Childhood Obesity: Most Experts Identified Physical Activity and 
the Use of Best Practices as Key to Successful Programs 	 
(07-OCT-05, GAO-06-127R).					 
                                                                 
In the past 30 years, the number of obese children has increased 
throughout the United States, leading some policy makers to rank 
childhood obesity as a critical public health threat. The rate of
childhood obesity has more than tripled for children between the 
ages of 6 and 11 and also increased for children of other ages	 
over the same period. According to a 2005 Institute of Medicine  
(IOM) report, there are approximately 9 million children	 
nationwide over the age of 6 who are considered obese. An	 
important consequence of childhood obesity is the increasing	 
number of children experiencing illnesses and other health	 
problems associated with obesity, such as hypertension and type  
II diabetes. The rise in obesity-related health conditions also  
introduces added economic costs. Between 1979 and 1999, 	 
obesity-associated hospital costs for children between the ages  
of 6 and 17 more than tripled, from $35 million to $127 million. 
Moreover, because studies suggest that obese children are likely 
to become overweight or obese adults--particularly if the	 
children are obese during adolescence--the increase in the number
of obese children may also contribute to health care expenditures
when they become adults. Obesity-related health expenditures are 
estimated to have accounted for more than 25 percent of the	 
growth in health care spending between 1987 and 2001. In 2000, an
estimated $117 billion was spent for health-related expenditures 
due to obesity, with direct costs accounting for an estimated $61
billion. These direct costs accounted for approximately 5 percent
of U.S. health expenditures. Nearly half of all medical spending 
related to adult obesity is financed by the public sector,	 
through Medicaid and Medicare. Some federal agencies support	 
efforts to target the issue of childhood obesity, and legislation
introduced in the current Congress also focuses on the issue,	 
including the Improved Nutrition and Physical Activity (IMPACT)  
Act and the Childhood Obesity Reduction Act. Congress asked us to
provide information on program strategies and elements experts	 
have identified as likely to contribute to success in addressing 
childhood obesity. Congress also asked us to provide information 
on how those strategies and elements have been implemented. In	 
this report we (1) describe the key strategies identified by	 
experts as most important to include in programs to prevent or	 
reduce childhood obesity; (2) provide examples of how selected	 
programs implemented the key strategies identified and challenges
these programs faced; (3) describe the program elements 	 
identified by experts as most important to include in programs to
prevent or reduce childhood obesity, as well as outcome measures 
identified as important; and (4) provide examples of how selected
programs implemented key elements identified and the challenges  
these programs faced, as well as examples of possible roles for  
the federal government. 					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-127R					        
    ACCNO:   A39239						        
  TITLE:     Childhood Obesity: Most Experts Identified Physical      
Activity and the Use of Best Practices as Key to Successful	 
Programs							 
     DATE:   10/07/2005 
  SUBJECT:   Children						 
	     Health care costs					 
	     Health care programs				 
	     Health surveys					 
	     Public health research				 
	     Strategic planning 				 
	     Health hazards					 
	     Nutrition research 				 
	     Nutrition surveys					 

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GAO-06-127R

October 7, 2005

Congressional Requesters

Subject: Childhood Obesity: Most Experts Identified Physical Activity and
the Use of Best Practices as Key to Successful Programs

In the past 30 years, the number of obese children1 has increased
throughout the United States, leading some policy makers to rank childhood
obesity as a critical public health threat. The rate of childhood obesity
has more than tripled for children between the ages of 6 and 11 and also
increased for children of other ages over the same period.2 According to a
2005 Institute of Medicine (IOM) report, there are approximately 9 million
children nationwide over the age of 6 who are considered obese.3 An
important consequence of childhood obesity is the increasing number of
children experiencing illnesses and other health problems associated with
obesity, such as hypertension and type II diabetes. The rise in
obesity-related health conditions also introduces added economic costs.
Between 1979 and 1999, obesity-associated hospital costs for children
between the ages of 6 and 17 more than tripled, from $35 million to $127
million.4 Moreover, because studies suggest that obese children are likely
to become overweight or obese adults-particularly if the children are
obese during adolescence-the increase in the number of obese children may
also contribute to health care expenditures when they become adults.
Obesity-related health expenditures are estimated to have accounted for
more than 25 percent of the growth in health care spending between 1987
and 2001.5 In 2000, an estimated $117 billion was spent for health-related
expenditures due to obesity, with direct costs accounting for an estimated
$61 billion. These direct costs accounted for approximately 5 percent of
U.S. health expenditures.6 Nearly half of all medical spending related to
adult obesity is financed by the public sector, through Medicaid and
Medicare.7 Some federal agencies support efforts to target the issue of
childhood obesity, and legislation introduced in the current Congress also
focuses on the issue, including the Improved Nutrition and Physical
Activity (IMPACT) Act8 and the Childhood Obesity Reduction Act.9

1In this report, the term "obese" refers to children who are considered
both overweight and at risk for overweight according to the Centers for
Disease Control and Prevention (CDC) standards for child-specific body
mass index (BMI) scores, as well as both overweight and obese adults. BMI
is an indirect measure of body fat calculated as the ratio of a person's
body weight in kilograms to the square of a person's height in meters.
According to CDC's 2000 growth charts, children are overweight when their
BMI is at or above the 95th percentile for their age and gender, while
children between the 85th and 95th percentile are considered at risk of
being overweight. BMI for children, also referred to as BMI-for-age, is
gender and age specific because the percentage of body fat in children
changes as they grow and because body fat in girls and boys differs.
Adults are considered overweight when their BMI is between 25.0 and 29.9
and obese when their BMI is 30.0 or above. In addition, in this report,
the term "children" refers to anyone under the age of 18.

2These data are for children at or above the 95th percentile of BMI for
age and gender. Cynthia L. Ogden, Katherine M. Flegal, Margaret D.
Carroll, and Clifford L. Johnson, "Prevalence and Trends in Overweight
Among US Children and Adolescents, 1999-2000," JAMA, vol. 288, no. 14
(2002) and Allison A. Hedley, Cynthia L. Ogden, Clifford L. Johnson,
Margaret D. Carroll, Lester R. Curtin, and Katherine M. Flegal,
"Prevalence of Overweight and Obesity Among US Children, Adolescents, and
Adults, 1999-2002," JAMA, vol. 291, no. 23 (2004).

3Institute of Medicine, Preventing Childhood Obesity: Health in the
Balance (Washington, D.C.: National Academies Press, 2005).

4These data are in 2001 dollars and reflect the change from 1979-1981 to
1997-1999. Guijing Wang and William H. Dietz, "Economic Burden of Obesity
in Youths Aged 6 to 17 Years: 1979 - 1999," Pediatrics, vol. 109 (2002).

You asked us to provide information on program strategies and elements
experts have identified as likely to contribute to success in addressing
childhood obesity. You also asked us to provide information on how those
strategies and elements have been implemented. In this report we (1)
describe the key strategies identified by experts as most important to
include in programs to prevent or reduce childhood obesity; (2) provide
examples of how selected programs implemented the key strategies
identified and challenges these programs faced; (3) describe the program
elements identified by experts as most important to include in programs to
prevent or reduce childhood obesity, as well as outcome measures
identified as important; and (4) provide examples of how selected programs
implemented key elements identified and the challenges these programs
faced, as well as examples of possible roles for the federal government.
Enclosure I contains the information we provided during our September 8,
2005, briefing of your staff.

The term "program strategy" refers to the issue to be addressed by the
program, such as improving nutrition choices and eating habits or
increasing physical activity. Components of the program that can affect
its success are referred to as "program elements." For example, conducting
a needs assessment prior to implementation, using best practice or
evidence-based programs, and conducting program evaluation are all
considered program elements.

5This information is for adults and reflects inflation adjusted per capita
spending. Kenneth E. Thorpe, Curtis S. Florence, David H. Howard, and
Peter Joski, "The Impact of Obesity on Rising Medical Spending," Health
Affairs, W4-480 (2004).

6Eileen Salinsky and Wakina Scott, "Obesity in America: A Growing Threat,"
(Washington, D.C.: National Health Policy Forum, July 2003).

7Eric A. Finkelstein, Ian C. Fiebelkorn, and Guijing Wang, "National
Medical Spending Attributable to Overweight and Obesity: How Much, and
Who's Paying?" Health Affairs, W3-219 (2003).

8S. 1325, 109th Cong. (2005). As introduced, it would, among other things,
direct the Secretary of the Department of Health and Human Services (HHS)
to coordinate with appropriate federal agencies as well as with leadership
within HHS in awarding competitive grants to plan and implement programs
that promote healthy eating behaviors and physical activity to prevent
eating disorders, obesity, being overweight, and related serious and
chronic medical conditions.

9S. 1324, 109th Cong. (2005). As introduced, it would establish a
Congressional Council on Childhood Obesity, charged with encouraging
elementary and middle schools to develop and implement plans to reduce and
prevent obesity, promote improved nutritional choices, and promote
increased physical activity among students. The proposed legislation would
also establish the National Foundation for the Prevention and Reduction of
Childhood Obesity to support and carry out efforts to prevent and reduce
childhood obesity through school-based activities.

To address these objectives, we conducted a written survey to identify
strategies and elements that experts believe are most important to include
when designing or implementing a program to prevent or reduce childhood
obesity.10 We chose to conduct a survey of experts because of the limited
availability of information on evaluated programs that describe successful
efforts to address childhood obesity. In May 2005, 233 experts in academia
and the private sector working in the fields of physical activity,
nutrition, and childhood obesity and government officials at the federal,
state, and local levels received the survey. (See enc. III for a copy of
this survey.) We received 141 completed surveys, 23 survey recipients
declined to participate, and 6 surveys were excluded, for an overall
response rate of 62 percent. The survey asked respondents to select from
among 9 options related to program strategies, 17 options related to
program elements, and 7 options related to outcome measures.11 In
addition, respondents were offered the option to choose an "other"
category for each of these questions, in which they could write in a
response. Some respondents selected this "other" category and provided
information that may have overlapped with one of the response options
offered in the question. We did not re-sort responses into different
categories. Respondents were also asked to rank the three strategies and
five elements they considered to be most important to include when
designing and/or implementing a program to target childhood obesity. We
analyzed survey responses, calculating weighted frequencies by assigning a
numeric value to weight the choices respondents' identified as the three
most important strategies and the five most important elements. We then
calculated an aggregated score based on the weighted frequencies. We also
calculated simple frequencies to identify how often experts chose a
particular outcome measure as important to the determination of a
program's success.

To obtain examples of how selected programs have implemented the key
program strategies and elements identified by experts through our survey,
we selected four programs and conducted telephone interviews with program
officials. To select the programs, we used specific criteria in order to
ensure program variety. These criteria included the program's funding
source, program setting, targeted population, and the program's
strategy.12 Of the four programs we selected, federal funding was the
initial funding source for three programs, and one of these programs
continues to have some federal funding. Two of the programs that initially
received federal funding are now supported by nonfederal funds, including
local funds. One program relies exclusively on private funding. Two of the
four programs were school-based while two others were community-based,
focusing on communities and including schools. In addition, one program
targeted both children and adults, while the other three focused primarily
on children. These interviews provided information on the approaches used,
problems encountered, and challenges overcome when implementing the key
strategies and elements. In addition, we obtained information on what
program officials perceived as possible federal roles targeting childhood
obesity. The information provided reflects the comments of program
officials we interviewed and cannot be generalized to all the programs. In
addition, the information provided by program officials does not reflect
all efforts underway to address childhood obesity or the implementation
approaches and challenges faced by other programs. (For additional
information on our methodology, see enc. II.)

10In our survey, we defined a "program" as an integrated set of planned or
sequential strategies, activities, and services that support clearly
stated goals.

11The strategies, elements, and outcome measures in the survey were drawn
from literature and interviews we conducted with individuals working at
federal agencies and national organizations.

12We selected programs that focused on different strategies using the
strategies most frequently selected on the survey responses received as of
May 20, 2005, although we continued to accept surveys through the end of
May 2005.

We did our work from February 2005 through September 2005 in accordance
with generally accepted government auditing standards.

Results in Brief

Experts we surveyed identified several key strategies to include in the
design or implementation of a program to prevent or reduce childhood
obesity. The program strategy identified by experts as most important was
"increasing physical activity." The second-highest-ranked strategy was the
"other" category, in which experts wrote in a variety of responses. The
number and variety of these write-in responses suggests that, beyond
physical activity, there is less consensus on which strategies should be
used to target childhood obesity. The strategy of improving children's
nutritional intake was identified as third in importance for programs
designed to prevent or reduce childhood obesity by surveyed experts.

Our interviews with officials at four programs provided different examples
of implementing the key strategies, including the top-ranked strategy,
increasing physical activity. For example, one school-based program
provided children with a card that was hole-punched when they walked at
recess and which the children could redeem when completed for small prizes
and incentives. Another program provided pedometers to encourage walking.
Program officials we interviewed also identified multiple challenges to
implementing key strategies that included policy concerns, such as a lack
of or inconsistent physical education requirements by school districts,
and infrastructure concerns, such as no sidewalks.

Experts we surveyed identified several key elements to include in the
design or implementation of a program to prevent or reduce childhood
obesity. The program element identified as the most important was the use
of best practice or evidence-based models. Experts also identified other
key elements including the suitability and acceptability of the program to
the target community, and sufficient financial and human resources.
Responses from surveyed experts indicate that there is no consensus on
what outcome measures should be used to determine program success.

Officials we interviewed at four programs provided a variety of examples
demonstrating how they implemented the top-ranked program element-use of
best practices or evidence-based program models. For example, one program
drew best practices from multiple sources, including clinical treatment
programs and programs aimed at children of other ages, to guide the
development of their prevention program. Program officials we interviewed
also identified challenges to implementing key elements that included
difficulties in working within school systems and communities to obtain
program acceptance, and resource constraints. Program officials also
identified several possible roles for the federal government related to
obesity, including supporting and staffing clearinghouses to provide
information on best practices.

Agency Comments and Our Evaluation

We received comments on the draft report from the Department of Health and
Human Services (HHS). These comments are provided in enclosure VI. HHS and
the Department of Agriculture (USDA) also provided technical comments
which we incorporated where appropriate. The Department of Education
informed us that it had no comments on the draft report.

In its written comments, HHS stated that our findings were inconsistent
with IOM's 2005 report, which found that preventing obesity involves both
regular physical activity and healthy eating behaviors. We believe that
our findings are consistent with IOM's 2005 report. Our survey results
show that both physical activity and nutritional strategies are important.
Although our surveyed experts ranked physical activity as a leading
strategy for programs that address childhood obesity, it is not the sole
strategy and our survey results fully support the importance of other
strategies, including improving children's nutritional intake. In
addition, our report provides illustrative examples of how program
officials have implemented both physical activity and nutrition-related
strategies. Our title, "Childhood Obesity: Most Experts Identified
Physical Activity and the Use of Best Practices as Key to Successful
Programs," which HHS suggests overstates the importance of physical
activity, is an accurate reflection of the survey responses. Consistent
with the IOM report, we provide background on the importance of both sides
of the energy balance equation-nutrition and physical activity. Our report
is also consistent with IOM's call for evidence-based best practices that
could help in setting priorities to address childhood obesity, and the
rankings from our surveyed experts suggest priorities based on their
experience.

HHS (and USDA in its technical comments) also raised questions about our
survey methods, including how survey respondents were selected, how the
response options offered to respondents were developed, and how analysis
of the many "other" responses written in by respondents was conducted. As
we noted in the draft report, we selected our survey respondents by using
a systematic approach to review literature, conference proceedings, and
hearings within a defined time frame and by developing clear decision
rules for selection. Because there is no comprehensive national inventory
of childhood obesity programs or experts in the field, a representative
sample is not possible. However, our approach was designed to ensure a
broad representation across sectors and fields involved in the issue. Both
HHS and USDA suggested that we provide additional detail on the survey
respondents and we have modified the report to provide information on the
affiliations of our survey respondents. As we noted in the draft report,
the response categories provided to respondents in the survey were
developed based on a review of the literature and interviews, and the
survey instrument was reviewed and pretested with each type of respondent
included in the sample, and was modified multiple times based on input
received before being implemented. HHS (and USDA in its technical
comments) suggested that we should have grouped response categories,
including those related to the program strategies and the "other"
responses written in by respondents, into broader categories. HHS
suggested that such grouping would alter the results, particularly related
to the leading program strategy. However, this is not accurate. Grouping
the response categories provided in the survey to form broader categories
such as physical activity or nutrition would not have changed the results.
Physical activity would remain as the leading strategy, with nutrition
strategies being important in the rankings, though ranked lower.
Furthermore, as we noted in the draft report, we did not re-sort the
"other" responses, because respondents deliberately chose to write a
response in the "other" category and re-sorting their responses would not
have accurately reflected the responses as we received them. Furthermore,
re-sorting the responses related to program strategies or "other" to form
larger categories would have resulted in a loss of information to the
reader about the diversity of the respondents' views; therefore we chose
to provide greater detail. HHS was concerned that the response categories
were incomplete. However, the survey made available several areas for
respondents to write in responses for an individual question as well as
generally, so respondents had ample opportunity to write in additional
information. Although HHS stated that we did not mention the use of policy
as a strategy to shape food and physical activity environments, this issue
is indeed identified as an "other" response that respondents wrote in.

HHS commented that the interviews with officials at four programs are
anecdotal and represent a small fraction of respondents who completed
surveys, which mischaracterizes our report. HHS's implication that we
selected programs associated with survey respondents is inconsistent with
our described methodology. The four programs were identified through
interviews and reviews of documents from multiple sources. Furthermore, as
the report states, the purpose of the interviews was not to evaluate these
specific programs, but to obtain examples that could illustrate concepts
in the survey results. As we stated, this was not a generalizable sample.

Finally, HHS suggested that the report incorporate more recent data on
prevalence of overweight among children, and provide information on the
disparities by race/ethnicity. We modified the report to reflect the
updated prevalence data; however, a detailed discussion on variations in
the prevalence of obesity among children was not in the scope of our work.

                                   - - - - -

As we agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution of this letter
until 30 days after the date of this letter. At that time, we will send
copies of this letter to the Secretaries of Health and Human Services,
Agriculture, and Education, appropriate congressional committees, and
other interested parties. In addition, the report will be available at no
charge on the GAO Web site at http://www.gao.gov .

If you or your staff have any questions about this report, please contact
me at (202) 512-7101 or [email protected]. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this report
are listed in enclosure VII.

Cynthia A. Bascetta

Director, Health Care

List of Requesters

The Honorable Bill Frist

Majority Leader

United States Senate

The Honorable Christopher J. Dodd

Ranking Minority Member

Subcommittee on Education and Early Childhood Development

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Jeff Bingaman

United States Senate

The Honorable Mary Bono

House of Representatives

The Honorable Kay Granger

House of Representatives

The Honorable Nita M. Lowey

House of Representatives

                             Scope and Methodology

To identify strategies and elements that experts believe are most
important to include when designing and/or implementing a program to
prevent or reduce childhood obesity, we conducted a written survey of
experts in academia and the private sector working in the fields of
physical activity, nutrition, and childhood obesity. We also surveyed
government officials at the federal, state, and local levels. We chose to
conduct a survey of experts because of the limited availability of
information on evaluated programs that describe successful efforts to
address childhood obesity. Because there is no comprehensive inventory of
childhood obesity experts, we used a systematic approach to identify
survey participants. We reviewed both national conference proceedings and
testimony from congressional hearings focused on childhood obesity held
from January 2004 through February 2005 to identify speakers focused on
this issue. Using multiple databases, including Medline, BIOSIS,
Cumulative Index to Nursing and Allied Health Literature, and the
Education Resources Information Center, we conducted a review of
literature published from January 2003 through February 2005 related to
preventing or reducing childhood obesity in the United States, identifying
primary authors of relevant literature as expert contacts for the survey.
To identify survey respondents from associations and foundations in the
private sector, we conducted an internet search to identify relevant
organizations and, when necessary, contacted the organization's
communications department or federal affairs office to identify an
appropriate contact. To identify survey respondents at federal agencies,
we relied on conversations with the Departments of Health and Human
Services, Education, and Agriculture and also identified respondents from
some federal agencies through our review of literature and conferences. In
addition to these sources, we also identified possible respondents from
interviews conducted when collecting background information and through
past GAO work. We compiled a list of 222 experts to receive the survey: 95
from academia, 46 from the public sector (federal, state, or local
government), 38 from foundations and associations, and 43 from the private
sector.

The survey was conducted during May 2005. We pretested the survey with
four experts representing academia, the public sector, foundations and
associations, and the private sector, and modified the survey based on
their responses. The survey was sent via e-mail as both a Microsoft Word
document and Acrobat Adobe PDF to experts, who were given the option to
return the survey by e-mail or by fax. For surveys that were marked
"undeliverable," correct e-mail addresses were obtained via telephone and
the survey was sent again. If a correct e-mail address could not be
obtained, the expert was dropped from our expert pool. Experts who did not
respond by the deadline were followed up with by both phone and e-mail, up
to three times.

The survey was sent to 233 experts-the 222 we identified and an additional
11 experts to whom the survey was forwarded by the original recipients. Of
these, 23 declined to participate. In addition, 6 survey recipients were
excluded because they could not be reached or returned unusable surveys.
We received 141 completed surveys for a 62 percent overall response rate.
Of the respondents completing the survey, 57 were from academia, 36 were
from the public sector (federal, state, or local government), 25 were from
foundations and associations, and 23 were from the private sector. The
survey asked respondents to select from among 9 options related to program
strategies, 17 options related to elements, and 7 options related to
outcome measures.1 (See enc. III for a copy of this survey.) In addition,
respondents were offered the option to choose an "other" category for each
of these questions, in which they could write in a response. Some
respondents selected this "other" category and provided information that
may have overlapped with one of the response options offered in the
question. In order to ensure an accurate reflection of survey responses,
we did not re-sort responses into a different category.

Respondents were asked to rank the three strategies they considered to be
most important to include when designing and/or implementing a program to
target childhood obesity, as well as the five elements they considered to
be most important. Respondents were also asked to identify outcome
measures they considered important to determine program success. In
addition to the questions related to program strategies, elements, and
outcome measures, survey respondents were also asked to provide
information on programs they considered to be successful or have shown
promise in preventing or reducing childhood obesity and their affiliation,
if any, with these programs. When completing the survey, respondents
represented themselves, not the organization or agency they were
affiliated with, and were allowed the option of remaining anonymous.

We analyzed survey responses, calculating weighted frequencies of the
program strategies and elements by assigning a numeric value to weight the
choices respondents identified as the three most important strategies and
the five most important elements.2 We then calculated an aggregated score
based on the weighted frequencies. We also calculated simple frequencies
to identify how often experts chose a particular outcome measure as
important to the determination of a program's success. We reviewed the
information written-in by respondents in the "other" category related to
program strategies and elements to examine common issues. In addition, we
used the information provided by survey respondents to compile a list of
programs they considered to be successful or showing promise in preventing
or reducing childhood obesity. (See enc. V.)

To illustrate how selected programs have implemented the key program
strategies and elements identified through our survey, we conducted
interviews with officials from four selected programs. To select these
programs, we developed a list of possible programs based on interviews and
documents.3 We looked for programs that focused on the strategies most
frequently selected from among the strategies listed in the survey, based
on results received as of May 20, 2005.4 We sorted programs according to
program setting, funding source, target population, and whether the
program targeted one or multiple strategies. We then selected four
programs to represent variety within these characteristics. Of the four
programs selected, federal funding was the initial funding source for
three programs, and one of these programs continues to have some federal
funding. Two of the programs that initially received federal funding are
now supported by nonfederal funds, including local funds. One program
relies exclusively on private funding. Two programs focus exclusively on
one program strategy-one on physical activity, the other on
nutrition-while the other two programs focus on multiple strategies,
including both physical activity and nutrition. Two of the four programs
were school-based while two others were community-based, focusing on
communities and including schools. In addition, one program targeted both
children and adults, while the other three focused primarily on children.
We spoke with multiple individuals connected with each program, including
one person who served the role of program manager.

1The strategies, elements, and outcome measures in the survey were drawn
from literature and interviews we conducted with individuals working at
federal agencies and national organizations.

2The numeric values assigned to the strategies identified as most, second
most, and third most important were 3 points, 2 points, and 1 point,
respectively. The numeric values assigned to the elements identified as
most, second most, third most, fourth most, and fifth most important were
5 points, 4 points, 3 points, 2 points, and 1 point, respectively.

3We did not include programs that were focused exclusively on media or
educational campaigns.

4We continued to accept surveys through the end of May 2005.

We conducted telephone interviews with program officials from each of the
four selected programs using a structured protocol. In addition, we
reviewed written materials on each of the selected programs. We asked
program officials for examples of how they implemented the key strategies
and elements identified through our survey and for information on the
problems encountered and challenges overcome during implementation. In
addition, we obtained information on what they perceived as possible
federal roles related to childhood obesity. The information provided
reflects the comments of program officials we interviewed and cannot be
generalized to all programs. In addition, the information provided by
program officials does not reflect all the efforts underway to address
childhood obesity or the implementation approaches and challenges faced by
other programs.

As part of our review, we also interviewed officials from the Departments
of Health and Human Services, Agriculture, and Education to obtain
background information about federally funded programs and initiatives,
including both current and completed programs. In addition, we reviewed
documentation provided by these agencies regarding their efforts to reduce
childhood obesity. We also interviewed officials and reviewed documents
from the Institute of Medicine and the Robert Wood Johnson Foundation to
obtain background information on childhood obesity and their efforts to
address the issue.

                          Survey on Childhood Obesity

  Data on Program Strategies, Elements, and Outcome Measures Obtained from GAO
                          Survey on Childhood Obesity

Table 1: Frequencies and Weighted Frequencies of Each Program Strategy

                                                   Survey respondent rankings
                                                 Frequency                    
                                                           
Possible survey response               of each strategy Weighted frequency
Reduce sedentary television or screen                                      
time                                                118                116
Promote breastfeeding among expectant                                      
mothers                                              52                 13
Promoted increased breastfeeding among                                     
nursing mothers                                      35                  6
Increase physical activity                          133                212 
Increase financial affordability of                                        
nutritious foods                                     81                 50
Increase access to nutritious foods in                                     
communities, homes, etc.                             96                 52
Improve children's nutritional intake               106                145 
Modified buildings, parks, or other                                        
spaces created by people to promote or                  
improve health                                      101                 69
Do not know                                           2                  0 
Othera                                              174                170 

Source: GAO Survey on Childhood Obesity.

Note: To determine frequencies, we examined how frequently a particular
program strategy was chosen by experts. To determine the weighted
frequencies, we assigned a numeric value to weight the choices ranked as
the three most important strategies, then calculated an aggregated score
based on the weighted frequencies. The numeric value for the strategy
identified as most, second most, and third most important were 3 points, 2
points, and 1 point, respectively.

aThese data include all "other" responses written-in for this question.

Table 2: Frequencies and Weighted Frequencies of Each Program Element

                                                   Survey respondent rankings
                                                 Frequency                    
                                                           
Possible survey response                of each element Weighted frequency
Assessment of gathered information to                                      
outline need for intervention                        42                 80
Specified target population for the                                        
designed program                                     74                 94
Specified program goals and objectives                                     
that describe impact/expected changes                97                186
Use of best practices or substantiated                                     
evidence from other effective programs              105                272
Suitability and acceptability of                                           
program to target community                         100                194
Determination of most appropriate                                          
setting for program to occur                         39                  9
Integration of program into existing                                       
efforts                                              64                 62
Training of staff/volunteers to                                            
implement program                                    71                 49
Collaboration with others in community                                     
for buy-in and ownership                             85                110
Presence of program advocate(s) to                                         
effect change                                        52                 52
Sufficient financial resources                      107                187 
Sufficient human resources                          103                140 
Sufficient program duration to monitor                                     
change over time                                     93                 99
Process evaluation (planned and/or                                         
implemented)                                         78                 44
Outcome evaluation (planned and/or                                         
implemented)                                        106                140
Program sustainability                               89                122 
Do not know                                           3                  4 
Othera                                               44                103 

Source: GAO Survey on Childhood Obesity.

Note: To determine frequencies, we examined how frequently a particular
element was chosen by experts. To determine the weighted frequencies, we
assigned a numeric value to weight the choices ranked as the five most
important elements, then calculated an aggregated score based on the
weighted frequencies. The numeric value for the element identified as
most, second most, third most, fourth most, and fifth most important were
5 points, 4 points, 3 points, 2 points, and 1 point, respectively.

aThese data include all "other" responses written-in for this question.

Table 3: Frequencies of Outcome Measures

                                                   Survey respondent rankings 
                                                                    Frequency 
                                                                              
                                                                      of each 
                                                                              
Possible survey response                                   outcome measure 
Body mass index (BMI)                                                  105 
Fitness levels (e.g. run-walk times, aerobic                               
capacity)                                                               95
Adiposity                                                               59 
Biomarkers (e.g., glucose levels, lipids)                               58 
Self-reported change in dietary intake                                  51 
Observed change in dietary intake                                       70 
Do not know                                                              2 
Othera                                                                 105 

Source: GAO Survey on Childhood Obesity.

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

aThese data include all "other" responses written-in for this question.

Programs Identified by Surveyed Experts

In a written survey conducted by GAO, experts were asked to provide the
names and locations of programs they believe have been successful or shown
promise in preventing or reducing childhood obesity.1 GAO did not
independently evaluate the programs listed.2

           o  Action for Healthy Kids, Skokie, Illinois
           o  America On the Move, Boston, Massachusetts
           o  Apache Healthy Stores Project, New Mexico
           o  Balance First, TM Ontario, Canada
           o  Be Active North Carolina
           o  Bienestar, California
           o  Bright Bodies Weight Management, Yale University School of
           Medicine - New Haven, Connecticut
           o  Brocodile the Crocodile, New York
           o  California Project LEAN (Leaders Encouraging Activity and
           Nutrition)
           o  Cardiovascular Health in Children and Youth Study (CHIC),
           University of North Carolina - Chapel Hill, North Carolina
           o  Cartographic Modeling Laboratory, University of Pennsylvania -
           Philadelphia, Pennsylvania
           o  *Childhood Weight Control Program, University of Buffalo -
           Buffalo, New York
           o  Children's Optimal Weight for Life Program, Children's Hospital
           Boston, Massachusetts
           o  Color Me Healthy, North Carolina
           o  Consortium to Lower Obesity in Chicago Children (CLOCC),
           Illinois
           o  Department of Defense's (DOD) Fresh Produce Program
           o  Department of Education's Carol M. White Physical Education
           Program
           o  Department of Health and Human Services (HHS) - National
           Institutes of Health's (NIH) Coronary Artery Risk Development in
           Young Adults (CARDIA) study
           o  Eat Well & Keep Moving, Baltimore City Public Schools and
           Harvard School of Public Health - Boston, Massachusetts
           o  Farm Fresh Choice, University of California - Berkeley,
           California
           o  Farm to Schools Program, Occidental College - Los Angeles,
           California
           o  Fitkid Project, Medical College of Georgia - Augusta, Georgia
           o  FoodChange, New York, New York
           o  Healthy Children Healthy Futures
           o  Healthy Living in the Pacific Islands, Honolulu, Hawaii
           o  Healthy Start
           o  HHS - Centers for Disease Control and Prevention (CDC) School
           Health Index
           o  HHS - CDC's VERB TM

           o  *HHS - NIH's Child and Adolescent Trial for Cardiovascular
           Health (CATCH)
           o  HHS - NIH's Girls Health Enrichment Multisite Study (GEMS)
           o  HHS - NIH and the National Recreational and Park Association's
           Hearts N' Parks
           o  HHS and Environmental Protection Agency's National Children's
           Study
           o  HHS's Head Start
           o  HHS's Steps to a HealthierUS
           o  Hip-Hop to Health Program, Chicago, Illinois
           o  Ho-Chunk Community Development Corporation, Walthill, Nebraska
           o  incentaHEALTH Program, Denver, Colorado
           o  Kaiser Permanente's Kid Shape(R), Oakland, California
           o  LEAP: The Live, Eat and Play Study, Royal Children's Hospital,
           Melbourne, Australia
           o  M-SPAN (Middle-School Physical Activity and Nutrition), San
           Diego State University, California
           o  New Moves, University of Minnesota - Minneapolis, Minnesota
           o  NikeGO / PE2GO, Beaverton, Oregon 
           o  Northwest Schools Obesity Prevention Consortium, University of
           Washington - Seattle, Washington
           o  Nutrition and Physical Activity Self Assessment for Child Care
           (NAP SACC), University of North Carolina - Chapel Hill, North
           Carolina
           o  Nutrition Education Aimed at Toddlers (NEAT), Michigan State
           University - East Lansing , Michigan
           o  Packard Pediatric Weight Control Program, Lucile Packard
           Children's Hospital at Stanford, California
           o  Pathways study, University of New Mexico - Albuquerque, New
           Mexico
           o  Physical Best Program, Champaign, Illinois
           o  *Planet Health, Harvard Prevention Research Center - Boston,
           Massachusetts
           o  Positive Coaching Alliance, Stanford University, California
           o  *Reducing Television Viewing to Prevent Childhood Obesity
           study, Stanford Prevention Research Center
           o  Shape Up America!
           o  SHAPEDOWN(R), University of California - San Francisco,
           California
           o  SPARK, San Diego, California
           o  Strategies for Metropolitan Atlanta's Regional Transportation
           and Air Quality, Atlanta, Georgia
           o  Student Centered Web-Based Communities: Multi-Disciplinary
           Approach for Adolescent Obesity Prevention, Purdue University -
           West Lafayette, Indiana
           o  TACOS Study, University of Minnesota - Minneapolis, Minnesota
           o  Take 10!,TM Atlanta, Georgia
           o  The California Endowment's Healthy Eating, Active Communities
           Initiative
           o  The Food Trust, Philadelphia, Pennsylvania
           o  The National Black Church Initiative, Washington, D.C.
           o  The Nutrition and Fitness for Life Program, Boston Medical
           Center, Massachusetts
           o  The Robert Wood Johnson Foundation's Active Living by Design /
           Healthy Eating by Design, University of North Carolina - Chapel
           Hill, North Carolina
           o  U Move with the Starzz, University of Utah - Salt Lake City,
           Utah
           o  U.S. Department of Transportation's Safe Routes to School
           o  United Way, Alexandria, Virginia
           o  Urban Nutrition Initiative (UNI), University of Pennsylvania -
           Philadelphia, Pennsylvania
           o  US Department of Agriculture's (USDA) Breastfeeding Promotion
           and Support
           o  USDA's Community Supported Agriculture
           o  USDA's Eat Smart. Play Hard.TM 
           o  USDA's Fit WIC
           o  USDA's Food Stamp Program
           o  USDA's Fruit and Vegetable Pilot Program
           o  USDA's Loving Support Makes Breastfeeding Work
           o  USDA's National School Lunch Program
           o  USDA's Team Nutrition
           o  Weight Management Program, Louisiana State University - Baton
           Rouge, Louisiana
           o  What's for Lunch? program, Brookline, Massachusetts
           o  WIN the Rockies (Wellness IN the Rockies) 
           o  YMCA Activate America

1Program locations are not always included. Programs noted with an
asterisk (*) were mentioned by at least 10 experts.

2Program names that could not be verified through an internet search were
excluded from this list. In addition, general listings of states, school
names, school districts, and hospitals were excluded.

           Comments from the Department of Health and Human Services

Now GAO-06-127R.

                     GAO Contact and Staff Acknowledgments

GAO Contact

Cynthia A. Bascetta, (202) 512-7101 or [email protected]

Acknowledgments

In addition to the person named above, Linda T. Kohn, Assistant Director;
Jessica Cobert; Krister Friday; Emily Gamble Gardiner; Nkeruka Okonmah;
and Kimberly A. Scott made key contributions to this report.

(290317)

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