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  • Alabama Department of Public Health

    Alabama Obesity Task Force

    Strategic Plan for thePrevention and Control

    of Overweight andObesity in Alabama

  • Letter from the State Health Officer ........1Executive Summary..................................2Overview of the obesity epidemic.............3

    What is obesity?...................................4Body Mass Index..............................4Over-fat............................................4Waist circumferences ........................5

    Obesity trends......................................5Influencing factors ...............................6

    Nutrition..........................................6Physical activity................................7

    General consequences ..........................7Health concerns ...............................7Economic .........................................9

    Alabama specifics....................................11Alabama trends (BRFSS) ...................12

    Alabama adults ...............................12Alabama youth/ children ................12Alabama racial andsocioeconomic influences ...............13

    Influencing factors ............................14Nutrition........................................14Physical activity..............................14Attitudes .......................................14

    General Consequences .......................15Health ............................................15Economic burden...........................16

    Healthy Alabama 2010...........................17

    Alabama State Obesity Task Force .........19History ..............................................20General guiding principlesof the task force .................................20

    Multifaceted approachguidelines .......................................20Evidenced-basedapproaches that work .....................22

    Alabama’s State Plan: ..............................23General comments .............................24How to use the state obesity plan ......24Six working groups:Perspectives in Alabama .....................25

    Nutrition subcommittee.................25Physical activitysubcommittee.................................26Data subcommittee ........................29Youth and familysubcommittee.................................31Community subcommittee.............32Healthcare subcommittee ...............34

    Additional areas of intervention .........34Media and social marketing............34Research .........................................35Funding concerns...........................35

    Resources for ImplementingThe Plan ...............................................36References ..............................................45

    Alabama Department of Public Health


  • he goal of the State ObesityTask Force was to develop andimplement a comprehensive,realistic state plan which willreduce the worsening obesityepidemic in Alabama. The

    plan was not to change approaches already inprogress, but rather to create a uniformapproach to reduce obesity. The AlabamaState Obesity Plan provides goals and objec-tives to follow at various social-ecological lev-els. The plan provides various approaches toaddress the impact of obesity on Alabama’scitizens including education and awareness,lifestyle and behavioral choices, community-based environmental strategies, school andworksite improvements, and policy develop-ment or changes. This plan does not addresspharmacological or medical interventions,however, these are also appropriate for certainindividuals based on established medical cri-teria. It is our hope that the plan is usedstatewide as a reference for selectingapproaches to implement. It can be benefi-cial in setting formal goals, such as in a cor-porate business plan, as well as in informalsettings, such as a community project.

    The various levels of influence, as noted inthe adaptation of a social-ecological model,are important since the question of whetherobesity is a personal concern versus a publichealth concern exists. I propose it is both.Obesity is a public health issue because anoverwhelming majority (80 percent) of per-sons who are obese have additional healthproblems. The individual has the ultimateresponsibility in making wise choices, but atthe same time the environment must support,encourage, and even reinforce personal deci-sion-making processes.

    In addressing weight concerns, an empha-

    sis will be placed on a healthy relationshipwith food, a healthy body weight, and a phys-ically active lifestyle. Approaches includelearning to select appropriate amounts andtypes of foods as well as learning personalcoping mechanisms to replace comfort eating.There is a consensus that people know they“should eat right”, but I am less convincedthat people know what actually is right orhow to do it.

    The approach in this report is to addressgood nutrition and physical activity through-out the lifecycle. Breastfeeding support is thelogical place to start, as breastfeeding decreas-es the chances of the child becoming over-weight while assisting the mother to return toa pre-pregnancy weight. The importance ofthe school day for our children and the workplace setting for adults cannot be understated.The structured school/ work setting can helppeople to make good decisions as long as thepositive options are there. Communitiesdeveloping walkable areas for all citizens,resulting in physical activity opportunitiesthat are readily available, can happen.

    Data will be a key in evaluation and forfuture documentation. It will be helpful tohave standardized health data at the county ortown level.

    To make this truly a plan for the entirestate, new partners are encouraged to join.With all of us working together, we can makea difference.

    “Alabama, together one choice, one step, andone life at a time!”


    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 1


  • In the United States, obesity has risen atan epidemic rate during the past 20 years. In2003, 15 states had obesity prevalence ratesof 15 to 19 percent; 31 states had rates of 20to 24 percent; and four states had rates morethan 25 percent. Alabama was one of the fourstates.

    To develop a multifacet approach, astatewide task force was organized in 2004.The task force included representatives fromstate and local governments, medical profes-sionals, academia and research, industry, com-munity, and citizen representatives. Thisreport is the result of their work.

    The Alabama Obesity State Plan providesa statewide focus for reducing and preventingobesity through healthy lifestyles that empha-size balanced eating patterns and adequatephysical activity. The strategies outlined inthe plan are targeted for all age groups, races,and socioeconomic classes. This plan will noteliminate existing efforts, but does encouragestatewide collaboration.

    General statements and opinions from thetask force set the tone for the overall goalsand measurable objectives. These statementsincluded:

    “Being overweight or obese is a very com-plex issue with many different contributingfactors. This plan must be passionate, cre-ative, and innovative with solutions that donot simply mimic other states.”

    “The severity of obesity in Alabama makesour challenge even greater. Media campaignsand public education are important but willnot be the only or best solution to a problemof this magnitude.”

    “Task force members must be willing tochallenge current ideas and solutions. Wemust "think outside the box" when develop-ing approaches to this problem. Ourapproach needs to combine prevention, inter-vention, evaluation, and research. This planmust have realistic, workable solutions.”

    The format of this report includes individ-ual sections on obesity trends in the nationand in Alabama, specific goals and actionssteps for each subcommittee, and tools or ref-erences to assist implementing the plan at alllevels.

    2 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama


  • Overview of theObesity


    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 3

  • WHAT IS OBESITY?Body Mass Index

    Obesity is defined as an excessively highamount of body fat or adipose tissue in rela-tion to lean body mass. Body Mass Index(BMI) is a common measure expressing therelationship (or ratio) of weight-to-height. Itis a mathematical formula in which a person'sbody weight in kilograms is divided by thesquare of his or her height in meters squared(wt/(ht)2. The BMI is more highly correlatedwith body fat than any other indicator ofheight and weight. Individuals with a BMIof 25 to 29.9 are considered overweight andare approximately 20 pounds above appropri-ate weight for height. Individuals with aBMI of 30 or more are considered obese andare 30 or more pounds over appropriateweight for height. For adults over 20 yearsold, BMI falls into one of these categories:

    Below is an example of calculating a BMIusing the English system and in the metricsystem.

    • English Formula:

    BMI= (Weight in Pounds)(Height in Inches X Height in Inches)

    (220)(75 X 75)

    A person who weighs 220 pounds and is 6feet 3 inches tall has a BMI of 27.5.

    • Metric Formula:Weight in Kilograms(Height in Meters)2

    99.791.905 X 1.905

    A person who weighs 99.79 kilograms and is1.905 meters tall has a BMI of 27.5.

    Use of BMI for Children

    The terms obese, overweight and at riskfor overweight are defined differently in pedi-atric populations than in adults (see chartbelow). Body Mass Index (BMI) is the pri-mary measure utilized to define weight statsin both adults and children. BMI is calculat-ed using the person’s weight and height and isa helpful indicator of weight status. Inadults, BMI is a fixed measurement withoutregard to gender or age. In children and ado-lescent, BMI is age and gender specific andtherefore the BMI measurement in this popu-

    4 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama


    Adult (21 and over)

    BMI Weight Status

    Below 18.5 Underweight

    18.5 – 24.9 Normal

    25.0 – 29.9 Overweight

    30.0 and Above Obese

    X 703

    x 703= 27.5


    = 27.5

    Children and Adolescent (2-20)

    BMI Weight Status


  • lation changes with age. Because of these dif-ferences between adult and children’s BMIs,the BMI for the pediatric population must beplotted on the CDC growth charts enablingon to determine BMI-for-age percentiles( The chart,Children & Adolescents, summarizes the cat-egories by BMI and percentages in children.

    BMI LimitationsBody Mass Index (BMI) reflects body

    composition and correlates well with bodyfat; however, it has limitations. A very mus-cular person may be in the overweight BMIcategory. For example, professional athletesmay be very lean and muscular, with very lit-tle body fat, yet due to the weight of theincreased muscle, they may weigh more thanothers of the same height. This would needto be considered in reviewing their BMI.While they may qualify as "overweight" dueto their large muscle mass, they are not neces-sarily "over fat," regardless of BMI.

    It is possible for a person who is in anappropriate BMI weight range to be “overfat”. By using a skinfold or fat analysizer, thepercent of body fat can be determined.

    Waist circumferences The amount of body fat (or adiposity)

    includes concern for both the distribution offat throughout the body and the size of theadipose tissue deposits. The waist size is anadditional, independent risk factor for certaindiseases and can be used in conjunction withthe BMI. Waist measurements reflect evi-dence that excess visceral fat - surroundingthe abdominal organs - increases the chanceof heart disease or diabetes. Research indi-cates that visceral fat (waist size) is more

    important in the disease process than subcu-taneous fat, which is just under the skin.Abdominal fat cells appear to produce certaincompounds that may influence cholesteroland glucose metabolism. Men are at risk whohave a waist measurement greater than 40inches (102 cm). Women who have a waistmeasurement greater than 35 inches (88 cm)are at risk. The waist size appears to be anindependent risk predictor when BMI is at

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 5

    Obesity Trends* Among U.S. and AdulthBRFSS, 1991, 1996, 2003

    *BMI≥30, or about 30 lbs overweight for 5’4” person

    10% - 14%< 10%No Data

    25%20% - 24%15% - 19%




  • 25- 34.9 NOTE: If a person has short stature (under

    5 feet in height) or has a BMI of 35 or above,waist circumference standards used for the gen-eral population may not apply.


    Obesity is occurring worldwide as well asnationally. The words “pandemic” and “epi-demic” have been used to describe the dra-matic upward trends seen in adults and chil-dren. According to the World HealthOrganization, the United States has the great-est incidence of overweight and obesity in theworld. The prevalence of obesity hasincreased steadily and is at epidemic levels.Results from the 1999–2002 National Healthand Nutrition Examination Survey(NHANES), using measured heights andweights, indicate that an estimated 65 percentof U.S. adults are either overweight or obese.The Centers for Disease Control (CDC) andPrevention report that Alabama is ranked firstin terms of number of adults with overweightand obesity.

    Adults are not the only ones with excessiveweight. Childhood obesity has become themost prevalent pediatric nutritional problemin the United States. Results from the1999–2002 National Health and NutritionExamination Survey (NHANES), using meas-ured heights and weights, indicate that anestimated 16 percent of children and adoles-cents ages six to nineteen years are over-weight. The prevalence rate has been risingsteadily in all age groups, with overweightbeing seen at younger ages. Excess weight inchildhood is frequently a precursor to adult

    obesity. The array of associated physical dis-orders and emotional problems that oftenaccompany obesity can persist, and frequentlyworsen, throughout life. Moreover, the prob-ability of adult obesity increases as overweightchildren age: 50 percent of children who areoverweight at age six will become overweightadults, by adolescence, the probability esca-lates to 80 percent. If one parent is over-weight or obese, the child has an 80 percentchance of being overweight or obese. Adultswho were overweight as children are atincreased risk for poor health for longer peri-ods than adults who were not overweight aschildren.

    Disparities in overweight and obesityprevalence exist in segments of the populationbased on race and ethnicity, gender, age, andsocioeconomic status. For example, over-weight and obesity are particularly commonamong minority groups and those with alower family income. The prevalence of over-weight and obesity is higher in women ofminority populations than in caucasianwomen. Among men, Mexican Americanshave a higher prevalence of overweight andobesity than caucasians or African Americans.For non-Hispanic men, the prevalence ofoverweight and obesity among Caucasians isslightly greater than among AfricanAmericans.

    Among school aged children, there is ahigher occurence of obesity in AfricanAmerican, Native American, Puerto Rican,Mexicans, and Native Hawaiins. Data fromCDC shows African American and HispanicChildren are at 21.5% as compared to 12.3%of Caucasians children.


    6 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

  • Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 7


    Obesity is a complex issue. Body weight isthe result of genes, metabolism, behavior,environment, culture, and socioeconomic sta-tus.

    Specific rare hereditary diseases mayincrease the risk of obesity. In addition, thereseems to be a general tendency for obesity torun in some families, though the reason forthis is not well understood. Behavior andenvironment play a large role influencingpeople to be overweight and obese. However,generally and very simplistically speaking obe-sity is a result of an energy imbalance. Thismeans most Americans are eating too manycalories and not getting enough physicalactivity.

    NutritionThe American eating pattern has been

    studied to identify reasons causing the obesityepidemic. The studies indicate thatAmericans have lost perception of the stan-dard serving size. Serving sizes started grow-ing in 1970, rose sharply in the 1980’s, andcontinued to increase in the 1990’s. It wasduring this time Americans lost the percep-tion of a serving size. According to theAmerican Diabetic Association, mostAmericans overestimate how much foodmakes up one serving.

    Americans are also eating away from homemore now than in the past. The AmericanCancer Society reports that servings in restau-rants are approximately two and a half timeswhat the average female needs. When largeportion sizes are coupled with the types offoods we consume, high fat, high sugar, highcalorie, weight gain is not a surprise.

    Eating for reasons not related to hungeralso plays an important role. Emotional eat-

    ing, whether it is out of boredom, seekingcomfort, relieving stress, or celebrating, canadd extra, unexpected calories.

    An emphasis is being placed on familymeals at home. Children eating more thanthree (3) meals per week with the family wereless likely to skip breakfast. The children alsohad better consumption of fruits, vegetables,and diary foods. Family meals frequency hada strong positive association with energyintake, percentage of calories from protein,calcium, iron, vitamins A, C, E, B6, folate,and fiber.

    Physical activityThe incidence of overweight and at risk of

    overweight is directly linked to lack of physi-cal activity and increase in inactivity, such asviewing television more than two hours perday. Our society has become very sedentary.Approximately 43 percent of adolescentswatch more than two hours of television eachday. Girls are less active than boys are andbecome even less active as they move throughadolescence. Numerous health-related organ-izations have recommended increased physicalactivity in order to decrease overweight andthe associated risk factors. The AmericanHeart Association, the Institute of Medicine,the United States Department of Health andHuman Services, the U. S. Surgeon General,Action for Healthy Kids, Centers for DiseaseControl and Prevention, and the RobertWood Johnson Foundation, are examples ofhealth-related agencies calling for increasedphysical activity for children.

    There are numerous reports that evaluatethe relationship between academic perform-ance and health behavior. Action for HealthyKids reports that in school districts across theUnited States, administrators, teachers, andresearchers are demonstrating that proper

  • 8 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

    nutrition and physical activity are linked toacademic achievement, self-esteem, mentalhealth, and improved school attendance.


    Health concernsOverweight and obesity are estimated to

    be second only to smoking as preventablecauses of death. The proportion of deathswhere obesity is a major contributing factorwill grow with continued increase in obesityprevalence. Life expectancy is predicted tofall in coming years because of obesity, a star-tling shift in a long-running trend towardlonger lives. It is estimated that within 50years, obesity will shorten the average lifespan of 77.6 years by at least two to fiveyears; more than the impact of cancer orheart disease.

    Obesity is linked to many health diseases, such as:

    • Arthritis - Osteoarthritis of knee and hip,Rheumatoid Arthritis

    • Birth Defects • Cancers - Breast Cancer, Colorectal

    Cancer, Esophagus and Gastric Cancer,Endometrial Cancer, Renal Cell Cancer

    • Cardiovascular disease• Carpal Tunnel Syndrome • Daytime Sleepiness • Deep Vein Thrombosis • End Stage Renal Disease • Gallbladder Disease • Gout • Heart Disorders • Hypertension• Impaired immune response • Impaired respiratory function

    • Infections following wounds • Infertility • Liver Disease • Low Back Pain • Obstetric and Gynecologic Complications• Pain • Severe acute biliary and alcoholic pancre-

    atitis • Sleep apnea• Stroke • Surgical complications • Type 2 Diabetes (Non Insulin Dependant

    Diabetes Mellitus) • Urinary Stress Incontinence

    Of these health concerns, the chart below liststhe leading causes of death in 2002 accordingto the CDC Division of Vital Statistics. Theseapply to both male and female adults.

    Obesity and overweight substantiallyincrease the risk of morbidity from hyperten-sion; dyslipidemia; type 2 diabetes; coronaryheart disease; stroke; gallbladder disease;osteoarthritis; sleep apnea and respiratoryproblems; and endometrial, breast, prostate,and colon cancers. Higher body weights arealso associated with increases in all-causemortality. Significant health problems occurin the pediatric age group as well as the adultpopulation.

    2002 Leading Causes of Death

    Heart Disease . . . . . . . . . . . . . . . . .28.5%

    Malignant Neoplasm (Cancer) . . . .22.8%

    Cerebrovascular Diseases (Stroke) . . .6.7%

    Chronic Lower Respiratory Disease . . .5.1%

    Accidents (Unintentional) . . . . . . . . .4.4%

    Diabetes Melitus . . . . . . . . . . . . . . . .3.0%

    Influenza/Pneumonia . . . . . . . . . . . .2.7%

    Alzheimer’s . . . . . . . . . . . . . . . . . . . .2.4%

  • Obesity is linked to cardiovascular diseaseand type 2 diabetes through the promotion ofinsulin resistance and other associated physio-logical abnormalities, including dyslipidemia,elevated blood pressure, and increased leftventricular mass. Overweight and insulinresistance have been linked to the early devel-opment of atheromata in young adults inde-pendent of other cardiovascular risk factors.Pulmonary, skeletal, dermatologic, immuno-logic, and endocrinologic systems displayobesity-related morbidities. These apply tomale and female as noted in the chart above.

    Cardiovascular HealthHeart disease and stroke are the principal

    components of cardiovascular disease and arelisted as the first and third leading causes of

    death in the United States. They account formore than 40 percent of all deaths. About950,000 Americans die of cardiovascular dis-ease each year, which amounts to one deathevery 33 seconds. It is estimated that 61 mil-lion Americans, almost one-fourth of thepopulation, have some form of cardiovasculardisease. High blood pressure is a major riskfactor for heart disease and the chief risk fac-tor for stroke and heart failure, and also canlead to kidney damage. It affects about 50million Americans–one in four adults. Studiesshow that the risk of death from heart diseaseand stroke begins to rise at blood pressures aslow as 115 over 75, and that it doubles foreach 20 over 10 millimeters of mercury (mmHg) increase. So, the harm starts long beforepeople get treatment.“Unless prevention steps are taken, stiffness andother damage to arteries worsen with age andmake high blood pressure more and more diffi-cult to treat. The new pre-hypertension categoryreflects this risk and, we hope, will prompt peo-ple to take preventive action early” said NHLBIDirector Dr. Claude Lenfant.Cancers

    Fat cells are not static deposits. Visceralfat is metabolically active and increased vis-ceral fat is linked to certain cancers. Obesityis strongly linked to cancer of the uterine lin-ing or endometrium. An overweight womanhas twice the risk of developing that cancer asa lean one; once she becomes obese the riskrises as much as three and a half (3.5) to five(5) fold. A person who is obese has up totriple the risk of kidney cancer and ofesophageal cancer as does someone in anappropriate body weight range. Overweightand obese men are 50 percent as likely as leanmen to get colon cancer; for women the extrarisk is 20 to 50 percent. Fat is linked to

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 9

    Obesity Related MorbiditiesCardiovascularAccelerated atherosclerosisDyslipidemia (increased triglycerides, lowHDL cholesterol level, increased LDLcholesterol level)

    HypertensionIncreased left ventricular massEndocrinologicHyperinsulinemiaInsulin resistanceEarly puberty (accelerated linear growthand bone age)

    Polycystic ovaries, dysmenorrheaRespiratoryHypoventilation (Pickwickian syndrome)More frequent respiratory infectionsSleep apneaOrthopedicCoxa varaSlipped capital femoral epiphysesBlount's diseaseLegg-Calve-Perthes disease

  • breast cancer in postmenopausal women andincreases the risk of the disease by 30 percentamong the overweight and 50 percent amongthe obese. Prostate cancer is more commonin men who have BMI of 35 or higher. Inaddition, these men have a 60 percent risk ofcancer recurrence within three years or more.This is twice the rate seen in men at theappropriate weight.

    DiabetesDuring the past ten years, the incidence of

    diabetes has nearly tripled. Overweight andobesity are significant risk factors for diabetes.The majority of adults diagnosed with dia-betes in the United States are either over-weight (85.2 percent) or obese (54.8 percent).Persons who have a body mass index (BMI)of more than 30 are 10 times more likely todevelop the illness; with a BMI above 35 for10 years, the risk increases to 80 times com-pared to a person of average weight.Projections are that 40 to 50 million UnitedStates residents could develop diabetes by2050.

    Type 2 diabetes in school children is a newphenomenon. Twenty years ago, it was rarefor an adolescent or child to be diagnosedwith type 2 diabetes. However, during thelast 20 years, childhood diabetes has increased10-fold. In several clinic-based studies, thepercentage of children with newly diagnoseddiabetes has risen from

  • Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 11


  • 12 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

    ALABAMA TRENDSAlabama is currently in an overweight and

    obesity epidemic situation regarding thehealth of its citizens. The nonprofit group,Trust for America's Health, named Alabamaas the “fattest state” in the nation in October2004. Mississippi and West Virginia followedin second and third places. Alabama rankedfirst in adult obesity based on 2003 data,with 28.4 percent of adults in the obese cate-gory.

    Alabama adultsSixty-three percent of Alabama adults are

    overweight and or obese. Obesity is definedas a BMI ≥30 and overweight is a BMI 25 to29.9. Of the 63 percent, 28.4 percent areobese and 34.8 percent are overweight.

    Overweight and obesity are prevalent andincreasing in Alabama. According to theAlabama Behavior Risk Factor SurveillanceSystem (BRFSS), from 1991 to 2001 obesityrates increased 76 percent. The BRFSS eval-uates weight status in Alabama adults by ask-ing height and weight questions in a randomdigit telephone survey. Questions are devel-oped by the Centers for Disease Control andPrevention (CDC). In 2003 in Alabama,approximately 28 percent of adults wereobese, with rates similar for men (27.1 per-cent) and women (29.6 percent). In addi-tion, approximately 35 percent of the adultswere overweight -- considerably more males(42.9 percent) than females (27.3 percent).

    Alabama youth/ childrenAlabama youth are also overweight. Self-

    reported data from the 2003 Youth RiskBehavior Survey (YRBS) showed 14 percent

    of youth were at risk for being overweightwith an additional 14 percent already over-weight, as defined as body mass index at orabove the 95th percentile for age.

    The Alabama Department of PublicHealth (ADPH) and the Alabama StateDepartment of Education collected heightand weight data on 822 adolescent studentsin six schools from different geographicregions in Alabama in 2001. Forty four (44)percent of the evaluated students were at riskfor overweight or overweight based uponbody mass index (BMI). In 2002, a studycompleted by ADPH staff of 1,182 studentsin the second, third, fourth, and fifth gradesin six public schools located in MonroeCounty, Alabama found approximately 17percent were at risk for overweight and 27percent were overweight. Rates were higherfor black students (29.8 percent) than forwhite students (23.6 percent).














    ≤ 24.9 25.0 - 29.9 ≥ 30Body Mass Index

    Alabama Adult BMI Categories - 2003



    of P



  • Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 13

    Alabama racial and socioeconomicdifferences

    Racial and socioeconomic differences inprevalence rates are also evident. In the over-weight category, the Hispanic population wasat 50.3 percent, the White population at 34.7percent, and the Black population was at 32.4percent. Obesity was prevalent in 37 percentof African american versus 26.5 percent ofCaucasian, and only 14 percent of Hispanics.The prevalence of obesity among persons atthe lowest income levels (less than $15,000annually) was approximately 32 percent,compared to a prevalence of almost 25 per-cent among persons with annual incomes ator exceeding $50,000. Obesity occurred inapproximately 28 percent of adults with lessthan a high school education, compared to 22percent among college graduates.

    A geographic study of obesity in Alabamawas completed utilizing BRFSS obesity datafrom 1995 to 2000 combined with USCensus 2000 data. The geographic distribu-tion of obesity illustrates the highest burden

    is in 16 counties, 15 of which are inAlabama's economically depressed region.This area, known as the Black Belt of thestate, was once known for the dark soil foragriculture. Although the region is known fortimber production, rich hunting and fishing,and Civil Rights history, the term Black Belt,has evolved to a reference to the predominateethnicity in the area.

    As indicated in the chart below, obesity rates are above 20 percent in all age groups, with the excep-tion of age 65 and older.

    Age Neither Overweight Overweight Obese

    nor Obese (BMI≤24.9) (BMI 25.0-29.9) BMI≥30

    18-24 % 53.1 26.7 20.3CI (45.3-60.9) (19.3-34.0) 14.5-26.0n 124 49 54

    25-34 % 39.8 31.2 29.0CI 35.1-44.6 26.6-35.7 24.5-33.5n 208 148 141

    35-44 % 30.3 36.3 33.3CI 26.1-34.5 31.7-40.9 28.8-37.9n 190 187 181

    45-54 % 28.9 37.3 33.8CI 24.9-32.9 32.8-41.9 29.5-38.1

    55-64 % 29.4 36.6 34.1CI 25.3-33.5 32.1-41.0 29.7-38.4n 179 202 199

    65+ % 41.7 39.4 18.9CI 37.7-45.6 35.4-43.4 15.7-22.1n 310 268 129



























































    Estimated Number of People at Risk for Obesity among Adults Aged 18 and Over Bases on

    Distribution by Age, Race, and Sex and AssignedRisk from the BRFSS, Alabama 2000


    NutritionIt is well established that consuming five

    or more servings of fruits and vegetables a dayand three servings of low fat milk are benefi-cial in weight control. However, in Alabama77.4 percent of adults do not eat 5 servings offruit and vegetables a day. Dietary Behaviorsof Alabama students indicate 85.5 percent ofninth through twelfth graders ate less thanfive servings of fruits and vegetables per dayduring the past seven days. Ninety two (92)percent of Alabama students drank less thanthree glasses of milk per day during the pastseven days, ranking the worst of all the states.

    Physical activityThere is little doubt that regular physical

    activity is good for overall health. Physicalactivity decreases the risk for diseases such ascolon cancer, diabetes, and high blood pres-sure and is beneficial for bone health, enhanc-ing mental clarity, and as a stress reducer. It

    is very important in weight control. Despiteall the benefits of being physically active,most Alabamians are sedentary.

    Alabama was ranked as the tenth worststate in terms of prevalence of no leisure timephysical activity. Twenty-seven percent ofAlabama adults reported participating in noleisure time physical activity.

    In addition, 60 percent of the populationdid not meet the national guidelines for mod-erate physical activity, and 79 percent did notmeet the guidelines for strenuous activity.Forty two (42) percent of Alabama studentsdid not participate in sufficient vigorousphysical activity; 81 percent of students didnot participate in sufficient moderate physicalactivity; 59 percent were not enrolled inphysical education class; 14 percent did notparticipate in any vigorous or moderate phys-ical activity; and 39 percent did not partici-pate in a sufficient amount of physical activi-ty.

    AttitudesIn October 2001, the Alabama

    Department of Public Health contracted withthe University of Alabama in Birmingham(UAB) to conduct a baseline telephone surveyof 400 adults on obesity issues in Alabama.Attitudes, beliefs, and health practices regard-ing weight were identified. The BMI's ofrespondents were calculated from self-report-ed heights and weights. Selected findingsincluded:

    (1) Approximately ten percent of thosewho were calculated as overweightresponded they were not overweight.

    (2) The most common reason for want-ing to lose weight was to be able tosee a child(ren) grow up.

    (3) The most frequent reasons for not eat-ing a healthy diet were: "it is too hardto count calories," "diets don't work,"“I am tired of hearing about dieting”,and "eating healthy is too expensive."

    14 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama












    Consume 5or more

    servings per day

    Consume lessthan 5

    servings per day

    Adult Consumption of Fruits and Vegetables per Day

    Alabama 2003



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    Health concernsThe life expectancy rate for an Alabama

    citizen is 74.1 years as compared to 77.2 yearsfor the average adult in the United States. In2001, the life expectancy for an Alabamaadult was comparable to the averageAmerican adult in 1981. This statistic placesAlabama 20 years behind the average state interms of average life expectancy in the UnitedStates. Unless changes are made in lifestylesand behaviors, today’s youth may be the firstgeneration in history to not outlive their par-ents.

    Some subgroups are at higher risk for obe-sity and its associated health problems. Ratesof chronic diseases in which obesity is a riskfactor are high in Alabama and dispropor-tionately high in similar subgroups. Forexample, in 1998 age-adjusted cardiovascularmortality rates were substantially higher forAfrican Americans (473.9 per 100,000) com-pared to Caucasian (383.9 per 100,000). In1998, the stroke mortality rate for AfricanAmericans was 44 percent higher than forCaucasian.

    The top two causes of death in Alabamaare cardiovascular disease (CVD) and cancer.Much research supports the nutrition andphysical activity impact on these diseases. In2002, CVD accounted for 36 percent of alldeaths. More Alabamians die each year fromCVD than from all forms of cancer com-bined. Alabama ranks 6th in the nation inheart disease deaths and 7th in stroke deaths.Alabama ranks above the national average indeaths due to heart disease. AfricanAmericans have the highest stroke death ratein Alabama. Alabama ranked third in terms

    of adult hypertension. Thirty-three percent ofthe total Alabama adult population indicatedthey had been diagnosed with hypertension.In addition, 38 percent of the total adultAfrican American population is at risk forhypertension. The Alabama Department ofPublic Health identified both high systolicand high diastolic blood pressures in Alabamaadolescents.

    Cancer is the second leading cause ofdeath accounting for 29,013 or 21.7 percentof all deaths from 1998 to 2000. The three-year crude death rate for cancer for the totalpopulation is 220.3 per 100,000 population.The African American and other races crudedeath rate is 184.4 and the Caucasian crudedeath rate is 234.1 per 100,000 race-specificpopulation. The 1998 to 2000 age-adjusteddeath rate1 for cancer for the total populationis 216.2 per 100,000 population. The

    African American and other races age-adjust-ed death rate is 243.1 and the Caucasian age

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 15




    Leading Causes of Death in Alabama - 2002

    Accidents 5%

    Cancer 21%

    All Other Causes 33%

    Respiratory Diseases %5

    Cardiovascular Disease 36%

  • adjusted death rate is 208.9.

    Diabetes An estimated 17 million Americans (6.2 per-cent of the population) now have diabetes.Alabama has one of the highest rate of diag-nosed diabetes (8.4 percent). In 2003, theage-adjusted prevalence of diagnosed diabetesranged from a high of 10.9 percent in PuertoRico to a low of 4.9 percent in Colorado.Diabetes is the sixth leading cause of death inAlabama with 3,964 or 3 percent of all deathsfrom 1998 to 2000. For African Americansand other races, diabetes is the fifth leadingcause of death. For Caucasians, diabetes is theseventh leading cause of death.True population statistics data and Alabamadata are not yet available regarding the preva-lence of type 2 diabetes in school children.However, verbal reports indicates that dia-betes in children is growing. Because of ele-vated risks in Alabama school students,Alabama experiences an even greater potentialfor type 2 diabetes in school-age children.

    Economics The report, "F as in Fat: How ObesityPolicies are Failing in America," stated thatAlabama spent the equivalent of $293 perperson on its 4 million plus residents last yearpaying for health care costs related to obesity- the ninth highest amount in the nation. Because of increases in health care costs andhealth insurance for state employees and pub-lic education employees, the Legislature helda special session in November 2004 to addressways to contain the rise in health insurancecosts.

    16 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

  • Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 17

    HealthyAlabama 2010

  • The overall goal for the Healthy Alabama2010 Objectives is to increase the lifeexpectancy and quality of life for Alabamians.The disparity in life expectancy betweenAlabama and the remainder of the nation hasactually grown wider in the past decade. Anumber of factors that can adversely affectlongevity include poverty, low levels of educa-tional attainment, higher rates of tobacco

    usage, higher rates of obesity, and more peopleliving a sedentary lifestyle and lower utilizationof preventive health care measures. These fac-tors result in higher death rates from chronicconditions such as heart disease, stroke, anddiabetes. The State Obesity Task forceacknowledges these goals and will assist inefforts to reach them.

    Physical Activity and Fitness


    18 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

    Adult Physical Activity1.1 Increase to 25 percent or more the proportion of adults aged 18 and older who engage regu-

    larly, preferably daily, in sustained physical activity for at least 30 minutes per day.

    AL Baseline AL Target US Baseline US TargetAdults 18 and older 17 (1997) 25 23 (1995) 30

    Adolescent Physical Activity1.2 Increase to 60 percent or more the proportion of students in grades 9-12 who engage in

    moderate physical activity for at least 20 minutes a day for 3 days per week.

    AL Baseline AL Target US Baseline US TargetStudents grades 9-12 55 (1997) 60 N/A N/A


    Weight Status1.3 Reduce to 20 percent or less the prevalence of being overweight (defined as a body mass

    index at or above 27.8 for men and 27.3 for women) among adults aged 18 and older.

    AL Baseline AL Target US Baseline US TargetAdults 18 and older 35 (1997) 20 N/A N/A

    Dietary Guidelines1.4 Increase to 40 percent or more the proportion of adults aged 18 years and older who meet

    the dietary recommendations of a minimum average daily goal of at least 5 servings of veg-etables and fruits.

    AL Baseline AL Target US Baseline US TargetAdults 18 and older 17 (1997) 40 N/A N/A

  • Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 19

    Alabama StateObesity Task


  • HISTORYDespite limited resources, the Alabama

    Department of Public Health (ADPH) andthe University of Alabama in Birmingham(UAB) pledged to work together to addresshealthy opportunities for all Alabamians.The obesity epidemic was acknowledged aswere different approaches that were beingtaken across the state to address it. The firstObesity Task Force meeting was held on May4, 2004 in Montgomery. Over 70 representa-tives attended from public health, academia,health care, education, businesses, and com-munity groups.

    The charge of the task force was to devel-op and implement a comprehensive state planto reduce obesity in Alabama among all seg-ments of the population. The purpose wasnot to change the approaches already inprogress, but rather to help Alabama worktogether as a whole. The task force membersagreed to utilize evidenced based practices indeveloping the plan. From the first meeting,it was clear the plan would be suitable forAlabama, building on the state’s unique char-acteristics and resources. Members agreed toaddress weight concerns through emphasizinga healthy relationship with food, a healthybody weight, and a physically active lifestyle.

    During the first meeting, members self-selected into committees: nutrition concerns,physical activity concerns, youth and families,community, data, and health care. The com-mittees met on a monthly basis from Junethrough November 2004 establishing goals,adding additional partners, and reviewingpotential solutions. By January 2005, each

    committee selected a chair. The task force,with 92 total members, became six, separate,yet coordinated committees all creating posi-tive working relationships. The committeesdeveloped realistic action steps from theestablished goals and objectives.


    Multifaceted approach guidelinesIn developing a state obesity plan, a social-

    ecological approach was used. This modelwas especially appropriate in addressing thevery complicated weight issues as it includesinfluences at multiple levels: individual, inter-personal, organizational, community, andpublic policy. This ecological perspectiveincludes the importance of approaching pub-lic health problems at multiple levels whilestressing interaction and integration of factorswith and across the levels. Strategies compatible with this model includeenhancing individual responsibility for posi-tive lifestyle change and garnering outsideforces through schools, worksites, and com-munity settings.

    At the center of the SEA is the individualsurrounded by increasing larger circles of influ-ence. These areas, interpersonal, organization-al, community, and policy will all influencepersonal choices. The relationship can bereciprocal; the environment affects health relat-ed behaviors and people through their actionscan affect the environment. The AlabamaState Obesity Plan is designed to enable per-sons to use the plan at any and all levels.

    20 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama


  • Individual Individuals are responsible for positive,

    sound, life style behavior choices that pro-mote a healthy body. To encourage this, apositive message that promotes healthy eatingand increased physical activity through cul-turally relevant approaches will be used. Theneed to raise the awareness of the increasedobesity rates and decreased physical activity asa serious health issue, its economic cost toAlabama, and its negative impact on the qual-ity of life exists.

    Interpersonal/GroupAlabama citizens are in multiple roles at

    any given time. A person may be a familymember, a friend, or a coworker/peer. All ofthe roles provide a social identity and canprovide or offer support. In addressing obesi-ty issues, Alabama citizens need to be sup-

    portive of others and be good role models inmaintaining a healthy weight, eating ahealthy meal pattern, and being physicallyactive.

    The task force will work to increase adultknowledge and skills about being role modelsfor positive eating and physical activitylifestyles in order to strengthen future genera-tion’s health outcomes. Additionally a focuson training adults who are parents, who workformally and informally with children andteens, and adults who influence policy andfunding decisions will be needed.

    Examples include an accountability systemin families or with friends for eating healthyfood selections. Support can be offeredthrough families and neighbors helping eachother become more physically active by goingfor a bike ride, inviting a neighbor to take awalk, or playing outside with the children.

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 21

    A Social-Ecological Model For Nutrition Evaluation

    Spheres of Influence 1

    Social Structure, Policy, Systems



    InterpersonalLifestyle Influences


    1 McElroy KR, Bibeau D, Steckler A. Glanz K. A perspective on health promotionprograms. Health Education Quarterly 15:351-377. 1988.

    Social Structure, PolicyLocal, State federalpolicies and laws thatregulate or supporthealthy actions

    Community: Socialnetworks, normsstandards (e.g. publicagenda, media agenda),or other existing channels

    Institutional/Organizational: Rules,regulation, policies andinformal structures(worksites, schools,religious groups)

    InterpersonalInterpersonal processand primary groups(family, peers, socialnetworks, associations)that provide social identity and roledefinitionIndividual: Individualcharacteristics thatinfluence behavior suchas Knowledge, attributes,beliefs, and personalitytraits

  • 22 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

    Institutional/OrganizationalAlabama’s businesses, industries, organiza-

    tions, educational sites, including day care,primary, secondary and higher educationinstitutions, work places, medical settings,and other places of employment will provideopportunities to promote good health andrecommended behaviors. These increasedopportunities can be through formal chan-nels, such as rules and policies, or throughinformal channels, such as suggestions orguidelines. Examples include employersencouraging physical activity breaks; healthyfood items being available in vendingmachines and in cafeteria selections; wellnessprograms providing information for allemployees; and employers encourage or pro-vide early assistance and appropriate preven-tion/treatment interventions.

    CommunityAlabama’s communities, social networks,

    and faith communities that exist formally orinformally among individuals, groups, andorganizations will promote and supportlifestyle choices to promote healthy bodies.To improve our communities and to makethem places where people are healthy, safe,and cared for, will take a unified effort.Collaborating effectively with other individu-als and organizations, both inside and outsidethe community, is necessary. This requires aprocess of people working together to addresskey issues that are important to them. Thecommunity environment will establish andpromote healthy eating and active lifestyles asthe norm rather than the exception.Community based strategies to supporthealthy eating and physical activity need tobe tailored for the individual community.Access to healthy foods choices and opportu-

    nities for physical activity by modifying com-munity and school environments is needed.Examples include churches, mosques, syna-gogues and other faith organizations thatserve meals to members to provide healthyfood selections and promote prayer walks orexercise classes at the facility; and for civicgroups to select a neighborhood environmen-tal issue to address in efforts to promotewalking.

    PolicyAlabama’s decision makers will be support-

    ive at local and state levels in creating oppor-tunities for healthy eating and physical activi-ty through policies and laws. This willrequire citizens to raise awareness and pro-mote action among elected and appointedofficials, foundations, and potential privatesector partners regarding the need for policychange, environmental change, and adequateresources to address overweight/ obesity inAlabama.

    Evidenced-based approaches that workThe obesity epidemic is a serious health

    problem that calls for immediate action toreduce its prevalence. Therefore, the task-force felt that actions should be based on evi-dence-based research. These interventions ortreatment approaches have been scientificallydemonstrated to be effective, regardless of thediscipline that developed them. This plan isbased on research findings that validate thepromoted concepts. However, the plan willnot be limited only to printed evidenced-based documentation.

  • Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 23

    Alabama’s StatePlan Addressing



    This report presents a plan with goals, rec-ommendations, strategies, and activitiesencouraging interventions that promotehealthy eating and physical activity asapproaches for Alabamians to reach andmaintain a healthy weight. In developing theplan, it was recognized that a great potentialfor synergy with enhanced communicationand coordination among various groups with-in the state exists. For example, media mes-sages can be tailored to be put into practice atschools, work places, and community sites.There will also be benefits of learning fromsuccesses across the state. The successfulapproaches can be tailored and implementedin a different location. This coordinatedfocus will assist in using limited resources andgenerating new resources by involving thewhole state.

    Committee members agreed that obesity isa very complex issue. Therefore, approachestaken will consider the relationships withfood. These relationships will be explored toaddress cultural, emotional, and traditionalbeliefs that determine eating habits.

    The plan does not focus on changes need-ed in the school environment. This isbecause the State Department of Educationdeveloped a Student Health Task Force. Theeducation task force met from September2004 through May 2005 in developing nutri-tion and physical activity related recommen-dations for public schools. The State ObesityTask Force supports the recommendations

    made, specifically that schools should providehealthy food choices and address physicaleducation options. Nutrition changes includefoods served through the cafeteria, in vendingmachines, and school stores; that fund raisingpolicies should utilize healthy foods or non-food items; and that teachers should use non-food items as rewards for classroom perform-ance in place of candy. School environmentapproaches include the recommendation tocomplete an assessment, such as The SchoolHealth Index, to identify potential areas forneeded change. Physical activity recommen-dations include evaluating all physical educa-tion (PE) waivers; having PE taught by certi-fied PE teachers in all grades; promoting life-time, enjoyable activities; reviewing the quali-ty of the classes taught; and limiting the stu-dents in each class to a specified ratio of stu-dents to teachers.


    The outlined approaches will not be suc-cessful without support of representativesfrom diverse segments of society, industriesand businesses, institutions, agencies, media,health care, families, schools, communities,non profit organizations, places of faith, andso on. Implementing the plan must be astatewide effort. Special attention may beneeded in communities that experience healthdisparities and have environments that arenot supportive of healthy nutrition habits orphysical activity opportunities. The plan can

    24 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama


  • be used by individuals at both the statewideand local levels. Agencies, institutions, andgroups can implement the strategies in workplans. Key stakeholders and decosionmakerscan use the report to increase awareness. It isthe Task Force’s hope that the plan can stimu-late new ideas, partnerships, and coalitions.



    Summary:The goal is to promote both primary and

    secondary prevention of obesity. The committee’s consensus is there are

    two groups who would greatly benefit from anutrition intervention plan. The first groupdoes not understand the health importance ofweight control and does not display anunderstanding of how to transform eatingpatterns to consume healthier foods. Thesecond group has “head knowledge”, but dueto environmental conveniences, personalbeliefs, and values is not convinced to makelifestyle changes.

    Both groups will benefit from a compre-hensive media plan and other approaches topromote healthy lifestyles. Such interven-tions could include community level educa-tion efforts, healthier eating choices to bereadily available, and opportunities for rewardincentives through work or insurance plans.

    Specific details:The nutrition subcommittee agreed that

    there are different levels of understanding of

    health consequences in individuals who areoverweight or obese. The first group may ormay not acknowledge they have a weightproblem. In fact, based on a survey complet-ed in 2001, almost 10 percent of Alabamianswho were overweight did not realize theywere. This group lacks an understanding inthe severity of the health risks associated withobesity and does not display a workingknowledge of how to transform eating pat-terns into healthier food intakes.Interventions will include educational oppor-tunities to include interactive sessions forlearning implementation skills. Topics willinclude, but not be limited to:• Health problems associated with obesity• Portion sizes • Healthy food choices • How to read food labels • How to prepare foods

    The second group knows the importanceof an appropriate body weight and increasedphysical activity level, but is not convinced tomake lifestyle changes. Educational effortsfor this group will need to address:• Changing knowledge into behavior• Making appropriate food choices that are

    easy and convenient• Learning healthier ways to prepare favorite


    Both groups will benefit from environ-mental improvements to foster healthier foodas the easier, low-cost choice. The environ-mental changes will be supplemented witheducational messages that address overcomingbarriers to losing weight.

    Educational strategies will include:• Providing programs to explore aspects of

    emotional eating; the uses, values, and

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 25

  • symbolism given to foods; and recognizingfullness versus hunger

    • Targeting families and friends in programsto build a support network for the personneeding to lose weight

    • Teaching parents and children skills toevaluate advertising tactics

    • Offering courses that teach skills neededto make better choices when eating awayfrom home

    • Promoting breastfeeding as weight controlbenefits for the mother and prevention forthe child.

    Environmental changes can be reached by:• Organizing policy and procedure changes

    including multi level legislation efforts toaddress issues such as:• Funding for community improvements• Allowing only well defined food choic-

    es, similar to the NutritionSupplemental Food Program forWomen, Infants, and Children (WIC)for all supplemental feeding programs

    • Providing reward type incentives forthe person who reaches and or main-tains appropriate body anthropometricprovided by places of work, industry,and/or insurance companies- not topenalize overweight or obese persons,but to reward for healthy body sizes

    • Reviewing and revising food purchas-ing policies at childcare settings,schools, and work environments topromote the purchase and consump-tion of high-nutrient quality foods

    • Increasing the availability of healthy foodchoices in rural areas of the state by • Supporting community gardens and

    farmer’s markets• Encouraging local eating establish-

    ments to reduce fat, sugar, and salt inpreparing “Southern style” foods

    • Encouraging food chains, stores andgrocers to provide alternative selections.

    Specific Objectives for the nutritionsubcommittee: 1.) To develop and disseminate a resource list

    to state, community, and health careagencies that will list programs and activi-ties across the state that address healthrelated topics such as nutrition and weightmanagement. These programs will targetall of the lifecycle stages. (This will alsoinclude examples of weight managementprograms that have been successful andsupported by research.)

    2) Consult with the data subcommittee todetermine prevalence of obesity, breast-feeding, and similar issues in Alabamacounties to identify areas that need theresource list and actual resources.

    3) Identify and choose a question for theBehavior Risk Factor Surveillance System(BRFSS) questionnaire that addresses theaffective domain of eating. (No nationalor state surveys include these questions atthis time.) This will assist in collectingdata to determine the impact of emotionaleating on obesity.

    Success StoriesCommunity train-the-trainer seminars arebeing conducted in Macon, Greene, andLowndes counties. Area ADPH employeesand community volunteers are trained usingthe New Leaf Intervention program. Theprogram is a structured nutrition and pyhsicalactivity and assessment program for cardio-vascular disease risk reduction through weightreduction. Community leaders will coordi-

    26 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

  • nate area weight loss seminars and lead sup-port groups to promote healthy eating andexercise habits among the women of ourstate.


    Summary:The goal is to promote physical activity as

    a norm. Two priorities were identified:Increase school programs for youth fitness todevelop lifelong habits, and develop exercise-friendly communities.

    Changes are needed at multiple levels inorder for physical activity to be accepted asthe norm. Educating the general populationon the need for daily routines with physicalactivity, with benefits explained is needed.This education will also strive to change theattitude and behaviors associated with thenegative association of exercise to a more pos-itive opinion of physical activity in order tomake fitness “cool” or popular.

    Changes will include, but are not limitedto improvements in schools, environmentalchanges to the community, policy changes inbusinesses, and educational efforts for the cit-izens.

    Specific details:In recognition of the importance of regu-

    lar physical activity for the health and welfareof all Alabamians, the physical activity sub-committee supports the 2005 DietaryGuidelines for Americans, and the respectivescientific positions of the American HeartAssociation and American Academy ofPediatrics regarding physical activity recom-mendations.

    Data shows an unfortunate decline in

    physical education requirements in schools.The school environment is an opportunityfor children and youth to develop an interestin lifetime, enjoyable physical activities.Students who are more active tend to performbetter in academics. Therefore, it is impor-tant to increase opportunities for physicalactivity for children and youth. Strategies toreach this goal include:• Developing school health councils to

    review, revise, implement, and monitor,school physical activity policies thatencourage the recommended 60 minutesof daily physical activity. Suggested poli-cies for health councils to begin withinclude, but are not limited to:• Incorporating physical activity into

    other subject lessons during the schoolday

    • Providing short physical activity breaksbetween lessons or classes

    • Providing before and after school pro-grams that include daily periods ofmoderate to vigorous physical activityfor all participants and providing infor-mation about these opportunities

    • Encouraging daily physical educationclass for all students including studentswith disabilities and special health-careneeds in grades K-12 to be taught bycertified physical education teacher

    • Opening school facilities, such as thegym and playground equipment,before, during, and after the schoolday, on weekends and during schoolvacations for use by the community,students, and staff

    • Educational efforts to assist in increasingphysical activity in the school environ-ment will include:• Teaching heath skills needed to main-

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 27

  • 28 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

    tain a physically active lifestyle andreduced time spent on sedentary activi-ties

    • Utilizing the data collected from theFitness Testing completed at school todevelop, promote, and implement aplan to improve the physical abilities ofthe students that has parental support

    • Support efforts will be needed and caninclude:• Supporting parents’ efforts to provide

    their children with opportunities to bephysically active outside of school

    • Utilizing national programs at the locallevel, such as “Walk to School” and“Safe Routes to School”

    • Encouraging parents and teachers to beactive role models for children

    Data shows that smart communitygrowth/planning has an impact on health andthe environment and that walkable, bikeablecommunities are increasingly preferred asenvironments that support opportunities forenjoyable physical activity. Therefore, it isimportant to increase opportunities for physi-cal activity in neighborhoods and communi-ties. To reach this goal, strategies include:• Improving the environment to promote

    physical activity by:• Developing or enhancing, advertising

    and promoting, and utilizing parks andtrails in Alabama for physical activity

    • Working together as members of com-munities and neighborhoods to createand/or enhance access to neighborhoodwalking trails

    • Completing a community assessmentto determine the changes needed tooffer physical activity venues. The

    assessment should include malls andchurches.

    • Collaborating with developers, home-builders, and city managers to developpolices making all new subdivisions bewalkable and bikeable

    • Working with zoning issues to increaseopportunities for physical activity inthe community, citing Auburn, AL as amodel bikeable, walkable community

    • Utilizing less involved improvements,such as repairing sidewalks, clearingpaths, adding pedestrian signs, etc. toencourage walking for transportationand leisure

    • Changing policies at businesses, placesof faith etc. to allow access to existingfacilities, such as gyms and play-grounds, and similar properties withconsiderations of liability issues

    • Sponsoring community activities thatpromote family- friendly activities toincrease opportunities for physicalactivity

    • Educational and awareness efforts in thecommunity to assist in increasing physicalactivity will include:

    • Offering education sessions on theimportance of daily physical activity inpromoting health, preventing chronicdisease, in weight loss and mainte-nance, and preventing obesity to civicgroups, clubs, businesses, etc

    • Developing a “Recognition of ActivityFriendly Communities” for communi-ties and neighborhoods that foster safeopportunities for daily physical activity

    • Providing information, on a centralweb site to promote opportunities forrecreation, exercise, and outdoor activi-ties at trails, parks, recreation centers,

  • etc • Providing educational seminars, classes,

    and discussions encouraging parents tobe positive, active, role models whosupport regular physical activity andlimit children’s recreational screen time

    As health care costs increase, and withnearly 30 percent of American workers obeseand at risk of chronic diseases, rising num-bers of companies are using workplace well-ness programs to improve employees’ health,reduce medical claims, and reduce employeeabsenteeism. Successful health promotionprograms report positive cost-benefit ratios.Healthy, active employees use less time off forsick days, as well as demonstrate increasedproductivity, and job satisfaction. Therefore,it is important to increase opportunities forphysical activities in the worksite environ-ment. To reach this goal, strategies include: • Educating employers on the business and

    financial advantage of offering a workplacehealth promotion program that provides: • 1) Educational sessions to employees

    including but not limited to: • the relationship between lifestyle and

    health • weight management • behavior change or skill building

    programs • information on maintaining healthy

    lifestyles • smoking cessation

    • 2) Walking or other physical activityprograms on site or subsidized mem-berships to local gyms

    • 3) Supportive environments to addressappropriate body weights

    • 4.) Low-cost services such as medicalcheckups

    • Education is needed for business leaders.Leaders need to encourage staff to becomephysically active. A statewide conferencefor business leaders featuring worksitewellness approaches is recommended.


    Summary:The Subcommittee agreed that improve-

    ments and additional data collection areneeded for nutrition and physical activity sur-veillance. The group expressed a long-termgoal of developing standards for collectingdata to be used statewide. The data subcom-mittee noted gaps in the nutrition and physi-cal activity type data available in Alabama.Without this data, a true evaluation on theprogress will not be accurate. Being able tocollect data with consistent data fields, styles,and stored in a central place is needed tomake complete projections and evaluations.

    Specific details:The data subcommittee felt it was impera-

    tive to assess the current state surveillance sys-tems. This process will include• Identifying sources of data from more

    than one county • Compiling the data • Looking for gaps • Providing data at the local level • Publicizing the available data

    After the data available are analyzed, anenhancement process will begin. Anenhanced data collection system is needed forimproved evaluation. This will include devel-oping a central depository of data that usesstandardized definitions, methods, and collec-tion tools.

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 29

  • Specific Objectives for the datasubcommittee:1. To identify large sources of nutrition and

    physical information, the committeemembers will review known existing datasources. Data sets will be searched forpre-determined sets of data, as determinedby the committee. As the review is com-pleted, missing information will be listed.This information will be used as an evalu-ation tool for other committee goals aswell as for an obesity surveillance reportfor the state of Alabama presented in theformat of compilations of several reportsfrom available sources of data. The datasources to review include, but are not lim-ited to:

    Dental recordsWIC (Women, Infants, and Children)Insurance programsSchool Health Index reports Wellness programsBRFSS (Behavioral Risk FactorSurveillance System)YRBSS (Youth Risk BehaviorSurveillance System)Body Trek (Jefferson County)Health Department intervention pro-grams (such as Jefferson County)

    2. Committee members felt that a systematicapproach to collecting data in the schoolsetting needed to be adopted. Across thestate, many local organizations and inter-vention groups within the task force maytake on screening initiatives in the schoolsystem. Therefore, the committee felt thatan appropriate project would be the cre-ation of a standardized data system forreporting height and weight data collectedby various groups. This would be a volun-tary system, at present.

    3. The committee will develop a guide ofcorrect procedures for collecting height andweight data. Committee members reviewedthe Guidelines for collecting heights andweights on children and adolescents in schoolsettings from the Center for Weight andHealth at the University of California,Berkeley. The materials would be field testedbefore going statewide. The developed guidewill be used in conjunction with a web-baseddata entry system.


    Summary:The Subcommittee narrowed concerns to

    three priorities: increasing awareness of iden-tification and consequences of overweightamong families, equiping caregivers withskills to promote healthy behaviors amongyouth, and providing opportunities across thelifespan to engage in healthy nutrition andphysical activity. Educational efforts willneed to include the family as well as theyouth. Information will need to be presentedin various formats with opportunities for skillbuilding.

    Specific details:The number of overweight and obese

    youth has been increasing dramatically inrecent decades, and there is no sign that thistrend is ending. Even though prevention andtreatment in clinical settings have been thefocus for interventions, researchers now agreethat trends in overweight arise from changesin social and environmental factors that needto be understood and modified for effectiveprevention. Many factors have been suggest-ed as causes of the “obesity epidemic” among

    30 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

  • children — reduced physical activity atschool and home, campus vending machines,television viewing, larger portion sizes, fast-food restaurants, video games, as well as oth-ers. Except for the National Health andNutrition Examination Survey (NHANES),there is little reliable data to track weightincrease among children. In Alabama, thereis no statewide screening of weight in chil-dren.

    The youth and family subcommittee feltthat to reach youth the family must beincluded. Strategies to reach the family willinclude, but not be limited to the following.

    Enhancing family/parent-centered preven-tion services for special populations includingchildren and adolescents with special healthcare needs, prenatal women, infants, children,and adolescents by providing:• Programs designed to foster family meal-

    times in order for children to learn fromthe conversations and interactions offriends and family at the table; for chil-dren to see what parents are eating and bewilling to taste new foods; for children tolearn table manners, and for families togrow closer together

    • Food tasting opportunities for families as agroup to try new foods or new preparationmethods

    • Classes on general health issues such as • The importance of getting enough

    sleep• The need for physical activity• Stress management techniques• Moderation of alcohol consumption• Work and home balance• Smoking cessation and abstinence from

    tobacco products

    Education should target obesigenic fami-

    lies where all immediate family members areoverweight/obese and not physically active.The entire family must be involved for sup-port.

    Program leaders need to find ways toreward families who are successful in makinglasting changes towards a healthy life style.This could include developing incentive pro-grams, such as tuition reimbursement, healthinsurance discounts, and reduction of co payor deductibles as a reward for reaching andmaintaining an appropriate body weight andphysically active lifestyle.

    Enhancing parental and grandparentalskills are needed. Programs providing servicesto parents in various settings could be activein obesity prevention. Examples of neededskills building areas include how to:• Breastfeed, with emphasis placed on the

    weight control benefits for the mother andthe child

    • Deal with children’s food choices and eat-ing behaviors to prevent indulgent styleparenting

    • Encourage physical activity and become amore active role model

    • Make consistent decisions to control whatfood comes into the house

    • Estimate appropriate food portionsaccording to the child’s age and activitylevel

    A statewide network of educators, healthproviders, lay leaders etc. who are willing todeliver the above messages needs to be devel-oped and shared with organizations dealingwith parents and children. The presentationsshould be offered in schools, churches, busi-nesses, etc. These presentations should alsoassist teachers, community leaders, and otheradults to be a positive role model for chil-

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 31

  • dren.A centrally located website should provide

    suggestions for parenting skills to assist inimproving children’s food intake and ways tobe more physically active.

    The community should provide opportu-nities to promote physical activity andhealthy lifestyles targeted at the youth. Thiswill include strategies that will:• Assist in finding transportation solutions

    to the event for youth, especially in ruralareas

    • Find ways to encourage the youth to usepaths and trails

    • Increase physical activity opportunities forthe non-athletic, non-competitive sportsyouth

    • Promote realistic teen/family fitness goalswith the clear message that fitness doesnot mean pro- athlete

    • Address barriers to physical activity, suchas research findings that found girls do notlike to sweat, overweight children feel selfconscious , etc.

    • Reward positive behavior


    Summary:Community leaders will collaborate with

    schools, churches, businesses, and others tocreate environments that permit lifestylechoices of regular physical activity, healthyeating, and healthy weight as accepted norms.Committee members urge community leadersto collaborate with leaders in schools, church-es, businesses, community organizations, andothers to create an environment that permitshealthy lifestyle choices of physical activityand healthy eating to be the accepted norm.

    The environment should provide safe areasfor physical activity, utilizing schools, emptybusiness buildings, and/or creating walking/exercise paths. Information listing walkingpaths and trails will be posted on a centralwebsite for easy accessibility

    Specifics:The community subcommittee addressed

    several environmental, policy, and organiza-tional aspects of making a healthier commu-nity. Approaches to take in the communitymay overlap with approaches outlined byother committees. Approaches include, butare not limited to:

    A community-wide assessment should becompleted by a collaboration between leadersrepresenting many different areas of the com-munity. Elected officials, leaders fromschools, churches, businesses, serviceproviders such as physicians and their staff,neighborhood associations, representatives ofindividuals in the committee, such as retirees,stay at home mothers, home schooled fami-lies, and other community representativesshould work together to create an environ-ment which permits healthy lifestyle choices.A grass roots effort is needed in all planningstages. This includes selecting an assessmenttool to use to determine community interest;the current nutritional and physical activityopportunities available, and potentialimprovements needed. The assessment resultswill be used to prioritize the needed commu-nity changes. Task force members can pro-vide technical assistance to local committeesto develop and implement a plan.

    If appropriate as indicated by the commu-nity assessment, the following approachesmay be developed:

    32 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

  • Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 33

    • Increasing the venues of physical activityopportunities

    • Improving the eating environment tomake healthier choices become the con-venient, easier, low-cost choices

    • Increasing availability of fresh producethrough farmer market/community gar-dens as well as local stores

    • Developing a family fitness board wherefamily check ins or screenings woulddetermine the “family of the month” basedon a set criteria such as the miles walkedor other measurable goal is accomplished.

    • Providing safe areas for physical activity byutilizing schools, empty business build-ings, creating walking/-exercise paths,hiking areas, swimming facilities, and orredesigning the downtown areas tobecome a pedestrian friendly neighbor-hood

    • Developing advocates within organizationsand with external professionals to promoteactivity in daily activities Businesses in the community should make

    changes to provide a healthy environment forstaff and to support efforts to develophealthy, active retirees. Approaches mayinclude wellness programs, environmentalenhancements to encourage stair use or otherphysical activity within and outside the busi-ness area, and improvements in food selec-tions provided. Business leaders can workwith insurance companies to develop policies.

    Places of faith need to support a healthyconcept as a service for their members andthe communities they serve. Many churchesare the center of activity in rural areas andcould offer physical activity opportunities,such as prayer walks or faith based weight lossprograms. Churches can review their ownpolicies, such as ensuring healthier foods andbeverages are served at routine meals,

    Wednesday night suppers.Schools need to be supportive for the stu-

    dents and the faculty. Schools can establish anenvironment that promotes appropriatelifestyle behaviors while decreasing health-related risks.

    Working together, community organiza-tions can offer onsite weight control pro-grams for families, healthy choices in vendingmachines and meal options, and providephysical activity avenues that will improve theoverall health of the community, thusdecrease costs associated with chronic disease.


    Summary:The goal is to enhance the skills of health

    professionals to prevent and treat weight-related problems. Medical professionalsshould obtain height, weight, and BMI meas-urements to assist in the proper care of thepatient. Physicians need to be more pro-active in identifying and addressing weightrelated problems. Counseling should be pro-vided in accurate, concise, consistent mes-sages with realistic implementation practicesfor the patient.

    Specific details:Medical professionals, including pediatricians,family practitioners, primary care physicians,nurse practioners, school nurses, andproviders at public and rural health clinics,etc. should obtain height, weight, BMI, andwaist measurements when appropriate, for allpatient assessments. Health risk assessmentscan be implemented to identify high-riskindividuals and provide information on howto lower the risks. Counseling should be pro-vided in accurate, concise, consistent mes-

  • 34 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

    sages with realistic implementation practicesfor the patient. A consensus of the subcom-mittee was all medical staff should set goodexamples for their patients and the communi-ty.

    Specific issues raised by the subcommitteeinclude:

    Training opportunities need to be availablefor health care providers to help them withbetter counseling skills. Survey based infor-mation indicates many physicians do not feeladequately prepared to discuss weight lossissues with their patients. Topics to includein counseling when appropriate include:• Health risks associated with obesity• Disease states seen in children as a direct

    result of being overweight and lackingphysical activity

    • Lifestyle changes that are sustainable andrealistic

    • Benefits of breastfeeding in reducing risksof future childhood weight problems

    Specific objectives of the medical subcom-mittee include:

    The subcommittee will work to develop atraining manual for use with pediatricpatients. The manual will include referencematerials, assessment questionnaires to beused in the office, counseling tips to follow,and handouts suitable for reproduction at theoffice. After the manual has been tested, itwill be provided to physicians, school nurses,and possibly other health professionals work-ing directly with children.

    The subcommittee feels more informationis needed for medical staffing on preventionand treatment of obesity. Plans includeworking with the Medical Association of theState of Alabama (MASA), Alabama Chapter

    of the American Academy of Pediatrics, andsimilar medical organizations to encouragephysicians and health professionals to makeoverweight discussions a priority.


    Media and social marketingThere are overlapping needs between pri-

    ority areas requiring systematic plans for mar-keting and media promotion activities. Acomprehensive, coordinated media plan willinclude various outlets, such as newspaperand magazines, radio, television, and theinternet. A series of consistent, simple mes-sages will be tailored to reach diverse popula-tions. The messages will be sensitive to cul-tural differences in body images; not support-ing overweight as being acceptable, but beingsensitive in how appropriate body weight ispresented. Messages will focus on communi-cation and intervention strategies to popula-tions at high risk for disease and disablingconditions.

    The messages will be developed in a seriesformat, in order to build on previous con-cepts. Some of the messages the committeerecommends to include are:• Healthy eating does not have to be more

    expensive• Physical activity does not mean the same

    as “exercise” and can be moderate, fittinginto any lifestyle

    • Physical activity can be very inexpensive,such as walking

    • Food selections are choices we make withsome choices better than others

    • Healthy lifestyles are “doable”

    The media plan should be shared with vari-

  • ous state associations and agencies for theiruse as well.

    ResearchThe Task Force supports the need for con-

    tinuous and rigorous research to documentcommunity health needs and assets, demon-strate effectiveness of educational and clinicalservice programs, and improve health out-comes.

    Funding concernsObtaining recurrent funding is a pressingneed before progress in determining localneeds and assets, implementing interventionactivities, and evaluating program impactsand outcomes can occur. Currently, TaskForce members must remember there are lim-ited funds for the priorities and objectiveslisted. Each member is charged to seek fund-ing sources, whether through partnerships or

    grants.Funding issues include support of third partyreimbursement for nutrition and physicalactivity services, working with insurance com-panies for treatment and prevention coverage,and lobbying for obesity to be covered byMedicare. These funding sources will providea funding for the health care provider as wellas open access to those needed services.


    What is the next step? To stop the obesity epidemic it will take all ofus working together. The Alabama StateObesity Plan is a guide to address obesity andrelated issues. The plan’s goals and strategieswill direct the Alabama Department of PublicHealth (ADPH) and the State Obesity TaskForce members. We urge you to join us inusing this plan as well.

    Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 35

  • Resources

    36 Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

  • The list of resources is not meant to be an all-inclusive list; rather, the list is a starting placefor suggestions of materials that may be ofbenefit to your particular interest.


    Coalition BuildingTo get physical activity and nutrition on

    your local agenda, the following steps takenfrom the University of Kansan CommunityToolbox may help. University of Kansas'Community Toolbox may be one of the finestsources of information for community build-ing techniques.

    Community SuccessesThe Center for Disease Control and

    Prevention (CDC) Nutrition and PhysicalActivity Communication Team (NuPAC) haslaunched a searchable Inventory ofQualitative Research in Nutrition andPhysical Activity. The site provides basicinformation about qualitative studies thathave been conducted in the fields of nutri-tion, physical activity, and other related fields.The inventory allows users to search forinformation using search fields, entering key-words, or searching the entire database.

    CDC’s online journal "Preventing ChronicDisease" is a peer-reviewed, electronic journal

    established to provide a forum for publichealth researchers and practitioners to sharestudy results and practical experience.


    eHealth magazine is a quarterly health andfitness