Liste 3 exemplos de estratégias de mídia que promovam opções saudáveis de estilo de vida

As 10 melhores estratégias de autocuidado para redução de estresse.

Você sempre pode controlar as circunstâncias que a vida lança no seu caminho, mas você pode controlar o quão bem você cuida de si mesmo. Isso é vital para construir resiliência em relação aos estressores da vida que você não pode eliminar por vários motivos. Quando você está muito cansado, comendo pouca nutrição, ou geralmente desacelerado, provavelmente será mais reativo ao estresse em sua vida. Você pode mesmo criar mais problemas para você, reagindo mal em vez de responder de um lugar de força calma.

Por outro lado, quando você está cuidando bem seu corpo e sua mente, você pode ser mais resiliente com o que vem, usar os recursos que você tem na sua vida ao máximo e tornar-se menos reativo em relação ao estresse que você enfrenta. Cuidar adequadamente de seu corpo, alma e mente pode mantê-lo na forma ideal para lidar com o estresse, o que lhe dá tanta resiliência quanto possível para ajudá-lo a gerenciar essas coisas incontroláveis ​​na vida. As seguintes são algumas das principais estratégias básicas de autocuidado que podem mantê-lo funcionando bem e pronto para os desafios da vida.

O sono é muito importante para o seu bem-estar emocional e físico. A falta de sono pode afetar negativamente sua capacidade de lidar com o estresse, ser produtivo e funcionar corretamente. Infelizmente, horários ocupados e estresse podem tornar o sono mais difícil. Entre ter muito pouco tempo para dormir, ter dificuldade em adormecer, e obter sono de baixa qualidade devido ao estresse, obter o olho fechado adequado não é sempre fácil, mas é vital.

Felizmente, há muitas coisas que você pode fazer para suportar seus hábitos de sono, usando estratégias de gerenciamento de tempo para criar mais tempo, para encontrar técnicas de relaxamento para ajudá-lo a adormecer e obter qualidade durante a noite toda. E se você realmente não consegue dormir o suficiente durante a noite, não subestime o valor de uma soneca de poder!

Muitas pessoas não estão conscientes da medida em que isso é verdade, mas uma dieta pobre pode realmente torná-lo mais vulnerável ao estresse. Ironicamente, o estresse (e as coisas na sua vida que o causam) podem tornar mais difícil para você manter uma dieta saudável, o que pode contribuir para mais estresse. Se você estiver muito ocupado, talvez seja mais difícil encontrar tempo para cozinhar refeições saudáveis, e você pode estar mais tentado a comer a conveniência e a conveniência não saudáveis. alimentos, o que pode agravar o estresse. Estar muito ocupado também pode criar estresse, e sentir-se estressado pode fazer você desejar alimentos não saudáveis ​​também, contribuindo para um ciclo vicioso. Embora horários agitados possam dificultar a obtenção de uma alimentação adequada, uma dieta pobre não é inevitável. Saiba como manter uma dieta saudável quando forçado. Você pode se surpreender com a quantidade de estresse que você pode lidar quando seu corpo está bem nutrido.

O exercício pode ser ótimo para você fisicamente e mentalmente. Ele fornece uma liberação de estresse e mantém seu corpo saudável. Também ajuda seu corpo a liberar endorfinas, o que aumenta seus sentimentos de bem-estar geral. Saiba mais sobre os efeitos positivos do exercício para aliviar o estresse e encontre recursos para começar uma atividade que lhe convier. (Sugestão: os animais de estimação fazem amigos excelentes para treinar!)

O apoio social pode mantê-lo mais saudável e feliz, criando um amortecedor contra o estresse. Os amigos podem buscá-lo quando estiver triste, fornecer informações sobre quando você está confuso e ajudá-lo a se divertir quando precisar demitir-se. Saiba como cultivar amizades de apoio e expandir seu círculo social para que você tenha alguém para se apoiar quando forçado. Não esqueça, é importante fornecer uma orelha de apoio quando seus amigos também precisam disso! Desenvolva habilidades de escuta eficaz para que você seja um melhor suporte para seus amigos e entes queridos.

Ter algum "tempo de inatividade" é importante, e os hobbies podem proporcionar uma boa distração do estresse e ajudá-lo a permanecer "no momento", o que também é uma ótima maneira de aliviar a tensão. Desenho e jardinagem são excelentes analgésicos, mas praticamente tudo o que você gosta pode funcionar. Há muitos analgésicos não convencionais que podem proporcionar um pouco de diversão e distração contra o estresse.

Cuidar do seu corpo por fora - com um tratamento de spa, por exemplo, pode fazer maravilhas para o seu estado interno. Não negligencie a importância de cuidar de você regularmente. Isso pode ajudá-lo a se sentir bem consigo mesmo e se sentir pronto para enfrentar o mundo.

Se você mantiver a atitude de que o estresse é um desafio - e não uma ameaça, você é melhor capaz de lidar com isso. Ao manter a mente nítida, você está mais equipado para resolver os problemas e assumir os "desafios" que a vida apresenta. Você pode querer mergulhar em aprender mais sobre um assunto que o fascina. A escola pode ter sido estressante, uma vez que você não precisa se preocupar com as notas, o aprendizado torna-se uma maneira de se concentrar e acentuar sua mente. Jogos como palavras cruzadas, Sudoku e desafios triviais podem ser divertidos de jogar e uma maneira de relaxar quando você está sentindo estresse.

Muito do que você experimenta na vida pode se sentir mais estressante ou menos, dependendo do seu ponto de vista. Olhar para coisas de um estado de espírito otimista não só pode diminuir seu nível de estresse, mas oferecer mais sucesso na vida e mais. Você pode até mudar padrões de pensamento negativos enraizados para outros mais positivos, usando afirmações positivas. Você é otimista? Se você não tiver certeza, este questionário sobre otimismo e redução do estresse pode dizer-lhe.

Manter suas emoções engarrafadas pode levar a uma explosão emocional mais tarde. Geralmente é mais saudável ouvir seus sentimentos, processá-los e tentar compreendê-los. Considere-os "mensageiros" que lhe dizem quando algo não está certo com o seu mundo. Uma ótima maneira de processar as emoções é o ato do jornal. Quando você escreve sobre seus sentimentos e soluções potenciais para seus problemas, você pode reduzir o estresse em sua vida e até mesmo ver alguns benefícios para a saúde.

A pesquisa mostra que um estilo de vida que inclui religião ou espiritualidade é geralmente um estilo de vida mais saudável. Muitas pessoas, especialmente os idosos, usam a oração como um grande analista de estresse e estratégia para a saúde emocional. Você pode usar a oração para melhorar o seu lado espiritual, ou usar a meditação de você, não se sinta à vontade com a oração. A prática espiritual é profundamente pessoal e, seja qual for sua prática, ela deve nutrir sua alma.

Estratégias e medidas comunitárias recomendadas para prevenir a obesidade nos Estados Unidos.

Laura Kettel Khan, PhD 1.

Kathleen Sobush, MS, MPH 2.

Dana Keener, PhD 3.

Kenneth Goodman, MA 3.

Amy Lowry, MPA 2.

Jakub Kakietek, MPH 3.

Susan Zaro, MPH 3.

1 Divisão de Nutrição, Atividade Física e Obesidade, Centro Nacional de Prevenção de Doenças Crônicas e Promoção da Saúde, CDC.

2 CDC Foundation, Atlanta, Geórgia.

3 ICF Macro, Atlanta, Geórgia.

Aproximadamente dois terços dos adultos dos EUA e um quinto das crianças nos EUA são obesos ou com excesso de peso. Durante 1980--2004, a prevalência de obesidade entre adultos dos EUA dobrou, e dados recentes indicam que 33% dos adultos dos EUA estão com sobrepeso (índice de massa corporal (IMC) 25,0-29,9), 34% são obesos (IMC ≥ 30,0), incluindo quase 6% que são extremamente obesos (IMC ≥40,0). A prevalência de sobrepeso entre crianças e adolescentes aumentou substancialmente em 1999-2004, e aproximadamente 17% das crianças e adolescentes dos EUA estão com sobrepeso (definidos como acima ou acima do percentil 95% do IMC específico do sexo para gráficos de crescimento da idade). Ser obeso ou excesso de peso aumenta o risco de muitas doenças crônicas (por exemplo, doença cardíaca, diabetes tipo 2, certos tipos de câncer e acidentes vasculares cerebrais). Inverter a epidemia de obesidade nos Estados Unidos requer uma abordagem abrangente e coordenada que use mudanças políticas e ambientais para transformar as comunidades em locais que apoiem e promovam escolhas de estilo de vida saudável para todos os residentes dos EUA. Os fatores ambientais (incluindo a falta de acesso aos supermercados de serviços completos, o aumento dos custos de alimentos saudáveis ​​e o menor custo de alimentos insalubres e a falta de acesso a locais seguros para jogar e exercitar) contribuem para o aumento das taxas de obesidade inibindo ou evitando alimentação saudável e comportamentos de vida ativa. São necessárias estratégias recomendadas e medidas adequadas para avaliar a eficácia das iniciativas da comunidade para criar ambientes que promovam boa nutrição e atividade física. Para ajudar as comunidades neste esforço, o CDC iniciou o Projeto de Medidas Comunitárias de Prevenção da Obesidade (Projeto Medidas). O objetivo do Projeto Medidas foi identificar e recomendar um conjunto de estratégias e medidas associadas que as comunidades e os governos locais podem usar para planejar e monitorar mudanças ambientais e políticas para a prevenção da obesidade. Este relatório descreve o processo de painel de especialistas que foi usado para identificar 24 estratégias recomendadas para a prevenção da obesidade e uma medida sugerida para cada estratégia que as comunidades podem usar para avaliar o desempenho e acompanhar o progresso ao longo do tempo. As 24 estratégias são divididas em seis categorias: 1) estratégias para promover a disponibilidade de alimentos e bebidas saudáveis ​​acessíveis), 2) estratégias para apoiar escolhas saudáveis ​​de alimentos e bebidas, 3) uma estratégia para incentivar a amamentação, 4) estratégias para incentivar a atividade física ou limitar a atividade sedentária entre crianças e jovens, 5) estratégias para criar comunidades seguras que apoiem a atividade física e 6) uma estratégia para incentivar as comunidades a se organizar para a mudança.

Preparador correspondente: Laura Kettel Khan, PhD, Divisão de Nutrição, Atividade Física e Obesidade, Centro Nacional de Prevenção de Doenças Crônicas e Promoção da Saúde, CDC, 4770 Buford Hwy, MS K-24, Atlanta, Georgia 30341-3717. Telefone: 770-488-6018; Fax: 770-488-6500; E-mail: ldk7cdc. gov.

Introdução.

As taxas de obesidade nos EUA aumentaram dramaticamente nos últimos 30 anos e a obesidade agora é epidêmica nos Estados Unidos. Os dados para 2003-2004 e 2005-2006 indicaram que aproximadamente dois terços dos adultos dos EUA e um quinto das crianças dos EUA eram obesos (definido para adultos como tendo um índice de massa corporal [IMC] ≥30,0) ou com excesso de peso (definido para adultos como IMC de 25,0-29,9 e para crianças com ou acima do percentil 95% do IMC específico do sexo para gráficos de crescimento da idade) (1,2). Entre os adultos, a prevalência de obesidade dobrou em 1980-2004, e dados recentes indicam que cerca de 33% dos adultos dos EUA estão com sobrepeso e 34% são obesos, incluindo quase 6% são extremamente obesos (definido como IMC ≥ 40,0) (3,4 ). Ser obeso ou excesso de peso aumenta o risco de muitas doenças crônicas (por exemplo, doença cardíaca, diabetes tipo 2, alguns cânceres e acidentes vasculares cerebrais). Embora a dieta e o exercício sejam determinantes importantes do peso, fatores ambientais além do controle de indivíduos (incluindo falta de acesso a supermercados de serviço completo, alto custo de alimentos saudáveis ​​e falta de acesso a locais seguros para jogar e exercitar) contribuem para aumentar taxas de obesidade, reduzindo a probabilidade de alimentação saudável e comportamentos de vida ativa (5 a 7).

Estados e comunidades estão respondendo à epidemia de obesidade nos Estados Unidos trabalhando para criar ambientes que apoiem alimentação saudável e vida ativa (8,9) e dando aos profissionais de saúde pública e aos decisores políticos a oportunidade de aprender com os esforços comunitários para prevenir obesidade. No entanto, a ausência de medidas para avaliar as mudanças políticas e ambientais no nível da comunidade impediu os esforços para avaliar a implementação desses tipos de iniciativas em nível de população para prevenir a obesidade. Para abordar esta questão, a CDC iniciou o Projeto Comunitário de Medidas Comunitárias para a Prevenção da Obesidade (o Projeto Medidas). O objetivo do Projeto Medidas foi identificar e recomendar um conjunto de estratégias de prevenção da obesidade e medidas sugeridas correspondentes que os governos locais e as comunidades podem usar para planejar, implementar e monitorar iniciativas para prevenir a obesidade. Para os propósitos do Projeto Medidas, uma medida é definida como um único elemento de dados que pode ser coletado através de uma avaliação objetiva das políticas ou do ambiente físico e que pode ser usado para quantificar o desempenho de uma estratégia de prevenção da obesidade. A comunidade foi definida como uma entidade social que pode ser classificada espacialmente com base em onde as pessoas vivem, trabalham, aprendem, adoram e brincam (por exemplo, casas, escolas, parques, estradas e bairros).

O processo do Projeto Medidas foi orientado por opinião de especialistas e incluiu uma revisão sistemática da literatura científica publicada, resultando na adoção de 24 estratégias recomendadas de nível ambiental e político para prevenir a obesidade. Este relatório apresenta o primeiro conjunto de recomendações abrangentes publicadas pelo CDC para promover uma alimentação saudável e vida ativa e reduzir a prevalência de obesidade nos Estados Unidos. Este relatório descreve cada uma das estratégias recomendadas, resume as evidências disponíveis em relação à sua eficácia e apresenta uma medida sugerida para cada estratégia que as comunidades podem usar para avaliar a implementação e acompanhar o progresso ao longo do tempo.

As estratégias recomendadas apresentadas neste documento foram desenvolvidas como resultado de um processo sistemático fundamentado em evidências disponíveis para cada estratégia, parecer de especialistas e documentação detalhada do processo do projeto e da lógica de tomada de decisão. Algumas estratégias exploratórias para as quais nenhuma evidência estava disponível foram incluídas nas recomendações com base em pareceres de especialistas e para determinar a eficácia da estratégia de prevenção da obesidade.

A Equipe de Projetos da Comunidade Comum para a Prevenção da Obesidade (a Equipe do Projeto de Medidas) incluiu funcionários do CDC, que mantiveram a autoridade primária de decisão do projeto; a Fundação CDC, que providenciou supervisão administrativa e fiscal para o Projeto; ICF Macro, uma empresa de consultoria em saúde pública que atuou como o centro de coordenação do projeto; Research Triangle Institute, uma empresa de consultoria em saúde pública que atuou como centro de coordenação durante a fase preliminar do projeto; e a International City / County Management Association (ICMA), que forneceu conhecimentos do governo local. Múltiplos subgrupos * forneceram informações e orientações para a equipe do Projeto de Medidas em aspectos específicos do projeto:

O Comitê Diretor do Funders forneceu orientação sobre o financiamento e os recursos do projeto, um Painel de especialistas selecionados de especialistas em área de conteúdo reconhecidos a nível nacional em áreas de planejamento urbano, ambiente construído, prevenção de obesidade, nutrição e atividade física, auxiliados na seleção das estratégias e medidas recomendadas; um grupo de trabalho CDC composto por representantes de divisões múltiplas de CDC forneceu contribuições para identificação, nomeação e seleção das estratégias recomendadas; um grupo de especialistas em medição analisou as medidas selecionadas para obter precisão técnica em sua estrutura, fraseão e conteúdo; Os especialistas do governo local forneceram conhecimento de gestão, recursos e perspectivas da cidade sobre a utilidade, viabilidade e viabilidade das estratégias e medidas para a capacidade e necessidades do governo local; e os Conselheiros Técnicos do CDC forneceram orientação sobre o projeto e protocolo do projeto.

Etapa 1: Identificação estratégica.

Para identificar possíveis estratégias ambientais e de nível político para a prevenção da obesidade, a equipe do Projeto Medidas pesquisou PubMed para revisões e metanálises publicadas durante o 1º de janeiro de 2005 - 3 de julho de 2007 usando os seguintes termos de pesquisa:

("nutrição" ou "alimento") E ("comunidade" ou "ambiente" ou "política") E ("obesidade" ou "excesso de peso" ou "doença crônica") e ("atividade física" ou "exercício") E ("comunidade" ou "ambiente" ou "política") E ("obesidade" ou "excesso de peso" ou "doença crônica").

A equipe do Projeto Medidas realizou uma pesquisa bibliográfica durante um período de publicação relativamente curto (2 anos), pois as análises e meta-análises foram supostas para conter e resumir a pesquisa que foi publicada antes de 2005. A pesquisa PubMed cedeu 270 artigos. Com base em uma revisão preliminar, 176 artigos foram considerados inadequados porque não se concentraram em mudanças ambientais ou de nível político, resultando em um total de 94 artigos. Sete relatórios adicionais e estudos reconhecidos como "documentos seminais" também foram recomendados para inclusão (8,10-15). A Equipe do Projeto Medidas completou uma revisão completa dos 94 artigos e sete documentos seminais, resultando na identificação de 791 estratégias potenciais de prevenção da obesidade. Estratégias semelhantes e sobrepostas foram colapsadas, resultando em um total final de 179 estratégias ambientais ou políticas para a prevenção da obesidade.

Passo 2: Priorização e seleção de estratégias.

Para auxiliar na priorização das 179 estratégias identificadas na pesquisa bibliográfica, a equipe do Projeto Medidas desenvolveu um conjunto de critérios de classificação estratégica com base nos esforços de projetos similares (16-21). Através de uma pesquisa on-line, os membros do Painel de especialistas selecionados classificaram cada estratégia de prevenção da obesidade nos seguintes critérios: alcance, mutabilidade, transferibilidade, tamanho de efeito potencial e sustentabilidade do impacto sobre a saúde (Caixa 1).

O Painel de Seleção de Peritos se reuniu para discutir e classificar a classificação das estratégias com base nos resultados da pesquisa on-line. O Painel identificou 47 estratégias como as mais promissoras, incluindo 26 estratégias de nutrição, 17 estratégias de atividade física e outras quatro estratégias relacionadas à obesidade. Em seguida, o Grupo de Trabalho CDC se reuniu para analisar as estratégias de uma perspectiva de saúde pública, o que resultou na seleção de 46 estratégias. A equipe do Projeto Medidas identificou 22 estratégias de nível político e ambiental que receberam a maior prioridade para a prevenção da obesidade no nível da comunidade. Além disso, foram adicionadas três estratégias para serem consistentes com o Programa de Nutrição e Atividades Físicas baseado em Estado do CDC para Prevenir a Obesidade. Uma estratégia adicional foi adicionada com base em pareceres de especialistas que apoiam a necessidade de políticas exploratórias e estratégias ambientais que considerem os sistemas alimentares locais e a produção, aquisição e distribuição de alimentos mais saudáveis ​​para consumo comunitário. Um total de 26 estratégias ambientais e políticas para a prevenção da obesidade foram selecionadas para avançar para a indicação de medição e fase de seleção do processo do projeto.

Passo 3: resumo.

Depois que as 26 estratégias foram selecionadas, a equipe do Projeto Medidas criou um resumo para cada estratégia que incluiu uma visão geral da estratégia, um resumo das evidências disponíveis em apoio à estratégia e as medidas potenciais que foram usadas para avaliar a estratégia conforme descrito na literatura. Quando disponível, os resumos também incluíam exemplos de como a estratégia foi usada pelas comunidades locais.

Etapa 4: nomeação e seleção de medidas.

Especialistas em área de conteúdo especializados em nutrição, atividade física e outros comportamentos relacionados à obesidade ajudaram a equipe do Projeto de Medidas na seleção de medidas potenciais que as comunidades podem usar para avaliar as estratégias recomendadas de prevenção da obesidade. Três pessoas foram designadas para cada estratégia de acordo com sua área de especialização. Cada grupo de três pessoas incluiu pelo menos um membro do CDC Workgroup e um membro externo do Select Panel; Para muitas estratégias, um especialista do governo local recrutado pela ICMA também participou. Os especialistas analisaram o resumo da estratégia e nomearam até três medições potenciais por estratégia. Os especialistas também classificaram cada medida como alta, média ou baixa para três critérios: utilidade, validade de construção e viabilidade (caixa 2).

Depois que as medidas potenciais foram nomeadas, os especialistas foram convocados por teleconferência para selecionar uma medida de primeira e segunda escolha para essa estratégia. Cada medida indicada foi discutida brevemente, e os especialistas tiveram a oportunidade de refinar a medida ou criar uma nova medida antes de votar nas medidas de primeira e segunda escolha. Após as teleconferências, a equipe do Projeto Medidas analisou as medidas de primeira e segunda escolha propostas para garantir que fossem viáveis ​​para que os governos locais coletissem e que o uso de definições e formulação fosse consistente.

Em seguida, um painel de seis especialistas em medição (dois de CDC, dois do Painel de Especialista Selecionado e dois do ICMA), especializado em desenvolvimento e avaliação de medições, analisou as medidas de utilidade, validade de construção e viabilidade e forneceu sugestões de melhoria. A Equipe do Projeto de Medidas analisou as sugestões dos especialistas em medidas e fez pequenas modificações nas medições com base em seus comentários. Nenhuma das preocupações levantadas pelos especialistas em medidas justificou a exclusão de qualquer das medidas de primeira escolha. Duas mudanças adicionais foram feitas depois de uma nova revisão pela equipe do Projeto de Medidas e uma revisão técnica pela Divisão de Nutrição, Atividade Física e Obesidade do CDC: 1) a medida de primeira escolha para a estratégia de segurança pessoal foi substituída pela medição de segunda escolha que se concentrou mais apropriadamente na avaliação de mudanças ambientais e de políticas; e 2) duas estratégias de preços semelhantes para alimentos e bebidas mais saudáveis ​​e para frutas e vegetais foram mescladas. Isso resultou em um total de 25 estratégias recomendadas e uma medida sugerida correspondente para cada estratégia.

Passo 5: teste piloto e revisões finais.

Vinte representantes do governo local, incluindo gerentes da cidade, planejadores urbanos e analistas orçamentários, que participam do Centro de Medição do Desempenho (CPM) da ICMA, se ofereceram para testar as medidas selecionadas. Para limitar o ônus do teste piloto para os participantes individuais dos governos locais, as comunidades foram divididas em três grupos, cada um dos quais incluiu uma mistura de comunidades pequenas, médias e grandes. A cada grupo foi atribuída oito ou nove medidas relativas à nutrição e à atividade física. Além disso, os participantes do governo local também foram convidados a fornecer feedback geral sobre sua capacidade de relatório sobre cada medida, o nível de esforço necessário para reunir os dados necessários e a utilidade percebida de cada medida. Também foram obtidas informações demográficas para comparar as respostas e o feedback entre comunidades de tamanho e população semelhantes. As comunidades receberam 6 semanas para completar o teste piloto. As respostas e os comentários do teste piloto foram resumidos pelo ICMA e serviram de base às discussões em uma reunião de usuário final realizada em janeiro de 2009.

A reunião do usuário final foi facilitada pela equipe do Projeto de Medidas e contou com a presença de representantes do governo local que testaram as medidas, membros do Painel de Especialistas Selecionados e especialistas em conteúdo e medição de CDC. Os resultados do teste piloto foram apresentados na reunião; A resposta geral foi positiva. Foram identificados vários desafios associados à resposta às medidas e sugestões de melhoria, pelo que foram feitas pequenas modificações e esclarecimentos em 13 medições. Três medidas foram modificadas para incluir locais adicionais para coleta de dados, como escolas ou instalações governamentais locais. Além disso, foram feitas quatro mudanças substanciais para as medidas: 1) a medida relacionada à localização da escola foi alterada para se concentrar mais na avaliação das mudanças ambientais e políticas; 2) o foco da medida relacionada ao aumento da segurança pessoal nas áreas em que as pessoas são fisicamente ativas foi alterado da iluminação pública para edifícios vagas, que os especialistas acreditavam ser um indicador mais significativo da segurança pessoal; 3) a medida relacionada ao aumento da disponibilidade de supermercados, incluindo lojas de supermercado de serviço completo, foi modificada para se concentrar no número de lojas localizadas em setores censitários desatendidos e não na porcentagem de supermercados a uma curta distância de uma parada de trânsito; e 4) a medida relacionada ao aumento da acessibilidade de alimentos e bebidas mais saudáveis ​​foi combinada e substituída pela medição relacionada às estratégias de preços. Essas modificações resultaram em um total de 24 estratégias recomendadas de prevenção da obesidade ambiental e política e sua correspondente medida sugerida (Tabela).

As estratégias recomendadas e as medidas sugeridas correspondentes são agrupadas em seis categorias; Para cada estratégia, é fornecido um resumo que inclui uma visão geral da estratégia, seguido de um resumo da evidência que apóia a estratégia e as medidas sugeridas correspondentes para a estratégia. Os termos-chave usados ​​ao longo deste relatório foram definidos separadamente (ver Apêndice para uma listagem completa desses termos). As comunidades que desejam adotar essas recomendações do CDC e informar sobre essas medidas sugeridas devem se referir ao guia detalhado de implementação e medição, que inclui protocolos de dados de medição, exemplos de nível comunitário e recursos úteis para a implementação da estratégia; Este guia está disponível em: cdc. gov/nccdphp/dnpao/publications/index. html.

Estratégias e medidas recomendadas para prevenir a obesidade.

Estratégias para promover a disponibilidade de alimentos e bebidas saudáveis ​​acessíveis.

Para que as pessoas façam escolhas saudáveis, as opções de alimentos saudáveis ​​devem estar disponíveis e acessíveis. As famílias que vivem em bairros de baixa renda e minorias muitas vezes têm menos acesso a opções mais saudáveis ​​de alimentos e bebidas do que as de áreas de maior renda. Cada uma das seguintes seis estratégias visa aumentar a disponibilidade de escolhas saudáveis ​​de alimentos e bebidas, particularmente em áreas desatendidas.

1. As comunidades devem aumentar a disponibilidade de opções mais saudáveis ​​de alimentos e bebidas em locais de serviço público.

A disponibilidade limitada de opções mais saudáveis ​​de alimentos e bebidas pode ser um obstáculo para a alimentação e o consumo saudáveis. Escolhas mais saudáveis ​​de alimentos e bebidas incluem, mas não estão limitados a, alimentos e bebidas densas de baixa energia com baixo teor de açúcar, gordura e sódio (11). As escolas são um local importante para aumentar a disponibilidade de alimentos e bebidas saudáveis ​​para crianças. Outros locais de serviço público posicionados para influenciar a disponibilidade de alimentos mais saudáveis ​​incluem programas extracurriculares, centros de assistência à infância, instalações recreativas comunitárias (por exemplo, parques, playgrounds e piscinas), edifícios de cidades e condados, prisões e centros de detenção juvenil. Melhorar a disponibilidade de opções mais saudáveis ​​de alimentos e bebidas (por exemplo, frutas, vegetais e água) pode aumentar o consumo de alimentos saudáveis.

O Guia Comunitário do CDC apresenta evidências insuficientes para determinar a eficácia das iniciativas de nutrição escolar multicomponente projetadas para aumentar a ingestão de frutas e vegetais e diminuir a ingestão de gordura e gordura saturada entre crianças em idade escolar (22,23). No entanto, análises de pesquisa sistemática relataram associação entre a disponibilidade de frutas e vegetais e o aumento do consumo (24,25). Os programas de barra de saladas de fazenda para escola, que produzem produtos de fazendas locais para escolas, mostraram aumentar o consumo de frutas e vegetais entre estudantes (12). Um estudo de controle randomizado de 2 anos de uma intervenção ambiental baseada na escola que aumentou a disponibilidade de alimentos com baixo teor de gordura nas áreas à la carte da cafeteria indicou que as vendas de alimentos com baixo teor de gordura aumentaram entre adolescentes atendidos em escolas expostas à intervenção (26).

Existe uma política para aplicar padrões nutricionais consistentes com as Diretrizes Dietéticas para os americanos (27) para todos os alimentos vendidos (por exemplo, menus de refeições e máquinas de venda automática) dentro das instalações do governo local em uma jurisdição local ou em campus de escolas públicas durante o dia escolar dentro o maior distrito escolar em uma jurisdição local.

Esta medida capta se os governos locais e / ou as escolas públicas estão aplicando padrões nutricionais consistentes com as Diretrizes Dietéticas para os americanos com alimentos vendidos em instalações do governo local e / ou escolas públicas (27). As comunidades que não usam as Diretrizes Dietéticas para os americanos ainda podem atender aos critérios de medição se seguirem outros padrões que são semelhantes ou mais fortes que os padrões nacionais.

2. As comunidades devem melhorar a disponibilidade de alternativas de alimentos e bebidas mais acessíveis em locais de serviços públicos.

Os alimentos mais saudáveis ​​geralmente são mais caros do que alimentos menos saudáveis ​​(28), o que pode representar uma barreira significativa para a compra e consumo de alimentos mais saudáveis, particularmente para os consumidores de baixa renda. Alimentos e bebidas mais saudáveis ​​incluem, mas não estão limitados a, alimentos e bebidas com baixa densidade de energia e baixo teor de calorias, açúcares, gorduras e sódio (11). As escolhas mais saudáveis ​​de alimentos e bebidas precisam estar disponíveis e acessíveis para que as pessoas as consumam.

Estratégias para melhorar a acessibilidade de alimentos e bebidas mais saudáveis ​​incluem a redução dos preços dos alimentos e bebidas mais saudáveis ​​e o fornecimento de cupons de desconto, vales que podem ser resgatados por alimentos mais saudáveis ​​e bônus vinculados à compra de alimentos saudáveis. As estratégias de preços criam incentivos para comprar e consumir alimentos e bebidas mais saudáveis, reduzindo os preços desses itens em relação a alimentos menos saudáveis. As estratégias de preços que podem ser aplicadas em locais de serviço público (por exemplo, escolas e centros recreativos) incluem, entre outras, a diminuição dos preços dos alimentos mais saudáveis ​​vendidos em máquinas de venda automática e nas cafeterias e aumentando o preço de alimentos e bebidas menos saudáveis ​​em stands de concessão.

A pesquisa demonstrou que reduzir o custo de alimentos saudáveis ​​aumenta a compra de alimentos saudáveis ​​(29,30). Por exemplo, um estudo indicou que as vendas de frutas e cenouras nas cafeterias da escola secundária aumentaram após os preços serem reduzidos (31). Além disso, as intervenções que reduziram o preço de petiscos saudáveis ​​e com baixo teor de gordura nas máquinas de venda automática na escola e no ambiente de trabalho demonstraram aumentar a compra de lanches mais saudáveis ​​(32,33). Um estudo recente estimou que uma redução de preço de 10% em frutas e vegetais incentivaria as pessoas de baixa renda a aumentar seu consumo diário de frutas de 0,96 xícara para 0,98-1,1 xícaras e aumentar o consumo diário de legumes de 1,43 xícaras para 1,46- -1,50 xícaras, em comparação com as 1,80 xícaras recomendadas de frutas e 2,60 xícaras de vegetais (34).

Além disso, as intervenções que fornecem cupões canjeáveis ​​para alimentos mais saudáveis ​​e bonos ligados à compra de alimentos saudáveis ​​aumentam a compra e o consumo de alimentos saudáveis ​​em diversas populações, incluindo estudantes universitários, receptores de serviços do Programa de Nutrição Suplementar para Mulheres, Bebês e Crianças ( WIC) e idosos de baixa renda (35-37). Por exemplo, uma intervenção baseada na comunidade indicou que os beneficiários de WIC que receberam vouchers semanais de US $ 10 para produtos frescos aumentaram o consumo de frutas e vegetais em comparação com um grupo de controle e sofreram o aumento 6 meses após a intervenção (38).

A policy exists to affect the cost of healthier foods and beverages (as defined by IOM [ 11 ]) relative to the cost of less healthy foods and beverages sold within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.

This measurement captures pricing policies that promote the purchase of healthier foods and beverages sold in local government facilities and public schools. Efforts to affect the relative cost of healthier food relative to the cost of less healthy foods can include increasing the cost of less healthy foods and beverages, setting a lower profit margin on healthier foods and beverages, or taking other actions that result in healthier foods and beverages being less expensive than (or at least no more expensive than) less healthy foods and beverages. The goal of such a policy would be to eliminate cost disincentives or provide cost incentives for the purchase of healthier foods and beverages.

3. Communities Should Improve Geographic Availability of Supermarkets in Underserved Areas.

Supermarkets and full-service grocery stores have a larger selection of healthy food (e. g., fruits and vegetables) at lower prices compared with smaller grocery stores and convenience stores. However, research suggests that low-income, minority, and rural communities have fewer supermarkets as compared with more affluent areas ( 39,40 ). Increasing the number of supermarkets in areas where they are unavailable or where availability is limited is might increase access to healthy foods, particularly for economically disadvantaged populations.

Greater access to nearby supermarkets is associated with healthier eating behaviors ( 39 ). For example, a cross-sectional study of approximately 10,000 participants indicated that blacks living in neighborhoods with at least one supermarket were more likely to consume the recommended amount of fruits and vegetables than blacks living in neighborhoods without supermarkets. Further, blacks consumed 32% more fruits and vegetables for each additional supermarket located in their census tract ( 41 ). Another study indicated that increasing the number of supermarkets in underserved neighbors increased real estate values, increased economic activity and employment, and resulted in lower food prices ( 42 ).

One cross-sectional study linked height and weight data from approximately 70,000 adolescents to data on food store availability ( 43 ). The results indicated that, after controlling for socioeconomic status, greater availability of supermarkets was associated with lower adolescent BMI scores and that a higher prevalence of convenience stores was related to higher BMI among students. The association between supermarket availability and weight was stronger for black students and for students whose mothers worked full-time ( 43 ).

The number of full-service grocery stores and supermarkets per 10,000 residents located within the three largest underserved census tracts within a local jurisdiction.

This measurement examines the availability of full-service grocery stores and supermarkets in underserved areas. Given that research has shown that low-income, minority communities tend to have fewer grocery stores than other areas, underserved areas are defined geographically for the purpose of this measurement as census tracts with higher percentages of low-income and/or high minority populations. Because some jurisdictions have numerous census tracts that meet the underserved criteria, the measurement limits the assessment to the three largest (i. e., those with the largest population) underserved census tracts within a local jurisdiction for the purpose of community cross-comparisons. The measurement is expected to illuminate areas that lack a sufficient number of full-service grocery stores and supermarkets to serve the population in those areas. Although no standard benchmark exists for this measurement, data collected local governments reporting on this measurement can lead to establishment of a standard.

4. Communities Should Provide Incentives to Food Retailers to Locate in and/or Offer Healthier Food and Beverage Choices in Underserved Areas.

Healthier foods and beverages include but are not limited to foods and beverages with low energy density and low calorie, sugar, fat, and sodium content as defined by IOM ( 11 ). Disparities in the availability of healthier foods and beverages between communities with different income levels, ethnic composition, and other characteristics are well documented, and limited availability of healthier food and beverage choices in underserved communities constitutes a substantial barrier to improving nutrition and preventing obesity ( 41 ).

To address this issue, communities can provide incentives to food retailers (e. g., supermarkets, grocery stores, convenience and corner stores, and street vendors) to offer a greater variety of healthier food and beverage choices in underserved areas. Such incentives, both financial and nonfinancial, can be offered to encourage opening new retail outlets in areas with limited shopping options, and existing corner and convenience stores (which typically depend on sales of alcohol, tobacco, and sugar-sweetened beverages) into neighborhood groceries selling healthier foods ( 44 ). Financial incentives include but are not limited to tax benefits and discounts, loans, loan guarantees, and grants to cover start-up and investment costs (e. g., improving refrigeration and warehouse capacity). Nonfinancial incentives include supportive zoning, and increasing the capacity of small businesses through technical assistance in starting up and maintaining sales of healthier foods and beverages.

The presence of retail venues that provide healthier foods and beverages is associated with better nutrition. Cross-sectional studies indicate that the presence of retail venues offering healthier food and beverage choices is associated with increased consumption of fruits and vegetables and lower BMI ( 45 ). One study indicated that every additional supermarket within a given census tract was associated with a 32% increase in the amount of fruits and vegetables consumed by persons living in that census tract ( 40 ). Another study indicated that greater availability of supermarkets was associated with lower adolescent BMI scores and a higher prevalence of convenience stores was related to higher BMI among students ( 43 ). The association between supermarket availability and weight was stronger for black students compared with white and Hispanic students, and stronger for students whose mothers work full-time compared with those whose mothers work part-time or do not work ( 43 ).

Local government offers at least one incentive to new and/or existing food retailers to offer healthier food and beverage choices as defined by IOM ( 11 ) in underserved areas.

This measurement assesses a wide range of incentives, both financial and nonfinancial, that local jurisdictions offer to food retailers to encourage the availability of healthier food and beverage choices in underserved areas. For the purpose of this measurement underserved areas are those identified by communities as having limited food retail outlets, and the available outlets (e. g., convenience stores and liquor stores) tend not to offer many healthy foods and beverages. The measurement is designed to capture incentives designed to entice new healthy food retailers to locate in underserved areas and to encourage existing food retailers to expand their selection of healthier food and beverage choices. The measurement does not prescribe the incentives that a local government should offer but rather assesses whether a local government is making an effort to improve the availability of healthier food and beverage choices in underserved areas.

5. Communities Should Improve Availability of Mechanisms for Purchasing Foods from Farms.

Mechanisms for purchasing food directly from farms include farmers' markets, farm stands, community-supported agriculture, "pick your own," and farm-to-school initiatives. Experts suggest that these mechanisms have the potential to increase opportunities to consume healthier foods, such as fresh fruits and vegetables, by possibly reducing costs of fresh foods through direct sales; making fresh foods available in areas without supermarkets; and harvesting fruits and vegetables at ripeness rather than at a time conducive to shipping, which might improve their nutritional value and taste (M. Hamm, PhD, Michigan State University, personal communication, 2008).

Evidence supporting a direct link between purchasing foods from farms and improved diet is limited. Two studies of initiatives to encourage participation in the Seniors Farmers' Market Nutrition Program ( 46 ) and the WIC Farmers' Market Nutrition Program ( 47 ) report either increased intention to eat more fruits and vegetables or increased utilization of the program; however, neither study reported direct evidence that the programs resulted in increased consumption of fruits and vegetables. The Farmers' Market Salad Bar Program in the Santa Monica--Malibu Unified School District aims to increase students' consumption of fresh fruits and vegetables and to support local farmers by purchasing produce directly from local farmers' markets and serving them in the district's school lunch program. An evaluation of the program over a 2-year period demonstrated that 30%--50% of students chose the salad bar on any given day ( 48 ). Access to farm foods varies between agricultural and metropolitan areas.

The total annual number of farmer-days at farmers' markets per 10,000 residents within a local jurisdiction.

This measurement assesses opportunities to sell and purchase food from local farms based on the number of days per year that farmers' markets are open and the number of farm vendors that sell food at those outlets. Although farmers' markets are only one mechanism for purchasing food from farms, they are considered by experts to be strong proxies of other, less common ways to purchase food from local farms, such as community-supported agriculture and "pick your own" programs. Information on farmer-days is collected on an ongoing basis by the managers of farmers' markets. The process of gathering information for this measurement might encourage more interaction between local governments and farmers' markets and individual farmers, which could spur more local initiatives to support local food production and purchasing food from local farms. Although no estimated standard exists for this measurement, data collected from local governments reporting on this measurement can lead to establishment of a standard.

6. Communities Should Provide Incentives for the Production, Distribution, and Procurement of Foods from Local Farms.

Currently the United States is not producing enough fruits, vegetables, whole grains, and dairy products for all U. S. citizens to eat the quantities of these foods recommended by the USDA Dietary Guidelines for Americans ( 27,49 ). Providing incentives to encourage the production, distribution, and procurement of food from local farms aims might increase the availability and consumption of locally produced foods by community residents, enhance the ability of the food system to provide sufficient quantities of healthier foods, and increase the viability of local farms and food security for communities (M. Hamm, PhD, Michigan State University, personal communication, 2008). Definitions of "local" vary by place and context but may include the area of the foodshed (i. e. a geographic area that supplies a population center with food), food grown within a day's driving distance of the place of sale, or a smaller area such as a city and its surroundings. Incentives to encourage local food production can include forming grower cooperatives, instituting revolving loan funds, and building markets for local farm products through economic development and through collaborations with the Cooperative Extension Service ( 50 ). Additional incentives include but are not limited to farmland preservation, marketing of local crops, zoning variances, subsidies, streamlined license and permit processes, and the provision of technical assistance.

Evidence suggests that dispersing agricultural production in local areas around the country (e. g., through local farms and urban agriculture) would increase the amount of produce that could be grown and made available to local consumers, improve economic development at the local level ( 51,52 ), and contribute to environmental sustainability ( 53 ). Although no evidence has been published to link local food production and health outcomes, a study has been funded to explore the potential nutritional and health benefits of eating locally grown foods (A. Ammerman, DrPH, University of North Carolina Center for Health Promotion and Disease Prevention, personal communication, 2009).

Local government has a policy that encourages the production, distribution, or procurement of food from local farms in the local jurisdiction.

This measurement captures local policies, as well as state - and federal-level policies that apply to a local jurisdiction and aim to encourage the production, distribution, and procurement of food from local farms. The measurement does not specify the content of relevant policies so that all policies designed to increase the production, distribution, and consumption of food from local farms may be included in the measure.

Strategies to Support Healthy Food and Beverage Choices.

Even when healthy food options are available, children and families often remain inundated with unhealthy food and beverage choices promoted by television advertisements and print media. In addition, unhealthy foods typically cost less than healthy foods, providing further economic incentives for their purchase and consumption. Each of the following four strategies aims to encourage consumers to make healthier choices by limiting exposure and access to less healthy food and beverage options.

7. Communities Should Restrict Availability of Less Healthy Foods and Beverages in Public Service Venues.

Less healthy foods and beverages include foods and beverages with a high calorie, fat, sugar, and sodium content, and a low nutrient content. Less healthy foods are more available than healthier foods in U. S. schools ( 54 ). The availability of less healthy foods in schools is inversely associated with fruit and vegetable consumption and is positively associated with fat intake among students ( 55 ). Therefore, restricting access to unhealthy food options is one component of a comprehensive plan for better nutrition.

Schools can restrict the availability of less healthy foods by setting standards for the types of foods sold, restricting access to vending machines, banning snack foods and food as rewards in classrooms, prohibiting food sales at certain times of the school day, or changing the locations where unhealthy competitive foods are sold. Other public service venues that could also restrict the availability of less healthy foods include after-school programs, regulated child care centers, community recreational facilities (e. g., parks, recreation centers, playgrounds, and swimming pools), city and county buildings, and prisons and juvenile detention centers.

No peer-reviewed studies were identified that examined the impact of interventions designed to restrict the availability of less healthy foods in public service venues. Federal nutritional guidelines prohibit the sale of foods of "minimal nutritional value" in school cafeterias while meals are being served. However, the guidelines currently do not prevent or restrict the sale of these foods in vending machines near the cafeteria or in other school locations ( 11 ). Certain states and school districts have developed more restrictive policies regarding competitive foods; 21 states have policies that restrict the sale of competitive foods beyond USDA regulations ( 56 ). However, no studies were identified that examined the impact of the policies in those states on student eating behavior.

A policy exists that prohibits the sale of less healthy foods and beverages (as defined by IOM [ 11 ]) within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.

This measurement captures all policies designed to restrict the availability of less healthy foods and beverages sold in local government facilities and in public schools.

8. Communities Should Institute Smaller Portion Size Options in Public Service Venues.

Portion size can be defined as the amount (e. g. weight, calorie content, or volume) of a single food item served in a single eating occasion (e. g. a meal or a snack), such as the amount offered to a person in a restaurant, in the packaging of prepared foods, or the amount a person chooses to put on his or her plate ( 23 ). Controlling portion size is important because research has demonstrated that persons often either 1) do not notice differences in portion sizes and unknowingly eat larger amounts when presented with a larger portion or 2) when eating larger portions, do not consume fewer calories at subsequent meals or during the rest of the day ( 57 ).

Evidence is lacking to demonstrate the effectiveness of population-based interventions aimed at reducing portion sizes in public service venues. However, evidence from clinical studies conducted in laboratory settings demonstrates that decreasing portion size decreases energy intake ( 58--60 ). This finding holds across a wide variety of foods and different types of portions (e. g., portions served on a plate, sandwiches, or prepackaged foods such as potato chips). Clinical studies conducted in nonlaboratory settings demonstrate that increased portion size leads to increased energy intake ( 61,62 ). The majority of studies that evaluated the impact of portion size on nutritional outcomes were short term, producing little evidence regarding the long-term impact of portion size on eating patterns, nutrition, and obesity ( 23 ). Intervention studies are underway that evaluate the impact of limiting portion size, combined with other strategies to prevent obesity in workplaces ( 63 ).

Local government has a policy to limit the portion size of any entree (including sandwiches and entrée salads) by either reducing the standard portion size of entrees or offering smaller portion sizes in addition to standard portion sizes within local government facilities within a local jurisdiction.

This measurement captures local government policies that aim to limit or reduce the portion size of entrées served in local government facilities. This measurement is limited to local government facilities, which represent only a small portion of the total landscape of food service venues but are within the influence of local jurisdictions. This measurement might prompt communities to consider policies that limit the portion size of entrees served in facilities that are owned and operated within a local jurisdiction.

9. Communities Should Limit Advertisements of Less Healthy Foods and Beverages.

Research has demonstrated that more than half of television advertisements viewed by children and adolescents are food-related; the majority of them promote fast foods, snack foods, sweets, sugar-sweetened beverage products, and other less healthy foods that are easily purchased by youths ( 11 ). In 2006, major food and beverage marketers spent $1.6 billion to promote food and beverage products among children and adolescents in the United States ( 64 ). Television advertising has been determined to influence children to prefer and request high-calorie and low-nutrient foods and beverages and influences short-term consumption among children aged 2--11 years ( 65 ). Therefore, limiting advertisements of less healthy foods might decrease the purchase and consumption of such products. Legislation to limit advertising of less healthy foods and beverages usually is introduced at the federal or state level. However, local governing bodies, such as district level school boards, might have the authority to limit advertisements of less healthy foods and beverages in areas within their jurisdiction ( 9 ).

Little evidence is available regarding the impact of restricting advertising on purchasing and consumption of less healthy foods ( 11,22,66,67 ). However, cross-sectional time-series studies of tobacco-control efforts suggest that an association exists between advertising bans and decreased tobacco consumption ( 22,68 ). One study estimated that a ban on fast-food advertising on children's television programs could reduce the number of overweight children aged 3--11 years by 18% and the number of overweight adolescents aged 12--18 years by 14% ( 69 ). Limited bans of advertising, which include some media but not others (e. g., television but not newspapers), might have little or no effect as the food and beverage industry might redirect its advertising efforts to media not included in the ban, thus limiting researchers' ability to detect causal effects ( 68 ).

A policy exists that limits advertising and promotion of less healthy foods and beverages, as defined by IOM ( 11 ), within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.

This measurement captures policies that prohibit advertising and promotion of less healthy foods and beverages within local government facilities and in schools. Although local government facilities and schools represent only a limited portion of the total advertising landscape, the chosen venue is within the influence of local jurisdictions. This measurement might prompt communities to consider policies that prohibit advertising and promotion of less healthy foods and beverages.

10. Communities Should Discourage Consumption of Sugar-Sweetened Beverages.

Consumption of sugar-sweetened beverages (e. g., carbonated soft drinks, sports drinks, flavored sweetened milk, and fruit drinks) among children and adolescents has increased dramatically since the 1970s and is associated with higher daily caloric intake and greater risk of obesity ( 70 ). Although consumption of sugar-sweetened beverages occurs most often in the home, schools and child care centers also contribute to the problem either by serving sugar-sweetened beverages or by allowing children to purchase sugar-sweetened beverages from vending machines ( 70 ). Policies that restrict the availability of sugar-sweetened beverages and 100% fruit juice in schools and child care centers might discourage the consumption of high-caloric beverages among children and adolescents.

One longitudinal study of a school-based environmental intervention conducted among Native American high school students that combined education to decrease the consumption of sugar-sweetened beverages and increase knowledge of diabetes risk factors with the development of a youth-oriented fitness center demonstrated a substantial reduction in consumption of sugar-sweetened beverages for a 3-year period ( 71 ). A randomized control study of a home-based environmental intervention that eliminated sugar-sweetened beverages from the homes of a diverse group of adolescents demonstrated that, among heavier adolescents, the intervention resulted in significantly (p = 0.03) greater reduction in BMI scores compared with the control group ( 72 ).

Licensed child care facilities within the local jurisdiction are required to ban sugar-sweetened beverages (including flavored/sweetened milk) and limit the portion size of 100% juice.

This measurement captures local and state level policies that aim to limit the availability of sugar-sweetened beverages for young children attending licensed child care facilities. Policies (at either the local or state level) should address both parts of the measurement. Restricting the availability of sugar-sweetened beverages in school settings has been discussed previously (see Communities Should Restrict Availability of Less Healthy Foods and Beverages in Public Service Venues).

Strategy to Encourage Breastfeeding.

Breastfeeding has been linked to decreased risk of pediatric overweight in multiple epidemiologic studies. Despite this evidence, many mothers never initiate breastfeeding and others discontinue breastfeeding earlier than needed. The following strategy aims to increase overall support for breastfeeding so that mothers are able to initiate and continue optimal breastfeeding practices.

11. Communities Should Increase Support for Breastfeeding.

Exclusive breastfeeding is recommended for the first 4--6 months of life, and breastfeeding together with the age-appropriate introduction of complementary foods is encouraged for the first year of life. Epidemiologic data suggest that breastfeeding provides a limited degree of protection against childhood obesity, although the reasons for this association are not clear ( 11 ). Breastfeeding is thought to promote an infant's ability to self regulate energy intake, thereby allowing him or her to eat in response to internal hunger and satiety cues ( 73 ). Some research suggests that the metabolic/hormonal cues provided by breastmilk contribute to the protective association between breastfeeding and childhood obesity ( 74 ). Despite the many advantages of breastfeeding, many women choose to bottle-feed their babies for a variety of reasons, including social and structural barriers to breastfeeding, such as attitudes and policies regarding breastfeeding in health-care settings and public and work places ( 75 ).

Breastfeeding support programs aim to increase the initiation and exclusivity rate of breastfeeding and to extend the duration of breastfeeding. Such programs include a variety of interventions in hospitals and workplaces (e. g., setting up breastfeeding facilities, creating a flexible work environment that allows breastfed infants to be brought to work, providing onsite child care services, and providing paid maternity leaves), and maternity care (e. g., polices and staff training programs that promote early breastfeeding initiation, restricting the availability of supplements or pacifiers, and providing facilities that accommodate mothers and babies). The CDC Guide to Breastfeeding Interventions identifies the following general areas of interventions and programs as effective in supporting breastfeeding: 1) maternity care practices, 2) support for breastfeeding in the workplace, 3) peer support, 4) educating mothers, 5) professional support, and 6) media and community-wide campaigns ( 76 ).

Evidence directly linking environmental interventions that support breastfeeding with obesity-related outcomes is lacking. However, systematic reviews of epidemiologic studies indicate that breastfeeding helps prevent pediatric obesity: breastfed infants were 13%--22% less likely to be obese than formula-fed infants ( 77,78 ), and each additional month of breastfeeding was associated with a 4% decrease in the risk of obesity ( 79 ). Furthermore, one study demonstrated that infants fed with low (<20% of feedings from breastmilk) and medium (20%--80% of feedings from breastmilk) breastfeeding intensity were at least twice as likely to have excess weight from 6 to 12 months of infancy compared with infants who were breastfed at high intensity (>80% of feedings from breastmilk) ( 80 ).

Systematic reviews indicate that support programs in health-care settings are effective in increasing rates of breastfeeding initiation and in preventing early cessation of breastfeeding. Training medical personnel and lay volunteers to promote breastfeeding decreases the risk for early cessation of breastfeeding by 10% ( 81 ) and that education programs increase the likelihood of the initiation of breastfeeding among low-income women in the United States by approximately twofold ( 75 ).

One systematic review did not identify any randomized control trials that have tested the effectiveness of workplace-wide interventions promoting breastfeeding among women returning to paid employment ( 82 ). However, one study demonstrated that women who directly breastfed their infant at work and/or pumped breast milk at work breastfed at a higher intensity than women who did not breastfeed or pump breast milk at work ( 83 ). Furthermore, evaluations of individual interventions aimed at supporting breastfeeding in the workplace demonstrate increased initiation rates and duration of breastfeeding compared with national averages ( 76 ).

Local government has a policy requiring local government facilities to provide breastfeeding accommodations for employees that include both time and private space for breastfeeding during working hours.

This measurement captures local policies that support breastfeeding among women who work for local government. Although in most cases infants are not present in the women's place of employment, the policy would require employers to designate time and private space for women to express and store breast milk for later use.

Strategies to Encourage Physical Activity or Limit Sedentary Activity Among Children and Youth.

Children spend much of their day in school or child care facilities; therefore, it is important that a portion of their recommended daily physical activity be achieved in these settings. The first three strategies in this section aim for schools to require daily PE classes, engage children in moderate to vigorous physical activity for at least half of the time spent in these classes, and ensure that children are given opportunities for extracurricular physical activity. The final strategy (strategy 15) aims to reduce the amount of time children spend watching televisions and using computers in licensed child care facilities.

12. Communities Should Require Physical Education in Schools.

This strategy supports the Healthy People 2010 objective (objective no. 22.8) to increase the proportion of the nation's public and private schools that require daily PE for all students ( 15 ). The National Association for Sport and Physical Education (NASPE) and the American Heart Association (AHA) recommend that all elementary school students should participate in >150 minutes per week of PE and that all middle and high school students should participate in >225 minutes of PE per week for the entire school year ( 84 ). School-based PE increases students' level of physical activity and improves physical fitness ( 23 ).

Many states mandate some level of PE in schools: 36 states mandate PE for elementary-school students, 33 states mandate PE for middle-school students, and 42 states mandate PE for high-school students ( 84 ). However, to what extent these requirements are enforced is unclear, and only two states (Louisiana and New Jersey) mandate the recommended >150 minutes per week of PE classes. Potential barriers to implementing PE classes in schools include concerns among school administrators that PE classes compete with traditional academic curricula or might detract from students' academic performance. However, a Community Guide review identified no evidence that time spent in PE classes harms academic performance ( 23 ).

In a systematic review of 14 studies, the Community Guide demonstrated that school-based PE was effective in increasing levels of physical activity and improving physical fitness ( 23 ). The review included studies of interventions that increased the amount of time spent in PE classes, the amount of time students are active during PE classes, or the amount of moderate or vigorous physical activity (MVPA) students engage in during PE classes.

Most studies that correlated school-based PE classes and the physical activity and fitness of students focused on the quality and duration of PE classes (e. g., the amount of physical activity during class, the amount of MVPA) rather than simply whether PE was required. However, requiring that PE classes be taught in schools is a necessary minimum condition for measuring the effectiveness of efforts to improve school-based PE class curricula.

The largest school district located within the local jurisdiction has a policy that requires a minimum of 150 minutes per week of PE in public elementary schools and a minimum of 225 minutes per week of PE in public middle schools and high schools throughout the school year as recommended by the National Association of Sports and Physical Education in 2006 ( 86 ).

This measurement captures whether PE is required in schools, as well as the minimum amount of time required in PE per week by grade level. The measurement specifies distinct standards for elementary and middle/high school levels that are based on NASPE recommendations.

13. Communities Should Increase the Amount of Physical Activity in PE Programs in Schools.

Time spent in PE classes does not necessarily mean that students are physically active during that time. Increasing the amount of physical activity in school-based PE classes has been demonstrated to be effective in increasing fitness among children. Specifically, increasing the amount of time children are physically active in class, increasing the number of children moving as part of a game or activity (e. g., by modifying game rules so that more students are moving at any given time, or by changing activities to those where all participants stay active), and increasing the amount of moderate to vigorous activity during class time are effective strategies for increasing physical activity.

In a review of 14 studies, the Community Guide demonstrated strong evidence of effectiveness for enhancing PE classes taught in school by increasing the amount of time students spend in PE class, the amount of time they are active during PE classes, or the amount of MVPA they engage in during PE classes ( 23 ). The median effect of modifying school PE curricula as recommended was an 8% increase in aerobic fitness among school-aged children. Modifying school PE curricula was effective in increasing physical activity across racial, ethnic, and socioeconomic populations, among males and females, in elementary and high schools, and in urban and rural settings.

A quasi-experimental study of the Sports, Play, and Active Recreation for Kids (SPARK) school PE program, which is designed to maximize participation in physical activity during PE classes, demonstrated that the program increased physical activity during PE classes but the effect did not carry over outside of school ( 85 ). The study identified no significant effects on fitness levels among boys (p = 29--55), but girls in the classes led by a PE specialist were superior in abdominal and cardio respiratory endurance to girls in the control condition (p = 0.03). The Child and Adolescent Trial for Cardiovascular Health (CATCH) is another intervention which aims to increase MVPA in children during PE classes. A randomized, controlled field trail of CATCH that was conducted with more than 5,000 third-grade students from 96 public schools over a 3-year period indicated that the intensity of physical activity in PE classes (class time devoted to MVPA) during the intervention increased significantly in the intervention schools compared with the control schools (p<0.02) ( 86 ).

The background and training of teachers who deliver PE curricula might mediate the effect of interventions on physical activity. For example, one study indicated that SPARK classes led by PE specialists spent more time per week in physical activity (40 minutes) than classes led by regular teachers who had received training in the curriculum (33 minutes) ( 85 ).

The largest school district located within the local jurisdiction has a policy that requires K--12 students to be physically active for at least 50% of time spent in PE classes in public schools.

This measurement assesses whether a school district has a policy that requires at least of 50% of PE classes be devoted to physical activity. The policy needs to apply to all grade levels to meet the measurement criteria.

14. Communities Should Increase Opportunities for Extracurricular Physical Activity.

Opportunities for extracurricular physical activity outside of school hours to complement formal PE increasingly are an important strategy to prevent obesity in children and youth ( 11 ). This strategy focuses on noncompetitive physical activity opportunities such as games and dance classes available through community and after-school programs, and excludes participation in varsity team sports or sport clubs, which require tryouts and are not open to all students. Research has demonstrated that after-school programs that provide opportunities for extracurricular physical activity increase children's level of physical activity and improve other obesity-related outcomes.

Intervention studies have demonstrated that participation in after-school programs that provided opportunities for extracurricular physical activity held both at schools and other community settings increased participants' level of physical activity ( 87,88) and improved obesity-related outcomes, such as improved cardiovascular fitness and reduced body fat content ( 89 ). Two pilot studies demonstrated that providing opportunities for extracurricular physical activity increased levels of physical activity ( 90 ) and decreased sedentary behavior ( 91 ) among participants.

The Promoting Life Activity in Youth (PLAY) program is designed to teach active lifestyle habits to children and help them to accumulate 30--60 minutes of moderate to vigorous physical activity per day. One study indicated that participation in PLAY and PE had a significant impact on physical activity among girls (p<0.001) but not for boys ( 90 ). Lack of access is a barrier that might limit the impact of increased availability of opportunities for extracurricular physical activity. In East Palo Alto, California, where the city provided buses from schools to the community center, 70% of the eligible girls attended dance classes at least 2 days a week. In Oakland, where the city did not provide buses, only 33% of eligible girls attended the class two or more times a week ( 91 ).

The percentage of public schools within the largest school district in a local jurisdiction that allow the use of their athletic facilities by the public during non-school hours on a regular basis.

This measurement captures the percentage of public schools within a community that make their athletic facilities available to the general public during non-school hours. This measurement might prompt communities to open more school athletic facilities to the public.

15. Communities Should Reduce Screen Time in Public Service Venues.

Mechanisms linking extended screen viewing time and obesity include displacement of physical activity; a reduction in metabolic rate and excess energy intake; and increased consumption of food advertised on television as a result of exposure to marketing of high energy dense foods and beverages ( 92,93 ). The American Academy of Pediatrics ( 94 ) recommends that parents limit children's television time to no more than to 2 hours per day. Although only a relatively small portion of television viewing and computer and video game use occurs in public service venues such as schools, day care centers, and after-school programs, local policymakers can intervene to limit screen viewing time among children and youth in these venues.

Long-term cohort studies have demonstrated a positive significant (p = 0.02) association between television viewing in childhood and body mass index levels in adulthood ( 92,93 ). In addition, a cross-sectional study indicated that the amount of time spent watching TV/video was significantly related to overweight among low-income preschool children (p<0.004) ( 95 ). A randomized controlled school-based trial indicated that children who reduced their television, videotape, and video game use had significant decreases in BMI (p = 0.002), tricep skin fold thickness (p = 0.002), and waist circumference (p<0.001) compared with children in control groups ( 96 ). The evidence surrounding children's television viewing and its relationship to physical activity has been somewhat inconsistent. A review evaluating correlates of childhood physical activity determined that some studies find time spent engaged in sedentary activities, specifically TV viewing and video use, has a negative association to physical activity, while other studies find no relationship ( 97 ). Multicomponent school-based intervention studies have demonstrated that spending less time watching television is associated with increased physical activity ( 98 ) and decreased risk of childhood obesity among girls but not boys ( 99 ).

Licensed child care facilities within the local jurisdiction are required to limit screen time to no more than 2 hours per day for children aged ≥2 years.

This measurement captures the presence of either local - or state-level policies aimed at reducing screen viewing time in child care settings. The screen viewing time limits specified by the measurement are based on the recommendations of the American Academy of Pediatrics. For the purpose of this measurement screen viewing time excludes video games that involve physical activity. Otherwise, determination of what constitutes screen viewing time is left to individual jurisdictions.

Strategies to Create Safe Communities That Support Physical Activity.

Certain characteristics of the built environment have been demonstrated to support physical activity. Each of the following eight strategies aims to increase physical activity through changes in the built environment by improving access to places for physical activity such as recreation areas and parks, improving infrastructure to support bicycling and walking, locating schools closer to residential areas to encourage non-motorized travel to and from school, zoning to allow mixed-use areas that combine residential with commercial and institutional uses, improving access to public transportation, and improving personal and traffic safety in areas where persons are or could be physically active.

16. Communities Should Improve Access to Outdoor Recreational Facilities.

Recreation facilities provide space for community members to engage in physical activity and include places such as parks and green space, outdoor sports fields and facilities, walking and biking trails, public pools, and community playgrounds. Accessibility of recreation facilities depends on a number of factors such as proximity to homes or schools, cost, hours of operation, and ease of access. Improving access to recreation facilities and places might increase physical activity among children and adolescents.

In a review based on 10 studies, the Community Guide concluded that efforts to increase access to places for physical activity, when combined with informational outreach, can be effective in increasing physical activity ( 100 ). The studies reviewed by the Community Guide included interventions such as creating walking trails, building exercise facilities, and providing access to existing facilities. However, it was not possible to separate the benefits of improved access to places for physical activity from health education and services that were provided concurrently ( 100 ).

A comprehensive review of 108 studies indicated that access to facilities and programs for recreation near their homes, and time spent outdoors, correlated positively with increased physical activity among children and adolescents ( 97 ). A study that analyzed data from a longitudinal survey of 17,766 adolescents indicated that those who used community recreation centers were significantly more likely to engage in moderate to vigorous physical activity (p≤0.00001) ( 101 ).

A multivariate analysis indicated that self-reported access to a park, and the perception that footpaths are safe for walking were significantly associated with adult respondents being classified as physically active at a level sufficient for health benefits ( 102 ). Another study that used self-report and GIS data concluded that longer distances and the presence of barriers (e. g., busy streets and steep hills) between individuals and bike paths were associated with non-use of bike paths ( 103 ).

The percentage of residential parcels within a local jurisdiction located within a half-mile network distance of at least one outdoor public recreational facility.

This measurement captures the percentage of homes within a local jurisdiction that are within walking distance of an outdoor public recreational facility. Recreational facilities are defined as facilities listed in the jurisdiction's inventory with at least one amenity promoting physical activity (e. g., walking/hiking trail, bicycling trail, open play field/play area). For consistency across jurisdictions, the measurement focuses on the entrance points to outdoor recreational facilities, although many recreational facilities have multiple points of entry.

17. Communities Should Enhance Infrastructure Supporting Bicycling.

Enhancing infrastructure supporting bicycling includes creating bike lanes, shared-use paths, and routes on existing and new roads; and providing bike racks in the vicinity of commercial and other public spaces. Improving bicycling infrastructure can be effective in increasing frequency of cycling for utilitarian purposes (e. g., commuting to work and school, bicycling for errands). Research demonstrates a strong association between bicycling infrastructure and frequency of bicycling.

Longitudinal intervention studies have demonstrated that improving bicycling infrastructure is associated with increased frequency of bicycling ( 104,105 ). Cross-sectional studies indicated a significant association between bicycling infrastructure and frequency of biking (p<0.001) ( 103,106,107 ).

Total miles of designated shared-use paths and bike lanes relative to the total street miles (excluding limited access highways) that are maintained by a local jurisdiction.

This measurement captures the availability of shared-use paths and bike lanes, as defined by the American Association of State Highway and Transportation Officials, relative to the total number of street network miles in a community. The numerator of this measurement includes both shared-use paths and bike lanes. The denominator of this measurement is limited to paved streets that are maintained by city/local government, and excludes limited access highways. Although no estimated standard exists for this measurement, data collected from local governments reporting on this measurement can lead to establishment of a standard.

18. Communities Should Enhance Infrastructure Supporting Walking.

Infrastructure that supports walking includes but is not limited to sidewalks, footpaths, walking trails, and pedestrian crossings. Walking is a regular, moderate-intensity physical activity in which relatively large numbers of persons can engage. Well-developed infrastructure supporting walking is an important element of the built environment and has been demonstrated to be associated with physical activity in adults and children. Interventions aimed at supporting infrastructure for walking are included in street-scale urban design and land use interventions that support physical activity in small geographic areas. These interventions can include improved street lighting, infrastructure projects to increase the safety of street crossings, use of traffic calming approaches (e. g., speed humps and traffic circles), and enhancing street landscaping ( 108 ).

The Community Guide reports sufficient evidence that street-scale urban design and land use policies that support walking are effective in increasing levels of physical activity ( 108 ). Reviews of cross-sectional studies of environmental correlates of physical activity and walking generally find a positive association between infrastructure supportive of walking and physical activity ( 109,110 ). However, some systematic reviews indicated no evidence of an association between the presence of sidewalks and physical activity ( 111 ). Other reviews indicated associations, but only for certain subgroups of subjects (e. g., men and users of longer walking trails) ( 108,109 ). Intervention studies demonstrate effectiveness of enhanced walking infrastructure when combined with other strategies. For example, evaluation of the Marin County Safe Routes to School program indicated that identifying and creating safe routes to school, together with educational components, increased the number of students walking to school ( 105 ). When considering the evidence for this strategy, planners should note that physically active individuals might be more likely to locate in communities that have an existing infrastructure for walking, which might produce spurious correlations in cross-sectional studies ( 109 ).

Total miles of paved sidewalks relative to the total street miles (excluding limited access highways) that are maintained by a local jurisdiction.

This measurement captures the availability of sidewalks in a local jurisdiction relative to the total miles of streets. The measurement does not take into account the continuity of sidewalks between locations. In this measurement total nonhighway street miles are limited to paved streets maintained by and paid for by local government and excludes limited access highways. Although no estimated standard exists for this measurement, data collected from local governments reporting on this measurement can lead to establishment of a standard.

19. Communities Should Support Locating Schools within Easy Walking Distance of Residential Areas.

Walking to and from school has been demonstrated to increase physical activity among children during the commute, leading to increased energy expenditure and potentially to reduced obesity. However, the percentage of students walking to school has dropped dramatically over the past 40 years, partially due to the increased distance between children's homes and schools. Current land use trends and policies pose barriers to building smaller schools located near residential areas. Therefore, requisite activities that support locating schools within easy walking distance of residential areas include efforts to change land use and school system policies.

The Community Guide indicated that community-scale urban design and land use policies and practices, including locating schools, stores, workplaces, and recreation areas close to residential areas, are effective in facilitating an increase in levels of physical activity ( 23,108 ). A simulation modeling study conducted by the U. S. Environmental Protection Agency (EPA) in Florida indicated that school location as well as the quality of the built environment between home and school has an effect on walking and biking to school. Specifically, this combination of school location and built environment quality would produce a 13% increase in nonmotorized travel to school ( 112 ). A cross-sectional study in the Philippines indicated that adolescents who walked to school expended significantly more energy than those who used motorized modes of transport. This association was not explainable by in-school or after-school sports or exercise. Assuming no change takes place in energy intake, the difference in energy expenditure between transport modes would lead to an expected 2--3-pound annual weight gain by youth who commute to school by motorized transport ( 113 ).

As a result of current land use trends and policies regarding school siting, very little work has been done to locate schools within neighborhoods. A study conducted by the Environmental Protection Agency suggests that the trend of building larger schools with larger catchment areas should be reversed to locate schools within neighborhoods ( 112 ). The distance between homes and schools is not the only factor that affects whether children walk to and from school. Among students living within 1 mile of school, the percentage of walkers fell from 90% to 31% between 1969 and 2001 ( 112 ). The decrease in walking to and from school has been attributed to a poor walking environment, defined as a built environment that has low population densities, little mixing of land uses, long blocks, and incomplete sidewalks ( 112 ). The majority of efforts to encourage walking to and from school involve improving the routes (e. g., Marin County's Safe Routes to School program) rather than improving the location of schools. Previous studies have recommended that local governments and school districts should ensure that children and youth have safe walking and bicycling routes between their homes and schools and encouraged their use ( 11 ).

The largest school district in the local jurisdiction has a policy that supports locating new schools, and/or repairing or expanding existing schools, within easy walking or biking distance of residential areas.

This measurement captures school district policies that encourage the location of new schools within close proximity of residential neighborhoods and/or to maintain schools that are already located in residential areas. This measurement includes policies that either provide incentives to build or keep schools in residential areas or prevent schools from being built in areas that can only be accessed by motorized vehicles. This measurement might prompt school districts to consider proximity to residential areas when siting schools.

20. Communities Should Improve Access to Public Transportation.

Public transportation includes mass transit systems such as buses, light rail, street cars, commuter trains, and subways, and the infrastructure supporting these systems (e. g., transit stops and dedicated bus lanes). Improving access to public transportation encourages the use of public transit, which might, in turn, increase the level of physical activity when transit users walk or ride bicycles to and from transit access points.

The Community Guide identified insufficient evidence to determine the effectiveness of transportation and travel policies and practices in increasing the level of physical activity or improving fitness because only one study of adequate quality was available ( 108 ). In a study that analyzed data from the 2001 National Household Travel Survey, researchers indicated that 29% of individuals who walk to and from public transit achieve at least 30 minutes of daily physical activity ( 114 ). Another study indicated that access to public transit was associated with decreases in the odds of using automobiles as a preferred mode of transportation and increases in the odds of walking and/or bicycling ( 115 ). In a cross-sectional study carried out in four San Francisco neighborhoods, researchers indicated that individuals with easy access to the Bay Area Rapid Transit System (BART) made, on average, 0.66 more nonmotorized trips than those who did not have access to BART ( 116 ).

Physically active individuals might be more likely to locate into communities with an infrastructure that supports physical activity, including neighborhoods with infrastructure supporting public transportation ( 110 ). Most neighborhood-level cross-sectional studies do not control for individual-level characteristics (e. g., ethnicity, age, socioeconomic status). Environmental factors, including infrastructure for public transit, also might affect different subpopulations differently ( 110,116 ).

The percentage of residential and commercial parcels in a local jurisdiction that are located either within a quarter-mile network distance of at least one bus stop or within a half-mile network distance of at least one train stop (including commuter and passenger trains, light rail, subways, and street cars).

This measurement captures access to the local public transit system based on the distance persons have to walk to and from bus stops and train stops, either from their homes or from commercial destinations. The measurement should be relatively easy to collect by local jurisdictions that have basic GIS capacity and information about the location of all bus and train stops in their jurisdiction. Using a network distance better represents the actual distances persons must travel on foot or bicycle to reach transit stops.

21. Communities Should Zone for Mixed-Use Development.

Zoning for mixed-use development is one type of community-scale land use policy and practice that allows residential, commercial, institutional, and other public land uses to be located in close proximity to one another. Mixed-use development decreases the distance between destinations (e. g., home and shopping), which has been demonstrated to decrease the number of trips persons make by automobile and increase the number of trips persons make on foot or by bicycle. Zoning regulations that accommodate mixed land use could increase physical activity by encouraging walking and bicycling trips for nonrecreational purposes. Zoning laws restricting the mixing of residential and nonresidential uses and encouraging single-use development can be a barrier to physical activity.

The Community Guide lists mixed-use development and diversity of residential and commercial developments as examples of community-scale urban design and land use policies and practices ( 23 ). The Community Guide rated the evidence for community-scale urban design and land use policies and practices as sufficient to justify a recommendation that these characteristics increase physical activity ( 23,108 ). The recommendation was based on a review of 12 studies in which the median improvement in some aspect of physical activity was 161% ( 23,108 ).

Studies using correlation analyses and regression models indicated that mixed land use was associated with increased walking and cycling ( 110,117--119 ). A review of quasi-experimental studies indicated residents from high walkability neighborhoods (defined by higher density, greater connectivity, and more land use mix) reported twice as many walking trips per week than residents from low walkability neighborhoods (defined by low density, poor connectivity, and single land uses) ( 110 ). A cross-sectional study conducted in Atlanta, GA indicated that odds of obesity declined as mixed land use increased ( 118 ).

Some increased level of physical activity among residents of mixed-use neighborhoods might be attributable to selection of these types of neighborhoods by persons more likely to engage in physical activity ( 119 ). Mixed-use development is often combined with multiple design elements from urban planning and policy, including density, connectivity, roadway design, and walkability.

Percentage of zoned land area (in acres) within a local jurisdiction that is zoned for mixed use that specifically combines residential land use with one or more commercial, institutional, or other public land uses.

This measurement assesses the proportion of land within a local jurisdiction that is zoned for mixed use including residential land use. Although mixed use does not always require a residential component, for the purpose of this measurement mixed-use development is defined as zoning that combines residential land use with one or more of the following types of land use: commercial, institutional, or other public use.

22. Communities Should Enhance Personal Safety in Areas Where Persons Are or Could Be Physically Active.

Personal safety is affected by crime rates and other nontraffic-related hazards that exist in communities. Limited but supportive evidence indicates that improving community safety might be effective at increasing levels of physical activity in adults and children. In addition, safety considerations affect parents' decisions to allow their children to play and walk outside ( 11 ). Interventions to improve safety, such as increasing police presence, decreasing the number of abandoned buildings and homes, and improving street lighting, can be undertaken by individual communities.

Cross-sectional studies have demonstrated a negative relationship between crime rates and/or perceived safety and physical activity in neighborhoods, particularly among adolescents ( 101,120,121 ). A systematic review indicated that observational measurements of safety (e. g., crime incidence) were negatively associated with physical activity, but subjective measurements (self-reported safety) were not correlated with physical activity ( 120 ).

Few intervention studies have evaluated the impact of policies and practices to improve personal safety on physical activity. However, one study indicated that improved street lighting in London led to reduced crime rates, less fear of crime, and more pedestrian street use ( 122 ). Some studies suggest that the relationship between safety and physical activity might vary by gender and/or other individual-level characteristics. For example, one study indicated that incidence rates of violent crimes were associated with lower physical activity in adolescent girls, but not in boys ( 121 ).

Persons of lower socioeconomic status depend more on walking as a means of transportation as compared with those of higher socioeconomic status, and they also are more likely to live in neighborhoods that are unsafe ( 11 ). This could explain why some studies do not find a positive association between perceived safety and physical activity. Reducing crime levels might require complex, multisectoral, and long-term efforts, which might go beyond the authority and capacity of local communities.

The number of vacant or abandoned buildings (residential and commercial) relative to the total number of buildings located within a local jurisdiction.

This measurement captures the percentage of buildings that are vacant or abandoned within a local jurisdiction, which is one of many environmental factors believed to be associated with perceived safety in neighborhoods. When residential or commercial buildings are vacant, places conducive to crime are more readily available, which might deter persons from engaging in physical activity. Vacant or abandoned lots are not intended to be counted for this measure.

23. Communities Should Enhance Traffic Safety in Areas Where Persons Are or Could Be Physically Active.

Traffic safety is the security of pedestrians and bicyclists from motorized traffic. Traffic safety can be enhanced by engineering streets for lower speeds or by retrofitting existing streets with traffic calming measurements (e. g., speed tables and traffic circles). Traffic safety can also be enhanced by developing infrastructure to improve the safety of street crossings (e. g., raised crosswalks and textured pavement) for nonmotorized traffic and for pedestrians.

The lack of safe places to walk, run, and bicycle as a result of real or perceived traffic hazards can deter children and adults from being physically active. Enhancing traffic safety has been demonstrated to be effective in increasing levels of physical activity in adults and children. Research suggests that persons living in neighborhoods with higher traffic safety are more physically active.

The Community Guide reviewed both community-scale and street-scale urban design and land use policies and practices, including interventions aimed at improving traffic safety. The review indicated that both community-scale and street-scale policies and practices were effective in increasing physical activity ( 108 ). On the basis of sufficient evidence of effectiveness, the Community Guide recommends implementing community-scale and street-scale urban design and land use policies to promote physical activity, including design components to improve street lighting, infrastructure projects to increase safety of pedestrian street crossings, and use of traffic calming approaches such as speed humps and traffic circles ( 23 ).

A review of 19 studies examined the effects of environmental factors on physical activity, five of which considered traffic safety ( 123 ). One study demonstrated significant effects of traffic safety on increased physical activity ( 102 ).

Local government has a policy for designing and operating streets with safe access for all users which includes at least one element suggested by the National Complete Streets Coalition ( completestreets ).

This measurement assesses whether a community has a policy for all-user street design, such as the Complete Streets program. Specific elements of the measurement are based on Complete Streets policy. To meet criteria for this measurement, local governments must incorporate at least one of the following elements in a local policy to enhance traffic safety for pedestrians:

specifies that "all users" includes pedestrians, bicyclists, transit vehicles and users, and motorists of all ages and abilities; aims to create a comprehensive, integrated, connected network; recognizes the need for flexibility: that all streets are different and user needs will be balanced; is adoptable by all agencies to cover all roads; applies to both new and retrofit projects, including design, planning, maintenance, and operations, for the entire right of way; makes any exceptions specific and sets a clear procedure that requires high-level approval of exceptions; directs the use of the latest and best design standards; directs that Complete Streets solutions fit within the context of the community; and establishes performance standards with measurable outcomes.

Strategy to Encourage Communities to Organize for Change.

Community coalitions and partnerships are a way for government agencies, private sector institutions, community groups, and individual citizens to come together for the common purpose of preventing obesity by improving nutrition and physical activity. The following strategy calls for local governments to participate in community coalitions or partnerships to address obesity.

24. Communities Should Participate in Community Coalitions or Partnerships to Address Obesity.

Community coalitions consist of public - and private-sector organizations that, together with individual citizens, work to achieve a shared goal through the coordinated use of resources, leadership, and action ( 11 ). Potential stakeholders in community coalitions aimed at obesity prevention include but are not limited to community organizations and leaders, health-care professionals, local and state public health agencies, industries (e. g., building and construction, restaurant, food and beverage, and entertainment), the media, educational institutions, government (including transportation and parks and recreation departments), youth-related and faith-based organizations, nonprofit organizations and foundations, and employers.

The effectiveness of community coalitions stems from the multiple perspectives, talents, and expertise that are brought together to work toward a common goal. In addition, coalitions build a sense of community, enhance residents' engagement in community life, and provide a vehicle for community empowerment. Research in tobacco control demonstrates that the presence of antismoking community coalitions is associated with lower rates of cigarette use. Based on this research, it is plausible that community coalitions might be effective in preventing obesity and in improving physical activity and nutrition.

Little evidence is available to determine the impact of community coalitions on obesity prevention ( 11 ). However, tobacco-control literature demonstrates that the presence of antismoking community coalitions is associated with lower rates of tobacco consumption. One study indicated that states with a greater number of anti-tobacco coalitions had lower per capita cigarette consumption than states with a lower number of coalitions ( 124 ).

Local government is an active member of at least one coalition or partnership that aims for environmental and policy change to promote active living and/or healthy eating (excluding personal health programs such as health fairs).

This measurement captures whether local governments participant in an active coalition that addresses active living and/or healthy eating within a local jurisdiction. Local government's participation can be based on a written agreement but can also include informal involvement in a community coalition. Coalitions should aim to address environmental and/or policy-level change for obesity prevention to meet the measurement criteria. Coalitions that only focus on awareness and/or individual level services are not included in this measure.

Limitações.

The recommended strategies and corresponding suggested measurements provided in this report are subject to at least seven limitations.

First, the 24 recommended community strategies are based on available evidence, expert opinion and transparent documentation; however, the suggested measurements have not been validated in practice. These measurements represent a first step that communities can use to assess local-level policies and environments that support healthy eating and active living. In addition, for a few of the recommended strategies, no evidence of an obesity-related health outcome exists. These recommendations were included on the basis of expert opinion that supported their inclusion to determine the effectiveness of the strategy for preventing obesity.

Second, to allow local governments to collect data, the suggested measurements typically assess only one aspect or dimension of a more complex environmental or policy strategy for preventing obesity. Although single indicators usually are inadequate for achieving in-depth community-wide assessment of complex strategies, they can be appropriate tools to assess local government's attention and focus on efforts to create an environment in which healthy eating and active living are supported.

Third, by design, the proposed measurements are confined to public settings that are under the authority of local governments and public schools. Although private settings are critical to the overall aim of preventing obesity, they are not addressed by this project because they are not under the authority of local jurisdictions. However, these obesity prevention strategies and their corresponding suggested measurements could be adapted to other settings throughout the community, outside the purview of local governments. In addition, all of the measurements pertaining to schools are limited to the largest school district within a local jurisdiction to ease the burden for data collection for jurisdictions that contain many school districts.

Fourth, many of the recommended strategies and suggested measurements might have more relevance to urban and suburban communities than to rural communities that typically have limited transit systems, sidewalk networks, and/or local government facilities. Many of the measurements require GIS capability; this technology might not yet be available in certain rural communities. However, this limitation will likely be temporary because of the rapid acquisition and implementation of GIS capability by local governments.

Fifth, certain of the suggested measurements require specific quantitation (e. g., the number of full-service grocery stores per 10,000 residents). Currently, no established standards exist by which communities can assess and compare their performance on a particular measure; data collected from local governments reporting on these measurements can lead to the emergence of a recommended standard.

Sixth, many of the proposed policy-level measurements have their own limitations. For example, although the measurements have been developed in consideration of local governments, a number of policies might be established at the state level, which would limit local variability within states. To assist in expanding our understanding of each policy, the measurement collection protocol recommends recording the key components of each policy, the date of enactment, and whether it is an institutional-, local-, or state-level policy. The measurements are designed to capture state and county policies that impact nutrition and physical activity environments at the local level.

Finally, certain policy measurements might not be highly sensitive to change from one year to the next. For example, after a community has a desired policy in place, several years might elapse before any verifiable change can be detected, quantified, and reported. Knowing that a policy exists does not reveal the extent to which that policy actually is implemented or enforced, if at all. Although implementation of and adherence to policies are critical to their impact, measuring the implementation of policies requires a level of assessment that might not be generally feasible for most local governments. Despite these limitations, drawing the attention of elected officials and government staffs to the existence of a policy serves as a catalyst for discussion and consideration with community members.

Próximos passos.

The next step for this project is to disseminate the recommended community strategies and suggested measurements for use by local governments and communities throughout the United States. To help accomplish this, an implementation and measurement guide will be published and made available through the CDC website (available at cdc. gov/nccdphp/dnpao/publications/index. html ). In addition, the measurements will be integrated into a new survey module that will be available to all members of ICMA's Center for Performance Measurement. Dissemination of these recommended obesity prevention strategies and proposed measurements is intended to inspire communities to consider implementing new policy and environmental change initiatives aimed at reversing the obesity epidemic. The recommended strategies and suggested measurements outlined in this report are being pilot tested in the Minnesota and Massachusetts state surveillance systems (Laura Hutton, MA, Minnesota Department of Health, personal communication, 2009; Maya Mohan, MPH, Massachusetts Department of Health, personal communication, 2009).

Agradecimentos.

The membership lists of the multiple subgroups that participated in the Measurements Project are listed on the inside back cover of this report. In addition, the following persons and organizations also contributed to this report: the International City/County Management Association; John Moore, PhD, CDC Foundation; Diane Dunet, PhD; Deborah Galuska, PhD, Division of Nutrition, Physical Activity, and Obesity, CDC. Support to the CDC Foundation was provided by the Robert Wood Johnson Foundation, the W. K. Kellogg Foundation, and Kaiser Permanente.

Referências.

Ogden CL, Carroll, MD, Curtin, LR, et al. Prevalence of overweight and obesity in the United States, 1999--2004. JAMA 2006;295:1549--55. Ogden CL, Carroll MD, Flegal KM. High body mass index for age among U. S. children and adolescents, 2003--2006. JAMA 2008;299:2401--5. Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States: no change since 2003--2004. Bethesda, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2007. CDC. Prevalence of overweight, obesity, and extreme obesity among adults: United States, Trends 1976--80 through 2005--2006. Hyattsville, MD: US Department of Health and Human Services, National Center for Health Statistics, CDC; 2008. Hill JO, Peters JC. Environmental contributions to the obesity epidemic. Science 1998;280:1371--4. Sallis JF, Glanz K. The role of built environments in physical activity, eating, and obesity in childhood. Future Child 2006;16:89--108. Sallis JF, Glanz K. Physical activity and food environments: solutions to the obesity epidemic. The Millbank Quarterly 2009;87:123--54. McCann B. Community design for healthy eating: how land use and transportation solutions can help. Princeton, NJ: Robert Wood Johnson Foundation; 2006. Joint Center for Political and Economic Studies and PolicyLink. A place for healthier living: improving access to physical activity and healthy foods. Washington, DC: Joint Center for Political and Economic Studies; 2004. Ewing R, Schmid RL, Killingsworth, R, et al. Relationship between urban sprawl and physical activity, obesity, and morbidity. American Journal of Health Promotion 2003;18:47--57. Institute of Medicine. Preventing childhood obesity: health in the balance. Washington, DC: The National Academies Press; 2005. Institute of Medicine. Progress in preventing childhood obesity: How do we measure up? Washington, DC: The National Academies Press; 2007. The Keystone Center. The Keystone forum on away-from-home foods: opportunities for preventing weight gain and obesity: final report 2006, Keystone, CO; The Keystone Center; 2006. Papas MA, Alberg AJ, Ewing R, et al. The built environment and obesity. Epidemiol Rev 2007;29:129--43. US Department of Health and Human Services. Healthy people 2010: understanding and improving health. 2ª ed. Washington, DC: US Department of Health and Human Services; 2000. Available at health. gov/healthypeople. CDC. Developing recommendations for future national diabetes objectives. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Doll R, Hill A. Mortality in relation to smoking: ten years' observations of British doctors. British Medical Journal 1964;35:1399--410. Glasgow R, Vogt T, Boles S. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health 1999;89:1322--7. Sanders JM. The program evaluation standards: how to assess evaluations of educational programs. Thousand Oaks, CA: Sage Publications, Inc.; 1994. Starr G, Rogers T, Schooley M, et al. Key outcome indicators for evaluating comprehensive tobacco control programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2005. US Department of Health and Human Services. Health consequences of smoking, 2004: 28th report of the Surgeon General. Washington, DC: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2004. Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases. Annu Rev Public Health 2006;27:341--70. CDC. The guide to community preventive services: what works to promote health? New York, NY: Oxford University Press; 2005. Faith MS, Fontaine KR, Baskin ML, Allison DB. Toward the reduction of population obesity: macrolevel environmental approaches to the problems of food, eating, and obesity. Psychol Bull 2007;133:205--26. Jago R, Baranowski T, Baranowski JC. Fruit and vegetable availability: a micro environmental mediating variable? Public Health Nutr 2007;10:681--9. French SA, Story M, Fulkesron JA, Hannan P. An environmental intervention to promote lower-fat food choices in secondary schools: outcomes of the TACOS Study. Am J Public Health 2004;94:1507--12. US Department of Health and Human Services, US Department of Agriculture. Dietary guidelines for Americans. 6ª ed. Washington, DC: U. S. Government Printing Office; 2005. Drewnowski A. Obesity and the food environment: dietary energy density and diet costs. Am J Prev Med 2004;27(Suppl):154--62. French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health 2001;22:309--35. Seymour JD, Yaroch AL, Serdula M, et al. Impact of nutrition environmental interventions on point-of-purchase behavior in adults: a review. Prev Med 2004;39(Suppl 2):S108--36. French SA, Story M, Jeffery RW, et al. Pricing strategy to promote fruit and vegetable purchase in high school cafeterias. J Am Diet Assoc 1997;97:1008--10. French SA, Jeffery RW, Story M, et al. Pricing and promotion effects on low-fat vending snack purchases: the CHIPS Study. Am J Public Health 2001;91:112--7. French SA, Jeffery, RW, Story M, et al. A pricing strategy to promote low-fat snack choices through vending machines. Am J Public Health 1997;87:849--51. Dong D, Lin B. Fruit and vegetable consumption by low-income Americans: would a price reduction make a difference?, Washington, DC: US Department of Agriculture, Economic Research Service; 2009. Anderson JV, Bybee DI, Brown RM, et al. Five a day fruit and vegetable intervention improves consumption in a low income population. J Am Diet Assoc 2001;101:195--202. Cincirpini P. Changing food selections in a public cafeteria: an applied behavioral analysis. Behavioral Modification 1984;8:520--39. Jeffery RW, French SA, Raether C, Baxter JE. An environmental intervention to increase fruit and salad purchases in a cafeteria. Prev Med 1994;23:788--92. Herman DR, Harrison GG, Afifi AA, Jenks E. Effect of a targeted subsidy on intake of fruits and vegetables among low-income women in the Special Supplemental Nutrition Program for Women, Infants, and Children. Am J Public Health 2008;98:98--105. Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U. S. Am J Prev Med 2008;36:74--81. Morland K, Wing S, Diez Roux A, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med 2002;22:23--9. Morland K, Wing S, Diez Roux A. The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study. Am J Public Health 2002;92:1761--7. The Reinvestment Fund. The economic impacts of supermarkets on their surrounding communities. Philadelphia, PA: The Reinvestment Fund; nd. Powell LM, Auld MC, Chaloupka FJ, et al. Associations between access to food stores and adolescent body mass index. Am J Prev Med 2007;33(Suppl):S301--7. US Department of the Treasury. Community development financial institution financing of supermarkets in underserved communities: a case study. Washington, DC: US Department of the Treasury; 2008. Zenk SN, Schulz AJ, Hollis-Neely T, et al. Fruit and vegetable intake in African Americans' income and store characteristics. Am J Prev Med 2005;29:1--9. Kunkel ME, Luccia B, Moore AC. Evaluation of the South Carolina seniors farmers' market nutrition education program. J Am Diet Assoc 2003;103:880--3. Conrey EJ, Frongillo EA, Dollahite JS, Griifin MR, et al. Integrated program enhancements increased utilization of Farmers' Market Nutrition Program. J Nutr 2003;133:1841--4. Mascarenhas M, Gottlieb R. The farmers market salad bar: assessing the first three years of the Santa Monica--Malibu Unified School District Program. Occidental, CA: Community Food Security Project Urban and Environmental Policy Institute, Occidental College; 2008:1--24. Buzby JC, Wells HF, Vocke G. Possible implications for U. S. agriculture from adoption of select dietary guidelines. Washington, DC: US Department of Agriculture; 2006. Feenstra GW, Local food systems and sustainable communities. American Journal of Alternative Agriculture 1997;12:28--36. Conner DS, Knudson WA, Hamm MW, Peterson HC. The food system as an economic driver: strategies and applications for Michigan. Journal of Hunger and Environmental Nutrition 2008:3:371--83. Swenson D. The economic impact of increased fruit and vegetable production and consumption in Iowa: phase II. Ames, IA: Leopold Center for Sustainable Agriculture; 2006. Hamm MW. Linking sustainable agriculture and public health: opportunities for realizing multiple goals. Journal of Hunger and Environmental Nutrition. In press. Delva J, O'Malley PM, Johnston LD. Availability of more-healthy and less-healthy food choices in American schools: a national study of grade, racial/ethnic, and socioeconomic differences. Am J Prev Med 2007;33(4 Suppl):S226--39. Kubik MY, Lytle LA, Hannan PJ, et al. The association of the school food environment with dietary behaviors of young adolescents. Am J Public Health 2003;93:1168--73. Government Accounting Office. School meal programs: competitive foods are available in many schools: actions taken to restrict them differ by state and locality. Washington, DC: Government Accounting Office; 2004. CDC. Do increased portion sizes affect how much we eat? Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Kral TV, Rolls BJ. Energy density and portion size: their independent and combined effects on energy intake. Physiol Behav 2004;82:131--8. Rolls BJ, Roe LS, Meengs JS. Reductions in portion size and energy density of foods are additive and lead to sustained decreases in energy intake. Am J Clin Nutr 2006;83:11--7. Rolls BJ, Roe LS, Meengs JS, Wall DE. Increasing the portion size of a sandwich increases energy intake. J Am Diet Assoc 2004;104:367--72. Diliberti N, Bordi PL, Conklin MT, et al. Increased portion size leads to increased energy intake in a restaurant meal. Obes Res 2004;12:562--8. Wansink B, Park SB. At the movies: how external cues and perceived taste impact consumption volume. Food Quality and Preference 2001;12:69--74. Pratt CA, Lemon SC, Fernandez ID, et al. Design characteristics of worksite environmental interventions for obesity prevention. Obesity 2007;15:2171--80. Comissão Federal de Comércio. Marketing food to children and adolescents: a review of industry expenditures, activities, and self-regulation. Washington, DC: Federal Trade Commission; 2008. Institute of Medicine. Food marketing to children and youth: threat or opportunity? Washington, DC: The National Academies Press; 2006. Ashe M, Feldstein LM, Graff S, et al. Local venues for change: legal strategies for healthy environments. J Law Med Ethics 2007;35:138--47. Hill, JO, Peters JC, Wyatt HR. The role of public policy in treating the epidemic of global obesity. Clin Pharmacol Ther 2007;81:772--5. Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. J Health Econ 2000;19:1117--37. Shin-Yi C, Inas R, Michael G. Fast-food restaurant advertising on television and its influence on childhood obesity. The Journal of Law and Economics 2008;51:599--618. CDC. Does drinking beverages with added sugars increase the risk of overweight? Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Ritenbaugh C, Teufel-Shone NI, Aickin MG, et al. A lifestyle intervention improves plasma insulin levels among Native American high school youth. Prev Med 2003;36:309--19. Ebbeling CB, Feldman HA, Osganian SK, et al. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics 2006;117:673--80. Fisher JO, Birch LL, Smiciklas-Wright H, Picciano MF. Breast-feeding through the first year predicts maternal control in feeding and subsequent toddler energy intakes. J Am Diet Assoc 2000;100:641--6. Dewey KG. Is breastfeeding protective against child obesity? J Hum Lact 2003;19:9--18. Dyson L, McCormick F, Renfrew MJ. Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev 2005:(2): CD001688. Shealy KR, Li R, Benton-Davis S, Grummer-Strawn L. The CDC guide to breastfeeding interventions. Atlanta, GA: US Department of Health and Human Services, CDC; 2005. Arenz S, Ruckerl R, Koletzko B, vonKries R. Breast-feeding and childhood obesity: a systematic review. Int J Obes Relat Metab Disord 2004;28:1247--56. Owen CG, Martin RM, Whincup PH, et al. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics 2005;115:1367--77. Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol 2005;162:397--403. Li R, Fein SB, Grummer-Strawn LM. Association of breastfeeding intensity and bottle-emptying behaviors at early infancy with infants' risk for excess weight at late infancy. Pediatrics 2008;122(Suppl 2):S77--84. Britton C, McCormick FM, Renfrew MJ, et al. Support for breastfeeding mothers. Cochrane Database Syst Rev 2007;(1):CD001141. Abdulwadud OA, Snow ME. Interventions in the workplace to support breastfeeding for women in employment. Cochrane Database Syst Rev 2007;(3):CD006177. Fein SB, Mandal B, Roe BE. Success of strategies for combining employment and breastfeeding. Pediatrics 2008;122(Suppl 2):S56--62. National Association for Sport and Physical Education and American Health Association. Shape of the nation report: status of physical education in the USA. Reston, VA: National Association for Sport and Physical Education; 2006. Sallis JF, McKenzie TL, Alcaraz JE, et al. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Am J Public Health 1997;87:1328--34. Luepker RV, Perry CL, McKinlay SM, et al. Outcomes of a field trial to improve children's dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA 1996;75:768--76. Engels HJ, Gretebeck RJ, Gretebeck KA, Jimenez L. Promoting healthful diets and exercise: efficacy of a 12-week after-school program in urban African Americans. J Am Diet Assoc 2005;105:455--9. Kelder S, Hoelscher DM, Barroso CS, et al. The CATCH Kids Club: a pilot after-school study for improving elementary students' nutrition and physical activity. Public Health Nutr 2005;8:133--40. Yin Z, Moore JB, Johnson MH, et al. The Medical College of Georgia Fitkid project: the relations between program attendance and changes in outcomes in year 1. Int J Obes (Lond) 2005;29(Suppl 2):S40--5. Pangrazi RP, Beighle A, Vehige T, Vack C. Impact of Promoting Lifestyle Activity for Youth (PLAY) on children's physical activity. J Sch Health 2003;73:317--21. Robinson TN, Killen JD, Kraemer HD, et al. Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study. Ethn Dis 2003;13(Suppl 1):S65--77. Hancox RJ, Milne BJ, Poulton R. Association between child and adolescent television viewing and adult health: a longitudinal birth cohort study. Lancet 2004;364(9430):257--62. Viner RM, Cole TJ. Television viewing in early childhood predicts adult body mass index. J Pediatr 2005;147:429--35. American Academy of Pediatrics. Children, adolescents, and television. Pediatrics 2001;107:423--6. Dennison BA, Erb TA, Jenkins PL. Television viewing and television in bedroom associated with overweight risk among low-income preschool children. Pediatrics 2002;109:1028--35. Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282:1561--7. Sallis JF, Prochaska JJ, Taylor WC. A review of correlates of physical activity of children and adolescents. Med Sci Sports Exerc 2000;32:963--75. Mueller M, Asbeck I, Mast M, et al. Prevention of obesity; more than an intention. Concept and first results of the Kiel Obesity Prevention Study (KOPS). International Journal of Obesity 2001;25(Suppl 1):S66--74. Gortmaker SL, Peterson K, Wiecha J, et al. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med 1999;153:409--18. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity. Uma revisão sistemática. Am J Prev Med 2002;22(4 Suppl):73--107. Gordon-Larsen P, McMurray RG, Popkin BM. Determinants of adolescent physical activity and inactivity patterns. Pediatrics 2000;105:E83. Booth ML, Owen N, Bauman A, et al. Social-cognitive and perceived environment influences associated with physical activity in older Australians. Prev Med 2000;31:15--22. Troped PJ, Saunders RP, Pate RR, et al. Associations between self-reported and objective physical environmental factors and use of a community rail-trail. Prev Med 2001;32:191--200. Macbeth AG. Bicycle lanes in Toronto. ITE Journal 1999;69:38--46. Staunton CE, Hubsmith D, Kallins W. Promoting safe walking and biking to school: the Marin County success story. Am J Public Health 2003;93:1431--4. Dill J, Carr T. Bicycle commuting and facilities in major U. S. cities: if you build them, commuters will use them. Transportation Research Record 2003;1829:116--23. Nelson A, Allen D If you build them, commuters will use them: association between bicycle facilities and bicycle commuting. Transportation Research Record 1997;1578:79--83. Heath GW, Brownson RC, Kruger J, et al. The effectiveness of urban design and land use and transport policies and practices to increase physical activity: a systematic review. Journal of Physical and Activity and Health 2006;3 (Suppl 1):S55--76. Owen N, Humpel N, Leslie E, et al. Understanding environmental influences on walking: review and research agenda. Am J Prev Med 2004;2767--76. Saelens BE, Sallis JF, Frank LD. Environmental correlates of walking and cycling: findings from the transportation, urban design, and planning literatures. Ann Behav Med 2003;25:80--91. Humpel N, Owen N, Leslie E. Environmental factors associated with adults' participation in physical activity: a review. Am J Prev Med 2002;22:188--99. Environmental Protection Agency. EPA 231-R-03-004. Travel and environmental implications of school siting. Washington, DC: Environmental Protection Agency; 2003. Tudor-Locke C, Ainsworth BE, Adair LS, Popkin BM. Objective physical activity of filipino youth stratified for commuting mode to school. Med Sci Sports Exerc 2003;35:465--71. Besser LM, Dannenberg AL. Walking to public transit: steps to help meet physical activity recommendations. Am J Prev Med 2005;29:273--80. Cervero R. Mixed land-uses and commuting: evidence from the American Housing Survey. Transportation Research Part A: Policy & Practice 1996;30:361--77. Kitamura R, Mokhtarian P, Laidet L. A micro-analysis of land use and travel in five neighborhoods in the San Francisco Bay Area. Transporation Research Record 1997;24:125--58. Saelens BE, Sallis JF, Black JB, Chen D. Neighborhood-based differences in physical activity: an environment scale evaluation. Am J Public Health 2003;93:1552--8. Frank LD, Andresen MA, Schmid TL. Obesity relationships with community design, physical activity, and time spent in cars. Am J Prev Med 2004;27:87--96. Frank LD, Schmid TL, Sallis JF, et al. Linking objectively measured physical activity with objectively measured urban form: findings from SMARTRAQ. Am J Prev Med 2005;28(Suppl 2):117--25. Ferreira I, van der Horst K, Wendel-Vos W, et al. Environmental correlates of physical activity in youth - a review and update. Obes Rev 2007;8:129--54. Gomez JE, Johnson BA, Selva M, Sallis JF. Violent crime and outdoor physical activity among inner-city youth. Prev Med 2004;39:876--81. Painter K. The influence of street lighting improvements on crime, fear and pedestrian street use, after dark. Landscape and Urban Planning 1996;35:193. Humpel N, Owen N, Leslie E, et al. Associations of location and perceived environmental attributes with walking in neighborhoods. Am J Health Promot 2004;18:239--42. Stillman FA, Hartman AM, Graubard BI, et al. Evaluation of the American Stop Smoking Intervention Study (ASSIST): a report of outcomes. J Natl Cancer Inst 2003;95:1681--91.

* A list of the members of these groups appears on the inside back cover of this report.

BOX 1. Criteria used by the Select Expert Panel to rate each proposed strategy to reduce obesity in the United States.

The strategy is likely to affect a large percentage of the target population.

The strategy is in the realm of the community's control.

The strategy can be implemented in communities that differ in size, resources, and demographics.

The potential magnitude of the health effect for the strategy is meaningful.

Sustainability of health impact.

The health effect of the strategy will endure over time.

BOX 2. Criteria used by content area experts to rate suggested measurements for each strategy.

The measurement serves the information needs of communities enabling them to plan and monitor community-level programs and strategies.

The measurement accurately assesses the environmental strategy or policy that it is intended to measure.

The measurement can be collected and used by local government (e. g. cities, counties, towns) without the need for surveys, access to proprietary data, specialized equipment, complex analytical techniques and expertise, or unrealistic resource expenditure.

TABLE. Summary of recommended community strategies and measurements to prevent obesity in the United States.

Strategies to Promote the Availability of Affordable Healthy Food and Beverages.

Communities should increase availability of healthier food and beverage choices in public service venues.

A policy exists to apply nutrition standards that are consistent with the dietary guidelines for Americans (US Department of Health and Human Services, US Department of Agriculture. Dietary guidelines for Americans. 6th ed. Washington, DC: U. S. Government Printing Office; 2005.) to all food sold (e. g., meal menus and vending machines) within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.

Communities should improve availability of affordable healthier food and beverage choices in public service venues.

A policy exists to affect the cost of healthier foods and beverages (as defined by the Institute of Medicine [IOM] [Institute of Medicine. Preventing childhood obesity: health in the balance. Washington, DC: The National Academies Press; 2005]) relative to the cost of less healthy foods and beverages sold within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.

Communities should improve geographic availability of supermarkets in underserved areas.

The number of full-service grocery stores and supermarkets per 10,000 residents located within the three largest underserved census tracts within a local jurisdiction.

Communities should provide incentives to food retailers to locate in and/or offer healthier food and beverage choices in underserved areas.

Local government offers at least one incentive to new and/or existing food retailers to offer healthier food and beverage choices in underserved areas.

Communities should improve availability of mechanisms for purchasing foods from farms.

The total annual number of farmer-days at farmers' markets per 10,000 residents within a local jurisdiction.

Communities should provide incentives for the production, distribution, and procurement of foods from local farms.

Local government has a policy that encourages the production, distribution, or procurement of food from local farms in the local jurisdiction.

Strategies to Support Healthy Food and Beverage Choices.

Communities should restrict availability of less healthy foods and beverages in public service venues.

A policy exists that prohibits the sale of less healthy foods and beverages (as defined by IOM [Institute of Medicine. Preventing childhood obesity: health in the balance. Washington, DC: The National Academies Press; 2005]) within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.

Communities should institute smaller portion size options in public service venues.

Local government has a policy to limit the portion size of any entree (including sandwiches and entrée salads) by either reducing the standard portion size of entrees or offering smaller portion sizes in addition to standard portion sizes within local government facilities within a local jurisdiction.

Communities should limit advertisements of less healthy foods and beverages.

A policy exists that limits advertising and promotion of less healthy foods and beverages within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.

Communities should discourage consumption of sugar-sweetened beverages.

Licensed child care facilities within the local jurisdiction are required to ban sugar-sweetened beverages, including flavored/sweetened milk and limit the portion size of 100% juice.

Strategy to Encourage Breastfeeding.

Communities should increase support for breastfeeding.

Local government has a policy requiring local government facilities to provide breastfeeding accommodations for employees that include both time and private space for breastfeeding during working hours.

TABLE. ( Continued ) Summary of recommended community strategies and measurements to prevent obesity in the United States.

Strategies to Encourage Physical Activity or Limit Sedentary Activity Among Children and Youth.

Communities should require physical education in schools.

The largest school district located within the local jurisdiction has a policy that requires a minimum of 150 minutes per week of PE in public elementary schools and a minimum of 225 minutes per week of PE in public middle schools and high schools throughout the school year (as recommended by the National Association of Sports and Physical Education).

Communities should increase the amount of physical activity in PE programs in schools.

The largest school district located within the local jurisdiction has a policy that requires K--12 students to be physically active for at least 50% of time spent in PE classes in public schools.

Communities should increase opportunities for extracurricular physical activity.

The percentage of public schools within the largest school district in a local jurisdiction that allow the use of their athletic facilities by the public during non-school hours on a regular basis.

Communities should reduce screen time in public service venues.

Licensed child care facilities within the local jurisdiction are required to limit screen viewing time to no more than 2 hours per day for children aged ≥2 years.

Strategies to Create Safe Communities That Support Physical Activity.

Communities should improve access to outdoor recreational facilities.

The percentage of residential parcels within a local jurisdiction that are located within a half-mile network distance of at least one outdoor public recreational facility.

Communities should enhance infrastructure supporting bicycling.

Total miles of designated shared-use paths and bike lanes relative to the total street miles (excluding limited access highways) that are maintained by a local jurisdiction.

Communities should enhance infrastructure supporting walking.

Total miles of paved sidewalks relative to the total street miles (excluding limited access highways) that are maintained by a local jurisdiction.

Communities should support locating schools within easy walking distance of residential areas.

The largest school district in the local jurisdiction has a policy that supports locating new schools, and/or repairing or expanding existing schools, within easy walking or biking distance of residential areas.

Communities should improve access to public transportation.

The percentage of residential and commercial parcels in a local jurisdiction that are located either within a quarter-mile network distance of at least one bus stop or within a half-mile network distance of at least one train stop (including commuter and passenger trains, light rail, subways, and street cars).

Communities should zone for mixed use development.

Percentage of zoned land area (in acres) within a local jurisdiction that is zoned for mixed use that specifically combines residential land use with one or more commercial, institutional, or other public land uses.

Communities should enhance personal safety in areas where persons are or could be physically active.

The number of vacant or abandoned buildings (residential and commercial) relative to the total number of buildings located within a local jurisdiction.

Communities should enhance traffic safety in areas where persons are or could be physically active.

Local government has a policy for designing and operating streets with safe access for all users which includes at least one element suggested by the national complete streets coalition ( completestreets )

Strategy to Encourage Communities to Organize for Change.

Communities should participate in community coalitions or partnerships to address obesity.

Local government is an active member of at least one coalition or partnership that aims to promote environmental and policy change to promote active living and/or healthy eating (excluding personal health programs such as health fairs).

Common Community Measures for Obesity Prevention Project Team.

John Moore, PhD Katie Sobush, MS, MPH, Amy C. Lowry, MPA, Danielle Jackson, MPH, CDC Foundation; Susan Zaro, MPH, Dana Keener, PhD, Ken Goodman, MA, Jakub Kakietek, MPH, ICF Macro; Mark Thompson, MURP, Donald Gloo, MBA, International City/County Management Association; Erika Fulmer, MHA, Jeannette Renaud, PhD, Research Triangle Institute; Laura Kettel Khan, PhD, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Funders Steering Committee.

Celeste Torio, PhD, Laura Leviton, PhD, Robert Wood Johnson Foundation; Loel Solomon, MPH, Kaiser Permanente; Linda Jo Doctor, MPH, W. K. Kellogg Foundation; Mary Gray, RD, U. S. Department of Agriculture; Robert Kuczmarski, PhD, Amy Yaroch, PhD, National Institutes of Health.

CDC Technical Advisors.

William Dietz, MD, PhD, Deborah Galuska, PhD, Casey Hannan, MPH, Jude McDivitt, PhD, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Sam Posner, PhD, Office of the Director, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Select Panelists.

Chairman: Frances Butterfoss, PhD, Eastern Virginia Medical School, Division of Behavioral Research & Community Health.

Members: Laura Brennen Rameriz, PhD, Transtria L. L.C., St. Louis, Missouri; Allen Cheadle, PhD, University of Washington, Health Promotion Research Center; John Cook, PhD, Boston University, School of Medicine, Department of Pediatrics; Reid Ewing, PhD, University of Maryland; Brian Flay, PhD, Oregon State University, College of Health & Human Sciences; Penny Gordon-Larsen, PhD, University of North Carolina at Chapel Hill, Department of Nutrition, Schools of Public Health and Medicine, Michael Hamm, PhD, Michigan State University, Department of Food Science & Human Nutrition, Jeffrey Harris, DrPH, MPH, RD, LDN, Westchester University, Nutrition & Dietetics Program; Laurie LaChance, PhD, University of Michigan, School of Public Health; Leslie Lytle, PhD, University of Minnesota, Division of Epidemiology & Community Health; Brian Saelens, PhD, University of Washington, Pediatrics; James Sallis, PhD, San Diego State University, Department of Psychology; Sarah Samuels, DrPH, Samuels & Associates; Gail Woodward-Lopez, MPH, University of California--Berkeley, Center for Weight and Health.

CDC Workgroup and Internal Content Area Experts.

Heidi Blanck, PhD, Leigh Ramsey Buchanan, PhD, David Dennison, MPH, Diane Dunet, PhD, Jackie Epping, PhD, Cathleen Gillespie, MS, Alison Heintz, Claire Heiser, MPH, Joel Kimmons, PhD, Sarah Kuester, MS, Kimberly Lane, PhD, RD, Carol MacGowan, MPH, Latetia Moore, PhD, Christopher Reinold, MPH, Candace Rutt, PhD, Tom Schmid, PhD, Jenna Seymour, PhD, Andrea Sharma, PhD, MPH, Katherine Shealy, MPH, Bettylou Sherry, PhD, Diane Thompson, MPH, Edward Weiss, MD, Holly Wethington, PhD, Division of Nutrition, Physical Activity, and Obesity; Sarah Lee, PhD, Terry O'Toole, MDiv, PhD, Seraphine Pitt-Barnes, PhD, Leah Robin, PhD, Division of Adolescent and School Health; Indu Ahluwalia, PhD, Alyssa Easton, PhD, Marilyn Metzler, Fred Ramsey, MS, Michael Sells, MSPH, CHES, Alexandria Stewart, Division of Adult and Community Health; Ralph Coates, PhD, Temeika Fairley, PhD, Staci Lofton, MPH, Phyllis Rochester, PhD, Division of Cancer Prevention and Control; Ann Albright, PhD, RD Carmen Harris, MPH, Qaiser Mukhtar, PhD, Dawn Satterfield, PhD, Division of Diabetes Translation; Michael Schooley, MPH, Division of Heart Disease and Stroke Prevention; Connie Bish, PhD, Shin Kim, MPH, Division of Reproductive Health; Nicole Kuiper, MPH, Natalie Whitney, MPH, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; Sarah Heaton, MPH, Susan Hobson, Dee Merriam, MLA, Heather Morrow-Almeida, MPH, Division of Environmental and Emergency Health Services; Anjana Banerjee, MPH, Division of Environmental Hazards and Health Effects, National Center for Injury Prevention and Control; Laurie Beck, MPH, Division of Unintentional Injury Prevention; Joanne Klevens, PhD, Division of Violence Prevention, National Center for Environmental Health, CDC.

Measurement Experts.

Allen Cheadle, PhD, University of Washington, Health Promotion Research Center; Brian Flay, PhD, Oregon State University, College of Health and Human Sciences; Tom Holland, Nish Keshav, MPA, MA, Center for Performance Measurement, International City/County Management Association; Michael Schooley, MPH, Division of Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Sue Lin Yee, MPH, Office of the Director, CDC.

Local Government Content Area Experts.

Wes Hare, MS, City Manager, City of Albany, Oregon; Thomas Forslund, MPA, City Manager, City of Casper, Wyoming; Peggy Merriss, MPA, City Manager, City of Decatur, Georgia; Amanda Thompson, MPA, Planning Director, City of Decatur, Georgia; David Ramsey, City Manager, City of Kirkland, Washington; Bonnie Svrcek, MPA, Deputy City Manager, City of Lynchburg, Virginia; Rick Freas, MPA, Deputy Budget and Research Director, City of Phoenix, Arizona.

Four Strategies for Promoting Healthy Lifestyles in Your Practice.

When practices promote fitness as the treatment of choice for all patients, good things happen.

Janet Ann McAndrews, BS, Sarah McMullen, MEd, CHES, and Susan L. Wilson, PhD.

Fam Pract Manag. 2011 Mar-Apr;18(2):16-20.

Article Sections.

Promoting healthy lifestyles is a challenge for many primary care practices. Although most patients understand the importance of physical activity and healthy eating, many seem unable to change their unhealthy behaviors to reduce weight and improve chronic conditions. Medications often take a predominant role in the treatment of these patients, even though medications alone are rarely completely effective for chronic conditions, and lifestyle changes have been shown to significantly reduce morbidity and mortality rates for most chronic diseases.1 In addition, patients can feel embarrassed and ashamed of their situations, and physicians can feel pressed for time, causing them to avoid the very dialogue they need to embrace in order to facilitate a breakthrough in improved health.

Há um caminho melhor.

Overview of the AIM-HI program.

The Americans in Motion-Healthy Interventions (AIM-HI) research study,2 conducted by the American Academy of Family Physicians (AAFP) National Research Network and the AAFP Americans In Motion program, involved 21 practices whose clinicians and office staff were encouraged to use AIM-HI strategies and educational tools, discussed below, to improve their personal fitness levels and to promote fitness as the “treatment of choice” for all patients. Fitness was defined using three domains – physical activity, healthy eating and emotional well-being. The research found improvements in three areas:

Self-reported eating behaviors.

41.8 percent of patients reported an increase of at least one-half serving of healthy foods per week at 10 months.

44.8 percent of patients reported a decrease of at least one-half serving of unhealthy foods per week at 10 months.

Self-reported physical activity.

The number of patients who reported physical activity of at least 20 minutes per day, three days per week increased by 10 percent from baseline to four months.

The number of patients who reported physical activity of at least 20 minutes per day three days per week increased by 10.1 percent from baseline to 10 months. (While this is only a slight increase over the previous measure, it shows that the improvements in physical activity seen at four months were maintained at 10 months.)

Total body weight.

11.8 percent of patients lost 10 pounds or more from baseline to 4 months.

17.8 percent of patients lost 10 pounds or more from baseline to 10 months.

All data are from patients who completed 10-month research visits. Of the 610 patients enrolled in the study, 62 percent remained in the study from baseline to 10 months.

The four strategies.

The AIM-HI approach to fitness promotion involves the following strategies.

1. Create a healthy office . The first step in fostering a healthy office culture is encouraging family physicians to be fitness role models. Most patients already view their personal physician as a role model, and they perceive physicians who practice healthy personal behaviors as more credible and better able to motivate them to make healthy lifestyle choices.3 These physicians are also more likely to provide fitness counseling to their patients.4.

Getting physicians involved raises personal awareness of fitness issues among office staff as well and encourages all members of the practice to “walk the talk,” make simple changes in their own lives and share their personal journeys with patients. As physicians and staff members meet personal fitness goals and incorporate the AIM-HI concepts and tools, changes become evident to patients.

It can be helpful to identify a champion to lead these efforts in your practice. That person can facilitate an initial staff meeting to express the importance of personal fitness and the desire to improve fitness among physicians, staff and patients. Since all members of the practice will need to buy into the program, use a collaborative process. Your practice may want to form a committee to assist the champion in launching and establishing this change.

Several practices in the research group issued staff challenges and created support teams to kick off the program. They also created fitness success posters highlighting staff members who had achieved significant milestones in reaching fitness goals, such as getting off medications, reducing blood pressure and glucose levels, losing weight and improving emotional well-being. Posters were placed strategically throughout the clinic to stimulate healthy internal competition and alert patients to the new fitness culture.

2. Make needed process changes . Conduct a brief, informal assessment of your practice by asking yourself the following questions:

How does your practice environment currently promote fitness (physical activity, healthy eating and emotional well-being)? Identify challenges you face, and imagine what it might look like if your clinic were successfully doing everything it could do to promote fitness.

What roles and responsibilities do staff members have in promoting fitness? This must be a team effort, not merely a physician responsibility. For example, front-desk staff can ask patients to complete a fitness inventory. The nurse or medical assistant can calculate BMI, measure waist circumference, review the fitness inventory and reinforce fitness concepts before the physician enters the exam room. After the exam, a staff member might return to the room to answer questions, help with goal setting or provide patient education. (For patient handouts on a variety of health-related issues, visit familydoctor/online/famdocen/home/healthy. html.)

What tools or systems do you need to implement to support your efforts? Your practice will likely need to make process changes such as adding BMI and waist circumference to routine vital sign measurements, incorporating a fitness inventory into periodic screenings, displaying fitness-related patient education materials in your reception area and exam rooms, and adding prompts or reminders for addressing fitness with patients.

3. Get patients involved . To initiate fit-ness conversations with patients, family physicians in the research study found it helpful to capitalize on teachable moments, such as poor laboratory results, a recent diagnosis of chronic illness, new patient visits, annual visits and well-child exams. They also found that switching from an advice-giving communication style to a more patient-centered, conversational style elicited a more receptive response from patients. Physicians in the study also used motivational interviewing techniques such as the following:

Open-ended questions – e. g., “How are you feeling about your health these days?”

Affirmation – e. g., “You may not be at your goal yet, but look at how far you've come.”

Reflective listening – e. g., “It sounds as though you don't feel confident about making this change but you do want to change.”

Summaries – e. g., “Let me summarize what we've just talked about.”

These techniques have proven effective to motivate healthy behavior change in patients.5 , 6 (Editor's note: Look for an article on motivational interviewing in the May/June issue of FPM , and find more information at motivationalinterview .)

When initiating fitness conversations with patients, the first objective is to assess their current levels of activity, healthy eating and emotional well-being and their readiness to change. Study results indicated that addressing each domain separately is more manageable and less overwhelming to patients. An assessment like the one shown below can be helpful.

The next step is to help patients set small, reasonable goals. To address the first domain of fitness, physical activity, goals do not need to involve joining a rigorous exercise program at an expensive gym or developing an athletic, muscle-bulging body or a model's figure. Dispel these concepts, and emphasize the term “physical activity” versus “exercise,” as the latter often is attached to ideas of unattainable body physiques and unachievable goals.

Rarely does lecturing patients on the importance of engaging in 30 to 60 minutes of uninterrupted physical activity every day result in long-term health behavior change.7 Instead, ask patients what they think they could do for just five to 10 minutes per day to improve their physical activity. If the patient is leading a sedentary lifestyle, taking one flight of stairs instead of the elevator, parking the car at the far end of the lot to increase steps, or walking the dog briskly can all be part of increasing physical activity. The idea is to build confidence and capacity, while avoiding injury or a sense of failure. Patients should feel positive about the goals they have selected. Ask them how confident they are in their ability to complete each goal. If their confidence is high, write the goal on a fitness prescription for the patient to take home, and note it in the patient's record so you can ask about it at future visits. If their confidence is low, work with them to select a more doable goal.

The second fitness domain is healthy eating, which involves more than just “good” dietary nutrition. Patients also need to understand the thought processes associated with their eating habits, and many will need to restore their physiological identification of hunger and learn to respond appropriately to it. In the AIM-HI program, patients were encouraged to think about why they were eating and to eat only when they were hungry. This non-diet approach allows patients to let go of rigid diet rules or strict weight-reduction diets that seldom work in the long run.8.

Emotional well-being is the third fitness domain. Because physical activity and healthy eating are often tied to patients' emotional health, addressing this domain can often jump-start their motivation to tackle the others. Some family physicians may feel uncomfortable questioning patients about their emotional well-being. However, failure to do so could be a missed opportunity to inspire healthy behavior changes. Ask patients if they are feeling sadness, stress or anxiety, and help them understand possible causes, such as a broken relationship, too many activities or even a lack of sleep. Share strategies for coping, such as learning to express feelings in appropriate ways, talking to a close friend, counselor or religious adviser, using relaxation methods and taking time for self-care.

Another way to address emotional well-being is through a food and activity journal in which patients record what they eat each day and how they feel. This can help patients understand how their emotions play a part in what they eat, and it can teach them not to reach for food in order to deal with stress or other emotions. Patients should also be encouraged to set small, achievable goals related to their emotional well-being, such as spending five minutes each morning in prayer or meditation or having lunch with a friend once a week.

THREE TOOLS.

The AIM-HI program utilizes three tools, which are available for download at americansinmotion.

A fitness inventory . This brief survey asks questions such as “How many hours each day do you spend watching TV or videos or on the computer?” and “How often does stress or depression affect your ability to pursue healthy lifestyle changes?” These questions are designed to assess the patient's level of physical activity, nutrition and emotional well-being, as well as his or her readiness to make changes in each of these areas.

A fitness prescription . This form is used to record one or more simple, measurable fitness goals that the patient and physician have agreed upon. The patient then takes this form home as a reminder of what was discussed. The form also lists follow-up dates.

A food and activity journal . Patients can use this template to record what they ate, how they felt and what they did to be active for one week.

4. Follow up . Most people change their behavior gradually. They may move forward and backward through the four stages of change – pre-contemplation, contemplation, preparation and action – before moving on to the maintenance stage, where the goal is to minimize relapse.9 Relapses of some sort are almost inevitable, but a mutually developed, individualized plan for support and follow-up can help patients sustain a healthier lifestyle. The plan should address how and when you will evaluate the patient's progress or renegotiate goals. In some cases, a face-to-face visit will be required. In other cases, follow-up can occur by phone or e-mail with a nurse, dietitian or health educator. Follow-up should occur within three weeks in most cases. The plan should also list resources in your community that can assist your patient, such as physical activity centers, walking groups, psychologists and health educators.

Think small changes.

Small, incremental changes are far more likely to be successful for your patients than an “all-or-nothing” abordagem. In the same way, small, incremental changes are the best approach for your practice as it transitions into a fitness culture. Select any one of the strategies and tools described in this article to begin experiencing the benefits of healthy lifestyles for you, your patients and ultimately your community.

IMPROVING PRACTICE THROUGH RESEARCH.

This article is part of a series from the AAFP National Research Network (NRN) and its affiliates, a national collaboration of primary care practice-based research networks. This series is designed to help family physicians put research results to use in their practices.

Leia o artigo completo.

Get immediate access, anytime, anywhere. Choose a single article, issue, or full-access subscription. Earn up to 6 CME credits per issue.

Already a member or subscriber? Entrar.

Get Full Access.

Includes: Immediate, unlimited access to all FPM content Up to 36 CME credits per year Access to the FPM app Print delivery option.

Access This Issue.

Includes: Immediate access to this issue CME credits in this issue.

Access This Article.

Includes: Immediate access to this article.

Janet Ann McAndrews is public health program manager for the AAFP in Leawood, Kan. Sarah McMullen, former director of the Americans in Motion program, is a consultant with Genesis Concepts and Consultants in San Antonio. Dr. Wilson is associate professor at New Mexico State University's College of Health and Social Services in Las Cruces. Author disclosure: nothing to disclose.

Referências.

1. Elmer PJ, Obarzanek E, Vollmer WM, Simons-Morton D, Stevens VJ, Young DR, et al. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med . 2006;144:485–495. .

2. McMullen S, McAndrews JA. Aiming higher: because fitness is always good medicine (making fitness thetreatment of choice for the prevention and treatment of chronic disease). Seminar presented at: AAFP/STFM Conference on Practice Improvement; Dec. 3, 2010; San Antonio. fmdrl/index. cfm? event=c. beginBrowseD&1=1#3205. Accessed Feb 22, 2011.

3. Hash RB, Munna RK, Vogel RL, Bason JJ. Does physician weight affect perception of health advice? Prev Med . 2003;36:41–44.

4. Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counseling practices. Br J Sports Med . 2009;43:89–92.

5. Polacsek M, Orr J, Letourneau L, Rogers V, Holmberg R, O'Rourke K, et al. Impact of a primary care intervention on physician practice and patient and family behavior: Keep ME Healthy – the Maine Youth Overweight Collaborative. Pediatrics . 2009;123(Suppl 5):S258–S266.

6. Rollnick S, Miller WR, Butler C. Motivational Interviewing in Health Care: Helping Patients Change Behavior . New York: Guilford Press; 2008.

7. Spink KS, Reeder B, Chad K, Wilson K, Nickel D. Examining physician counseling to promote the adoption of physical activity. Can J Public Health . 2008;99:26–30.

8. Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med . 2007;147:41–50.

9. Greene GW, Rossi SR, Rossi JS, Velicer WF, Fava JL, Prochaska JO. Dietary applications of the stages of change model. J Am Diet Assoc . 1999;99:673–678.

Copyright © 2011 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmservaafp for copyright questions and/or permission requests.

This page will be removed from your Favorites Links. Você tem certeza?

Want to use this article elsewhere? Get Permissions.

Artigos relacionados.

Editor's Collections.

Related Topic Searches.

MOST RECENT ISSUE.

Access the latest issue.

Alertas de E-mail.

Don't miss a single issue. Sign up for the free FPM email table of contents and e-newsletter.

Forex zlecenia przeciwstawne.

Target 1 - Health systems will be strengthened to ensure sustained delivery of effective and comprehensive, patient-centred cancer control programmes across the life-course Target 3 - Global tobacco consumption, overweight and obesity, unhealthy diet, alcohol intake, and levels of physical inactivity, as well as exposure strategies other known risk factors will have fallen significantly Target 4 - The cancer causing infections human papillomavirus HPV and hepatitis B virus HBV will be covered by universal vaccination programmes.

In many countries, negative public perceptions and stigma lifestyle with lifestyle stifle strategies public discussion and perpetuate misconceptions about this disease. This obstructs efforts to raise awareness about cancer prevention, healthy behaviours and seeking early diagnosis for signs and symptoms.

Individuals and communities need to be made aware that at least one third of the most common cancers can be prevented through reducing alcohol consumption, healthier diets and improved physical activity levels. Beyond the four common risk factors, protection from ultraviolet UV radiation is also critical for skin cancer prevention.

Additionally, occupational and environmental exposures including to asbestos, contribute substantially to the cancer burden. Several of the most common cancers such as liver and cervical cancers are associated with infections healthy HBV and HPV, respectively. Media Cancer Day Home About World Cancer Day Our Supporters Frequently Asked Questions FAQ Background Information Media Press releases Get Involved Map of Impact Materials Using our materials Stories Share your story Strategies, United Kingdom Alejandra, Mexico Alisandra, Singapore Alison, United States Anabel, Cuba Antonia, United Kingdom Bahija, Morocco Benjamin, Germany Biemba, Zambia Binta, Nigeria Brunella, Italy Cara, Media Catalina, Spain Cathy, Australia C.

Eunetta, Antigua and Barbuda Chaikhwa Nani, Botswana Dahlia, United States Deni, South Africa Elija, Finland Ethan, United States Gisella, Peru Ian, United Kingdom Isabel, UK Jamshed, Pakistan Jen, Promote States Jennifer, United Kingdom Jessica, Canada Jessica, United Kingdom Jessika, United States Jheric, Philippines Joanne, Canada Julia, United States Kirungi, Rwanda Leslie, Promote Rico Luigia, Italy Lumepa, Samoa Manuel, Portugal Marcella, El Salvador Maria, Argentina Paul, Rwanda Paul, UK Rebecca, Media Sallahuddin, Pakistan Options, Kenya Sandra, United States Sharon, United States Sharron, United Kingdom Sophia, Bangladesh Simon, Canada Susanne, Media Tina TfailUnited States Trudi, Australia Usha, Canada Will, United Kingdom Vicky, Greece Yasmine, Indonesia.

Search Lifestyle form Search. The World Cancer Declaration Targets to be that by Meeting this challenge is not beyond us if we work together to: Meeting The Challenge Empowering individuals media the right to health The right to health is enshrined in the Universal Lifestyle of Human Rights and embraced by the international community.

Promoting an enabling healthy for healthy living in our communities The conditions in which people live and work influence their capacity to choose healthy lives. A whole-of-government approach promote essential to develop and implement evidence-based policies, laws and programmes that reduce the level of exposure to lifestyle factors for cancer and make it easier for individuals to adopt healthy lifestyle choices.

For example, tobacco taxation has been identified as the strategies most important population-wide measure that governments healthy take to reduce major risk factors for NCDs. Action must go beyond the health sector to include education, sport, urban planning and agriculture. For example, schools can foster a health - promoting culture by providing healthy meals, facilities for recreation and include nutrition and physical activity in core curricula.

Investing in health systems that support that lives For governments, investing in prevention of cancer is cheaper than dealing with the consequences. For example, the HPV vaccine should be considered as a platform to improve options health together with other public health interventions such as reproductive options and nutrition and education. Similarly, HBV vaccination should be integrated into reproductive, maternal, newborn, and child health RMNCH services as part of routine post-natal care.

The recently launched Promote Cancer Control Partnership ICCP portal aims to strategies countries by providing best practice promote and a searchable database of published NCCPs It is Not Beyond Us to meet the challenge options Governments realise that investing in prevention of cancer healthy cheaper than dealing with the consequences.

Children and adolescents are included in policies and strategies that promote options behaviours. Healthy and HPV vaccines are offered as part of national immunisation schedules to prevent infection and to reduce the human and financial toll of liver and cervical that in countries with high rates of incidence. All schools and workplaces take measures that make healthy choices the default choice. Technical support and best practice resources are available to assist all countries to implement global NCD commitments as part of a national cancer control plan.

Individuals, families, health professionals, policy makers that politicians are aware that with the right strategies, around a third of cancers can be prevented through diet, physical activity and being a healthy weight. Show the world that we can, I can… get involved in the fight against cancer.

Contact Us Advisory that Media WCD Report Past WCD Resources Terms and Conditions.

2 thoughts on “Media strategies that promote healthy lifestyle options”

Record depreciation using a 5-year life on the equipment, the straight-line method, and no salvage value.

Bunnel himself, the man who actually discovered and named Yosemite Valley.

4 Steps to a Healthy Lifestyle.

Test yourself: How do your habits measure up?

WebMD archives content after 2 years to ensure our readers can easily find the most timely content.

">From the WebMD Archives.

Think you're leading a healthy lifestyle? Aside from occasionally veering off the path, most of us think we do a fair job of maintaining our health with good (or at least OK) eating habits and physical activity whenever we manage to fit it in. But is that enough to be considered "healthy?"

According to a recent study, very few adults actually meet the criteria for a healthy lifestyle. The study, published in the Archives of Internal Medicine, showed that only 3% of American adults got a perfect score on what the authors say are the four basic criteria for healthy living. Just 13.8% met three of the criteria; 34.2% met only two criteria. Women scored slightly better than men.

See how well you measure up on the researchers' four keys to healthfulness:

Do you smoke? Are you able to maintain a healthy weight (a BMI of 18-25), or are you successfully losing weight to attain a healthy weight? Do you eat at least 5 servings of fruits and vegetables daily? Do you exercise 30 minutes or more, 5 times a week?

The good news is that these behaviors should not be foreign to you, as all but one are an integral part of the Weight Loss Clinic. Numbers 2 through 4 are the foundation of the WLC program, habits that we continually discuss, write about, and recommend.

Everyone knows smoking is bad for your health. If you are one of the lucky ones who never became addicted to nicotine, pat yourself on the back. Smokers, I hope you are working diligently to kick your habit. It's impossible to underestimate the importance of a smoke-free life for your health -- as well as for the sake of those around you.

4 Steps and More.

While those four habits are indisputably important for a healthy lifestyle, some may argue that more factors should be taken into consideration. What would be on your list?

Just for fun, I came up with my own personal top 10 list of healthy behaviors (beyond the four basics) that contribute to wellness and satisfaction with one's lifestyle:

Brush and floss daily to keep your teeth and gums healthy and free of disease. Get a good night's rest . Well-rested people not only cope better with stress, but may also have better control of their appetites. Research has shown that a lack of sleep can put our "hunger hormones" out of balance -- and possibly trigger overeating. Enjoy regular family meals . This allows parents to serve as good role models, can promote more nutritious eating, and sets the stage for lively conversations. Being connected to family and/or friends is a powerful aspect of a healthy life. Smile and laugh out loud several times a day . It keeps you grounded, and helps you cope with situations that would otherwise make you crazy. Read the comics, watch a sitcom, or tell jokes to bring out those happy feelings. Meditate, pray, or otherwise find solace for at least 10-20 minutes each day. Contemplation is good for your soul, helps you cope with the demands of daily life, and may even help lower your blood pressure. Get a pedometer and let it motivate you to walk, walk, walk . Forget about how many minutes of activity you need; just do everything you can to fit more steps into your day. No matter how you get it, physical activity can help defuse stress, burn calories, and boost self-esteem. Stand up straight . You'll look 5 pounds lighter if you stand tall and tighten your abdominal muscles. Whenever you walk, think "tall and tight" to get the most out of the movement. Try yoga . The poses help increase strength and flexibility and improve balance. These are critical areas for older folks especially, and both men and women can benefit. Power up the protein . This nutrient is an essential part of your eating plan, and can make up anywhere from 10%-35% of your total calories. Protein lasts a long time in your belly; combine it with high-fiber foods and you'll feel full on fewer calories. Enjoy small portions of nuts, low-fat dairy, beans, lean meat, poultry, or fish. Last but not least, have a positive attitude . Do your best to look at life as if "the glass is half full." You must believe in yourself, have good support systems, and think positively ("I think I can, I think I can…") to succeed.

It's All about You.

Your list of healthy lifestyle behaviors may be different from mine. The most important thing to remember is that you can make a difference in your health and well-being. Take charge of your life, and be mindful of small behavior changes that can make your lifestyle a healthier one.

SOURCES: Archives of Internal Medicine, April 25, 2005.

Today On WebMD.

Boost Your Metabolism.

10 ways to do it.

Belly Fat: Best & Worst Foods.

Do you know what to eat and what to avoid?

Worst Sandwiches.

Avoid these double-fisted diet wreckers.

Best Diet Tips Ever.

22 ways to stay on track.

Recomendado para você.

9 Seeds You Should Be Eating.

9 Ways to Eat Clean.

Foods You Can't Stop Eating -- But Should.

Lose Weight Without Dieting.

Worst Restaurant Meals.

Surprising Reasons You're Gaining Weight.

What Is a Gluten-Free Diet?

Truth About Sugar Cravings.

Fat-Fighting Foods.

25 Low-Calorie Snacks.

High-Protein Diets.

Low-Carb Snacks.

Ferramentas e Recursos.

Health Solutions.

More from WebMD.

Sobre.

WebMD Network.

For Advertisers.

&cópia de; 2005 - 2018 WebMD LLC. Todos os direitos reservados.

WebMD does not provide medical advice, diagnosis or treatment.

Hotline Information.

Suicide Prevention Information.

Learn about Advance Directives.

Why Give to DBSA.

Annual Reports & IRS 990.

Donor Privacy Policy.

Individual Giving.

Bequests & Planned Giving.

DBSA Ambassador Program.

Our Community Partners.

Learn about our upcoming programs, services and ways you can become involved.

Click here to sign-up.

Mood Disorders.

Educational Materials.

Treinamento & amp; Consultation.

Find a Professional.

Finding the Right Treatment.

Personal Wellness Tools.

Research Studies.

Find a Support Group.

Young Adults.

Peer Inspiration.

Support Locator.

DBSA Chapters & Support Groups.

What they DoFind a Support GroupStart a ChapterDBSA State OrganizationsChapter Spotlights Help Others.

Advocate for Mental Health.

Helping Someone with a Mood Disorder.

Becoming a Peer Provider.

Learn About Peer SpecialistsJoin the Peer Leadership Center About DBSA.

About DBSA.

For the Media.

Healthy Lifestyles:

Improving and Maintaining the Quality of Your Life.

You Have the Power to Change.

Whether you are newly diagnosed with a mood disorder or have been managing depression or bipolar illness for years, you can benefit from a healthy lifestyle. While you cannot change your diagnosis, you can change aspects of your life to manage or lessen your symptoms and improve the quality of your life.

When you were first diagnosed with a mood disorder, you may have felt powerless or afraid. This page will suggest ways to empower yourself and play an active role in the way you live day-to-day with your illness. Regular appointments with your health care provider and attendance at DBSA support group meetings, in addition to the suggestions outlined here, can put a healthy lifestyle within your reach.

This web page was developed from a survey of DBSA support group members—people living with a mood disorder just like you—as a resource on the lifestyle issues they said were of greatest concern. Add a few ideas of your own, or ask for suggestions from your doctor or DBSA support group. Use the checklist found at the end of this page to periodically evaluate your lifestyle. Many of the suggestions detailed here may become habits after a period of time, and healthy habits help build a healthy life.

Reducing Stress.

Stress can cause or worsen symptoms of mania or depression. It is important to learn what causes your stress, ways to identify and deal with stressors, and ways to minimize your day-to-day stress level. Stress may be caused by a variety of factors, both external and internal, some of which you may not be aware of. Repeated or constant stress can lead to tension, chronic pain, anxiety, and an inability to enjoy life. With the right treatment and therapy, you can learn to anticipate and deal with stress, and with support, you can work on breaking out of stressful patterns or situations.

Recognizing and Handling Causes of Stress.

Learn how to recognize causes of stress, such as difficult people, financial matters, noise, lack of time, or high pressure situations. Review your daily activities periodically in search of triggers you may not be aware of look for patterns in your symptoms and stress levels. You may want to discuss your stressors with your doctor or therapist.

Keeping a journal of the time of day and what you were doing when you felt stress can be helpful. Many people have also found a mood calendar to be a great help. DBSA offers a personal calendar to track symptoms of mania and depression, mood swings, medications taken, and co-existing symptoms. You can also go online and use our free DBSA Wellness Tracker, an interactive tool designed to chart your moods, symptoms, lifestyle, medication, and overall physical health. It allows you to generate reports to see trends or patterns in your health that you can share with your health care provider.

Whenever possible, develop ways to control when and where you deal with stressful situations or people, choosing times when you are as calm and rested as possible.

Develop ways to prepare yourself for stressors that can’t be avoided, such as talking with a trusted friend before dealing with a stressful situation, setting aside time to be alone after stressful incidents, or taking a break during the day for a brief rest or meditation.

Canceling or postponing a stressful encounter if you are not feeling well is a legitimate way of taking care of yourself.

Communication.

Arrange to have a supportive buddy (possibly someone from your DBSA group) and set aside time to talk to one another about stressful issues and offer support and guidance.

When things are troubling you, talk about them with a trusted friend, family member, or health care provider before stress builds up and leads to a crisis.

If you are not ready to talk about a troubling issue, write down your feelings and thoughts in a journal or on paper you throw away. Writing can be a good release, and reading your journal entries over a period of time can give you some insights into some of your thought, feeling, or behavior patterns.

It may be easier for you to express yourself through music, art, or other creative activities. It is not necessary for you to worry about the quality of your work or share it with anyone when you are finished.

Relaxation.

Allow yourself to relax and set aside time for relaxation. Make a commitment to spend some time relaxing at the same time each day or week. Write it on your schedule or calendar if you need to be reminded.

Experiment with different relaxation methods until you find the one that is right for you. Here are some methods that have worked for others:

Walking Listening to music Light exercise, such as dancing or bicycling Breathing, muscle tension, or visualization exercises. These involve taking deep breaths and concentrating on your breathing; or tensing, then relaxing muscle groups one by one, from toes to head; or visualizing a calm, safe, stress-free place. Ask a therapist for suggestions or instructions. Meditation or yoga Music Art.

Spend some time using your relaxation techniques immediately before or after stressful events.

Don’t use alcohol or illegal drugs to cope with stress.

Other Stressors.

Evaluate your money management and ask yourself if it could be contributing to your stress level. Learn ways you can get out of debt. Consider budgeting: calculate the money you need for fixed monthly expenses such as rent/mortgage, utilities, transportation, and food, and try to set aside money for these things before the bills are due.

Evaluate your time management and ask yourself if it could be contributing to your stress level. Consider keeping a personal planner or calendar. Leave notes for yourself as extra reminders of important tasks, phone calls, or appointments.

Set realistic expectations for yourself. No one can do it all. Perfection is impossible, yet many people believe they must be perfect and put themselves under stress trying to achieve perfection. Work on accepting yourself as you are and not punishing yourself for your mistakes. Concentrate on being satisfied with your accomplishments rather than feeling inadequate because of things you have not done. Break large tasks down into small, manageable steps.

Physical Well-Being.

Healthy sleeping, eating, and physical activity habits do not have to be complicated, depriving, or uncomfortable, and can make a big difference in the way you feel. Many people have found that simple changes, such as eliminating caffeine or taking walks regularly, have helped stabilize their moods. Though symptoms of your mood disorder may disrupt sleeping, eating, or physical activity, making things as consistent as possible, especially sleeping, can help keep your symptoms from worsening. Regular habits can also help you spot the beginning of a manic or depressive episode more quickly.

Lack of sleep or too much sleep can worsen moods. Keep a regular sleep schedule whenever possible. Set an alarm if necessary, and try to get up at the same time every morning, even on weekends, and go to sleep around the same time every night. If you tend to have insomnia, try avoiding naps during the day, since they can interfere with nighttime sleep.

Adopt bedtime rituals or ways that you can slowly wind down from your day and ease yourself into bed. Try using relaxation exercises to get to sleep.

Avoid over-the-counter sleep medicines, unless your doctor has recommended them and is monitoring your use of them.

Avoid caffeine, especially near the end of the day. Check ingredients. Certain sodas and teas can contain as much caffeine as a cup of coffee. Large meals may keep you awake; light snacks may help you sleep (milk and turkey are often helpful).

Changing the time of day you take your medication may help you sleep. Discuss your medication, its side effects, dosage, and time of day taken with your doctor.

If at all possible, avoid late evening or overnight shift work. If you must work a late shift, try to work the same hours every night, so you are asleep at the same time and for the same amount of time each day.

If you wake up early in the morning and are unable to get back to sleep, it may be helpful to get out of bed and do a quiet activity like reading.

If you find yourself needing significantly more or less sleep than usual, you may be experiencing symptoms of depression or mania. Be aware of any changes in your sleep patterns and discuss them with your doctor or mental health professional.

Eating Right.

Eat a variety of foods daily to get the energy, protein, vitamins, minerals, and fiber you need. Include plenty of vegetables and fruits (preferably raw) and whole grains.

Moderate your intake of fat, cholesterol, sugars, and salt.

Drink at least 8 glasses (64 oz.) of water per day, or more if you exercise. If you are taking certain types of medication, you may require even more water. Check with your doctor or pharmacist.

Moderate your intake of alcohol and caffeine, or better yet, avoid them completely.

Avoid crash diets that deprive you of food or of one or more food groups. Instead of radical diets, use a combination of regular physical activity and smaller portions at mealtimes if you are concerned about your weight.

Be aware of changes in your appetite. Loss of appetite or overeating may be symptoms of depression. Discuss any changes with your doctor.

Don’t skip meals, even if your energy and appetite are low.

If you tend to overeat, look for stressors or triggers that may cause overeating. Discuss ways to avoid or cope with these triggers with your doctor or therapist. It may be useful to write down how you are feeling or what has been happening at the time you overeat to help determine your triggers.

Have food on hand that is healthy, quick, and easy to eat, such as fresh fruit, yogurt, whole grain bread, crackers, or bagels for times when you are in a hurry or don’t feel like preparing a meal. Try to schedule regular grocery shopping trips so you don’t have to eat fast food or junk food just because you are hungry.

Choose a method of physical activity that you enjoy—one that will not feel like a chore. You may want to choose several activities so you have variety.

Focus on making the experience as pleasant as possible. For example, if you feel self-conscious exercising in a gym or outdoors, begin by exercising at home. If you feel you need extra motivation or company, try exercising with a friend or family member.

Consult your doctor before beginning any exercise regimen. Do not choose a method of exercise that puts your health at risk. Consider all of the medications you are taking and be sure that factors such as increased heart rate and sweating will not cause problems with your medication. You may need to take special precautions when you exercise, such as drinking extra water.

Start slowly and work up to a healthy frequency. Pace yourself so you don’t run out of energy and become discouraged early.

Don’t ignore your own physical limitations or exercise to the point of pain.

A good exercise goal to work toward is 30 minutes per day, 3 times per week.

Work more physical activity into your daily routine. Take the stairs instead of the elevator, get off the bus before your stop and walk an extra block, or park at the far end of the parking lot.

A good treatment plan is the foundation of a healthy lifestyle. Though it may take time to adjust to medication and therapy, they are your best defenses against symptom recurrence. Everyone has a different physical and emotional makeup, so it often takes time and patience for you and your doctor or mental health professional to find the right treatment strategy for you. It is most important that you communicate your needs to your health care providers and work with them to discover the best possible approach to symptom management. Your loved ones can play an important role in your treatment plan, too. You can help them to help you by making them aware of your medication needs and having them watch for signs of symptom recurrence.

Your Health Care Provider.

Talk with your doctor about your medication and any side effects you may be experiencing. It may be helpful to write down your questions and bring your list with you to your appointment. Take notes on what your doctor tells you.

If you have trouble talking about particular concerns, you may want to bring a trusted friend or family member to the appointment with you or request that your appointment begin in the doctor’s office rather than the examination room. If you need extra time to discuss particular concerns, let the doctor’s office know when you make your appointment. If questions arise after your appointment and your doctor is unable to speak with you, see if a nurse is available to address your concerns.

If you are dissatisfied with your health care provider or the treatment plan you have been given, talk with him or her about it. If your difficulties cannot be resolved, seek another health care provider. For interpersonal or talk therapy, choose a therapist who treats you with respect, listens to you, recognizes your needs, and is skilled in treating people with mood disorders.

Medication.

Learn the facts about medication from your doctor, pharmacist, and DBSA. Ask your doctor or pharmacist to give you the detailed written materials that are packaged with your medication. DBSA also publishes several brochures describing the various treatment options. Know what side effects to expect and what to do if these side effects interfere with your daily activities. Talk to your doctor about ways to minimize any uncomfortable side effects. If you have particularly troublesome side effects, see if other treatment plans are available.

Never stop taking medication or alter your dosage without talking to your doctor first. Never augment your medication with herbal or over-the-counter remedies without first checking with your doctor.

Know what time(s) of day to take your medication(s) and take them at the same time every day. If you have trouble remembering, use a wristwatch with an alarm or place a reminder note in a highly visible place.

Find out if there are any specific foods or activities you need to avoid. Some medications may reach high levels in the body if you become dehydrated or sweat excessively. Others may react with certain foods or alcohol or may cause you to be sensitive to sun or light.

Support and Symptom Monitoring.

Keep track of your symptoms using a journal or DBSA’s mood calendar mentioned above in the Reducing Stress section. Learn to recognize patterns and combinations of symptoms that may indicate that you are or may soon be having a manic or depressive episode. Inform your health care provider and loved ones when you feel your symptoms increasing and ask them to observe your behavior.

If you are experiencing symptoms of mania or hypomania, have someone else hold on to your credit cards, bank documents, and car keys. Avoid shopping, gambling, or drinking, and try to maintain a regular sleep schedule. Your doctor may prescribe additional medication.

If you are experiencing symptoms of depression, try to avoid isolation by scheduling brief, manageable meetings or outings with others. Adjust your activity schedule so that you are not overwhelmed, but have small things to do each day. Have loved ones lock away or remove anything you might use to harm yourself.

Write down a plan of action to follow if your symptoms become severe and you are unable to take part in day-to-day activities. Include the names of your health care providers, medications you would and would not prefer to be given, facilities where you would and would not prefer to be treated, and other important information, such as medication allergies. Also include necessary insurance information such as provider, group number, and phone number.

Write down directions for care of your children and/or pets, as well as a way to notify your employer and the things to tell him or her in the event that you are unable to function or need to be hospitalized.

Make a list of symptoms that may indicate trouble:

Self-destructive behavior Abusive or violent behavior Extreme agitation or irritability Grandiose ideas An increase in compulsive behaviors, spending, gambling, sexual activity, or substance abuse Major changes in sleep habits, inability to get out of bed, or decreased need for sleep Thoughts or threats of suicide.

If you are thinking about death or suicide, go to a hospital emergency room or contact a medical professional or a capable loved one or friend immediately.

Consult your health care provider to determine whether you should develop a medical advance directive, and consult legal counsel to determine if a statement of Power of Attorney is appropriate.

Relationships.

Living with a mood disorder can make it difficult to maintain friendships, family relationships, and intimate partnerships. Relationship trouble may arise from unpredictable or careless behavior during manias or social withdrawal during depressions, and may be made worse by others’ lack of understanding of mood disorders. Though you may feel lonely and isolated at times, you are not alone—almost everyone who has dealt with a mood disorder has been frustrated by interpersonal difficulties. Education, communication, and acknowledgement of feelings are some things to keep in mind when working to build or rebuild relationships.

Volunteer, join community activities, take classes, or find other ways to involve yourself socially. Attend your DBSA group regularly and participate in social events the group holds. If there is no group in your area, consider starting one. There are surely other people near you who need support. DBSA can help you take the first steps.

Educate your friends about your illness and explain that it may cause you to have mood swings or act in ways they are not used to seeing you act. Be honest about your needs and limitations.

Be aware of, or ask others to watch for, inappropriate behavior on your part, such as talking incessantly or being demanding, and be open to constructive criticism from friends. Rather than becoming defensive when someone points out such behaviors, consider their comments and try to learn from them.

If you are going through a period when you need extra support, try to depend on more than one of your friends. You will get a variety of perspectives and avoid wering out one friend.

Share your progress and stable moods with the friends who have supported you.

Show that you are determined to work on managing your symptoms and demonstrate to your family that you are following your treatment plan. Try to keep a positive attitude. Often, your family will reflect it back to you.

Encourage your family to get support, too. They can discuss their reactions to your diagnosis, symptoms, or behavior and ask questions with a qualified therapist or at a DBSA support group meeting.

Let your children know they are not to blame for your illness. Explain this to them while keeping their developmental level in mind. For young children, it may be easier to say you aren’t feeling well or that you are taking medication to help you feel better. Older children can also be affected. They may be concerned about who will take care of them or what they can and can’t depend on. They may be more focused on how your mood disorder affects them than how it affects you. If they do not understand that your mood disorder is an illness, you may want to explain that you are going through a very difficult time but are getting help, and still care very much about them.

If your child is diagnosed with a mood disorder, educate the entire family about the illness, work to reduce stress in the home, and improve your listening and communication skills. Help your child learn relaxation and coping methods and work for stress reduction and other accommodations at his or her school. Find a doctor who is knowledgeable about mood disorders in children.

Consider family therapy as a way to discuss the changes that are happening and develop ways you and your family can help one another.

Set aside some time for you and your partner to be alone together with as few distractions as possible. This may mean taking a walk together in the morning, having dinner together, or just lying down quietly together at the end of the day.

Consider couples therapy, where feelings and fears can be expressed in a safe manner. Your partner can offer another perspective to your therapist and help you make use of your therapist’s suggestions in your day-to-day life.

Be open with your partner about any sexual side effects of your medications. If you experience sexual dysfunction, work on non-sexual intimacy, such as touching and holding.

Be open with your doctor about any sexual side effects of your medications. Be aware of changes in your sex drive and discuss them with your doctor to determine whether they are side effects or symptoms of your illness. If you feel uncomfortable talking about sexual issues, it may be helpful to use techniques, such as writing down your concerns beforehand or talking to your doctor in his or her office rather than the examination room.

Mood disorders can affect people on the job in many ways. Sometimes it may be necessary to reduce work hours or stop working completely in order to deal with depressive or manic symptoms. Other times, work is not a problem, but questions may arise about how open to be about your illness.

It is important to be in a work environment that is not uncomfortable or unduly stressful and does not aggravate your symptoms. If you are not employed, volunteer activities can help you maintain a daily routine, provide contact with others, and give you a sense of accomplishment. Whether you are employed part-time, full-time, unemployed, or involved in volunteer work, it can be helpful to consider your stress level and needs for accommodation as well as your unique skills and long-term goals.

Don’t let past setbacks keep you from pursuing your goals. Though you may not have the job you originally planned, you can still do satisfying, rewarding work.

If you have been unemployed for significant periods of time, emphasize your skills on your resume rather than your employment dates.

Be aware of factors that may help or hinder your work.

Assess your skills.

Look at classified ads for jobs you would like to have and make a list of qualifications needed for each one. Find out what you have to do to obtain the needed skills for your ideal job(s) and what jobs or education may help you learn or improve those skills.

Find out if your community offers job training programs or placement services.

Pace yourself and conserve your energy. Working part-time for a while is better than working overtime and exhausting yourself right away.

Be alert for symptoms of worsening mania or depression. If you are worried that they may significantly interfere with your job or put you or your co-workers in danger, take the day off and arrange to see your doctor or mental health professional as soon as possible.

Talking with Your Employer About Mood Disorders.

However, if you need accommodation on the job, such as shorter hours, a different start time, more frequent breaks, or extended time off, you may need to be honest with your supervisor. Set up a meeting with him or her and bring the facts (including written educational materials, if you want) about your mood disorder. Consider asking your doctor or therapist to write a letter on your behalf. Know your rights. If you think you have been discriminated against in a hiring or employment situation, find out the facts and the next steps to take from the Equal Employment Opportunity Commission (EEOC).

A healthy lifestyle can be yours.

Paying attention and making changes to aspects of your life, such as stress management, physical fitness, medical treatment, relationships, and daily job or volunteer activities, can have far-reaching positive effects on your mental and physical health. There is no right or wrong way to go about making these changes and you can make them at your own pace. The right healthy lifestyle plan is the one that works best for you.

Personal Wellness Checklist.

I know my biggest stress triggers. Eles são:

Wellness Options.

Finding the Right Treatment.

Recovery Steps.

Partnering with a Clinician.

Medications.

Technological Devices.

Support Groups.

Personal Wellness Tools.

Facing Us Clubhouse.

DBSA Wellness Tracker.

Wellness Toolbox.

Preparing for a Crisis.

Research Studies.

Learn About Research Studies.

Find Research Studies.

Peer Support Research.

WeSearchTogether.

OUR MISSION: DBSA provides hope, help, support, and education to improve the lives of people who have mood disorders.

The Power of Peers.

DBSA envisions wellness for people who live with depression and bipolar disorder. Because DBSA was created for and is led by individuals living with mood disorders, our vision, mission, and programming are always informed by the personal, lived experience of peers.