Mike Gilmartin, Lia Delaney, Bryden Moore, Gina Cherbonneaux 4/24/15

An Analysis of the Socioeconomic Factors that Contribute to Childhood Obesity in the

United States

Abstract

Childhood obesity is a public health issue that has been highlighted as a Healthy People

2020 goal centered on both reducing the proportion of children and adolescents who are obese,

and to prevent inappropriate weight gain in the population. According to the Centers for Disease

Control and Prevention (CDC), in the United States, approximately 17% (12.7 million) of

children and adolescents ages 2 to 19 years old are suffering from obesity, a condition defined as

having a BMI at or above the 95th percentile. The poorest parts of the country show the highest

incidences of obesity, implying a strong correlation between socioeconomic status and health

related to nutrition. The current study examined literature focusing on childhood obesity and the

socio-economic factors that influence it, and interventions to reduce the prevalence. Evidence-

based strategies were compiled based on the literature to help us recommend the most effective

and feasible actions that will prevent a further increase in childhood obesity. The results have

promising future implications of reducing the incidence of childhood obesity and associated

disparities with socioeconomic classes, particularly in Massachusetts. Approaching this problem

using the socioecological model, we aim to develop policies and strategies to be used at the

community, state, and federal levels.

Background

Childhood obesity is a critical public health issue in the United States (US), especially

since the US has the highest rates of obesity worldwide (The Economist, 2014). Figure 1

illustrates the high obesity rates in the United States by state. Obesity itself is defined as having

a body mass index (BMI) of greater than or equal to 30. BMI is a measure of body fat based on

an individual’s height and weight; it is calculated by dividing weight in kilograms by height in

meters squared. Childhood obesity is specifically defined as having a BMI greater than or equal

to the 95th percentile of that child’s age group (Ebbeling, Pawlak, & Ludwig, 2002). In the

United States, the prevalence of childhood obesity has increased 300% over the past 20 years

(Messiah, Lipshultz, Natale, & Miller, 2013) Approximately 17% (or 12.5 million) of children

aged 2-19 are obese today in the United States (Centers for Disease Control and Prevention,

2014). An examination of younger age groups shows that 9.7% of children aged 0-2 and 25% of

kids less than 5 years of age are either overweight or obese (Messiah et al., 2013).

The incidence of obesity in children is an issue due to the broad range of health issues

that it is associated with during adolescent years and throughout adulthood. Obese children are

showing health outcomes such as high blood pressure, type 2 diabetes, and elevated blood

cholesterol levels, which are usually not experienced until adulthood (American Heart

Association, 2014). Obese children also tend to become obese adults; these young adults will

likely have much higher risks of chronic disease and obesity-related diseases, which has

tremendous implications for the healthcare system. Research shows that the cost of obesity-

related health care expenses in 2012 was between $147-$210 billion in the United States

(Janssen, Boyce, Simpson, & Pickett, 2006). Psychosocial consequences of childhood obesity

are also a significant problem for obese children. Many experience depression, eating disorders,

and poor self esteem as a direct result of their obesity (Ebbeling et al., 2002). For the first time in

decades, the life expectancy of Americans is projected to decrease as a consequence of obesity

alone (Messiah et al., 2013).

The risk factors for childhood obesity are vast and exist at the individual, community, and

environmental levels. Risk factors at an individual level include being born to a woman who is

overweight or obese (Messiah et al., 2013). Maternal BMI is one of the strongest predictors of

childhood obesity measured in children aged nine (Catalano et al., 2009). While physical

activity is an independent risk factor of childhood obesity, it is important to note the tendency for

children who exercise to be more physically fit. The U.S. physical activity recommendations for

children are 60 minutes of exercise 5 days a week, but only 37% of children meet this standard

(Jin & Jones-Smith, 2015). Heavy screen watching and sedentary activities are individual risk

factors for childhood obesity as well. Screen time promotes energy intake since it displaces

physical activity while simultaneously being associated with the consumption of energy dense

foods (Wolch et al., 2011). Likewise, TV advertisements market fast food restaurants that can

influence children’s unhealthy eating habits. Other individual risk factors that are products of a

family environment include average sleep time, breakfast consumption, and a lack of family

meals.

While looking at the community level, socioeconomic status is a major risk factor of

childhood obesity. One of the biggest associations for obesity and overweight qualities in

children is being of low socioeconomic status (Shrewsbury & Wardle, 2008). Several studies

have found that low SES children have a greater risk of being obese compared to children of

high SES. This is a product of the many risk factors that are often associated with the low

socioeconomic lifestyles or the low-income neighborhoods in which people reside. Furthermore,

the “built environment”, which can affect individuals who live in both urban and rural areas,

plays a large role in one’s physical environment and it is not always conducive for a healthy

lifestyle (Lutfiyya, Lipsky, Wisdom-Behounek, & Inpanbutr-Martinkus, 2007). Underfunded

school districts are also a risk factor for childhood obesity, often allowing vending machines

onto school property in order to increase revenue, or subcontracting lunch programs that

incorporate fast food (Ebbeling et al., 2002). These factors result in further inequalities between

populations of different socioeconomic status with regards to obesity rates.

Environmental risk factors of childhood obesity are important to consider as well.

Pollution exposure has been linked to outcomes such as acute/chronic health conditions like

asthma, further limiting the children’s physical abilities, and as a result is risk factor for

childhood obesity (Wolch et al., 2011).

There are several protective factors for childhood obesity as well. A few of these

protective factors include consuming low energy dense foods, having small portion sizes,

increasing physical activity, and being breast fed. Additionally, being involved in extracurricular

activities is a protective factor as it promotes activity and increases a child’s energy expenditure

(Ebbeling et al., 2002). At the societal level, the proximity of high quality playground facilities

to one’s home protects against childhood obesity, as they incentivize activity in children (Wolch

et al., 2011). Most significantly, a child’s family life has an immense impact on their risk for

developing obesity. Parents have the potential to protect their child from obesity by creating a

home environment that positively supports their emotional and physical needs. When parents

adopt healthy eating and activity behaviors, and create a healthy environment, children indirectly

learn how to make healthy choices themselves (Golan & Crow, 2004). Many of these factors are

aligned with a supportive home environment, or one that has the privilege to live in a community

that provides healthy resources, often associated with higher socioeconomic status (SES), or

privileged neighborhoods.

There are two aspects of research that contribute to the association between obesity and

socioeconomic status. The first focuses on how the individual characteristics of the poor, such as

lack of education and low income, contribute to the development and maintenance of obesity.

Individuals in poverty may not be able to afford healthy foods that would help them maintain a

normal body weight (Janssen et al., 2006). The second theme linking SES and obesity focuses

on individuals’ environments. “Obesogenic environment” is a term for an environment that it is

primarily occupied by the poor and disadvantaged, a low income neighborhood, which promotes

the consumption of energy dense foods and is not conducive for physical activity participation

(Janssen et al., 2006).

Research has found that the efforts that are set forth to combat childhood obesity are

furthering the disparities between low and high SES children (Hillier-Brown et al., 2014). A

study looking at different levels of intervention to combat childhood obesity found limited

evidence that previous interventions have been effective. The study states, “while some

individual and community based interventions may be effective in reducing socioeconomic

inequalities in obesity-related outcomes amongst children, further research is required,

particularly of more complex, societal level interventions and amongst adolescents” (Hillier-

Brown et al., 2014). Due to the lack of effective intervention methods, the current study will

analyze childhood obesity and its relationship with socioeconomic status. Risk factors such as

access to healthy foods, lack of family meals, food deserts and food swamps, lack of nutrition

education, single parent households with long work hours, low physical activity opportunities,

and increased screen time will be examined. The analysis of how they are associated with the

lifestyles of low-income families, or living in a low-income neighborhood, is imperative to

finding effective prevention and intervention techniques.

Figure 1: Rates of overweight and obese children in the United States by individual states

(2007).

Methods

Databases specifically used for the investigation of childhood obesity include Google

Scholar, PubMed, the Community Health Rankings, the Community Guide, and the Centers for

Disease Control and Prevention (CDC) website. All sources were chosen for their good quality

and their scientific peer-reviewed acceptance. Many search terms were utilized in an effort to try

and discover the greatest amount of relevant information. First, general terms such as “childhood

obesity” and “socioeconomic status” were searched in order to obtain general knowledge about

the epidemic. Moreover, information was sought out on a more national and international level.

However, as research continued, the search terms became progressively more specific. Search

terms consisted of words like scope, magnitude, risk, protective, interventions, SES, disparities,

media, education, physical activity, physical education, TV, park access, urban, rural, school-

based, technology, behavioral, marketing, parenting, youth, Massachusetts, legislation, and

nutrition, all of which are related to childhood obesity. With such a wide range of searched

terms, there were thousands of articles to choose from. Google Scholar and PubMed provided

the greatest amount of peer-reviewed articles to compare.

The Community Health Rankings, the CDC website, and the Community Guide did not

include peer-reviewed articles. Community Health Rankings were used to compare different

aspects of culture within the separate Massachusetts counties. Additionally, the Community

Guide and the CDC website focused on interventions that are recommended on a national level

for childhood obesity. Due to the large amount of information available on childhood obesity,

inclusion and exclusion criteria were important. Studies were noticed and selected based on their

titles, abstracts, findings, relevance, sample sizes, and credibility. Furthermore, future

implications of a study were considered as a major reason to utilize its information. Ultimately,

hundreds of abstracts were evaluated in the literature review, dozens of articles were read

completely, and dozens of articles were used in the analysis process.

Findings

Inter/Intrapersonal Level Interventions

Individual behaviors are a main factor of childhood obesity, including child behaviors of

physical activity and diets, and also the contribution of the parent-child relationship (Berry,

2004). Today there is an overall lack of physical activity in children; the majority caused by

excessive television viewing (Robinson, 1999) which is now a regular daily activity in family

lives. Cara Ebbeling states “Television viewing is thought to promote weight gain not only by

displacing physical activity, but also by increasing energy intake.” (Robinson, 1999)

Additionally, families’ diets often consist of easy options such as fast food restaurants or dine in

restaurants, which serve heavy portions with many carbohydrates. Simple interventions on this

level include homemade meals and less television time. Because the interpersonal level is

difficult for interventions due to working with children, parental involvement is critical in

encouraging daily physical activity and healthy eating behaviors.

The Massachusetts Child at Play is an obesity prevention program in the state of

Massachusetts that works on different socioeconomic levels to help decrease childhood obesity

rates. MA Child at Play suggests parents serve healthy snacks and meals, limit sugary drinks,

keep the child active for 60 minutes a day, and limit child television and computer time

everyday. It also encourages modelling these activities to serve as role models (MA Children at

Play, 2015). The most progressive family-based interventions start in the household, which puts

children on the right path throughout their lives. However, this is a hard model to enforce in

communities due to limitations presented from societal factors.

Institutional Level

Serious implications can result from poor health habits, as individuals are highly

influenced by their environments; this is especially true for children who spend much of their

time within institutions of learning. School systems influence children’s health habits via food

choice within cafeterias, having physical activity based classes, and educating on the myriad of

other health topics. One study decided to test this knowledge by comparing the effectiveness of

different school programs in preventing childhood obesity. Three comparisons were made

consisting of a control school system with no program, one with a nutrition program, and a third

with a Annapolis Valley Health Promoting Schools Project (AVHPSP) (Veugelers & Fitzgerald,

2005). The AVHPSP was a multifaceted program that incorporated ideas consistent with CDC

recommendations. Ultimately, the inclusion of nutrition education within the curriculum, the

excellent food quality, the trained staff, the involvement of the community, and the program

evaluation helped make AVHPSP the superior childhood obesity prevention strategy (Veugelers

& Fitzgerald, 2005). The ‘no program’ school systems and the solely nutrition based school

programs showed no noticeable differences between each other in outcome status. Interestingly,

AVHPSP school districts had only 4% obesity rates compared to the roughly 10% of the other

two types of schools measured. Furthermore, sedentary levels were lower among AVHPSP

schools at only 16% compared to the other types measured at 21%. The statistic of overweight

individuals in AVHPSP schools was also half the number of no program districts and the

nutrition based districts (Veugelers & Fitzgerald, 2005).

Another promising study showed the power of classroom curriculums in shaping

children’s behavior (Robinson, 1999) . The class was dedicated to trying to reduce TV,

videotape, and video game usage. By the end of the six-month curriculum, the children in the

class reduced their tricep skinfold thickness and waist circumference, which was directly

attributable to their reduced electronic consumption. The class only group watched 8.8 hours of

TV per week and played 1.32 hours worth of video games per week. The controlled non-class

group watched 14.46 hours worth of TV on average and played 4.24 hours worth of video games

per week. There was also one millimeter less in tricep skinfold thickness and one centimeter less

in waist circumference among the intervention group (Robinson, 1999).

After-school programs were also generally regarded as effective at increasing daily

physical activity, which helps reduce one of the biggest risk factors for childhood obesity.

Implementation of after school programs exhibits the effectiveness of a simple environmental

change approach on health and fitness (Gortmaker, 2012).

Community Level

One intervention that showed short-term effectiveness in a school or community setting

was nutrition and/or physical activity education combined with practical sessions. The

intervention consisted of exercise sessions as well as education on nutrition, physical activity and

healthy lifestyles. The studies examined had intervention periods of 4- 8 months; although some

showed decreases in BMI there were also long-term ineffectiveness shown after intervention

periods ended. These interventions were significantly more effective than ‘education only’

interventions, which has not shown to produce long-term effective results (Veugelers &

Fitzgerald, 2005; Hillier-Brown, 2011).

Group based weight loss or weight gain prevention programs showed effectiveness both

in school and health center settings. These studies were aimed to both improve obesity-related

behaviors, including diet or physical activity, and prevent further weight gain. Although these

interventions are generally effective during the program length at maintaining or decreasing

BMI, there was not universal beneficial effects after long term follow-up (Hillier-Brown, 2011).

This could be attributed to the fact that most education is directed towards children, when it is

known that programs and initiatives that incorporate parents are proven to be more effective.

Parents or caregivers are purchasing the food, deciding activities, and generally creating the

home environment and thus, education must be directed at them and their actions (Golan, 2014).

The community level interventions have shown to be most successful in environments

such as community health centers. These public spaces are ideally situated to play a leading role

in prevention and intervention of childhood obesity. They provide an area where many of the

aforementioned approaches could be improved, as education could be extended to parents

through Healthy Weight Clinics or Group Programs (Tavares, 2014). Healthy weight clinics that

take a dual approach to education and physical activity were shown to have effective follow-up

results within the year. During weekly meetings, parents were given education on healthy habits

and home environments, while the children were engaged in a fun physical activity, such as

dance or swim lessons (Tavares, 2014).

The Massachusetts Obesity Research Demonstration (MA-CORD) study was a

comprehensive intervention to prevent and reduce childhood obesity in two selected cities in

Massachusetts, and used a multi-faceted approach to improve the health of the community. This

approach of multi-level interventions was seen as the most effective approach to this

multifaceted public health problem (Tavares, 2014).

Massachusetts State Level

In the United States, several individual states have used a variety of initiatives with an

overall goal to prevent and lower rates of childhood obesity. Figure two illustrates the drastic

relationship between low income and obesity rates, identifying a problem in Massachusetts that

is being targeted with progressive initiatives. Massachusetts has set a number of proposals and

legislation into action over the past few years. Former Massachusetts Governor Deval Patrick

signed Executive Order 509 (EO 509) in 2009, mandating that Massachusetts state agencies

“follow specific nutrition standards when contracting for the purchase of foods and beverages”

(Department of Public Health, 2012). This order is part of the Mass in Motion initiative, “a

statewide movement that promotes opportunities for healthy eating and active living in the places

people live, learn, work and play” (Department of Public Health, 2015). Under EO 509, MA

state agencies now have standards for purchased foods, for meals and snacks that are served, and

for specific populations such as elderly and children.

Much of the effort to reduce childhood obesity has come from implementation of state

legislation and public policy regarding nutritional standards for children. The National

Conference of State Legislatures (NCSL) reports that in 2014, there were 22 states, including

Massachusetts, which enacted school nutrition legislation or had implemented school nutrition

resolutions. Specific to Massachusetts was a bill enacted in 2013 that called for the

incorporation of “obesity prevention programs, including nutrition and wellness programs, into

school curricula to address the nutrition and lifestyle habits needed for healthy development”

(National Conference of State Legislatures, 2014). Additionally, this bill provides funding for

the expansion of the summer meals program and universal school breakfast program and

mandates that $200,000 more than what was spent in 2013 be put towards the universal school

breakfast program so that every child who receives funds under the program receives a free,

healthy breakfast. This bill also provides funds to pay for Massachusetts’ share of the National

School Lunch program, which is equal to $5,416,986 (National Conference of State Legislatures,

2014). In 2013, Massachusetts considered imposing a tax on candy, soft drinks and sugar

sweetened beverages, and using the tax to fund childhood obesity prevention efforts; no such

proposal has been enacted as of yet (National Conference of State Legislature, 2014).

Other public policy efforts to reduce childhood obesity in Massachusetts have centered

on increasing children’s physical activity and on implementing school wellness programs. The

NCSL (2014) states that in 2013, Massachusetts proposed legislation requiring schools that do

not offer physical education classes daily, to give students at least 30 minutes of physical activity

either in their classrooms or during recess each day. Massachusetts has also proposed a

requirement for schools to train individuals to measure students’ BMI in grades 1, 4, 7, and 10.

Fortunately, Massachusetts receives a number of grants from the CDC to prevent and control

obesity and diseases related to obesity (State of Obesity, 2014).

Massachusetts has done a great deal to create standards and pass laws that will aid in the

reduction of overall obesity rates and childhood obesity rates especially. While Massachusetts

has implemented nutritional standards for competitive foods, which are foods or beverages

served or sold at school that are not under the USDA school meals program, in schools, there is

still no limitation on when and where they can be sold (State of Obesity, 2014). However,

Massachusetts is one of the 35 states and Washington D.C. that has mandatory farm-to-school

programs, it has policies for physical education requirements in schools, for safe routes to

school, and for complete street programs as well. Still, much more needs to be done in order to

reduce the prevalence of childhood obesity in Massachusetts.

Figure 2: Rates of children who are overweight or obese compared with median

household income in Massachusetts (2010-2011).

Recommendations

Due to the fact that obesity is a multifaceted issue, we developed a three-tiered plan of

recommendations from a state level policy change to individual interventions. Using these

recommendations, childhood obesity can begin to be combated in Massachusetts, especially in

areas of low SES.

Inter/Intrapersonal Level

Parents are the main target in prevention of childhood obesity, they are the ones who

decide the meals their children receive and mostly how their child’s time is spent throughout the

day. MA Child at Play is a good start with the guidelines they hold in place for parents, however

just guidelines are not enough (MA Child at Play). Weight is determined by the amount of

calories consumed and and calories expended. However in order to be both effective at a

population level, as well as a cost effective strategy, intervention studies must be targeted at

larger levels and Parents need assistance from the other examined levels to make an impact on

the child and their lifestyle. The schools are directly involved and can help educate children on

healthy lifestyles as well as supplying them with healthy lunch meals and scheduled time for

exercise everyday. Recommendations at the individual level include schools providing

pamphlets to parents about healthy living and give recommendations for daily activities to help

children develop a healthier lifestyle. The pamphlets would include suggestions on ways to limit

children’s TV viewing time, ways to increase their physical activity levels, and ways to

implement healthy snack/meal options. The school setting will allow the targeting of all children,

and provide some basic education to the correct audience.

With the resources provided from the state and community level interventions,

individuals can take advantage of prevention programs and teaching groups. This will allow

children and parents across socioeconomic levels the environment and opportunity to improve

health. On the individual level alone it is hard to find tools to reduce or prevent childhood

obesity; however with the help from the other levels there are many strategies that will be

beneficial to the population.

Community and Institutional Levels

Community based approaches need to be targeted from institutions that reach populations

indiscriminately, such as schools or health centers. These can be targeted interventions in these

environments, or initiatives to improve already labeled “obesogenic” environments, which are

considered universal interventions. Households and families are exposed to and in constant

interaction with the broader ‘community-level’ obesogenic pressures and practices, thus, the

community needs to be involved in the prevention effort. Children spend most of their active

time at school and as such this setting is an attractive target for actions aimed at installing and

adopting healthy lifestyle in a sustainable way and a target that has proven to offer potentially

effective paths for prevention already.

Community health centers, with state funding, should provide group weight gain

prevention programs and teaching groups with a dual parent and child approach. With the

support of this group, parents can be given the tools through information and strategies to make

healthier choices for themselves and their child. Group based programs that follow a model of

providing an activity for the children that promotes activity or a healthy lifestyle while providing

education or nutrition information to parents.

At an institutional level, one can recognize the profound impact that school

systems can have on altering childhood obesity rates. Teachers and other staff members have the

ability to influence the students in a variety of ways. For this reason, we recommend the

implementation of a multi-faceted school based program in every middle school in

Massachusetts that would successfully address every part of the children’s school experience.

Furthermore, for optimal results, school systems should be designed around the CDC

recommendations for a functioning school district. More specifically, those recommendations

would alter a school’s policy on nutrition, curriculum, food service, nutrition education, staff

training, family/community involvement, and evaluation (Veugelers & Fitzgerald, 2005). In

similar fashion, we recommend that schools educate the children’s parents.

After school program options should be implemented in all public schools, specifically of

low SES communities, and in order to provide an alternative to sedentary activities or home

environments. The programs should provide a safe environment for sports and activity based

games, and be accessible for all students, thus encouraging physical activity and limiting screen

time. Collectively, these school recommendations will improve the health of children by giving

them positive tools to use on a daily basis. Above all, these recommendations will help shorten

the gap between high SES and low SES communities with respect to childhood obesity rates.

Massachusetts State Level

In order to achieve real results and lower the rates of obesity in Massachusetts, the major

effort will need to be a focus on increasing funds to schools and community health centers. It is

a practical and cost-effective way to target this larger level, with one model but some level of

individuality. Since the problem lies heavily in areas of low SES areas, taxes alone will not be a

sufficient way to increase funding since these areas do not obtain the same amount of tax money

as areas of high SES. A primary recommendation is to increase access to subsidized after school

programs for children to allow a safe environment for physical activity and an alternative to

sedentary activities at home. A recommendation for areas of low SES is to form coalitions with

state funded individuals have positions in school systems with the sole job to write and apply for

grants. These grants will give these schools the funding needed to incorporate school activity

programs, group based weight clinics, and nutrition and health based education. Since there is

also a need for funding in order to increase access to healthy food in low SES areas, another

recommendation is that Massachusetts give subsidies to schools that use farm to school programs

and have healthy snack options offered in their vending machines. In turn, the money from these

subsidies can be used to provide meals that are truly healthy and nutritious to their students and

create other obesity prevention initiatives.

Further recommendations include the distribution of funding designated for healthy

weight clinics that are part of a dual approach for parents and children in community health

centers across the state. The plan for decreasing childhood obesity in Massachusetts and in the

United States needs to begin at the state level, in order to have a trickle down effect that will

target the community and the individual.

Executive Summary

The purpose of this project was to examine how past childhood obesity interventions

have worked and whether or not they adequately impacted low SES children. Additionally, we

wanted to analyze low SES children in an effort to understand why they were more at risk of

becoming obese compared to their wealthier counterparts. With the help of the research, we

wanted to propose interventions that would shorten the gap between the different SES groups

with respect to the childhood obesity rates. For our literature review, we utilized Google Scholar,

PubMed, the CDC website, The Community Guide, and the Community Health Rankings. The

inclusion criteria for the peer reviewed studies had to do with the studies relevance, results, and

implications for the future. Moreover, the Community Health Rankings allowed us to compare

the different Massachusetts’ counties health outcomes. A Massachusetts obesity prevention

program called Child at Play has been utilized across the state with promising results. The

program works with different SES groups by providing suggestions and guidelines to parents on

healthy meals, physical activities for children, and ways to limit the child’s screen time (MA

Children at Play, 2015). At the state level, Massachusetts has enacted bills that have created

standards for purchased foods among all school districts (Department of Public Health, 2012).

We recommend increased statewide funding for group based weight gain prevention and weight

loss programs, as well as for access to subsidized after school programs. At the community level,

we recommend that schools incorporate a multifaceted weight gain prevention based program

including nutritional education components, physical activity components, a trained staff,

involvement with the community, and good food quality (Veugelers & Fitzgerald, 2005). In

order to target the individual, we recommend that parents receive pamphlets from the schools

educating them about how to live a healthier life. The parental knowledge has the power to

translate into healthier habits within their homes which will lead to a decrease in childhood

obesity. We have research and designed a set of recommendations that will allow a multifaceted

approach to the public health problem of childhood obesity.

References

American Heart Association. (2014). Overweight in children. Retrieved from

http://www.heart.org/HEARTORG/GettingHealthy/HealthierKids/ChildhoodObesi

y/Overweight-in-Children_UCM_304054_Article.jsp

Berry, D. (2004). Family-Based Interventions for Childhood Obesity: A Review. Journal of

Family Nursing, 429-449.

Catalano, P. M., Farrell, K., Thomas, A., Huston-Presley, L., Mencin, P., de Mouzon, S. H., &

Amini, S. B. (2009). Perinatal risk factors for childhood obesity and metabolic

dysregulation. The American Journal of Clinical Nutrition, 90(5), 1303-1313.

doi:10.3945/ajcn.2008.27416 [doi]

Centers for Disease Control and Prevention. (2014). Childhood obesity facts. Retrieved from

http://www.cdc.gov/obesity/data/childhood.html

Ebbeling, C. B., Pawlak, D. B., & Ludwig, D. S. (2002). Childhood obesity: Public-health crisis,

common sense cure. Lancet, 360(9331), 473-482. doi:S0140-6736(02)09678-2 [pii]

Golan, M., & Crow, S. (2004). Targeting parents exclusively in the treatment of childhood

obesity: Long-term results. Obesity Research, 12(2), 357-361. doi:10.1038/oby.2004.45

[doi]

Gortmaker SL, Lee RM, Mozaffarian RS, et al. Effect of an afterschool intervention on increases

in children’s physical activity. Med Sci Sports Exerc 2012;44:450–457.

Hillier-Brown, F. C., Bambra, C. L., Cairns, J.-M., Kasim, A., Moore, H. J., &

Summerbell, C.D. (2014). A systematic review of the effectiveness of individual,

community and societal level interventions at reducing socioeconomic inequalities in

obesity amongst children. BMC Public Health, 14(1), 834. http://doi.org/10.1186/1471-

2458-14-834

http://doi.org/10.1038/oby.2004.45

Janssen, I., Boyce, W. F., Simpson, K., & Pickett, W. (2006). Influence of individual- and area-

level measures of socioeconomic status on obesity, unhealthy eating, and physical inactivity

in canadian adolescents. The American Journal of Clinical Nutrition, 83(1), 139-145.

doi:83/1/139 [pii]

Jin, Y., & Jones-Smith, J. C. (2015). Associations between family income and children's

physical fitness and obesity in california, 2010-2012. Preventing Chronic Disease, 12, E17.

doi:10.5888/pcd12.140392 [doi]

Leibowitz, R., Foley, M., Gapinski, M. A., Sheetz, A., & Smith, L. A. (2012). The state of

childhood weight in massachusetts, 2011. (1). Health and Human Services: mass.gov.

Lutfiyya, M. N., Lipsky, M. S., Wisdom-Behounek, J., & Inpanbutr-Martinkus, M. (2007). Is

rural residency a risk factor for overweight and obesity for U.S. children? Obesity (Silver

Spring, Md.), 15(9), 2348-2356. doi:15/9/2348 [pii]

MA Children at Play. (n.d.). Retrieved March 28, 2015.

Marshall University. (2010). In Joan C. Edwards School of Medicine (Ed.), 2007 rates of

overweight and obese children. https://musom.marshall.edu/getmoving/stats.asp

Massachusetts Department of Public Health. (2012). Massachusetts state agency food standards.

Mass.gov: Health and Human Services.

Messiah, S. E., Lipshultz, S. E., Natale, R. A., & Miller, T. L. (2013). The imperative to prevent

and treat childhood obesity: Why the world cannot afford to wait. Clinical Obesity, 3(6),

163-171. doi:10.1111/cob.12033 [doi]

National Conference of State Legislature. (2013). Childhood obesity legislation - 2013 update of

policy options. ncsl.org:

Robinson, T. N. (1999). Reducing children's television viewing to prevent obesity: A

randomized controlled trial. Jama, 282(16), 1561-1567. doi:joc90434 [pii]

Shrewsbury, V., & Wardle, J. (2008). Socioeconomic status and adiposity in childhood: A

systematic review of cross-sectional studies 1990-2005. Obesity (Silver Spring, Md.), 16(2),

275-284. doi:10.1038/oby.2007.35 [doi]

Taveras, E. M., Blaine, R. E., Davison, K. K., Gortmaker, S., Anand, S., Falbe, J., … Smith,

L. (2014). Design of the Massachusetts Childhood Obesity Research Demonstration

({MA}-{CORD}) Study. Childhood Obesity (Print), 11(1).

http://doi.org/10.1089/chi.2014.0031

The Economist. (2014). Obesity rates: Fat of the lands. Retrieved from

http://www.economist.com/node/17118939

The State of Obesity. (2014). The state of obesity in Massachusetts. stateofobesity.org: Trust for

America's Health; Robert Wood Johnson Foundation.

Veugelers, P. J., & Fitzgerald, A. L. (2005). Effectiveness of school programs in preventing

childhood obesity: A multilevel comparison. American Journal of Public Health, 95(3),

432-435. doi:95/3/432 [pii]

Wolch, J., Jerrett, M., Reynolds, K., McConnell, R., Chang, R., Dahmann, N., . . . Berhane, K.

(2011). Childhood obesity and proximity to urban parks and recreational resources: A

longitudinal cohort study. Health & Place,17(1), 207-214.

doi:10.1016/j.healthplace.2010.10.001 [doi]

Individual Tasks Throughout The Semester

Background: Unanimously, we decided to split up the research tasks into scope and magnitude groups. Bryden

and Gina sought out information on the magnitude, while Mike and Lia looked for information on the

scope. Collectively, everyone contributed to the research on the risk and protective factors of childhood

obesity. Once all of the information was gathered, we were responsible for drafting summaries of our

areas individually. We met as a group to collaborate and put together the different pieces into a seamless

paper. The citation process was also a group effort as everyone individually cited the references that they

used independently. Similarly, everyone worked together to provide feedback and continuously edit the

background. Delegation was used to equally divide the tasks such as final editing, citation managing, and

submitting the paper. Great communication through the Google doc helped the editing process run

smoothly.

Methods and Findings:

The findings and the methods paper went very smoothly with everyone in the group

contributing equally. As a group, we met outside of class to organize the tasks that needed to be

done for the paper. Lia focused on community interventions, Bryden focused on state level

interventions, Gina focused on interpersonal/intrapersonal interventions, while Mike focused on

institutional interventions. Additionally, everyone contributed to the editing process by reading

over and commenting on our writings in the google doc. Mike edited the original draft, while

Lia, Gina, and Bryden worked on the the final edits. Furthermore, Mike completed the methods

section by asking everyone individually what resources they used for their research. All of the

group members also cited the resources that they used and correctly formatted them under the

references section. By the end of the paper, Lia made the final revisions and completed the final

submission. Ultimately, this paper was a success as everyone in the group contributed with

relevant researched information.

Recommendations and Conclusions:

Like all other sections of the paper, this section was worked on equally by all group

members. Gina wrote recommendations for the individual level, Lia wrote recommendations for

the community level, Mike recommended for the institutional level, and Bryden worked from the

state level. We came together to discuss the best approach to a multifaceted intervention, and

agreed upon a set of recommendations for our conclusion. Furthermore, everyone took the time

to edit their sections in the methods/findings paper based on the TA feedback. Following that,

Bryden solely worked on editing the background paper. Once all of the edits were done, Lia

organized the final paper by bringing together all of the different sections. Moreover, two graphs

were implemented in the paper by Lia and Bryden in order to support the text. Towards the end

of the process, Mike completed the executive summary as well as the task sheet. Once that was

complete, Bryden alphabetized all of our references and submitted the final paper. As a group,

we met outside of class on multiple occasions in an effort to organize our thoughts and writings.

Ultimately, our group effectively distributed equal amounts of work to all group members which

is why our project ran smoothly.