What is being done to fight child obesity in Kentucky, which ranks third nationally in the problem? (second in a series)

Students in Kenton County Schools sample kale chips
as part of an effort to incorporate more fruit and
vegetables into their diets. (School district photo)

By Tara Kaprowy
Kentucky Health News

Now that all schools are back in session, cafeterias in every corner of Kentucky are bustling with students sweeping through lunch lines, sitting down with their best friends and sampling their meal.

It's in these loud, boisterous rooms that the fight against childhood obesity, which is higher in Kentucky than in all but a few states, is beginning to take shape.

Many children eat more than half their calories at school, but schools are just one of the battlegrounds. Across the country and the state, there are initiatives that are gaining traction to take a bite out of the problem.

When school started this year, the 556,000 Kentucky kids who get their lunch from school cafeterias may have noticed a more apples and oranges on their plates. With the goal of creating a healthier school environment, the United States Department of Agriculture has revamped school lunch regulations for the first time in 15 years. Many of the changes involve what some see as the saviors of kids caught in the obesity epidemic: fruit and vegetables.

In order for lunches to qualify for School Lunch Program funding, students now must have at least one serving of fruit or vegetables on their plate by the time they reach the cash register. And "vegetable" no longer just means French fries. And at least once each week, schools must serve a green, leafy vegetable like broccoli or spinach, plus an orange or red vegetable like carrots, and a legume like lentils or chickpeas, which are a good blend of protein and carbohydrates with very little fat.

Food service directors are optimistic elementary students
will adjust to school lunch changes, but high schoolers
are a different story. (Kenton County Schools photo)

Will students actually eat those foods? Julia Bauscher, food service director at Jefferson County Public Schools, is optimistic about elementary school students. So is Ginger Gray, director of food services in Kenton County, who has been serving such vegetable dishes as broccoli parmesan and kale chips for several years.

"Kids are more open to trying new things than adults realize." Gray said, but "It takes persistence. You can't just say I tried it once and kids didn't eat it so you don't try it again." 

High school students are a harder sell. Sylvia Moore, child nutrition and food service director at Mercer County Schools, said lunch participation rates have dropped by about 5 percent since the beginning of the school year. "Just this week I was up at the high school to stand at the garbage can. I was just there a minute when a girl came and tossed her totally-untouched orange in front of me," she said. "We are already making healthier garbage cans," not healthier students, she added.

The media angle

Another nationwide effort involves what children see on TV, which could have a big impact. A 2009 study found they average more than 32 hours a week. Excessive TV viewing is linked to a sedentary lifestyle, and American children see about $1.6 billion a year worth of food and beverage marketing. "It's a double-whammy," said Josh Golin, associate director for the Campaign for Commercial-Free Childhood. "It's the combination of not moving, and being urged to consume unhealthy food."

(Kentucky  Health News photo)

By 2015, that will change on channels of the Walt Disney Co., which will no longer put ads for products like Capri Sun and Kraft Lunchables (left), as well as a variety of candy, sugared cereal and fast food.

The television show iCarly, popular on Nickelodeon, is approaching the issue differently, encouraging viewers to create their own wacky veggie dish and submit the recipe for the "iCarly iCook with BirdsEye" intiative. Spots on the channel show the kinds of dishes the contest wants, like a "veggie sundae," which consists of a scoop of carrots, cauliflower and broccoli in a banana split dish.

A 2006 study showed 88 percent of the food ads on Nickeldeon promoted unhealthy food. A year later the channel announced its characters like Dora the Explorer and SpongeBob SquarePants would be licensed to sell only healthy foods; that's why Dora appears on packages of frozen edamame -- green soybeans, often in their pods.

Teaching the basics, and behaviors

Statewide programs are also infiltrating directly into communities. One involves cooking classes, with teachers from the University of Kentucky's Nutrition Education Program setting up demonstrations everywhere from public housing to women's crisis centers to church basements.

For 10 weeks, the teachers educate low-income adults about the basics of cooking with the hope they will change the way they feed their families. "We talk to them about how to use coupons, how to use dried beans instead of canned beans, how to use those leftovers and how to stretch their food dollars so they can provide good-tasting and nutritious food," said Debra Cotterill, the program's director.

The 43-year-old program was created to teach people how to use government commodities, like big blocks of cheese, that they received in the 1970s. Since obesity has become so prevalent, Cotterill said the emphasis has changed and interest in classes is up dramatically. In fact, Cotterill said the extension program's whole mission has expanded.

"It is not enough to share information, we also have a responsibility to help change behaviors," she said. "Now, all agents do some type of nutrition education in their work somewhere or other, even the ag agents, because it's become such a problem in our counties."

State regulations lack some specificity

Since many children entering kindergarten are already overweight, state government is examining preschools and daycare centers to see what policies they have in place when it comes to nutrition and physical activity. Though there are state regulations for licensed child care centers, "the language is not specific," explained Elaine Russell, the state's obesity prevention coordinator. For example,  regulations say bread should be served with meals, but don't specify the type of bread, such as whole grain or whole wheat, and don't prohibit high-fat snacks or sugar-sweetened beverages.

As part of a pilot program, state workers went to nine facilities each in Northern Kentucky, the lower Green River region and the Barren River region to assess their policies, teach directors and staff about obesity in Kentucky and discuss goals with directors and staff about their goals.

They also taught them the program 5-2-1-0, a catchy way of reminding students they should have five servings of vegetables each day, no more than two hours of screen time, at least one hour of physical activity and drink zero sugary beverages. The program is being pushed by pediatricians and at offices where poor mothers sign up for the Women, Infants and Children nutrition program. "Our goal is to make sure our parents hear this from more than one spot," Russell said. "We can change these policies but unless parents understand why we're making them, they probably won't stick."

Many facilities in the pilot program didn't have wellness policies before the process, but all did afterward. However, Russell would also like to see child-care centers adopt the standards for nutrition and physical activity as suggested in Caring for Our Children: National Health and Safety Performance Standards, which have stronger guidelines that promote active play every day and follow minimum standards as recommended by the USDA's Child and Adult Care Food Program. "Some states require at least two hours of physical activity a day, she said. "Physical activity is encouraged in Kentucky, but it's not specified. Kentucky rules do limit screen time, but kids are still allowed to watch two hours a day."

An early start

Some programs focus on even younger children, including infants, and pregnant women. "A lot of times when we talk about childhood obesity, we kind of default into talking about school-age kids," said Amy Swann, senior policy analyst for Kentucky Youth Advocates. "But if we're going to take a really multi-faceted approach, what we now know is it actually starts with the mother's nutrition while she's pregnant."

(University of Louisville Hospital photo)

That idea is behind the Kangaroo Care Initiative, which promotes skin-to-skin contact with new mothers and their babies in order to promote breastfeeding and bonding. Among other benefits, breastfeeding can help reduce the risk of obesity. One study showed children who were breastfed were 22 percent less likely to be overweight by age 14, said Marlene Goodlett, Kentucky's breastfeeding coordinator.

The effort started in 2007 with the University of Louisville's Hospital Center for Women and Infants. This year, U of L partnered with the WIC program to train all 51 birthing hospitals in the state. Now, 84 percent of them have implemented Kangaroo Care. One of the first hospitals on board was Flaget Memorial Hospital in Bardstown, where breastfeeding rates increased to 61 percent from 49 percent.

Community lessons

From a walking trail mowed on land owned by the community hospital in Winchester, to the Hopkinsville farmers' market accepting food stamps, there are local efforts to combat obesity in place that, inch by inch, are causing change.

(Photo by Steve Patton, UK College of Agriculture)

These success stories are detailed in the report "Shaping Kentucky's Future: A Community Guide to Reducing Obesity," funded in part by the state health department, which illustrates ways Kentucky communities are making policy, environmental and systems changes.

One of these is the Better Bites program in Lexington, a revamp of how food is sold at swimming-pool concession stands in Lexington. "We learned you could exercise at the pool for two hours, go to the concession and get a standard hamburger, fries and soft drink combo and you would actually take in more calories that you're burning. That was a shocking statistic for us and really propelled us along," said Brian Rogers, deputy director of enterprise at Lexington Parks and Recreation. Organizers introduced menu items like yogurt and fresh fruit, replaced hot dogs with turkey dogs, standard popcorn with low-fat popcorn and sold only baked chips at two public swimming pools in the city starting last year. This summer, candy sales went down 20 percent. and the Better Bites menu items constituted 15 to 20 percent of all sales, up from 10 percent last summer, Rogers said.

Berea is concentrating its efforts on environmental change with its Complete Streets project, which is aimed at making the city's streets more accessible to walking and biking. Two major projects — a bridge project that includes sidewalks and bike lanes and a three-mile trail that connects downtown with the Indian Fort Theatre — are opening up much more territory to pedestrians. The city has coupled these efforts with simple changes like making walkways more visible, installing bike racks around town, and changing the timing on lights to give pedestrians more time to cross the road.

Mayor Steve Connelly said the effort is about culture change. "I do think that we have perhaps by accident created these barriers to walk and bike largely since the 1950s when America really fell in love with the Interstate, franchise restaurants, the suburbs and the automobile," he said. "Really, we need to get back to walking as second nature." With each installation of more sidewalks and trails, though, that is exactly what is happening, Connelly said. "It's the classic when you build it, they're out there using them," he said.

Still a way to go

While progress is being made, experts say the nation is just beginning to round the corner on the problem. Though some studies show childhood obesity and overweight rates may be leveling off, many kids are simply graduating from the overweight to the even more unhealthy obese category, said Dr. Christopher Bolling, a Kenton County pediatrician.

After a visit this fall to school cafeterias to document changes that are happening there, perhaps reporter Lenny Bernstein said it best in The Washington Post: "If we don't yet know how well we're doing in this battle, we are at least figuring out how to develop our weapons."

NEXT: Why the obesity epidemic is such a difficult problem to solve.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Students in Kenton County Schools sample kale chips
as part of an effort to incorporate more fruit and
vegetables into their diets. (School district photo)

By Tara Kaprowy
Kentucky Health News

Now that all schools are back in session, cafeterias in every corner of Kentucky are bustling with students sweeping through lunch lines, sitting down with their best friends and sampling their meal.

It's in these loud, boisterous rooms that the fight against childhood obesity, which is higher in Kentucky than in all but a few states, is beginning to take shape.

Many children eat more than half their calories at school, but schools are just one of the battlegrounds. Across the country and the state, there are initiatives that are gaining traction to take a bite out of the problem.

When school started this year, the 556,000 Kentucky kids who get their lunch from school cafeterias may have noticed a more apples and oranges on their plates. With the goal of creating a healthier school environment, the United States Department of Agriculture has revamped school lunch regulations for the first time in 15 years. Many of the changes involve what some see as the saviors of kids caught in the obesity epidemic: fruit and vegetables.

In order for lunches to qualify for School Lunch Program funding, students now must have at least one serving of fruit or vegetables on their plate by the time they reach the cash register. And "vegetable" no longer just means French fries. And at least once each week, schools must serve a green, leafy vegetable like broccoli or spinach, plus an orange or red vegetable like carrots, and a legume like lentils or chickpeas, which are a good blend of protein and carbohydrates with very little fat.

Food service directors are optimistic elementary students
will adjust to school lunch changes, but high schoolers
are a different story. (Kenton County Schools photo)

Will students actually eat those foods? Julia Bauscher, food service director at Jefferson County Public Schools, is optimistic about elementary school students. So is Ginger Gray, director of food services in Kenton County, who has been serving such vegetable dishes as broccoli parmesan and kale chips for several years.

"Kids are more open to trying new things than adults realize." Gray said, but "It takes persistence. You can't just say I tried it once and kids didn't eat it so you don't try it again." 

High school students are a harder sell. Sylvia Moore, child nutrition and food service director at Mercer County Schools, said lunch participation rates have dropped by about 5 percent since the beginning of the school year. "Just this week I was up at the high school to stand at the garbage can. I was just there a minute when a girl came and tossed her totally-untouched orange in front of me," she said. "We are already making healthier garbage cans," not healthier students, she added.

The media angle

Another nationwide effort involves what children see on TV, which could have a big impact. A 2009 study found they average more than 32 hours a week. Excessive TV viewing is linked to a sedentary lifestyle, and American children see about $1.6 billion a year worth of food and beverage marketing. "It's a double-whammy," said Josh Golin, associate director for the Campaign for Commercial-Free Childhood. "It's the combination of not moving, and being urged to consume unhealthy food."

(Kentucky  Health News photo)

By 2015, that will change on channels of the Walt Disney Co., which will no longer put ads for products like Capri Sun and Kraft Lunchables (left), as well as a variety of candy, sugared cereal and fast food.

The television show iCarly, popular on Nickelodeon, is approaching the issue differently, encouraging viewers to create their own wacky veggie dish and submit the recipe for the "iCarly iCook with BirdsEye" intiative. Spots on the channel show the kinds of dishes the contest wants, like a "veggie sundae," which consists of a scoop of carrots, cauliflower and broccoli in a banana split dish.

A 2006 study showed 88 percent of the food ads on Nickeldeon promoted unhealthy food. A year later the channel announced its characters like Dora the Explorer and SpongeBob SquarePants would be licensed to sell only healthy foods; that's why Dora appears on packages of frozen edamame -- green soybeans, often in their pods.

Teaching the basics, and behaviors

Statewide programs are also infiltrating directly into communities. One involves cooking classes, with teachers from the University of Kentucky's Nutrition Education Program setting up demonstrations everywhere from public housing to women's crisis centers to church basements.

For 10 weeks, the teachers educate low-income adults about the basics of cooking with the hope they will change the way they feed their families. "We talk to them about how to use coupons, how to use dried beans instead of canned beans, how to use those leftovers and how to stretch their food dollars so they can provide good-tasting and nutritious food," said Debra Cotterill, the program's director.

The 43-year-old program was created to teach people how to use government commodities, like big blocks of cheese, that they received in the 1970s. Since obesity has become so prevalent, Cotterill said the emphasis has changed and interest in classes is up dramatically. In fact, Cotterill said the extension program's whole mission has expanded.

"It is not enough to share information, we also have a responsibility to help change behaviors," she said. "Now, all agents do some type of nutrition education in their work somewhere or other, even the ag agents, because it's become such a problem in our counties."

State regulations lack some specificity

Since many children entering kindergarten are already overweight, state government is examining preschools and daycare centers to see what policies they have in place when it comes to nutrition and physical activity. Though there are state regulations for licensed child care centers, "the language is not specific," explained Elaine Russell, the state's obesity prevention coordinator. For example,  regulations say bread should be served with meals, but don't specify the type of bread, such as whole grain or whole wheat, and don't prohibit high-fat snacks or sugar-sweetened beverages.

As part of a pilot program, state workers went to nine facilities each in Northern Kentucky, the lower Green River region and the Barren River region to assess their policies, teach directors and staff about obesity in Kentucky and discuss goals with directors and staff about their goals.

They also taught them the program 5-2-1-0, a catchy way of reminding students they should have five servings of vegetables each day, no more than two hours of screen time, at least one hour of physical activity and drink zero sugary beverages. The program is being pushed by pediatricians and at offices where poor mothers sign up for the Women, Infants and Children nutrition program. "Our goal is to make sure our parents hear this from more than one spot," Russell said. "We can change these policies but unless parents understand why we're making them, they probably won't stick."

Many facilities in the pilot program didn't have wellness policies before the process, but all did afterward. However, Russell would also like to see child-care centers adopt the standards for nutrition and physical activity as suggested in Caring for Our Children: National Health and Safety Performance Standards, which have stronger guidelines that promote active play every day and follow minimum standards as recommended by the USDA's Child and Adult Care Food Program. "Some states require at least two hours of physical activity a day, she said. "Physical activity is encouraged in Kentucky, but it's not specified. Kentucky rules do limit screen time, but kids are still allowed to watch two hours a day."

An early start

Some programs focus on even younger children, including infants, and pregnant women. "A lot of times when we talk about childhood obesity, we kind of default into talking about school-age kids," said Amy Swann, senior policy analyst for Kentucky Youth Advocates. "But if we're going to take a really multi-faceted approach, what we now know is it actually starts with the mother's nutrition while she's pregnant."

(University of Louisville Hospital photo)

That idea is behind the Kangaroo Care Initiative, which promotes skin-to-skin contact with new mothers and their babies in order to promote breastfeeding and bonding. Among other benefits, breastfeeding can help reduce the risk of obesity. One study showed children who were breastfed were 22 percent less likely to be overweight by age 14, said Marlene Goodlett, Kentucky's breastfeeding coordinator.

The effort started in 2007 with the University of Louisville's Hospital Center for Women and Infants. This year, U of L partnered with the WIC program to train all 51 birthing hospitals in the state. Now, 84 percent of them have implemented Kangaroo Care. One of the first hospitals on board was Flaget Memorial Hospital in Bardstown, where breastfeeding rates increased to 61 percent from 49 percent.

Community lessons

From a walking trail mowed on land owned by the community hospital in Winchester, to the Hopkinsville farmers' market accepting food stamps, there are local efforts to combat obesity in place that, inch by inch, are causing change.

(Photo by Steve Patton, UK College of Agriculture)

These success stories are detailed in the report "Shaping Kentucky's Future: A Community Guide to Reducing Obesity," funded in part by the state health department, which illustrates ways Kentucky communities are making policy, environmental and systems changes.

One of these is the Better Bites program in Lexington, a revamp of how food is sold at swimming-pool concession stands in Lexington. "We learned you could exercise at the pool for two hours, go to the concession and get a standard hamburger, fries and soft drink combo and you would actually take in more calories that you're burning. That was a shocking statistic for us and really propelled us along," said Brian Rogers, deputy director of enterprise at Lexington Parks and Recreation. Organizers introduced menu items like yogurt and fresh fruit, replaced hot dogs with turkey dogs, standard popcorn with low-fat popcorn and sold only baked chips at two public swimming pools in the city starting last year. This summer, candy sales went down 20 percent. and the Better Bites menu items constituted 15 to 20 percent of all sales, up from 10 percent last summer, Rogers said.

Berea is concentrating its efforts on environmental change with its Complete Streets project, which is aimed at making the city's streets more accessible to walking and biking. Two major projects — a bridge project that includes sidewalks and bike lanes and a three-mile trail that connects downtown with the Indian Fort Theatre — are opening up much more territory to pedestrians. The city has coupled these efforts with simple changes like making walkways more visible, installing bike racks around town, and changing the timing on lights to give pedestrians more time to cross the road.

Mayor Steve Connelly said the effort is about culture change. "I do think that we have perhaps by accident created these barriers to walk and bike largely since the 1950s when America really fell in love with the Interstate, franchise restaurants, the suburbs and the automobile," he said. "Really, we need to get back to walking as second nature." With each installation of more sidewalks and trails, though, that is exactly what is happening, Connelly said. "It's the classic when you build it, they're out there using them," he said.

Still a way to go

While progress is being made, experts say the nation is just beginning to round the corner on the problem. Though some studies show childhood obesity and overweight rates may be leveling off, many kids are simply graduating from the overweight to the even more unhealthy obese category, said Dr. Christopher Bolling, a Kenton County pediatrician.

After a visit this fall to school cafeterias to document changes that are happening there, perhaps reporter Lenny Bernstein said it best in The Washington Post: "If we don't yet know how well we're doing in this battle, we are at least figuring out how to develop our weapons."

NEXT: Why the obesity epidemic is such a difficult problem to solve.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Read More

Child obesity is a complex problem, intimidating to those who are fighting it (last in a series)

Dr. Christopher Bolling prepares to see a patient.

By Tara Kaprowy
Kentucky Health News

Nearly every weekday, pediatrician Christopher Bolling starts his day by scooping up his lap top and stepping into one of his cheerfully-appointed exam rooms. After greeting his young patients, who are generally passing the time by playing games on their parents' cell phones, Bolling begins his examinations. During his 21 years of practice, those exams have increasingly ended with Bolling counseling parents about their children's weight.

"I tell them I'm not worried about this as a cosmetic issue, I'm worried about this as a health issue," he said in an interview. "This isn't about your child being ugly or undesirable, we talk about them being healthy and not healthy."

But, though dedicated to his cause, Bolling, of Crestview Hills in Kenton County, said he is keenly aware that his counseling is not nearly enough to help his patients overcome the weight that is impeding their health. "What makes this problem unique is it is so multifactorial, there are so many pieces to it," he said. "It's food, it's activity, it's portion size, it's fruit and vegetables, it's screen time and safety. And it makes it really intimidating to know what to do with it."

"We're swimming upstream in a flooded river," agreed Debra Cotterill, director of the Nutrition Education Program at the University of Kentucky. "Even for people who know it, it's still hard. Weight is an issue I have to address every single day of my life and I understand how it is for people. You're talking about change of behaviors."

It's like smoking, but it's different

But a sweeping change in behavior is going to be what it takes to turn the tide of the obesity epidemic, experts say, and that is one reason fighting obesity is often likened to the battle against smoking. The fact that it is just as, if not more, deadly is another parallel, as is the fact that it is just as, if not more, far-reaching.

But there are key differences in battling the two problems, Judith Graham noted in a story for Kaiser Health News. First, other than an increase in health-care costs, there is no compelling argument that implies that another person's weight adversely affects others, like second-hand smoking does for smoking, or drunk driving does for drinking to excess. "The notion that my behavior as a smoker can have an effect on you and can make you sick was critically important in accelerating people's intolerance of smoking and their willingness to see the government take action," Michael Ericksen, director of the Institute of Public Health at Georgia State University, told Graham.

Compounding the issue is there is nearly no end to the variety of food that can contribute to the problem. Unlike Big Tobacco, the food industry also cannot be demonized as easily, Graham points out. But most importantly, "unlike alcohol and tobacco, you can't go cold turkey on food," Bolling said. "You have to keep eating."

But if there is consensus on how to approach the issue, it is to take a lesson from the battle against smoking, which is to focus on changing the environment that encourages bad habits. "It's about changing our culture," explained Elaine Russell, Kentucky's obesity prevention coordinator. "We need an environment where the healthy choice is the easy choice."

That involves policy change, setting up systems that support the policy changes, and environmental change, Russell said, all of which have to happen together. "There's no one solution that's going to do it," she said. "If we embed it in our policies, but we don't embed it into our environment, how do we make the healthier choice? If we just educate people but we don't provide them with a healthy environment, then how do they make those healthy choices? We could do an educational campaign at our worksite, but if we have unhealthy vending machines there, how can you make the changes?"

Local action is needed

Russell said change needs to happen at the local level, since every community has different needs and "starts with high-level partners really being engaged," she said. "We need to pull together those leaders and ask them what the highest priority is, ask them what feasibly can be done and start checking them off."

Some of those changes can be as easy as placing bananas and apples at the front of the pool concession stand so children see them first, as they did in Lexington. The same is being done in school cafeteria lines. But others cost money that communities don't necessarily have, as the Healthy Children's Task Force learned in Laurel County when trying to assess students' body-mass index, a rough measure of fat to weight.

In 2005, the task force started collecting BMIs of a select group of children in kindergarten to see where the county stood. It found 37 percent were either overweight or obese, and quickly decided the goal should be to bring that number down to 31 percent, the statewide average at the time. Using a grant from the parent company of the local hospital, they talked to parents, hired gym teachers, had schools incorporate 10 minutes of physical activity in the classroom periodically during the day, talked to kids about nutrition, and got them to cook and sample fruit and vegetables from a mobile demonstration kitchen.

The overweight rates of the children, who were repeatedly assessed each year, did decrease by the targeted 6 percent, but when funding ran out, the program faltered. For a few years, part of the effort was restored, but the task force has disbanded. "You get real gung-ho on it and something else comes along," said school nurse Duff Holcomb, who led the effort. "It makes me feel terribly guilty, but that is just the way it is. We proved what works."

After a recent analysis showed 12 states, including Kentucky, have adult obesity levels over 30 percent, Jeffrey Levi, executive director of Trust for America's Health, acknowledged the financial problem: "We're not investing anywhere near what we need to in order to bend the obesity curve and see the returns in health and savings."

(Photos by Tara Kaprowy)

More regulation is one option, a move that is generally cheap in cost but can be politically expensive. New York City Mayor Michael Bloomberg is learning that, after proposing a ban in New York City on the sale of supersize sodas and other sugary drinks by restaurants, movie theaters and street carts. Residents are deeply divided on the issue — 60 percent oppose the ban — and critics have lambasted Bloomberg, accusing him of running a "nanny state."

But limiting food and drink choices may have an effect on people's health, a recent study indicates. The removal of trans fats from many processed and fast foods like French fries and cookies probably reduced the proportion of kids with high cholesterol in the past decade, researchers think.

More regulation, particularly in how food is marketed to children, is what Josh Golin, associate director for the Campaign for Commercial-Free Childhood, would like to see. "We can't rely on the companies to self-regulate or develop their own policies," he said. "We see a lot of self-serving regulations that vary from company to company. What we really need is to level the playing field and make the rules enforceable."

In addition, Bolling suggested "there are several organizations that advocate that we could make a big impact on childhood obesity by placing an excise tax on sodas." A report by the Rudd Center for Food Policy and Obesity at Yale University indicated that a 10 percent tax on soft drinks would result in about an 8 percent reduction in consumption. Studies on alcohol and tobacco taxes indicate similar findings. A Rudd Center calculator shows a 1-cent tax on each ounce of sugar-sweetened beverages sold in Kentucky could result in nearly $200 million in revenue for the state.

Whether regulation or investing more money in the problem are part of the solution, Bolling said solving the problem will take time and a variety of efforts. "We have to solve everything together," he said. "It's about personal responsibility, but it's also about supportive families, it's about primary care medical people knowing what to say to their patients, it's about workplaces and schools creating good environments and it's communities providing opportunities to be healthy. I think we're going to turn the tide. We've done it before with seat belts, with bicycle helmets, with smoking. While this problem is complicated, we already see people really waking up to it."

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Dr. Christopher Bolling prepares to see a patient.

By Tara Kaprowy
Kentucky Health News

Nearly every weekday, pediatrician Christopher Bolling starts his day by scooping up his lap top and stepping into one of his cheerfully-appointed exam rooms. After greeting his young patients, who are generally passing the time by playing games on their parents' cell phones, Bolling begins his examinations. During his 21 years of practice, those exams have increasingly ended with Bolling counseling parents about their children's weight.

"I tell them I'm not worried about this as a cosmetic issue, I'm worried about this as a health issue," he said in an interview. "This isn't about your child being ugly or undesirable, we talk about them being healthy and not healthy."

But, though dedicated to his cause, Bolling, of Crestview Hills in Kenton County, said he is keenly aware that his counseling is not nearly enough to help his patients overcome the weight that is impeding their health. "What makes this problem unique is it is so multifactorial, there are so many pieces to it," he said. "It's food, it's activity, it's portion size, it's fruit and vegetables, it's screen time and safety. And it makes it really intimidating to know what to do with it."

"We're swimming upstream in a flooded river," agreed Debra Cotterill, director of the Nutrition Education Program at the University of Kentucky. "Even for people who know it, it's still hard. Weight is an issue I have to address every single day of my life and I understand how it is for people. You're talking about change of behaviors."

It's like smoking, but it's different

But a sweeping change in behavior is going to be what it takes to turn the tide of the obesity epidemic, experts say, and that is one reason fighting obesity is often likened to the battle against smoking. The fact that it is just as, if not more, deadly is another parallel, as is the fact that it is just as, if not more, far-reaching.

But there are key differences in battling the two problems, Judith Graham noted in a story for Kaiser Health News. First, other than an increase in health-care costs, there is no compelling argument that implies that another person's weight adversely affects others, like second-hand smoking does for smoking, or drunk driving does for drinking to excess. "The notion that my behavior as a smoker can have an effect on you and can make you sick was critically important in accelerating people's intolerance of smoking and their willingness to see the government take action," Michael Ericksen, director of the Institute of Public Health at Georgia State University, told Graham.

Compounding the issue is there is nearly no end to the variety of food that can contribute to the problem. Unlike Big Tobacco, the food industry also cannot be demonized as easily, Graham points out. But most importantly, "unlike alcohol and tobacco, you can't go cold turkey on food," Bolling said. "You have to keep eating."

But if there is consensus on how to approach the issue, it is to take a lesson from the battle against smoking, which is to focus on changing the environment that encourages bad habits. "It's about changing our culture," explained Elaine Russell, Kentucky's obesity prevention coordinator. "We need an environment where the healthy choice is the easy choice."

That involves policy change, setting up systems that support the policy changes, and environmental change, Russell said, all of which have to happen together. "There's no one solution that's going to do it," she said. "If we embed it in our policies, but we don't embed it into our environment, how do we make the healthier choice? If we just educate people but we don't provide them with a healthy environment, then how do they make those healthy choices? We could do an educational campaign at our worksite, but if we have unhealthy vending machines there, how can you make the changes?"

Local action is needed

Russell said change needs to happen at the local level, since every community has different needs and "starts with high-level partners really being engaged," she said. "We need to pull together those leaders and ask them what the highest priority is, ask them what feasibly can be done and start checking them off."

Some of those changes can be as easy as placing bananas and apples at the front of the pool concession stand so children see them first, as they did in Lexington. The same is being done in school cafeteria lines. But others cost money that communities don't necessarily have, as the Healthy Children's Task Force learned in Laurel County when trying to assess students' body-mass index, a rough measure of fat to weight.

In 2005, the task force started collecting BMIs of a select group of children in kindergarten to see where the county stood. It found 37 percent were either overweight or obese, and quickly decided the goal should be to bring that number down to 31 percent, the statewide average at the time. Using a grant from the parent company of the local hospital, they talked to parents, hired gym teachers, had schools incorporate 10 minutes of physical activity in the classroom periodically during the day, talked to kids about nutrition, and got them to cook and sample fruit and vegetables from a mobile demonstration kitchen.

The overweight rates of the children, who were repeatedly assessed each year, did decrease by the targeted 6 percent, but when funding ran out, the program faltered. For a few years, part of the effort was restored, but the task force has disbanded. "You get real gung-ho on it and something else comes along," said school nurse Duff Holcomb, who led the effort. "It makes me feel terribly guilty, but that is just the way it is. We proved what works."

After a recent analysis showed 12 states, including Kentucky, have adult obesity levels over 30 percent, Jeffrey Levi, executive director of Trust for America's Health, acknowledged the financial problem: "We're not investing anywhere near what we need to in order to bend the obesity curve and see the returns in health and savings."

(Photos by Tara Kaprowy)

More regulation is one option, a move that is generally cheap in cost but can be politically expensive. New York City Mayor Michael Bloomberg is learning that, after proposing a ban in New York City on the sale of supersize sodas and other sugary drinks by restaurants, movie theaters and street carts. Residents are deeply divided on the issue — 60 percent oppose the ban — and critics have lambasted Bloomberg, accusing him of running a "nanny state."

But limiting food and drink choices may have an effect on people's health, a recent study indicates. The removal of trans fats from many processed and fast foods like French fries and cookies probably reduced the proportion of kids with high cholesterol in the past decade, researchers think.

More regulation, particularly in how food is marketed to children, is what Josh Golin, associate director for the Campaign for Commercial-Free Childhood, would like to see. "We can't rely on the companies to self-regulate or develop their own policies," he said. "We see a lot of self-serving regulations that vary from company to company. What we really need is to level the playing field and make the rules enforceable."

In addition, Bolling suggested "there are several organizations that advocate that we could make a big impact on childhood obesity by placing an excise tax on sodas." A report by the Rudd Center for Food Policy and Obesity at Yale University indicated that a 10 percent tax on soft drinks would result in about an 8 percent reduction in consumption. Studies on alcohol and tobacco taxes indicate similar findings. A Rudd Center calculator shows a 1-cent tax on each ounce of sugar-sweetened beverages sold in Kentucky could result in nearly $200 million in revenue for the state.

Whether regulation or investing more money in the problem are part of the solution, Bolling said solving the problem will take time and a variety of efforts. "We have to solve everything together," he said. "It's about personal responsibility, but it's also about supportive families, it's about primary care medical people knowing what to say to their patients, it's about workplaces and schools creating good environments and it's communities providing opportunities to be healthy. I think we're going to turn the tide. We've done it before with seat belts, with bicycle helmets, with smoking. While this problem is complicated, we already see people really waking up to it."

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

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Doctors' letter to the editor about the importance of physical activity is worthy of consideration from all Kentucky newspapers

Given its timeliness and message, Kentucky Health News encourages editors of Kentucky newspapers to consider publishing this compelling letter.

Physical activity — a daily staple

To the editor:

The 2012 London Olympics were a feast. Nobody with a hunger for sports, national rivalries or stories of individual struggles and accomplishment should have left the table unsatisfied. The Games served up a bounty of the very best.

After the feast, though, we need good, daily nutrition. Seeing the world's best athletes break records and vie for top honors, we can take their example and weave physical activity, exercise and sport into our daily lives. There's only one Usain Bolt, but millions of us run full-tilt through our careers and family life. The gymnastic magic of Gabby Douglas can inspire our headlong tumble through competing obligations and the flexibility to get it all done.

Translating Olympic activities into everyday life is more than a metaphor. With sedentary lifestyles linked to one in four deaths from non-communicable diseases, and with preventable conditions consuming unsustainable portions of health care costs, we must act individually and as a society to keep ourselves fit and healthy.

Food for thought

The facts are undeniable, and the evidence continues to mount. As the Games were poised to begin, no less an authority than The Lancet published a series of articles that underscore the extraordinary peril of physical inactivity for global health and national economies. Experts from Harvard, the Centers for Disease Control and Prevention, and around the world made the case for urgent action: "In view of the prevalence, global reach, and health effect of physical inactivity, the issue should be appropriately described as pandemic, with far-reaching health, economic, environmental, and social consequences."

The reality is that the United States will not be able to grow it economy fast enough or large enough to pay for the treatment of rising levels of highly avoidable diseases and conditions, many of which are related to low levels of physical activity. This calls for collective action to encourage and enable all people to become and remain more active, whether through activities of daily living, exercise or sports.

On an individual level, we will each benefit from meeting at least minimum guidelines for physical activity. The payoff is improved health and quality of life for the individual, greater productivity in the workplace, and lower health costs for all of us. The alternative is unthinkable.

That's food for thought, indeed. As we push back from the table, still savoring a 17-day feast of athletics and achievement, let's make a menu of physical activity part of our daily lives. Anything less is too hard to swallow.

Janet Walberg Rankin, president, American College of Sports Medicine
Dr. Robert Sallis, chair, "Exercise is Medicine" Global Initiative

Given its timeliness and message, Kentucky Health News encourages editors of Kentucky newspapers to consider publishing this compelling letter.

Physical activity — a daily staple

To the editor:

The 2012 London Olympics were a feast. Nobody with a hunger for sports, national rivalries or stories of individual struggles and accomplishment should have left the table unsatisfied. The Games served up a bounty of the very best.

After the feast, though, we need good, daily nutrition. Seeing the world's best athletes break records and vie for top honors, we can take their example and weave physical activity, exercise and sport into our daily lives. There's only one Usain Bolt, but millions of us run full-tilt through our careers and family life. The gymnastic magic of Gabby Douglas can inspire our headlong tumble through competing obligations and the flexibility to get it all done.

Translating Olympic activities into everyday life is more than a metaphor. With sedentary lifestyles linked to one in four deaths from non-communicable diseases, and with preventable conditions consuming unsustainable portions of health care costs, we must act individually and as a society to keep ourselves fit and healthy.

Food for thought

The facts are undeniable, and the evidence continues to mount. As the Games were poised to begin, no less an authority than The Lancet published a series of articles that underscore the extraordinary peril of physical inactivity for global health and national economies. Experts from Harvard, the Centers for Disease Control and Prevention, and around the world made the case for urgent action: "In view of the prevalence, global reach, and health effect of physical inactivity, the issue should be appropriately described as pandemic, with far-reaching health, economic, environmental, and social consequences."

The reality is that the United States will not be able to grow it economy fast enough or large enough to pay for the treatment of rising levels of highly avoidable diseases and conditions, many of which are related to low levels of physical activity. This calls for collective action to encourage and enable all people to become and remain more active, whether through activities of daily living, exercise or sports.

On an individual level, we will each benefit from meeting at least minimum guidelines for physical activity. The payoff is improved health and quality of life for the individual, greater productivity in the workplace, and lower health costs for all of us. The alternative is unthinkable.

That's food for thought, indeed. As we push back from the table, still savoring a 17-day feast of athletics and achievement, let's make a menu of physical activity part of our daily lives. Anything less is too hard to swallow.

Janet Walberg Rankin, president, American College of Sports Medicine
Dr. Robert Sallis, chair, "Exercise is Medicine" Global Initiative

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Kentucky students will get extra education in nutrition, exercise

Kentucky children will get extra nutrition education at school starting Oct. 1, thanks to a $6 million federal grant intended to instill better eating and physical-activity habits in families eligible for food stamps.

The education will be provided by local health departments. It will encourage students to:
• Fill half their plates with fruits and vegetables; drink fat-free or low-fat milk; and make sure they eat whole grains.
• Increase physical activity and cut down on sedentary behaviors.
• Consume the appropriate amount of calories for their age.

Kentucky students will get more nutrition education
aimed at getting those eligible for the Supplemental
Nutrition Assistance Program to make healthy food
choices. (Photo from The Lane Report)

Details about how many children will benefit from the education and how many minutes of instruction they will receive per week have not yet been ironed out, said Beth Fisher, spokeswoman for the Cabinet for Health and Family Services.

"Sometimes children can be the best teachers, so our hope is that they will pass on to their parents some of what they have learned at school about the importance of nutrition and physical activity," said Teresa James, acting commissioner of the Department of Community Based Services. "If children ask their parents to serve more fruits and vegetables, or take a walk instead of watching TV and the parents comply, this effort can benefit the entire household — just look at the influence children have had on recycling." (Read more)

Kentucky children will get extra nutrition education at school starting Oct. 1, thanks to a $6 million federal grant intended to instill better eating and physical-activity habits in families eligible for food stamps.

The education will be provided by local health departments. It will encourage students to:
• Fill half their plates with fruits and vegetables; drink fat-free or low-fat milk; and make sure they eat whole grains.
• Increase physical activity and cut down on sedentary behaviors.
• Consume the appropriate amount of calories for their age.

Kentucky students will get more nutrition education
aimed at getting those eligible for the Supplemental
Nutrition Assistance Program to make healthy food
choices. (Photo from The Lane Report)

Details about how many children will benefit from the education and how many minutes of instruction they will receive per week have not yet been ironed out, said Beth Fisher, spokeswoman for the Cabinet for Health and Family Services.

"Sometimes children can be the best teachers, so our hope is that they will pass on to their parents some of what they have learned at school about the importance of nutrition and physical activity," said Teresa James, acting commissioner of the Department of Community Based Services. "If children ask their parents to serve more fruits and vegetables, or take a walk instead of watching TV and the parents comply, this effort can benefit the entire household — just look at the influence children have had on recycling." (Read more)

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Being sedentary is just as deadly as smoking, series finds

Getty Images photo by George Doyle

Physical inactivity is such a problem worldwide it has become as deadly as smoking, a series of studies has found. Lack of exercise causes about one in 10 premature deaths worldwide, in large part because it contributes to heart disease, Type 2 diabetes, breast cancer and colon cancer.

"If physical inactivity could be reduced by just 10 percent, it could avert some 533,000 deaths a year; if reduced by 25 percent, 1.3 million deaths could be prevented," reports Alice Park for Time Healthland.

In a study published in the journal Lancet, researchers "calculated something called a population attributable fraction (PAF), a measure of the contribution of risk factors like physical inactivity to diseases such as heart disease or diabetes, and even risk of death," Park reports. That calculation indicated how many incidences of disease could have been prevented if people started exercising like they should. PAFs were calculated for 123 countries and showed overall that physical inactivity is responsible for 6 percent of heart disease, 7 percent of Type 2 diabetes and 10 percent of breast and colon cancers.

The numbers also showed people living in the Americas have the most physically inactive populations — 43 percent of people don't get enough exercise — while people who live in Southeast Asia are the most active. The Americas' reliance on cars and other vehicles is considered a major factor in their sedentary lifestyles, with just 4 percent of people in the U.S. walking to work and fewer than 2 percent using a bicycle to commute.

Experts say sufficient physical activity is the equivalent of 150 minutes of moderate exercise a week, which could mean 30 minutes of fast walking five times a week.

Another paper in the series pointed to steps people and communities can take to be more active: using signs to suggest taking the stairs rather than the elevator, or free exercise classes at public parks, for example. Maintaining streets and improving lighting can raise activity levels by 50 percent, some studies show. Researchers also discussed an effort in Bogotá, Colombia, where some city streets are closed to cars and vehicles on Sunday mornings and public holidays. Each week, about 1 million people show up to exercise. The effort has spread to Kentucky and been dubbed Second Sunday Kentucky.

Some experts took issue with the comparison with smoking, since "even if smoking and inactivity kill the same number of people, far fewer people smoke than are sedentary, making tobacco more risky to the individual," Park reports. (Read more)

Getty Images photo by George Doyle

Physical inactivity is such a problem worldwide it has become as deadly as smoking, a series of studies has found. Lack of exercise causes about one in 10 premature deaths worldwide, in large part because it contributes to heart disease, Type 2 diabetes, breast cancer and colon cancer.

"If physical inactivity could be reduced by just 10 percent, it could avert some 533,000 deaths a year; if reduced by 25 percent, 1.3 million deaths could be prevented," reports Alice Park for Time Healthland.

In a study published in the journal Lancet, researchers "calculated something called a population attributable fraction (PAF), a measure of the contribution of risk factors like physical inactivity to diseases such as heart disease or diabetes, and even risk of death," Park reports. That calculation indicated how many incidences of disease could have been prevented if people started exercising like they should. PAFs were calculated for 123 countries and showed overall that physical inactivity is responsible for 6 percent of heart disease, 7 percent of Type 2 diabetes and 10 percent of breast and colon cancers.

The numbers also showed people living in the Americas have the most physically inactive populations — 43 percent of people don't get enough exercise — while people who live in Southeast Asia are the most active. The Americas' reliance on cars and other vehicles is considered a major factor in their sedentary lifestyles, with just 4 percent of people in the U.S. walking to work and fewer than 2 percent using a bicycle to commute.

Experts say sufficient physical activity is the equivalent of 150 minutes of moderate exercise a week, which could mean 30 minutes of fast walking five times a week.

Another paper in the series pointed to steps people and communities can take to be more active: using signs to suggest taking the stairs rather than the elevator, or free exercise classes at public parks, for example. Maintaining streets and improving lighting can raise activity levels by 50 percent, some studies show. Researchers also discussed an effort in Bogotá, Colombia, where some city streets are closed to cars and vehicles on Sunday mornings and public holidays. Each week, about 1 million people show up to exercise. The effort has spread to Kentucky and been dubbed Second Sunday Kentucky.

Some experts took issue with the comparison with smoking, since "even if smoking and inactivity kill the same number of people, far fewer people smoke than are sedentary, making tobacco more risky to the individual," Park reports. (Read more)

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