Archive for April 22, 2008

Trends

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Source: CDC

U.S. Obesity Trends 1985–2006

During the past 20 years there has been a dramatic increase in obesity in the United States. This slide set illustrates this trend by mapping the increased prevalence of obesity across each of the states.

In 2006, only four states had a prevalence of obesity less than 20%. Twenty-two states had a prevalence equal or greater than 25%; two of these states (Mississippi and West Virginia) had a prevalence of obesity equal to or greater than 30%.

Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults. Prevalence estimates generated for the maps may vary slightly from those generated for the states by the BRFSS as slightly different analytic methods are used.

Prevention

{ April 22, 2008 @ 3:07 am } · { Web Articles }
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Source: American Obesity Association

Prevention
Teaching healthy behaviors at a young age is important since change becomes more difficult with age. Behaviors involving physical activity and nutrition are the cornerstone of preventing obesity in children and adolescents. Families and schools are the two most critical links in providing the foundation for those behaviors. Families
Parents are the most important role models for children. Results from an American Obesity Association survey show that:

  • The majority of parents in the U.S. (78 percent) believe that physical education or recess should not be reduced or replaced with academic classes.
  • Almost 30 percent of parents said that they are “somewhat” or “very” concerned about their children’s weight.
  • 12 percent of parents considered their child overweight.
  • Comparing their own childhood health habits to their children’s, 27 percent of parents said their children eat less nutritiously, and 24 percent said their children are less physically active.
  • 35 percent of parents rated their children’s school programs for teaching good patterns of eating and physical activity to prevent obesity as “poor,” “non-existent,” or “don’t know.”
  • Among six choices of what they believed to be the greatest risk to their children’s long-term health and quality of life, 5.6 percent of parents chose “being overweight or obese.” More parents selected other choices as the greatest risk: alcohol (6.1 percent), sexually transmitted disease (10 percent), smoking (13.3 percent), violence (20.3 percent), and illegal drugs (24 percent).
  • In terms of their own behavior, 61 percent of parents said that it would be either “not very difficult” or “not at all difficult” to change their eating and/or physical activity patterns if it would help prevent obesity in any of their children.

The AOA’s survey results indicate that parents understand the importance of regular physical education for their children. Their unfamiliarity or inadequate rating of their children’s school obesity prevention program is likely due to the lack of programs across the nation. Parents appear to underestimate the health risk of excess weight to their children, and the difficulty in achieving and maintaining behavioral changes associated with obesity prevention. Additional studies are needed to develop appropriate public health programs to better educate parents in identifying and understanding changes in their children’s weight, to incorporate the family in prevention efforts, and to improve school-based obesity prevention programs that include increasing physical education classes.

  • For more details on AOA’s survey, read the Executive Summary.Here are some ways that parents can establish a lifetime of healthy habits for their family:Create an Active Environment:
    • Make time for the entire family to participate in regular physical activities that everyone enjoys. Try walking, bicycling or rollerblading.
    • Plan special active family-outings such as a hiking or ski trip.
    • Start an active neighborhood program. Join together with other families for group activities like touch-football, basketball, tag or hide-and-seek.
    • Assign active chores to every family member such as vacuuming, washing the car or mowing the lawn. Rotate the schedule of chores to avoid boredom from routine.
    • Enroll your child in a structured activity that he or she enjoys, such as tennis, gymnastics, martial arts, etc.
    • Instill an interest in your child to try a new sport by joining a team at school or in your community.
    • Limit the amount of TV watching.

    Create a Healthy Eating Environment:

    • Implement the same healthy diet (rich in fruits, vegetables and grains) for your entire family, not just for select individuals.
    • Plan times when you prepare foods together. Children enjoy participating and can learn about healthy cooking and food preparation.
    • Eat meals together at the dinner table at regular times.
    • Avoid rushing to finish meals. Eating too quickly does not allow enough time to digest and to feel a sense of fullness.
    • Avoid other activities during mealtimes such as watching TV.
    • Avoid foods that are high in calories, fat or sugar.
    • Have snack foods available that are low-calorie and nutritious. Fruit, vegetables and yogurt are some examples.
    • Avoid serving portions that are too large.
    • Avoid forcing your child to eat if he/she is not hungry. If your child shows atypical signs of not eating, consult a healthcare professional.
    • Limit the frequency of fast-food eating to no more than once per week.
    • Avoid using food as a reward or the lack of food as punishment.

    Schools

    Outside of the home, children and adolescents spend the majority of their time in school. So, it makes sense that schools provide an environment that promotes healthy nutrition and physical activity habits. Only a few creative programs are being tested in schools across the country.

    Overweight and Obesity

    Results of a 1999 national survey showed that 16 percent of high school students were overweight (Body Mass Index (BMI) greater than the 85th percentile and below the 95th percentile) and nearly 10 percent were obese (BMI more than or equal to the 95th percentile). Self-reported height and weight was used. The survey, called the Youth Risk Behavioral Surveillance System (YRBSS), is conducted by the Centers for Disease Control and Prevention (CDC), and uses a nationally representative sample of students in grades 9 to 12.

    Here are more results from the 1999 YRBSS:

    • More male students (17 percent) were overweight than female students (14 percent), and obese (12 percent of males and 8 percent of females).
    • More black students (22 percent) were overweight than white students (14 percent).
    • More black and Hispanic female students (23 and 18 percent, respectively) were overweight than white female students (12 percent).
      • When asked to describe their weight, 30 percent of students thought of themselves as overweight.
      • More female students (36 percent) than male students (24 percent) considered themselves overweight.
      • More Hispanic students (37 percent) than white and black students (29 and 25 percent, respectively) considered themselves overweight.
      • 43 percent of students reported that they were trying to lose weight.
      • More female students (59 percent) than male students (26 percent) reported that they were trying to lose weight.
      • More Hispanic students (51 percent) reported that they were trying to lose weight than white students (43 percent) and black students (36 percent).
      • More than half (58 percent) of students reported the use of exercise (during the 30 days before the survey) to lose weight or to avoid gaining weight.
      • More female students (67 percent) reported the use of exercise for weight loss or maintenance than male students (49 percent). More white female students (70 percent) reported the use of exercise for weight loss or maintenance than black female students (59 percent).
      • 40 percent of students reported that they ate less food, fewer calories, or foods low in fat (during the 30 days before the survey) to lose weight or to avoid gaining weight.
      • More female students (56 percent) reported that they ate less food, fewer calories, or foods low in fat than male students (25 percent) to lose weight or to avoid gaining weight.
      • More white students (42 percent) reported that they ate less food, fewer calories, or foods low in fat than black students (34 percent) to lose weight or to avoid gaining weight.
      • More white female students (60 percent) reported that they ate less food, fewer calories, or foods low in fat than Hispanic female students (51 percent) and black female students (43 percent) to lose weight or to avoid gaining weight.
      • 13 percent of students reported fasting (“without eating for 24 hours or more” ) to lose weight or to avoid gaining weight.
      • More female students (19 percent) reported fasting than male students (6 percent) to lose weight or to avoid gaining weight
      • 8 percent of students reported taking diet pills, powders, or liquids without a doctor’s advice to lose weight or to avoid gaining weight.
      • More female students (11 percent) reported taking diet pills, powders, or liquids without a doctor’s advice than male students (4 percent) to lose weight or to avoid gaining weight.
      • More white female students (12 percent) reported taking diet pills, powders, or liquids without a doctor’s advice than black female students (6.9 percent) to lose weight or to avoid gaining weight.
      • 5 percent of students reported vomiting or taking laxatives to lose weight or to avoid gaining weight.
      • More female students (7 percent) reported vomiting or taking laxatives than male students (2 percent) to lose weight or to avoid gaining weight.

      • Self-Perception of Weight

      Weight Loss Attempts

      Methods of Weight Loss:

      Exercise

      Change of Eating Behaviors

      Fasting

      Use of Dietary Supplements

      Purging / Laxative Use

    • Find more 1999 YRBSS results from the CDC’s Morbidity and Mortality Weekly Report and from the CDC’s Youth ‘99 Online Analysis.

    Creating a Healthy Eating Environment in Schools

    Recommended daily servings of fruits and vegetables are not being met by today’s youth. According to the Centers for Disease Control and Prevention, “51 percent of children and adolescents eat less than one serving a day of fruit, and 29 percent eat less than one serving a day of vegetables that are not fried.”

    According to the U.S. Department of Agriculture (USDA), children drink 16 percent less milk now than in the late 1970’s, and 16 percent more of carbonated soft drinks. The consumption of non-citrus juices such as grape and apple mixtures increased by 280 percent.

    A coalition of five medical associations and the USDA proposed a “Prescription for Change: Ten Keys to Promote Healthy Eating in Schools” to be used for guidance in school nutrition programs. Their prescription is:

    1. Students, parents, food service staff, educators and community leaders will be involved in assessing the school’s eating environment, developing a shared vision and an action plan to achieve it.
    2. Adequate funds will be provided by local, state and federal sources to ensure that the total school environment supports the development of healthy eating patterns.
    3. Behavior-focused nutrition education will be integrated into the curriculum from pre-K through grade 12. Staff who provide nutrition education will have appropriate training.
    4. School meals will meet the USDA nutrition standards as well as provide sufficient choices, including new foods and foods prepared in new ways, to meet the taste preferences of diverse student populations.
    5. All students will have designated lunch periods of sufficient length to enjoy eating healthy foods with friends. These lunch periods will be scheduled as near the middle of the school day as possible.
    6. Schools will provide enough serving areas to ensure student access to school meals with a minimum of wait time.
    7. Space that is adequate to accommodate all students and pleasant surroundings that reflect the value of the social aspects of eating will be provided.
    8. Students, teachers and community volunteers who practice healthy eating will be encouraged to serve as role models in the school dining areas.
    9. If foods are sold in addition to National School Lunch Program meals, they will be from the five major food groups of the Food Guide Pyramid. This practice will foster healthy eating patterns.
    10. Decisions regarding the sale of foods in addition to the National School Lunch Program meals will be based on nutrition goals, not on profit making.
  • Read more recommendations from this coalition of medical associations and the USDA in, Healthy School Nutrition Environments: Promoting Healthy Eating Behaviors.

    • Creating an Active Environment in Schools

    Nationwide in 1999, approximately 56 percent of high school students were enrolled in a physical education (PE) class and only 29 percent attended PE class daily, according to the Center for Disease Control and Prevention’s (CDC) Youth Behavioral Risk Factor Surveillance System (YRBSS). Participation in high school sports was 55 percent, with a higher participation rate from male students (62 percent) than females (48 percent).

    The CDC partnered with experts from other federal agencies, state agencies, universities, voluntary organizations, and professional associations to develop Guidelines for School and Community Programs to Promote Lifelong Physical Activity Among Young People. The 10 recommendations in the guidelines are:

    1. Policy

    Establish policies that promote enjoyable, lifelong physical activity.

    • Schools should require daily physical education and comprehensive health education (including lessons on physical activity) in grades K-12.
    • Schools and community organizations should provide adequate funding, equipment, and supervision for programs that meet the needs and interests of all students.

    2. Environment

    Provide physical and social environments that encourage and enable young people to engage in safe and enjoyable physical activity.

    • Provide access to safe spaces and facilities and implement measures to prevent activity-related injuries and illnesses.
    • Provide school time, such as recess, for unstructured physical activity, such as jumping rope.
    • Discourage the use or withholding of physical activity as punishment.
    • Provide health promotion programs for school faculty and staff.

    3. Physical Education Curricula and Instruction

    Implement sequential physical education curricula and instruction in grades K-12 that

    • Emphasize enjoyable participation in lifetime physical activities such as walking and dancing, not just competitive sports.
    • Help students develop the knowledge, attitudes, and skills they need to adopt and maintain a physically active lifestyle.
    • Follow the National Standards for Physical Education.
    • Keep students active for most of class time.

    4. Health Education Curricula and Instruction

    Implement health education curricula and instruction that

    • Feature active learning strategies and follow the National Health Education Standards.
    • Help students develop the knowledge, attitudes, and skills they need to adopt and maintain a healthy lifestyle.

    5. Extracurricular Activities

    Provide extracurricular physical activity programs that offer diverse, developmentally appropriate activities both noncompetitive and competitive for all students.

    6. Family Involvement

    Encourage parents and guardians to support their children’s participation in physical activity, to be physically active role models, and to include physical activity in family events.

    7. Training

    Provide training to enable teachers, coaches, recreation and health care staff, and other school and community personnel to promote enjoyable, lifelong physical activity among young people.

    8. Health Services

    Assess the physical activity patterns of young people, refer them to appropriate physical activity programs, and advocate for physical activity instruction and programs for young people.

    9. Community Programs

    Provide a range of developmentally appropriate community sports and recreation programs that are attractive to all young people.

    10. Evaluation

    Regularly evaluate physical activity instruction, programs, and facilities.

    Causes

    { April 22, 2008 @ 3:05 am } · { Web Articles }
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    Source: American Obesity Association

    There are many factors that contribute to causing child and adolescent obesity – some are modifiable and others are not.

    Modifiable causes include:

    • Physical Activity – Lack of regular exercise.
    • Sedentary behavior – High frequency of television viewing, computer usage, and similar behavior that takes up time that can be used for physical activity.
    • Socioeconomic Status – Low family incomes and non-working parents.
    • Eating Habits – Over-consumption of high-calorie foods. Some eating patterns that have been associated with this behavior are eating when not hungry, eating while watching TV or doing homework.
    • Environment – Some factors are over-exposure to advertising of foods that promote high-calorie foods and lack of recreational facilities.

    Non-changeable causes include:

    • Genetics – Greater risk of obesity has been found in children of obese and overweight parents.

    Prevalence and Identification

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    Source: American Obesity Association
    About 15.5 percent of adolescents (ages 12 to 19) and 15.3 percent of children (ages 6 to 11) are obese. The increase in obesity among American youth over the past two decades is dramatic, as shown in the tables below.

    Table 1.
    Prevalence of Obese Children
    (Ages 6 to 11) at the
    95th percentile of
    Body Mass Index (BMI)
    1999 to 2000 15.3%
    1988 to 1994 11%
    1976 to 1980 7%
    Table 2.
    Prevalence of Obese Adolescents
    (Ages 12 to 19) at the
    95th percentile of
    Body Mass Index (BMI)
    1999 to 2000 15.5%
    1988 to 1994 11%
    1976 to 1980 5%

    A measurement called percentile of Body Mass Index (BMI) is used to identify overweight and obesity in children and adolescents. The Centers for Disease Control (CDC), the supplier of national growth charts and prevalence data, avoids using the word “obesity” for children and adolescents. Instead, they suggest two levels of overweight: 1) the 85th percentile, an “at risk” level, and 2) the 95th percentile, the more severe level.

    The American Obesity Association uses the 85th percentile of BMI as a reference point for overweight and the 95th percentile for obesity.

    We do so, because the 95th percentile:

    • corresponds to a BMI of 30, which is the marker for obesity in adults. The 85th percentile corresponds to the overweight reference point for adults, which is a BMI of 25.
    • is recommended as a marker for children and adolescents to have an in-depth medical assessment.
    • identifies children that are very likely to have obesity persist into adulthood.
    • is associated with elevated blood pressure and lipids in older adolescents, and increases their risk of diseases.
    • is a criteria for more aggressive treatment.
    • is a criteria in clinical research trials of childhood obesity treatments.

    Growth Charts – Identifying Obesity in Your ChildParents and healthcare professionals in the U.S. have used growth charts since the late 1970’s to follow the progress in physical growth of infants, children and adolescents. In May 2001, the CDC developed new growth charts to include BMI.

    American Obesity Association

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    Source: American Obesity Association

    Obesity in children and adolescents is a serious issue with many health and social consequences that often continue into adulthood. Implementing prevention programs and getting a better understanding of treatment for youngsters is important to controlling the obesity epidemic.

    Many parents are rightly concerned about their child’s weight and how it affects them. They look for specific answers for prevention and treatment options. Unfortunately, the state of the science is a lot less precise than we would like. Are kids too concerned about their weight? What are the best strategies for prevention? What treatments work over a long time? Researchers are trying to answer those and many other questions. In many cases, common sense works well.

    In situations where there are serious health, psychological or social problems, parents should seek out the best possible advice.

    Note: The term “childhood obesity” may refer to both children and adolescents. In general, we use the word, “children” to refer to 6 to 11 years of age, and “adolescents” to 12 to 17 years of age. If otherwise, and when possible, we will use a specific age or age range.

    Defining Childhood Obesity

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    Source: KidSource.com

    Between 5-25 percent of children and teenagers in the United States are obese (Dietz, 1983). As with adults, the prevalence of obesity in the young varies by ethnic group. It is estimated that 5-7 percent of White and Black children are obese, while 12 percent of Hispanic boys and 19 percent of Hispanic girls are obese (Office of Maternal and Child Health, 1989).

    Some data indicate that obesity among children is on the increase. The second National Children and Youth Fitness Study found 6-9 year olds to have thicker skinfolds than their counterparts in the 1960s (Ross & Pate, 1987). During the same period, others documented a 54 percent increase in the prevalence of obesity among 6-11 year olds (Gortmaker, Dietz, Sobol, & Wehler, 1987).

    Defining Obesity in Children and Adolescents

    Obesity is defined as an excessive accumulation of body fat. Obesity is present when total body weight is more than 25 percent fat in boys and more than 32 percent fat in girls (Lohman, 1987). Although childhood obesity is often defined as a weight-for-height in excess of 120 percent of the ideal, skinfold measures are more accurate determinants of fatness (Dietz, 1983; Lohman, 1987).

    A trained technician may obtain skinfold measures relatively easily in either a school or clinical setting. The triceps alone, triceps and subscapular, triceps and calf, and calf alone have been used with children and adolescents. When the triceps and calf are used, a sum of skinfolds of 10-25mm is considered optimal for boys, and 16-30mm is optimal for girls (Lohman, 1987).

    The Problem of Obesity

    Not all obese infants become obese children, and not all obese children become obese adults. However, the prevalence of obesity increases with age among both males and females (Lohman, 1987), and there is a greater likelihood that obesity beginning even in early childhood will persist through the life span (Epstein, Wing, Koeske, & Valoski, 1987).

    Obesity presents numerous problems for the child. In addition to increasing the risk of obesity in adulthood, childhood obesity is the leading cause of pediatric hypertension, is associated with Type II diabetes mellitus, increases the risk of coronary heart disease, increases stress on the weight-bearing joints, lowers self-esteem, and affects relationships with peers. Some authorities feel that social and psychological problems are the most significant consequences of obesity in children.

    Causes of Childhood Obesity

    As with adult-onset obesity, childhood obesity has multiple causes centering around an imbalance between energy in (calories obtained from food) and energy out (calories expended in the basal metabolic rate and physical activity). Childhood obesity most likely results from an interaction of nutritional, psychological, familial, and physiological factors.

    • The FamilyThe risk of becoming obese is greatest among children who have two obese parents (Dietz, 1983). This may be due to powerful genetic factors or to parental modeling of both eating and exercise behaviors, indirectly affecting the child’s energy balance. One half of parents of elementary school children never exercise vigorously (Ross & Pate, 1987).
    • Low-energy ExpenditureThe average American child spends several hours each day watching television; time which in previous years might have been devoted to physical pursuits. Obesity is greater among children and adolescents who frequently watch television (Dietz & Gortmaker, 1985), not only because little energy is expended while viewing but also because of concurrent consumption of high-calorie snacks. Only about one-third of elementary children have daily physical education, and fewer than one-fifth have extracurricular physical activity programs at their schools (Ross & Pate, 1987).
    • HereditySince not all children who eat non-nutritious foods, watch several hours of television daily, and are relatively inactive develop obesity, the search continues for alternative causes. Heredity has recently been shown to influence fatness, regional fat distribution, and response to overfeeding (Bouchard et al., 1990). In addition, infants born to overweight mothers have been found to be less active and to gain more weight by age three months when compared with infants of normal weight mothers, suggesting a possible inborn drive to conserve energy (Roberts, Savage, Coward, Chew, & Lucas, 1988).

    Treatment of Childhood Obesity

    Obesity treatment programs for children and adolescents rarely have weight loss as a goal. Rather, the aim is to slow or halt weight gain so the child will grow into his or her body weight over a period of months to years. Dietz (1983) estimates that for every 20 percent excess of ideal body weight, the child will need one and one-half years of weight maintenance to attain ideal body weight.

    Early and appropriate intervention is particularly valuable. There is considerable evidence that childhood eating and exercise habits are more easily modified than adult habits (Wolf, Cohen, Rosenfeld, 1985). Three forms of intervention include:

    1. Physical ActivityAdopting a formal exercise program, or simply becoming more active, is valuable to burn fat, increase energy expenditure, and maintain lost weight. Most studies of children have not shown exercise to be a successful strategy for weight loss unless coupled with another intervention, such as nutrition education or behavior modification (Wolf et al., 1985). However, exercise has additional health benefits. Even when children’s body weight and fatness did not change following 50 minutes of aerobic exercise three times per week, blood lipid profiles and blood pressure did improve (Becque, Katch, Rocchini, Marks, & Moorehead, 1988).
    2. Diet ManagementFasting or extreme caloric restriction is not advisable for children. Not only is this approach psychologically stressful, but it may adversely affect growth and the child’s perception of “normal” eating. Balanced diets with moderate caloric restriction, especially reduced dietary fat, have been used successfully in treating obesity (Dietz, 1983). Nutrition education may be necessary. Diet management coupled with exercise is an effective treatment for childhood obesity (Wolf et al., 1985).
    3. Behavior ModificationMany behavioral strategies used with adults have been successfully applied to children and adolescents: self-monitoring and recording food intake and physical activity, slowing the rate of eating, limiting the time and place of eating, and using rewards and incentives for desirable behaviors. Particularly effective are behaviorally based treatments that include parents (Epstein et al., 1987). Graves, Meyers, and Clark (1988) used problem-solving exercises in a parent-child behavioral program and found children in the problem-solving group, but not those in the behavioral treatment-only group, significantly reduced percent overweight and maintained reduced weight for six months. Problem-solving training involved identifying possible weight-control problems and, as a group, discussing solutions.

    Prevention of Childhood Obesity

    Obesity is easier to prevent than to treat, and prevention focuses in large measure on parent education. In infancy, parent education should center on promotion of breastfeeding, recognition of signals of satiety, and delayed introduction of solid foods. In early childhood, education should include proper nutrition, selection of low-fat snacks, good exercise/activity habits, and monitoring of television viewing. In cases where preventive measures cannot totally overcome the influence of hereditary factors, parent education should focus on building self-esteem and address psychological issues.

    References

    References identified with an EJ or ED number have been abstracted and are in the ERIC data base. Journal articles (EJ) should be available at most research libraries; documents (ED) are available in ERIC microfiche collections at more than 700 locations. Documents can also be ordered through the ERIC Document Reproduction Service: (800) 443-3742. For more information contact the ERIC Clearinghouse on Teacher Education, One Dupont Circle, NW, Suite 610, Washington, DC 20036; (202) 293-2450.

    Becque, M. D., Katch, V. L., Rocchini, A. P., Marks, C. R., & Moorehead, C. (1988). Coronary risk incidence of obese adolescents: Reduction by exercise plus diet intervention. Pediatrics, 81(5), 605-612.

    Bouchard, C., Tremblay, A., Despres, J-P, Nadeau, A., Lupien, P. J., Theriault, G., Dussault, J., Moorjani, S., Pinault, S., and Fournier, G. (1990). The response to long-term overfeeding in identical twins. The New England Journal of Medicine, 322(21), 1477-1482.

    Dietz, W. H., & Gortmaker, S. L. (1985). Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics, 75(5), 807-812.

    Dietz, W. H. (1983). Childhood obesity: Susceptibility, cause, and management. Journal of Pediatrics, 103(5), 676-686.

    Epstein, L. H., Wing, R. R., Koeske, R., & Valoski, A. (1987). Long-term effects of family-based treatment of childhood obesity. Journal of Consulting and Clinical Psychology, 55(1), 91-95. EJ 352 076.

    Gortmaker, S. L., Dietz, W. H., Sobol, A. M., & Wehler, C. A. (1987). Increasing pediatric obesity in the United States. American Journal of Diseases of Children, 141, 535-540.

    Graves, T., Meyers, A. W., & Clark, L. (1988). An evaluation of parental problem-solving training in the behavioral treatment of childhood obesity. Journal of Consulting and Clinical Psychology, 56(2), 246-250. EJ 373 116.

    Lohman, T. G. (1987). The use of skinfolds to estimate body fatness on children and youth. Journal of Physical Education, Recreation & Dance, 58(9), 98-102. EJ 364 412.

    Office of Maternal and Child Health. (1989). Child health USA ‘89. Washington, DC: U.S. Department of Health and Human Services, National Maternal and Child Health Clearinghouse. ED 314 421

    Roberts, S. B., Savage, J., Coward, W. A., Chew, B., & Lucas, A. (1988). Energy expenditure and intake in infants born to lean and overweight mothers. The New England Journal of Medicine, 318, 461-466.

    Ross, J. G., & Pate, R. R. (1987). The National Children and Youth Fitness Study II: A summary of findings. Journal of Physical Education, Recreation and Dance, 58(9), 51-56. EJ 364 411.

    Wolf, M. C., Cohen, K. R., & Rosenfeld, J. G. (1985). School-based interventions for obesity: Current approaches and future prospects. Psychology in the Schools, 22, 187-200. EJ 318 072.