The Pennington Biomedical Research Center Prevention of Childhood Obesity Laboratory

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Welcome Supersized The Problem of Obesity in
Vermont
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Overweight ObesityHealthy Vermonters 2010
Goals and Challenges

• Jan K. Carney, MD, MPH
• Vermont Department of Health

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Facts

• Being overweight substantially increases risks
  for diseases such as
• High blood pressure
• Type 2 diabetes
• Osteoarthritis
• Heart disease and stroke
• Certain cancers

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BMI Body Mass Index
BMI (Body Mass Index) 704.5 times weight (in
pounds) divided by height (in inches) squared
(wt/ht2)
Over Healthy Weight BMI of 25 or more
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Facts

• In Vermont
• 53 of adults are obese or overweight
• that translates to about 226,615 Vermonters above
  a healthy weight

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Facts

• The percentage of obese adults in Vermont has
  increased 71 percent since 1990.

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Facts

• In Vermont
• 23 of youth in grades 812 are overweight or
  close to becoming overweight
• that translates to about 7,110 students

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Facts

• Even modest weight loss by overweight individuals
  can decrease their risk for these diseases.

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Healthy Vermonters 2010 Objectives

• Reduce the percentage of adults age 20 who are
  obese.
• Goal 15 VT 2000 18

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Healthy Vermonters 2010 Objectives

• Reduce the percentage of youth who are obese or
  overweight.
• Goal 5 VT 2001 10 (grade 812)

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Facts

• Achieving and maintaining a healthy weight
  requires a balanced, reduced-calorie diet and
  increased physical activity.

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Physical Activity Nutrition
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2000 Dietary Guidelinesfor Americansfrom USDA
and US Department of Health and Human Services

• Aim for fitness, aim for a healthy weight and be
  physically active each day.
• Choose a variety of grains daily, especially
  whole grains.
• Choose and prepare foods with less salt.

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2000 Dietary Guidelinesfor Americans

• Choose a variety of fruits and vegetables daily.
• Select fresh, frozen, dried and canned products
  to obtain five or more servings of fruits and
  vegetables daily.
• Maintain a diet with no more than 30 percent of
  calories from any type of fat.

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Healthy Vermonter 2010 Objectives

• Increase the percentage of people who eat 2
  daily servings of fruit.
• Goal 75 VT 1998 50
• (age 18)
• VT 2001 41
• (grades 812)

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Healthy Vermonter 2010 Objectives

• Increase the percentage of people who eat 3
  daily servings of vegetables.
• Goal 50 VT 1998 41
• (age 18)
• VT 2001 16
• (grades 812)

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Facts

• Physical activity and healthy eating decrease the
  risks for premature heart disease, stroke, high
  blood pressure, cancer, diabetes, arthritis and
  osteoporosis.
• Regular activity helps build and maintain healthy
  bones and muscles, controls weight, reduces
  feelings of depression and anxiety, and promotes
  well-being.

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Facts

• Television viewing (and now computer use) is the
  primary sedentary leisure activity in the U.S.
• In Vermont, 18 percent of students in grades 8 to
  12 spend five or more hours each day watching TV
  or playing video games or using computers for fun.

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Facts

• School physical education programs can increase
  participation in physical activity and help
  students develop the knowledge, attitudes and
  skills they need to engage in lifelong physical
  activity.

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Healthy Vermonter 2010 Objectives

• Increase the percentage of adults age 18 who
  engage in regular physical activity.
• Goal 50 VT 2000 33

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Healthy Vermonter 2010 Objectives

• Increase the percentage of middle and high
  schools that require daily physical education for
  all students.
• Goal 25 VT Data Not Available

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U.S. Surgeon Generals Recommendations on
Physical Activity and Health

• People of all ages benefit from a moderate amount
  of daily physical activity (30 minutes of
  exercise five or more times a week).
• Physical activity need not be strenuous to be
  beneficial.

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Where Do We Begin
Strategies for Healthier Children

• Melinda S. Sothern, PhD
• Prevention of Childhood Obesity Laboratory
• Pennington Biomedical Research Center
• Louisiana State University
• Department of Pediatrics
• LSU Health Sciences Center

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When most of todays parents were kids

• There were no computers, video games, cable TV
  and few fast food restaurants.

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Today U.S. Children watch TV an average of 20 to
30 hours per week.
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Hard to Swallow Food Facts

• Americans eat out an average of 3.7 time per week
• 57 of American eat away from home every day.
• 1/3 of those eating out eat fast food.
• Soft drink intake increased 500 in the past 50
  years.
• 40 of males 12-59 years eat fast food daily.

Ludwig, 2001 Gallup, 1990Barlow Dietz, 1998
Borrud, 1997
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When most of todays parents were kids

• The family got together at dinnertime, sat at the
  kitchen table and ate a home cooked meal.
• Back then only 5-10 of Americas children were
  overweight.

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Increasing Prevalence of Overweight Children
gt85th percentile for Body Mass Index gt95th
percentile for Body Mass Index
Source U.S. Centers for Disease Control
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Prevalence of Obesity among U.S. Adults, BRFSS,
1985
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Prevalence of Obesity among U.S. Adults, BRFSS,
1995
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Prevalence of Obesity among U.S. Adults, BRFSS,
1999
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Reaching Epidemic Proportions Overweight
Children

• Overweight conditions are the most prevalent
  nutritional problems facing children from all
  racial-ethnic, age, and sex groups.
• Genetics plays an important role but, the
  family environment has the greatest impact on a
  childs weight condition.

Dowda, et al, 2001 Straus Knight,1999
Fogelholm, et al, 1999
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GENETICS PERMITS OBESITY.ENVIRONMENT CAUSES
OBESITY.
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When most of todays parents were kids

• Most kids spent their days riding bikes, climbing
  trees, and playing tag.

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If you let me play I will like myself more. I
will have more self confidence. I will be 60
less likely to get cancer. I will be 80 less
likely to get heart disease. I will be less
likely to become an obese adult.
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Health Consequences of Overweight Conditions
during Childhood

• High Cholesterol
• Insulin Resistance - Type 2 Diabetes
• Bone and Joint Disorders
• Asthma
• Sleep Apnea
• Low exercise tolerance
• Increased viral infections
• Premature maturation
• Psychological problems

Source Hill and Throwbridge, 1998
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Emotional Consequences

• The most serious and prevalent long-term
  consequence is psychosocial, i.e. depression,
  lowered self-esteem, social discrimination
• Overweight children are targets of early and
  systematic discrimination by peers, family
  members and teachers.
• Overweight children mature younger. Early
  maturation is associated with low self-esteem.

Source Hill and Throwbridge, 1998
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Prevention and Treatment of Chronic Diseases in
Childhood
Health Care
Family
Community
Government
School Environment
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HealthCare

• Identify children at-risk early in childhood and
  provide frequent monitoring.
• Behavioral therapy and parent training and
  education.
• Physician training.
• Affordable outpatient programs.
• Medical insurance reimbursement.
• Medical insurance incentives.

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Risk Factors for Obesity and Chronic Disease

• Socioeconomic Status
• Parental Obesity - under 6 years of age
• Body Mass Index - over 6 years of age
• Critical development periods
• Birth
• 5-6 years (adiposity rebound)
• Puberty (12-15 years of age)
• Sedentary Behaviors
• Birth Weight
• Formula versus Breastfeeding
• Poor Nutrition - Food Preferences

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Socioeconomic Status

• There is a striking relationship between obesity
  and social class.
• Obesity is 7 times more frequent among Caucasian
  women of the lowest socioeconomic level than
  among those of the highest level.
• There is a similar relationship in men, but to a
  lesser degree.

Moore, Stunkard, Srole, et al, Ob. Res., 1997
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Obese Parents

• If both parents are non-obese the child has only
  a 7 chance of developing obesity during
  adulthood.
• If one parent is obese the risk of developing
  obesity is increased to 40.
• If both parents are obese the risk for
  developing obesity doubles to 80.

Whitaker, et al, NE J Med, 1997
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As children mature, their weight condition is a
stronger predictor of adult obesity.
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80 of overweight 12 year olds will become obese
adults.
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0

Age 6
Age 12
Age 21
Parents Weight
Years
Childs Weight
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Diagnosing Obesity and Chronic Disease Risk

• History Physical exam
• Anthropometric measures
• Weight and height
• Waist, hip and midarm circumference
• Laboratory evaluation
• Chem 20 CBC w/diff lipid profile thyroid
  profile
• Blood pressure
• Maturation level (Tanner stage)

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Body Mass Index
The body mass index (BMI) adjusts body weight for
height using the following formula.
Weight (kg)/Height (m2) An adult with a BMI
score of gt 27 is considered overweight, gt
30 is considered clinically obese
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Diagnosing Childhood Obesity and Chronic Disease
Risk

• A Body Mass Index (BMI) gt85th percentile for age
  and race is classified as at risk for overweight.
• A BMI gt95th percentile for age and race is
  classified as overweight.

Source US Centers for Disease Control
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U.S.Centers for Disease Control Body Mass Index
Percentiles for Children and Adolescents
Healthy Weight 50th-85th
Severely Overweight gt 97
Age (yrs.)
At Risk for Overweight gt 85th
Overweight gt 95
5
15-17
gt 17
gt 18
gt 18
8
16-18
gt 20
gt 21
gt 18
11
17-20
gt 20
gt 23
gt 25
14
19-23
gt 23
gt 26
gt 28
17
21-25
gt 25
gt 28
gt 30
Males
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Diagnosing Obesity and Chronic Disease Risk

• Body composition
• Dual Energy X-ray Absorptiometry
• Skin folds
• Bioelectrical impedance
• Dietary history
• Physical activity rating
• Psychological measures
• Self esteem
• Depression
• Self-efficacy

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Body Mass Index 31 Weight 230 Height
60 Percent body fat 12
Body Mass Index 31 Weight 230 Height
60 Percent body fat 55
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Differences in Bone Density and Weight in
Overweight and Normal Weight Youth.

• 20 overweight
• children
• 20 normal weight children
• Age matched (12-17 years)
• DEXA

Olivier, Loftin, Sothern, 2001
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Sedentary Behaviors and Children
Physical Activity is Not Just Sports
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Young children will engage in various types of
physical activity if provided with an environment
that promotes free play.
DiNubile, 1993
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Spontaneous activity declines 50 between the
ages of 6-16 years.
DiNubile, 1993
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Overweight conditions are lowest among children
watching 1 or fewer hours of TV per day. In
females increased TV-watching is associated with
overweight conditions.
Crespo, et al, 2001 Dowda, et al, 2001
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Children and Television
Gortmaker, 1996 Hernandez, 1999
Hours of TV per Day
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Teen age girls are consistently shown to be less
physically active than teen age boys.
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Children and Sedentary Behaviors
Exercise Tolerance
Physical Activity
Snacking TV watching
Body Mass Index
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Overweight Children and Sedentary Behaviors
Physiologic Function
Physical Activity
Body Mass Index
Snacking TV watching
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Diagnosing Obesity and Chronic Disease Risk

• Exercise tolerance
• Graded treadmill test
• Indirect calorimetry
• Heart rate and blood pressure
• Field fitness test
• Shuttle run
• Strength and flexibility
• 80 maximum test
• Flex test

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Overweight youth compared to Values for Normal
Weight Youth (Age 12.4 years)
Parameter N Mean SD Normal Range
Percent Fat 24 43.1 27.1 lt30
Cholesterol 50 170.8 29.3 lt170
LDL 31 123.5 25.7
lt110
VO2Max 22 19.8 4.4
45-53
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Exercise Tolerance in Children with Increasing
Overweight Levels
O2 L/min
Four group repeated measures ANOVA p lt0.03
Sothern, et al, 1999
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Heart Rate during Walking in Children with
Increasing Overweight Levels
Normal Weight 37.8 of Maximum Heart Rate
Walking 3.5 mph
Overweight 47.8 of Max Heart Rate
Severe Obesity 85.3 of Max Heart Rate
Clinical Obesity 65.4 of Max Heart Rate
Sothern, et al, 1999
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30 Minute Rule

• Research indicates that after 30 minutes of
  mental work the ability to concentrate begins to
  decline.
• Sitting burns only 33-50 calories per
  hour.

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Anything is Better than Sitting!

• Flex at Your Desk
• Hot Seat (chair squats)
• Raise the Roof (overhead press)
• Stand and stretch
• Off the Wall (wall push-ups)
• Tippy Toes (calf raise)
• Music break (dance to one song)
• Stand like a tree and balance
• Reward positive behavior with indoor or outdoor
  play periods

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What is the Best Type of Physical Activity for
Preventing and Treating Chronic Diseases in
Childhood?
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The best physical activity is the type that
the child will actually do.
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Pediatric Expert Committee Recommendations to
Increase Physical Activity

• Intervention should begin early in overweight
  children gt3 years.
• Interventions should be family-based and include
  parenting skills.
• Limit TV-watching to lt2 hours/week
• Incorporate activity into usual daily routines,
  i.e. walking to school.
• Promote unstructured outdoor play in young
  children, individual or group sports in older
  children.

Barlow Dietz, 1998
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Initial Physical Activity Strategies by Medical
History, Age Weight Condition
Level
Age
Physical Activity Approach
Normal Wt Obese Parent
Family counseling, fitness education, free play,
reduce TV, parent training
? 6
gt85th BMI
Structured weight bearing activities, free play,
reduce TV, parent training
7-18
Alternate non-weight bearing activities, free
play, reduce TV, parent training
gt95th BMI
7-18
gt97th BMI
Non-weight bearing activities, free play, reduce
TV, parent training
7-18
Close medical supervision required.
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Provide opportunities for young children to
safely climb, run and jump to encourage the
development of muscular strength and endurance.
Sothern, 2001
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Children at Risk for Overweight Conditions, 7-18
Years

• Limit access to TV/video/computer
• Recommended Aerobic Activities
• Weight-bearing such as brisk walking, treadmill,
  field sports, roller blading, hiking, racket
  ball, tennis, martial arts, skiing, jump rope,
  indoor/outdoor tag games.
• NOTE Guidelines should be readjusted every
  10-15 weeks based on evaluation results.
• Parent training and fitness education

Sothern, 2000
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Overweight Children, 7-18 Years

• Limit access to TV/video/computer
• Recommended Aerobic Activities
• Non-weight-bearing such as swimming, cycling,
  strength/aerobic circuit training, arm specific
  aerobic dancing, arm ergometer (crank), recline
  bike, and interval walking.
• Walking with frequent rests as necessary.
  Gradually work up to longer walking periods and
  fewer rest stops.
• NOTE Guidelines should be readjusted every
  10-15 weeks based on
• Parent training and fitness education

Sothern, 2000
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Severely Overweight Children, 7-18 Years

• Limit access to TV/video/computer
• Recommended Aerobic Activities
• Non-weight-bearing only such as swimming, recline
  bike, arm ergometer, seated (chair) aerobics and
  seated or lying circuit training.
• NOTE Guidelines should be readjusted every
  10-15 weeks based on
• Parent training and fitness education
• Other emotional and dietary concerns must be
  addressed during treatment.

Sothern, 2000 Myers, et al, 1998 Strauss, 2000
Barlow Dietz, 199, von Almen, 1985
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PrescribedDuration of Exercise
Moderate Intensity Progressive Exercise
Min./ Session
90
Volume of Exercise in Severely Overweight
Children
Min.
p lt 0.0001
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What is the Best Dietary Strategy for Preventing
and Treating Chronic Diseases in Childhood?
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I do like vegetables Thats why I hate to see
them brutally killed and eaten!
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Pediatric Expert Committee Nutrition
Recommendations

• Well-balanced meals and a healthy approach to
  eating.
• Food guide pyramid
• Elimination of high calorie snacks
• Stoplight diet
• Gradual changes in food preparation to promote
  family support
• Stay away from adult-focused commercial programs.

Barlow Dietz, 1998
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Birth weight and Childhood Obesity

• Low birth weight is associated with obesity and
  Type 2 Diabetes later in life.
• Low birth weight may be due to intra-uterine
  growth retardation that results from poor fetal
  nutrition and/or stress.
• The impact of low birth weight may be exacerbated
  in susceptible populations especially those
  exposed to early environments conducive to
  obesity.

McGarry, 2002 Ong, 2000 Barker, 1995 Law,
1996 Neel, 1962
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Breast feeding and Childhood Obesity

• The prevalence of obesity in 5-6 year-old
  children who were never breast fed is almost
  double that of breast fed children.
• The risk of childhood obesity declines as the
  duration of breast feeding increases.
• Breast feeding is associated with improved immune
  function. Obesity has been associated with
  inflammatory disease.

Von Kries, 1999 Liese, 200 Das, 2001 Dietz,
2001
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Childhood Food Attitude and Practices

• How parents present foods to their young children
  greatly impacts their food preferences.
• Pressure to eat and concern for childs weight
  are associated with increased fat in children.
• If left unattended, young children will select
  foods they enjoy and leave behind the foods they
  dislike.

Birch, Ch. Dev., 1980 and 1995 Spruijt-Metz, 2002
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Childhood Food Attitude and Practices

• Providing rewards for eating nutritious foods
  initially enhances preference, but has a negative
  effect later when the reward is removed.
• Children will eat less if served less or if
  allowed to serve themselves.
• As the children mature, the parental influence is
  reduced and the influence of peers may change
  food preferences.

Birch, Ch. Dev., 1980 and 1995 Ob Res, 2001
98
The strategy of having a child eat a food in
order to obtain a reward tends to reduce the
childs liking for the food she is rewarded for
eating.
Childhood Food Preferences
Birch, Young Children, 1995
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Methods to Increase Vegetable Intake

• Three bite rule
• Grade the vegetables
• A excellent, lets have this more often
• C OK, well try again
• F No way
• Teach children that all food is OK. Some, such as
  vegetables, are grow tall food and others, like
  candy, are not.

Sothern et al, Trim Kids, Harper Collins, 2001
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Initial Nutrition Strategies by Medical History,
Age Weight Condition
Level
Age
Nutrition Approach
Family nutrition education and parent training
Normal Wt Obese Parent
? 6
Portion Control, balanced low fat, low sugar
plans
gt85th BMI
7-18
gt95th BMI
7-18
Balanced low calorie diet
gt97th BMI
Medically prescribed diet
7-18
Close medical supervision required.
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Comprehensive Weight Management Strategies in
Clinical Settings

• Multi-disciplinary, family based interventions in
  a clinical setting promote long-term (10-years)
  weight loss in young, overweight (gt85th BMI)
  children (Epstein, et al, 1988).
• Multi-disciplinary, family based interventions in
  a clinical setting promote significant weight
  loss over one year in obese (gt95th BMI) children,
  7-17 years (Sothern, et al, 1996-2000 clinical
  outcome trials).

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Overweight Children Treatment Intervention

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Hurray, Im there!
Im still at my goal weigh!
Committed to Kids Pediatric Weight Management
How long will it take?
Level IV lt 85th BMI
Team Kids Club
Level III gt 85th BMI
Level II gt 95th BMI
Level I gt 99th BMI
10 wks
20 wks
30 wks
1 year
18 yrs.
Start
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Weight and Body Mass Index after Diet, Exercise
and Behavioral Counseling




p lt 0.001 (RM ANOVA) Baseline vs. 10ks
1-year. NS 10 weeks vs. one year.
Sothern,et al, Acta Pedia, 2000
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The Impact of Significant Weight Loss on Selected
Physiologic Parameters in Youth

• Body Mass Index ?
• Percent Fat ?
• Lean Body Mass unchanged
• Resting Energy expenditure unchanged
• Oxygen Uptake (VO2)
• absolute unchanged
• relative ?
• Total Cholesterol and LDL ?
• Growth Velocity ??
• IGF-1 ?

Sothern, et al, 2000
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How to Promote Behavior Change

• Mastery Experiences For new behaviors to occur
  individuals must experience initial success.
• Physiologic Feedback Cues that enhance the
  ability to accomplish the behavior positive
  reinforcement for goals achieved.
• Role modeling Observational learning through the
  behavior of others.
• Knowledge Transfer Belief that the targeted
  behavior will benefit them.

Social Cognitive Theory Hunter, 1996 Sothern
Hunter, 1999
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Mastery

• Set short-term, achievable nutrition, physical
  activity and weight loss goals.
• Expose children to varied activities in a
  non-intimidating and nurturing environment.
• Encourage participation in aerobic activities
  appropriate for age and size.
• Realize that young children have immature
  metabolic systems. Dont impose adult exercise
  goals.

Sothern et al, Trim Kids, Harper Collins, 2001
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Physiologic Feedback

• Teach pacing techniques such as breathing and
  heart rate monitoring.
• The sight, smell and taste of food provide clues
  to recognize cravings from hunger.
• Re-evaluate the childs condition every 3-6
  months and provide activity rewards for goals
  achieved.
• Dont draw attention to unhealthy activities with
  negative comments. Instead, praise the child when
  they choose active play or healthy foods.

Sothern et al, Trim Kids, Harper Collins, 2001
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Knowledge Transfer

• Provide ongoing family fitness and nutrition
  education.
• Enroll children in structured dance, sport or
  movement classes. Make sure the teachers are
  qualified. And if the child is already
  overweight, discuss his or her condition
  beforehand with the teacher.
• Replace TV, computer, video games with indoor and
  outdoor play.

Sothern et al, Trim Kids, Harper Collins, 2001
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Role Modeling

• Families that play together, stay healthy
  together. Reserve at least 1/2 day of each
  weekend for family physical fitness.
• Parents dont have to be thin but they must set a
  good example by preparing and selecting healthy
  foods and participating in physical activities on
  a regular basis.
• Create and environment for active play both
  inside and outside the home.

Sothern et al, Trim Kids, Harper Collins, 2001
112
Family

• Observe the childs eating and physical activity
  behaviors.
• Schedule frequent sessions with the pediatrician
  for advice and monitoring.
• Discourage consumption of high sugar beverages.
• Select healthy fruits and snacks as treat foods,
  i.e. grapes, raisins, etc.

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Family

• Require that all drinks and foods be consumed at
  the kitchen or dining table or other designated
  area.
• Schedule mid-morning and mid-morning healthy
  snacks - make them attractive.
• Always require children to eat a healthy
  breakfast.
• Discourage snacking after dinnertime.

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Parent Tip
Even if your child is genetically designed to be
overweight, his or her environment can be
adjusted to combat this predisposition. Your
child may become chubby even with adjustments. He
or she does not have to be doomed to a life of
ill health. Weight management is the key.
Sothern, et al, Trim Kids, 2001
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School Environment

• Create a physically active school environment
• Increase free play or recess time.
• Offer daily physical education.
• Practice the 30-minute rule.
• Make academic classes more physically active.
• Decrease homework.

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Should Schools Diagnose Obesity?

• The diagnosis of obesity requires specific
  training in pediatric medicine.
• The body mass index is a first step in a series
  of obesity assessments.
• Labeling children as obese in front of peers may
  cause long term emotional damage.

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School Environment

• Encourage walking and biking to school
• 19 of students walk to school
• The two biggest barriers to walking to school are
  distance and traffic danger.
• In kids reporting no barriers, 64 walk and 21
  bike to school

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School Environment

• According to experts, too much homework can
  create family stress, cut into family time and
  foster tension.
• In Piscataway, New Jersey, the local school board
  recently voted to set firm limits on homework.
• Weekends and holidays are homework-free.
• Teachers give 1-hour assignments that children
  can try on their own.

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When Will the Children Play?

• Parents of overweight children report that the
  biggest barrier to getting their kids more
  physically active is too much homework.
• Teen age girls report homework as the no. 2
  barrier to being physically active.
• Overweight children between the ages of 6 and 17
  years report an average of 3 hours of homework
  per night.

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Time for Play School versus Home Environment
Children spend about 48 of their waking hours
in school related activities.
48 hrs/wk
70 hrs/wk
35 hrs/wk
15 hrs/wk
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Play Now! Homework Later!

• When children get home after school, their brains
  are tired, but not their bodies.
• Theyve had a long day in a sedentary environment
  and need to be active to let off steam
• Instead of a snack, hand your child a glass of
  water and send him outside to ride a bike, skate,
  play ball or tag for about 30 minutes. Indoors he
  can dance, shoot hoops with foam balls or skip
  rope.
• Then when he does homework, hell concentrate
  better.

Sothern et al, Trim Kids, Harper Collins, 2001
123
School Environment

• Create a nutritious school environment
• Replace vending machines with healthy
  alternatives.
• Allow consumption of water in class.
• Modify school lunch.
• Provide nutrition education in science, health or
  other academic class.

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School-time Food Facts

• 87 of schools offer vending machines.
• Vending machines offer
• Juice drinks and soda (81-88),
• Candy bars, cookies, chips (54-60)
• 31 of schools offer stores run by students.
• 80 of student-run school stores sell candy and
  no fruit, 47 are open during lunch.
• Snacks sold in school stores average 8.7 grams
  of fat and 23 grams of sugar

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Community

• Walking, bike and inline skating trails
• Walk to school programs
• Walking clubs, fun-runs, bike tours
• Safe neighborhoods
• More parks and green areas
• Recreation programs
• Nutrition and fitness education

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Government

• Social marketing
• Public policy changes to improve school, health
  care, and community environment
• Nutrition focused food stamp program
• Crime prevention
• Health care reform
• Minimal standards for recess and PE
• School lunch and snack policy

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How Can We Help?

• Parents Lobby to Promote Lifestyles for
  physically Active Youth.
• Let the children...
• P.L.A.Y.

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LAZY BOY
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for more information www.trimkids.com
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