In 2004, the Institute of Medicine published an authoritative report on the prevention of childhood obesity.⁵ That report identified many factors that are considered likely contributors to the development of childhood obesity and argued that a comprehensive, national strategy that operates on all levels of society and addresses all of the factors will be necessary to successfully stem the growing epidemic. The article on prevention that appeared in Pediatrics³ also took a comprehensive view of the problem. The following table summarizes some of the major factors thought to be associated (either positively or negatively) with childhood obesity. Policy and environmental factors considered important in the prevention of childhood obesity are not included in the following discussion, but the comments section highlights research needs that will lay the foundation for progress in prevention.

Factor	Association with Obesity	Comments
Total Energy Intake	Increased total energy intake is assumed to be positively associated with obesity, but solid evidence is lacking; intake data are often self-reported (notoriously inaccurate)	Lack of association is due to inaccurate measurement of dietary intake; improved methodology for assessing intake in humans is an urgent research need
Dietary Fat	Some studies report positive association and some do not; NO study has found low fat intake to be associated with high body fat	Improved methodology to permit accurate measurement of dietary intake is urgently needed
Calcium/Dairy Foods	It is suggested that low intake is associated with greater adiposity (fatness); however, rigorous studies and convincing data are lacking	Calcium/dairy intake may be a marker for a better diet and/or a healthier lifestyle that accounts for lower adiposity
Fruits and Vegetables (F&V)	Evidence supports a "modest effect" of high intake of F&V with lower levels of body fatness; NO study has found high F&V intake associated with high body fat	More than one third of F&V intake consists of iceberg lettuce, frozen potatoes (French fries) and potato chips; more precise classification of F&V and measures of intake are needed
100% Fruit Juice	Data are unclear; large intakes (≥ 12 oz per day) are positively associated with obesity; AAP* recommends a limit of 4 to 6 oz. per day for children ages 1 to 6; 8 to 12 oz. per day for ages 7 to 18.	Improved measures of dietary intake would help to clarify the association of fruit juice intake with body fat content
Soda (Pop), Sugar-Sweetened Beverages, Soft Drinks, Fruit Drinks	Evidence is strong that intake of these beverages is positively associated with increased fatness; AAP* recommends that these beverages be eliminated from schools	Consensus is growing that these beverages promote obesity and that reducing intake can contribute to prevention of weight gain in children and teens
Breakfast Skipping	Obese children and teens skip breakfast more often than those who are lean; there is evidence that skipping breakfast may increase the risk of obesity	Defining what constitutes an appropriate breakfast is a challenge and is needed to strengthen the evidence
Eating Out/Fast Food	Meals taken outside the home are associated with higher intake of calories and dietary fat than the same meal prepared at home; eating out is considered a risk factor for obesity, although studies lack precise definitions of "eating out" and "fast food"	Better measurement of dietary intake and more uniform definition of "eating out" and "fast food" would strengthen the evidence
Portion Size	Evidence suggests that larger portions are associated with higher intake of calories and increased body fatness of children	What constitutes an appropriate portion size at various ages needs to be clarified
Snacking	No association between snacking and adiposity is consistently reported, but snacks tend to be higher in fat, sugar, energy density and lower in nutrient content; measures of intake are often imprecise	What constitutes a healthy snack (energy density, fat and sugar content, and nutritional quality) and what is an appropriate snacking frequency need to be clarified
Family Meals	Family meals are associated with better dietary quality—increased intake of F&V and milk and lower intake of fried food and soft drinks	Better measures of dietary intake are needed to clarify this association
Parental Control of Child's Food Intake	Inconsistent findings, but it is hypothesized that strategies to promote a child's self-regulation of intake is associated with lower body fat content	More precise definition of parental control and how such control influences a child's ability to self-regulate food intake is needed
Physical Activity	Levels of physical activity in many domains (at home, in the community, walking to school, in-school physical education, etc.) have declined; strong gender and age differences in physical activity exist and in activity preferences; consensus recommendation is that school-aged youths should get ≥ 60 minutes of moderate to vigorous physical activity daily	Difficult to accurately measure physical activity, especially in various domains (home, school, etc.) in which children live; impact of physical environment (sidewalks, bike paths, school location, traffic patterns, zoning, etc.) on activity levels needs to be better understood; influence of parents and parental activity needs more research attention
Sedentary Behavior (TV, videos, computer games, etc)	Strong association between limiting sedentary behavior and reduced body fat content; consensus recommendation is no TV or video for children up to age 2 and not more than 2 hours per day in older children	Role of TV and computer in the bedroom on child's sedentary behavior and the role of parental and family TV viewing habits need more research attention
Family Dynamics	A healthy family lifestyle can positively influence the health of children; coaching parents can yield positive changes in child behavior and improved weight control; parents can support physical activity directly by playing with their children or through programs	Culturally sensitive evidence-based parent coaching strategies need to be developed and disseminated as a high priority research need
Parenting Style	Parenting styles range from very controlling (authoritarian or punitive) to very indulgent or even disengaged (neglectful). The ideal style is described as "authoritative" and some evidence suggests this style is associated with more physical activity and less sedentary behavior	Further characterization of an authoritative parenting style and precisely how to foster and adopt such a style is a high priority research need
Prenatal Environment	Exposure to maternal diabetes and other features of an altered intrauterine environment is associated with subsequent development of childhood obesity	Mechanisms of this effect and how maternal obesity predisposes infant to become obese in early childhood need to be clarified
Infancy	Breastfeeding is considered weakly protective against obesity; AAP* supports breastfeeding for obesity prevention	Most studies do not adequately define breastfeeding; two critical factors are exclusivity of breastfeeding and duration; hospitals should promote only breastfeeding and not market formula
Weaning Foods	Three important factors for protecting against obesity in children are the quality of the diet upon weaning, portion control, and the "emotional context" in which food is eaten	Clear guidance on what constitutes a "healthful array of foods in the correct portion size" is needed for each age level; guidance is also needed on how to permit the child to choose "what and how much to eat" from a healthful variety of foods
Parental Modeling of Healthy Lifestyle	There is evidence that parental diet and exercise habits and inactivity influence those same habits in children	Careful consideration of all aspects of parental lifestyle including TV viewing, TV in the bedroom, etc., should be considered in light of its impact on the child's "energy environment"

*AAP is the American Academy of Pediatrics

A valuable contribution of the Pediatrics article on the prevention of childhood obesity is a section offering an overview of various ways in which clinicians can structure their office practice and intervene with pediatric patients and their families.³ It includes a description of motivational interviewing and other clinical counseling skills and behavioral strategies that are considered effective. The article acquaints the interested reader with these clinical skills and concepts and suggests additional clinical training that may be useful. If you have a strong interest in childhood obesity prevention, the Pediatrics article,³ as well as the IOM report,⁵ are worthwhile reading.

Higher rates of illness among those with disabilities is not surprising given the challenges they face getting more exercise. For example, some physical fitness facilities are not designed to be accessible to people with disabilities, and transporting people to and from facilities can be a problem. As individuals with disabilities grow older, their primary caregivers may find it challenging helping them maintain fitness.

Thoughtful policymaking and program planning at the community level is needed to ensure that American adults who live with disabilities have access to a wide variety of facilities and programs that can produce positive experiences with physical activity. The goal is to design programs at which they can succeed and to adapt the environment so that they can have fun, too.

In order for adults with disabilities to experience success in physical activity, specific accommodations are often required that take into account not only the type of disability, but also the severity of the disability. For example, providing an adult with cerebral palsy with a positive experience playing sledge hockey, a sport that allows people with physical disabilities to play ice hockey, may call for modifications to the rules of the game, especially if the adult is playing with peers who do not have disabilities. Accommodations in this instance might include changing the distance that opponents can travel, playing with a longer stick, or permitting the player to shoot on a larger target.

Focus on the Individual

When working alongside an adult with an intellectual disability who is not motivated to participate in physical activity, facilitators must learn more about the adult in order to determine what might motivate him/her to participate. Because of the need for individualized attention, it is usually necessary to have one support member working with each adult to adapt techniques and provide encouragement, thereby enhancing the chances of success.

In summary, to afford adults with disabilities ample opportunity to enjoy physical activity:

1. Policymakers, program developers and facilities planners must understand how critical physical activity is for the good health of this population
2. Programs and facilities must address accessibility and transportation needs
3. Equipment, game rules, and physical facilities (e.g., wheelchair ramps, wide hallways, etc.) must accommodate the widest possible range of needs
4. Appropriate individualized goals related to participation in physical activity should be set and healthy rewards for participation should be in place
5. Activities should be appealing to the age group of the target population
6. Physical activity experiences should emphasize social interaction and be presented in an upbeat and safe environment (i.e., music that the individuals enjoy. etc)

The I Can Do It, You Can Do It Program uses two distinct strategies to accomplish its goals. First, the program establishes a mentoring model in which healthy adults are paired with children and adults with disabilities in community-based, client-centered programs to encourage regular physical activity participation and healthy eating habits. Second, the program encourages the use of incentives to motivate participants. The Presidential Active Lifestyle Awards (PALA) program is used to encourage participation in regular physical activity a minimum of five days a week, 30 minutes per session. Upon achievement of these goals, participants receive PALA patches, medals, and certificates.

SRU, with the support of the Office on Disability, has awarded national grants to seven universities, a school district and a recreation center throughout the US that will develop, implement, and evaluate their own programs. The goal is to establish I Can Do It, You Can Do It mentoring programs in every state in the United States. This fall, SRU will conduct another Request for Proposals (RFP). Grants are for $15,000 to each successful awardee. Requirements include three waves of eight-week physical activity sessions and nutrition education during the year. A minimum of 60 mentees (individuals with disabilities) and 40 to 60 mentors (healthy adults) per session are required to participate in this initiative. Interested parties are encouraged to contact:

Robert Arnhold, PhD
Director, I Can Do It, You Can Do It Program
Slippery Rock University, Room 15
Stoner Educational Complex
Slippery Rock, PA 16057
724-738-2847
robert.arnhold@sru.edu

Each TOPS chapter is called upon to "walk" 1000 miles. When this goal is realized, the organization will reach the million-mile mark and make strides to improve the health and wellness of its nearly 180,000 members.

It is said that a journey of 1000 miles begins with a single step. That first step is often the most difficult one to take. Whatever your age and fitness level is, TOPS encourages appropriate exercise as an essential part of long-term weight loss and maintenance. Members at similar fitness levels team up with each other to walk or do some type of alternate aerobic activity throughout the week, receive awards for their progress as mileposts are reached, and have fun throughout the journey.

All actual miles walked or run count for the challenge. Each 30 minutes of alternative physical activity may be exchanged for a mile, as well. Members also earn bonuses for sustaining a single session of walking or qualifying physical activity for at least 45 minutes and for engaging in the activity five or more days each week.

TOPS invites you to join in this one-year trek. Find a friend or family member to walk by your side and get up, get out, and get going. Just take the first step and keep putting one foot in front of the other. Travel along with TOPS and measure your progress. Mile-marker cities and estimated dates of arrival have been designated along the Million-Mile Trek route. For more information about TOPS, the Million-Mile Trek, or to find a chapter near you, visit TOPS or call (414) 482-4620.

Southwest Turkey Soup
Makes 8 servings

INGREDIENTS:

• 1 Tbsp. extra virgin olive oil
• 1 large onion, coarsely chopped
• 2 cloves garlic, crushed
• 2 scallions, chopped, divided
• 1/4 tsp. cayenne pepper (or crushed red pepper flakes)
• 1/2 tsp. ground cumin
• Salt and freshly ground pepper, to taste
• 1 1/2 cups cooked, shredded turkey
• 1 (28-oz.) can whole peeled tomatoes, drained
• 2 plum tomatoes, chopped
• 4 cups low fat, reduced-sodium chicken broth
• 1 (4-oz.) can chopped green chile peppers
• 1 tsp. lime juice
• 1 avocado, pitted, peeled and diced
• 1/4 cup fresh cilantro, chopped, divided
• 3/4 cup shredded, low fat Monterey Jack cheese
• 2 handfuls baked corn tortilla chips, roughly crushed

DIRECTIONS:

1. Heat oil in large pot over medium heat. Sauté onion, garlic, half of the scallions and spices for about 5 minutes. Add turkey, canned tomatoes, fresh tomatoes, broth, chile peppers and lime juice. Bring to a boil, then reduce heat and simmer for 18 to 20 minutes.
2. Stir in avocado and cilantro and simmer 15 to 20 minutes until slightly thickened.
3. Spoon into bowls, top with shredded cheese, remaining scallions and cilantro. Add crushed tortilla chips just before serving.

Nutritional analysis per serving: 200 calories, 8 grams total fat, 2.5 grams saturated fat, 12 grams carbohydrate, 19 grams protein, 3 grams dietary fiber, 420 milligrams sodium.

Source: American Institute for Cancer Research