Childhood Obesity Prevention for the Greater Kansas City Area

 
Childhood Obesity Prevention for the Greater Kansas City Area
KANSAS CITY CHILDHOOD OBESITY COLLABORATIVE-WEIGHING IN

         Childhood Obesity
         Prevention for the
   Greater Kansas City Area
     Inventory of Community Capacity and Assets

                                                         2011

CHILDREN’S MERCY HOSPITALS AND CLINICS-2401 GILLHAM – KANSAS CITY MO 64108
Childhood Obesity Prevention for the Greater Kansas City Area
Contents
INTRODUCTION ..........................................................................................................................................................4
   The Problem ...........................................................................................................................................................4
   Purpose and Objectives ..........................................................................................................................................4
   Definition—Childhood Obesity Prevention ............................................................................................................4
   Criteria for Inclusion in the Community Capacity and Asset Inventory .................................................................5
   Process to Collect Asset Information .....................................................................................................................6
RESULTS ......................................................................................................................................................................6
   Inventory Categories ..............................................................................................................................................6
   Population, Racial/Ethnic and Income Groups Served ...........................................................................................8
   Information Needs and Communication Channels. ...............................................................................................9
   Programs ............................................................................................................................................................. 10
   Collaboration ....................................................................................................................................................... 11
   Resources and Assets .......................................................................................................................................... 13
   Priority Activities Related to Childhood Obesity ................................................................................................. 13
   Other.................................................................................................................................................................... 15
DISCUSSION ............................................................................................................................................................. 16
   Population group focus ....................................................................................................................................... 16
       School-age children ......................................................................................................................................... 17
       Pregnancy ........................................................................................................................................................ 18
       Breastfeeding .................................................................................................................................................. 19
       Infancy and Early Childhood ............................................................................................................................ 20
   Other Issues Related to Childhood Obesity Prevention Capacity ....................................................................... 22
       Information Needs........................................................................................................................................... 22
       Capacity to Track Childhood Obesity Indicators.............................................................................................. 22
       Communication-Message Dissemination ........................................................................................................ 23
       Systems Approach ........................................................................................................................................... 24
       Governance Framework .................................................................................................................................. 25
       Treatment ........................................................................................................................................................ 26
Works Cited ............................................................................................................................................................. 26
APPENDIX 1-Interview Tool ..................................................................................................................................... 29
APPENDIX 2-Agencies and Organizations Interviewed ........................................................................................... 34
APPENDIX 3-Agencies and Organizations Interviewed by Population Group ......................................................... 35
APPENDIX 4-State and National Agencies, Organizations and Programs ............................................................... 36
APPENDIX 5-Programs by Strategies ....................................................................................................................... 44

This report was written by staff from Kansas City Childhood Obesity Collaborative-Weighing In based at
Children’s Mercy Hospitals and Clinics with support from the Health Care Foundation of Greater Kansas City.
The opinions expressed in this report are those of the author and do not necessarily reflect the views of the
Foundation.

September 2011

For questions about the content of the report, contact:

Deborah Markenson, MS, RD, LD
Kansas City Childhood Obesity Collaborative-Weighing In
Children’s Mercy Hospitals and Clinics
Telephone: 816-234-9223
E-mail: dmarkenson@cmh.edu
INTRODUCTION
The Problem

There is deep concern about the health of our children and the epidemic of childhood obesity. Kansas City data
reflect that 31% of low-income children under five years of age are overweight or obese (1) and for older
children, Score 1 for Health found that 41% of school-age children they assessed were overweight, obese or very
obese. (2). These children are at risk for early development of diabetes, heart disease and other serious health
and social problems. As stated by Melody Barnes, Chair of the White House Task Force on Childhood Obesity in
its Report to the President, “This is not the future we want for our children, and it is a burden for our health
care system that we cannot bear. Nearly $150 billion per year is now being spent to treat obesity-related
medical conditions.” This translates annually to an estimated $212 million in medical spending attributable to
obesity in Kansas City, Mo. (3), (4) The problem requires serious attention and fortunately, as stated by the
White House Report, there are clear, concrete steps we can take as a society to help our children reach
adulthood at a healthy weight. (5)

This community capacity inventory was done to help identify the current capacity within the Greater Kansas City
area to address childhood obesity and inform future directions for the Kansas City Childhood Obesity
Collaborative-Weighing In and other interested parties. This report details the results of the capacity
assessment along with specific recommendations on next steps for three population groups—prenatal, early
childhood and school-age. In addition, the report outlines infrastructure and general support recommendations
for next steps that build on current capacity and help us advance collective efforts to take “clear, concrete
steps” to seriously address childhood obesity and create a region where our children can enjoy optimal growth
and development.

Purpose and Objectives

Compile a composite of Greater Kansas City’s community capacity and assets impacting childhood obesity in
order to support planning and collaborative prevention efforts.

1. Identify, describe and categorize the capacity and types of activities in which stakeholders, institutions and
   associations are currently engaged in the Greater Kansas City area related to childhood obesity.
2. Subdivide community assets to address childhood obesity into population groups, namely, prenatal, early
   childhood (children 0-5 years), and school-aged (children 6-18 years).
3. Identify existing interdependencies and areas primed for creating collaboration to better address childhood
   obesity.
4. Identify existing resources for sustainable interventions in areas of policy, influence on social norms,
   leadership and commitment to prevention of childhood obesity.
5. List, describe and categorize the current and future information needs reported by key stakeholders,
   institutions and associations for addressing childhood obesity.

Definition—Childhood Obesity Prevention

This inventory includes those individuals or organizations that are engaged in childhood obesity prevention,
conduct or participate in activities that address healthy eating, active living and management of a child’s weight.
These efforts could be part of research, policy, program, advocacy, or environmental initiatives and could impact
Childhood Obesity Prevention-Inventory of Community Capacity and Assets
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one or more population groups, including parents or caregivers, pregnant women, and children, birth through
18 years of age. (6) Prevention may include these specific activities:

      Research to identify effective programs or approaches for addressing childhood obesity or associated risk
      factors;
      Programs to encourage children and/or their caregivers to maintain a proper balance between food
      (energy intake) and physical activity (energy expenditure )to support growth and healthy development, or
      manage obesity;
      Environment changes to address diet or physical activity risk factors for childhood obesity.
      “Environment" means the built or physical environment (i.e., sidewalks, parks, recreation facilities) and
      the non-built or social environment (i.e., availability of fruits and vegetables, crime rate); or
      Policy changes to decrease the prevalence of childhood obesity, including policies to address diet or
      physical activity. Policy means any decisions, guidelines, recommendations or requirements that exist
      within an organization, setting or local community, as well as policies at the state or national level.

Criteria for Inclusion in the Community Capacity and Asset Inventory

Singular and collective actions of many agencies, organizations, institutions and governmental entities may
impact children’s growth, development and healthy weight status in the Greater Kansas City area. For the
purpose of this review, criteria were established to help identify those agencies that are taking specific actions
that contribute to the prevention of childhood obesity. The following characteristics were used to determine
which agencies and individuals were included in this review:
        Show interest and influence others on the issue;
        Demonstrate history of involvement in childhood obesity prevention activities;
        Conduct related scope of services (e.g., healthy eating, active living);
        Have current capacity (i.e., expertise, staff) to deliver services;
        Were either a not-for-profit or governmental agency;
        Have authority or oversight related to enforcement of laws, regulations or policies to address childhood
        obesity and its risks; and/or
        Provide resources or supports for childhood obesity prevention in the Greater Kansas City area.

Agencies which exhibited one or more of these criteria in relation to childhood obesity prevention were included
to the extent that they were identified through this inventory process. This review focused on supports
available for Jackson County, Missouri and Wyandotte County, Kansas since there were finite resources available
to conduct this review and the rates for childhood obesity and its risks are higher in these two counties
compared to others in the region. The author recognizes that there are other agencies that represent capacity to
address childhood obesity in these counties and within the metro-wide area. In addition, this review focused on
the prevention aspects of childhood obesity and did not collect information on programs designed primarily to
treat and manage childhood obesity. Also, physical assets (such as parks, bike paths, or sidewalks) were not
captured in this community asset inventory.
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Process to Collect Asset Information

Community childhood prevention asset information was collected through direct interviews and review of
information available on these agencies’ websites. An interview tool (Appendix 1) was developed and used to
provide a consistent way to collect key information for the community capacity and asset profile. Information
on state and federal level programs that oversee or provide supports for childhood obesity prevention efforts is
also included. This information was collected from state and federal websites and from information directly
obtained from staff in the Kansas and Missouri State offices.

RESULTS
A total of 25 entities are included based on information collected from interviews. (Appendix 2 and 3) In
addition, information was collected from an additional 38 state and national programs from their websites
(Appendix 4). Based on the information collected, assets and capacity are categorized into two broad
categories: 1) type of agency or organization and 2) population group.

Inventory Categories: Kansas City Collaboratives–Distinct membership collaborations whose mission
relate to or directly support efforts to prevent childhood obesity were included in this category. There are
overlaps in memberships between these collaboratives. Four collaboratives are included in this review.

    1.   Building a Healthier Heartland
    2.   Greater Kansas City Food Policy Coalition
    3.   Kansas City Childhood Obesity Collaborative-Weighing In
    4.   Mother and Child Health Coalition

         Figure 1. Kansas City Collaboratives Addressing Childhood Obesity Prevention Issues

                                                Greater KC Food Policy
                                                      Coalition

                               KC Childhood
                                                                          Building a
                                  Obesity
                                                                          Healthier
                               Collaborative-
                                                                          Heartland
                                Weighing In

                                                Mother and Child Health
                                                       Coalition
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Community Agencies
   Community Agencies - Not-for-profit organizations providing services primarily in the Kansas City metro area
   were included in this category. Representatives from these eight organizations were interviewed:
           5. Blue KC
           6. Children’s Mercy Family Health Partners
           7. Health Care Foundation of Greater Kansas City
           8. KC Healthy Kids
           9. Menorah Legacy Foundation
           10. Mid America Regional Council –including Early Learning and Head Start
           11. Mid-America Coalition on Health Care
           12. YMCA of Greater Kansas City

    Agencies Supporting Schools – There are a number of programs or agencies that provide specific supports to
    schools to improve nutrition, meals, physical activity, physical education, health education and health.
    Representatives from each of these organizations were interviewed:
            13. Alliance for a Healthier Generation
                Children’s Mercy Family Health Partners (also reflected in the community group)
            14. Energy Balance 4 Kids
            15. Junior League of Kansas City (The League’s childhood obesity prevention supports are primarily
                school based)
            16. Kansas Coordinated School Health Services
            17. PE4Life
            18. Score 1 For Health

Local Public Health Agencies - Based in a county or municipality, these entities provide a set of services and
oversight as authorized by statutes, ordinances or regulations to protect and improve the population’s health:
            19. Independence City, (MO) Health Department
            20. Jackson County,( MO) Health Department
            21. Kansas City,( MO) Health Department
            22. Unified Government of Wyandotte County, (KS) Health Department

State or Federal Government or National Initiative – These programs or agencies are state or federal based and
provide services or oversight within authority granted by state or federal law, regulations and policy. Interviews
were conducted with representatives from the following organizations:
            23. US Department of Health and Human Services
            24. University Extension (MO)
            25. University of Kansas
                Kansas Coordinated School Health Services (also shown in school supports section)
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The following are a list of primarily government based supports that were not directly interviewed but their
respective resources and programs are available to aid local efforts, considered to be of value, and included in
general inventory (Appendix 4)

Federal Government Supports
   Let’s Move Initiative
   Centers for Disease Control and Prevention
         Division of Nutrition and Physical Activity
         Pediatric Nutrition Surveillance System
         Pregnancy Surveillance System
         Division of Adolescent and School Health Programs , including Youth Risk Behavior Surveillance
           System, School Health Policies and Programs and others
         Behavioral Risk Factor Surveillance System
         The Community Guide
    US Department of Health and Human Services-Agency for Healthcare Research and Quality (AHRQ)
    Innovations Exchange: Paths to healthy weight

Federal Government Supports with Administering State Agencies
   USDA (US, KS, MO, local agency administering program where applicable)
         Special Nutrition Assistance Program (SNAP)
         School Meals Program – School Breakfast and Lunch
         Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
         Child and Adult Care Food Program (CACFP)
         Summer Food Service Program (SFSP)

State specific supports
    Coordinated School Health Services(MO and KS)
    Missouri Council on Activity and Nutrition

National Non-Profits

    Robert Wood Johnson Foundation
    National Collaborative on Childhood Obesity Research (NCCOR)
    National Institute of Health Care Quality (NICHQ)-Healthy Weight Collaborative and Childhood Obesity
    Action Network (COAN)
    Yale Rudd Center for Food Policy and Obesity
    Alliance for a Healthier Generation

Population, Racial/Ethnic and Income Groups Served

Each interviewee was asked to identify which of the following population group(s) they served: prenatal
(pregnant women); parents or caregivers for children, 0-18 years of age; early childhood-infants to five years of
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age; kindergarten through 12th grade-school-age children; or general- serve all populations or not specific to any
one population. The results are shown in Table 1 and the name of the agencies by population group is included
in Appendix 3. Sixteen (64%) reported that they served all population groups, four reported that they focused
on 0 to 5 years of age, nine addressed school-age children, six served parents, and one addressed the prenatal
population.

                          Table 1 Number of Agencies Serving Each Population Group

                                   Population Group                 Number       Percent
                        Prenatal                                            1          4%
                        0 to 5 years                                        4         16%
                        Kindergarten through 12th Grade                     9         36%
                        Parents                                             6         24%
                        All Population Groups                             16          64%

All interviewees reported that they served all racial/ethnic groups with none serving primarily either African
American or Hispanic. Six (24%) stated that they had a higher proportion of African American and/or Hispanic
individuals but did not primarily serve that group. Interviewees were also asked to identify which income levels
their agency served from four options that ranged from all income levels to high income levels. A total of 17
(68%) served all income levels and eight (32%) served primarily low income levels.

Information Needs and Communication Channels.

Organizations were asked whether they have the types of information needed to support current activities and
program objectives related to lowering risks and rates of childhood obesity. A total of 16 agencies (67%) stated
that, in general, they had sufficient information and 8 agencies (33%) stated that they did not have sufficient
information or would like to have more specific information to support current activities and program
objectives. A total of 13 agencies (54%) identified barriers to access or the use of information. The two main
barriers noted were 1) limited availability of information on childhood obesity prevalence, and 2) lack of staff
time and expertise to find and interpret information to support program efforts. It was also noted by a
membership organization that there was a loss of continuity in transfer of information due to board member
and volunteer turnover.

All interviewees were asked if they needed information or had information to share in four specific areas and
their responses are shown in Table 2 below. The type of information most needed related to what programs
and approaches are effective, followed by prevalence data for local areas, and specific information about other
resources or programs available for the Greater Kansas City area. When each interviewee was then asked to
identify their top three priorities for information needed to support their agency’s childhood obesity activities,
those specific items aligned with the prior categories. The top specific need was for information on how to
conduct effective programs, followed by obesity prevalence data with preferences for it packaged at a local
level, e.g., by school, by neighborhood, by city. A close third was a need for information on resources and
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programs available in the metro area. In addition, several stated that it would be of value to know priority areas
for collaboration and how they could best complement existing efforts to prevent obesity. Over half of the
respondents have information they can share but there is wide variance in the types, comparability, and ability
to compile this information in a consistent manner.

                          Table 2 Childhood Obesity Information Needs and Priorities

                       Information                                Need more              Have            Priority
                                                                 information       information can
                                                                    (N=25)               share
                                                                                        (N=25)
1. Information to understand or describe the extent to                 20 (80%)            15 (68%)         1
   which obesity prevention programs and treatments
   are effective (i.e. solutions and effectiveness)

2. The prevalence and incidence of childhood obesity in                19 (76%)            16 (64%)         2
   your target area
3. Information about obesity-related programs, activities              17 (68%)            14 (56%)         3
   and resources in your area (i.e., linkages and
   resources)
4. How obesity impacts a child's health and well-being                 11 (44%)            10 (40%)
   over time (i.e., disease burden)

Almost half of the interviewees reported that they disseminated regular newsletters (most were electronic) to
members or constituent groups. All reported that they had websites and one-third reported that they used
social media (e.g., Facebook, blogs, Twitter). All indicated they would be willing to distribute information about
childhood obesity or specific actions being taken in the Greater Kansas City area that would be of interest to
their staff, members or residents.

Programs

Information was collected on the types of services, programs and activities that each agency conducted related
to childhood obesity. A total of 73 programs or activities were reported with more detailed information about
objectives, target population, frequency and means to determine effectiveness detailed for three-fourths of
these programs. There were varying types of activities, ranging from screening to programs designed to change
behaviors or improve knowledge. Others targeted policies or environmental changes to modify behaviors and
risks for childhood obesity, including environmental changes to address diet or physical activity risk factors.
Table 3 below classifies the approaches into 12 different strategy categories, of which 6 are current strategies
recommended by the Centers for Disease Control and Prevention (CDC) to address childhood obesity. (7) A total
of 26 programs (36%) were within CDC’s recommended strategy listing. A full listing of the programs is found in
Appendix 5.
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                      Table 3 – Number of Programs Arranged by Community Strategies

                                                                                              Programs        %
                                                                                                 by
                         Community Strategies to Prevent Obesity                              Strategy
 CDC Recommended Community Strategy Categories
 Promote the availability of affordable healthy food and beverages                                     9
 Create safe communities that support physical activity                                                7
 Encourage communities to organize for change                                                          6
 Encourage physical activity or limit sedentary activity among children and youth                      3
 Support healthy food and beverage choices                                                             1
 Encourage breastfeeding                                                                               0
                                       Total Programs within CDC Recommended Strategies               26     36%
 Other Strategies
 School focused                                                                                       14
 Screening and treatment                                                                               9
 Research based efforts                                                                                8
 Education programs and other activities                                                               6
 Infant and early childhood focused                                                                    6
 Funding support                                                                                       4
                                                     Total Programs within Other Strategies           47     64%
                                                                             Total Programs           73

Collaboration

All interviewed indicated that they currently collaborate with others within the community on childhood obesity
prevention efforts for the Greater Kansas City area. A total of 68 different agencies or types of agencies were
listed as collaborators. There was no list from which to choose; interviewees simply identified those agencies
with which they collaborated. Eleven interviewed (44%) indicated they collaborate with schools. The specific
agencies most frequently listed as those with which interviewees collaborated included KC Healthy Kids (40%-
10); Building a Healthier Heartland (28%-7) Weighing In, Children’s Mercy Hospitals and Clinics, the Greater
Kansas City Food Policy Coalition, and the Mother and Child Health Coalition (all 24%-6); and local public health
agencies (20%-5).
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          Table 4 Agencies Reported as Collaborators and Frequencies by Those Interviewed (N=25)

                     Agencies with which                                 Number Percent
                     Interviewees (N=25) Collaborated                    of times
                                                                         reported
                     School(s)/School Districts                                11   44%
                     KC Healthy Kids                                           10   40%
                     Building a Better Heartland                                7   28%
                     Food Policy Coalition                                      6   24%
                     Weighing In                                                6   24%
                     Children’s Mercy Hospital and Clinics                      6   24%
                     Mother and Child Health Coalition                          6   24%
                     Local Public Health Agency                                 5   20%
                     University of Kansas                                       4   16%
                     Mo Council on Activity and Nutrition (MoCAN)               4   16%
                     MU Extension                                               3   13%
                     Beans and Greens Program                                   3   13%

All indicated that they would be willing to collaborate on new or other childhood obesity prevention strategies.
School-based projects led the list as most frequently identified type of new project or broader collaboration that
the agencies would be willing to add. Many referenced the importance of making sure new collaborations used
evidence based approaches that would complement existing efforts. Specific items identified included Walking
School Bus, calorie counts on menus, and eliminating trans fats in non-chain restaurants on a metro wide basis.
One interviewee indicated a willingness to provide seed money to local innovative, trailblazing programs. Those
programs’ successes, in turn, would better position them to attract support from other funders. This individual
indicated interest in fostering “the excellence that is part of this area” and believed those in the Midwest were
too hesitant to embrace their strengths and be “great."

The interviewees were asked to rank how feasible it would be for their organization to get involved in more
collaborative projects related to childhood obesity on a scale of 1 to 10 (10 being the highest). Responses
ranged from 3 to 10 with 8 as the average.

Responders identified who they viewed as a leader or organization that is influential in advancing the Greater
Kansas City area’s ability to prevent childhood obesity and critical to have on board for collaborations. These
responses are shown in Table 5 below. A total of 43 different organizations, categories and individuals were
identified. Children’s Mercy Hospitals and Clinics was the organization most frequently identified by 64% of the
responders. The other top leaders were Weighing In and KC Healthy Kids, both at 36%, schools (32%), University
of Kansas (28%), and Building a Healthier Heartland and local public health agencies (both-24%). Dr. Sarah
Hampl was the only individual identified multiple times.
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    Table 5 Agencies Identified as Influential Leaders in Advancing Childhood Obesity Prevention Efforts as
                                        Percent of Total Interviews (N=25)

                         Influential Leaders or Organizations          Number of Percent
                                                                      interviewees
                                                                        that listed
                   Children's Mercy Hospitals and Clinics                         16  64%
                   Weighing In                                                      9 36%
                   KC Healthy Kids                                                  9 36%
                   School(s)/School Districts                                       8 32%
                   University of Kansas                                             7 28%
                   Building a Healthier Heartland                                   6 24%
                   Local Public Health Agencies                                     6 24%
                   Health Foundations                                               5 20%
                   Sarah Hampl, M.D.                                                4 16%
                   Chamber of Commerce                                              3 12%
                   Mid America Regional Council                                     3 12%

Resources and Assets

Each person was asked to identify their organization’s most valuable resources and strongest assets and the
following themes were found in the responses:

        Broad network and reach,
        Expertise and willingness to provide technical assistance,
        Funding,
        Reputation and top quality staff,
        Resources and supports for evidence-based school approaches,
        Students and scholars from university-based organizations,
        Visionary leadership and committed boards interested in addressing childhood obesity, and
        Volunteer pool.

Those interviewed indicated that there was significant potential for additional childhood obesity collaboration.
While the collective values could not be quantified, 23 out of 25 reported that they would be willing to devote
funds, resources or staff time for a collaborative project on childhood obesity.

Priority Activities Related to Childhood Obesity

Interviewees were asked to identify the top three priority activities to prevent childhood obesity. A diverse
array of activities was reported. The most frequent types of activities related to schools, community
collaboration, and activities focused on policy and environmental changes and these were fairly evenly
distributed between categories. Table 6 depicts a matrix of these activities grouped by setting and focus area.
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                                         Table 6 Matrix of Priority Activities Reported

     Setting            School                     Neighborhood                Community-Region                       Other

 Type of
 Activity
General        Provide technical               Support neighborhood           Create sustainable             Support Head Start and
               assistance and resource         based initiatives              corridors                      child care initiatives
               supports                        Increase community             Support linkage between        Educate employers on
               Support after school            mobilization on HE/AL          schools and worksites/         health plan design
               programs                        Conduct adult and youth        corporate support              Collect and analyze data
               Launch and maintain             HE/AL programs                 Work to align activities       Increase public awareness
               school-based programs,                                         Increase and strengthen        of problem and solution
               Secure school district                                         community health planning      Market services and
               support                                                        Collaborate with others on     provide rationale for use
               Conduct youth                                                  HE/AL activities               Seek and maintain funding
               empowerment program                                            Provide technical              to support activities
               Change school                                                  assistance and resource        Survive tight times
               environments and policies                                      supports                       Educate and provide
               Conduct school-based                                           Establish enforceable policy   resources to healthcare
               screenings and refer at risk                                                                  professionals
               for weight management           Increase community                                            Provide health coaching
               treatment                       gardening                                                     Advocate for insurance
               Provide counseling for                                                                        coverage for weight
               overweight/ obese children                                                                    management services
               and their families
Healthy        Conduct nutrition education     Increase access to local,      Improve access to local        Change mindset on use of
Eating (HE)    Establish school gardens        affordable healthy food        foods                          fresh fruits and vegetables
               Provide nutrition counseling                                   Promote purchase of local
                                                                              foods in institutions
                                                                              Expand Beans and Greens
                                                                              program
                                                                              Establish Food Policy
                                                                              Coalition
Active         Document impact of              Advocate for livable streets
Living (AL)    physical activity levels on     and improved parks
               academic success                Promote use of walking         Support Metro Green Trail
               Increase physical activity      trails                         System
               opportunities
               Add walking trails

Those interviewed were asked to indicate whether they anticipated changes in their priorities or activities
relating to childhood obesity and why they anticipated those changes. While several indicated that they could
not predict those changes, most reflected that these activities would remain a priority and that efforts would
become more effective not only from improved alignments with others but also from enhanced insights
regarding what works. Several others indicated that they anticipated a continued shift from programs to
broader scale policy and others expected that health care reform may impact access to health care and how
treatment is managed, which in turn may impact prevention activities. The key types of changes anticipated as
they relate to childhood obesity activities are depicted in Figure 2.
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                    Figure 2. Proportional Reflection of Changes Forecast by Interviewees

                                                                    Align and increase collective
                                                                    efforts (8)
                                                                    Become more effective (6)

                                                                    Keep childhood obesity
                                                                    prevention as ongoing priority (4)
                                                                    Shift from program to policy &
                                                                    environment focus (2)
                                                                    Adapt based on health care
                                                                    reform (3)
                                                                    Not sure (2)

Other

A total of 23 (92%) indicated they would like to see an ongoing process to update an inventory of assets or
community resources available to prevent childhood obesity for the Greater Kansas City area.

Individuals were asked for other comments related to their organizations’ childhood obesity activities. The
general themes and some quotes are included in Table 7. The primary themes reinforced by those interviewed
include maximizing the use of their respective resources and working collaboratively to address childhood
obesity.
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                                          Table 7 General Comments

        Theme (Number)                                               Quotes
  Strong support for ongoing         Like bi-state working relationship and ability of region to identify common
  efforts and collaboration (6)      needs and issues. There is an openness and willingness to share and
                                     partner in the area.
                                     "Want to be at the table." Have broad range of resources and expertise
                                     and comprehensive array of community programs that can be tailored and
                                     adapted to match needs of area/community/school/setting.
                                     Very serious about childhood obesity, focus of the board and CEO, part of
                                     [the organization’s] national movement.
                                     Much more effective to be collaborative. Need to make changes in the
                                     system with clear focal points.
  Committed to maximizing the        Our programs facilitate integration and maximize current use of
  use of their resources and         resources.
  supporting others (6)

  Would like firmer funding to        A lot of us are on soft money--would like to have longer term initiatives,
  support childhood obesity           real concern about throwing money at non-sustainable efforts.
  resources (2)                       Would like to see community listing of those that have interest in funding
                                      childhood obesity initiatives.

  Expand and focus efforts (2)        Would like to see more done with child care and school partners
                                      Would like to do more in this arena. Recognize the First Lady's efforts and
                                      I have real concerns regarding what our children are eating.

DISCUSSION
Population group focus

This report organizes the childhood obesity prevention capacity by three population groups, namely prenatal,
early childhood and school age. Risks for childhood obesity are known for each of these groups and evidence is
growing on approaches that are promising or have proven to lower risks for obesity. This population focus
provides a manageable route to review the current capacity and consider next steps that build and leverage our
current capacity to address the complex problem of childhood obesity in more effective and efficient ways.

Valuable capacity represented by Greater Kansas City area agencies and organizations include or primarily focus
on environmental and policy changes to improve healthy eating and active living for all population groups. These
approaches benefit all population groups. KC Healthy Kids, The Greater Food Policy Coalition, Building a
Healthier Heartland and the local public health agencies, to name a few, represent important capacity focused
on the environment and policy domains. These approaches are complementary and reinforce the population
focused efforts.
Childhood Obesity Prevention-Inventory of Community Capacity and Assets
Greater Kansas City Area
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School-age children
 The population group for which this inventory reflects the largest capacity is for school-age children. It is
important to note that no one from a school or school district was interviewed but all of those interviewed
supported schools, with six of the interviewees primarily focused on schools and an additional four agencies also
reporting supports for this group. While there were some overlaps in school-based resources and supports,
efforts are coordinated and represent capacity that can be further leveraged by promoting the availability of
these agencies’ services and selecting one or two strategies to coordinate across agencies for the Greater Kansas
City area. In addition, some of those that served all population groups were not aware of the services and
programs available from the school-focused agencies. These agencies could help promote services available
from those specializing in supports for schools, thus helping more schools access those specialized resources.
This in turn could free up time for the agencies serving all groups to focus efforts on areas with fewer resources.
It is also noted that those specializing in school programs and activities are better equipped to assess what each
individual school district and their respective schools need, and consequently tailor supports and resources
provided. There is a wide range of needs among school districts so this tailored approach is helpful.

The most frequent program category was school programs (19% of all programs) and the most frequently
reported collaboration was with schools, with 11 or 44% reporting that they collaborated with schools. In
addition, activities in schools setting were high among those activities reported as priorities to prevent
childhood obesity and there were a diverse array of these activities. This is clear evidence that schools are
currently a focus for obesity prevention efforts and—given the number of school-age children in Kansas City, the
existing mechanisms in schools for education and reinforcement of healthy behaviors, the increased insights we
have on what is effective and the enhanced academic success experienced by physically active and well-
nourished children—schools should remain a focus area.

The Healthy, Hunger-Free Kids Act of 2010 authorized funding for federal school meal and child nutrition
programs and increases access to healthy food for low-income children. This bill reauthorized child nutrition
programs for five years and included $4.5 billion in new funding for these programs over 10 years.
Reauthorization strengthens programs and regulations to implement the provisions of this Act are expected in
2012. (8) "The Healthy, Hunger-Free Kids Act makes the most significant investment in the National School
Lunch program in more than 30 years,” according to U.S. Secretary of Education Arne Duncan. (9)

Some new requirements that will improve nutrition and reduce risks for childhood obesity include these steps:

        Gives USDA the authority to set nutritional standards for all foods regularly sold in schools during the
        school day, including vending machines, the “a la carte” lunch lines, and school stores.
        Provides additional funding to schools that meet updated nutritional standards for federally-
        subsidized lunches. This is an historic investment, the first real reimbursement rate increase in more
        than 30 years.
        Helps communities establish local farm to school networks, create school gardens, and ensures that
        more local foods are used in the school setting.
        Expands access to drinking water in schools, particularly during meal times.
        Sets basic standards for school wellness policies including goals for nutrition promotion and education
        and physical activity, while still permitting local flexibility to tailor the policies to their particular needs.
        Increases the number of eligible children enrolled in school meal programs by using Medicaid data to
        directly certify children who meet income requirements.
Childhood Obesity Prevention-Inventory of Community Capacity and Assets
Greater Kansas City Area
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        Allows more universal meal access for eligible students in high poverty communities by eliminating
        paper applications and using census data to determine school-wide income eligibility.
        Expands USDA authority to support meals served to at-risk children in afterschool programs.

While national efforts are increasing, state support for coordinated school health services has decreased in
                                    recent years. Missouri has staff available through the Missouri Department
                                    of Health and Senior Services to support school health services but funding
                                    and direct grants to schools have been decreased. The Missouri Department
                                    of Elementary and Secondary Education do not have dedicated staff for
                                    coordinated school health services.

                                  Kansas has supported school health services since 2003. While the program
                                  received a budget cut this year (10) supports remain and Kansas Health
                                  Foundation is funding efforts to compile measures of fitness, including weight
                                  related to academic achievement. The Kansas Department of Education also
                                  tracks self-reported ratings of school districts wellness policies by basic,
                                  advanced or exemplary using the state's School Wellness Policy Model
                                  guidelines. (11)

                                    Recommendations to increase capacity for school-based activities:
1. Compile and disseminate a document that lists and describes the agencies and programs available to
   support schools and how to access those services.
2. Assess and track school policies using the online Kansas school wellness policy tracking resource and other
   sources to capture the current status of policies.
3. Conduct planning to compile the Greater Kansas City area’s action plan to enhance school policies,
   environments and practices. This should focus on helping schools meet the new regulations and policies
   that will be required by the Healthy, Hunger Free Kids Act of 2010. Kansas City has notable capacity and
   commitment to collaboration in providing supports for schools. This will be an asset to help schools meet
   the new higher-bar expectations that will be required.
4. Link and coordinate plans for schools as appropriate with other community policy and environment focused
   initiatives to reinforce school actions.
5. Compile succinct position paper summarizing school-based strategies, actions and benefits.
6. Establish consistent messages for use by schools and multiple community school partner groups on food and
   fitness issues to effectively communicate and reinforce actions being taken to improve healthy eating and
   active living and lower risks for obesity.

Pregnancy
Mothers’ pre-conception weight and weight gain during pregnancy are two of the most important prenatal
determinants of childhood obesity. (5) The Mother and Child Health Coalition was the only agency represented
in this inventory that served the prenatal population but their capacity to address the prenatal determinants of
childhood obesity could be considered quite extensive in view of the over 200 member agencies reflected in
their network from the Greater Kansas City area. Targeted and effective services are also available through the
WIC programs in the area for low-income pregnant women.

There have been dramatic changes in the population of women having babies. American women are now a
more diverse group; they are having more twin and triplet pregnancies, and they tend to be older when they
Childhood Obesity Prevention-Inventory of Community Capacity and Assets
Greater Kansas City Area
Page 19

become pregnant. Women today are also heavier; a greater percentage is entering pregnancy overweight or
obese, and many are gaining too much weight during pregnancy. Many of these changes carry the added burden
of chronic disease, which can put the mother and her baby’s health at risk. New guidelines and insights for how
much weight a woman should gain during pregnancy were issued by the Institute of Medicine in 2009. (12)

Recommendations to strengthen capacity to reduce a child’s risks for obesity prior to and during pregnancy

1. Build on the current infrastructure and supports made available through the Mother and Child Health
   Coalition, Weighing In, and local WIC programs to:
   a. Review existing approaches and identify ways to increase the number of pregnant women and women
       planning pregnancies who have access to information and
       supports to conceive at a healthy weight and maintain a
       healthy weight during pregnancy. Identify recommended            White House Task Force on Childhood
       policies and procedures to enhance supports to increase          Obesity-Report to the President
       the proportion of women who are at a healthy weight and
       have a healthy weight gain during pregnancy.                     Recommendation 1.1: Pregnant women
   b. Assess specific training and resources available to agencies      and women planning a pregnancy should
       serving this target population and augment if needed to          be informed of the importance of
       enhance approaches to support healthy weights of                 conceiving at a healthy weight and having
                                                                        a healthy weight gain during pregnancy,
       pregnant women.
                                                                        based on the relevant recommendations of
2. Take actions to track trends of women’s pre-pregnancy weight
                                                                        the Institute of Medicine. Specifically,
   and weight gain during pregnancy for the greater Kansas City         health care providers, as well as …local
   area in order to further refine actions needed and evaluate          agencies, medical societies, and
   which actions are effective.                                         organizations that serve pregnant women or
                                                                         those planning pregnancies should provide
Breastfeeding                                                            information concerning the importance of
Breastfeeding has been linked to healthy weight children in              conceiving at a normal BMI and having a
multiple epidemiologic studies. Systematic reviews also indicate         healthy weight gain during pregnancy. (5)
that support programs in health-care settings (e.g., Baby-Friendly
Hospital Initiative –BFHI-
http://www.babyfriendlyusa.org/eng/index.html ) are effective in
increasing rates of breastfeeding initiation and in preventing early
cessation of breastfeeding. (7).

At the national level efforts are increasing to support breastfeeding. The White House Task Force on Childhood
Obesity in their Report to the President recommended that hospitals and health care providers should use
maternity care practices that empower new mothers to breastfeed, such as the Baby-Friendly hospital
standards. (5) Healthy People 2020 goals have specific objectives to increase the proportion of infants being
breastfed. (13) The Surgeon General’s Call to Action to Support Breastfeeding has specific recommendations for
mothers and families, health care providers, communities, employers, public health and researchers to increase
the number of infants that are breastfed. (14). The Healthy, Hunger Free Kids Act of 2010 also expands support
for breastfeeding through the WIC program. In addition, health care reform requirements (Section 4207 of the
Patient Protection and Affordable Care Act ) amended the Fair Labor Standards Act (FLSA), or federal wage and
hour law to require employers to provide reasonable break time and a private, non-bathroom place for nursing
Childhood Obesity Prevention-Inventory of Community Capacity and Assets
Greater Kansas City Area
Page 20

mothers to express breast milk during the workday, for one year after the child’s birth. The new requirements
became effective when the Affordable Care Act was signed into law on March 23, 2010.

CDC’s recent report card on rates of breastfeeding at six months shows both Kansas (41.0) and Missouri (35.1)
lagging behind the U.S. rate of 44.3 percent. (15) In the Kansas City area there are supports for breastfeeding
such as those provided by agencies offering WIC services, availability of community breastfeeding classes, social
media networks for new parents, local mother to mother support groups, training on the new requirements for
employers to support breastfeeding employees, and efforts at hospitals to support breastfeeding mothers and
their infants. Specifics on these efforts were not captured as part of this survey. The agencies interviewed for
this inventory did not indicate evidence of community wide efforts to accelerate the implementation of the
Baby-Friendly Hospital Initiative. Only two agencies reported limited activities related to breastfeeding.
Concerted efforts to coordinate broader community-based efforts to increase breastfeeding were not reported
but training was made available on the new requirements for employers to support their breastfeeding
employees.

Recommendations for increasing capacity to support of breastfeeding

1. Build on current infrastructure and resources through the Mother and Child Health Coalition and identify
   feasible actions to increase the number of hospitals in the Greater Kansas City area that are interested and
   pursuing a Baby-Friendly Designation. Strive to have hospitals in the region on the map within the next two
   years. (http://www.babyfriendlyusa.org/eng/03.html)
2. Identify if Kansas City employers are experiencing any barriers or problems in providing supports for their
   employees who are breastfeeding and if they are, explore ways to assure needed and reasonable supports
   for women in the workforce who are breastfeeding.
3. Convene representatives from child care agencies to compile strategies to identify and implement “baby-
   friendly” guidelines to support breast fed infants and their mothers to increase the proportion of mothers
   who are able to breastfeed for longer periods.

Infancy and Early Childhood
The data reveal that the problem of obesity in infancy and early childhood is pervasive and growing. Almost
one-fourth of children aged 2-5 are overweight or obese and the proportions of overweight and obese children
in this age group have doubled in 30 years (16).

The childhood obesity epidemic requires a sense of urgency and new avenues for prevention focused on the first
5 years of life. (17) Development is more rapid during these early years than at any other time after birth, and
young children’s early experiences are “built into their bodies,” affecting neural, metabolic, and behavioral
systems in ways that can influence the risk for obesity, health, and well-being through the life span. (18), (19),
(20) A number of key factors influence the risk for obesity in an infant or young child, including prenatal
influences, eating patterns, physical activity and sedentary behaviors, sleep patterns, and marketing and screen
time. Young children are totally dependent on parents, caregivers and others to provide environments and
support practices that shape these factors.

Only four or 16% of the agencies assessed as part of this obesity prevention inventory focused on the early
childhood population group. While an additional sixteen agencies supported all populations (including early
childhood), there were limited programs or activities reported for this age group. Collectively, agencies
Childhood Obesity Prevention-Inventory of Community Capacity and Assets
Greater Kansas City Area
Page 21

reported a total of six programs that focused on infants and/or early childhood. The Mid-America Regional
Council (MARC) that serves as the Head Start Administrator for the Missouri region represents solid interest and
capacity to address risks for childhood obesity for the area’s children with the highest risks. There are other
strong agencies and organizations addressing early childhood and child care issues for this region that were not
included in this survey, e.g., resource and referral services for parents and child care providers. Weighing In’s
Early Childhood Working Group has representatives from those agencies and their participation reflects
additional capacity that will be essential to advancing Kansas City’s efforts to prevent childhood obesity during
this critical early growth and development stage.

Recently, the Greater Kansas City Obesity Collaborative1 was one of ten teams selected nationally to participate
in the Healthy Weight Collaborative, a project created by the Affordable Care Act and supported through the
Prevention and Public Health Fund. The Kansas City team will link constituents from three sectors—primary
care, public health and community-based organizations—in innovative partnerships in the Kansas City area. This
team is exploring a target population of children 2-5 years of age and their families for its initial goals to expand
obesity treatment and prevention efforts beyond the walls of a clinician’s office and into the community.

The Healthy, Hunger Free Kids Act of 2010 also has provisions supporting nutrition and wellness in child care
settings through the federally-subsidized Child and Adult Care Food Program. The White House Task Force on
Childhood Obesity (5) recently published IOM recommendations on Early Childhood Obesity Prevention Policies
(17). These clearly underscore strategies that can build on Kansas City’s current capacity and strengthen obesity
prevention practices that need to begin in early life.

Recommendations for increasing capacity to support obesity prevention practices for children under five
years of age

1. Assess current standards and practices within child care settings and organizations supporting these
   settings. Select specific actions to increase the proportion of child care facilities that follow best practices
   and establish and maintain policies and child care environments that support physical activity, nutrition,
   healthy feeding practices and professional development opportunities for staff.
2. Review current licensing standards and the Quality Rating and Improvement System to identify to what
   degree these processes support evolving program practices regarding nutrition, feeding practices, physical
   activity, and screen time in early education and child care settings.
3. Track and share progress of the Greater Kansas City Obesity Collaborative to develop and test new
   approaches to achieve and maintain healthy weight for children and families using quality improvement
   methods. This initiative will focus on best ways to assess overweight and obesity risks among children,
   refine treatment protocols and guidelines for those with a body mass index (BMI) ≥85th and 95th percentiles,
   and refine best approaches for the family as a whole. This effort will help identify ways to replicate best

1
 The Kansas City Obesity Collaborative core team members consist of representatives from the following agencies:
Children’s Mercy Hospitals and Clinics-Primary Care Clinics, Children’s Mercy Family Health Partners, Kansas City Childhood
Obesity Collaborative—Weighing In, Kansas City (MO) Health Department, the YMCA of Greater Kansas City, and KC Healthy
Kids. The team will use quality improvement methods to develop and test new approaches to achieve and maintain healthy
weight for children and families.
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