ISSUE REPORT
of Obesity:
Better Policies for a
Healthier America 2017
AUGUST 2017
Acknowledgements
Trust for Americas Health is a non-profit, non-partisan organization dedicated to saving
lives by protecting the health of every community and working to make disease prevention
a national priority.
For more than 40 years the Robert Wood Johnson Foundation has worked to improve
health and healthcare. We are striving to build a national Culture of Health that will
enable all to live longer, healthier lives now and for generations to come. For more infor-
mation, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on
Facebook at www.rwjf.org/facebook.
TFAH would like to thank RWJF for their generous support of this report.
Cynthia M. Harris, PhD, DABT Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA
Vice President of the Board, TFAH Executive Director
Director and Professor Hogg Foundation for Mental Health at the
Institute of Public Health, Florida A&M University University of Texas at Austin
REPORT AUTHORS
Laura M. Segal, MA Jack Rayburn, MPH
Director of Public Affairs Senior Government Relations Manager
Trust for Americas Health Trust for Americas Health
Stacy E. Beck, JD
Consultant
TABLE OF CONTENTS
Table of Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . 4 4. School-Based Physical Activity Programs 49 Obesity:
Obesity Policy
a. Physical Education & Physical Activity
SECTION 1. The State of Adult Obesity . . . . . 11 Breaks . . . . . . . . . . . . . . . . . . . . . 49
A. Overview . . . . . . . . . . . . . . . . . . . . . . . . 11 b. Recess . . . . . . . . . . . . . . . . . . . . . 50
B. State-by-State Adult Obesity Rates . . . . 16 c. Safe Routes to Schools . . . . . . . . . 51
d. Shared Use . . . . . . . . . . . . . . . . . . 51
series
C. National Adult Obesity Rates . . . . . . . . . 17
e. Health Assessments . . . . . . . . . . . 52
D. Inequity and Obesity . . . . . . . . . . . . . . . 20
5. ESSA Implementation . . . . . . . . . . . . . . 52
1. Racial and Ethnic Groups . . . . . . . . . . 20
2. Education and Income . . . . . . . . . . . . 23 6. CDC School-Based Initiatives . . . . . . . . . 53
3. Regional Differences . . . . . . . . . . . . . 24
C. Community Policies & Programs . . . . . . 54
1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . 54
SECTION 2. The State of Childhood Obesity . 26 a. Importance of Place . . . . . . . . . . . . 54
A. Overview . . . . . . . . . . . . . . . . . . . . . . . . 26 b. Food Deserts and Food Swamps . . . 54
B. N
ational Childhood Obesity Rates c. Impact of the Environment . . . . . . . 55
(NHANES) . . . . . . . . . . . . . . . . . . . . . . . 29
2. Community-Based Programs . . . . . . . . . 57
C. Early Childhood Obesity Rates (WIC) . . . 31 a. CDC Programs . . . . . . . . . . . . . . . . 58
D. O
besity Rates in Children Ages 10-17 b. Fiscal Policies and Innovative
(NSCH) . . . . . . . . . . . . . . . . . . . . . . . . . 32 Financing Strategies . . . . . . . . . . 63
E. High School Obesity Rates (YRBSS) . . . . 33 1. Taxes and Subsidies . . . . . . . . . 63
2. Healthy Food Financing Initiative . 64
3. New Markets Tax Credit . . . . . . . 64
SECTION 3. Key Obesity-Prevention Policies . 34
4. Wellness Trusts . . . . . . . . . . . . . 65
A. Early Childhood Policies & Programs . . . 35 5. Pay-for-Performance and Social
1. Nutrition and Physical Activity for Young Impact Bonds . . . . . . . . . . . . . . 66
Children . . . . . . . . . . . . . . . . . . . . . . . . 36 6. Philanthropic Investments . . . . . 66
2. Child and Adult Care Food Program c. HHS, USDA and FDA Obesity-Prevention
(CACFP) . . . . . . . . . . . . . . . . . . . . . . . . . 37 and Nutrition Education Initiatives . . 68
3. Child Care and Development Block Grant 1. Dietary Guidelines . . . . . . . . . . . 68
(CCDBG) . . . . . . . . . . . . . . . . . . . . . . . . 38
2. Menu Labeling . . . . . . . . . . . . . 68
4. Head Start . . . . . . . . . . . . . . . . . . . . .39
3. Food Labels . . . . . . . . . . . . . . . 68
5. State Requirements for Early Care and
d. Operation Live Well and Healthy Base
Education . . . . . . . . . . . . . . . . . . . . . . . 40
Initiative . . . . . . . . . . . . . . . . . . . . 69
6. Every Student Succeeds Act Early
e. Complete Streets . . . . . . . . . . . . . 70
Childhood Education Components . . . . . . 41
f. Nutrition Assistance . . . . . . . . . . . 71
7. WIC . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3. Business Initiatives . . . . . . . . . . . . . . . . . 73
B. School-Based Policies & Programs . . . . . 43
1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . 43 D. Health, Healthcare & Obesity . . . . . . . . . 77
1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . 77
2. Obesity & Academic Achievement . . . . . 43
2. Healthcare Coverage & Programs . . . . . 79
3. School Nutrition . . . . . . . . . . . . . . . . . . . 44
a. Medicare & Medicaid . . . . . . . . . . . 79
a. School Meal Programs . . . . . . . . . . 44
b. Child Obesity-Related Health
b. Smart Snacks in Schools . . . . . . . . 46 Provisions . . . . . . . . . . . . . . . . . . 80
c. Summer Food Service Program . . . . 46 c. Healthcare & Hospital Programs . . . 84
d. Water in Schools . . . . . . . . . . . . . . 47 1. Screening Services . . . . . . . . . . . 84
e. Fruit and Vegetable Programs . . . . . 48 2. Fruit, Vegetable and Physical Activity
Prescriptions . . . . . . . . . . . . . . . 84
AUGUST 2017
The State of
INTRODUCTIION
Introduction
Obesity:
Obesity is one of the biggest health concerns in communities
Obesity Policy across the country, with about 70 percent of county officials
Series ranking it as a leading problem where they live. Factors related
to obesity are also rated as communities priority health issues,
including nutrition and physical activity at 58 percent, heart disease
and hypertension at 57 percent and diabetes at 44 percent.1
There has been progress to address the Individuals who are obese are at
epidemic. After decades of increasing, increased risk for type 2 diabetes, heart
the national obesity rate among 2- to disease, some forms of cancer, dementia
19-year-olds has begun to level off and and a number of other health concerns.
the rise of obesity among adults has Children who are overweight or obese are
slowed over time. Yet obesity remains a at greater risk for high blood pressure,
bigger threat to our health and country type 2 diabetes and heart disease. And the
now than it was a generation ago. If longer children are overweight or obese,
trends continue, children today could the more likely they are to remain so
be the first generation to live shorter, into adulthood. At a broader level, high
less healthy lives than their parents. obesity rates also have a significant impact
on the larger community.
Obesity rates vary state-to-state, but
remain high nationwide. Across the l besity is a financial issue. The obesity
O
United States, more than one in three crisis costs our nation more than $150
adults and one in six children (ages billion in healthcare costs annually6
2-19) are obese and one in 11 young and billions of dollars more in lost
children (ages 2-5) are obese.2 Adult productivity.7 The public and officials
obesity rates range from a high of 37.7 are rightly concerned about making
in West Virginia to a low of 22.3 in sure every taxpayer dollar is spent wisely.
Colorado.3 Childhood rates are highest Investing in obesity prevention provides
in Mississippi (21.7 percent) and lowest a significant return on investment for
in Oregon (9.9 percent).4 Obesity the American taxpayer. Each state and
rates also differ from county to county, community is impacted by the cost of
and neighborhood to neighborhood. obesity severe obesity alone costs
More than 20 states have counties with state Medicaid programs between $5
adult obesity rates above 40 percent, million in Wyoming and $1.3 billion in
including 29 counties in Mississippi California each year.8 Overall obesity-
and 14 counties in Alabama. Only two related healthcare costs range from $279
states have counties with adult obesity per person per year in Wyoming to $768
AUGUST 2017
Obesity rates are higher among l And there are income and/or
60+ Years women (40.4 percent) compared education inequities.
to men (35.0 percent).17 Within
Nearly 33 percent of adults who
the last decade (2005 to 2014),
Obesity Rates for Adults by Race did not graduate high school
the obesity rate among women
and Ethnicity were obese compared with 21.5
increased by 5.1 percent, while the
percent of those who graduated
rate among men only increased by
from college or technical college.
1.7 percent.
[2008-2010 data]
42.6% 48.4% Women are also almost twice as
More than 33 percent of adults
likely (9.9 percent) to be extremely
who earn less than $15,000 per
obese compared to men (5.5
Latinos Blacks year are obese compared with
percent).17
24.6 percent of those who earned
In addition, rates are the highest at least $50,000 per year.25 [2008-
among middle-age adults (41 2010 data]
36.4% 12.6% percent for 40- to 59-year-olds),
compared to 34.3 percent of 20- to
39-year-olds and 38.5 percent of
Whites Asians adults ages 60 and older.17
The State of
WHAT IS OBESITY?
Obesity means an amount of body fat that has demonstrated that a high BMI is
exceeds the level generally considered strongly correlated with the same negative
healthy for a particular height. 39,40
There are health consequences as high body fat,
many methods of measuring body fat, some although the association between BMI does
of which are expensive and time consuming. vary among ethnic groups.
Body mass index, which is inexpensive
BMI is a persons weight in kilograms divided
and easy to calculate, is typically used as
by his or her height in meters squared. For
a proxy. Health officials recommend that
measurements in pounds and inches, BMI is
individual health assessments should
calculated using the following formula:
consider other factors as well. Research
For adults, BMI levels are associated with the following weight classifications:
Richard R. Jeffries,
this report. This surveys advantages Improved aerobic and
muscular fitness Rear Admiral, U.S. Navy (Retired) and
include: (a) it is the largest ongoing Improved balance and bone health former Medical Officer of the U.S. Marine Corps
Improved joint mobility
telephone health survey in the world; Improved mental health
Reduced risk of falling
(b)each state survey is representative Extended years of active life
277714-B
of the population of that state; and
May 2017
(c)the survey is conducted annually,
so new obesity data are available each
year. Downsides of this survey include: FOR MORE INFORMATION PLEASE VISIT:
Division of Nutrition, Physical Activity, and Obesity
(a) small samples that in some states www.cdc.gov/nccdphp/dnpao
WA MT ND
MN VT ME
SD WI
OR
ID NH
WY MI NY
IA MA
NE
PA RI
IL IN OH CT
NV UT NJ
CO
KS MO WV DE
KY VA MD
DC
CA
OK TN NC
NM AR
AZ
SC
MS AL GA
TX LA
n No Data
n <10%
FL
AK n >10% & <15%
HI n >15% & <20%
n >20% <25%
n >25% <30%
n >30%
2016 Adult Obesity Rates
WA ND
MT
MN
VT ME
SD WI
OR
ID NH
WY MI NY
IA MA
NE
PA RI
IL IN OH CT
NV UT NJ
CO
KS MO WV DE
KY VA MD
CA DC
OK TN NC
NM AR
AZ
SC
MS AL GA
TX LA
n >20% to <25%
FL n >25% to <30%
AK
n >30% to <35%
HI
n >35% to <40%
Trends in obesity prevalence among adults aged 20 and over (age-adjusted) and youth
aged 219 years: United States, 19992000 through 20132014
40
37.7
Adults1
35.7 34.9
34.3 33.7
30 32.2
30.5 30.5
Percent
20
Youth1,2
0
19992000 20012002 20032004 20052006 20072008 20092010 20112012 20132014
Survey years
1
Significant increasing linear trend from 19992000 through 20132014.
2
Test for linear trend for 20032004 through 20132014 not significant (p>0.05)
NOTE: All adult estimates are age-adjusted by the direct method to the 2000 U.S. census population using the age groups
2039, 4059, and 60 and over.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey.
FL
AK
HI
WA ND
MT
MN
VT ME
SD WI
OR
ID NH
WY MI NY
IA MA
NE
PA RI
IL IN OH CT
NV UT NJ
CO
KS MO WV DE
KY VA MD
CA DC
n >10% to <15% n >25% to <30% n >40% <45%
OK TN NC
AZ NM AR
SC
n >15% to <20% n >30% to <35% n Data not available
MS AL GA
TX LA n >20% to <25% n >35% to <40%
FL
AK
HI
50 20 and over 2039 4059 60 and over Prevalence of obesity among adults
44.6 ages 20 and over, by sex and age:
41.0 40.4 United States, 20132014
40 39.4
37.7 38.5 37.2 37.5 37.0
34.3 35.0
31.6
30
Percent
20
NOTES: Totals were age-adjusted by the direct method to
the 2000 U.S. census population using the age groups
10 2039, 4059, and 60 and over. Crude estimates are
37.9% for all, 35.2% for men, and 40.5% for women.
SOURCE: CDC/NCHS, National Health and Nutrition
Examination Survey, 20132014.
0
All Men Women
TFAH RWJF StateofObesity.org 19
D. INEQUITY AND OBESITY
Obesity disproportionately OBESITY BY RACE/ETHNICITY 2013-2014 DATA17
affects different communities Race/Ethnicity Obesity Rate
Asian* 12.6%
including communities of
Black* 48.4%
color, communities with high Latino** 42.6%
levels of poverty, and adults White* 36.4%
with lower education levels. * Black, White and Asian rates are for non-Hispanic members of each race.
** Persons of Hispanic origin may be of any race.
Obesity and Extreme Obesity Rates for Adults, National Health and Nutrition Examination Survey (NHANES), 2013-201417
(with Native American/Alaska Native Rates per 2014 National Health Interview Survey48)
70
60
57.2%
50 48.4% 46.9%
42.3% 7.1%
40 38.0% 37.9% 38.2%
36.4% 34.7%
30
20
16.8%
12.6% 12.4% 12.6 12.4%
10 8.7% 9.7%
7.1% 7.6% 7.2%
N/A Unknown N/A 5.4% 5.6% N/A
0 Asian* Black* Hispanic** Native White* Asian* Black* Hispanic** White* Asian* Black* Hispanic** White*
American/
Obese Extreme Obese Alaska Native Obese Extreme Obese Obese Extreme Obese
* Black, White and Asian rates are for non-Hispanic members of each race. N/A data only included 2 participants.
** Persons of Hispanic origin may be of any race.
Nebraska
Montana
Minnesota
Maryland
Maine
Kentucky
Kansas
Indiana
Colorado
Arizona
Alaska
Alabama
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Percent Rates
Source: CDC58
Children Ages 10-17 Who are Obesity Rate by Level of Urbanization, 2012
Overweight of Obese, by Location (County Health Rankings Report, 2016)58
50
Key Health Factors by Level of Urbanization
Large Urban Large Suburban Smaller Metro Rural
40 38.2
35.5
30.1
30 BEST WORST
Rural communities face different counterparts. One reason may be the pools, tracks, tennis courts and sports
challenges than their urban and lower rates of physical activity among fields.66 A New England Journal of Medicine
suburban counterparts. Fewer children urban residents compared to suburban study found that when low-income
in rural areas walk to school, and the dwellers. This disparity may be caused by families were provided housing vouchers
populace relies heavily on automobiles the fact that there are often fewer safe that allowed them to move out of a
for transportation. Lifestyle differences places to play and be physically active in high-poverty neighborhood, adults
may also contribute, including higher urban environments, along with fewer experienced lower rates of extreme
rates of television watching, higher venues selling healthy, affordable foods. obesity and diabetes than adults who
calorie consumption and lower rates received vouchers for housing within the
Researchers are still trying to understand
of exercise in rural areas.60 There high-poverty neighborhood or adults who
aspects of small cities that may be
are also likely structural differences received no housing vouchers at all.67
different from larger urban areas. One
at play, which may include lack of
study found that low-income women in Living in a predominantly racial/ethnic
nutrition education, fewer nutrition
small cities (less than 40,000) had a higher minority community also correlates with
services, fewer sidewalks and reduced
risk of obesity, which actually increased certain environmental factors that may
access to facilities that foster healthy
if they lived within a one-mile radius of a contribute to obesity. For example, one
behavior, such as recreation centers
supermarket.63 This study contrasts with study found that fast-food establishments
and supermarkets that sell healthy,
other research that revealed that living were more prevalent in both high-income
affordable food.60,61 Some strategies
close to a supermarket has been shown to and low-income Black communities
to improve diet and physical activity
lower the risk of obesity.64 than in White communities.68 Another
that have been effective in rural areas
found that minority neighborhoods
include farmers markets, farm-to-school Low-income communities face their own
were significantly less likely to have
programs, activity programs for older unique challenges. Numerous studies
recreational facilities than White
adults, and increasing access to new or have found that healthy foods are less
neighborhoods.66 A study of food stores
existing facilities for physical activity.62 available in low-income communities.65
found four times more supermarkets
One study found that low-income
While urban communities have lower located in White neighborhoods than
neighborhoods were 4.5 times more
rates of obesity than rural communities, Black neighborhoods.69
likely than high-income neighborhoods
inner-city residents have higher
to lack recreational facilities such as
rates of obesity than their suburban
The State of
SECTION 2: THE STATE OF CHILDHOOD OBESITY
There are even signs that childhood has also declined from a high of 15.9
obesity rates are starting to decline, percent in 2010 to 14.5 percent in 2014,
particularly among young children the most recent year for which data are
and in communities that have taken available.21 There are increasing examples
comprehensive obesity-prevention of signs of progress where areas have
approaches. Between 2010 and 2014, implemented a wide range of strategies
31 states and three territories reported to make healthy foods and beverages
declines in obesity rates among toddlers available in schools and communities,
(ages 2 to 4) whose families participate and have integrated physical activity into
in the Special Supplemental Nutrition daily life ranging from a 24.1 percent
Program (SNAP) for Women, Infants, and decline in obesity for children under 6 in
Children (WIC) nutrition program for Eastern Massachusetts to a 13.4 percent
low-income families. The national obesity decline among kindergarten to fifth-
rate among children in the WIC program graders in Kearney, Nebraska.71
NCHS Health E-Stats July 2016
AUGUST 2017
Despite these positive trends, childhood l 1 percent of American children have
9
obesity remains an American epidemic. poor diets and less than half get the One-quarter of American high
More than 12 million U.S. children are recommended 60 minutes of daily school students watch three
obese one out of every six children.72 physical activity.76
Obese children have an increased risk of or more hours of TV on an
l lmost two-thirds of American youth
A
developing a range of health problems,
consume a sugary beverage on any
average school day.
including high blood pressure and high
given day.77
cholesterol, which are both risk factors
for heart disease.72 Obesity can also cause l quarter of American high school
A
sleep apnea, bone and joint problems, students (24.7 percent) watch three or
and chronic health conditions such as more hours of television on an average
asthma and type 2 diabetes.72 Obese school day.78
children are at increased risk of being
l chools have reduced recess time
S
bullied and suffering from depression,
in favor of academic instruction,
while a healthy diet and physical activity
particularly among older children.79
in childhood is associated with better
mental health.72 More than 200,000 As with adults, environmental factors
youth under the age of 20 have type 2 also play a role in childhood obesity.
diabetes, and many more are at risk for Some children have limited access to
developing diabetes.73 Obese children safe places to play, while others live
are also likely to grow up to be obese in food deserts where there are few
adults,74 at risk for all health problems nearby places for their parents to buy
associated with obesity. affordable, healthy foods to serve their
families. One study found that the odds
of a child being obese or overweight
More than 90% of American increases by 20 percent to 60 percent if
children have poor diets. he or she lives in a neighborhood with
unfavorable conditions such as poor
housing, unsafe surroundings and/or
Socioeconomic factors are also strongly limited access to sidewalks, parks and
correlated with childhood obesity. In fact, recreation centers.80 Unhealthy foods are
one recent study found that family income heavily marketed to children, with Black
plays a larger role than race or ethnicity youth exposed to a greater amount of
in predicting childhood obesity, and that unhealthy food marketing than White
One study found that the
the relationship between Black and Latino youth.81 Accordingly, efforts to prevent odds of a child being obese or
children and obesity disappeared after childhood obesity must address all of
overweight increases by 20%
controlling for income.75 these factors.
to 60% if he or she lives in a
There are multiple factors that may Because kids are still growing, obesity is
explain why the United States has measured differently among children neighborhood with unfavorable
significant numbers of overweight than adults. Instead of a simple BMI conditions such as poor
and obese children. Like their adult measurement, a childs BMI is compared
counterparts, most children in the United to others of the same age and sex.
housing, unsafe surroundings
States are not eating enough nutritious Children with BMIs at the 95th percentile and/or limited access to
foods or getting sufficient physical or above are considered obese, and those
sidewalks, parks and recreation
activity: family and environmental factors with a BMI between the 85th and 95th
are key. For example: percentiles are considered overweight. centers.
Prevalence of obesity among youth ages 219 years, by sex and age: United States,
20112014
30 219 years 25 years 611 years 1219 years
25
1
20.5
1
21.0
1
20.1
20
17.0
1
17.5 1
17.6 17.1
1
17.5
16.9
Percent
15
10 8.9 9.2
8.6
0
All Males Females
1
Significantly different from those aged 25 years.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 20112014.
25
21.9
1,2 22.4
1,2,4
1,2
21.4
1
20.7
20 1,2
19.5
1,2
18.4
Percent
1
14.7
1
15.1
15 14.3
11.8
3
10
8.6
5.3
5
0
All Males Females
1
Significantly different from non-Hispanic Asian persons.
2
Significantly different from non-Hispanic White persons.
3
Significantly different from females of the same race and Hispanic origin.
4
Significantly different from non-Hispanic Black persons.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 20112014.
As with adults, obesity rates vary by race and ethnicity, with Latino
and Black children having higher obesity rates than White and
Asian children.23
20% 21.9%
19.5%
Obesity Rate
15%
14.7%
10%
8.6%
5%
0%
Asian Black Hispanic White
Race/Ethnicity
WA
MT ME
ND
VT
OR MN
ID NH
SD WI NY MA
WY MI
CT RI
NE IA PA NJ
NV
OH DE
UT IL IN
CA MD
CO WV
KS MO VA DC
KY
NC
AZ TN
OK
NM AR SC
MS AL GA <10%
10% to <15%
TX LA 15% to <20%
20% to <25%
FL
AK
HI
NC
State obesity rates among high school AZ TN
OK
NM AR SC
students in 2015 ranged from a low GA No Data
MS AL
of 10.3 percent in Montana to a 10% to <15%
TX LA 15% to <20%
high of 18.9 percent in Mississippi,
FL
with a median of 13.3 percent.85 The AK
information from YRBSS is based on a HI
Male students had higher obesity Note: Data not available for Colorado, District of Columbia, Georgia, Iowa, Kansas, Louisiana, Minne-
rates than female students (16.8 sota, New Jersey, Ohio, Oregon, Texas, Utah, Washington and Wisconsin.
Source: CDC, Youth Risk Behavior Surveillance System
percent vs. 10.8 percent).
An interactive map is available at stateofobesity.org
American Indian/Alaska Native,
Black and Hispanic students had
higher rates than White and Asian
students, as seen in the chart below.
Obesity Rates for High School Students by Race/Ethnicity and Gender, YRBSS 1999 to 2015
1999 2001 2003 2005 2007 2009 2011 2013 2015
TOTAL
10.6% 10.5% 12.0% 13% 12.8% 11.8% 13% 13.7% 13.9%
BY RACE/ETHNICITY
American Indian/ Alaska Native N/A 17.2% 17.5% 13% 19.5% 8.2% 17.5% 9.10% 15.9%
Asian 3.6% 6.7% 6.8% 5.4% 7.2% 7.2% 9.8% 5.6% 5.5%
Black
12.3% 16.0% 16.1% 15.9% 18.3% 15.0% 18.2% 15.7% 16.8%
Latino 13.2% 15.1% 16.2% 16.7% 16.3% 14.9% 14.1% 15.2% 16.4%
Native Hawaiian/ Other Pacific Islander
12.5% 7.5% N/A N/A N/A 20.1% 21.4% 7.5% N/A
White 10.0% 8.8% 10.3% 11.7% 10.6% 10.2% 11.5% 13.1% 12.4%
Multiple Race 11.2% 9.2% 9.6% 13.5% 13.5% 13.4% 13.6% 15.2% 17.5%
BY GENDER
Female 7.4% 6.9% 8.1% 9.9% 9.4% 8.1% 9.8% 10.9% 10.8%
Male 13.7% 14.2% 15.7% 15.9% 16.2% 15.2% 16.1% 16.6% 16.8%
Note: The CDC uses the term Hispanic in analysis. = non-Hispanic
The State of
SECTION 3: KEY OBESITY-PREVENTION POLICIES
State has regulations requiring licensed Early Care and Education programs to provide
meals and snacks that meet USDA standards
AUGUST 2017
Yes No
Budgets for Some Key Federal
Enacted Budget Enacted Budget Numbers Served by
Child Care and Obesity-Related
FY 2017 FY 2016 Program
Programs86, 87, 88, 89, 90
HELPING YOUNG C
CHILDREN THRIVE
B D
HEALTHY PRACTICES
14 IN
Nearly 1 in 4 children
Obesity puts children at risk
for Type 2 diabetes,
asthma, anxiety and
$
depression, and low Obesity costs the US
(aged 2 to 5) are health care system
self-esteem.
overweight or have $147 billion a year.
obesity.
60%OF 3-TO
5-YEAR-OLDS
are cared for in an ECE facility
at least once a week.*
PRE-K PRESCHOOL CHILD CARE CENTER
The ECE setting can directly influence what children eat and drink and
how active they are, and build a foundation for healthy habits.
* These facilities include childcare centers, family care homes, Head Start programs, preschool, and pre-kindergarten programs.
obesity rates ranged from a low of 19.2 Greater than 10% increase
percent in Massachusetts to a high of 6%10% increase
32.1 percent in Mississippi. Of the 37 1%5% increase
states or territories that also collected this HI No change
information in 2011, 30 saw increases in 1989 U.S. Standard Certificate of Live Birth
SOURCE: NCHS, National Vital Statistics System. data not available as of January 1, 2011
obesity rates between 2011 and 2014 and
seven had no significant change.
Professional Development
State allows early care and education
providers to meet professional development
requirements through online training.
Yes No
BREASTFEEDING
Breastmilk is the healthiest food for in- Rates of breastfeeding in the United Breastfeeding rates also vary widely be-
fants. The American Academy of Pediatrics States have increased in recent years. Of tween states. Mississippi has the lowest
(AAP) recommends exclusive breastfeed- babies born in 2013, 81.1 percent were rates, with only 52.0 percent of babies
ing for the first six months of life and con- breastfed at birth, more than half (51.8 born in 2013 ever breastfed and 9.3 per-
tinuing to breastfeed through the first year percent) were still breastfeeding at six cent breastfed exclusively at six months.120
of life. Breastfeeding is associated with a months, and nearly a third (30.7 percent) Idaho has the highest rate of ever breast-
number of long-term medical benefits for were breastfeeding at one year. 120
But, fed at 92.9 percent, and Montana has the
babies, including reduced risk of respira- only 22.3 percent of babies were exclu- highest rate of babies being breastfed ex-
tory tract infections, gastrointestinal tract sively breastfed at six months. clusively at six months at 33.8 percent.
infections and diabetes.114
Research has also repeatedly shown level, blood pressure, blood glucose
that American children are not getting and smoking status. It found that Fewer than half of American
enough activity or eating enough very few children meet all measures
children get the recommended
nutritious foods. In 2016, the American of a healthy heart. For example, 91
Heart Association released a scientific percent of American children have amount of daily aerobic
statement outlining seven measures of poor diets and less than half get the physical activity.
cardiovascular health, which include recommended 60 minutes of daily
physical activity, diet, BMI, cholesterol aerobic physical activity.76
SMART
The Healthy, Hunger-Free Kids Act of 2010 requires USDA to establish
The Smart Snacks in School rule nutrition standards for all foods sold in schools beyond the federally-
supported meals programs. This new rule carefully balances science-based
SNACKS
requires all food sold at schools nutrition guidelines with practical and flexible solutions to promote
during school hours to meet federal healthier eating on campus. The rule draws on recommendations from the
Institute of Medicine, existing voluntary standards already implemented by
nutrition standards,153 although states thousands of schools around the country, and healthy food and beverage
are permitted to exempt certain school IN SCHOOL offerings already available in the marketplace.
Equals 1 calorie Shows empty calories*
fundraisers from the standards.154
A review by the Institute for Health Before the New Standards After the New Standards
Research and Policy at the University of
Chicago found that, as of March 2017,
21 states and Washington, D.C., have 286 249 242 235 136 170 161 118 95 68 0
TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL
Donut
CALORIES
Chocolate
CALORIES
Regular
CALORIES
Peanuts
CALORIES
Light
CALORIES
Low-Fat
CALORIES
Granola
CALORIES
Fruit Cup
CALORIES
No-Calorie
Sandwich Flavored Bar Cola Popcorn Tortilla Bar (oats, (w/100% flavored
the rulemeaning all foods sold at Cookies Candies
(1 large)
(1 bar-1.6 oz.) (12 fl. oz.)
(1 oz.)
(Snack bag) Chips fruit, nuts) Juice) Water
(6 medium) (2.2 oz. pkg.) (1 oz.) (1 bar-.8 oz.) (Snack cup (12 fl. oz.)
school, even for fundraising efforts, 182 177 147 112 126 0 17 0 32
4 oz.)
0 0
must comply with the USDAs Smart Empty
Calories
Empty
Calories
Empty
Calories
Empty
Calories
Empty
Calories
Empty
Calories
Empty
Calories
Empty
Calories
Empty
Calories
Empty
Calories
Empty
Calories
State Requires Physical Education for Elementary, Middle and High Schools
WA
MT ME
ND
VT
OR* MN
ID NH
SD WI NY MA
WY MI
CTRI
NE IA PA NJ
NV
OH DE
UT IL IN
CA MD
CO WV State has minimum time requirements for elementary,
KS MO VA DC
KY middle and high schools
NC State has minimum time requirements for elementary
AZ TN
OK and middle schools
NM AR SC
GA State has minimum time requirements for elementary
MS AL and high schools
TX LA State has minimum time requirements for elementary,
middle or high schools
FL
AK State has no minimum requirements
HI State has student assessment in physical education or
of physical fitness
* State met national recommendations for weekly time in
Source: SHAPE America and AHA Voices for Healthy Kids physical education
l The Play Every Day! Campaign, which l The Healthy Futures Challenge, which l Supporting Alaskan schools by
encourages children to engage in encourages kids to participate in school- providing physical education training to
active play by educating parents about based physical fitness challenges, staff and teachers, assisting schools in
the benefits of physical exercise and promotes physically active Alaskan developing and implementing wellness
encouraging them to serve fewer role models, and supports low-cost policies, and supporting the serving of
sugary drinks to their kids; community physical activity events; and local foods in Alaskan schools.179
d. Shared Use
One strategy for promoting physical can help reduce barriers to use by laying Kansas, Ohio, Oklahoma and Utah
activity is the shared use of recreational out clear rights and responsibilities on go further and require shared use.184
facilities. For example, schools can make issues such as liability, maintenance, States can encourage shared use by
their gymnasiums, tracks, fields and safety and scheduling.185 providing funding or other incentives
playgrounds available for community to schools that share their facilities,
Thirty states and Washington, D.C.,
use before and after school times and but Arkansas and Washington are the
have laws encouraging schools to
on weekends. This can be particularly only states to do this.184 In addition,
make facilities available for use by
helpful in low-income communities 42 percent of U.S. municipalities have
the community through shared-use
where there is less access to recreational shared use agreements.186
agreements, while Georgia, Maryland,
opportunities. Shared use agreements
TFAH RWJF StateofObesity.org 51
e. Health Assessments
In order to monitor levels of childhood assessment programs in schools, but does
obesity, a number of states have put in offer guidance on how to implement
place school-based BMI measurement a program that provides appropriate
programs. These can be used for safeguards for students.187 Fewer than half
surveillance of population trends or of the states either require or encourage
screening of individual patients for the collection of BMI data or have a
purposes of intervention. CDC does not program in place to collect either BMI or
make a recommendation regarding BMI height and weight information.175,188
5. ESSA Implementation
In addition to its early childhood via formula and instead giving them
components, the Every Student the option to award their funding
Succeeds Act has elementary and competitively (where no school may
secondary school provisions that can receive less than $10,000).190
help students maintain a healthy weight
The law also authorizes a Promise
by improving their nutrition and
Neighborhood program to provide
increasing their physical activity levels.
pipeline services to low-income
ESSAs new Student Support and communities suffering one or more
Academic Enrichment Grants can be signs of distress, which can include high
used for health and physical education. rates of childhood obesity. ESSAs Full-
Districts receiving grants larger Service Community Schools Program
than $30,000 must conduct a needs supports local school districts partnering
assessment which could include how with community-based organizations
the school environment helps support to provide coordinated academic,
nutrition and physical activity and social and health services to improve
must spend 20 percent of its grant on educational outcomes for children in
safe and healthy school activities.189 neighborhoods facing high rates of
Block grants will be distributed to states obesity and other challenges.110
under the Safe and Healthy Students
ESSA allows schools the flexibility to
program.School districts and schools
choose how portions of their Title II
can apply to their state department of
professional development money is
education for funding for a wide range
allocated, which can include support for
of safety, health and school-climate
promoting health and wellness priorities,
programs that include health education
providing for additional school health
and physical education. While the
professionals, or educators and staff
program is authorized at $1.6 billion
training to support improving health.110
under ESSA, Congress provided only
$400 million for Student Support State education agencies must also
and Academic Enrichment Grants develop state accountability systems, which
in fiscal year 2017 necessitating must include at least one non-academic
one year exemptions to several of the performance measure. For instance,
requirements of the grant program, Connecticuts system assesses physical
including that States award their funds activity and chronic absenteeism.191
1. Overview
a. Importance of Place b. Food Deserts and Food Swamps
While the causes of the obesity crisis Food deserts are areas where residents
are complex, public health experts have little or no access to affordable,
have become increasingly aware of the healthy food. Food deserts typically lack
role that environmental factors play in nearby grocery stores and residents are
obesity. For example, the place a person forced to rely on processed food from
lives will help determine whether: convenience stores or fast-food retailers
to feed their families.
l ublic transportation is available for
P
commuting to work; The U.S. Department of Agriculture
estimates that more than 23 million
l here are nearby supermarkets that
T
Americans live in a low-income area that
sell affordable, healthy foods;
is more than a mile from the nearest
l here are sidewalks allowing children
T supermarket in urban areas and more
to safely walk or bike to school; than 10 miles away in rural areas.204
About half of the people who live in
l here are nearby parks in which to
T
such food deserts earn less than 200
play and exercise;
percent of the poverty level.205
l ocal schools provide free meals for
L
Some communities can also be classified
all students;
as food swamps areas that have an
l here is easy access to fresh, local
T overabundance of unhealthy food
produce from a farmers market; options, such as fast-food and convenience
stores, while having limited availability
l Local roads include bike lanes; and
of healthy options and fresh foods. For
l urchases of sugar-sweetened beverages
P instance, many low-income communities
are discouraged through taxation. have nearly twice the number of fast-food
restaurants and convenience stores as
higher-income areas.206, 207, 208 The high
availability of inexpensive and unhealthy
options influence the choices that families
in those neighborhoods make.
54 TFAH RWJF StateofObesity.org
c. Impact of the Environment
The term built environment means all The Community Preventive Services
the physical aspects of the places where we Task Force, a group of public health
live, work and go to school. The way our and prevention experts appointed by
environments are built can help determine CDCs director, has recommended
our level of physical activity and influence built environment approaches that
obesity rates. One simple example is stairs. combine transportation system
When an apartment building or office interventions with land use and
building has a centrally located, well-lit environmental design.210 In other
elevator bank and a dark stairwell stuck in words, as communities update or plan
a corner, people tend to take the elevator. new transportation systems, they should
But when stairwells are clean, safe, well- do so in conjunction with land use
lit and centrally located, research shows decisions in ways that make physical
they are used more frequently.209 Research activity easier and more accessible.
has unsurprisingly found a link between For example, if a town decides to
built environments and obesity, with the build a bike path, it might build it so it
odds of a child being obese or overweight connects a neighborhood to a nearby
increasing by 20 percent to 60 percent park, encouraging families to bike
if he or she lives in a neighborhood with instead of drive. Or it might install a
unfavorable environmental aspects, sidewalk that allows people to walk to a
such as poor housing, unsafe conditions light rail station, making it easier both
and/or no access to sidewalks, parks and to walk and use public transportation.
recreation centers.80
County adult obesity % Population living % County population below % Children below
County County population1 County
prevalence2 in rural areas3 poverty line5 poverty line5
Chicot 11,800 47.4% 54.3% Chicot 32.4% 45.0%
Craighead 96,443 40.4% 32.2% Craighead 21.5% 31.5%
Jefferson 77,435 40.9% 30.9% Jefferson 24.5% 37.3%
Monroe 8,149 42.5% 69.0% Monroe 30.2% 46.8%
Selected Racial/Ethnic Demographics in High Obesity Counties High Obesity Counties of Arkansas
in Arkansas
100
80
60
40
20
0
Chicot Craighead Jefferson Monroe Craighead
Chicot
County adult obesity % Population living % County population below % Children below
County County population1 County
prevalence2 in rural areas3 poverty line5 poverty line5
Barbour 27,457 40.5% 67.8% Barbour 26.7% 44.1%
Bibb 22,915 41.4% 68.4% Bibb 18.1% 30.8%
Bullock 10,914 48.5% 51.4% Bullock 21.6% 31.9%
Chambers 34,215 41.4% 49.1% Chambers 24.1% 42.1%
Coosa 11,539 41.7% 100.0% Coosa 20.9% 30.4%
Crenshaw 13,906 44.8% 100.0% Crenshaw 19.1% 24.8%
Cullman 80,406 40.3% 73.2% Cullman 18.8% 25.8%
Escambia 38,319 44.7% 63.5% Escambia 25.4% 37.4%
Greene 9,045 47.4% 100.0% Greene 32.9% 56.0%
Lowndes 11,299 42.5% 100.0% Lowndes 26.7% 37.6%
Macon 21,452 40.2% 55.5% Macon 27.3% 43.5%
Pickens 19,746 41.7% 100.0% Pickens 27.2% 36.7%
Sumter 13,763 45.0% 100.0% Sumter 38.0% 46.9%
Wilcox 11,670 48.9% 100.0% Wilcox 39.2% 50.3%
Selected Racial/Ethnic Demographics in High Obesity Counties High Obesity Counties of Alabama
in Alabama
Bullock, Greene, Lowndes, Macon, Sumter and Wilcox are located in the
mid-section of Alabama known as the Black Belt. These are counties
that, historically, have majority Black populations.
Cullman
100
80
Pickens
60
Bibb Chambers
Coosa
40
Greene
20 Sumter
Macon
Lowndes
0 Bullock
Barbour Bibb Bullock Chambers Coosa Crenshaw Cullman Escambia Greene Lowndes Macon Pickens Sumter Wilcox Wilcox
Barbour
Crenshaw
Percent White (non-Hispanic/Latino) Percent Black
Escambia
6. Philanthropic Investments
A number of national and regional for more than a decade, RWJF made and business leaders, the foundation is
philanthropic institutions also invest investments to build initiatives and working to advance changes in public
in state and local efforts to prevent strategic partnerships to ensure that all policy, community environments and
and reduce obesity and the factors children grow up at a healthy weight. In industry practices that can help children
that contribute to it. For instance, alliance with a growing coalition of civic have a healthy start in life.
Pioneering Healthier Communities (PHC) initiative uses funding The Kids Safe and Healthful Foods project provides nonpartisan
from CDC and corporate and foundation donors to support a analysis and evidence-based recommendations to ensure that all
collaborative community process to develop policy, system and foods sold in schools are safe and healthy and that the USDA adopts
environmental changes that promote healthy living.268 Launched rigorous school food safety policies and science-based nutrition
in 2004, PHC empowers communities with strategies and mod- standards. The project also helps give schools the resources they
els to support sustainable change in their communities. Partic- need to train cafeteria employees and replace outdated and broken
ipating YMCAs, as major partners, bring together a cross-sector kitchen equipment. The Kids Safe and Healthful Foods project is a
team of leaders from the private, public and nonprofit sectors. joint initiative of RWJF and The Pew Charitable Trusts.273
to reflect the latest assessments of requirements until May 7, 2018, in Amount per serving
Calories 230
nutrition science. The 2015-2020 edition order to consider how we might further Total Fat 8g
% Daily Value*
10%
Saturated Fat 1g 5%
emphasizes the idea that Americans reduce the regulatory burden or increase Trans Fat 0g
Cholesterol 0mg 0%
Sodium 160mg 7%
should shift food choices toward more flexibility of the rule.276 Total Carbohydrate 37g
Dietary Fiber 4g
13%
14%
Total Sugars 12g
Most federal food programs are required at the point of purchase, awareness * The % Daily Value (DV) tells you how much a nutrient in
a serving of food contributes to a daily diet. 2,000 calories
a day is used for general nutrition advice.
studies suggests menu labeling reduces identify calorie count and serving size;
Americans is conducting an 18-month
review study that began in late 2016. calories purchased or consumed, but l equiring added sugars (sugars and
R
evidence from real-world cafeteria and syrups added to foods or beverages
2. Menu Labeling restaurant studies regarding calories when they are processed or prepared,
purchased or menu items selected is not including naturally occurring
Recognizing that many consumers do not
mixed; and sugar) to be listed;
know or underestimate the calories
in foods, and to enable consumers l he impact of menu labeling is not
T l odifying the list of required
M
to make informed and healthy food uniform. Research has found it may nutrients (adding Vitamin D and
choices, the Affordable Care Acts (ACA) have a greater effect on women than potassium, making Vitamin A and
nutrition labeling provisions require men, on higher-calorie items and among C voluntary) to reflect the latest
large chain restaurants, convenience certain types of restaurant chains. nutrition science; and
stores and grocery stores to list the
calorie count of ready-to-eat items sold 3. Food Labels l Updating serving size requirements.278
on the premises.275 While the FDA To better reflect the latest scientific These new requirements represent the first
published a rule implementing this knowledge about healthy eating, the comprehensive update to the nutrition
requirement in 2014, the compliance FDA updated the Nutrition Facts label label in more than two decades.278
71%
year in lost productivity.42 Obesity causes 3 most common reasons young people are ineligible.
61%
would increase theirready
height and weight
to deploy. addressing the obesity crisis.283
a leading advocate of the original and therefore help ensure our national
Both obesity and low levels of
physical fitness increase the risk for
injury among active military personnel.
LOCAL PROFILE: Making Phoenix Safer for HIGH IMPACT INITIATIVE: EXPANDING PUBLIC
Walking & Biking TRANSPORTATION
Recognizing that making streets safer and more accessible
increases physical activity and fosters community
engagement, Vitalyst Health Foundation supports efforts to
build Complete Streets in Phoenix and throughout the state
of Arizona.285 Their work has included:
Introducing or expanding public
l Helping pass two city ordinances that require the city to
transportation has been shown Taking public
use Complete Streets principles in designing transportation
to increase physical activity,
improvements, including street lighting and other transportation can
and is one of the high-priority
pedestrian and bicycle safety measures; lead to 33 minutes of
HI-5 CDC community prevention
l Working with the newly created Complete Streets Advisory programs. 287
Research has extra walking per day.
Board to implement these improvements; and found that people using public
transportation often walk or
l Developing a Complete Streets policy guide to help
bike at either end of the trip building more physical activity
educate stakeholders and the public about the benefits
into their daily routine. A review of 10 years of studies of the
of Complete Streets.286
relationship between public transportation and physical activity
With these efforts, Vitalyst hopes to make Phoenix a found that using public transportation results in 8 to 33 minutes
healthier city for its residents to live, work and play. of additional walking per day.288 Public transportation is typically
a local or regional responsibility, but is often supported by state
and/or federal funding.
18%
of the total cost to raise a child
goes towards food
United States
Department of
Agriculture
Urban Northeast
$264,090
$45,370 $2,280 Urban Midwest
Private $227,400
Urban West
Urban $245,460
$20,090 $3,900 Urban South
Public $1,690 $232,050
$1,580
*Includes room
and board.
VS VS
Rural Areas
Rural
$193,020
$233,610 $2,400
0-2 3-5 6-8 9-11 12-14 15-17
Age in years
*U.S. average for middle-income, married-couple families. Total costs are from birth through age 17. January 2017
Source: Expenditures on Children by Families, 2015. Revised March 2017
U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. Misc. Pub. No. 1528-2015. USDA is an equal opportunity provider, employer, and lender.
3. Business Initiatives
Research demonstrates that multi- to plan and build communities that
component workplace wellness Workplace wellness programs encourage walking, biking and taking
programs can be an important strategy boost employee health and public transportation; and engaging the
in preventing and reducing obesity. A healthcare industry to support a broad
number of reviews have found these productivity and reduce range of community programs.
initiatives can pay for themselves by absenteeism. State governments as employers and
increasing productivity and reducing
contractors can establish policies and
absenteeism.303 They also have been
based healthcare can make sure their serve as a role model by setting nutrition
shown to reduce weight, body fat and
plans cover obesity-prevention services standards for food sold in government
BMI, and increase physical activity.306
including BMI screening, and nutrition office buildings and other state-run
Many state health departments have
and physical activity counseling. facilities. Reviews of state efforts,
developed resources to assist employers
however, reveal that only a small number
in creating effective wellness programs, Business investments are also needed
of states are taking full advantage of this
such as the Work Well Texas program to create healthier communities. There
authority. A 2013 CDC review of state
discussed in a subsequent section. need to be increased investments and
public health policies assessed whether
Worksite nutritional programs have incentives for the food industry to
states had implemented a nutrition
similarly positive effects, boosting build supermarkets and set up farmers
standards policy for the sale of food and
employee health and productivity markets in low-income communities.
beverages on state executive branch
and reducing absenteeism.306 Like Examples of business initiatives include
policy. Only two states earned the highest
governments, businesses can require incentivizing fitness companies to
score (green), two states earned yellow,
that all food sold on its premises develop gyms and other recreation
and 47 states earned the lowest score
in workplace cafeterias and vending facilities in underserved neighborhoods;
(red), because they either had no policy
machines meet established nutritional supporting transportation initiatives
at all or it did not meet CDCs criteria.304
standards. Businesses that offer employer- to work with government on all levels
With funding from CDC, the Texas l Training food service providers from
Department of State Health Services Colorado school districts on how to
created Work Well Texas, a statewide prepare fresh meals that both taste
resource to help public and private good and are good for students.312
1. Screening Services
Healthcare providers can screen their low-income patients with nutrition
patients for obesity and refer obese assistance programs such as SNAP, WIC
patients to counseling. As noted and the school meal programs. In fact,
above, both are preventive services the American Academy of Pediatrics
recommended by the U.S. Preventive recommends that pediatricians screen
Services Task Force.343 Healthcare their patients for food insecurity and
providers can also screen their patients know how to refer eligible families for
for food insecurity and help connect services.365
A New York City fruit and 2. Fruit, Vegetable and Physical Activity Prescriptions
vegetable prescription program Wholesome Wave, a nonprofit and/or by referring patients to certified
organization, has partnered with doctors trainers or exercise programs. In a
reduced the BMIs of 42% of
to enable low-income families to buy pilot program at four Kaiser Northern
participants more produce via its Fruit and Vegetable California centers, a physical activity
Prescription (FVRx) program. Doctors prescription program was associated with
write fruit and vegetable prescriptions weight loss in overweight patients and
for patients at risk of obesity, providing improved blood sugar control for patients
them coupons for free produce with diabetes.367 Kaiser Permanente was
redeemable at participating stores and the first major health plan to ask patients
farmers markets. Between 2012 and about their physical activity levels and
2015, Wholesome Waves FVRx program record the information in their electronic
in New York City helped increase fruit medical records. In 2016, Kaiser
and vegetable consumption for nearly Permanente and the American College of
3,000 people, resulting in reduced BMIs Sports Medicine issued a call to action to
for 42 percent of participants.366 the medical community to make physical
activity assessment a standard of care
Similarly, doctors can prescribe physical
that is obtained and recorded at every
activity for their patients by suggesting
medical visit.368
a recommended amount of exercise
The State of
SECTION 4: RECOMMENDATIONS
Recommendations
Obesity:
The State of Obesity reports have documented how, over the past
15 years, significant progress has been made toward preventing Obesity Policy
obesity and stabilizing obesity rates, especially among children, series
by promoting better nutrition and increased physical activity
through local, state and federal programs and policy changes,
and collaborations between the public and private sectors.381, 382
decade, and have even declined in some should invest in efforts to address the
areas of the country.381, 384, 385 Between 2010 obesity crisis, including the hospitals,
and 2014, 31 states and three territories health insurers, employers and
reported obesity rate declines among low- businesses, social services, community
income 2- to 4-year-old children receiving organizations and philanthropies.
WIC benefits.21
l rioritize Early Childhood Policies
P n ederal program need sufficient
F
and Programs. resources to support physical
n HS, USDA and the Department
H education and physical activity
of Education should issue regular throughout the school day
guidance covering programs such as and healthier school initiatives
Head Start, the Child and Adult Care (including, but not limited to ESSA
Food Program and early childhood Title I and Title IV and programs
programs supported through ESSA supported by DASH and DNPAO).
that encourage healthier meals,
opportunities for physical activity, limits ederal, state and local programs
F
on screen time and other supports that should be expanded to eliminate
promote health. And policies should lead from water in schools and to
support strong preconception and make safe, free water available to all
prenatal health support. students.
The State of
APPENDICES
ANNUAL DATA
Data for this analysis was obtained from for Whites, Blacks and Latinos and
the Behavioral Risk Factor Surveillance gender. Another variable, overweight
System dataset (publicly available on was created to capture the percentage of
the web at www.cdc.gov/brfss). The adults in a given state who were either
data were reviewed and analyzed for overweight or obese. An overweight
TFAH and RWJF by Sarah Ketchen adult was defined as one with a BMI
Lipson, PhD. greater than or equal to 25 but less than
30. For the physical inactivity variable a
BRFSS is an annual cross-sectional
binary indicator equal to one was created
survey designed to measure behavioral
for adults who reported not engaging
risk factors in the adult population
in physical activity or exercise during
(18 years of age or older) living in
the previous thirty days other than their
households. Data are collected from
regular job. For diabetes, researchers
a random sample of adults (one per
created a binary variable equal to one if
household) through a telephone
the respondent reported ever being told
survey. The BRFSS currently includes
by a doctor that he/she had diabetes.
data from 50 states, the District of
Researchers excluded all cases of
Columbia, Puerto Rico, Guam and the
gestational and borderline diabetes as
Virgin Islands.
well as all cases where the individual was
Variables of interest included BMI, either unsure, or refused to answer.
physical inactivity, diabetes, hypertension
To calculate prevalence rates for
and consumption of fruits and
hypertension, researchers created a
vegetables five or more times a day. BMI
dummy variable equal to one if the
was calculated by dividing self-reported
respondent answered Yes to the
weight in kilograms by the square of self-
following question: Have you ever been told
reported height in meters. The variable
by a doctor, nurse or other health professional
obesity is the percentage of all adults in
that you have high blood pressure? This
a given state who were classified as obese
definition excludes respondents
(where obesity is defined as BMI greater
classified as borderline hypertensive and
than or equal to 30). Researchers also
women who reported being diagnosed
provide results broken down by race/
with hypertension while pregnant.
AUGUST 2017
Alaska A
Arizona C C C C C
Arkansas D,F C C C C C
California C
Colorado C C C C,F C,F C,F C,F C C
Connecticut D C C
Delaware C,F C,F F F
D.C. A A A A A A
Florida C,F C C C C
Georgia L C C C C C C
Hawaii D,G,F C,F
Idaho C
Illinois F F F
Indiana C,F C,F C,F
Iowa D,V C
Kansas C C
Kentucky C,F
Louisiana A C C
Maine C C C
Maryland D,G,F C C C C C
Massachusetts
Michigan C,F C C
Minnesota D C
Mississippi A A A A A A
Missouri C,F C,F
Montana D,F
Nebraska C,F C,F
Nevada A A
New Hampshire
New Jersey D,F C,F C,F C,F C,F
New Mexico D,F C,F C,F C,F
New York D
North Carolina D,F C,F C,F C,F C C,F C,F C,F C,F
North Dakota C,F
Ohio C C
Oklahoma C,F C
Oregon C C C
Pennsylvania D
Rhode Island D,F C C C C C C C
South Carolina D C
South Dakota
Tennessee C,F C,F C,F
Texas C,F C,F C,F C
Utah D,F C,F C
Vermont C,F C,F C,F C,F C,F C,F C,F C,F
Virginia C C C C C
Washington F C,F C,F C,F
West Virginia D C C C,F F C,F C C C
Wisconsin D,F F F F F
Wyoming C,F
Total States 20 States + D.C. 8 States 23 States 32 States 27 States 13 States 10 States 12 States 7 States
Note: *Applies to Child Care Centers or Child Care Family Care Homes only. = State has a law, statute or both.
A = All Child Care Facilities; C = Child Care Centers; D = Child Day Care Centers; G = Child Care Group Homes; F = Child Care Family Homes; L = Child
Learning Centers; V = Child Development Centers
TFAH RWJF StateofObesity.org 91
Appendix B:
NEMOURS STATE POLICY REVIEW ON OBESITY PREVENTION: EARLY CHILDHOOD EDCUATION
State Early Childhood Education (ECE) Licensing Regulations/Quality Rating and Improvement System (QRIS) Standards to Prevent Obesity (Ages 0 to 5)
Private
Screen Time: Nutritional USDA
Breastfeeding: Breastfeeding Drinking
Healthy Eating: Physical State has Standards: State
State has Space: State Water: State CACFP: State
State has Activity: State regulations has regulations
regulations has regulations has regulations has regulations
regulations has regulations requiring licensed requiring licensed
requiring licensed requiring licensed requiring licensed requiring licensed
requiring licensed requiring licensed ECE programs that ECE programs
ECE programs ECE programs to ECE programs to ECE programs to
ECE programs ECE programs to either prohibit to provide food
to allow/ have a private make drinking meet CACFP for
to have healthy have time for daily screen time for (meals and
encourage onsite space available water available to meals and snacks
eating policies physical activity children under age snacks) that meet
breastfeeding for mothers to children
2 or sets limits USDA standards
breastfeed infants
Alabama L L L L L L
Alaska L L L L L
Arizona L L L L L
Arkansas L,Q L L,Q L L L
California L L L L
Colorado L,Q L,Q
Connecticut L L L
Delaware L,Q L L,Q L L
D.C. L L L L L
Florida L L L L L
Georgia L,Q L L,Q L L L
Hawaii L L L L
Idaho Q Q
Illinois L L L L
Indiana L,Q L L,Q L,Q L
Iowa L,Q L L L
Kansas L L L
Kentucky L L L L
Louisiana L L L L
Maine L L,Q L L
Maryland L,Q L,Q Q L L Q
Massachusetts L,Q L,Q L L
Michigan L,Q L L,Q L L L Q
Minnesota L,Q L,Q L L
Mississippi L L L L L L L
Missouri L L L
Montana L,Q L,Q L L Q
Nebraska L,Q Q L,Q Q L Q
Nevada L,Q L,Q L,Q L Q
New Hampshire L L L
New Jersey L,Q Q L,Q L L L
New Mexico L,Q L,Q L,Q L L
New York L,Q L,Q L,Q L,Q L L,Q
North Carolina L L L L L L L
North Dakota L,Q L L,Q L L
Ohio L L L L L
Oklahoma L L,Q Q L
Oregon L,Q L,Q L,Q L
Pennsylvania L,Q L,Q L
Rhode Island L L,Q L L
South Carolina L,Q L,Q L,Q L L,Q
South Dakota L L
Tennessee L L L L L
Texas L,Q L L L L L
Utah L,Q Q Q L,Q Q Q L
Vermont L L L L L
Virginia L L L L L
Washington L,Q L,Q
West Virginia L L L L L
Wisconsin L,Q
L,Q
L
L
Wyoming L L
Total States 50 States + D.C. 22 States + D.C. 4 States + D.C. 50 States + D.C. 28 States 43 States 26 States + D.C. 5 States
Note: = State has either licensing regulations, QRIS Stanadards or both.
L= licensing regulations; Q = QRIS Standards