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Montana Nutrition and Physical Activity State Plan to
Prevent Obesity and Other Chronic Diseases 2006 - 2010
Table of Contents:
Letter from Governor Schweitzer and DPHHS Director Miles
Acknowledgments
Executive Summary
The Overweight and Obesity Epidemic: A Call to Action
Montana's Response to the Call
Goal 1: Increase Physical Activity among Montana Residents
Goal 2: Increase Fruit and Vegetable Consumption among
Montana Residents
Goal 3: Promote Caloric Balance among Montana Residents
Goal 4: Increase Breastfeeding of Montana Infants
Evaluation
Afterword
Appendices:
Appendix A: Definition of Terms and Acronyms
Appendix B: Fifteen Priorities for Action
Appendix C: A Note on School Wellness Policies and
Practices
Appendix D: Task Force Members
Appendix E: Strategy Chart: Social Area and
Socio-Ecological Sphere
Appendix F: End Notes (For the text file, end notes
have also been incorporated into the text)
Letter from Governor Schweitzer and DPHHS Director Miles:
Office of the Governor, State of Montana
Brian Schweitzer, Governor
John Bohlinger, Lieutenant Governor
We are proud to introduce the 2006-20010 Montana Nutrition and Physical Activity
Plan to Prevent Obesity and Other Chronic Diseases. The overarching purpose of
the plan is to help improve the health and welfare of Montanans by reducing
chronic diseases associated with obesity.
Obesity in the United States has reached epidemic proportions, and Montana is
not immune. Obesity increases the risk of illness due to high blood pressure,
high cholesterol, type 2 diabetes, and other diseases. The personal and economic
costs of these conditions can be devastating.
Although Montanans are relatively fit compared to residents of other states,
half of all adult residents are still overweight or obese. Fortunately, Montana
has many assets that we can capitalize on to try to stop and perhaps even
reverse the trend toward obesity and other chronic illnesses. These include an
abundance of beautiful outdoor recreation sites, a traditional heritage
emphasizing physical activity, high rates of breast feeding, and a population
that is still among the most active in the nation. By building on these and
other strengths, we can encourage Montanans to eat well, move more, and enjoy
longer, healthier lives.
The plan described in this document emphasizes policy and environmental changes
that existing institutions can make to increase the likelihood that Montanans
will eat healthier food and engage in more physical activity. It is a wonderful
start, but the real work is ahead of us. In order to make physical activity and
healthy eating a part of our everyday lives, institutions such as schools, day
care centers, health facilities, worksites, and tribal and community agencies,
will need to find ways to promote these activities among the people whose lives
they touch.
We challenge everyone to work together to fulfill the vision of moving Montanans
toward healthy lifestyles in healthy communities.
(Signed) Brian Schweitzer, Governor, State of Montana
Joan Miles, Director, Department of Public Health and Human Services
State Capitol
P.O. Box 200801
Helena, Montana 59620-0801
Telephone: 406-444-3111
Fax: 406-444-5529
Website: http://www.mt.gov
Table of Contents
Acknowledgments:
The development of the 2006-2010 Montana Nutrition and Physical Activity State
Plan to Prevent Obesity and Other Chronic Diseases (State Plan) was made
possible by a capacity building grant from the federal Centers for Disease
Control and Prevention (CDC) to fund the Montana Nutrition and Physical Activity
Program (NAPA). In a unique partnership, The Montana Department of Public Health
and Human Services (DPHHS) contracted with Montana State University to house and
staff the program. This State Plan was created with extensive input from the
Cardiovascular Disease/Obesity Prevention Task Force. We want to thank Task
Force members for their expertise. We would also like to acknowledge the
stakeholders who reviewed and commented on the State Plan, and we appreciate the
fine work of Judy Garrity, who helped weave input from Task Force members and
stakeholders into an integrated working document.
Table of Contents
Executive Summary:
This State Plan outlines goals, objectives and strategies to prevent and reduce
overweight and obesity among Montanans. Overweight and obesity raise the risk of
illness from type 2 diabetes, heart disease, high blood pressure, high
cholesterol, certain types of cancer, arthritis, gallbladder disease, and other
chronic conditions. (End Note #1: U.S. Department of Health and
Human Services. Overweight and Obesity: Health Consequences page. Available at:
http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_consequences.htm
Accessed March 30, 2006.)
During the past three decades the prevalence of overweight and obesity among
American adults and children has increased dramatically. (End Note
#2: Centers for Disease Control and Prevention National Center for Health
Statistics. National Health and Nutrition Examination Survey. Prevalence of
Overweight and Obesity Among Adults: United States, 1999-2002 page. Available at
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm .
Accessed April 12, 2006.) In 2004, more than half of all adults in Montana were
overweight or obese. (End Note #3: Centers for Disease Control
and Prevention National Center for Chronic Disease Prevention and Health
Promotion Behavioral Risk Factor Surveillance System. Prevalence Data Montana
Demographics Weight Classification Based on BMI page. Available at
http://apps.nccd.cdc.gov/brfss/display.asp?cat=DE&yr=2004&qkey=4409&state=MT
. Accessed April 12, 2006.) The number of children who were overweight or at
risk for becoming overweight increased. (End Note #4: Montana
Office of Public Instruction. 2005 Youth Risk Behavior Survey Montana High
School Trend Report page. Available at
http://www.opi.mt.gov/PDF/YRBS/Trend05HS.pdf . Accessed April 12, 2006.) If
this trend is not reversed, it will have serious negative personal and economic
consequences for Montanans.
The State Plan is intended as a starting point in identifying and coordinating
efforts to promote healthier lifestyles among our state's residents. Activities
outlined in the State Plan focus on achieving the following goals:
1. Increasing Physical Activity
2. Increasing Fruit and Vegetable Consumption
3. Promoting Caloric Balance
4. Increasing Breastfeeding of Infants
Members of the Cardiovascular Disease/Obesity Prevention Task Force who helped
create this State Plan committed their time and knowledge to workgroups
addressing these goals in: work sites; healthcare; the broader community; and
settings impacting children, youth, and families. The priority populations
addressed in this plan are 1) children and 2) adults in the workplace. Key
strategies for this plan include:
1. Piloting policies and practices to increase opportunities for physical
activity and healthy eating at work sites.
2. Providing training to health care providers and hospital personnel working to
make Montana hospitals "Breastfeeding Friendly."
3. Delivering technical assistance to city and county planners and bicycle and
pedestrian advocates in their work to make communities more walkable and
bikeable.
4. Supporting professionals and community leaders in American Indian communities
as they design and implement efforts to promote healthy nutrition and physical
activity opportunities for children.
5. Piloting interventions to promote healthy nutrition and physical activities
in preschool and daycare facilities.
The State Plan objectives will be accomplished through the joint efforts of
state agencies, nonprofit organizations, tribal leaders, businesses, and
schools. The NAPA program will play a facilitative role in supporting and
coordinating these efforts.
The Overweight and Obesity Epidemic: A Call
to Action.
Across Montana, in small towns, in urban areas, and on reservations, community
residents and leaders are expressing concern about the health dangers of
obesity, and they are seeking ways to promote good nutrition and physical
activity. Interest in this topic can be found among individuals in virtually all
spheres of life – for example, parents and grandparents, teachers, employers,
elected officials, and health care professionals. This is extremely fortunate
because a successful effort to make healthy eating and adequate physical
activity a part of the daily life of all the state's residents will require
changes in homes, schools, work sites, neighborhoods, and other settings. The
State Plan is an effort to begin identifying and coordinating what individuals,
organizations, state agencies and other institutions can and will do to promote
healthier lifestyles in the coming years. It is intended as a starting point and
resource for all the people who want to take action in their own area of
influence, so that they can become a part of the whole effort to bring about the
vision of healthy people in healthy
communities throughout the state.
The obesity epidemic is gaining momentum in America and in Montana as adults and
children are consuming more calories and spending less time engaged in physical
activity. Overweight and obesity substantially raise the risk of illness from
high blood pressure, high cholesterol, type 2 diabetes, heart disease,
gallbladder disease, arthritis, sleep disturbances and problems breathing, and
certain types of cancers. (End Note #5: US Department of Health
and Human Services. Overweight and Obesity: Health Consequences page. Available
at:
http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_consequences.htm
. Accessed March 30, 2006.)
Overweight and obesity are defined by a measurement called the Body Mass Index
(BMI). The BMI expresses the relationship (or ratio) of weight-to-height and is
an indicator of overweight and obesity. Adults with a BMI of 25 to 29.9 are
considered overweight, while adults with a BMI of 30 or more are considered
obese. (End Note #6:US Department of Agriculture. Dietary
Guidelines for Americans 2005 page. Available at:
http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter3.htm
Accessed March 30, 2006.)
During the past three decades, the prevalence of overweight and obesity among
U.S. adults has increased dramatically, as shown in Figure 1.
Description of Figure 1: Age- adjusted prevalence of
overweight and obesity among U.S. adults, age 20-74 years. Age was adjusted by
the direct method to the year 2000 U.S. Bureau of the Census estimates using the
age groups 20-39, 40-59, and 60-74years. Overweight is defined as having a BMI
greater than 25.0. Obesity is defined as having a BMI greater than 30.0.
According to the National Health and Nutrition Examination Survey(NHANES) II, in
1976-1980, 47% of 11,207 U.S. adults were overweight and 15% were obese.
According to NHANES III, in 1988-1994, 56% of 14,468 U.S. adults were overweight
and 23% were obese. According to NHANES for 1999-2002, 65% of 7,494 U.S. adults
were overweight and 31% were obese. Source:
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obsefig2.GIF . End
of description.
According to the 2004 Behavioral Risk Factor Surveillance System (BRFSS), 37% of
Montana adults are overweight, and 20% of Montana adults are obese. (End Note
#7: Centers for Disease Control and Prevention National Center
for Chronic Disease Prevention and Health Promotion Behavioral Risk Factor
Surveillance System. Prevalence Data Montana Demographics Weight Classification
Based on BMI page. Available at
http://apps.nccd.cdc.gov/brfss/display.asp?cat=DE&yr=2004&qkey=4409&state=MT
.
Accessed April 12, 2006.) In other words, more than half of all adults in the
state are beyond a healthy weight and are therefore at increased risk for
several chronic diseases.
Description of Figure 2: Obesity by body mass index: Montana versus nationwide.
Obesity is defined as adults with a BMI equal to or greater than 30. In 1990,
about 8% of Montana adults were obese and about 11% of all American adults were
obese. In 1991, about 10% of Montana adults were obese and about 12.5% of all
American adults were obese. In 1992, about 10.5% of Montana adults were obese
and about 12.5% of all American adults were obese. In 1993, about 11% of Montana
adults were obese and about 12.5% of all American adults were obese. In 1994,
about 12.5% of Montana adults were obese and about 13% of all American adults
were obese. In 1995, about 12.5% of Montana adults were obese and about 15% of
all American adults were obese. In 1996, about 13% of Montana adults were obese
and about 16% of all American adults were obese. In 1997, about 13.5% of Montana
adults were obese and about 15.5% of all American adults were obese. In 1998,
about 14% of Montana adults were obese and about 17.5% of all American adults
were obese. In 1999, about 15% of Montana adults were obese and about 18% of all
American adults were obese. In 2000, about 15% of Montana adults were obese and
about 19% of all American adults were obese. In 2001, about 18% of Montana
adults were obese and about 21% of all American adults were obese. In 2002,
about 17.8% of Montana adults were obese and about 22.5% of all American adults
were obese. Source: Centers for Disease Control and Prevention (CDC). Behavioral
Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department
of Health and Human Services. Centers for Disease Control and Prevention, 2002.
End of description.
While excess weight creates negative health consequences for Americans of all
ages, it is particularly devastating for children. The consequences of
overweight in childhood are psychosocial and physical. Overweight children face
increased cardiovascular risk factors such as abnormal glucose tolerance,
hypertension and high cholesterol. (End Note #8: Dietz WH.
Health consequences of obesity in youth: childhood predictors of adult disease.
Pediatrics [serial online]. 1998; 101: 518-525. Available at:
http://www.pediatrics.org/cgi/content/full/101/3/S1/518 . Accessed March 14,
2006.) Between 1979 and 2000, annual hospital costs for overweight-related
conditions in young people aged 6-17 increased from $35 million to $127 million.
(End Note #9: Wang W, Dietz, WH. Economic burden of obesity in
youths aged 6 to 17 years: 1979-1999. Pediatrics [serial online]. 2002; 109:
81-. Available at:
http://www.pediatrics.org/cgi/content/full/109/5/e81 . Accessed March 14,
2006.) In addition, overweight children are more likely to become overweight
adults and to face ongoing health risks as a result. (End Note
#10: American Obesity Association Fact Sheet. Obesity in Youth page.
Available at:
http://www.obesity.org/subs/fastfacts/obesity_youth.shtml . Accessed March
22, 2006.) Nationwide, the prevalence of overweight among 6- to 11-year olds
more than doubled and the prevalence of overweight among 12- to 19-year olds
tripled between 1980 and 2000. (End note #11: Ogden CL, Flegal
KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US
children and adolescents, 1999-2000. JAMA [serial online]. 2002; 288: 1728-1732.
Available at: www.jama.com . Accessed March
14, 2006.) By the end of the twentieth century, 16% of American children and
adolescents were overweight. (End Note #12: Centers for
Disease Control and Prevention National Center for Health Statistics. Prevalence
of Overweight Among Children and Adolescents: United States, 1999-2002 page.
Available at
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm . Accessed
April 12, 2006.) According to the 2005 Youth Risk Behavior Survey (YRBS), 9% of
Montana high school students are overweight, and an additional 13% are at risk
of becoming overweight. (Overweight among individuals 2-19 years old is defined
as the 95th percentile or greater of BMI-for-age, and at risk for overweight is
defined as the 85th percentile or greater, but less than the 95th percentile, of
BMI-for-age). (End Note #13: Ogden CL, Carroll MD, Flegal KM.
Epidemiologic trends in overweight and obesity. Endocrinology and Metabolism
Clinics of North America. 2003; 32:741-760.)
Description of Figure 3: Prevalence of overweight among children and adolescents
ages 6-19 years. Overweight is defined as children and young people ages 2-19
with a BMI-for-Age at or above the 95th percentile. Starting with 1971-1974,
data excluded pregnant women. Pregnancy status wasn't available for 1963-65 and
1966-1970. Sources of data are CDC/NCHS, NHES and NHANES. From 1963 to 1970, 4%
of children 6-11 years of age were overweight and 5% of children 12-17 years of
age were overweight (Note: Data for 1963-1965 are for children 6-11 years of
age. Data for 1966-1970 are for adolescents 12-17 years of age, not 12-19
years.) From 1971 to 1974, 4% of children ages 6-11 were overweight and 6% of
children 12-19 were overweight. From 1976 to 1980, 7% of children ages 6-11 were
overweight and 5% of children 12-19 were overweight. From 1986 to 1994, 11% of
children ages 6-11 were overweight and 11% of children 12-19 were overweight.
From 1999 to 2002, 16% of children ages 6-11 were overweight and 16% of children
12-19 were overweight. Source:
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm . End of
description.
In 2001, the US Surgeon General issued the Call to Action to Prevent and
Decrease Overweight and Obesity, identifying 15 activities as national
priorities for immediate action. (See Appendix B). (End Note #14:
US Department of Health and Human Services. Overweight and Obesity: A Vision for
the Future page. Available at:
http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_vision.htm .
Accessed March 30, 2006.) In 2002, the US Congress charged the Institute of
Medicine (IOM) with developing a national agenda for decreasing the prevalence
of overweight in the nation's children and youth. To address this charge, the
IOM appointed a committee of 19 experts in child health, obesity, nutrition,
physical activity, and public health. The final report from the committee was
released on September 30, 2004 and presented a plan for action. (End Note
#15: Institute of Medicine of the National Academies.
Preventing Childhood Obesity: Health in the Balance. Washington, DC: The
National Academies Press; 2001.)
Table of Contents
Montana's Response to the Call:
This State Plan was developed by NAPA staff in concert with the Montana
Cardiovascular Disease/Obesity Prevention Task Force. The latter represents a
broad spectrum of partners who participated throughout all phases of the
planning process,
beginning in October of 2004.
The goals of the State Plan are to:
1. Increase physical activity among Montana residents.
2. Increase fruit and vegetable consumption among Montana residents.
3. Promote caloric balance among Montana residents.
4. Increase breastfeeding of Montana infants.
Task Force members as well as other partners committed their time and knowledge
to workgroups addressing these goals in: work sites; healthcare; the broader
community; and settings impacting children, youth, and families. Because
American Indians experience significantly higher rates of diseases related to
overweight and obesity (particularly type 2 diabetes and cardiovascular
disease), tribal members were represented on each workgroup. (End Note
#16: National Institute of Diabetes and Digestive and Kidney
Diseases. Strategic Plan on Minority Health Disparities, Introduction page.
Available at:
http://www.niddk.nih.gov/federal/planning/Introduction.pdf. Accessed
March 22, 2006.) In addition, a Native American Workgroup was formed to generate
suggestions for eliminating disparities for this racial group. Workgroups met on
a regular basis to develop SMART objectives related to the particular goals and
strategies to move the objectives forward. (End Note #17:
SMART objectives are: Specific/Single outcome; Measurable, Achievable,
Related/Reasonable, and Time bound. Develop strategies for each of the
objectives.)
These goals were selected because they are based on scientific evidence
documenting that they are promising strategies for helping reduce or prevent
overweight and obesity. For example, the evidence that physical activity can
play an important role in helping people achieve and maintain a healthy weight
is strong. The techniques described in this State Plan for increasing physical
activity are drawn from The Community Guide to Preventive Services, a systematic
review of science-based population-oriented health interventions. (End Note
#18: Centers for Disease Control and Prevention. Community
Guide to Preventive Services. Available at:
http://www.thecommunityguide.org/pa/default.htm . Accessed March 30, 2006.)
In other cases, because the field of obesity prevention on a broad scale is
relatively new, research into effective strategies is in an earlier stage. The
evidence is suggestive (but not conclusive) that increasing breastfeeding,
increasing fruit and vegetable consumption, decreasing sugar-sweetened beverage
consumption, decreasing time spent watching television, and monitoring portion
sizes can help people maintain a healthy weight. Because of the severity of the
obesity epidemic, the CDC Division of Nutrition and Physical Activity has
recommended that states not wait for the best possible evidence, but rather that
they act on the best available evidence in an effort to halt and reverse the
trend of rising weights among Americans. The State Plan uses a socio-ecological
framework. (End Note #19: The Center for Health Promotion and
Disease Prevention, The University of North Carolina at Chapel Hill. Wisewoman
Manual. Chapter 6 page. Available at
http://www.hpdp.unc.edu/wisewoman/Chapter6.pdf . Accessed April 20, 2006.)
Socio-Ecological Model:
Socio-ecology refers to the interrelations between people and their social and
physical environments. The general thesis is that environments can either
promote or restrict certain behaviors. For example, if an individual does not
feel safe walking in a park because of overgrown bushes along a pathway, he or
she will not go to that park. Or, if people cannot purchase fresh produce or
other healthy foods at reasonable prices within their respective communities,
they will eat whatever food is available. The socio-ecological model can be
thought of as an onion, with one layer wrapping around another. There are five
"layers" in the model, and each layer is influenced by the other layers.
Description of Figure 4: the Socio-Ecological Model. The
model is oval. Near the top and enclosed by the other layers is an oval labeled
"individual". The individual is surrounded by the "interpersonal" layer. The
interpersonal layer is surrounded by the "institutional/organizational" layer.
The institutional/organizational layer is surrounded by the "community" layer
and the community layer is surrounded by the "policy" layer. End of description.
The individual is at the center of the model. At this level, we consider the
internal determinants of behavior, such as knowledge, attitudes, beliefs, and
skills. Individual behaviors can be changed by increasing knowledge, influencing
attitudes, challenging beliefs, and/or teaching new skills. For example,
individuals are targeted for certain educational campaigns (such as exercise
programs), skill-building seminars and courses, or one-on-one counseling to
change perspectives and beliefs. In the socio-ecological model, it is important
to realize that the individual is largely influenced by his/her family,
educational institution, worksite, community, and by the policies and laws that
influence society as a whole.
The next layer (working outward from the center) is the interpersonal. Humans
are social animals who group together for survival, support, social identity,
knowledge, and skills. Interpersonal interventions target groups, such as family
members or peers. Examples include: information for parents; providing trained
home visitors; or developing support groups (such as weight management groups or
walking clubs).
The institutional/organizational layer is the third level. Organizations are
groups that often have a formalized purpose, mission, and written or unwritten
agreements regarding acceptable behavior (such as schools, health care settings,
workplaces, faith communities, or community organizations). At this level, an
attempt is made to change the policies, practices, and/or physical environment
of an organization. Examples include: providing flex time and/or facilities for
physical exercise, providing healthful dining options, or encouraging team
exercise experiences.
At the community level, all efforts of all members of a community (such as
community organizations, workplaces, schools, community leaders, and private
citizens) are coordinated to bring about change. Examples include: collaboration
among community leaders to influence social norms and policies about nutrition;
forming a community coalition to assess the availability of high quality,
nutritious foods in neighborhoods and local food establishments; developing
educational presentations for other groups; developing a media advocacy strategy
promoting the need for environments that support healthy eating; or working with
local community groups to establish neighborhood walking trails.
The policy level forms the outermost layer of the socio-ecological model. This
level deals with developing and enforcing policies and laws that can increase
beneficial health behaviors. Example: a state law ensuring that breastfeeding is
allowed in all public places.
Priority Populations:
Children: Overweight in childhood and adolescence is a predictor for obesity in
adulthood. (End Note #20: American Obesity Association Fact
Sheet. Obesity in Youth page. Available at:
http://www.obesity.org/subs/fastfacts/obesity_youth.shtml . Accessed March
22, 2006.) Overweight is also reported to be the most significant factor in the
dramatic escalation of type 2 diabetes in youth and contributes to other health
problems (such as asthma, hypertension, and orthopedic complications). (End note
#21: Ibid.) African American, Hispanic American and American
Indian children and adolescents have particularly high overweight prevalence.
(End note #22: Ibid.) Nationwide, the percentage of American
Indian children with a BMI-for-age at or above the 95th percentile is more than
twice as high as it is in the general population. (End note #23:
National Institute of Diabetes and Digestive and Kidney Diseases. Strategic Plan
on Minority Health Disparities, Introduction page. Available at:
http://www.niddk.nih.gov/federal/planning/Introduction.pdf . Accessed March
22, 2006.) The prevalence of overweight among American Indian children has
serious implications for their immediate and long-term health, and for the
health of their communities. The strategies in this plan that address nutrition
and physical activity among children apply to all young people in Montana,
including American Indian children. For example, strategies that will be
implemented in settings such as schools and WIC and Head Start Programs will
impact American Indian as well as non-Indian young people. Because the risk for
obesity and related chronic diseases among American Indian children is so great,
some additional strategies will be implemented through organizations
specifically serving American Indians and will focus special attention on
promoting health among tribal young people.
Adults in the workplace: In Montana, according to the 2000 census, 701,168
people are age 16 and over. Of that number, 71% of males (245,572 of 346,102)
are employed and 60% of females (212,734 of 355,066) are employed. (End note
#24: US Census Bureau, Census 2000 Profiles. Table DP-1.
Profile of General Demographic Characteristics: 2000 page. Available at:
http://www.bozeman.org/gdc/upload/Montana%20Demographic%20Profile%20-%202000.pdf
. Accessed March 30, 2006.) While those percentages include people who are
self-employed, the vast majority work in an established workplace for at least
part of the day. This makes the workplace the most advantageous arena for
promoting healthy nutrition and physical activity.
Table of Contents
Goal 1: Increase Physical Activity among Montana Residents:
Sedentary Lifestyles: For a variety of reasons, Americans today tend to be far
more sedentary than in past eras. Modern technology has replaced many of the
physically exerting jobs of the past, and in today's market, most wage-earners
are sitting at a desk for the majority of their workdays. Communities are built
to accommodate drivers, not walkers. And, outdoor recreational activities are
more and more often replaced by indoor activities such as watching television
and playing computer games.
In tribute to the wealth of outdoor recreational activities in Montana, we have
one of the highest percentages of adults in the nation that meet or exceed the
minimum physical activity requirements, according to the 2003 BRFSS. (End note
#25: Centers for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health Promotion, Behavioral Risk
Factor Surveillance System. Prevalence Data Physical Activity 2003 Adults with
30+ Minutes of Moderate Physical Activity Five or More Days per Week, or
Vigorous Physical Activity for 20+ Minutes Three of More Days
per Week page. Available at
http://apps.nccd.cdc.gov/brfss/list.asp?cat=PA&yr=2003&qkey=4418&state=All .
Accessed April 12, 2006.) However, more than 40%of Montana adults are not
meeting minimum physical activity guidelines and 20% are completely sedentary.
In the past, many Montana livelihoods were intimately tied to the land and one's
ability to work it through farming and ranching. Montana childhood experiences
of yesteryear were filled with hours of natural, vigorous outdoor play, walking
or biking to school, and participating in physical chores that were necessary
for the family's economic stability. Today, housing and commercial developments
are replacing agricultural land. These economic and cultural changes have
affected the way Montanans earn their livelihood as well as created more
dependence on the automobile for transportation. We have "engineered" physical
activity out of our lives, and the results are not healthful. Now, we must find
new ways to build physical activity into the daily routines of children, adults
and Montana families.
Benefits of Physical Activity: Physical activity is a key factor in achieving
and maintaining a healthy weight, and it offers many additional benefits. In
fact, physical activity is one of 10 leading health indicators listed in the
Department of Health and Human Services US document Healthy People 2010:
Understanding and Improving Health (Healthy People 2010). (End note
#26: US Department of Health and Human Services, Healthy
People 2010: Understanding and Improving Health page. Available at:
http://www.healthypeople.gov/LHI/lhiwhat.htm . Accessed March 30, 2006.)
People who are physically active are less likely to die of coronary heart
disease, the nation's leading cause of death, and they are less likely to
develop many chronic diseases such as high blood pressure, type 2 diabetes,
osteoporosis, and certain cancers. (End note #27: US
Department of Health and Human Services, Centers for Disease Control and
Prevention. Physical Activity for Everyone: The Importance of Physical Activity
page. Available at:
http://www.cdc.gov/nccdphp/dnpa/physical/importance/index.htm . Accessed
March 22, 2006.) In addition, physical activity reduces symptoms of anxiety and
depression, promotes healthy bones and joints and reduces arthritis pain. (End
note #28: Ibid.) Because the physical and mental health
benefits of physical activity are well documented, and because the economic
costs of inactivity and obesity are high, public insurance programs and
employers who provide insurance benefits to employees have an economic interest
in promoting physical activity. (End note #29: Studies and
reviews of the economic costs of physical inactivity and obesity include: 1.
Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical activity: the
evidence. Canadian Medical Association Journal [serial online]. 2006; 174
(6):801. Available from: Canadian Medical Association. Accessed March 29, 2006;
and 2. Garrett NA, Brasure M, Schmitz KH, Schultz MM, Huber MR. Physical
inactivity: Direct cost to a health plan. American Journal of Preventive
Medicine [serial online]. 2004; 27 (4):304-309. Available from: E-Science
Server, Los Alamos, CA. Accessed March 28, 2006.) For school children, exercise
is associated with improved academic outcomes and reduced anxiety, depression
and disruptive behavior. (End note #30: Symons CW, Cinelli B,
James TC, Groff P. Bridging Student Health Risks and Academic Achievement
through Comprehensive School Health Programs. Journal of School Health [serial
online]. 1997; 67: 220-228. Available at:
http://find.galegroup.com . Accessed March 14, 2006.)
Opportunities: The state of Montana has many opportunities to increase the
physical activity of all residents:
Outdoor Activities: Montana is still a place where people can enjoy outdoor
activities under the grandeur of the "Big Sky." People who live and work in
Montana as well as those who visit the state are often drawn here because of the
plethora of hiking, biking, skiing, rafting, and other outdoor activities that
exist.
Walkable Communities: Because our communities are relatively small and (in
comparison to other states) undeveloped, we have the opportunity to promote more
active community environments. Encouraging developments with a more traditional
neighborhood design, such as streets connected in a more grid-like style with
sidewalks/bike lanes and trees and stores make walking and biking an easier,
safer, more convenient and more enjoyable choice.
In 2005, the US Department of Transportation awarded $1 million to Montana to
orchestrate "Safe Routes to School" programs for infrastructure projects and
education/promotion campaigns to make it safer for children to walk and bike to
school.
School Wellness: The Montana School Board Association, the Montana Office of
Public Instruction(OPI) and the Montana Board of Public Education are supportive
of school wellness policies. Such policies will help pave the way for increased
physical activity of staff, students, and (indirectly) their families.
A number of advocacy organizations in Montana are willing to work with schools
to determine how to raise the physical activity of students in a way that is
affordable.
Worksite Wellness: In recent years the DPHHS Cardiovascular Health Program has
surveyed hundreds of large and small employers across Montana and has identified
a strong interest among many employers in promoting physical activity and other
healthy behaviors among employees. In 2005, the Missoula City-County Health
Department surveyed 250 local employers with similar results. These employers
are motivated by a variety of factors including a desire to reduce absenteeism,
increase productivity, increase staff morale, and control rising health
insurance costs.
Some employers are already instituting innovative weight control and fitness
programs. For example, the State of Montana offers the Why Weight program, a
pilot weight loss project that reimburses eligible employees up to $300 for
reducing their BMI (they must be willing to speak with the health coach). In
2005, the State also piloted a fitness program for hunters, which it plans to
repeat in coming years. Similarly, the Joint Powers Trust, which provides group
health benefit plans to thousands of city and county employees, is introducing a
program to promote physical activity and other healthy behaviors in an effort to
reduce insurance premiums. Information on the financial "return on investment"
will be tracked, analyzed, and shared with other employers. At the same time,
Blue Cross Blue Shield of Montana has designed and offers to their employer
groups worksite health promotion tools, resources, and training at no additional
cost, all in an effort to assist these groups in managing their health risk. In
addition, the Montana Council for Worklife Wellness is a statewide coalition of
people working on promoting health in the workplace. These are just a few
examples of ways that employers and even the insurance industry are working to
promote physical activity and other healthy behaviors among Montana workers.
Minimum Recommendations for Physical Activity: The minimum recommendations for
physical activity follow. (End note #31: US Department of Health and Human
Services and U.S. Department of Agriculture. Dietary Guidelines for Americans,
2005 page. Available at:
http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter4.htm .
Accessed March 30, 2006.)
For adults: 30 minutes of moderate physical activity at least five days a week
can reduce the risk of chronic disease. Most people can receive even greater
health benefits by engaging in physical activity of longer duration or greater
intensity. 60 minutes of moderate-to-vigorous on most days of the week is
recommended to help prevent gradual unhealthy weight gain in adulthood.
For previously overweight or obese adults: 60-90 minutes of moderate physical
activity most days of the week can help sustain weight loss.
For children and teens: At least 60 minutes of moderate-to-vigorous physical
activity every day of the week is recommended.
Moderate physical activity consists of activity that raises the pulse above the
resting heart rate but does not make the person perspire or breathe heavily.
Examples include brisk walking, gardening, dancing, and bicycling slowly.
Vigorous physical activity consists of activity that makes the person perspire
and breathe heavily. Examples include jogging, playing basketball, and
cross-country skiing.
Objective 1A to Increase Physical Activity:
By 2006, establish a statewide Physical Activity Advisory Council to assist
local communities in promoting policy and environmental supports for increasing
physical activity for all Montanans.
Performance Indicators:
1. Intact representative Advisory Council.
2. Activities consistent with promotion of policy and environmental supports.
Measurement: Document review, including Advisory Council membership list,
meeting
agendas, and minutes.
Strategies:
1. Identify and recruit members to establish an Advisory Council. Lead Agency:
NAPA.
2. Assist the Advisory Council in formulating a strategic plan for action. Lead
Agency: NAPA.
3. Coordinate efforts to secure funding/resources for projects identified in the
strategic plan. Lead Agency: NAPA.
4. Facilitate the exchange of information among Advisory Council members and
local coalitions who promote (or would like to promote) physical activity
through communication mechanisms such as an Advisory Council listserv, NAPA web
site, conference calls, and face-to-face meetings. Prospective Advisory Council
members
include but are not limited to those in the following table. Lead Agency: NAPA.
For more information about the Physical Activity Advisory Council or to become
involved, contact NAPA at (406) 994-5734 or email
costakis@montana.edu .
Description of Table: Prospective Advisory Council Members. Fish, Wildlife and
Parks: Support and, as possible, fund efforts to increase the length,
accessibility and connectivity of trails for non-motorized use in urban areas.
University of Montana Rural Institute: Work with community-based Montana
Disability and Health Accessibility Ambassadors and others to assess, promote,
and disseminate information about accessible physical activity opportunities for
people with disabilities. Cascade County: Pilot a county-based multi-agency
coalition to promote collaborations that will increase awareness of and access
to physical activity opportunities among county residents. Montana Department of
Transportation: Promote the use of "Safe Routes to School" funds to support city
and county efforts to make environmental changes that will enable students to
walk or bike to school safely. Montana State University Division of Health
Sciences: Network with associations of medical professionals to promote physical
activity as a method of preventing obesity. National Parks Service, Sonoran
Institute/Montana Smart Growth Coalition: Deliver technical assistance on topics
such as land use planning, street and trail connectivity, and pedestrian, and
bicycle-friendly development. Missoula City-County Health Department: Pilot
projects to increase physical activity in schools, worksites and community
settings.
Objective 1B: To Increase Physical Activity
By 2010, increase the number of large school districts that adopt written
implementation plans consistent with current physical activity guidelines. Large
school districts are defined as the ten school districts in Montana with the
highest enrollment. "Current physical activity guidelines" are defined as
recommendations in the USDA Dietary Guidelines for Americans, 2005.
Performance Indicator: Written implementation plans that are consistent with
physical activity guidelines.
Measurement: Pre/post surveys of the ten largest school districts in Montana,
using a rating system to determine consistency with physical activity guidelines
(based on Action for Healthy Kids model policy guidelines).
Strategy: Disseminate school wellness policy implementation tools highlighting
model written implementation plans to all school districts in the state. Lead
Agencies: Action for Healthy Kids, OPI.
Objective 1C to Increase Physical Activity:
Through 2009, maintain or improve the 2005 percentage of Montana high school
students (14%) who report that they engaged in at least one hour of physical
activity every day during the previous 7 days.
Performance Indicator: 14% (or more) of students report engaging in at least one
hour of physical activity every day during the previous 7 days.
Measurement: YRBS.
Strategies:
1. Publicize school wellness policy implementation tools highlighting model
written implementation plans. Lead Agencies: Action for Healthy Kids, OPI.
2. Provide technical assistance (including consulting services, links to
relevant websites, and access to alternative physical activity curricula) to
schools as they operationalize written implementation plans. Lead Agency: NAPA.
3. Provide technical assistance, including evaluation, to at least one model
K-12 (Kindergarten-12) school or high school, and disseminate the evaluation
information to Montana educators. Lead Agencies: Team Nutrition, NAPA.
4. Promote "Safe Routes to School" in Montana communities. Lead Agency: MT
Department of Transportation.
5. Encourage schools to enroll students in "Big Sky Fit Kids," a 3-month fitness
program for youth 18 and under, and track participation. Lead Agency: Big Sky
State Games.
Objective 1D to Increase Physical Activity: Through 2009, maintain or improve
the 2005 percentage of Montana 7th and 8th grade students (15%) who report that
they engaged in at least one hour of physical activity every day during the
previous 7 days.
Performance Indicator: 15% (or more) of students report engaging in at least one
hour of physical activity every day during the previous 7 days.
Measurement: YRBS.
Strategies:
1. Publicize school wellness policy implementation tools highlighting model
written implementation plans. Lead Agencies: Action for Healthy Kids, OPI.
2. Provide technical assistance (including consulting services, links to
relevant websites, and access to alternative physical activity curricula) to
schools as they operationalize written implementation plans. Lead Agency: NAPA.
3. Provide technical assistance, including evaluation, to at least one model
K-12, K-8,o
middle school, and disseminate the evaluation information to Montana educators.
Lead Agencies: Team Nutrition, NAPA.
4. Promote "Safe Routes to School." Lead Agency: MT Department of
Transportation.
5. Encourage schools to enroll students in "Big Sky Fit Kids" and track
participation. Lead Agency: Big Sky State Games.
Objective 1E to Increase Physical Activity: By 2010, complete and evaluate at
least one intervention using one of the Community Guide physical activity
interventions (selected from the list below), and disseminate results through
the Advisory Council and the NAPA website. (End note #32:
Centers for Disease Control and Prevention. Community Guide to Preventive
Services, Physical Activity page. Available at:
http://www.thecommunityguide.org/pa/default.htm . Accessed March 30, 2006.)
Performance Indicator: The evaluation of at least one intervention designed to
increase physical activity.
Measurement: Document review, including an evaluation plan and completed
evaluation report of the community-based intervention.
Strategies:
1. Pilot and evaluate policies and practices to promote physical activity at
worksites in at least two communities. Lead Agencies: Missoula and Flathead
City-County Health Departments, NAPA.
2. Maintain, evaluate, and enhance low-cost physical activity programs such as
"Steps to a New You" and "Shape Up Montana"/"Big Sky Fit Kids" in rural counties
throughout Montana. Lead Agencies: MSU Extension, Big Sky State Games.
3. Plan and implement a project to provide culturally appropriate physical
activity opportunities for American Indian children. Lead Agencies:
Montana/Wyoming Boys and Girls Club Native American Alliance, St. Labre Indian
Education Association, Indian Health Service Billings Area Office.
4. Provide a Nutrition and Physical Activity Self-Assessment for Childcare (NAPSACC)
kit to at least four interested preschools or daycare facilities, and deliver
training workshops and technical assistance as appropriate. Lead Agency: NAPA.
5. Create and publicize an incentive system to recognize preschool and childcare
facilities that exceed minimum standards for physical activity. Lead Agency:
DPHHS Child and Adult Care Food Program.
6. Adapt, evaluate and disseminate a version of "Steps to a New You" for older
adults. Lead Agency: MSU Extension.
7. Pilot a community-wide campaign to promote physical activity in at least one
county, and evaluate and disseminate results. Lead Agency: Cascade County
Physical Activity Council.
Objective 1F to Increase Physical Activity: By 2010, increase minutes per day of
moderate and/or vigorous physical activity among American Indian children at one
reservation preschool or daycare facility.
Performance Indicator: Increased minutes of moderate or vigorous physical
activity conducted at one facility.
Measurement: Activity logs listing the number of minutes of moderate to vigorous
physical activity conducted at one preschool/day care facility prior to and
following the initiation of the intervention.
Strategies:
1. Introduce a physical activity component into the curriculum for early
childhood education at tribal colleges. Lead Agency: MSU Early Childhood
Education Distance Partnership Program.
2. Host a train-the-trainer training for preschool providers, dietitians,
diabetes educators, community health representatives, and other stakeholders
serving American Indians. The training will prepare participants to teach
parents/guardians about the physical activity and nutrition needs of children,
with a focus on infants and children up to age 5. Lead Agency: NAPA.
3. Provide incentives for parents/guardians of American Indian infants and
children up to age 5 who complete courses on physical activity and nutrition
needs of preschool aged children. Lead Agency: NAPA.
4. Provide mini-grants to reservation-based agencies and Urban Indian Clinics to
support increasing opportunities for physical activity among American Indian
children, including children aged birth-5. Lead Agency: NAPA.
Table of Contents
Goal 2: Increase Fruit and Vegetable Consumption among
Montana Residents.
Recommendations: The 2005 Dietary Guidelines for Americans were released in
January of 2005. Whereas eating a healthy balance of nutritious foods was
underscored in the Dietary Guidelines, a strong emphasis was also placed on
calorie control and physical activity." These new Dietary Guidelines represent
our best science-based advice to help Americans live healthier and longer lives.
The report gives action steps to reach achievable goals in weight control,
stronger muscles and bones, and balanced nutrition to help prevent chronic
diseases such as heart disease, diabetes and some cancers. Promoting good
dietary habits is key to reducing the growing problems of obesity and physical
inactivity, and to gaining the health benefits that come from a nutritionally
balanced diet." Tommy G. Thompson, Former Secretary, US Department of Health &
Human Services. (End note #33: News release from HHS Press
Office and USDA Press Office dated Wednesday, Jan. 12, 2005. Available at:
http://www.hhs.gov/news/press/2005pres/20050112.html . Accessed March 30,
2006.)
One of the recommendations of the 2005 Dietary Guidelines is that every person
consume a minimum of five fruit and vegetable servings per day. (End note
#34: US Department of Agriculture. Dietary Guidelines for
Americans 2005 page. Available at
http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter5.htm .
Accessed April 12, 2006.) The 2005 Dietary Guidelines further recommend a
selection of fruits and vegetables that includes all five vegetable subgroups
(dark green, orange, legumes, starchy vegetables, and other vegetables) several
times a week.
Realities: Dietary habits as measured by self-reported consumption of five or
more servings of fruits and vegetables a day have not improved in recent years.
Montana BRFSS data indicate that only 21% to 24% of adult Montanans consumed the
recommended five servings of fruits and vegetables from 1994-2000. Similarly, in
1994, approximately 22% of the US population reported eating at least five
servings of fruits and vegetables per day, and in 2000, the prevalence remained
relatively unchanged at 23%.
The YRBS reports fruit and vegetable consumption by youth at an even lower rate
than adults.
Description of Figure 5: Percentage of Students Who Ate Five or More Servings
per Day of Fruits and Vegetables during the Past Seven Days. In 1999, 19.5% of
students ate five or more servings per day of fruits and vegetables during the
past seven days. In 2001, 19.4% of students ate five or more servings per day of
fruits and vegetables during the past seven days. In 2003, 16.7% of students ate
five or more servings per day of fruits and vegetables during the past seven
days. In 2005, 17% of students ate five or more servings per day of fruits and
vegetables during the past seven days. Source: 2005 Youth Risk Behavior Survey
Montana High School Trend Report. End of description.
No matter what kind of food a person eats, the basic rule to lose weight is that
people must take in fewer calories than they expend. Fruits and vegetables are
foods with "low energy density," that is, they have relatively few calories per
gram. So people can eat a large volume of fruits and vegetables and feel full
without consuming an excessive amount of calories. Several short-term studies
suggest that increasing fruits and vegetables in people's diet results in their
eating to the point of fullness while consuming fewer calories. (End note
#35: Studies and reviews include: 1. Rolls BJ, Ello-Martin JA,
Tohill BC. What can intervention studies tell us about the relationship between
fruit and vegetable consumption and weight management? Nutrition Reviews 2004;
62:1-17; and 2. Lin BH, Morrison BM. Higher fruit consumption linked with lower
body mass index. Food Review 2002;25(3): 28-32.) Substituting fruits and
vegetables for more energy-dense foods appears to be a promising practice for
helping people maintain or lose weight. In addition, fruits and vegetables are
rich in micronutrients and phytochemicals, important for proper metabolic
functioning and overall health.
Objective 2A to Increase Fruit and Vegetable Consumption: By 2010, pilot at
least four new interventions (selected from the list of strategies below) to
increase access to fruits and vegetables in workplace and community settings.
Performance Indicator: Establishment of four pilot interventions to increase
access to fruits and vegetables.
Measurement: Document review, including written descriptions or proposals of
pilot interventions, and outcome data; observation and verbal reports of program
implementation.
Strategies:
1. Identify and collaborate with a stakeholder team located in at least one
American Indian reservation or Urban Indian Clinic to identify barriers (such as
access, price, quality, habit, variety) and facilitative factors to fruit and
vegetable consumption (such as buying local, congregate meal sites, food
pantries, community gardens, and farmer's markets). Work with the team to plan
and pilot interventions. Lead Agency: NAPA.
2 . Identify and collaborate with a stakeholder team located in a community of
1,500 to 5,000 residents to identify barriers and facilitative factors to fruit
and vegetable consumption. Work with the team to plan and pilot interventions.
Lead Agency: NAPA.
3. Work with stakeholders in at least two urban areas to pilot policies and
practices promoting fruit and vegetable consumption in the workplace. Lead
Agencies: Missoula and Flathead City-County Health Departments.
4. Maintain/expand initiatives in counties throughout Montana to teach
low-income children and adults about affordably incorporating fruits and
vegetables into the diet. Share information on best practices and lessons
learned with other interested agencies through forums such as the statewide Eat
Right Montana coalition. Lead Agencies: Food Stamp Nutrition Education, Expanded
Food and Nutrition Education Program.
5. Review and update 4H curriculum to ensure that the current USDA guidelines
regarding fruit and vegetable consumption are incorporated. Lead Agencies: 4H,
Extension Nutrition Education.
6. Seek funding to assess the availability of fruits and vegetables in food
banks/pantries, and propose methods of increasing fruit and vegetable
inventories. Lead Agency: Montana Food Bank Network.
7. Explore and implement methods of linking local producers of fruits and
vegetables with consumers (such as schools, food banks and senior centers). Lead
Agency: MSU Ad Hoc Farm to Table Project.
8. Create and publicize an incentive system to recognize preschool and child
care facilities that exceed minimum standards, as set by the Child and Adult
Care Food Program, for fruit and vegetable offerings. Lead Agency: DPHHS Child
and Adult Food Care Program.
9. Provide a NAP SACC kit to at least four interested preschools or daycare
facilities, and deliver training workshops and technical assistance as
appropriate. Lead Agency: NAPA.
10. Offer mini-grants to public and nonprofit agencies to promote fruit and
vegetable consumption, with a special emphasis on school- and preschool-based
garden-to table projects involving children. Lead Agencies: NAPA, Eat Right
Montana.
Objective 2B to Increase Fruit and Vegetable Consumption: By 2010, increase the
number of large school districts that adopt written implementation plans that
increase opportunities for fruit and vegetable consumption among students. Large
school districts are defined as the ten school districts in Montana with the
highest enrollment.
Performance Indicator: Written implementation plans that increase opportunities
for consumption of fruits and vegetables.
Measurement: Pre/post surveys of the 10 largest districts in Montana, using a
rating system to determine opportunities for fruit and vegetable consumption
(based on Action for Healthy Kids model policy guidelines).
Strategies:
1. Publicize school wellness policy implementation tools highlighting model
written implementation plans. Lead Agencies: Action for Healthy Kids, OPI.
2. Provide technical assistance to schools as they implement written
implementation plans to increase fruit and vegetable consumption. Lead Agency:
Team Nutrition.
Objective 2C to Increase Fruit and Vegetable Consumption: Increase the
percentage of Montana high school students who report eating five or more
servings of fruits and vegetables per day during the previous 7 days from 17% in
2005 to 19% in 2009.
Performance Indicator: 19% (or more) of Montana high school students report
eating 5 or more fruits or vegetables a day during the previous 7 days.
Measurement: YRBS.
Strategies:
1. Publicize school wellness policy implementation tools highlighting model
written implementation plans. Lead Agencies: Action for Healthy Kids, OPI.
2. Provide technical assistance to schools as they operationalize written
implementation plans to increase fruit and vegetable consumption among students.
Lead Agency: Team Nutrition.
Objective 2D to Increase Fruit and Vegetable Consumption: By 2010, increase from
27% in 2004 to 30% the proportion of Montana schools in which students can
purchase fruit or vegetable snacks in vending machines or at the school store,
canteen, or snack
bar.
Performance Indicator: 30% (or more) of Montana schools report offering fruits
or vegetables in vending machines or at the school store, canteen, or snack bar.
Measurement: Montana School Health Profiles.
Strategy: Provide information about mini-grant opportunities and technical
assistance to school administrators and food service personnel. Lead Agencies:
NAPA, Eat Right Montana.
Table of Contents
Goal 3: Promote Caloric Balance among Montana Residents.
A basic premise of the 2005 Dietary Guidelines is that nutrient needs should be
met primarily through consuming nutrient-dense foods that provide substantial
amounts of vitamins and minerals (micronutrients) and relatively few calories.
Foods that are low in nutrient density are foods that supply calories but
relatively small amounts of micronutrients, sometimes none at all. The greater
the consumption of foods or beverages that are low in nutrient density, the more
difficult it is to consume enough nutrients without gaining weight, especially
for sedentary individuals. The consumption of added sugars, saturated and
transfats, and alcohol provides calories while providing little, if any, of the
essential nutrients. (End note #36: US Department of Health
and Human Services. Dietary Guidelines for Americans 2005 page. Available at:
http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm .
Accessed March 30, 2006.)
Maintaining weight requires balancing "energy input" (calories taken in through
eating) with "energy output" (calories burned). Losing weight requires burning
more calories than are taken in. Many aspects of modern life influence how easy
or difficult it is to balance "calories in" with "calories out." Three
developments that deserve special consideration are the increase in portion
sizes, the increase in the amount of sugar-sweetened beverages that children and
adults consume, and the increase in the
amount of time that Americans spend watching television.
The following table demonstrates the difference in portion size in the past 20
years (energy input) as well as the exercise needed to burn the extra calories
(energy output).
Description of Table: Energy Input and Energy Output 2004. 20 years ago, a
typical bagel had 140 calories and was 3" in diameter. Today, the typical bagel
has 350 calories (210 more) and is 6" in diameter. To burn the extra calories, a
130 pound individual would have to rake leaves for 50 minutes. 20 years ago, a
typical cheeseburger had 333 calories. Today, the typical cheeseburger has 590
calories (257 more). To burn the extra calories, a 130 pound individual would
have to lift weights for one hour. 20 years ago, typical French fries had 210
calories and weighed 2.4 ounces. Today, typical French fries have 610 calories
(400 more) and weigh 6.9 ounces. To burn the extra calories, a 160 pound
individual would have to walk leisurely for 1 hour, 10 minutes. 20 years ago, a
typical soda had 85 calories and weighed 6.5 ounces. Today, a typical soda has
250 calories (165 more) and weighs 20 ounces. To burn the extra calories, a 160
pound individual would have to work in the garden for 35 minutes. 20 years ago,
a typical turkey sandwich had 320 calories. Today, a typical turkey sandwich has
820 calories (500 more). To burn the extra calories, a 160 pound individual
would have to ride a bike 1 hour, 35 minutes. 20 years ago, a typical coffee
with whole milk and sugar had 45 calories and weighed 8 ounces. Today, a typical
coffee with steamed whole milk and mocha syrup has 350 calories (305 more) and
weighs 16 ounces. To burn the extra calories, a 130 pound individual would have
to walk for 1 hour, 20 minutes. 20 years ago, a typical serving of pizza was 2
slices with 500 calories. Today, a typical serving of pizza is 2 slices with 850
calories (350 more). To burn the extra calories, a 130 pound individual would
have to golf for one hour while walking and carrying clubs. 20 years ago, a
typical chicken Caesar salad had 390 calories with a volume of 1.5 cups. Today,
a typical chicken Caesar salad has 790 calories (400 more) with a volume of 3.5
cups. To burn the extra calories, a 160 pound individual would have to walk the
dog for 1 hour, 20 minutes. Source: National Heart, Lung and Blood Institute,
Obesity Education Initiative
www.nhlbi.nih.gov . End of description.
Sugar-sweetened Beverages: From 1947 to 1997, the per capita consumption of
carbonated soft drinks in the US increased from approximately 10 gallons to more
than 50 gallons per year. (End note #37: Gerrior S, Putnam J,
Bente L. Milk and Milk Products: Their Importance in the American Diet. Food
Review [serial online]. May-August 1998: 29-37. Available at:
http://www.ers.usda.gov/publications/foodreview/may1998/may98e.pdf .
Accessed March 23, 2006.) Consumption of sugar-sweetened soft drinks has become
particularly high among children and adolescents. (End note #38:
Smiciklas-Wright H, Mitchell DC, Mickle SJ, Cook AJ, Goldman JD. Foods Commonly
Eaten in the United States, Quantities Consumed Per Eating Occasion and in a
Day, 1994-96 page. Available at:
http://www.ars.usda.gov/SP2UserFiles/Place/12355000/pdf/Portion.pdf.
Accessed March 23, 2006.) Increased consumption of sugar-sweetened beverages is
associated with increased BMI in children and adolescents, and decreased
sweetened beverage consumption is associated with decreased BMI. (End note
#39: Studies and reviews include: 1. Dietz, WH.
Sugar-sweetened beverages, milk intake, and obesity in children and adolescents.
Journal of Pediatrics [serial online]. 2006 Feb; 148 (2):152-154. Available at:
http://www.jpeds.com/ . Accessed March 22,
2006; and 2. Ebbling CB, Felman HA, Osganian SK, Chomitz VR, Ellenbogen SJ,
Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body
weight in adolescents: a randomized, controlled pilot study. Pediatrics [serial
online] . 2006 Mar; 117(3):673-80. Available at:
www.pubmed.gov . Accessed March 13, 2006.
Television: Parents surveyed in 2000 reported that American children typically
spent more than four and a half hours each day watching television or videos,
playing computer or video games, or surfing the internet; of this "screen time,"
more than half was spent watching television. (End note #40:
Woodard EH, Gridina, N. Media in the Home, The Fifth Annual Survey of Parents
and Children. 2000. The Annenberg Public Policy Center, Survey Series No. 7.
Available at: http://www.appcpenn.org .
Accessed ???.) Time spent watching television is positively associated with
overweight among children. (End note #41: Crespo CJ, Smit E,
Troiano RP, Bartlett SJ, Macera CA, Anderson RE. Television watching, energy
intake, and obesity in US children. Archives of Pediatric Adolescent Medicine.
2001; 155:360-365.) Proposed mechanisms to explain this association include the
possibility that the time spent watching television may displace physical
activity, thus decreasing energy output, and the possibility that television
viewing may result in increased energy intake either because children eat snacks
while watching TV or because they are exposed to, and respond to, more
advertising promoting high-calorie foods. (End note #42:
Robinson TN. Does Television Cause Childhood Obesity? JAMA [serial online].
1998; 279:959-960. Available at:
http://jama.ama-assn.org/cgi/content/full/279/12/959 . Accessed March 23,
2006.) One study has shown that children who reduce the amount of time they
spend watching television and video tapes and playing video games also reduce
their BMI.(End note #43: Robinson TN. Reducing Children's
Television Viewing to Prevent Obesity. JAMA [serial online]. 1999;
282:1561-1567. Available at:
http://jama.ama-assn.org/cgi/content/full/282/16/1561 . Accessed March 23,
2006.)
According to the 2005 YRBS, approximately 1 of 4 Montana high school students
spend three or more hours watching TV on an average school day, and YRBS trend
data shows that younger students (7th and 8th graders) are consistently spending
more time watching TV than high school students. (End note #44:
Montana Office of Public Instruction. 2005 Youth Risk Behavior Survey Montana
High School Trend Report page and Montana Grades 7-8 Trend Report page.
Available at
http://www.opi.mt.gov/PDF/YRBS/Trend05HS.pdf and
http://www.opi.mt.gov/PDF/YRBS/Trend05G7-8.pdf . Accessed April 27, 2006.)
The American Academy of Pediatrics recommends that television and video time be
limited to a maximum of two hours per day. (End note #45:
American Academy of Pediatricians. Policy Statement, Prevention of Pediatric
Overweight and Obesity page. Available at:
http://aappolicy.aappublications.org/cgi/content/full/pediatrics ;
112/2/424. Accessed March 22, 2006.)
Description of Figure 6: TV viewing and Obesity. Prevalence of obesity by daily
hours of television watched among US children aged 8 to 16 years, from 1988 to
1994. 8% of children who watched tv for an hour or less per day were obese (10%
of boys and 6% of girls). 11% of all children who watched tv for two hours per
day were obese (13% of boys and 9% of girls). 15% of all children (both boys and
girls) who watched tv for three hours per day were obese. 18% of all children
who watched tv for four hours per day were obese (17% of boys and 20% of girls).
18% of all children who watched tv for 5 or more hours per day were obese (20%
of boys and 15% of girls). Source: End note #41: Crespo et al.
TV watching, energy intake and obesity in US children. Archives of Pediatric and
Adolescent Medicine, 2001; 155:360. End of description.
Objective 3A to Promote Caloric Balance: Ensure that at least 4 stories are
carried by Montana media each year to educate the public about the relationship
between energy
intake and energy output.
Performance Indicator: 4 or more stories printed or aired each year in Montana.
Measurement: Document review, including printed articles and transcripts of
electronic public education articles.
Strategies:
1. Initiate relationships with media partners, including media serving
predominantly rural and American Indian readers/viewers/listeners. Lead Agency:
NAPA.
2. Provide media partners with information about current science on factors
impacting energy intake (portion size, sweetened beverage consumption,
volumetrics) and energy output (screen time, built environment). Lead Agency:
NAPA.
3. Work with key stakeholders on reservations to support tribal newspapers in
running stories featuring traditional Native American physical activities and
eating habits that foster caloric balance. Lead Agency: NAPA.
4. Work with practitioners in the fields of mental health and addiction to
develop stories for newsletters and media outlets about possible links between
mental health and healthy physical activity, eating behaviors, and caloric
balance. Lead Agency: NAPA.
Objective 3B to Promote Caloric Balance: By 2010, increase the number of large
school districts that adopt written implementation plans that decrease
opportunities for high-calorie sweetened beverage consumption among students.
Large school districts are defined as the ten school districts in Montana with
the highest enrollment.
Performance Indicator: Written implementation plans within the ten largest
school districts that are consistent with guidelines for limiting student access
to sweetened beverages.
Measurement: Pre/post surveys of the ten highest enrollment districts in
Montana, using a rating system to determine consistency with sweetened beverage
guidelines (based on Action for Healthy Kids model policy guidelines).
Strategies:
1. Publicize school wellness policy implementation tools highlighting model
written implementation plans. Lead Agencies: Action for Healthy Kids, OPI.
2. Disseminate the model Montana Beverage Association policy to all
kindergarten, elementary, middle and high schools in Montana. Lead Agency:
Montana Beverage Association.
3. Provide training and technical assistance to schools as they adopt practices
that decrease opportunities for sweetened beverage consumption among students.
Lead Agency: Team Nutrition.
Objective 3C to Promote Caloric Balance: By 2008, identify and explore at least
3 unique issues that impact physical activity and eating behaviors in American
Indian families.
Performance Indicator: Provision of financial resources to representatives of
the Native American Workgroup to the Task Force for development of resources or
events addressing at least three issues.
Measurement: Document review, including financial reports of monies provided for
resources or events addressing issues identified.
Strategy:1. Provide technical assistance and funding, as allowed through CDC, to
support efforts organized/authorized by the Native American Workgroup. Lead
Agency: NAPA.
2. Seek resources to sponsor a Healthy Families: Awakening Montana! Conference
for Native Americans. Lead Agency: University of Montana Continuing Education.
Objective 3D to Promote Caloric Balance: By 2010, reduce scheduled minutes per
day of TV/screen time at one or more preschool/daycare facility.
Performance Indicator: Decreased minutes of TV/screen time at one facility.
Measurement: Activity logs listing the number of minutes of TV/screen time
engaged in at one preschool/daycare facility prior to and following the
initiation of the intervention.
Strategies:1. Provide a NAP SACC kit to at least four interested preschools or
day care facilities, and deliver training workshops and technical assistance as
appropriate. Lead Agency: NAPA.
2. Network with health care professional associations to determine current
provider policies and practices that promote the reduction of TV/screen time
among children
Lead Agency: NAPA.
Objective 3E to Promote Caloric Balance: By 2008, in one worksite of 40 or more
employees, increase average physical activity and fruit and vegetable
consumption among employees and monitor employees' BMI.
Performance Indicator: Increased physical activity and fruit and vegetable
consumption.
Measurement: Compare self-reported baseline data on physical activity levels and
fruit and vegetable consumption prior to intervention and after intervention.
Strategy: 1. Make a comprehensive nutrition and physical activity program
available to all employees of the Flathead City-County Health Department. (Track
changes in physical activity rates, fruit and vegetable consumption rates, and
percent body fat as well as BMI.) Lead Agency: Flathead City-County Health
Department.
Table of Contents
Goal 4: Increase Breastfeeding of Montana Infants.
Recent studies suggest that breastfeeding may be an effective strategy for
helping to prevent childhood obesity. For example, a study of 32,200 Scottish
children observed at 39-42 months showed that the prevalence of obesity in these
preschool-aged children was significantly lower among those that had been
breastfed. (End note #46: Armstrong J, Reilly J, Child Health
Information Team. Breastfeeding and lowering the risk of childhood obesity.
Lancet [serial online]. 2002:359 2003-2004. Available at:
www.thelancet.com . Accessed March 16,
2006.) Another study, conducted in Germany, analyzed data on 9,357 5- and
6-year-old children and concluded that breastfeeding in infancy was a protective
factor against obesity in these school-aged children, and that the protective
effect increased as the duration of breastfeeding increased. (End note
#47: Von Kries R, Koletzko B, Sauerwalk T, vonMutius E,
Barnette D, Grunert V, vonVoos H. Breast feeding and obesity: Cross sectional
study. BMJ 1999: 319 147-150.) In the US, an analysis of 15,000 children 9 to 14
years of age found that children who had been exclusively or mostly fed breast
milk for the first six months of life had a significantly lower risk of being
overweight in adolescence than did children who had been exclusively or mostly
fed formula. (End note #48: Dietz WH. Breastfeeding may help
prevent childhood overweight. JAMA [serial online]. 2001:285 (19) 2506-2507.
Available at: www.jama.com . Accessed March
16, 2006.)
In addition to preventing obesity, scientific research has proven that
"breastfed infants have a healthier start in life." (End note #49:
US Food and Drug Administration. HHS Blueprint to Boost Breastfeeding. FDA
Consumer Magazine. [serial online]. May-June 2006. Available at:
http://www.fda.gov/fdac/features/2003/303_baby.html . Accessed March 30,
2006.) Breast milk provides the optimum balance of nutrients for infant growth
and development as well as protection against viruses, bacteria, and parasites.
Although infant formulas are closely regulated by the Food and Drug
Administration for nutritional quality, the exact composition of breast milk
cannot be duplicated. (End note #50: Ibid.)
Because breastfeeding provides an intimate interaction between mother and
infant, it is impossible to determine whether weight control is associated with
the physiologic qualities of breast milk or the feeding and parenting patterns
associated with nursing. The American Academy of Pediatrics recommends that
mothers feed their infants with breast milk exclusively for the first six
months.(End note #51: American Academy of Pediatricians.
Policy Statement, Breastfeeding and the Use of Human Milk page. Available at:
http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b100/6/1035
. Accessed March 30, 2006.) To move closer to that ideal, the Healthy People
2010 goals are: 75% of women will initiate breastfeeding; 50% of women will
continue breastfeeding for six months; and 25% of women will continue
breastfeeding for one year. (End note #52: Centers for Disease
Control and Prevention; Health Resources and Service Administration. Healthy
People 2010, Maternal, Infant, and Child Health page. Available at:
http://www.healthypeople.gov/document/html/volume2/16mich.htm#_Toc494699668
. Accessed March 30, 2006.)
Breastfeeding initiation rates may vary from one region to another in Montana.
Overall, the initiation rate in the state is 82% – higher than the Healthy
People 2010 goal. However, fewer than half of all Montana infants are still
receiving any breast milk at six months. Evidence collected by NAPA staff
through focus groups and interviews with key informants around the state
suggests that women stop breastfeeding prematurely for a variety of reasons,
including:
1. Embarrassment
2. Low maternal motivation
3. Breastfeeding difficulties
4. Lack of education/misconception (not enough milk to feed baby)
5. Lack of health care provider support and overall lactation support and
promotion
6. Work-related obstacles
7. Returning to work
8. Lack of family support
9. Lack of access to peers or health care professionals who can help with
breastfeeding difficulties
Description of Figure 7: Prevalence of Breastfeeding by Duration, U.S., Montana,
2003. 70.9% of U.S. infants ever received breast milk in 2003. 82.3% of Montana
infants ever received breast milk in 2003. 74.7% of infants in the Montana
Women, Infants and Children Program ever received breast milk in 2003. 36.2% of
U.S. infants received some breast milk at six months of age in 2003. 44.5% of
Montana infants received some breast milk at six months of age in 2003. 30.8% of
infants in the Montana Women, Infants and Children Program received some breast
milk at six months of age in 2003. 17.2% of U.S. infants received some breast
milk at one year of age in 2003. 22.9% of Montana infants received some breast
milk at one year of age in 2003. 20.7% of infants in the Montana Women, Infants
and Children Program received some breast milk at one year of age in 2003.
U.S. figures come from Centers for Disease Control and
Prevention. Breastfeeding National Immunization Data, Table 3: Any and Exclusive
Breastfeeding Rates by Age page. Available at:
http://www.cdc.gov/breastfeeding/data/NIS_data/2003/age.htm . Accessed March
31, 2006 (End note #53). Montana figures come from Centers for
Disease Control and Prevention. Breastfeeding National Immunization Data, Table
2: Geographic-specific Breastfeeding Rates, 2003. Available at:
http://www.cdc.gov/breastfeeding/data/NIS_data/2003/state.htm . Accessed
March 31, 2006 (End note #54). Montana WIC figures come from
Montana DPHHS WIC Program. State Plan and Policies Manual. 7-D Pediatric
Surveillance System (PedNSS) 2003 Report -- Breastfeeding Targets page.
Available at
http://www.dphhs.mt.gov/PHSD/family-health/nutrition-wic/pdf/CHAPTER7.pdf .
Accessed April 3, 2006 (End note #55). Source of the figure:
2003 National Immunization Survey and 2003 PedNSS Report. End of description.
Breastfeeding Coalition: In 2005, the CDC sponsored a training in Montana
entitled "Using Loving Support to Build a Breastfeeding-Friendly Community".
Forty-four people attended the training, including: nurses, pediatricians,
lactation consultants, public health professionals, and representatives from
hospitals, health care associations, local breastfeeding coalitions,and
nonprofit organizations. Training participants are now forming a statewide
Breastfeeding Coalition. For more information about the Breastfeeding Coalition
or to become involved, contact NAPA at (406) 994-5710 or email
lhellenga@montana.edu .
One of the first tasks of the Coalition is to assist Montana hospitals in
achieving "Baby Friendly" recognition. To be "Baby Friendly," a hospital must
have the following Ten Steps to Successful Breastfeeding in place:
Step 1: Have a written breastfeeding policy that is routinely communicated to
all health care staff.
Step 2: Train all health care staff in skills necessary to implement this
policy.
Step 3: Inform all pregnant women about the benefits and management of
breastfeeding.
Step 4: Help mothers initiate breastfeeding within a half-hour of birth.
Step 5: Show mothers how to breastfeed and how to maintain lactation even if
they should be separated from their infants.
Step 6: Give newborn infants no food or drink other than breast milk, unless
medically indicated.
Step 7: Practice rooming-in, which allows mothers and infants to remain together
24 hours a day.
Step 8: Encourage breastfeeding on demand.
Step 9: Give no artificial teats or pacifiers (also called dummies or soothers)
to breastfeeding infants.
Step 10: Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from the hospital or clinic.
(End note #56: BFHI USA. The Ten Steps To Successful
Breastfeeding page. Available at:
http://babyfriendlyusa.org/eng/10steps.html . Accessed May 4, 2006.)
The Coalition will focus special attention on Step 10 and will promote
strategies that can prolong breastfeeding, including CDC-recommended strategies
in the following areas: maternity care practices initiated in the hospital;
support for breastfeeding in the workplace; peer support; lactation education
for mothers; professional support by health
professionals; and marketing initiatives that support or encourage
breastfeeding.
Objective 4A to Increase Breastfeeding: By 2006, establish a statewide
Breastfeeding Coalition to promote "Breastfeeding Friendly" communities.
Performance Indicators: 1. Intact representative Coalition; and 2. Activities
consistent with promotion of "Breastfeeding Friendly" communities.
Measurement: Document review, including coalition membership list, meeting
agendas and minutes.
Strategies:
1. Identify and enlist Coalition members. Lead Agencies: NAPA, WIC.
2. Assist the Coalition in developing a strategic plan. Lead Agency: NAPA.
3. Assist the Coalition in securing funding needed to implement the strategic
plan. Lead Agency: NAPA.
Objective 4B to increase breastfeeding: By 2010, increase by at least 10% the
number of Montana hospitals (that deliver babies) that have at least 3 of the
Ten Steps to Successful Breastfeeding within their infant feeding policy.
Performance Indicator: Hospitals reporting policies that are consistent with the
Ten Steps to Successful Breastfeeding.
Measurement: Pre/post Hospital Breastfeeding Surveys, administered to all
Montana hospitals that deliver babies, with items measuring hospital conformance
to the Ten Steps to Successful Breastfeeding.
Strategies:
1. Engage health care professionals, through their professional associations, to
collect information from and disseminate information to association members
regarding
policies and practices promoting breastfeeding initiation. Lead Agency: NAPA.
2. Using the self-appraisal tool from Baby-Friendly USA to review policies and
practices in hospitals, develop and implement a system to assess current
breastfeeding initiation policies and practices; tracking systems for
breastfeeding initiation rates; and breastfeeding initiation rates as available.
(End note #57: Ibid.) Lead Agency: NAPA.
3. Work with stakeholders to develop and disseminate to health care facilities a
model maternal care practices policy based on the Ten Steps to Successful
Breastfeeding to support breastfeeding initiation. Lead Agency: NAPA, Coalition.
4. Provide education and training to support nurses as they adopt and implement
policies and care guidelines to help mothers initiate breastfeeding in health
care facilities. Lead Agency: NAPA, Coalition.
5. Identify and support stakeholder teams to maintain/expand or plan/implement
culturally appropriate programs promoting breastfeeding among American Indians.
Lead Agency: NAPA.
Objective 4C to increase breastfeeding: By 2009, secure legislation supporting
breastfeeding in the workplace across the state.
Performance Indicator: The enactment of proposed legislation related to
supporting breastfeeding in Montana workplaces.
Measurement: Document review, including proposed and enacted Montana state
legislation related to breastfeeding in workplaces.
Strategies:
1. Educate legislators about similar legislation in other states, and provide
assistance in developing legislation to be adopted in Montana. Lead Agency:
Montana Dietetic Association.
2. Identify proponents to facilitate passage of legislation supporting
breastfeeding in the workplace. Lead Agency: Montana Dietetic Association.
Objective 4D to increase breastfeeding: By 2010, conduct a pilot project on
policies and practices to promote breastfeeding in worksites in at least one
community and disseminate the results.
Performance Indicators: 1. Implementation of policies and practices within
worksites in one community; and 2. Dissemination of changes resulting from pilot
policies and practices.
Measurement: Document review, including description of pilot policies/procedures
implemented, outcome data, and process used to disseminate data and lessons
learned.
Strategy:1. Provide technical assistance and resources to employers in Missoula
as they adopt "Breastfeeding Friendly" practices. Lead Agency: Missoula
City-County Health Department.
Evaluation:
Context: Evaluation of the State Plan will be guided by a philosophy of
continuous program improvement. Evaluation activities will be ongoing, with an
emphasis on the use of information for refining strategies. Our focus will be on
collecting and reporting data that program personnel and various stakeholder
groups understand and value. We believe that this approach will facilitate the
most effective and efficient use of resources during our capacity building
phase. Initial evaluation activities will focus on assessing short and
intermediate range outcomes, including progress toward achieving objectives
outlined in the plan.
Expected Benefits: Following from the socio-ecological model that guided
development of the State Plan, we expect improvements to occur at multiple
levels within our state. At an individual level, we expect that citizens of
Montana will enjoy improved health outcomes and better quality of life. We hope
that families will have more opportunities to engage in healthy lifestyle
activities and that health care costs will be reduced for families. We
anticipate community environments with greater physical activity capacity,
breastfeeding supports, and access to high quality and affordable fruits and
vegetables. These environmental changes should also encourage reduced health
care costs for local businesses. At a regional and state level, we expect
increased policies that support community level health initiatives. We
anticipate increased integration of resources to support healthy nutrition and
physical activity across Montana, resulting in reduced health care cost burden
at the state level.
Evaluation team: An evaluation team will be established to plan, conduct, and
oversee evaluation activities. This team will consist of the following members:
(1) at least one member of the NAPA staff; (2) a program evaluator; (3)
personnel responsible for implementing strategies/objectives being evaluated;
(4) at least one member of the Cardiovascular Disease/Obesity Prevention Task
Force. Evaluation team membership will change, depending on the area of the plan
being evaluated.
The evaluation team will be responsible for reviewing and approving the
evaluation design for specific plan areas (objectives and strategies). The team
will review evaluation data as it is collected and assist with the
interpretation of findings. Team members will suggest additional analytic
strategies and evaluation questions as they arise during the evaluation process.
They will also be responsible for disseminating evaluation results to their
local stakeholder groups.
Stakeholder Roles: Stakeholder involvement in ongoing evaluation activities will
also be different for each evaluation area. The evaluation team will articulate
major stakeholder groups for each evaluation topic. Stakeholders may assist in
data collection or interpretation of results. They may also be participants in
determining how data will be used to make program refinements. Other stakeholder
groups may be primary receiving
audiences of information.
Evaluation results will be shared with the Cardiovascular Disease/Obesity
Prevention Task Force and major partners on a regular basis. Updates about the
evaluation process and findings will be provided to the Task Force members at
least annually. Task Force members and major partners will be encouraged to
provide input about the value of evaluation results and approaches. They will
also be asked to share additional questions that emerge as a result of
evaluation findings. These questions will be included in the evaluation process,
as appropriate.
The evaluation team and Task Force members will identify community stakeholders
who are the primary audiences for evaluation reporting. The evaluation team will
develop a plan to disseminate relevant information for each identified group.
Evaluation plans and results will also be shared with funders at regular
intervals. Funders will be asked whether evaluation information meets their
particular needs and in what areas the evaluation process can be improved.
Table of Contents
Afterword:
An Evolving Plan: This State Plan has been developed by a Task Force of
stakeholders who have knowledge of many obesity prevention activities taking
place around the state. Because there is dynamic energy behind the State Plan,
Task Force members, NAPA staff, and personnel of lead agencies (as listed in
this document) will continue to engage partners, create ideas, and generate
activities. Such activities will be periodically publicized through the NAPAweb
site at www.montana.edu/mtnapa .
Please let us know if:
1. You are involved with an organization that is promoting physical activity,
fruit and vegetable consumption, breastfeeding, and/or caloric balance. We want
to assure that your organization is duly recognized in this plan.
2. You have an idea for a new project that you would like to discuss with NAPA
staff .
It is our hope that the NAPA web site will help make the State Plan an evolving
document, and that stakeholders around the state will use the web site to
exchange information and share success stories.
Additional Opportunities: Many creative objectives and strategies were generated
by Task Force workgroups for inclusion in the State Plan. However, not all of
those suggestions could be included because of limited human and/or financial
resources. When no commitment was obtained from a lead agency, the objective or
strategy was moved to an "additional opportunities "category. These ideas,
summarized below, will be reviewed periodically by the Task Force to determine
whether circumstance have changed and the opportunity can be developed.
Health Care Workgroup Ideas:
1. Increase the percentage of Montana health care providers who refer overweight
and obese patients to a dietitian by disseminating community-specific resources
on consulting dietitians, fitness facilities, and weight management for
providers to give to
their overweight and obese patients.
2. Increase the percentage of health care providers who give their overweight
and obese patients an "exercise prescription' to promote regular physical
activity by developing and distributing exercise prescription pads for health
care providers to use as a weight management tool.
3. Increase the percentage of Montana health care providers who consistently
discuss the health risks of obesity with their overweight and obese patients by
developing a chart-based reminder system for clinic staff to use when counseling
overweight and obese patients.
4. Increase the percentage of health care providers who regularly assess the
height, weight, and BMI of youth by disseminating resource materials to
pediatricians. These resource materials would: 1) assist parents in helping
their children to achieve and maintain a healthy weight through lifestyle
behavior change and family interventions; and 2) assist communities and schools
in collectively developing and implementing a plan on pediatric weight
management that is appropriate for their individual community and setting.
Community Workgroup Ideas:
1. Increase policies that support mixed-use community design, placement of
parks, sidewalks, paths and trails in and around towns by increasing the number
of Montana communities with: a) government-endorsed written plans to complete
trail systems; and b) a city or county adopted master park plan, including
guidelines for environmentally sound new park development (such as designing all
new parks for both active and passive users, for sports groups and self-directed
activities, and for people of all ages and abilities).
2. Increase physical activity among older adults by working with: a) DPHHS Aging
Services and Montana Parks and Recreation to promote trail usage by older
adults; b) schools and malls to increase access to areas where the elderly can
be active during inclement weather; and c) senior centers to promote ongoing
physical activity programs.
3. Decrease the proportion of persons with disabilities who report environmental
barriers to accessing public facilities for physical activity by increasing the
number of recreational facilities that are compliant with the Americans with
Disabilities Act (ADA). This would be accomplished by: a) improving surfacing on
parking areas, RV pads, pathways and trails; b) upgrading restrooms for ADA
compliance; c) removing impediments to accessibility at primitive and remote
sites if possible; d) offering accessible hunting opportunities; e) providing
ADA compliant park benches and picnic tables; f) working with the Montana
Council on Developmental Disabilities and Montana Parks and Recreation to
promote park and trail use by people with disabilities; and g) educating persons
with disabilities about the availability of ADA compliant recreational
sites and activities.
4. Increase food security and access to nutritious foods among low-income
families by working with: a) public assistance programs to increase
participation in the Food Stamp Program, WIC, School Nutrition and other food
assistance programs; b) the Montana Food Bank Network, grocery stores and other
donors to improve the quality of food available to low-income individuals; and
c) educating low-income families about purchasing and eating nutritious foods on
a budget.
5. Educate parents about positive feeding relationships, the value of family
meals, and proper nutrition by: a) increasing the number of health care
providers who counsel parents about positive feeding relationships as a
preventative health measure; b) launching a social marketing campaign about the
importance of family meals; c) increasing the number of grocery stores and
restaurants that post nutrition labels on products; d) increasing the number of
healthy choices in vending machines; and e) educating adults involved in after
school and community youth programs about the importance of providing nutritious
snacks.
Native American Workgroup Ideas:
1. Deal with health disparities in the Montana population (rural social change
impacts the food supply in rural communities) by: a) measuring "food
insecurity"; b) researching the effects of poverty on health; c) promoting
"historical trauma" awareness through community and tribal colleges; d)
determining baseline data on existing food bank services; e) dealing with the
"feast or famine phenomenon" by assuring adequately stocked and sustainable food
banks in all communities; f) researching and documenting the issue of equal
access to resources in Montana and eliminating competitive funding; g) providing
child care so that community members can participate in health education and
health enhancement activities, and assuring that congregate child care meets
high standards, such as trained "safe sitters" who are paid for their work; h)
providing transportation to people in need of services; i) assuring equal access
to services from a culturally congruent perspective; j) promoting exemplary WIC
services in all communities; k) collaborating with the Golden Triangle Economic
Development Council
to reduce health disparities in that region.
2. Optimize a rich array of existing community resources by: a) developing a
resource wheel; b) developing community resource directories to inform community
members of existing community resources; c) considering youth as resources and
engaging community youth groups in meaningful community activities.
3. Develop community coalitions and networks by: a) facilitating the movement of
community stakeholders from a perspective of "scarcity" to a perspective of
"abundance" and gain commitments for collaboration; b) sending minutes of
community coalition meetings to Tribal Councils and/or City/County Commissions,
and inviting members to attend meetings; c) using social marketing strategies to
acknowledge successful collaborative efforts (such as the Northern Cheyenne Boys
and Girls Club straw bale building or the breastfeeding coalition formed on the
Flathead Reservation).
4. Educate professionals and community members to: a support each child's normal
growth with appropriate feeding from birth; b) advocate for home economics as a
curriculum option in middle and secondary schools to impact nutritious
meal-planning skills, parenting skills, and consumer skills; c) strengthen the
collaborative effort between USDA-employed staff and nutrition professionals
employed by tribal and Indian Health Service programs; d) provide media literacy
and social marketing education; e) promote avenues for healing; and f) identify
funding sources.
5. Promote policy changes in the State Legislature and Tribal Councils to: a)
eliminate soda pop in school vending machines, and replace with juice and/or
water; b) deal with the issue of the sustainability of healthy foods; and c)
provide centralized services for food banks, commodities and a community
demonstration kitchen.
6. Change the environment to facilitate enjoyable physical activities through:
a) community and national forest trail systems; b) school and community
playgrounds; c) promoting family activities; and d) supervised, structured play
activities.
Worksite Workgroup Ideas: All the major ideas were incorporated.
Children/Youth/Family Workgroup Ideas:
1. Increase the proportion of Montana parents/guardians who recognize 7
important nutrition, physical activity, and anti-tobacco messages: 5 fruits and
vegetables, 4 glasses of water, 3 servings of low-fat dairy products, 3 servings
of whole grain foods, less than 2 hours of screen time, 1 hour of physical
activity, and no tobacco.
Appendices:
Table of Contents
Appendix A: Definitions of Terms and Acronyms:
Action for Healthy Kids: This nonprofit organization was formed to address the
epidemic of overweight, undernourished and sedentary youth by focusing on
changes at school.
Big Sky Fit Kids: Offered every spring by Big Sky State Games, this is a free
youth team wellness program that encourages youth age 18 and under to develop
healthy physical activity and eating habits.
BMI: The Body Mass Index expresses the relationship (or ratio) of
weight-to-height, is measured in kg/m2, and is an indicator of overweight and
obesity.
BMI-For-Age: BMI-for-age, based on standardized growth charts, is a measurement
recommended for children two and older and for adolescents to screen for risk of
overweight and identify children who may need further assessment and possible
treatment. Detailed information on growth charts is available at
http://www.cdc.gov/growthcharts/
BRFSS: Behavioral Risk Factor Surveillance System.
CACFP: The mission of the DPHHS Child and Adult Care Food Program is to infl
uence healthy lifestyle choices by facilitating program participation and
compliance, funding nutritious meals, and providing effective training.
CDC: Centers for Disease Control and Prevention.
Community Guide: The Community Guide to Preventive Services, published by the US
Centers for Disease Control and Prevention, is a systematic review of
science-based population-oriented health interventions.
DPHHS: The Montana Department of Public Health and Human Services.
NAPA: The Montana Nutrition and Physical Activity Program.
NAP SACC: The Nutrition and Physical Activity Self-Assessment for Child Care is
a tool developed as part of the North Carolina Healthy Weight Initiative aimed
at improving the eating and physical activity environments in child care
centers.
Obese: A term describing adults with a BMI at or above 30.0 kg/m2.
OPI: Montana Office of Public Instruction.
Overweight: A term describing adults with a BMI of 25.0 to 29.9 kg/m2 or
children and young people age 2-19 with a BMI-for-age at or above the 95th
percentile.
Overweight (at risk for): A term describing children and young people ages 2-19
with a BMI-for-age at or above the 85th percentile but less than the 95th
percentile.
Safe Routes to School (SR2S): Programs sustained by parents, community members,
community leaders and local, state, and federal governments to improve the
health and well-being of children by enabling and encouraging them to walk and
bicycle to school.
Administered by the MT Department of Transportation.
Shape Up Montana: Offered every spring by Big Sky State Games, this is a team
wellness program that challenges adults to be physically active and to eat
healthfully.
Steps to a New You: A program developed by Wellness in the Rockies and offered
through MSU Extension Services, designed to move adults toward healthier
lifestyles.
USDA: United States Department of Agriculture.
Volumetrics: A theory based on the idea that people tend to eat a certain weight
of food each day. By selecting foods that have relatively few calories per
gram—such as fruits, vegetables, and foods that contain a lot of water—people
may be able to avoid hunger, feel satisfied, and lose weight.
WIC: The Special Supplemental Nutrition Program for Women, Infants and Children
provides nutrition services to: pregnant women; breast-feeding women; women who
recently gave birth; infants (birth to 12 months); and children (one to five
years of age) who are determined by a health professional to be at medical or
nutritional risk and below 185% of Federal Poverty Income Guidelines.
Table of Contents
Appendix B: Fifteen Priorities:
Fifteen Priorities for Action Identified in the Call to Action to Prevent and
Decrease Overweight and Obesity
1. Change the perception of overweight and obesity at all ages. The primary
concern should be one of health and not appearance.
2. Educate all expectant parents about the many benefits of breastfeeding.
3. Educate health care providers and health profession students in the
prevention and treatment of overweight and obesity across the life span.
4. Provide culturally appropriate education in schools and communities about
healthy eating habits and regular physical activity, based on the Dietary
Guidelines for Americans, for people of all ages. Emphasize the consumer's role
in making wise food and physical activity choices.
5. Ensure daily, quality physical education in all school grades. Such education
can develop the knowledge, attitudes, skills, behaviors, and confidence needed
to be physically active for life.
6. Reduce time spent watching television and in other similar sedentary
behaviors.
7. Build physical activity into regular routines and playtime for children and
their families. Ensure that adults get at least 30 minutes of moderate physical
activity on most days of the week. Children should aim for at least 60 minutes.
8. Create more opportunities for physical activity at worksites. Encourage all
employers to make facilities and opportunities available for physical activity
for all employees.
9. Make community facilities available and accessible for physical activity for
all people, including the elderly.
10. Promote healthier food choices, including at least 5 servings of fruits and
vegetables each day and reasonable portion sizes at home, in schools, at
worksites, and in communities.
11. Ensure that schools provide healthful foods and beverages on school campuses
and at school events.
12. Create mechanisms for appropriate reimbursement for the prevention and
treatment of overweight and obesity.
13. Increase research on behavioral and environmental causes of overweight and
obesity.
14. Increase research and evaluation on prevention and treatment interventions
for overweight and obesity, and develop and disseminate best practice
guidelines.
15. Increase research on disparities in the prevalence of overweight and obesity
among racial and ethnic, gender, socioeconomic, and age groups, and use this
research to identify effective and culturally appropriate interventions.
Table of Contents
Appendix C: A Note on School Wellness Policies and
Practices:
During the public comment process in the development of this State Plan, a
number of community members suggested that schools develop very specific
policies detailing how better nutrition and more physical activity will be
promoted.
By the beginning of the 2006-2007 school year, all schools must have a school
wellness policy in place if they want to continue to be eligible for federal
reimbursements for School Nutrition Programs (the National School Lunch Program,
the School Breakfast Program, and the Special Milk Program). The Montana School
Board Association has developed a model school wellness policy for schools to
adopt. It provides general guidance and does not include specific
recommendations due to the fact that many Montana school boards prefer broad
policy language. The details of policy implementation steps are included in a
written implementation plan that outlines the policy's nutrition, physical
activity and student wellness goals.
Because the school wellness policy mandate deadline for policy adoption will
happen at roughly the same time this State Plan is published (June 2006), we
believe we can have the most impact by working with schools to develop written
implementation plans. Creating the written implementation plans will provide
schools with the opportunity to document their intention to implement specific
practices. Action for Healthy Kids will take the lead on collecting resources to
help schools make decisions about which specific practices to adopt. Team
Nutrition, OPI, NAPA, and the Montana School Board Association will publicize
these resources to schools. NAPA will provide technical assistance and will
monitor the development and quality of the written implementation plans adopted
by the state's largest school districts and, as possible, will also work with
Montana's many small schools.
Table of Contents
Appendix D: Cardiovascular Disease/Obesity Prevention
Task Force Members:
Diane Arave, Wellness Officer, State of Montana Healthcare and Benefits Bureau
Ninia Baehr, RN, Program Manager, Montana Nutrition & Physical Activity Program
Katie Bark, RD, Team Nutrition, Montana State University
Laura Behenna, Health Educator, Lewis & Clark City-County Health
Janet Belcourt, Principal Investigator, Diabetes Education in Tribal Schools,
Stone Child College
Lena Belcourt, Legislative Analyst, Rocky Boy Health Board
Bonnie Bentley, Physical Fitness Coordinator, Fort Belknap Tribal Health
Department Diabetes Prevention Program
Suzanne Binne-Huse, Health & Nutrition Manager, Missoula Early Head Start
Lori Bird In Ground, Crow Tribal Health Program
Lynda Blades, MPH, CHES, Program Manager, DPHHS - Cardiovascular Health Program
Ellen Brown, MPA, Senior Community Health Specialist, Missoula City-County
Health Dept.
Anne Burnett, MN, APRN-BC, FNP, Stroke Center Coordinator, Benefis Healthcare
Tracy Burns, MS, RD, Healthy Lifestyles, Inc., Great Falls, Consultant to Rocky
Boy Health Board
Mary Ann Carlson, MD, Montana Chapter, AAP
Cliff Christian, Montana Director of Government Affairs, American Heart
Association, American Stroke Association
Chris Clasby, MSW, Employment Specialist, Disability Advisor, University of
Montana
Cathy Costakis, MS, Physical Activity Coordinator, Montana Nutrition & Physical
Activity Program
Phyllis Dennee, MS, CFCS, Nutrition Education Specialist, Montana State
University Extension
Christine Emerson, MS, RD, Director, School Nutrition Programs, Montana Office
of Public Instruction
Chelsea Fagen, BS, Health Education Specialist, DPHHS - Cardiovascular Health
Program
Kitty Felix, Missoula Urban Indian Center
Chris Fogelman, RD, MPH, Breastfeeding Coordinator, DPHHS - WIC Program
Crystelle Fogle, MBA, MS, RD, Health Services Specialist, DPHHS - Cardiovascular
Health Program
Steve Gaskill, Associate Professor, Exercise Science, Health and Human
Performance Dept., University of Montana
Jason Gleason, MS, FNP-C
Dorothy Gohdes, MD, DPHHS - Consultant
Donna Greenwood, RN, MSN, Associate Professor Nursing, Carroll College
Todd Harwell, MPH, Bureau Chief, DPHHS - Chronic Disease Prevention and Health
Promotion Bureau
Dayle Hayes, MS, RD, President, Nutrition for the Future, Inc.
Sharon Hecker, MD, St. James Healthcare
Dan Heil PhD, Montana State University, Department of Health & Human Development
Steven Helgerson, MPH, MD, Montana State Medical Officer, DPHHS
Lynn Hellenga, MS, RD, Nutrition Coordinator, Montana Nutrition & Physical
Activity Program
Pat Hennessey, MS, RD, Director, Healthy Mothers Healthy Babies Nutrition
Resource Project
Dwight R. Hiesterman, MD, FACP, Clinical Consultant, Mountain-Pacific Quality
Health Foundation
Kathleen Humphries, PhD, Nutrition Programs Director, Montana Disability and
Health Program, University of Montana Rural Institute
Jacque Jakovac, RN, MA, Medical Policy/QI Coordinator, Blue Cross Blue Shield of
MT
Charlene Johnson, MPH, RD, Indian Health Service - Crow Service Unit PHS Indian
Hospital
Lee Ann B. Johnson, MPH, Health Promotion Specialist, DHHS PHS – Billings Area
Indian Health Service
Liz Johnson, RNCNP, Program Manager, DPHHS - Montana Diabetes Program
Diane Jones, APRN, Director of Nursing, Wheatland Memorial Hospital
Dan Keith RN, MBA, Administrator, Home Health of Montana
Cathy Kendall, Division Administrator, Health Enhancement and Safety, Montana
Office of Public Instruction
Mary Ellen LaFromboise, Director, Community Health Representatives,
BlackfeetTribe
Gloria Lambertz, Montana Association of Health, PE, Recreation & Dance
Pam Langve-Davis, Bicycle/Pedestrian Coordinator, Montana Department of
Transportation
Christopher Lepore, Director, State Government Affairs, Johnson & Johnson
Greg Lind, MD
Catherine Lisowski, MS, ES, Kalispell Regional Medical Center; President,
Montana Association of Cardiovascular and Pulmonary Rehabilitation Associates
Margaret Mall, RD, CDE, Bc.ADN, Consultant, Northern Cheyenne Tribe Diabetes
Program
Christopher Mast, DDS, Montana Dental Association
Emily Matt Salois, MSW, ACSW, Consultant
Michael McNamara, MS, Secondary Prevention Specialist, DPHHS- Cardiovascular
Health Program
Minkie Medora, MS, RD, Food Policy Council Member of the Montana Food Bank
Network
Tom Mexican-Cheyenne, Community Health Director, Northern Cheyenne
Mary P. Miles, PhD, Assistant Professor, Montana State University Dept. of Human
Development
Linda Olsen, RN, CHE, Administrator, Regional Physician Services, Billings
Clinic
Carrie Oser, MPH, Epidemiologist, DPHHS - Diabetes and Cardiovascular Health
Programs
Lynn Paul, EdD, RD, MSU Extension Food and Nutrition Specialist
Brenda Peppers, Nutrition Specialist, DPHHS- Child and Adult Care Food Program
Mary Pittaway, MA, RD, LD, Nutrition Services Supervisor, Missoula City-County
Health Dept.
Manuella Realbird-Mesteth, Crow Tribal Health
Brad Roy, PhD, CHE, FACSM, Administrator, The Summit, Kalispell Regional Medical
Center
Donna Russell-Cook, Director, Cardiovascular Services, St. Vincent Healthcare
Karen Sanford-Gall, Executive Director, Big Sky State Games-Shape Up Montana
LuMary Spang, Crow Tribal Health
Mary Stein, MS, Adjunct Instructor, MSU
Patti Steinmuller, MS, RD, LN, Nutrition Educator, Burns Technology Center, MSU
Marni Stevens, MS, RD, Nutritionist, DPHHS - Aging Services
Jason Swant, Health Education Specialist, DPHHS - Tobacco Use Prevention Program
Elaine Taylor, President, Montana Beverage Association
Kristin Thompson, RHIA QM/HEDIS Coordinator/Quality Management, Blue Cross Blue
Shield of Montana
Walt Timmerman, Resource Program Manager - Parks Division, Montana Fish,
Wildlife & Parks
Meg Ann Traci, PhD, Project Director, Research & Training Center on
Disabilities, University of Montana Rural Institute
Ellen Wangsmo, MSPH, Preventive Health Specialist II, Yellowstone City-County
Health Department
Suzie Eades Wood, NSCA-CPT, Operations Director, Big Sky State Games/Shape Up
Montana/Big Sky Fit Kids
Robert Wynia, MD
Table of Contents
Appendix E: Description of Strategy Chart: Social Area
and Socio-Ecological Sphere. The Social Area encompasses health care, the
worksite, the community, and children/youth/the family. Socio-Ecological Spheres
are individual, interpersonal, institutional/organizational, community, and
policy/systems/environment. Physical Activity Objective 1A, Strategies 1-4,
relate to the "community" Social Area and to the "community" Socio-Ecological
Sphere. Physical Activity Objective 1B, Strategy 1, relates to the
"children/youth/the family" Social Area and to the
"institutional/organizational" Socio-Ecological Sphere. Physical Activity
Objective 1C, Strategies 1-5, relate to the "children/youth/the family" Social
Area and to the "institutional/organizational" Socio-Ecological Sphere. Physical
Activity Objective 1D, Strategies 1-5, relate to the "children/youth/the family"
Social Area and to the "institutional/organizational" Socio-Ecological Sphere.
Physical Activity Objective 1E, Strategy 1 relates to the "worksite" Social Area
and to the "institutional/organizational" Socio-Ecological Sphere. Physical
Activity Objective 1E, Strategy 2 relates to the "community" Social Area and to
the "interpersonal" Socio-Ecological Sphere. Physical Activity Objective 1E,
Strategy 3 relates to the "children/youth/the family" Social Area and to the
"interpersonal" Socio-Ecological Sphere. Physical Activity Objective 1E,
Strategy 4 relates to the "children/youth/the family" Social Area and to the
"institutional/organizational" Socio-Ecological Sphere. Physical Activity
Objective 1E, Strategy 5 relates to the "children/youth/the family" Social Area
and to the "community" Socio-Ecological Sphere. Physical Activity Objective 1E,
Strategy 6 relates to the "community" Social Area and to the "interpersonal"
Socio-Ecological Sphere. Physical Activity Objective 1E, Strategy 7 relates to
the "community" Social Area and to the "community" Socio-Ecological Sphere.
Physical Activity Objective 1F, Strategy 1 relates to the "children/youth/the
family" Social Area and to the "individual" Socio- Ecological Sphere. Physical
Activity Objective 1F, Strategy 2 relates to the "children/youth/the family"
Social Area and to the "community" Socio-Ecological Sphere. Physical Activity
Objective 1F, Strategy 3 relates to the "children/youth/the family" Social Area
and to the "individual" Socio-Ecological Sphere. Physical Activity Objective 1F,
Strategy 4 relates to the "children/youth/the family" Social Area and to the
"community" Socio-Ecological Sphere. Fruits and Vegetables Objective 2A,
Strategies 1 and 2 relate to the "community" Social Area and to the "community"
Socio-Ecological Sphere. Fruits and Vegetables Objective 2A, Strategy 3 relates
to the "worksite" Social Area and to the "institutional/organizational"
Socio-Ecological Sphere". Fruits and Vegetables Objective 2A, Strategy 4 relates
to the "children/youth/the family" Social
