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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 children[Footnote 1] 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.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 6] Nearly half of all medical spending related 
to adult obesity is financed by the public sector, through Medicaid and 
Medicare.[Footnote 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) Act[Footnote 8] and the 
Childhood Obesity Reduction Act.[Footnote 9] 

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

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

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.[Footnote 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.[Footnote 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.[Footnote 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.) 

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 bascettac@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major contributions 
to this report are listed in enclosure VII. 

Signed by: 

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: 

[End of section] 

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

Briefing for Staff of Congressional Requesters: 
September 8, 2005: 

Introduction: 

In the past 30 years, the number of obese children[NOTE 1] has 
increased throughout the United States, leading some policy makers to 
rank childhood obesity as a critical public health threat. 

* The rate of childhood obesity has more than tripled for children 
between the ages of 6 and 11 and also increased for children of other 
ages over that 30-year period. [NOTE 2]

* According to a 2005 Institute of Medicine report, nationwide 
approximately 9 million children over the age of 6 are considered 
obese. [NOTE 3] 

NOTES: 

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

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

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

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.[NOTE 4] 

* Increased numbers of obese children who become obese adults may 
affect future health expenditures, including Medicaid and potentially 
Medicare. 

- Obesity-related health expenditures are estimated to have accounted 
for more than 25 percent of the growth in health care spending between 
1987 and 2001. [NOTE 5] 

- In 2000, an estimated $117 billion was spent for health-related 
expenditures due to obesity with $61 billion in direct costs. These 
direct costs accounted for approximately 5 percent of U.S. health 
expenditures. [NOTE 6] 

- Nearly half of all medical spending related to adult obesity is 
financed by the public sector, through Medicaid and Medicare. [NOTE 7] 

Some federal agencies support efforts to target the issue of childhood 
obesity. Legislation introduced in the current Congress also focuses on 
the issue, including the Improved Nutrition and Physical Activity Act 
and the Childhood Obesity Reduction Act. [NOTE 8] 

NOTES: 

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

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

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

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

[8] S. 1325. 109th Con. (2005) and S. 1324. 109th Con. (2005). 

Reporting Objectives: 

Describe the key strategies identified by experts as most important to 
include in programs to prevent or reduce childhood obesity. 

Provide examples of how selected programs implemented the key 
strategies identified and challenges these programs faced. 

Describe the program elements identified by experts as most important 
to include in programs to prevent or reduce childhood obesity, as well 
as outcome measures identified as important. 

Provide examples of how selected programs implemented key elements 
identified and the challenges those programs faced, as well as examples 
of possible roles for the federal government. 

Scope and Methodology: 

In this report, "program strategies" refers to the issue to be 
addressed by the program, such as improving nutrition choices and 
eating habits or increasing physical activity. 

"Program elements" refers to components of the program that can affect 
its success. For example, conducting a needs assessment prior to 
implementation, using best practice or evidence-based programs, and 
conducting program evaluation are all considered program elements. 

We surveyed 233 experts in the fields of physical activity, nutrition, 
and childhood obesity to identify the program strategies, elements, and 
outcome measures that are, in their view, important to include when 
designing and/or implementing a program to prevent or reduce childhood 
obesity. [NOTE 9] 

* Survey respondents were asked to select from among several options 
related to program strategies, elements, and outcome measures, and were 
offered the option to choose an "other" category for each of these 
questions in which they could write in a response. 

* Some respondents selected the "other" category, providing information 
that may have overlapped with one of the response options offered in 
the question, such as physical activity or nutrition intake. Although 
we reviewed the "other" responses for common issues, we did not re-sort 
these responses. 

NOTE: 

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

Survey respondents were also asked to rank the three strategies and 
five elements they considered to be most important to include when 
designing and/or implementing a program to target childhood obesity. 

* Weighted frequencies: 

- We assigned a numeric value to weight the choices ranked as the three 
most important strategies and five most important elements. 

- We then calculated an aggregated score based on the weighted 
frequencies. 

Survey respondents were also asked to identify outcome measures they 
considered important to the determination of a program's success. 

* Frequencies: 

- We examined how frequently a particular outcome measure was chosen by 
experts. 

After surveying experts, we conducted telephone interviews with 
officials at four selected programs targeting childhood obesity. To 
select the programs, we used specific criteria to ensure program 
variety. These criteria included the program's funding source, program 
setting, targeted population, and strategy. [NOTE 10] We asked program 
officials at each program whether and how they implemented key 
strategies and program elements identified by surveyed experts.[NOTE 
11] Our purpose was to determine the approaches used, challenges 
encountered, and obstacles overcome. In addition, we obtained 
information from program officials on what they perceived as possible 
federal roles related to preventing or reducing childhood obesity. 

NOTES: 

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

[11] Throughout this report, the term "surveyed experts" refers to the 
people who completed the survey. The term "program officials" refers to 
the people we interviewed at the four selected programs. 

Federal funding was the initial funding source for three of the four 
selected programs, and one of these programs continues to receive some 
federal funding. The two programs that initially received federal 
funding are now supported by other, nonfederal funds, including local 
and private funds. One program we selected relies exclusively on 
private funding. 

Two programs were school-based while two others were community-based, 
focusing on communities and including schools. 

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

Two programs focused on multiple strategies and two focused on a single 
strategy. 

Background: 

Increase in Childhood Obesity: 

Between the early 1970s and 2000, the rate of childhood obesity has 
more than tripled for children between the ages of 6 and 11. [NOTE 12] 
(See fig. 1.) 

During that same time period, the rate of childhood obesity more than 
doubled for both children between the ages of 2 and 5 and between the 
ages of 12 and 19. 

[12] These data are for children at or above the 95th percentile of BMI 
for age and gender. Ogden et. al., "Prevalence and Trends in Overweight 
Among US Children and Adolescents, 1999-2000," JAMA, vol. 288, no. 14 
(2002) and Hedley et al., "Prevalence of Overweight and Obesity Among 
US Children, Adolescents, and Adults, 1999-2002," JAMA, vol. 291, no. 
23 (2004). 

Figure 1: Percent increase in childhood obesity: 

[See PDF for image] 

Notes: The National Health and Nutrition Examination Survey (NHANES) is 
an ongoing cross-sectional, nationally representative examination 
survey conducted by the Centers for Disease Control and Prevention's 
National Center for Health Statistics. The survey collects data on the 
health of U.S. residents. 

[a] These data are for children at or above the 95th percentile of BMI 
for age and gender. 

Source: GAO (image) based on Ogden et al., "Prevalence and Trends in 
Overweight Among US Children and Adolescents, 1999-2000," JAMA, vol. 
288, no. 14 (2002), and Hedley et al., "Prevalence of Overweight and 
Obesity Among US Children, Adolescents, and Adults, 1999-2002," JAMA, 
vol. 291, no. 23 (2004). 

[End of figure] 

Health Consequences of Childhood Obesity: 

Children are experiencing illness and other health problems associated 
with obesity, including: [NOTE 13] 

* Type II diabetes; 
* Hypertension. 

In addition, obesity is associated with other physical, social, and 
emotional health consequences, including: 

* Sleep apnea; 
* Orthopedic problems; 
* Depression; 
* Negative body image; 
* Stigma. 

NOTE: 

[13] See, for example, Office of the Surgeon General, "The Surgeon 
General's Call to Action to Prevent and Decrease Overweight and Obesity 
2001," (Washington, D.C. 2001) and Salinsky et al., "Obesity in 
America: A Growing Threat," (Washington, D.C. National Health Policy 
Forum, July 2003). 

Obesity Can Result from an Imbalance in the "Energy Balance Equation" 

At the most basic level, obesity results from an imbalance in what 
experts refer to as the "energy balance equation." [NOTE 14] 

* Obesity can result when increased or excess energy intake (calories 
consumed) is combined with decreased or unchanged energy expenditure 
(insufficient physical activity). (See fig. 2.) 

Figure 2: Imbalanced energy equation: 

[See PDF for image] 

Source: GAO (image). 

[End of figure] 

[14] The energy balance equation is expressed as "energy intake = 
energy expenditure." Energy balance is determined by the relationship 
between energy intake (food/caloric) and energy expenditure 
(activity/exercise). See, for example, Institute of Medicine, 
Preventing Childhood Obesity: Health in the Balance (Washington, D.C. 
National Academies Press, 2005). 

Factors Contributing to Childhood Obesity: 

Each side of the energy balance equation is affected by the complex 
interaction of social, biological, behavioral, dietary, environmental, 
and economic factors. 

* For example, children may receive nutrition education and healthy 
foods while in school, but may not have access to healthy foods in the 
surrounding community or may lack role models who demonstrate healthy 
lifestyle choices. 

* Moreover, changes to diet may be insufficient to reduce childhood 
obesity without a corresponding increase in physical activity. 

Federal Agencies and Others are Participating In Efforts to Prevent and 
Reduce Childhood Obesity: 

At the federal level, the Departments of Health and Human Services, 
Agriculture, and Education have all supported initiatives that target 
childhood obesity, in some cases working in partnership with private 
organizations. These initiatives include research and education, as 
well as financial and technical support for program implementation. 

In addition to federal agencies, a variety of private organizations and 
public-private partnerships have also undertaken efforts to reduce the 
effects of factors that contribute to childhood obesity. These efforts 
may target a single issue, such as dietary change, while others may 
coordinate activities across multiple issues, such as both dietary 
change and physical activity. 

Federal and Private Efforts to Address Childhood Obesity Have Not Been 
Evaluated: 

While a variety of efforts are underway in both the federal and private 
sectors to address childhood obesity, few programs have undergone the 
rigorous evaluations needed to definitively identify what types of 
interventions are successful. 

The Institute of Medicine's 2005 report on childhood obesity noted that 
a "robust evidence base" on which interventions have an impact on 
reducing or preventing childhood obesity is not yet available, but 
because of the magnitude of the problem, there is an urgent need to 
take action. [NOTE 15] The Robert Wood Johnson Foundation has funded 
the Institute of Medicine to continue working in this area. 

NOTE: 

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

Surveyed Experts Identified Several Key Program Strategies, Including 
Increasing Physical Activity: 

Experts we surveyed identified several key strategies as important to 
include in programs designed to prevent or reduce childhood obesity. 

* When responses were weighted by importance, increasing physical 
activity was ranked as the most important strategy. [NOTE 16] (See fig. 
3. See enc. IV for additional data.) 

NOTE: 

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

Figure 3: Strategies Identified by Surveyed Experts: 

[See PDF for image] 

Notes: 

Figure is based on weighted data from ranked strategies identified by 
experts. (See ends. III and IV for more information on survey questions 
and respondent data.) 

Source: GAO Survey on Childhood Obesity, May 2005. 

"Other" refers to answers written in by survey respondents in the 
category labeled "other." 

[End of figure]

The second-highest ranked strategy was the "other" category. [NOTE 17] 
The number and variety of write-in responses suggests that, beyond 
physical activity, there is less consensus on which strategies should 
be used to target childhood obesity. 

* Among the various write-in responses, the most common issues listed 
were: 
- Involving parents; [NOTE 18] 
- General nutrition-related initiatives, such as encouraging water 
consumption; 
- Food policy-related initiatives, such as removing high-sugar and high-
fat foods from school vending machines. 

* Experts also wrote in strategies related to: 
- Education; 
- Physical activity-related initiatives, such as requiring physical 
activity in schools at all levels; 
- Altering child-targeted food marketing/advertising. 

The strategy of improving children's nutritional intake was identified 
as third in importance for programs designed to prevent or reduce 
childhood obesity by surveyed experts. 

NOTES: 

[17] "Other" refers to answers written in by survey respondents in the 
category labeled "other." 

[18] By parents, we mean the child's primary care giver. Parental 
involvement includes a range of activities such as promoting physical 
activities for families, improving parent's fitness levels, promoting 
authoritative parenting practices regarding foods choices, and 
educating caregivers on portion sizes. 

Program Officials Identified Several Examples of and Challenges to 
Implementing Experts' Key Strategies: 

Increasing Physical Activity: Examples: 

Several program officials we interviewed identified walking as a means 
of increasing physical activity. 

* At one school, a teacher started an activity to encourage children to 
walk at recess. As an incentive, children were given cards, and a hole 
was punched in the card each time the child completed the school 
walking course. Students could then redeem the punched cards for small 
prizes such as colorful pencils or erasers. Another school walking 
program provided incentives including wrist bands, water bottles, and 
jump ropes to encourage children to walk at least 5 miles a week. 

* One program worked with a community to increase children's physical 
activity by developing a program to encourage children and parents to 
walk to school. This type of program is commonly referred to as a 
"walking school bus." 

* Another program provided pedometers to children and adults to 
encourage walking. In one community involved in this program, this 
effort resulted in an increased resident demand for places to walk, 
which in turn resulted in an increase in the number of local walking 
paths from one to five. 

Increasing Physical Activity: Challenges: 

Program officials reported that existing community and school 
infrastructures may present challenges to increasing physical activity, 
such as no school bicycle racks, no sidewalks, heavy traffic, and 
unsafe neighborhoods. 

Officials also reported that physical education policy, which varies by 
state and local school districts, may also present challenges. Some 
states do not require physical education for children and others lack 
physical education specifications defining its frequency and duration. 

* One program official stated that, while there is a state physical 
education requirement for all schools, schools can receive waivers. In 
addition, many schools do not have physical education teachers or share 
physical education teachers with multiple other schools. 

Improving Nutritional Intake: Examples: 

One program official we interviewed noted that some schools no longer 
involve food in school-sponsored fund raising events. For example, 
students could sell Halloween costumes instead of candy to raise money. 

Another program purchased vending machines that dispense milk-instead 
of sweetened beverages-for placement in schools. That program also 
provided coupons for fresh fruits and vegetables that could be redeemed 
at local grocery stores. 

Another program provided a salad bar with fresh fruits and vegetables 
purchased from local farmers as a daily lunch option. 

Improving Nutritional Intake: Challenges: 

* Program officials from a school-based program noted that children 
received mixed messages, receiving information on healthy lifestyles 
through their program while still being offered unhealthy food in the 
school environment. [NOTE 19] 

* Program officials we interviewed also expressed concern about the 
foods provided through the National School Lunch Program. For example, 
one program official who works for a school district's Food and 
Nutrition Services told us that meats lower in fat should be available. 
Another program official with a school-based program noted that schools 
are not currently reimbursed for bottled water that is served during 
after-school programs, though they can be reimbursed for fruit 
beverages. 

NOTE: 

[19] For additional information on competitive foods and school meals, 
see GAO, School Meal Programs: Competitive Foods Are Available in Many 
Schools; Actions Taken to Restrict Them Differ by State and Locality, 
GAO-04-673 (Washington, D.C. Apr. 23, 2004), GAO, School Lunch Program: 
Efforts Needed to Improve Nutrition and Encourage Healthy Eating, GAO-
03-506 (Washington, D.C. May 9, 2003), and GAO, School Meal Programs: 
Competitive Foods Are Widely Available and Generate Substantial 
Revenues for Schools, GAO-05-563 (Washington, D.C. Aug. 2005). 

One program official told us school district financial staff resisted 
altering the bidding process to allow schools to purchase seasonal 
produce from local farmers. 

Multiple program officials, including a nutrition specialist employed 
by a school district's Food and Nutrition Services, told us that 
preparation of fresh fruits and vegetables is time and labor intensive 
and requires schools to have a kitchen located at the school. 

An individual who helped develop a school-based program identified the 
need to educate food service staff on the preparation of nutritious 
foods. 

One program official said people are often confused by information on 
proper nutrition that seems to change frequently. Because of this, 
increasing physical activity was an easier strategy to sustain. 

Surveyed Experts Identified Several Key Program Elements, Including the 
Use of Best Practices: 

* Experts we surveyed identified several key elements as important to 
include in programs designed to prevent or reduce childhood obesity. 

* The use of best practices[NOTE 20] was ranked as the most important 
element by survey respondents when responses were weighted by 
importance. [NOTE 21] (See fig. 4. See enc. IV for additional data.) 

NOTES: 

[21] The survey defined best practices as new lessons learned about 
effective program activities that have been developed and implemented 
in the field and have been shown to produce positive outcomes. 

[22] When calculated as straight frequencies, the use of best 
practices, outcome evaluation, and sufficient financial resources were 
identified most frequently by survey respondents. 

Figure 4: Key Elements Identified by Surveyed Experts: 

[See PDF for image] 

Source: GAO Survey on Childhood Obesity, May 2005. 

Note: 

Figure is based on weighted data from ranked elements identified by 
experts. (See encs. III and IV for more information on survey questions 
and respondent data.) 

[End of figure] 

Surveyed Experts Varied on How to Measure Outcomes: 

In addition to surveying experts on program elements, we also asked 
them to identify outcome measures that should be used to measure a 
program's ability to prevent or reduce childhood obesity. (See fig. 5.) 
(See enc. IV for additional data.) 

Our survey showed agreement among experts that body mass index (BMI) 
and fitness levels can be used as possible outcome measures. However, a 
large number also selected "other." This suggests that, while there was 
agreement among experts on the importance of using best practices, 
there is a lack of consensus on how best to measure the success of 
programs designed to prevent or reduce childhood obesity. 

Figure 5: Outcome Measures Identified by Surveyed Experts: 

[See PDF for image] 

Source: GAO Survey on Childhood Obesity, May 2005. 

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

[a] Body mass index is an indirect measure of body fat calculated as 
the ratio of a person's body weight in kilograms to the square of a 
person's height in meters. 

[b] "Other" refers to answers written in by survey respondents in the 
category labeled "other." Examples of "other" measures included waist 
circumference, psychological measures (e.g., attitudes, self-esteem), 
and decreased TV viewing. 

[c] Adiposity refers to excessive body fat. 

[d] Biomarkers are anatomic, physiologic, biochemical, or molecular 
parameters associated with the presence and severity of specific 
disease states. For example, biomarkers for obesity could include 
insulin levels. 

[End of figure] 

Selected Programs Identified Several Examples of and Challenges to 
Implementing Experts' Key Elements: 

Use of Best Practices: Examples: 

Officials from one community-based program obtained information from 
initiatives in another state and from an international conference. 
Within their own community, they looked to a program conducted by local 
police to increase children's physical activity and promote 
neighborhood safety. 

Officials from another community-based program drew on information from 
public health programs and a curriculum created by another program. 

Use of Best Practices: Challenges: 

In the absence of best practice models for their targeted population, 
officials from one school-based program reported that they used 
practices from obesity programs targeting other age groups. In 
addition, they used information collected through clinical treatment of 
obese children. The program also drew on theories of health behavior 
and learning to create the framework for the program. 

An official from another school-based program focusing on improving 
children's nutrition told us that, when they started, no best practice 
models that addressed their specific needs were available. Because of 
this, they developed their own model. This program is now 
institutionalized throughout its home school district and has developed 
materials to help others develop similar programs. 

Suitability and Acceptability to Community: Examples: 

One program developed broad programmatic goals, then worked with 
specific communities to develop objectives that targeted the specific 
needs of those communities. 

Another program created multiple versions of its educational materials 
to be sensitive to a community's religious beliefs. 

A school-based program offered pre-made salads and sold them on lunch 
carts so that older students who no longer ate in the cafeteria but 
were still a part of that program's targeted population would 
participate in the program. 

To address cultural and language diversity, two programs translated 
materials into Spanish to reach a broader population. 

Suitability and Acceptability to Community: Challenges: 

* Program officials noted that working within a school system can pose 
challenges because of: 

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

- The need for programs to work within school resource constraints-for 
example, be low cost and require no additional staff. 

- The need for programs to have school administrators' support in order 
to operate. 

Sufficient Human Resources: Examples: 

* To address human resource needs, some program officials told us they 
looked within the program's community to find people to fill key paid 
and volunteer staff positions. 

* One program hired neighborhood residents to help implement the 
program. 

* In a school-based program, parents volunteered to clean and prepare 
the fresh fruits and vegetables served to children. One of these 
parents was later hired to help facilitate the program at a local 
school. 

Sufficient Human Resources: Challenges: 

Some programs identified challenges which, though not specific to 
programs targeting childhood obesity, make it difficult to ensure 
sufficient human resources. 

* Officials from one program stated that staffing instability can 
result from a lack of long-term funding. For example, when paid 
positions are dependent on unstable funding, staff may leave during the 
course of the program to accept more secure jobs. 

* Officials from another program acknowledged the difficulty of 
recruiting volunteers and are trying to work with other organizations 
with similar interests to pool resources. 

Sufficient Financial Resources: Examples: 

Officials told us that for a program to be implemented in a school 
setting, funds often need to be provided to the schools. 

* One program awarded grants to schools to support special projects 
designed to reach program goals, and also provided reimbursement to 
schools for data collection activities needed for the program 
evaluation. Program officials reported that the ability to provide 
these small grants to a community can generate enthusiasm for the 
program in that community. 

* Another program official noted the importance of providing funds for 
teacher training, as well as a small stipend for a program coordinator. 

Officials stated that financial contributions from communities also 
helped provide sufficient resources to support the programs. For 
example, in one community, contributions were used to purchase walkie- 
talkies and handheld traffic signs needed by crosswalk guards for the 
initiative to promote walking to school. 

Another program official stated that it is important to partner with 
organizations in the private sector that will act as "program 
champions." Such advocates can often raise funds needed as a catalyst 
to implement programs. 

Sufficient Financial Resources: Challenges: 

One program official reported that obtaining funding for program 
implementation beyond initial research activities can be difficult. 

The uncertainty of future funding was also identified by officials from 
one program as a challenge to program continuity. Those officials also 
noted that grant funding needs to be flexible and allow for innovation. 

Specified Program Goals and Objectives: Examples: 

Most program officials we spoke with said they developed goals and 
objectives that described program impact or expected changes. For 
example, one program developed the following goal, objective, and 
expected impact: [NOTE 22] 

* Goal-Enhance the well-being of individuals by improving their 
attitudes and behaviors related to food, physical activity, and body 
image, and to build communities' capacity to sustain these changes. 

* Objective-Create educational and promotional materials, including a 
communitywide multimedia campaign, to achieve the program goals. 

* Expected Impact-Positive changes in attitudes toward eating, physical 
activity, and body image. 

NOTE: 

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

Specified Program Goals and Objectives: Challenges: 

Officials from one program stated that it is difficult to attribute 
individual-level change to interventions implemented on a communitywide 
basis. 

Officials from another program noted that measuring the result of 
prevention is also difficult, regardless of whether the intervention is 
at the individual or community level. 

Outcome Evaluation: Examples: 

Program officials we interviewed from one school-based program used a 
randomized control trial design. [NOTE 23] 

* Because this program had been rigorously evaluated, it was selected 
by a private funder for inclusion as part of a larger program and is 
currently being disseminated to other schools. 

Program officials we interviewed at other programs had conducted or 
planned to conduct an outcome evaluation of their programs, using both 
qualitative and quantitative measures. 

NOTE: 

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

Outcome Evaluation: Challenges: 

One program official expressed an interest in conducting an outcome 
evaluation, but was unable to find the human and financial resources 
for such an evaluation. 

Officials from one program told us that measuring changes in outcomes 
for individual children during school can be disruptive and found that 
extensive evaluation can detract from the enthusiasm of participating 
schools and teachers. 

Program officials at a school-based program noted that schools may not 
have the capability or expertise to conduct outcome evaluations. 
However, they noted that schools are better able to conduct process 
evaluations, which provide information on how an intervention is 
implemented. 

Officials from one program noted that, because extensive evaluation is 
costly and labor intensive, once rigorous evaluation of an intervention 
has been conducted, the program should not be asked frequently to 
conduct repeated outcome evaluations. 

Program Officials Also Commented on Possible Federal Roles in Targeting 
Childhood Obesity: 

In addition to asking officials from four programs about the 
implementation of key program elements, we also asked them what they 
considered to be potential roles for the federal government related to 
childhood obesity. 

* Officials from some programs reported that they believe the federal 
government has a role in developing and staffing clearinghouses to 
provide information and materials on programs, and to identify best 
practices gleaned from other programs. [NOTE 24] 

* Officials from one program expressed concern that seeing the effect 
of a community intervention can take 8 to 10 years, and some current 
federal grant structures do not allow time to see a program's effect on 
the targeted population. 

NOTE: 

[24] Some information resources do currently exist, such as Team 
Nutrition, a Department of Agriculture effort that shares information 
on school-based nutrition programs. Action for Healthy Kids and Shaping 
America's Youth, both of which are supported by federal agencies, 
private organizations, and professional associations, also provide 
information on programs targeting childhood obesity. 

Officials from one program told us that the federal government should 
provide communities with information but allow them the flexibility to 
determine what will work in their localities. 

Program officials also noted that they see a role for the federal 
government in regulating children's exposure to food advertising and 
marketing. 

Concluding Observations: 

Our survey indicates that experts consider increasing physical activity 
as a leading strategy for programs aimed at preventing or reducing 
childhood obesity. Nutritional intake was also identified as one of the 
key strategies, though experts ranked strategies that targeted physical 
activity higher than strategies that targeted nutrition. One possible 
explanation for this was offered by a program official who said that 
increasing physical activity was an easier strategy to sustain because 
people were often confused by information on nutritional issues. 

Beyond increasing physical activity, the responses from experts were 
quite varied and covered many different strategies, although some of 
these may have overlapped with other strategy response categories on 
the survey. The number and variety of write-in responses suggests a 
lack of agreement on which strategies are important to include in 
programs addressing childhood obesity. 

With regard to program elements, experts ranked developing best 
practices or evidence-based program models highest-even higher than 
funding support. The need for this element was noted in several ways. 

* Our survey revealed little consensus on how to measure program 
outcomes. We believe this lack of consensus on outcome measures may 
limit the ability to determine best practices. Body mass index was the 
outcome measure most often identified by experts, but an equal number 
of experts offered other measures, such as psychological measures and 
decreased television viewing. 

* Some program officials noted the lack of program models (models in 
general as well as models for specific age groups) as a barrier when 
initially establishing a program. 

Although some information resources exist, some program officials 
suggested that the federal government provide information and materials 
on programs through mechanisms such as the development of a 
clearinghouse and the maintenance of a database on best practices. 

[End of slide presentation] 

[End of section] 

Enclosure II: Scope and Methodology: 

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

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

The survey was sent to 233 experts--the 222 we identified and an 
additional 11 experts to whom the survey was forwarded by the original 
recipients. Of these, 23 declined to participate. In addition, 6 survey 
recipients were excluded because they could not be reached or returned 
unusable surveys. We received 141 completed surveys for a 62 percent 
overall response rate. Of the respondents completing the survey, 57 
were from academia, 36 were from the public sector (federal, state, or 
local government), 25 were from foundations and associations, and 23 
were from the 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.[Footnote 13] 
(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.[Footnote 14] 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.[Footnote 15] 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.[Footnote 16] 
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. 

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. 

[End of section] 

Enclosure III: Survey on Childhood Obesity: 

[See PDF for image] 

[End of figure] 

[End of section] 

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

Table 1: Frequencies and Weighted Frequencies of Each Program Strategy: 

[See PDF for image] 

Source: GAO Survey on Childhood Obesity. 

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

[A] These data include all "other" responses written-in for this 
question. 

[End of table] 

Table 2: Frequencies and Weighted Frequencies of Each Program Element: 

[See PDF for image] 

Source: GAO Survey on Childhood Obesity. 

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

[A] These data include all "other" responses written-in for this 
question. 

[End of table] 

Table 3: Frequencies of Outcome Measures: 

[See PDF for image] 

Source: GAO Survey on Childhood Obesity. 

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

[A] These data include all "other" responses written-in for this 
question. 

[End of table] 

[End of section] 

Enclosure V: Programs Identified by Surveyed Experts: 

In a written survey conducted by GAO, experts were asked to provide the 
names and locations of programs they believe have been successful or 
shown promise in preventing or reducing childhood obesity.[Footnote 17] 
GAO did not independently evaluate the programs listed.[Footnote 18] 

* Action for Healthy Kids, Skokie, Illinois; 
* America On the Move, Boston, Massachusetts; 
* Apache Healthy Stores Project, New Mexico; 
* Balance First, TM Ontario, Canada; 
* Be Active North Carolina; 
* Bienestar, California; 
* Bright Bodies Weight Management, Yale University School of Medicine - 
New Haven, Connecticut; 
* Brocodile the Crocodile, New York; 
* California Project LEAN (Leaders Encouraging Activity and Nutrition); 
* Cardiovascular Health in Children and Youth Study (CHIC), University 
of North Carolina - Chapel Hill, North Carolina; 
* Cartographic Modeling Laboratory, University of Pennsylvania - 
Philadelphia, Pennsylvania; 
* *Childhood Weight Control Program, University of Buffalo - Buffalo, 
New York; 
* Children's Optimal Weight for Life Program, Children's Hospital 
Boston, Massachusetts; 
* Color Me Healthy, North Carolina; 
* Consortium to Lower Obesity in Chicago Children (CLOCC), Illinois; 
* Department of Defense's (DOD) Fresh Produce Program; 
* Department of Education's Carol M. White Physical Education Program; 
* Department of Health and Human Services (HHS) - National Institutes 
of Health's (NIH) Coronary Artery Risk Development in Young Adults 
(CARDIA) study; 
* Eat Well & Keep Moving, Baltimore City Public Schools and Harvard 
School of Public Health - Boston, Massachusetts; 
* Farm Fresh Choice, University of California - Berkeley, California; 
* Farm to Schools Program, Occidental College - Los Angeles, 
California; 
* Fitkid Project, Medical College of Georgia - Augusta, Georgia; 
* FoodChange, New York, New York; 
* Healthy Children Healthy Futures; 
* Healthy Living in the Pacific Islands, Honolulu, Hawaii; 
* Healthy Start; 
* HHS - Centers for Disease Control and Prevention (CDC) School Health 
Index; 
* HHS - CDC's VERB TM; 
* *HHS - NIH's Child and Adolescent Trial for Cardiovascular Health 
(CATCH); 
* HHS - NIH's Girls Health Enrichment Multisite Study (GEMS); 
* HHS - NIH and the National Recreational and Park Association's Hearts 
N' Parks; 
* HHS and Environmental Protection Agency's National Children's Study; 
* HHS's Head Start; 
* HHS's Steps to a HealthierUS; 
* Hip-Hop to Health Program, Chicago, Illinois; 
* Ho-Chunk Community Development Corporation, Walthill, Nebraska; 
* incentaHEALTH Program, Denver, Colorado; 
* Kaiser Permanente's Kid Shape®, Oakland, California; 
* LEAP: The Live, Eat and Play Study, Royal Children's Hospital, 
Melbourne, Australia; 
* M-SPAN (Middle-School Physical Activity and Nutrition), San Diego 
State University, California; 
* New Moves, University of Minnesota - Minneapolis, Minnesota; 
* NikeGO/PE2GO, Beaverton, Oregon; 
* Northwest Schools Obesity Prevention Consortium, University of 
Washington - Seattle, Washington; 
* Nutrition and Physical Activity Self Assessment for Child Care (NAP 
SACC), University of North Carolina - Chapel Hill, North Carolina; 
* Nutrition Education Aimed at Toddlers (NEAT), Michigan State 
University 
- East Lansing, Michigan; 
* Packard Pediatric Weight Control Program, Lucile Packard Children's 
Hospital at Stanford, California; 
* Pathways study, University of New Mexico - Albuquerque, New Mexico; 
* Physical Best Program, Champaign, Illinois; 
* *Planet Health, Harvard Prevention Research Center - Boston, 
Massachusetts; 
* Positive Coaching Alliance, Stanford University, California; 
* *Reducing Television Viewing to Prevent Childhood Obesity study, 
Stanford Prevention Research Center; 
* Shape Up America!; 
* SHAPEDOWN®, University of California - San Francisco, California; 
* SPARK, San Diego, California; 
* Strategies for Metropolitan Atlanta's Regional Transportation and Air 
Quality, Atlanta, Georgia; 
* Student Centered Web-Based Communities: Multi-Disciplinary Approach 
for Adolescent Obesity Prevention, Purdue University - West Lafayette, 
Indiana; 
* TACOS Study, University of Minnesota - Minneapolis, Minnesota; 
* Take 10!,TMAtlanta, Georgia; 
* The California Endowment's Healthy Eating, Active Communities 
Initiative; 
* The Food Trust, Philadelphia, Pennsylvania; 
* The National Black Church Initiative, Washington, D.C.; 
* The Nutrition and Fitness for Life Program, Boston Medical Center, 
Massachusetts; 
* The Robert Wood Johnson Foundation's Active Living by Design/Healthy 
Eating by Design, University of North Carolina - Chapel Hill, North 
Carolina; 
* U Move with the Starzz, University of Utah - Salt Lake City, Utah; 
* U.S. Department of Transportation's Safe Routes to School; 
* United Way, Alexandria, Virginia; 
* Urban Nutrition Initiative (UNI), University of Pennsylvania - 
Philadelphia, Pennsylvania; 
* US Department of Agriculture's (USDA) Breastfeeding Promotion and 
Support; 
* USDA's Community Supported Agriculture; 
* USDA's Eat Smart. Play Hard.TM; 
* USDA's Fit WIC; 
* USDA's Food Stamp Program; 
* USDA's Fruit and Vegetable Pilot Program; 
* USDA's Loving Support Makes Breastfeeding Work; 
* USDA's National School Lunch Program; 
* USDA's Team Nutrition; 
* Weight Management Program, Louisiana State University - Baton Rouge, 
Louisiana; 
* What's for Lunch? program, Brookline, Massachusetts; 
* WIN the Rockies (Wellness IN the Rockies); 
* YMCA Activate America. 

[End of section] 

Enclosure VI: Comments from the Department of Health and Human 
Services: 

DEPARTMENT OF HEALTH & HUMAN SERVICES: 
Office of Inspector General: 
Washington, D.C. 20201: 

SEP 22 2005: 

Ms. Cynthia A. Bascetta: 
Director, Health Care: 
U.S. Government Accountability Office: 
Washington, DC 20548: 

Dear Ms. Bascetta: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO's) draft correspondence entitled, 
"CHILDHOOD OBESITY: Most Experts Identified Physical Activity and the 
Use of Best Practices as Key to Successful Programs" (GAO-05-950R). 
These comments represent the tentative position of the Department and 
are subject to reevaluation when the final version of this report is 
received. 

The Department provided several technical comments directly to your 
staff. 

The Department appreciates the opportunity to comment on this draft 
report before its publication. 

Sincerely, 

Signed by: 

Daniel R. Levinson: 
Inspector General: 

Enclosure: 

The Office of Inspector General (OIG) is transmitting the Department's 
response to this draft report in our capacity as the Department's 
designated focal point and coordinator for U.S. Government 
Accountability Office reports. OIG has not conducted an independent 
assessment of these comments and therefore expresses no opinion on 
them. 

COMMENTS OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ON THE U.S. 
GOVERNMENT ACCOUNTABILITY OFFICE'S DRAFT CORRESPONDENCE ENTITLED, 
"CHILDHOOD OBESITY: MOST EXPERTS IDENTIFIED PHYSICAL ACTIVITY AND THE 
USE OF BEST PRACTICES AS KEY TO SUCCESSFUL PROGRAMS" (GAO-05-950R): 

The Department of Health and Human Services (HHS) appreciates the 
opportunity to review the U.S. Government Accountability Office's 
(GAO's) draft correspondence. Comments focus primarily on concerns 
regarding the survey methodology and the absence of published and 
widely recognized scientific evidence in the findings of the report. 

The draft presents findings that are inconsistent with the 2005 
Institute of Medicine (IOM) report, Preventing Childhood Obesity. IOM 
appointed a 19-member multidisciplinary committee with expertise in 
child health and development, obesity, nutrition, physical activity, 
economics, education, public policy, and public health to address the 
charge. Information was gathered through 6 meetings, a literature 
review, and commissioned papers over a 24-month study period. The major 
findings from this process noted "preventing obesity involves healthful 
eating behaviors and regular physical activity with the goal of 
achieving and maintaining energy balance at a healthy weight." Although 
GAO references the IOM report, the recommendations or findings of IOM 
are not explicitly included in the draft. Because the IOM committee was 
charged with developing a prevention-focused action plan to decrease 
the prevalence of obesity in children and youth in the United States, 
including identifying promising approaches for prevention efforts, this 
seems to be a missed opportunity. 

The finding in the draft regarding physical activity suggests that 
childhood obesity is only a physical inactivity problem; it is not. HHS 
concurs with the IOM report that preventing obesity involves both 
healthful eating behaviors and regular physical activity. Therefore, 
HHS's efforts to address obesity reflect a balanced approach (i.e., 
nutrition and physical activity) to prevent and control childhood 
obesity. Presently, the draft obscures the importance of nutrition in 
preventing obesity. The draft title also suggests that increasing 
physical activity is far more important than any other strategy, and 
the survey data do not support this conclusion. HHS suggests that GAO 
should consider how the categories for the multiple response options in 
the survey were developed and how they may have biased the findings. 
Also, the document does not mention the use of policy as a strategy to 
shape food and physical activity environments. For example, evidence 
shows that marketing affects food choices and influences dietary 
habits, with subsequent implications for weight gain and obesity. 

HHS has other concerns regarding GAO's methodology and conclusions, and 
suggests that analysis of the "other" category could be improved. The 
list of strategies includes one goal and two methods related to 
nutrition; these are all interrelated and may logically be counted 
together in the analysis. The three strategies "improve children's 
nutritional intake," "increase access to nutritious foods," and 
"increase affordability of nutritious foods" are methods to improve 
nutritional intake. If the survey responses for these three strategies 
were grouped, the total number of responses for nutrition would be 
greater than the number for physical activity, whether frequencies or 
weighted frequencies are used. Thus, the survey data do not support the 
draft's strong emphasis on physical activity as far more important than 
nutrition or several other strategies. 

In addition, the fact that this category for program strategies ranked 
number 2 in terms of "consensus" leads to additional concerns about the 
appropriateness of the list of options provided. The survey response 
options included a mix of specific strategies (i.e., breast feeding) 
and general strategies (i.e., increasing physical activity and 
improving children's nutritional intake). The respondents did not have 
the option to select the combination of increasing physical activity 
and having healthy eating habits as a solution. In addition, several 
key strategies were excluded from the list of response options (e.g., 
increasing time children spend in moderate or vigorous physical 
activity, taking physical education classes, increasing intake of 
fruits and vegetables, decreasing portion sizes, altering child- 
targeted food marketing/advertising). Therefore, it could be useful to 
resort the "other" responses into the remaining categories. 

The draft does not indicate to whom the survey was initially sent (only 
the type of organization) nor how the sample was identified. This 
brings into question whether the survey respondents were truly 
representative of most experts. The draft describes how the respondents 
were chosen and states that they were experts in physical activity and 
nutrition; however, the draft does not indicate the background of the 
respondents. HHS suggests that the final product should delineate the 
positions of the 141 respondents used in the analysis (i.e., how many 
were from academia, Government, private sector) and include criteria 
for determining their expertise. This would allow the reader to better 
understand the survey results. 

Despite the fact that the draft stresses the need for evidence-based 
practices, it includes information which may be considered anecdotal, 
such as information from interviews of program officials from the four 
selected programs. Only 4 programs out of the 141 completed surveys 
were considered for the final analysis, which is less than .03 percent 
representation. This substantial limitation may bias the report, and it 
should be included in the final product so that findings can be 
interpreted correctly and used accordingly. 

The draft cites the 1999-2000 data on the prevalence of overweight. HHS 
suggests that GAO use the 1999-2002 prevalence data from the 2004 JAMA 
article: Hedley et al. Prevalence of Overweight and Obesity Among US 
Children, Adolescents, and Adults, 1999-2002. JAM. Jun 
2004;291(23):2847-2850. In addition, the report should describe the 
disparities in overweight prevalence by race/ethnicity as documented in 
the JAMA article. 

Overweight Prevalence Among Youth Ages 12-19, By Sex and Ethnicity, 
1999-2002: 

[See PDF for image] 

[End of table] 

[End of section] 

Enclosure VII: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

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

Acknowledgments: 

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

(290317): 

FOOTNOTES 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[15] We did not include programs that were focused exclusively on media 
or educational campaigns. 

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

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

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