“Healthy Lifestyles to Reduce Obesity” MSS National Service Project 2004 Proposals Introduction: In 2003, obesity became the number one preventable cause of death surpassing tobacco for the first time. 30.5% of American adults and 15% of American youth are obese, with obesity being defined as a body mass index (BMI) ≥ 30. This trend points to possible devastating consequences for our already strained healthcare system. People who are obese have a greater likelihood of developing hypertension, hypercholesterolemia, coronary artery disease, non-insulin dependent diabetes mellitus, stroke, and various cancers. Our youth must be targeted in this campaign. Children who develop healthy lifestyle strategies while they are young tend to go on to live as healthier adults. Obesity is a modifiable lifestyle hazard that affects both sexes and all ethnic groups regardless of economic status. With appropriate intervention, we can make a difference in our individual states. However, we can not begin to solve this problem by targeting children alone. We must also educate our adult population on the importance of a healthy diet and exercise in order to extend their lives. We must teach that some health conditions can be reversed by diet, such as hypertension and non-insulin dependent diabetes mellitus. Our MSS is eager to combat this issue, and to this end, five different proposals have been written by medical students across the country to make us more aware of this problem, and how to work together to create a healthier United States. As you will see, this campaign can be taken to many different arenas…schools, workplaces, and even hospitals are great places to start these projects. There is no population that is immune to this epidemic, and medical students are in a position to make a difference. We have the ability to go out into our communities and educate our future patients on the health risks posed by obesity. Hopefully this module will be of assistance as your chapters begin to do that. The Facts about Obesity As the BMI of the United States increases every year, obesity is no longer an issue we can avoid. We need to target all segments of the population and make an attempt to teach our future patients about the very real dangers of being obese. Here are some facts about obesity in the United States: - Between 16 and 33 percent of children and adolescents are obese. Source: American Academy of Child and Adolescent Psychiatry, AACAP Facts for Families #79 (2004). - If one parent is obese, there is a 50 percent chance that the children will also be obese. However, when both parents are obese, the children have an 80 percent chance of being obese. Source: American Academy of Child and Adolescent Psychiatry, AACAP Facts for Families #79 (2004). - Obesity more than doubles your chance of developing high blood pressure. Source: National Institutes of Health, Third National Health and Nutrition Examination Survey, (NHANES III). - Mexican American and black (non-Hispanic) adults in the U.S. are considerably more overweight and obese than white (non-Hispanic) adults. Source: American Obesity Association, AOA Fact Sheets: Obesity in Minority Populations (2002). - Type 2 diabetes, a condition traditionally associated with middle-aged adults, is beginning to occur several decades earlier as obesity afflicts an ever greater number of children and adolescents in the United States. Source: Pediatrics. 2002 Nov; 110(5):1003-7. Childhood obesity: a new pandemic of the new millennium. (2002). - Overweight and obesity can be a risk factor for diabetes, heart disease, high blood pressure, gallbladder disease, arthritis, breathing problems, and some forms of cancer. Source: National Institutes of Health, Third National Health and Nutrition Examination Survey, (NHANES III). - Approximately 127 million adults in the U.S. are overweight, 60 million obese, and 9 million severely obese. Source: American Obesity Association, AOA Fact Sheets: Obesity in Minority Populations (2002). - The age group with the highest prevalence of overweight and obesity among men is 65 to 74 years, and among women, 55 to 64 years. Source: American Obesity Association, AOA Fact Sheets: Obesity in Minority Populations (2002). - Approximately 30.3 percent of children (ages 6 to 11) are overweight and 15.3 percent are obese. For adolescents (ages 12 to 19), 30.4 percent are overweight and 15.5 percent are obese. Source: American Obesity Association, AOA Fact Sheets: Obesity in Minority Populations (2002). Many of these statistics came from the American Obesity Association web site. It can be found at www.obesity.org. This web site includes fact sheets that can be used when educating patients about obesity. AMA Policy and Funding Obesity has been a focus of various policies within the AMA. Below is a sample of the policy passed by the AMA House of Delegates. D-60.990 Exercise and Healthy Eating for Children Our AMA shall: (1) seek legislation that would require the development and implementation of evidence- based nutrition standards for all food served in K-12 schools irrespective of food vendor or provider; and (2) work with the US Public Health Service and other federal agencies, the Federation, and others in a coordinated campaign to educate the public on the epidemic of childhood obesity and enhance the K-12 curriculum by addressing the benefits of exercise, physical fitness, and healthful diets for children. (Res. 423, A-02) D-150.993 Obesity and Culturally Competent Dietary and Nutritional Guidelines Our AMA and its Minority Affairs Consortium will study and recommend improvements to the US Department of Agriculture‘s Dietary Guidelines for Americans and Food Guide Pyramid so these resources fully incorporate cultural and socioeconomic considerations as well as racial and ethnic health disparity information in order to reduce obesity rates in the minority community, and report its findings and recommendations to the AMA House of Delegates by the 2004 Annual Meeting. (Res. 428, A-03) D-295.990 Nutritional and Dietetic Education for Medical Students Our AMA will: (1) offer to assist the American Society for Clinical Nutrition in meeting its commitment to ensure that medical schools have appropriate faculty role models to teach clinical nutrition; and (2) identify and disseminate to medical schools new instructional initiatives that heighten the relevance of clinical nutrition content to medical practice. (CME Rep. 1, I-99) D-440.980 Recognizing and Taking Action in Response to the Obesity Crisis Our AMA will: (1) collaborate with appropriate agencies and organizations to commission a multidisciplinary task force to review the public health impact of obesity and recommend measures to better recognize and treat obesity as a chronic disease; (2) actively pursue, in collaboration and coordination with programs and activities of appropriate agencies and organizations, the creation of a "National Obesity Awareness Month"; (3) strongly encourage through a media campaign the re- establishment of meaningful physical education programs in primary and secondary education as well as family-oriented education programs on obesity prevention; (4) promote the inclusion of education on obesity prevention and the medical complications of obesity in medical school and appropriate residency curricula; and (5) provide a progress report on the above efforts to the House of Delegates by the 2004 Annual Meeting. (Res. 405, A-03) H-60.979 Physician-Based Physical Activity and Exercise Counseling Protocols for Youth and Adolescents It is the policy of the AMA, in collaboration with appropriate agencies, to assist in the development of physician-based physical activity assessment and counseling protocols for youth and adolescents, including the development of training materials to instruct physicians in the use of these protocols. (Res. 186, I-90; Reaffirmed: Sunset Report, I-00) H-150.953 Obesity as a Major Public Health Program Our AMA will: (1) urge physicians as well as managed care organizations and other third-party payors to recognize obesity as a complex disorder involving appetite regulation and energy metabolism that is associated with a variety of comorbid conditions; (2) work with appropriate federal agencies, medical specialty societies, and public health organizations to educate physicians about the prevention and management of overweight and obesity in children and adults, including education in basic principles and practices of physical activity and nutrition counseling; such training should be included in undergraduate and graduate medical education and through accredited continuing medical education programs; (3) urge federal support of research to determine: (a) the causes and mechanisms of overweight and obesity, including biological, social, and epidemiological influences on weight gain, weight loss, and weight maintenance; (b) the long-term safety and efficacy of voluntary weight maintenance and weight loss practices and therapies, including surgery; (c) effective interventions to prevent obesity in children and adults; and (d) the effectiveness of weight loss counseling by physicians; (4) encourage national efforts to educate the public about the health risks of being overweight and obese and provide information about how to achieve and maintain a preferred healthy weight; (5) urge physicians to assess their patients for overweight and obesity during routine medical examinations and discuss with at-risk patients the health consequences of further weight gain; if treatment is indicated, physicians should encourage and facilitate weight maintenance or reduction efforts in their patients or refer them to a physician with special interest and expertise in the clinical management of obesity; (6) urge all physicians and patients to maintain a desired weight and prevent inappropriate weight gain; (7) encourage physicians to become knowledgeable of community resources and referral services that can assist with the management of overweight and obese patients; and (8) urge the appropriate federal agencies to work with organized medicine and the health insurance industry to develop coding and payment mechanisms for the evaluation and management of obesity. (CSA Rep. 6, A-99) H-150.960 Improving Nutritional Value of Snack Foods Available in Primary and Secondary Schools The AMA supports the position that primary and secondary schools should replace foods in vending machines and snack bars, which are of low nutritional value and are high in fat, salt and/or sugar, with healthier food choices which contribute to the nutritional needs of the students. (Res. 405, A-94) H-150.971 Food Labeling and Advertising Our AMA believes that there is a need for clear, concise and uniform labeling on food products and supports the following aspects of food labeling: (1) Required nutrition labeling for all food products that includes a declaration of carbohydrates, protein, total fat, total saturated and polyunsaturated fatty acids, cholesterol, sodium and potassium content, and number of calories per serving. (2) Use of and/or ingredient labeling to declare the source of fats and oils. Knowledge of the degree of saturation is more important than knowing the source of oils in food products. It is not uncommon for manufacturers to use blends of different oils or to hydrogenate oils to achieve specific functional effects in foods. For example, vegetable oils that are primarily unsaturated may be modified by hydrogenation to more saturated forms that bring about desired taste, texture, or baking characteristics. This recommendation is therefore contingent upon nutrition labeling with saturated fat content. (3) The FDA's proposed rule on food labeling that requires quantitative information be provided on both fatty acid and cholesterol content if either one is declared on the label, as an interim step. (4) Warning statements on food labels are not appropriate for ingredients that have been established as safe for the general population. Moreover, the FDA has not defined descriptors for foods that are relatively higher in calories, sodium, fat, cholesterol, or sugar than other foods because there are no established scientific data indicating the level at which any of these substances or calories would become harmful in an individual food. (5) Our AMA commends the FTC for its past and current efforts and encourages the Commission to monitor misleading food advertising claims more closely, particularly those related to low sodium or cholesterol, and health claims. (6) Our AMA supports the timely approval of the Food and Drug Administration‘s proposed amendment of its regulations on nutrition labeling to require that the amount of trans fatty acids present in a food be included in the amount and percent daily value, and that definitions for "trans fat free" and "reduced trans fat" be set. (BOT Rep. C, A-90; Reaffirmed: Sunset Report, I-00; Appended: Res. 501, A-02) H-150.996 Nutrition Courses in Medicine Our AMA recommends the teaching of adequate nutrition courses in elementary and high schools and that the LCME work toward enhancement of the teaching of nutrition in medical schools. (Sub. Res. 66, I- 77; Reaffirmed: CLRPD Rep. C, A-89; Reaffirmed: Sunset Report, A-00) H-170.984 Healthy Living Behaviors Our AMA encourages all state medical associations to become involved in the promotion of healthy living behaviors for children and youth through quality physical and wellness activities, and encourages all physicians to provide advocacy by working with parents, schools and community organizations to develop programs and services for the children and youth population. (Res. 129, I-89) H-170.999 Health Instruction and Physical Education in Schools The AMA reaffirms its long-standing and fundamental belief that health education should be an integral and basic part of school and college curriculums, and encourages state and local medical societies to work with the appropriate health education officers and agencies in their communities to achieve this end. (BOT Res., A-60; Reaffirmed: CLRPD Rep. C, A-88; Reaffirmed: Sunset Report, I-98) H-425.994 Medical Evaluations of Healthy Persons The AMA supports the following principles of healthful living and proper medical care: (1) The periodic evaluation of healthy individuals is important for the early detection of disease and for the recognition and correction of certain risk factors that may presage disease. (2) The optimal frequency of the periodic evaluation and the procedures to be performed vary with the patient's age, socioeconomic status, heredity, and other individual factors. Nevertheless, the evaluation of a healthy person by a physician can serve as a convenient reference point for preventive services and for counseling about healthful living and known risk factors. (3) These recommendations should be modified as appropriate in terms of each person's age, sex, occupation and other characteristics. All recommendations are subject to modification, depending upon factors such as the sensitivity and specificity of available tests and the prevalence of the diseases being sought in the particular population group from which the person comes. (4) The testing of individuals and of population groups should be pursued only when adequate treatment and follow-up can be arranged for the abnormal conditions and risk factors that are identified. (5) Physicians need to improve their skills in fostering patients' good health, and in dealing with long recognized problems such as hypertension, obesity, anxiety and depression, to which could be added the excessive use of alcohol, tobacco and drugs. (6) Continued investigation is required to determine the usefulness of test procedures that may be of value in detecting disease among asymptomatic populations. (CSA Rep. D, A-82; Reaffirmed: CLRPD Rep. A, I-92; Reaffirmed: CSA Rep. 8, A-03) H-440.902 Obesity as a Major Health Concern The AMA: (1) recognizes obesity in children and adults as a major public health problem; (2) will study the medical, psychological and socioeconomic issues associated with obesity, including reimbursement for evaluation and management of obese patients; and (3) will work with other professional medical organizations, and other public and private organizations to develop evidence-based recommendations regarding education, prevention, and treatment of obesity. (Res. 423, A-98) H-470.990 Promotion of Exercise within Medicine and Society Our AMA supports (1) education of the profession on exercise, including instruction on the role of exercise prescription in medical practice in its continuing education courses and conferences, whenever feasible and appropriate; (2) medical student instruction on the prescription of exercise; (3) physical education instruction in the school system; and (4) education of the public on the benefits of exercise, through its public relations program. (Res. 56, I-78; Reaffirmed: CLRPD Rep. C, A-89; Reaffirmation I-98) H-470.991 Promotion of Exercise Our AMA: (1) supports the promotion of exercise, particularly exercise of significant cardiovascular benefit; and (2) encourages physicians to prescribe exercise to their patients and to shape programs to meet each patient's capabilities and level of interest. (Res. 83, parts 1 and 2, I-77; Reaffirmed: CLRPD Rep. C, A-89; Reaffirmed: Sunset Report, A-00) H-470.997 Exercise and Physical Fitness The AMA encourages all physicians to utilize the health potentialities of exercise for their patients as a most important part of health promotion and rehabilitation, and urges state and local medical societies to emphasize through all available channels the need for physical activity for all age groups and both sexes. Other organizations and agencies concerned with the health of the public should be informed of the interest, support and activities of the AMA in this area and should be encouraged to join with the Association in promoting physical fitness through all appropriate means. (BOT Rep. K, A-66; Reaffirmed: CLRPD Rep. C, A-88; Reaffirmed: Sunset Report, I-98) Project Ideas Obesity is becoming a central issue in the United States because of the health impact it is causing. Six proposals were written that could be used as an excellent start for projects in your chapters. Trimming the Fat off Childhood Obesity AMA-Community Service Committee members Vision To educate children about the dangers of obesity, inactivity, and poor eating habits in hopes of curtailing the risking epidemic of childhood obesity. Specifically, the program will aim to increase awareness of this condition and the associated sequelae, improve the nutritional-value of foods at school, promote the health of children, encourage more physical activity in children, and educate parents, children, and community about the benefits of a healthy lifestyle. Program Information rd th The proposed program will focus on 3 -6 graders and is meant to be a guideline for chapters to use when presenting to children. The idea behind the program is to make children aware of the dangers of obesity and also to make it fun. The first part will discuss the factors that lead to obesity such as watching TV, playing video games, eating fast food, and not being active. The group will try to make it interactive for the students. Ideas include having the children list reasons why the above activities are not healthy, ―gross out‖ type information about the content of fast food, or use models such as a heart and show how and where obesity will damage it. Another option is to create a game with where the children will answer questions about obesity. The second part of the program will consist of each child drawing a picture or creating a list of steps the child will take to prevent him or her from becoming obese. While the children are drawing, the presenting students will spend time with each child and talk with him or her individually and help them think of ideas. The child will sign this picture/list and take it home along with a letter to the parents talking about what their child learned about obesity. The letter will serve as a ―pledge‖ that the child takes to start living healthier. Also, the medical students could have any child who wants to present their picture to the class. Medical and Community Involvement In an attempt to raise awareness in the local community, students would make contact with the medical societies, school boards, and health care facilities and examine more methods fight childhood obesity. Possible ideas include working to improve playgrounds and parks to facilitate their use, helping children select healthier foods on their own in school, setting up an exchange of athletic equipment for video games, provide an after school aerobics class for children, and recognize and promote schools that institute programs regarding the ideals of healthy children. Timeline 1. Beginning of the school year - Hold AMA-MSS chapter meeting to determine interest level amongst medical students. Delegate responsibilities such as who is in charge of contacting schools, gathering models/posters, and searching statistics relevant to the local community. 2. 2 months prior - Contact and schedule dates with local schools and after-school programs to see if they would be interested in the program. 3. 1-month prior - Obtain necessary materials including the heart models, the letter to the parents, and any necessary items for the children‘s drawings. Also, delegate which student will present each section. Possible contact media outlets to provide coverage of the event. 4. Day of – Have fun and be sure to leave materials for the teachers and parents. 5. 2-4 months after – follow up with the school and see how the children are doing. Highlight the progress in local medical society newsletters, local papers, or school bulletins. Contact Information For more information, contact any of the authors Clay Cessna email@example.com, Holli White firstname.lastname@example.org, and Rick Patch email@example.com. AMA-MSS and Fitness Forward: FitMD>>FitKidz Jason Langheier and Alison Troy, Duke Medical School AMA-MSS Summary Changes in the American lifestyle over the last 30 years have created an epidemic of overweight and obesity, and rising mental health problems, among adults, and now youth. Healthy People 2010 states a need for reducing overweight and obesity, mental health problems, health disparities and increasing physical activity. Facilitating healthy lifestyles amongst youth can contribute to all of those goals; an AMA- MSS wide service project on this topic could help dramatically reduce the obesity epidemic in children and future adults. The primary ―Wellness Targets‖ are to ―Be Active, Eat Smart, Sleep Well, Don‘t Stress and Be Aware.‖ In order to facilitate such behaviors, we can translate and communicate the latest scientific information about healthy eating, physical activity and sleep via numerous channels, including schools, primary care clinics and even local businesses, such as grocery stores. We will provide electronic tools to facilitate the creation of community-specific directories for physical activity (i.e. parks, gyms, etc.) and healthy eating (restaurants, shopping list guides) by local MSS chapters. Youth, parents, and physicians will be able to access this information electronically, via booklets chapters may produce, or via personalized recommendation software known as FitNet. In addition, we hope to expand opportunities for physical activity by having medical students and pre-medical students they mentor, to teach children at primary care clinics about ―Fitness Anywhere‖ opportunities, such as jump roping and ‗PediAerobics,‘ using information booklets. Finally, we hope to pay head to motivate youth and their parents to take advantage of healthy lifestyles opportunities we explain to them, by encouraging them to earn Drive to Fitness points and certificates in classrooms, similar to the stars for reading approach. At Duke, we are working in 27 elementary schools in the fall and co-branding the effort with Coach K and the basketball team; nationally, we hope to facilitate a partnership with the NCAA or see local customization of co-branding by MSS chapters, for optimal motivation of kids. Goals of the Project: 1. Educate patients and parents about the benefits of a physically active lifestyle (‗Be Active‘), healthy eating (‗Eat Smart‘), good sleep (‗Sleep Well‘), stress management (‗Don‘t Stress‘) and general health awareness (‗Be Aware‘), in order to primarily address the problem of pediatric obesity (www.fitnessforward.org). 2. Provide the instruction and, in some cases, low-cost equipment for enjoyable physical activity that can be conducted anywhere. 3. Motivate patients to maintain a regular schedule of physical activity and to take responsibility for their well-being. 4. Engage medical students in the promotion of healthy lifestyles to their patients and the community throughout their career, by helping them learn how to integrate healthy habits into their own life in spite of the stressful nature of medical school and the profession. 5. Provide medical students with the opportunity to positively impact patient healthcare during their education and to interact with primary care physicians in a clinic setting. 6. Continue to provide basic anti-smoking information alongside physical activity and healthy nutrition information, when cost-effective. The Need For Healthy Lifestyles Amongst Youth The Social Need: The need for guidance on healthy living is larger than ever. The Centers for Disease Control (CDC) has stated that seven out of ten deaths are ‗preventable‘ and that the current epidemic of overweight and obesity may reverse the gains in cardiovascular disease achieved by modern medical therapy. The Surgeon General‘s Healthy People 2010 outlines the most critical health indicators and goals for improving on them. Of those indicators, we hope to primarily address 1) Overweight and Obesity and 2) Lack of Physical Activity. In the process of promoting healthy lifestyles in youth, we also hope to have positive effects on 3) Mental Health and to decrease 4) Health Disparities amongst minorities and the economically disadvantaged. Overweight and Obesity: According to the National Health Examination Survey (NHANES), about 64% of adults (aged 20-74) in the U.S. over 20 years old are overweight (Body Mass Index, or BMI ≥ 25). Over 30% are obese (BMI ≥ 30). That‘s 39 million Americans, twice the amount that were obese in 1980. The rise in overweight and obesity has been dramatic (Table 1: Rise in Adult Overweight and Obesity in the U.S.) and primarily the result of increased consumption of sugar-sweetened foods and beverages, high-fat fast-food, snack-foods, decreased physical activity, stress and sleep issues, according to numerous public health studies. Minorities are disproportionately affected, with nearly 80% of African- American women in the US being overweight or obese (Table 2: Rise in Overweight Prevalence by Racial/Ethnic Group and Gender). Furthermore, women of lower socioeconomic status (income ≤ 130 percent of poverty threshold) are almost 50% more likely be obese than women with higher incomes than them; non-Hispanic white teens from lower income families also have a greater prevalence of overweight than higher-income families. The most recent cost studies suggest that obesity accounted for 5.7% of healthcare expenditures, nearly as much as smoking, with a price tag of $75 billion. Over half of that was paid by taxpayers, in the form of $39 billion spent on obesity-related illness by Medicaid and Medicare. Previous year 2000 estimates accounting for worker productivity had put the total cost at $117 billion ($61 direct healthcare costs, $56 billion indirect costs due to lost wages). Indeed, the number of 30-49 year olds who could not do routine tasks or take care of themselves (‗disabled‘) rose by more than half from 1984 to 2000. The top disablers were mental health issues (discussed below) and problems linked to obesity, such as musculoskeletal pain. Table 1: Rise in Adult Overweight and Obesity in the U.S. NHANES II NHANES III (1988- NHANES 1999- (1976-80) 94) 2000 (n=11,207) (n=14,468) (n=3,601) Overweight or obese 47 56 64 (BMI ≥ 25) Obese (BMI ≥ 30) 15 23 31 Table 2: Rise in Overweight Prevalence by Racial/Ethnic Group and Gender Men Prevalence (%) Women Prevalence (%) Racial / Ethnic 1988- 1999 - 1999 to 1988 -1994 Group 1994 2000 2000 Black (non- 58.2 60.1 68.5 78 Hispanic) Mexican American 69.4 74.4 69.6 71.8 White (non-Hispanic) 61.6 67.5 47.2 57.5 Worse than the cost is that obesity increases the risk of death by 50-100%, and kills an estimated 300,000 people per year. A weight gain of 11-18 pounds doubles the risk of type 2 diabetes; indeed, 80% of diabetics are overweight. Diabetes in turn increases risk of heart disease 2-4 times. In fact, overweight, metabolic syndrome and obesity greatly increase the risk for numerous deadly diseases in addition to diabetes, hypertension, high cholesterol and heart disease; they include stroke, many types of cancer, sleep apnea, breathing problems, menstrual irregularities, pregnancy complications, surgical risk, stress incontinence, psychological disorders and more, as summarized by the Surgeon General‘s Call to Action on Obesity in 2001, and supplemented by additional research in the Fitness Forward disease pyramid, showing that obesity confers higher risk for almost every disease among the top ten killers in the U.S. (Figure 1: Cascade of top diseases in the US, www.fitnessforward.org/obesity links go to scientific explanations). Figure 1: Cascade of top diseases in the US The most unfortunate victims of the rapid changes that have decreased healthy living are children. From 1963-1974, only 4% of 6-11 year old Americans were overweight; by 1999-2000 that figure had more than tripled to 15%. In total, about 1 in 3 children are now either overweight (euphemism for childhood th th obesity- above the 95 percentile BMI for age and sex) or at risk for overweight (above the 85 percentile BMI for age and sex). A disturbing fact states that children ages 5-11 in North Carolina have shown a 40% rise in being overweight from 1995-2000 alone, suggesting that obesity related illness and death will only continue to increase with future generations unless society and medicine alter their strategies to educate and empower its youth to be more fit. Given the current prevalence of overweight, perhaps it is no surprise that 75% of Americans do not exercise, including 35% of all high school students. This decline in physical activity (especially in girls), physical education and poor sleeping habits relative to an increase in sedentary activities such as TV watching and video gaming, along with an increase in the accessibility (heavy marketing, ubiquitous distribution and low-cost) and consumption of high portion, energy-dense fast foods, processed snack foods and sugar-sweetened beverages and poor cooking habits among some ethnicities, have been shown to be among the primary drivers of the dangerous rise in youth and adult BMIs. As alluded to earlier, socioeconomic barriers contribute to lack of education about overweight health risks and healthy behaviors, and often preclude the buying of healthier foods and safe membership or equipment for physical activity and entertainment; these reasons contribute to why we see higher rates of overweight in lower-income families and recent immigrants. As an example, this increased prevalence of obesity is seen in many transition homes for foster children in North and South Carolina, where a full 25% of children are overweight, and in Haitian children in Boston, MA, 37% of which are overweight. Given the rising childhood rates, and the difficulty of correcting obesity in adults with lower metabolic rates and more sedentary lifestyles (90% percent of those that lose weight through diets gain it back), addressing the problem aggressively in our youth is not only critical but perhaps the most efficient strategy to ultimately ending the epidemic. Weight status in youth is also correlated with weight status in adulthood. The lifestyle we learn in our youth is most often the one we maintain throughout the rest of our lives. Maintenance of a healthy BMI is primarily determined by a ‗simple‘ equation of healthy growth plus output (physical activity, thermogenesis, brain activity) equal to input (caloric intake). For most of those who are already overweight, consistently eating less and being more physically active will decrease weight; creating permanent lifestyle improvements, and readjusting diet and exercise for growth will help maintain a healthy weight. Due to the numerous positive benefits associate with physical activity, recommendations state that children and adults should strive for at least 30 minutes daily of moderate intensity physical activity. An alternate approach that may be equally beneficial would be to engage in 10-minute bouts of moderate intensity activity throughout the day, for a total accumulation of at least 30 minutes for adolescents and adults and 60 minutes for children. Walking briskly or biking for pleasure or transportation, swimming, engaging in sports and games, participating in physical education, and doing tasks in the home and garden may all contribute to accumulated physical activity. Use of pedometers for the 10,000 steps/ day program in adults has shown some success. But achieving daily physical activity recommended amounts is often prevented by a lack of physical education time in schools, dangerous neighborhoods and cold winter conditions. Since pediatric overweight has only recently been highlighted as a severe public health problem, the CDC standard of using BMI for the screening and diagnosis of overweight is not yet regularly followed, with only 12.5% of pediatricians, 13.3% of PNPs and 19.9% of RDs using BMI percentile as a screening tool; 82.1% of pediatricians just use their ―clinical impression.‖ Because of the lack of tradition, long-standing recommendations and financial motivation, not enough providers are addressing childhood overweight head-on via facilitative prescriptions or referrals beyond general advice. Nationally, only 25% of pediatricians refer overweight children to such specialized weight programs (i.e. Nutrition and Fitness for Life, Shapedown), 12% to pediatric obesity specialist, 10% to pediatric subspecialists, 7% to exercise specialists, 6% to self-help programs and 4% to camps (non mutually-exclusive categories). Furthermore, providers are often not even good role models for children to lose weight, with over 1/3 of pediatricians (over ½ among males) and PNPs being overweight (BMI over 25) in another survey conducted by the CDC. Yet, it‘s not that providers don‘t recognize the problem; over 75% of pediatricians, PNPs and RDs understand the need for treatment of overweight youth. And, it‘s not that they don‘t believe they offer some effectively-delivered specific advice; the majority self-report that they do a good job of recommending changes in eating patterns and limitations of certain foods often. The problem is that they don‘t do enough to actually facilitate a change, as a provider would when a child has an ear infection, and they prescribe an effective antibiotic. In order to contain the obesity/ overweight epidemic, the problem must be addressed through community education and in-clinic facilitation, through primary care screening, prevention and treatment that is standardized and goes beyond brief warnings and educational pamphlets—without breaking the bank. Addressing overweight could not only improve the health of numerous individuals, it could also improve the financial health, of healthcare itself. Although little research on treating childhood obesity has been conducted, studies at the University of Pittsburgh shows that interventions which promote physical activity and healthy eating can lead to a 9% reduction in weight for adults. When applied to an obese population distribution, this amount of weight loss would lead to a 44% decrease of obesity (note: this model does not account for the healthcare cost of those that are overweight, yet not obese; it also uses an adult distribution for obesity). Since the 2003 cost of obesity was estimated at $75 billion, if the entire U.S. were to gradually increase adoption of AMA-MSS Service Project Fitness Forward interventions over 10 years, we would expect over a $1 billion dollar savings on the cost of obesity, for those 10 years. For just North Carolina and Massachusetts, the present value would be over $37 million dollars. This model uses Behavioral Risk Factor Surveillance System (BRFSS) data, which is conveniently broken into states (calculations for other states available on request). BRFSS is based on self-reported figures, which underestimate the incidence of obesity. Very approximately, given different BMI parameters for children and use of NHANES rather than BRFSS data, savings on obesity in youth would amount to over $171 million. At the very least, this model ( Table 3: Value of Fitness Forward at Reducing Obesity Over 10 Years) displays that gradually adopted and effective obesity interventions can drastically decrease obesity rates over time, and create a great deal of value for society. In the case of FitNet and the Drive to Fitness, clinical studies will be carried out to verify the effectiveness of these combined interventions in treating and preventing weight loss. Fortunately, it is already known that basic nutrition and physical activity education prevents excessive weight gain over 6 months, and jump roping and other physical activities improve youth self-esteem. Furthermore, the positive effect of Fitness Forward in preventing and treating mental illness is not accounted for in this analysis, due to the lack of a large enough number of studies to justify specific treatment effects. Nonetheless, given the relationship of mental illness to obesity and lack of physical activity, it is likely that an AMA Fitness Forward Service Project would create additional social value beyond addressing overweight and obesity. Table 3: Value of Fitness Forward at Reducing Obesity Over 10 Years 10th yr 10-year Present Obese reduction 2001 reductio Value of 10- Population populati Obese spend / in Category Obesity n in # of year (000s) on year ($000s) obesity Rate % obese benefits (000s) spend (000s) ($000s) ($000s) US 288,369 20.9 60,312 75,000,000 635 165,226 1,003,587 MA 6,428 16.1 1,035 1,286,913 14 2,835 9,055 NC 8,320 22.4 1,864 2,317,607 18 5,106 28,081 All Youth 5-19 80,261 15.0 12,039 12,663,813 177 27,899 171,425 Additional Assumptions: 10% discount rate; 5% of obese people will use FitNet; 10% will make permanent lifestyle changes Mental Health: It has been estimated that about 21% of U.S. adults have mental health problems, a figure which climbs near 30% when also considering addictive disorders. About 16.4% have anxiety disorders and 7.1% have mood disorders, including major depression, bipolar disorder, schizophrenia, anorexia nervosa and major cognitive impairments. As an example of a poor city, Durham, North Carolina residents report 7 days per month of poor mental health, compared to only 3 nationally. In Durham, about 44% of the poor, and 34% with only a high school education or less report depression, compared to 19% overall. Durham residents appear in state psychiatric wards twice as often as the rest of North Carolina‘s population. Perhaps most concerning is that about 21% of US children are now also estimated to have mental disorders with at least some functional impairment ( Table 4: Youth Mental and Addictive Disorders). Sadly, approximately 5-9% of children ages 9 to 17 are classified as having serious emotional disturbance (SED). Some children do overcome their mental illnesses, while others develop mental problems as adults. Table 4: Youth Mental and Addictive Disorders Ages 9 to Prevalence 17 (%) Anxiety 13.0 disorders Mood 6.2 disorders Disruptive 10.3 disorders Substance 2.0 abuse Any disorder 20.9 At any one time, 10-15% of children show signs of depression, with about 5% of 9-17 year olds having the full diagnosis of major depression. One-year prevalence rates peak in adolescence at about 8.3%, compared to 0.4-2.5% in children, and 5.3% in adults. Suicide is the third most common cause of death in youth, claiming the lives of 1.6, 9.5 and 13.6 youth per 100,000, for ages 10-14, 15-19 and 20-24, respectively. Today, the suicide rate in 15-19 year old males is three times higher than it was in the early 1960s, elevating suicide as the second most common cause of death in this age bracket. Suicide disproportionately effects minorities; from 1980- 1997, the incidence of suicide in black males increased 161%. Some studies have suggested that firearm availability is the cause of increased suicide, but, rates have similarly spiked in other modernized nations where firearm deaths are rare, leaving some to believe that it is not the method, but the cause for wanting to die, that is on the rise. In total, 60% of high school children report some suicidal ideation. In Durham Public Schools, there has been a 48% increase in children with emotional handicaps since 1994, as well as a 48% increases in suicides. Another disturbing trend in the mental health of children is the way in which it is diagnosed and treated, as displayed by the example of attention-deficit hyperactivity disorder (ADHD). In the U.S., ADHD is the most commonly diagnosed behavioral disorder of childhood at a 6-month prevalence of 5%; it exists in other cultures, but, with different prevalences. Increased rates in the U.S. are thought to be due in part to more inclusive diagnostic criteria. Furthermore, it has been suggested that the majority of diagnoses of ADHD are made in U.S. children who meet only some of the necessary criteria to be considered to have the disorder, helping triple pharmacological treatment among preschool children from 1990-1995, as well as drug-treatment increases of 170% for 5-14 year olds and 311% for 15-19 year olds in the last 15 \ years. Stimulants are the most common and efficacious drug therapy used for youth diagnosed with ADHD, although the long-term effects of none of the drug categories have been fully determined. The 5 Wellness Targets: On the surface, addressing obesity and lack of physical activity, with parallel improvements in mental health and health disparities, seems overwhelming. However, rather than focusing the mission of the National Service Project on a singular negative, i.e. the problem of obesity, the mission of Fitness Forward project focuses on positive behaviors which can prevent or improve multiple conditions: Lead Youth to Live Well. Addressing 5 major ―Wellness Targets‖ (Be Active, Eat Smart, Sleep Well, Don‘t Stress, Be Aware- drugs and accidents), which all link to help address the Healthy People 2010 problems discussed above, requires similar marketing and behavior change methods. Furthermore, to solve problems like obesity and depression, increased physical activity, healthy nutrition and other wellness messages should be delivered in an integrated fashion, in order to effectively resolve those problems in the long-term. Finally, the health indicators of overweight and obesity, lack of physical activity, mental health problems and health disparities are highly correlated with one another. Lack of physical activity contributes to overweight and obesity, which can also be both a cause and effect of mental health problems. Furthermore, as shown in the earlier statistics, minorities and low-income populations are at significantly higher risk for obesity and mental health problems, and thus the other problems these conditions promote Increasing physical activity (Be Active) is itself a goal of Healthy People 2010, because epidemiology and scientific studies show that it can prevent and treat overweight via caloric expenditure, and thus decrease the risk for the top killers caused by stress, overweight, disordered eating and high cholesterol high blood pressure, such as heart disease, stroke, diabetes and cancer (Figure 1: Cascade of top diseases in the US). Regular physical activity can also prevent mental illnesses including depression and anxiety, and is as effective as pharmaceutical therapies at treating depression in certain patients (www.fitnessforward.org/wellnesstargets/beactive.htm). Healthy nutrition is a complex topic, but studies have shown that a well-balanced diet also can prevent overweight due to limits on caloric consumption and hunger, thus decreasing the risk for top killers such as heart disease, stroke, diabetes and cancer. Healthy eating habits and nutrition can also improve academic and athletic performance, and mental health, decreasing feelings of depression (www.fitnessforward.org/wellnesstargets/eatsmart.htm). More recent studies from a respected member of our scientific advisory board, Walter Willett, M.D. (Chair of Nutrition, Harvard School of Public Health), echoes the sentiment of government recommendations of balance, but suggest refinements to the USDA Food Guide Pyramid that distinguish between healthy and unhealthy fat, carbohydrate and protein sources (www.hsph.harvard.edu/nutritionsource/pyramids.html). Dr. Willett has agreed to be an advisor for our effort, if AMA-MSS selects this as our National Service Project. The health importance of sleep has been seemingly underappreciated by the public and medicine, including by physicians themselves, until recently. Now studies show that disordered sleep and sleep deprivation can cause metabolic dysfunction, increasing risk for overweight and diabetes. Studies are now beginning to show that poor sleep can lead to an increase in risk for heart disease, and certainly specific sleep disorders such as sleep apnea greatly increase risk for heart disease, brain damage and daytime accidents. Finally, while most people are very familiar with the mental effects of major sleep deprivation or disordered sleep, most people also neglect the significant effects of chronic, low-grade sleep deprivation. It can increase risk for depression, trigger mania in those with bipolar disorder, is the most common reason for misdiagnosis of ADHD in children, significantly dampens awareness and increases risk for accidents and injury, and prevents proper memory consolidation (http://www.fitnessforward.org/wellnesstargets/sleepwell.htm). Minimizing stress requires planning, and can be difficult in the modern American society. However, among the best ways to minimize stress, are to prescribe to the first three Wellness Targets. Consistent, well-balanced physical activity, nutrition and sleep are among the best ways to ward off stress; this is why these are the core focus of initiatives such as the Coach K Drive to Fitness. Additional activities and relaxation techniques such as meditation are also useful supplements to stay well in a society where people‘s senses are now bombarded with unprecedented levels of sensory stimulation, information and indirect forms of communication with others (www.fitnessforward.org/wellnesstargets/dontstress.htm). Being Aware is a broad, but much needed Wellness Target, aimed at helping people be cognizant of near-term dangers in their environment in general, and as they are engaged in physical activity and social situations. In promoting more physical activity, it is important to promote safety in parallel. In promoting weight control, it is important to warn against the dangers of anorexia and bulimia, also. Fortunately, once again, adhering to the first 3 Wellness Targets (Be Active, Eat Smart, Sleep Well) aids in the achievement of this Wellness Target, by greatly reducing the risk of youth becoming involved in accidents, engaging unsafe sexual practices or addicted to drugs. While we do not aim to focus on traffic accidents, sexual health or recreational drug use, we would like to direct youth to already available information on healthy practices on these critical health topics, with a particular emphasis on smoking prevention (www.fitnessforward.org/wellnesstargets/beaware.htm). Indeed, the AMA-MSS National Service Project to decrease smoking amongst youth has helped fill a critical public health need, and ceasing all emphasis on it would be unfortunate. We found in our North Carolina medical schools State Fair program that it is easy to disseminate information regarding overweight, physical activity and balanced diet, alongside anti- tobacco education. Framework for Change The social need to resolve the problems indicated earlier, are great, and taking a positive approach to promoting wellness behaviors in young people is perhaps the most productive approach to fighting the obesity epidemic and achieving related Healthy People 2010 goals. Public health changes have 4 main components. The first is the science that drives Discovery of public health problems—from bacteria in contaminated water supplies, to high sugar consumption correlating to an increase in obesity prevalence in children. The second is creating Opportunities to facilitate preventing the problem via healthy lifestyles—be it usage of sewers and toilets to protect water supplies or the creation of physical activity programs that can be performed within a unique individual‘s seemingly constraining environment. The third is a recognition that people come from all different starting points, genetically and environmentally, and have different contexts in which they can make the Choice to undertake healthy living (―DOC‖). Just as in motivating purchase behaviors with product marketing, youth can be motivated first externally, and then internally, to live well, as shown with the ―No Butts…‖ National Service Project. The final component is the glue that holds the other three together—comprehensible Information, Communication and Education (―ICE‖). It is here where we are concentrating our main initial efforts at Duke and in North Carolina, through marketing, information technology and personalization techniques, that connect youth at Medical Schools, to patients in primary care clinics and youth in elementary and middle schools, to opportunities and motivational programs for healthy living, and one another. As with the previous National Service Project, it will be beneficial for medical students to work via many channels and media, but begin with a narrow focus before expanding, to ensure early success plus faculty and community buy-in. Eventually, we want to provide and further develop materials not only for use in schools, primary clinics, and family homes, but also grocery stores and other community venues, should the AMA-MSS House choose healthy lifestyles promotion and childhood overweight as its National Service Project. Various interconnected programs that could be implemented for the National Service Project align with the ―ICE- DOC‖ model (Figure 2: ICE-DOC Approach to Public Health Improvement) Discovery Scientific evidence that Information/ being physically active, Communication/ eating a healthy, balanced diet, sleeping well, Education minimizing stress and being aware of dangers such as drugs and accidents must be relayed to policy makers, physicians, families and Opportunities youth Help youth and families learn ways to be physically active in any setting with FitJUMP!, PediAerobics, after school basketball with medical student coaches, etc. Use FitNet Information/ directory approach to help youth find safe, affordable opportunities for activity and healthy eating, close to home. Communication/ Education Choice Motivate youth, teachers, families and physicians with co-branded “Drive to Fitness” programs (i.e. Coach K for Durham, NC; potentially with NCAA for other US cities) Figure 2: ICE-DOC Approach to Public Health Improvement Ultimately, each AMA-MSS chapter and medical school needs to customize initiatives to best meet the needs of their community. We hope that the description of these programs will provide some guidance in creating a high-impact and sustainable initiative to facilitate healthy lifestyles in youth. First, in order to tailor efforts to different communities, some research must be done about ongoing programs and available outlets for physical activity, and, ideally health eating. We will provide the web- based infrastructure and back-end database tools which will allow medical students and other volunteers to enter, store and easily access information specifically about their community, such as fitness venues, locations, hours of operation, membership fees, age restrictions, trail guides, etc… (FitNet Directory). Each MSS chapter will then have the option to use the database they have created as a simple searchable directory which can also be printed as booklets for parents, physicians, teachers and/or old enough youth. Alternatively, MSS chapters may choose to use FitNet‘s online personalized lifestyle planning tools. This will allow youth and parents to securely enter fitness and eating preferences, schedules, other restriction and/or budget information, and will generate a personalized healthy lifestyle calendar, maps, directions, food shopping list and more. The tool is being upgraded to be attractive for use by children, without requiring extensive time periods sitting in front of a computer. Regardless of which option is used, community-specific directories of opportunities for healthy living are much needed resources that parents and physicians seek and can rarely find. Children often want to be more active, but are pushed into activities or eating foods they do not like do to poor communication, deterring them from living healthy. Furthermore, cold weather, parent schedules, lack of knowledge of venue location, suburban sprawl, perceptions of crime and budget constraints keep parents from allowing their kids to play outside or use fitness facilities. FitNet, even as a simple directory, helps to overcome this problem. It also helps to identify the areas of greatest need in the community, so that local MSS chapters can best focus their efforts. Furthermore, major players are interested in partnering with AMA-MSS, if the Fitness Forward project is selected as a framework for the National Service Project. One such example is the Department of Interior (DOI). Michael Suk, special assistant to the Secretary of Interior, spoke at the Interim meeting in Hawaii (2003) about pediatric obesity; he agreed to work with the FitNet initiative to promote the use of public lands for physical activity and recreation. We will release FitNet in June of 2004 and another upgrade in September of 2004. It has been said that in order to See a Change, You Must First Be the Change. In that vain, as part of the FitMD initiative, we want AMA members and medical students to be the first to make use of FitNet, customized for their community and school environment, and equipped with additional capabilities, such as automatic synchronization with online calendars (i.e. Outlook), and online communities connecting students with similar types of fitness preferences from orientation onward. The biggest barriers to a healthy lifestyle as a medical student and physician are lack of time and motivation (given exhaustion), so communicating the existence of nearby activities during free time and peer fitness partners to help motivate healthy living should go a long way. In addition, we will provide materials that help students think through ways to promote innovations in their curriculum, and in student health, to help make medical school a culture that promotes healthy living. For example, at Duke, we will coordinate wellness visits for all incoming medical students at orientation, and immediately encourage use of FitNet. Emory began a study of the Healthy Doc-Health Patient phenomenon, and we hope that the AMA-MSS National Service Project can help more student doctors grow into good role models for their patients and the community. With medical students as healthy role models and with community-specific information about opportunities to live healthy (even for low-income families), we then hope to get medical students engaged as leaders in the primary care and school settings. Use of FitNet at home, in schools and at the doctor‘s office cannot solve the problem for everyone. However, at least in terms of physical activity, we can educate youth about Fitness Anywhere, the concept that you can engage in fun forms of physical activity in almost any environment (such as in the safety of your own room, outside, even in front of the TV if necessary) at little to no cost. Two such examples are FitJUMP! and PediAerobics. Jump-roping is among the highest energy burning activities of all exercises, and has been shown to increase self-esteem in youth. It can be done almost anywhere, including in the security of the home. It can also be fun and part of a group activity, especially for younger children. Jump ropes are inexpensive, and can be purchased for less than one dollar/ rope. Furthermore, the power of health-care providers giving a non-pharmaceutical prescription to children and parents has shown success in the past with programs like Reach Out and Read; over 14,000 trained providers, nurses and other clinicians now hand out over 3 million books to 1.5 million children 0-5 in all 50 states to enhance literacy and child development. A simple intervention such as handing out jump ropes with guidelines and information could be easily and cost-effectively replicated in primary care clinics and beyond, nationwide, as part of the National Service Project. At Duke Med, we are implementing FitJUMP! as a partnership between primary care providers and student volunteers. Medical students will encourage BMI screenings; and primary care providers will th identify children (ages 5 and older) with a BMI in the 85 percentile or higher or with other risk factors for overweight who should be given a jump-rope or other supplementary healthy lifestyles education. As done in the pilot program of FitJUMP! at Boston Medical Center, students will meet with these patients while they are in the office for a routine physical. They will distribute jump ropes and instruction booklets, which will also include information on the other Wellness Targets, and discuss the benefits of physical activity and a healthy lifestyle, practice jumping rope with the patient, and teach them to keep a log of their activity (either on FitNet or on paper, depending on patient and parent preference). Ideally, students will track patients and meet with them again at another visit, or, if permission is given, call the patient at home to record progress and encourage continuation. Jump-roping is not for everyone, so we also want to offer children ―PediAerobics‖ options. These will be a set of ‗body circuits‘ for children, a combination of calisthenics and stretching put to different types of music which can also be done in the safety of one‘s home, free of charge. Now, with education about opportunities for youth to be active and eat smart provided, the final piece of the puzzle is to provide motivation. Sometimes, the desire to live a healthy lifestyle is enough, but, for those who have developed poor health habits, initial external incentivization helps promote contemplation, planning and action in terms of changing habits. Reward programs for children can be very effective strategies for promoting certain behaviors, as shown by the success of the stars for reading programs across U.S. schools. At Duke, the Coach K Drive to Fitness will be used in 27 Durham public elementary schools in the fall of 2004. Children will be encouraged to earn points for achieving certain Wellness Targets on a daily basis, such as limiting daily television/computer viewing to less than 2 hours (Be Active), being physically active for at least 30 minutes (Be Active), going a day without drinking a sugar sweetened beverage (Eat Smart- drink water, reduced-fat milk, or 100% fruit or vegetable juice), and getting a full nights rest of at least 7- 10 hours (Sleep Well). Teachers and parents can also help their children to earn points by joining them in these choices. Points will be rewarded with bronze, silver and gold certificates and free or discount passes for various activities, such as bowling. Students at each school will also compete in a March Madness Physical Challenge Tournament, according to the physical challenges laid out by the President‘s Challenge, with top point earners competing in Cameron Indoor Stadium or the Emily Krzyzewski Family Life Center. We hope that a Drive to Fitness point system can similarly be used by other MSS chapters in public schools near them, and that we can arrange a partnership with the NCAA or NBA to offer motivational co-branding specific to different communities. Currently, Duke medical and pre-medical students are piloting the Drive to Fitness at Central Elementary School in Hillsborough, NC, where we have a strong relationship with the principal. This venue serves as an excellent training ground for some 30 volunteers, some of which will be Durham school leaders in the fall. Volunteers are facilitating the Drive to Fitness with point tracking booklets, classroom posters, and data entry into FitNet online for centralized tracking of points. They are also encouraged to teach Fitness Anywhere programs, use of FitNet and general healthy lifestyles education (the 5 Wellness targets) as part of their experience with different classes in Central Elementary School. Once they become School Leaders, they will recruit additional volunteers from the medical, graduate and undergraduate schools of the triangle region to educate more classrooms. Furthermore, some students have shown an active interest in physical education classes and after school intramural sports, and are creating a mini- basketball league for Central Elementary. This is both a fun break for medical students, and a much needed activity for school children. Medical students will also have an opportunity to create customized programs for the school they lead, with the guidance of the School Playbook, a framework that discusses the different areas which can be improved in schools to promote healthy lifestyles (www.fitnessforward.org/channels/educators). Education about healthy lifestyles can also be given via grocery stores, an effort we piloted in November of 2003 (www.fitnessforward.org/programs/fitguide.htm). Medical students all across the country can implement programs that turn the latest science on healthy living and disease prevention into kid, teacher, and parent-friendly information, opportunities, and motivation to improve lifestyle habits in both patients and themselves. Such programs offer students a chance to have a positive influence in the lives of our patients, and offer an opportunity to work with physicians and other care providers to address problems they too will face in their careers. Such a National Service Project would also allow the medical students the chance to be leaders and mentors by recruiting and coordinating other medical students as well as pre-medical students, to engage in volunteering at primary care clinics and schools. Contact Information: For more information, please contact Jason Langheier at firstname.lastname@example.org or Alison Troy at email@example.com Junior High Olympics Goals of this Project: To encourage junior high school students to participate in team and individual sports To motivate junior high students to exercise and improve their capabilities To increase awareness in these students of their current state of health and understanding of nutrition. Local and National Projects: Locally, medical students go to junior high schools and present the students information on reading nutrition labels, safe ways to exercise, AHA guidelines, the negative effects of obesity. Eating disorders should also be discussed. Teachers are encouraged to get the classes to share healthful recipes, and for cafeterias to post nutritional information on food offered by the school. A booklet listing recommendations for healthful food found in popular chain restaurants might be shared. Students are encouraged to keep a food/exercise diary. Nationally, students from each class sign up for different sport events (basketball, soccer, sprint, mile run, are some examples). Once a week the P.E classes are asked to set aside time for the students to train for these events, keeping note in their journals of their progress. At the end of May (which is National Physical Fitness Month), the classes in each school compete with each other. Medals are awarded to the winners. Local media coverage will increase awareness in the community. Contact Information: For more information, please contact Jasmine Dao at firstname.lastname@example.org Slimming Down America! University of Missouri - Kansas City School of Medicine Goals of the Project: To address the issue of obesity as a national Public Health Crisis. To raise awareness on obesity and the multiple chronic diseases obesity causes. To identify overweight and obese individuals within the community through Body Mass Index (BMI) measurements and to educate these individuals on obesity management. To identify individuals who have also begun to develop chronic disease(s) such as hypertension and to educate these individuals on management of these complications. To deliver pamphlets on obesity and related chronic illnesses, as well as to provide a list of local clinics to this patient population in order to ensure that these people know where to find physician for treatment. To decrease obesity throughout the nation and in turn decrease spending on overweight and obesity as illnesses. Local and National Project Ideas: 1) Set up an information booth at a specified function (such as a children‘s health fair) or at a local venue (such as in a library or supermarket). 2) Measure people‘s Body Mass Index (BMI) and blood pressure at these events. 3) Hand out pamphlets about obesity, related chronic illnesses, and a list of local clinics with physicians to help treat these patients To actually carry out this project, first a specific area needs to be targeted. Ideally, this area would include people who traditionally not a part of the covered patient population of the local hospitals or clinics. Once an area of the community has been identified, a local venue needs to be selected. These venues would most probably include local community centers, grocery stores, Wal-marts, libraries, and other such areas. Other possibilities to set up these information booths include at community functions such as local health fairs or city wide celebrations. Once a location has been chosen, a proposal should be submitted to the managers of the venue to outline the specific goals of the project. After securing a location, the next step involves procuring the materials. The specific screening tests include measuring BMI, blood pressure, and body fat. To conduct these tests, a scale, a blood pressure cuff, and a body fat caliper is needed. Most medical students should have a scale and a blood pressure cuff and the booth volunteers should be able to provide these materials. However, all these materials can also be obtained from the teaching hospital as well. To obtain these materials, you can either contact central supply to borrow the materials for the week. In addition, pamphlets on obesity management education, obesity associated illnesses, hypertension management, and a diabetes symptom screening and management need to be obtained. Specific hospital clinics, such as the diabetic clinic, should have available educational pamphlets. If not, local free health clinics or organizations such as the American Diabetic Association have the necessary materials and are willing to donate these supplies. For the most part, each venue should be able to provide the necessary table and space for a booth. Additional goodies to have at the booth include some freebies such as candy, stickers, magnets, and pens. Contact Information: For more information, please contact Hannah Zimmerman at email@example.com The Skinny On Fat University of Kentucky College of Medicine and the University of Louisville AMA-MSS chapters Project Goals Influence medical students to promote healthy lifestyle choices amongst all patients they see. Educate children under the age of eighteen about health risks associated with obesity and the benefits of a healthy diet and exercise plan Work closely with community members creating healthy weight loss initiatives, and implementing models that work. Pursue legislative activities to push for more effective obesity legislation. Project Ideas Projects are organized according to the project goal they promote. Goal One: Influence medical students to promote healthy lifestyle choices amongst all patients they see. Project 1. Clinic Brochure Campaign Medical students would develop very simple and brief brochures featuring pertinent facts about, and risks rd th of, obesity, as well as locally relevant resources and suggestions for intervention. 3 and 4 year students would pass out brochures with brief counseling on the importance of healthy weight and activity to all patients they see (regardless of weight) in outpatient primary care (i.e. Family Practice and Internal Medicine) clerkships. rd th Medical student role: development of brochure by AMA-MSS students; distribution by 3 /4 year clinical students. Institutional role: Authorize brochure and its distribution, and encourage (not force) clinical students to participate. Provide for a training session on obesity and nutrition counseling as well. Time commitment: 6-7 hours per person in small group designing brochure Resources needed: funds to produce brochure Project 2. Screening/Counseling At Student Run Clinics One health professional student would serve as ―obesity screener‖ each night that the local student-run clinic is open. Each patient seen would have measurements taken and BMI calculated and their risk for obesity consequences briefly reviewed. The screener would give each patient brief counseling on the importance of healthy weight and activity. If time permits, could meet longer with those desiring. Medical student role: to serve as screener along with other health professions students. To develop a training session for those volunteering to be screeners. One person or a committee needed to schedule screeners for clinic dates. Institution role: might have to approve of added function at clinic Resources needed: patient education materials, training session materials, place to hold confidential screenings at clinic Project 3. AMA-MSS Cookbook As a national project, the AMA-MSS can create a cookbook that can serve to raise funds for individual chapters. The cookbook shall include healthy recipes submitted by student members throughout the nation. Possibly a competition could be created amongst individual chapters for with ―best dish‖ categories and the largest number of submissions. The cookbooks could be sold in hospital gift shops, or used as part of a patient education program. Goal Two Educate children under the age of eighteen about health risks associated with obesity and the benefits of a healthy diet and exercise plan Project 4. Fighting Teen Obesity in Rural High Schools This proposed project is a multifaceted project focusing on fighting obesity in the teen population. The core of the project involves traveling to rural high school classrooms and educating the students about several issues involved in obesity, such as diabetes, heart disease, and the epidemiology of obesity. However, the project also offers solutions by educating the students on exercise plans, the content of fast food (often the only away-from-home food option in rural areas), and a mini physiology lab on the GI system. Several learning tools utilized at the University of Louisville to increase student and medical student participation level will be used: a palm pilot classroom set, interactive fact quizzes, question and answer sessions on higher education, and meetings with local, rural physicians (for medical students). Goals/Accomplishments: 1. Educate at-risk (teenage) population on obesity and related topics. 2. Build working relationships with rural schools often intimidated by metropolitan medical systems. 3. Create opportunities for positive health changes. 4. Serving as role models for students in areas with overall lower education levels. 5. Expose medical students to rural areas in need of quality physicians. 6. Allow medical students interaction with state medical society member physicians. 7. Allow medical students to practically apply classroom knowledge using a public health format. 8. Facilitate creativity in learning and sharing of knowledge for the medical student. Project Outline at University of Louisville 1. Presentation outline 2. Question and Answer/Quiz Session 3. Palm Pilot Project 4. Grant writing 5. State medical society reception 1. The presentation is broken up into four components: basic GI physiology, diabetes & obesity, eating disorders, exercise physiology & plans. Each section will be taught in a format compatible with a high school level education. a. Basic GI – This part talks about the path that a bolus of food normally takes - the physiological changes that occur with ingesting food, the organs involved in modification, as well as the locations where absorption of different nutrients occurs. Models are an excellent tool to teach this section and are easily obtained from local physicians. The section ends with a discussion of excretory pathways. b. Diabetes & Obesity – This section begins with a discussion of obesity definitions and the concept of body mass index followed by a discussion on diabetes. The diabetes discussion covers distinctions between different types of diabetes, the basis of the disease, and complications of the disease. This section includes several gross anatomy and microscopic photographs. c. Eating Disorders – This section will cover a number of common eating disorders (anorexia nervosa & bulimia) as well as other less often addressed issues(emotional overeating, leptin deficiencies). While all aspects of this section do not correlate with obesity, it is important to include these topics, again considering the target audience. d. Exercise Physiology – This section emphasizes positive ways for teens to improve their eating habits and knowledge base, an important component of this project. Consequently, this presentation ends with a discussion of exercise plans, changes in diet, and calculation of body mass index (using a Palm Pilot classroom set). Additionally, content of common fast foods and the concept of ―empty calories‖ are covered. Often local hospitals have displays already on file regarding fast food and related health risks. A local hospital is an excellent resource for this section. This project can be expanded depending on time availability and resources. 2. A brief period set aside for students to ask questions about obesity and related issues can be helpful. Often the students have relatives struggling with obesity related issues and they may want to ask for more information. Also, this is a great time to invite questions about college preparation and the pursuit of further education. The educational perspective of a medical student can prove invaluable to these students. Prior to a visit to a rural school, compile a list of local phone numbers where further assistance may be available after your departure, for example local clinics, eating disorder hotlines, and websites (both fun and educational) for further investigation. To further augment the audience interest, the Q&A time can be used to distribute any items you may have brought such as pens, notepads, college materials, informational pamphlets, etc. This increases the medical school‘s profile in the rural area. 3 and 4. Depending on each medical school‘s resources and administrative support, grant options are available for community service projects. Inquire with the administration as to any grants that are currently up for application and may apply to the project at hand. Grants are not always monetary. At the University of Louisville, our relationship with the Palm One Corp. allowed us to obtain a classroom set of Palm Pilots for use in the project. We were able to develop programs on the existing software for use in the classrooms such as an ad hoc network in the classrooms, which allowed us to prepare an interactive quiz. 5. The rural focus of this project presents a unique opportunity to interact with rural state medical society member physicians. A reception or dinner is easily planned with local physicians. This gives the medical students additional incentive to participate and allows them to begin relationships with rural physicians. Project 5. Elementary School Healthfest The prevalence of obesity in children has more than doubled, and in adolescents has more than tripled, since 1976 and nearly 80 percent of overweight or obese adolescents will remain overweight or obese as adults. Healthfests can be designed to complement traditional school carnivals and science fairs. Medical students can design education stations, healthy food eating contests, exercise demonstrations, walk-a- thons, healthy food demonstrations, etc. Most educators welcome an eager group of medical students willing to come and teach their students at special events and in the classroom. This project is a time effective and feasible project for any medical school AMA chapter that provides advantages not only for high school students but also involved medical students. Project 6. PTA and School Board Initiatives As members of the community, parents, and future physicians we are welcome at PTA, school board meetings, and school based decision council meetings. The following topics can be prepared and discussed at these meetings: educate school staff, parents and community about the issues affecting the health of children such as obesity, exercise, and nutrition discuss guidelines for healthful snacks and foods in vending machines, school stores, and other venue‘s within the school‘s control encourage adherence to single portion sized as defined by the USDA Food Guide Pyramid in foods offered in the school setting discuss guidelines addressing ―party guidelines‖ for snacks and refreshments served at school parties, celebrations, and meetings encourage recess before lunch develop guidelines to address using food as a discipline or reward for students encourage non-food fundraisers such as flowers, gift wrap, sporting events and family fun runs plan health promotion activities for students, parents, and staff that encourage the healthy eating such as cooking demonstrations, school gardens, and nutrition guest speakers promote walking or bicycling to and from school using safe programs include information on physical activity through school communications, such as monthly calendars, newsletters, family fun nights, or health fairs increase awareness of low or no cost access resources for physical activities such as pools, churches, or parks *Adapted from the Colorado Physical Activity and Nutrition State Plan 2010 Goal Three Work closely with community members creating healthy weight loss initiatives, and implementing models that work. Project 7. National 10,000 Step Relay The 10,000 Step Relay serves as an event to bring the national service project to a climax. The relay encourages people of all ages and levels of fitness to discover how easy exercise can be. Rationale: 10,000 steps is roughly two miles, a goal most physicians encourage patients to achieve. Instead of targeting traditional 5K audiences, participants will be school age students and their families, patients desiring to try an exercise plan, etc. Instead of receiving a T-shirt, participants will be given a pedometer to keep. This visual reminder of how many steps a person has taken during the day will encourage the simple, yet effective, act of walking. Medical Student Role: Individual AMA-MSS chapters will host the relay at a date determined at a national level. High schools tracks or community walking trails should serve as the event location. The event should be free, thus sponsorship should be obtained. Following the lead of the National AMA-MSS, individual chapters should coordinate the event as they see fit. Project 8. Start Small, Feel Better: A Community-Based Intervention by Medical Students ―Start Small, Feel Better‖ is a six-week intervention that was used by a group of seven University of Kentucky College of Medicine students to great effect in a community-based center. This intervention can serve as a simple model that is that any group of medical students can replicate and/or modify within a community-based setting. This basic health education series can be done with minimal time commitment and little or no cost. This intervention can be implemented in any community setting (i.e. community centers, churches, parent groups, homeless shelters). The goal of Start Small, Feel Better is for medical students to educate a community group on the basics of healthy living. This program includes six sessions: 1) Introduction: Introduce the program, get to know the group, set goals 2) Nutrition: Introduce simple modifications for a healthier diet 3) Exercise: Emphasize moderate activity 30 minutes per day, five days a week 4) Stress relief: Ways of relieving stress mentally and physically 5) Health Impact: How healthy lifestyle choices improve health, decrease illness 6) Wrap-up: Gauge progress, how to maintain a healthy lifestyle going forward Start Small, Feel Better emphasizes setting small goals to achieve short-term, immediate results in order to promote healthy behavior for the long-term. The ultimate objective of the program is two-fold; first, that clients achieve a lasting, modest improvement in overall health by means of continued application of the simple measures taught in the context of this six-session program, and second, that they will be motivated to learn more about health and make further improvements in their lifestyle, allowing them to assume responsibility for their choices and health status. Project 9. The Great Weight Loss Office Pool This program is patterned after traditional ―final four‖ office pools. Participants will be challenged to lose weight or lower their BMI. An entry fee will be paid, and the participant that loses the most percentage weight wins the pot. The participants‘ weight or BMI would be determined at the start of the competition. Regular check-ins would occur throughout the length of the competition. Goal is to encourage weight loss in a setting traditionally associated with sedentary habits. The competition style of the program will serve as a support group for those involved. Design: Medical students will contact the head of local businesses, schools, hospital departments, churches, and send information fliers about the competition. Each place of business can appoint project head to set up the program at the place of business. In the beginning, medical students will perform physical exams on the participants, BMI assessment, and body fat measurement. The duration of this competition can be set by the place of employment. Aside from regular weight check-ins, another round of measurements and a physical exam could be performed by medical students as a way to follow up. Project 10. Church Forums Medical students recruit lay or ministerial leaders from local places of worship to participate in a 3- meeting forum concerning how these religious entities could help their members (both individually and as a whole) fight obesity through better diets and exercise. An effort should be made to target congregations made up of vulnerable populations, e.g. low SES, migrant workers, elderly. The first meeting would consist of a brief presentation of the problem of obesity by the medical students, followed by brainstorming by the group. The students would facilitate discussion and supply ideas garnered by research. The whole group would likely find options they would not have known about or thought of individually. Single places of worship or groups with similar populations could then break off and work on the strategies most likely to be helpful for their congregations. The last 30 minutes would be dedicated to each group deciding on at least one feasible measure to be carried out over the next 6 months. (Meeting time 2-2.5 hrs) At the second meeting, approximately 3 months later, the group would reconvene to discuss progress and lessons learned so far. It would be a time to share strategies and adjust plans if necessary. (Meeting time approx. 1 hr) At the last meeting after approximately 6 months, the group would meet to review successes and places for further growth, and make plans for continuing their efforts in promoting health to their congregations. They would also brainstorm with the medical students the role these students could feasibly play in helping with these efforts in the future. (Meeting time approx. 1.5 hrs) Medical student role: Research obesity and community-based strategies to reduce it. Recruit interested volunteers from places of worship. Facilitate meetings and serve as resources. Time involvement: 3 meetings, including prep time of about 6-7 hours; recruiting time 3-4 hrs per person involved; religious group‘s time commitment depends on scope of plans and goals. Resources needed: possibly phoning/publicity, place to meet, presentation materials, resource materials Possible variations: 1. instead of places of worship, get area gyms and community centers together to brainstorm how to provide exercise opportunities for low SES groups 2. Involve not just medical students, but also public health, nursing, dentistry, and other allied health students Goal Four Pursue legislative activities to push for more effective obesity legislation. Project 11. Letter Writing Campaign After meetings with state representatives concerning a national service project on obesity, it was determined the all letters to legislators should be hand written; if they are not, they will be thrown away!!! SAMPLE LETTER February 27, 2004 Representative Joe Smith State Capitol Building Capitol City, ST 40000-0000 Dear Representative Smith, My name is John Jones, and I am a medical student at State University who lives in your district. I am writing to you about House Bill 1000, the bill relating to obesity in children. During my medical education, I have observed numerous children who are overweight, and have seen how this affects their psychological and physical development. This is a grave problem in our state that I believe the legislature has the unique opportunity to address now. The Surgeon General has already declared that obesity is an epidemic in children, and the specific measures in this bill will help to slow this problem down. I particularly believe that the portion regarding increasing physical activity during the school day will help motivate our increasingly sedentary, Nintendo driven youth. I would like to ask for your support on this bill. Measures like these will save up to $250,000 per year in medical cost for a child like with type II diabetes. The savings in medical care for a child who suffers from type II diabetes because they have been above their suggested body weight since age 3 is reason enough to pass this bill. And, it could help prevent the problem form occurring in the future. Thank you for your time. Sincerely, John Jones State University College of Medicine Class of 2005 Contact Information: For more information, please contact Jessica McFarlin at firstname.lastname@example.org Taking a Bite Out of Childhood Obesity Goals of the Project To implement effective, multi-faceted interventions that help curb the national obesity epidemic among today‘s youth (see Figure 1 below). Train AMA-MSS members to become strong teachers and to improve their nutritional knowledge. (This training will prove extremely useful to students as they ascend the medical ladder.) To provide the AMA-MSS with a service project that is flexible enough to be implemented at both the national and local levels. In other words, medical students can combat the epidemic by championing national health policy initiatives while also working to fight obesity in their local communities. To encourage AMA-MSS members to develop innovative ideas that can also be implemented by other organizations to fight the obesity epidemic. To create the first ―nationally‖ coordinated obesity campaign that involves medical students from around the country. Figure 1. Comprehensive Model for Obesity Prevention Among Today‘s Youth *School-based approaches for preventing and treating obesity. Story, M. International Journal of Obesity, Mar99 Supplement 2, Vol. 23 Issue 3, ps43, 1p. Local Project Ideas At the local level, the NSP would entail a comprehensive approach that is based on the above model. Local chapters would be able to create individual projects that support existing anti-obesity programs and that are in the interest of the community. Using the model proposed above, there can be a concerted effort to combat the obesity epidemic at the local level. A few proposed ideas are as follows: 1. Increase physical activity of children and adolescents a. Medical students would work to establish weekly Sports Leagues that encourage intramural participation from all students. These sports leagues can be in a variety of sports and would be open to all. Emphasis would be placed on aerobic sports, such as basketball, swimming, running, wrestling, etc. b. For those students who are more inclined to participate in noncompetitive physical endeavors, activities such as dance, yoga, and martial arts can also be taught by medical students in an after-school setting. c. For younger children, games can be designed that involve a good amount of running or aerobic exercise. d. Many other physical activity ideas can be developed by local AMA-MSS chapters. 2. Health education for children and adolescents a. Under guidance from a national education program, medical students can organize workshops at local elementary and high schools on nutrition, diet, and exercise. Emphasis should be placed on helping students develop the knowledge, attitudes and behavioral skills they need to establish and maintain healthy eating and a physically active lifestyle. b. These modules can involve classroom games and other incentives. Follow-up classes can involve informal surveying to motivate students to continue to exercise and eat healthy food. c. Nutrition experts from medical schools around the country can be encouraged to submit ―Healthy Eating Strategies‖ to our AMA-MSS, which the NSP can compile into a ―Healthy Eating Handbook‖ for students and parents (see 4a). 3. Reinforce the importance of the obesity issue with school teachers and administrators a. Medical students would also reinforce the importance of diet classes or nutrition counseling with principals and senior school administrators. b. May be able to create a small educational module that could be implemented by all teachers at a particular school. c. Medical students can encourage local administrators to evaluate the vending machines in their schools. They can encourage schools to require that vending machines provide healthy alternatives in addition to what is currently offered. 4. Promote community interventions a. The role of the school in preventing and treating childhood obesity must be conceptualized as only one part of broader community and health care interventions. b. Medical students can broaden their message to local communities by creating flyers that can be given to parents at home. This in turn, can help parents to promote a healthy lifestyle for their kids and themselves. State and National Project Ideas At the state and national levels, the NSP would entail a policy-based approach that would focus on environmental and public health strategies. Some of the policy initiatives that can be promoted to local and state legislatures include the following: 1. Health promotion programs to motivate and support responsible health choices. 2. Community initiatives to promote and enable health choices. 3. Health care and insurance systems that put prevention first by reducing risk factors and complications of chronic disease. At the national level, the NSP could involve the development of national guidelines and a national educational module that could be used by medical students to educate children and adolescents. The NSP would also involve obtaining funds from various federal sources to develop these nationwide educational modules. In addition, the funding would also help to fight the epidemic in local communities. Contact Information: For more information, please contact Sunny Ramchandani email@example.com Web Resources The internet is a fantastic resource for all kinds of useful information on the obesity epidemic in the United States. Some sites provide information on facts and figures, while others provide information to use in your projects. Here are some great web sites with brief descriptions. American Medical Association Working Group on Childhood Obesity http://www.ama-assn.org/ama/pub/article/3216-8158.html This website describes the meeting of the AMA Working Group on Managing Childhood Obesity. The group examined cultural and racial differences in obesity as well as working to figure out ways to work on this problem. American Heart Association Position Statement on Childhood Activity http://www.americanheart.org/presenter.jhtml?identifier=4596 This site describes the American Heart Association‘s position on childhood obesity and the health risks inherent in living as an obese person. The site also describes the importance of physical education and exercise for good health. American Heart Association Recommendations on Childhood Obesity http://www.americanheart.org/presenter.jhtml?identifier=4670 On this site, the American Heart Association states that obese children are more likely to be obese adults. Successfully preventing or treating obesity in childhood may reduce the risk of adult obesity. This may help reduce the risk of heart disease and other diseases. American Academy of Pediatrics Policy on Childhood Obesity http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424 This site describes the position of the American Academy of Pediatrics when it comes to childhood obesity. The statement proposes strategies for early identification of excessive weight gain by using body mass index, for dietary and physical activity interventions during health supervision encounters, and for advocacy and research. American Obesity Association http://www.obesity.org Here you will find what may well be the most comprehensive site on obesity and overweight on the Internet. Obesity is not a simple condition of eating too much. It is now recognized that obesity is a serious, chronic disease. No human condition—not race, religion, gender, ethnicity or disease state— compares to obesity in prevalence and prejudice, mortality and morbidity, sickness and stigma . Obesity Online http://www.obesity-online.com OBESITY - ONLINE is a multi-disciplinary forum for research and treatment of massive obesity, including plastics, psychiatry, endocrinology, nutrition, nursing, dietetics and allied health. NAASO: The North American Association for the Study of Obesity http://www.naaso.org This website provides scientific information on obesity research. There is information for many levels, from students to attending health care professionals. American Cancer Society http://www.cancer.org The ACS is a nationwide community-based voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving, lives, and diminishing suffering from cancer through research, education, advocacy, and service. Their website includes information on obesity‘s contribution to cancer risk as well as information about the Great American Weigh-In. Kraft Foods’ Obesity Initiatives http://www.kraft.com/obesity/pressrelease.html This website outlines Kraft Foods‘ commitment to aid in the battle against obesity. This is a good resource for counseling patients on how to eat well. National Library of Medicine http://www.nlm.nih.gov/medlineplus/obesity.html National statistics and a wealth of additional information on obesity. National Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/nccdphp/dnpa/obesity/ This site provides comprehensive information about obesity and health, including the latest data, state highlights, fact sheets, and tons more! This page also has a long list of websites with up to date information on the obesity epidemic. Shape Up America! http://www.shapeup.org/ This website is designed to provide you with the latest information about safe weight management, healthy eating, increased activity and physical fitness. Nutrition.gov http://www.nutrition.gov/html/aboutus.html NUTRITION.GOV, a new federal resource, provides easy access to all online federal government information on nutrition. This national resource makes obtaining government information on nutrition, healthy eating, physical activity, and food safety, easily accessible in one place for many Americans. Providing accurate scientific information on nutrition and dietary guidance is critical to the public's ability to make the right choices in the effort to curb obesity and other food related diseases. WholeFitness.com http://www.wholefitness.com/kidsfitness.html Do your children spend more time inside the house watching television or playing computer games than they spend playing outside? If that is the case, this website gives options for children to get them off the couch and get them in shape! The Surgeon General's Call to Action http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_consequences.htm This website lists and gives details about the effects of obesity on health.