely to receive adequate care to treat obesity. Shaming individuals for their weight status is, therefore, counterproductive. Weight-based discrimination will not motivate people to lose weight and lead a healthier lifestyle, and instead, promotes a cycle of perpetual weight gain (Wang, 2008).

Inspired by the U.S. civil rights movements of the 1960’s, the women’s movement, and the LGBTQ movement, the fat acceptance movement has played a significant counter-role in fat shaming discourse. Established in 1969, the fat acceptance movement is a part of the human rights movement to promote diversity in body size. The movement currently does not promote a single strategy to combat fat shaming. For example, some parts of the movement aim to redefine the current negative connotation of “fat,” and instead use positive or neutral descriptors for weight (Kirkland, 2008; Saguy, Gruys, & Gong, 2010). Other factions of the movement advocate for “coming out as fat” as a mechanism to “reaffirm” identity instead of “disclose” identity (Saguy & Ward, p.54, 2010). At the same time, some disagree with “coming out as fat” as an effective strategy. This group argues that because weight is visibly apparent it is difficult to fully “come out as fat,” and advocates for a public “flaunting” of identity. Scholars have compared this idea to the LGBTQ movement because each group refuses to hide its identities for the sake of conforming. For example, lesbian women hold hands in public instead of refusing to show public displays of affection, or an overweight woman wears brightly colored clothing instead of wearing dark colored clothing to avoid “standing out” (Saguy & Ward, 2011). While there are multiple factions, each advocating for different methods to promote diversity in body size, the group as a whole endorses body image as a part of human rights.

Prominent groups such as the National Association to Advance Fat Acceptance or the International Size Acceptance Association advocate for increased discussion of the obese as a marginalized group similar to other disciplines such as Women and Gender Studies or Black Studies (Saguy, Gruys, & Gong, 2010). Similar to fat acceptance movements, these disciplines change the American narrative of the “deserving citizen,” advocating for increased protections under current anti-discrimination laws. These movements point to genetic predisposition as the primary cause of obesity status, and contest that obese individuals are arbitrarily and unjustly singled out in employment under Title VII of the 1964 Civil Rights Act. Yet, fat acceptance groups are largely counter to historic American rhetoric and are marginalized from society for their weight status as well as for attempting to claim their rights. As a result, the movement lacks resources to claim its legal rights as a marginalized group, and still faces the daily realities of being an outsider to the law and traditional American discourses (Kirkland, 2008). Ultimately, the fact acceptance movement represents one prominent attempt to spread greater awareness about the current stigma of overweight and obesity. To combat the obesity epidemic as well as discourses of fat shaming, a broader understanding of obesity is necessary. Individual-centered obesity prevention approaches are not only counter-productive but also fail to address underlying causes of obesity. Interventions targeting low-income children that are most at risk for obesity are central to not only addressing social issues, but also to preventing future heath complications.

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Public health professionals must view their roles within the context of a larger societal obligation to explore new avenues for preventing obesity among low-income children.

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Appendix 1: Allegheny College Institutional Review Board- Request for IRB Review

Allegheny College Institutional Review Board (IRB)

REQUEST FOR IRB REVIEW

Submission of IRB application

● IRB requests must be submitted by the member of the Allegheny faculty or staff ● Students cannot submit requests directly● Applications must be submitted as a SINGLE PDF file ● Naming Files must follow the protocol below:

FACULTYLASTNAME_IRBPROPOSAL_ACADEMICYEAR_TWO_WORDDESCRIPTOR(e.g. BOWDEN_IRBPROPOSAL_2013_BEE-SURVEY)

IRB Approval

Approval to conduct research is based on the information/materials submitted with this application. A change in procedure, materials, or information approved by the IRB requires approval by the IRB. If you are approved but subsequently alter your project, then contact the chair of the IRB for advice on what would be required.

Contact Persons

If the principal investigator is a student, then information for primary faculty supervisor must also be include in table below

Principal Investigator name (s) Email Telephone Address/Office

Cailyn Lingwall, Student [email protected] (814) 221-3998 Box 902

Professor Caryl Waggett, GHS Studies [email protected] (814) 332-2715 Carr Hall Room 207

Project Description

Date SubmittedDecember 12, 2014

Title of ProjectAn evaluation of physical activity among preschoolers at an income eligible Pre-K Counts program in a rural community with a winter climate.

Brief (25 word limit) Description ofthe Project

Evaluate physical activity among preschoolers at the Meadville Children’s Center using pedometers (step count) as an indicator of physical activity. Compare local findings to recommendations, and conduct intervention to meet identified deficit in physical activity.

Researcher Ethics Certification

Complete the following information on all persons involved in the research including the PI, faculty supervisor, and any

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research collaborators/assistants.

● For status, indicate whether the person is faculty, student, administration, staff, or community partner.

● Before any project can be approved, all persons involved in the design, data collection, and/or analysis must have OHRP (Office of Human Research Protection) certification. See “Guidance for Proposers” on IRB main page to learn how to get certified.

Name Status OHRP Certification Date

Cailyn Lingwall Student 8/27/2014

Caryl Waggett Professor 2/7/2015

Type of Research (Please check all that apply)

___ faculty research X senior project research Department _Global Health Studies ___ course research. Department and Course Number _____________ ___ administration research ___ other (please specify) _______________________________________

Research History and FundingIs the research a continuation of a previously reviewed and approved project? ______Yes __X____ No

Is the research funded by either external or Allegheny College research grants? _____ Yes ___X__ No If yes, please indicate the type of grant received and its source.

Will be applying for Class of ’39 funds. _____Yes

Descriptions of Review Requests:

Exemption: Research that involves no more than minimal risk and meets criteria specified by federal regulations may qualify for exemption. Children under the age of 18 years CANNOT be included in any proposal for which an exemption is requested.

Expedited Request: The Institutional Review Board (IRB) uses an expedited review process to review studies that meet the categories adopted by the Department of Health and Human Services (DHHS), or the Food and Drug Administration (FDA) and that involve no greater than “minimal risk.” Expedited review procedures allow the IRB to review and approve studies that meet the criteria without a full committee review.

Full Review: Research that cannot meet the criteria for exempt or expedited review must be submitted for full review. Any study including children under the age of 18 years automatically prompts a full review.

The following assessment questions will help you decide which type of request your proposal is.

Assessment of Exemption, Expedited, or Full Review Requests

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Answer the following questions: Yes No

1. Does the research use fetuses, neonates, pregnant women, children (persons under the age of 18), the elderly, prisoners, the physically or developmentally challenged, or other potentially vulnerable populations as participants?

X

2. Could the information collected put participants at risk of civil or criminal liability or be damaging to the respondent’s financial standing, employability, or reputation?

X

3. Does data collection involve sensitive behaviors (i.e., information about sexual behavior, illegal activities, alcohol use)?

X

4. Is there any foreseeable risk to participants beyond risks associated with everyday activities? X

5. Is this an assessment or comparison of educational strategies or techniques studied in an educational setting? X

6. Does the research use educational tests, surveys, interviews, or observation of public behavior, where responses can be linked to individual participants?

X

7. Can persons in the research be identified personally, even if you are using available publicly available documents, records, or data?

X

8. Does federal law require confidentiality of participant responses? X

9. Can participation in the research damage the participant’s employability, financial standing, or reputation? X

10. Does the research involve any deception, even minor deception such as a cover story? X

● If you answered NO to all the above questions, then you are eligible to apply for an EXEMPTION

● If you answered NO to Questions 1-9, and YES to Question 10 (Minor Deception), and if privacy can be protected (though data need not be anonymous, just confidential), then you are eligible to apply for an EXPEDITED REQUEST

● If you answered YES to any of questions 1-9, then you MUST proceed with a FULL REVIEW

Type of Review Requested (Check one) __ Exemption__ Expedited Request_X_ Full Review

Description and Rationale of Project (250 word limit)

The purpose of the project is to identify current physical activity among low-income preschoolers in a preschool setting, analyze how much physical activity is unmet, and finally conduct an intervention to address this deficit. Pedometers will be used to measure the average number of steps taken per day (9:15 a.m.-1:30 p.m.) by students in two Pre-K Counts classes at the Meadville Children’s center.

Currently, one in eight preschoolers in the United Sates is obese (Let’s Move 2013). The established link between poverty and obesity is especially urgent in Meadville and Crawford County given that 45.1% of children under the age of 18 are considered in poverty (U.S. Census Bureau 2012). Carrie Dinsmore, Executive Director at the Meadville Children’s Center, noted that all of the children come from families living 300% below the poverty line. Dinsmore notes that many of the children have few or no opportunities for physical activity during the winter time outside of what is provided by the MCC during the school day. In addition to health benefits, increased physical activity aids preschoolers in the development of motor skills, coordination, social skills, and positive self-esteem (National Head Start Association).

The results will be used to identify gaps in physical activity and develop short ‘movement breaks’ for the normal school

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day that include 10 minutes of sustained activity. Examples of activities include using Brain Booster cards or simple yoga poses. Finally, the results and activities will be shared with Head Start Programs which serves additional income eligible preschoolers in the Meadville region.

Methods/Procedures ( Describe the methods/procedures to be used to collect data) Week 0: Disseminate consent form to parents of preschoolers at Meadville Children’s Center before Christmas break.

Note: Data will be collected and recorded for approximately 32 students. Data will be stored according to each student’s first name and last initial. This identification is necessary to track each student’s progress over time. Data will be stored and locked in Professor Waggett’s office. In the final written product, data will be displayed using randomly assigned identification numbers, and no identifiable information will be disclosed.

Weeks 1-3: Data will record the child’s first name and last initial. However, within the results of the final written product, data will be recorded using unique participant ID numbers. Each participant (approximately 32 students) will be randomly assigned a unique identification number, which will be matched with the number on the pedometer.

Begin pedometer testing the second week of January. Each day for 3 weeks, pedometers will be zeroed and put on students at 9:15 a.m. Then, the pedometer will be taken off at 2:30 p.m. to record the number of steps. Once data are recorded, the pedometer will then be zeroed.

Pedometers will be attached to a colored sash which will be worn around the child’s waist. This is necessary to account for variation in clothing such as dresses or skirts. It is impractical to place pedometers on shoes because it is likely that the children will change shoes before going outside to play, which could yield inaccurate results if the pedometers are not transferred to the change in shoes. The four full-time Pre-K Counts teachers with Child Abuse Clearances, and training by the MCC will assist me in placing pedometers on children.

Compare results to findings/recommendations cited in literature for average number of steps per day for ages 4-6. Assess deficit in activity among local preschoolers.

Weeks 4-7: Conduct 10 minute, mid-morning physical activity session each day for 3 weeks. Each day for 3 weeks, pedometers will be zeroed and put on students at 9:15 a.m. Then, the pedometer will be taken off at 2:30 p.m. to record the number of steps. Once data is recorded, the pedometer will then be zeroed.

Week 8-10: Conduct a 15 minute focus group with students to discuss what they liked and didn’t like about the activities (please see attached questions). Conduct a 30-45 minute focus group with teachers to discuss major barriers to physical activity within a day care setting. (please see attached questions). Compile and analyze results. Share with Meadville area Head Start programs also serving income eligible preschoolers.

Survey Questions ● Include a list (in an appendix) or a description of questions to be asked or surveys to be administered to research

participants● Published questionnaires/surveys do not need to be attached; in this case, provide a bibliographic reference for

each questionnaire/survey

Completion of Application● If you are applying for an EXEMPTION, THEN STOP HERE.

● If you are applying for an EXPEDITED OR FULL REVIEW, then complete the remainder of this application.

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Additional Information Required for Expedited or Full Reviews

Participant Information (Participants are those from whom information is being collected)

Participants will be : Pre K Counts students and staff members Yes No

Allegheny College students X

Allegheny College employees X

Adults not belonging to vulnerable group (vulnerable group = prisoners, nursing home residents, patients, etc.)

X

Members of an identified vulnerable group X

Participant Compensation

Will participants receive any form of compensation for their participation? Yes ____ No _X___ If yes, indicate the compensation provided.

Permission Letter

If participants are recruited from existing organizations, groups, schools, classes, etc., then include a letter from the relevant group/organization granting permission to recruit participants. The letter should be attached at the end of this form.

Protection of Privacy

Data are anonymous if there is no foreseeable way that individual participants can be linked to their responses. In studies requiring linkages between responses collected at different times, coding systems that do not require the use of participant names to link responses must be used. Data are confidential if participants’ responses could be linked to their responses (for example, if participants perform a task with an experimenter present who may know them), but those links are not recorded, or the list linking responses at different times via name or ID# is destroyed once the data are combined.

Will your data be anonymous? _____ confidential _X____ neither _____

Maintenance of Confidentiality

Please indicate how anonymity or confidentiality will be maintained. If “neither,” please explain why a waiver of confidentiality is being requested.

Anonymity will be maintained using unique, randomly assigned identification #s for each participant.

Informed Consent

● Research participants have the right to be informed of any aspect of the research that might reasonably affect their decision to participate in the research.

● The table below identifies the major elements of informed consent. Please review them carefully and then indicate whether the element will be included or if a modification or exclusion is being requested for that element.

Modification Requested

Element Included

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Statement that participation is voluntary and that there can be no consequences for either failure to participate or termination of participation.

X

A place for the participant to affirm that they are over 18 X (parent signature)

Statement that the project is research X

Statement of the rationale for the research X

Description of the length of participation X

Description of the methods/procedures to be used X

Identification of experimental procedures X

Description of any foreseeable risks or discomfort X

Statement of the benefits of the research to the participants or others. Note: Compensation is not seen as a benefit.

X

Statement about the extent to which information provided by participants will be kept anonymous or confidential.

X

If more than minimal risk is involved, an explanation of available treatments should injury occur and where additional information can be obtained. N/A N/A

Contact information for both the researcher (and research supervisor if the researcher is a student) along with the chair of the IRB in case there is injury or a question concerning participant rights.

X

Requests for Modification or Exclusion of Elements of Informed Consent

IRB applicants are allowed to modify or exclude elements of informed consent listed above if all of the following conditions are met:

1. The research involves no more than minimal risk. 2. Participant rights are not altered by a waiver/modification. 3. The research could not be practicably conducted without the modification. 4. The participants are fully debriefed, including an explanation for the modification, following participation whenever possible.

A complete waiver of informed consent is granted if either condition below is met:

1. When the signed informed consent form is the only document linking a participant to the research and when the linkage would constitute a breach of confidentiality, a participant should be given a choice about whether a signed informed consent form is desired. 2. There is minimal risk and the procedures would not require consent outside the research context.

Explain your rationale for requesting a modification or waiver of informed consent: N/A

Documentation

Participants (or legal representatives) can be given a written informed consent document containing the information in Part 2 below or a short form indicating that the information has been provided verbally when there is a witness to that verbal statement. What is to be stated verbally must be approved by the IRB and include the elements of a written consent form.

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Type of informed consent to be used:Written ____X (Parent Consent Form)_______ Verbal ____X (Child Assent Form)_________

Debriefing

In many cases, the major benefit research participants receive is their contribution to the acquisition of new knowledge through research. Often, the only way they will fully understand their contribution is through the debriefing. The importance of debriefing is greater if there has been any modification or waiver of informed consent since this is the opportunity to inform participants of the change or omission and the justification for it. For the debriefing to be valuable, it must be clearly written at a level appropriate to the participants. Scientific terms should be avoided when possible and any necessary jargon defined. A complete debriefing should contain the following components. There are, however, circumstances when either the debriefing or specific elements of a debriefing may be waived. Please complete the following, indicating whether a waiver is being requested.

Waiver Requested?

Yes No

A. A request to waive all components of a debriefing X

B. Components of a Complete Debriefing X

● An explanation of the rationale for the research and the procedures used. X

● An explanation and justification of any deceptions used in the research. X

● A statement of the research hypotheses. X

● An offer to provide participants with a copy of the findings of the research when completed with appropriate contact information to request the results

X

● Contact information for the principal investigator, the research supervisor (if the PI is a student), and the chair of the IRB.

X

● Sources the participants might consult if they desired additional information on the topic. X

● An opportunity to ask any questions and/or have concerns addressed X

In general, it is expected that the debriefing will be given in writing immediately following data collection, although it is recognized that exceptions to that goal may be required. If the debriefing is to be done orally or at a later time, explain below:

If a waiver from debriefing or for any component of the debriefing is requested, explain:Informed Consent and Debriefing Documents

Attach copies (TO THIS FORM, IN THE SAME FILE) of consent forms, permission letters, and instructions to participants.

Record-Keeping

OHRP requires that the researcher (or faculty supervisor, if the researcher is a student) is required to retain the signed and dated consent forms and any questionnaires or other materials completed by each research participant in a secure location

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for a period of three years. These documents must be available to authorized individuals. If having a secure location is difficult, please contact the chair of the IRB for assistance.

PI (or faculty supervisor) maintaining records: ___Professor Caryl Waggett

Location of informed consent forms (building and contact information if different from the PI’s office, or the faculty supervisor’s office if the PI is a student): Carr Hall Room 224 .

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IRB appendix 2: Survey Questions

30-45 minute focus group with MCC teachers:

1.) How long have you been a preschool teacher, and what is your position at the MCC?

2.) Describe the structure and activities of a typical school day.

3.) How much physical activity do you think that preschool children should get per day?

4.) In your opinion, do you think that the children get enough physical activity each day? If so, why? If not, why?

5.) In your opinion, do you see anything preventing the children from being more active? If so, why? If not, why?

6.) What ways does physical activity benefit preschoolers?

7.) Are there ways that you currently create physical activity opportunities for your students? If so, what?

15 minute focus group with MCC preschoolers:

1.) How did the activities make you feel? (Verbally remind them of examples of past activities).

2.) Was there an activity that we didn’t do that you wanted to do?

3.) Which activity(ies) were your favorite?

4.) Which activity(ies) were your least favorite?

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PARENTAL CONSENTIRB appendix 3: Parental Consent Form

Parents,

Cailyn, a senior and Global Health Studies major at Allegheny College would like to conduct her senior project at the MCC. She will be collecting data each day using pedometers for 6 weeks, and doing 10 minute physical activities for 3 of those weeks. Pedometers will be attached using sashes tied around their waist. Names will be recorded only for the purpose of assigning pedometers. All names will be erased in the final product. Cailyn is asking your permission to collect the number of steps taken and do short activities as a part of her senior project. Please fill out the form below and return it to your classroom teacher as soon as possible.

Thank you,

Yes, I give permission for this information to be recorded and for my child’s

participation in physical activity.

No, I do not give permission for this information to be recorded and for my child’s participation in physical activity.

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Research Participant Consent FormAn evaluation of physical activity among preschoolers at the MCC Pre-K Counts program

Cailyn Lingwall, Global Health Studies studentAllegheny College

What is this project studying? The purpose of this research is to study physical activity among students in the Pre-K Counts program, figure out how much physical activity is unmet, and do a 10 minute activity to increase physical activity.

How will information be collected?Pedometers will be placed attached to a colored sash which will be worn around the child’s waist during the normal school day. Pedometers will be taken off at the end of each day. The results will be recorded every day for six weeks during the spring of 2015.

Are there risks involved? The risks of your child’s participation are no more than during daily free play.

Are there benefits to my child or others? The potential benefit of this project for your child will be an increased opportunity for physical activity. The results from the project will be shared with all of the classes within Meadville Children’s Center and also shared with Head Start programs serving preschoolers in the Meadville area.

Are there incentives involved? There is little incentive for your child to participate but gratitude from the student researcher.

Will information be kept private? Data will record my child’s first name and last initial. For the final product, each child will be given a unique participant ID number, and no identifiable information will be used. No names will be recorded for interview responses collected. Any reports made based on this study will focus on average number of steps taken per day and general physical activity patterns.

Data and consent forms will be stored separately and locked in the Department of Global Health Studies at Allegheny College. Your child’s number of steps recorded or interview responses will not impact observations from the Meadville Children’s Center. Data collected will be destroyed when it is no longer needed.

Can my child quit if he/she doesn’t want to participate? Yes. I understand my child’s participation is completely voluntary, and is free to leave at any time without penalty.

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Questions or concerns?Please call Cailyn Lingwall at (814) 221-3998 or email her at [email protected]. You may also contact Dr. Caryl Waggett at [email protected]. For any questions about the treatment of your child, please contact Ann Kleinschmidt, Chair of the Allegheny College Institutional Review Board (IRB) at [email protected].

Child’s Name:

Parent’s Signature: Date Researcher’s Signature: Date

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PRE-SCHOOL CHILD ASSENT FORMWaggett/Lingwall-GHS IRB appendix 4: Child Assent Form

Verbal Script: Today I will be writing down the number of steps you took. If you don’t want to wear a pedometer at all, that is alright and you don’t have to. If you want to wear one, I will put the pedometer on you at 9:15 every morning. I will take it off at 1:30 every afternoon. If you need to go home, find your teacher and she will take the pedometer off.

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PRE-SCHOOL CHILD PHOTO RELEASE FROMWaggett/Lingwall-GHSIRB appendix 5: Photo Release Form

Dear MCC Pre-K Counts Parents,

Cailyn, a senior Global Health Studies major at Allegheny College, has been conducting her senior project at the MCC. She is working with the Pre-K Counts classrooms to determine how active the children are during the school days in winter. She is designing and implementing classroom physical activities with your child’s Pre-K Counts teachers. During that time, photographs of your child will be taken to include in her senior project and presentations, as well as in the reports for the MCC. No names or identifiable information will be included in any product. Please fill out the form below and return it to your classroom teacher as soon as possible. Thank you,

My Child’s Name ________________________________________________________________ Pre-K Counts Teacher ___________________________________________________________ Parent/Guardian Signature _______________________________________________________ Parent/Guardian Name __________________________________________________________ Date _________________________________________________________________________

Yes, photographs of my child may be used in this project. No, photographs of my child may not be used in this project.

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