Health Affairs, 25, no. 4 (2006): 992-1004 doi: 10.1377/hlthaff.25.4.992 © 2006 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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Prevention

Arkansas Fights Fat: Translating Research Into Policy To Combat Childhood And Adolescent Obesity

PROLOGUE: As noted in this volume, in Health Affairs’ 2002 Determinants of Health issue, and by numerous others, public investment in prevention-related policies and interventions has persistently received short shrift compared with direct medical care. This is the case despite a growing body of evidence revealing the dividends in cost savings and health improvement potentially available through increased policy focus on population health and prevention. The stakes involved could hardly be overstated. Statistics from the Centers for Disease Control and Prevention (CDC) show that preventable chronic diseases account for seven of every ten deaths and affect quality of life for more than ninety million Americans.

Because obesity acts as a harbinger of several costly and debilitating chronic diseases, an increasingly persuasive case exists for policymakers to formulate and facilitate implementation of populationwide interventions targeting obesity. However, major progress at the national level has remained elusive. In the face of a federal leadership vacuum on the issue, some states have stepped in to craft strategies directed at turning back the clock on obesity and other health threats.

This paper chronicles Arkansas’ pioneering experience in marshalling the best available evidence, stakeholders’ input, and bipartisan coalitions to devise policies and interventions aimed at controlling the state’s childhood obesity epidemic. It also offers important lessons for other states and localities seeking to do the same. Kevin Ryan (RyanKevinW{at}uams.edu) is associate director of the Arkansas Center for Health Improvement (ACHI) and assistant professor at the University of Arkansas for Medical Sciences (UAMS); Paula Card-Higginson and Suzanne McCarthy are senior associates there; and Michelle Justus is a policy analyst. Joseph Thompson is ACHI director, the first Arkansas surgeon general, and UAMS associate professor. Perspectives follow by Arkansas Gov. Mike Huckabee, former U.S. surgeon general David Satcher, and SPARC (Sickness Prevention Achieved through Regional Collaboration) president Douglas Shenson.

Abstract

 
National recommendations to address the emerging obesity epidemic include increased awareness, individual interventions, and environmental changes. However, guidance for translating public health and clinical evidence into meaningful policies has been limited. Arkansas formulated and passed simple yet powerful legislation to combat childhood obesity through actions in public schools. Specific legislative requirements were straightforward. Importantly, the act included an independent mechanism to identify, examine, debate, and develop further action steps. Based on our experience, we present a framework for developing a cross-sector approach to translating science into policy and practice, and we offer this guide to other states facing similar health threats.

Historically, most efforts to combat obesity have focused on individual-level interventions. In 2003 Arkansas charted a different path. Drawing upon expertise from the arenas of public health, clinical science, and public policy, it implemented innovative legislation to combat childhood obesity by creating healthier public school environments. Actions taken in 2003 have spawned rules, regulations, and voluntary changes within the health care and educational communities. In this paper we present a brief case study of Arkansas’ activities. We also discuss a four-step framework for responding to the epidemic: assessing the problem, implementing population- and individual-level interventions, and conducting surveillance to monitor progress. We believe that by incorporating this framework as a translational strategy, other states can optimize health policy development and implementation to have a positive impact on the obesity epidemic.

Background

Top Background A Case Study: Obesity... A Framework For State... NOTES

 
The dramatic and disturbing trends in both childhood and adult obesity, coupled with increased health and financial burdens associated with weight problems, have stirred health policy–oriented organizations and federal agencies to propose recommendations to confront this crisis. These recommendations include those made by the U.S. surgeon general in 2001, with fifteen prioritized activities for individuals, families, communities, schools, organizations, and governments.³ These activities centered on communicating with and educating the public about health issues related to overweight and obesity; taking action to assist Americans in balancing healthful eating with regular physical activity; and investing in research on the causes, prevention, and treatment of overweight and obesity.

Because overweight children have a high probability of becoming obese adults (compared with normal-weight children), and overweight in childhood is linked to increased morbidity in adulthood, other national recommendations have centered on preventing childhood obesity.⁴ In 2003 the American Academy of Pediatrics recommended strategies to foster prevention and early identification of overweight in children.⁵ A year later the IOM proposed a comprehensive national strategy including actions for families, schools, industry, communities, and government. The IOM’s plan identified both short- and long-term interventions as well as recommendations for the roles and responsibilities of numerous stakeholders.⁶

However, many of these recommendations fail to offer a methodology to build support, mobilize resources, and ultimately achieve effective policy implementation. As with any effort to confront an emerging epidemic, existing knowledge is usually not sufficient to guide a comprehensive response, while the slow pace of traditional research to develop new knowledge does not provide readily available guidance for action. Yet inaction is not a palatable option in the face of the obesity epidemic. A translational framework to employ existing knowledge to generate rational responses is an essential component of deploying effective obesity policies and interventions. This translational aspect of policy development offers an opportunity to understand, inform, and improve the linkages between scientific development and practical applications.

A Case Study: Obesity In Arkansas

Top Background A Case Study: Obesity... A Framework For State... NOTES

 
The Arkansas General Assembly passed Act 1220 of 2003 to address the crisis of childhood obesity.⁷ The goals of this landmark legislation were to improve the environment within which children go to school and learn health habits every day, to engage the community to support parents and to build a system that encourages health, and to increase awareness of childhood obesity. It contained these provisions: (1) Create a fifteen-member statewide Child Health Advisory Committee (CHAC) to make recommendations to the State Board of Education and State Board of Health regarding physical activity and nutrition standards and related environment in public schools; (2) employ community health promotion specialists; (3) eliminate access to vending machines in public elementary schools; (4) require that schools disclose contracts for competitive (that is, non–USDA School Lunch Program) foods and beverages; (5) assess annually body mass index-for-age (BMI) of all public school students (K–12), with the results and an explanation of possible health effects reported to parents on school report cards; and (6) create school district–level nutrition and physical activity advisory committees to raise awareness and create local policies.⁸ The legislation was designed to be comprehensive and multifaceted. A conceptual framework developed by the authors, which describes this process using Arkansas’ historical perspective, offers a model for other states to use in addressing obesity through state policy changes.

Conceptual framework. The conceptual framework of action that underlies the Arkansas policy to combat obesity not only involves individuals and their families but also considers the places where people live, work, and learn. For example, children spend a substantial part of their day in school, and a majority of their education and interpersonal experiences occur in this context. Schools are a valued community resource, and teachers represent influential role models for children. Thus, the conceptual framework that supports Arkansas’ approach to addressing childhood obesity is based largely on using the state’s legislative power to create a positive, supportive, safe, and healthy school environment.

In Arkansas, approximately 262 school districts are autonomous and under local control. However, the state is constitutionally responsible for an equitable education for all students and provides more than $3,500 annually per student. The Arkansas Board of Education and the State of Arkansas generally have the authority, responsibility, and duty to establish and maintain safe and healthy school environments in which parents entrust their children. Additionally, and importantly, studies have indicated that schools’ ability to achieve a high-quality education for students may be compromised when students’ health is at risk.⁹ Thus, Arkansas began by taking steps to change the nutrition and physical activity environments in the state’s public schools as an effort to combat obesity.

Creating and implementing a statewide initiative. Problem recognition. Recognizing the burden that increasing rates of obesity place on both individual health and the health care system, in 1999 health policy leaders stimulated a nonbinding resolution in the Arkansas Senate requesting the Arkansas Department of Health (ADH) to study childhood and adult obesity, develop recommendations to address the issue, and publish a report guiding state action.¹⁰ In answering this request, the ADH recommended that legislation create comprehensive programs to combat obesity.¹¹ With this first small step, Arkansas began a translational path from public health surveillance to policy implementation.

Concurrent with the public health interest, the state’s graduate medical education institution—the University of Arkansas for Medical Sciences (UAMS)—was funded by the National Heart, Lung, and Blood Institute with a Nutrition Academic Award. Of the twenty-two such awards that year, Arkansas’ was one of two that focused on nutrition education specifically related to obesity. Part of the funding was used to convene a summit of approximately 100 state leaders from policy, education, media, health care, environmental design, and business fields. From this Arkansas Preventive Nutrition and Physical Activity Summit held in March 2002, recommendations emerged including a call to create a new state agency dedicated solely to the nutrition and physical activity of Arkansans; develop a healthier school environment; change guidelines for food marketing and restaurant menu information; change policies in public food assistance programs; and, most radically, place the individual BMI measurements of Arkansas school children on school report cards in an attempt to increase public awareness of the importance of nutrition and physical education.¹²

In 2002 a meeting hosted by the National Conference of State Legislatures (NCSL) also became influential in the development and implementation of Arkansas’ strategy. Several Arkansas legislators were encouraged to attend a discussion sponsored by the Health Resources and Services Administration (HRSA) introducing the concept of legislation to address obesity and create healthier environments. The delegation agreed to begin formulating and prioritizing legislation intended to promote healthy lifestyles for younger Arkansans.

Time for change. Public health interests were formally engaged through the Arkansas Senate resolution, the medical education and scientific communities had prioritized recommendations for action, and legislative champions were informed and activated through a trusted source of information. But the window of opportunity to stimulate change in the state was not yet truly open.

In late 2002 Arkansas struggled to balance the increased costs of governmental programs with a depressed tax base. During the budget development process, Medicaid’s rapidly rising costs became a major concern for both the executive and legislative branches. Short-term cost containment strategies were unlikely to solve the long-term increases in demand for chronic disease care.

As the Democratic speaker of the house and the Republican governor struggled to create a budget, both experienced personal illnesses that, by their respective reports, focused their attention on the health impact of obesity. The speaker (Herschel Cleveland) had suffered a heart attack, and the governor (Mike Huckabee) was diagnosed with type 2 (adult onset) diabetes. Both conditions are associated with excessive weight and inadequate physical activity. The private experiences and public leadership decisions of the state’s elected officials became intertwined and were perceived by many to be reflected in the advancement of subsequent health-related initiatives. Although the impact of these personal experiences on Arkansas’ obesity activities is difficult to quantify, it is likely substantive. For example, after his diagnosis of diabetes, Governor Huckabee lost more than 100 pounds. In championing healthy lifestyles, he has inspired positive individual behavior change and maintenance of effort at all levels of the statewide obesity initiative.

Forming and refining the policy. In the early weeks of the 2003 Arkansas General Assembly, legislative and executive branch leaders were generally perceived as being at odds on a number of issues. Many political observers reported being pessimistic regarding the passage of substantive legislation in any area, health-related or otherwise. Yet when considering health needs of Arkansans, political leaders worked hard to develop a unified plan of action. During the session, the speaker of the house asked the ADH (executive branch) to develop model legislation that would operationalize the discussions of the prior two years.

Building largely upon the policy recommendations from the prevention summit, a concise legislative proposal was developed. The proposed legislation targeted the school environment as a vehicle to reach all children and modify behavior related to obesity. It included explicit requirements where clear agreement was likely (for example, removal of vending machines from elementary schools). Where controversy would require deliberation (such as vending machine restrictions in junior and senior high schools), an authorized mechanism—the CHAC—was created to make future recommendations to the Arkansas Board of Education (ABE). Unlike most committees established by the legislature, the CHAC recommendations were to be made directly to the independent ABE without review or approval by either the legislature or the governor.

Legislation was introduced 18 February 2003 in the Arkansas General Assembly. Receiving only one negative vote as it passed through both legislative chambers, Act 1220 became law with the governor’s signature 11 April 2003.

Challenges and lessons learned. Arkansas Act 1220 was signed into law with broad-based, bipartisan support and without controversy. This lack of controversy, however, was likely due to the simplicity of the bill and the placement of authority with the CHAC for recommending future actions to the ABE. Components of the law, as outlined above, were concise and had been readily supported in the political discourse that preceded the act’s approval.

However, heated and sometimes acrimonious debate soon ensued. The education community had largely been absent from the discussion of obesity. In the 2003 session, the debate on funding for public education continued to dominate the focus of both the Department of Education (DOE) and local school administrators, preventing engagement on "noneducational" issues. As a result, only when health proponents began to request implementation of Act 1220 did controversial issues arise; these centered on the perception of unfunded mandates for state agencies and schools, local versus state control, and privacy.

CHAC recommendations. The CHAC was explicitly charged with reviewing the evidence, balancing competing interests, and making recommendations on school nutrition and physical activity directly to the ABE. Support for the legislation was gained in part by explicit identification of membership to the CHAC in the act. Fifteen organizations were selected to appoint CHAC members.¹³ Balanced representation of education, health, academic, and private perspectives ensured full debate and strived for development of consensus decisions. Although staffing needs for the CHAC were considerable, personnel costs were minimal; CHAC members devoted their time as in-kind contributions.

After a year-long review of the evidence, debate over national recommendations, and consideration of local impact, the CHAC made recommendations to the ABE in early 2005. These included changing foods provided in cafeterias, competitive foods (such as vending machines) offered and access to them, professional development for food service staff, physical education (PE) staff qualifications, and PE/physical activity requirements for students. After public comment in June 2005, the ABE proposed modified, less stringent rules incorporating the interests of school administrators and of corporate bottlers and vendors. A critical issue for debate was whether the recommendations would be required of all schools statewide or implemented voluntarily.

After a second public comment period that included a reversal of the governor’s preference for voluntary implementation in support of local control, the ABE adopted stringent rules in August 2005 that closely matched CHAC recommendations: mandating changes to competitive foods offered to include healthy options, restricting access to competitive foods to specific times during the school day, and increasing physical activity contact hour requirements in grades K–12.¹⁴

Concerns about unfunded mandates. When Act 1220 was passed, no fiscal support was provided to public or private agencies charged with implementing the law. Indeed, certain mandates (for example, pouring contract and vending machine restrictions) had the potential to reduce or eliminate local funding upon which schools had become dependent. In addition, the act’s express lack of providing for clear responsibility and funding to support the requirement for BMI assessments of some 450,000 public school children paralyzed both the ADH and the DOE in their implementation efforts. Leaders from the Arkansas Center for Health Improvement (ACHI), an independent health policy research center, met with ADH and DOE officials and other state stakeholders to discuss implementation. At the request of both departments, the ACHI assumed a leadership role and established a team to develop statewide protocols to assess the BMI of all public school children in Arkansas. Designation of the ACHI as the entity responsible for implementation decompressed the tension and allowed more constructive dialogue to ensue among government agencies and stakeholders. Using its own funding and additional philanthropic support, the ACHI developed and validated a BMI measurement protocol, worked with the Arkansas Education Service Cooperatives and community health nurses to train school staff on how to conduct BMI assessments, created a secure BMI database, and disseminated individual and confidential child health reports to parents of approximately 346,000 Arkansas students assessed in the first year.¹⁵ These actions eliminated, in part, schools’ concerns about conducting annual BMI assessments.

Local versus state control. As in many states, control and direct oversight of school activities in Arkansas is largely retained at the local (school district) level. This tradition of local control supported several school district superintendents and other officials and leaders who publicly resisted compliance with Act 1220 state mandates. Such resistance was not statewide but instead ranged from local school personnel privately questioning the merits of BMI screening to one district superintendent who sent out letters giving parents an opportunity to choose to not have their children’s BMI measured and reported (Act 1220 is silent on the ability to opt out of BMI measurement). Although sporadic, this initial resistance had the potential to erode the impact of the statute if it gathered steam. Delivery of rigorously developed and tested screening protocols and equipment to schools and general support by parents ultimately eliminated most resistance to BMI screening.

Despite the CHAC recommendations to the ABE for standardized requirements across the state, public comment and testimony about proposed nutrition and physical activity rules reflected strong interest in maintaining local control of school activities. Resistance to proposed restrictions on vending machine access and content was led both by school administrators and by lobbyists representing soft drink and vending companies. This resistance originally resulted in a laissez-faire response to proposed ABE rules by state legislative and executive leaders who did not want to force change on local school administrators. Initially, many of these leaders proposed publicly that the ABE should allow the rules to be voluntarily adopted by each school district. However, the tenor of growing national dialogue combined with documentation and articulation of school administrators’ financial incentives to not implement the new rules (such as school payments from soft drink companies in excess of $100,000 per month for certain school districts), and advice from the newly appointed Arkansas surgeon general led the governor to ask the ABE to promulgate a directive that local school districts be required to adopt the new rules on nutrition and physical activity.¹⁶ These new rules were passed and communicated statewide in the summer of 2005.¹⁷

Politics and privacy. Act 1220’s initial requirement that each child’s BMI be conveyed to parents on academic report cards became a source of controversy locally and nationally. Other concerns related to measuring students’ BMI were also raised. For some, measurement of students’ weight in school became an issue. Although obtaining and providing student health information to parents by school officials is common in the scholastic environment (such as school-based vision, hearing, and scoliosis screenings), the measurement of students’ weight to generate BMIs was decried by some as not appropriate in school. Others felt that parents already had this information, and thus the assessment was unnecessary. Some thought that it was the role of health care providers to diagnose weight problems. Finally, and despite lack of supportive scientific evidence, some expressed concern that BMI screening would contribute to the development of eating disorders, especially among younger adolescent females.

Some local editorial writers and columnists became vocal regarding what they perceived to be impingement on personal freedom or overstepping of governmental authority.¹⁸ National media, reporting on the law, noted negative reactions from parents and students in states that had implemented or considered similar laws.¹⁹ Other stories highlighted the limitations of BMI screening and focused on the potential for false positives, especially among muscular athletes.²⁰

In December 2003 a special session of the Arkansas General Assembly was called, with a mandate to address education issues (primarily related to school funding). During the session, the CHAC and others endorsed changing the manner in which BMI measurements were to be reported to parents (shifting from including BMI on grade report cards to generating separate and confidential child health reports provided directly to parents). In response, an amendment to Act 1220 requiring a separate health report of students’ BMI be sent to parents was introduced and passed.²¹ Creating these confidential child health reports proved effective in addressing the privacy concerns of many Act 1220 opponents.

A Framework For State Action To Combat Childhood Obesity

Top Background A Case Study: Obesity... A Framework For State... NOTES

 
Based on the history of Arkansas’ initiative to combat obesity, we developed a framework that encapsulates and summarizes our state’s experiences (Exhibit 1). This framework includes four key components: initial assessment (primary data), population interventions, individual interventions, and ongoing surveillance. Some of these actions were required by the original legislation. Others were generated as a result of the CHAC recommendations. Finally, opportunities to build upon and supplement components in the legislation have been identified and operationalized and are contributing to the local and state response.

National learning opportunities. Arkansas’ implementation of a broad-based and multifaceted set of strategies to ameliorate childhood obesity includes a number of specific learning opportunities for other states. (1) Requiring but not funding activities in schools not directly related to education may generate resistance; such resistance can be overcome by presenting schools with tools and technical assistance to minimize cost and school efforts associated with implementation. (2) State-versus-local control issues can create tension and resistance to activities regardless of the potential positive benefits. (3) Addressing privacy concerns when dealing with sensitive health information is essential in garnering acceptance of activities such as BMI assessments. (4) Tailoring local empirical data to provide school- and district-specific information that documents the scope of the problem is critically important to maintaining the program’s viability through the first year of implementation. (5) Long-term support and programmatic sustainability can be encouraged by incorporating activities into existing state agency work plans and budgets.

Successes in the Arkansas experience. The two-stage strategy—specific, noncontroversial mandates and a mechanism for future changes—has enabled expansion of activities to support families, clinicians, and educators engaged in efforts to combat obesity. Because of requirements in the Arkansas law, vending machines have been eliminated from elementary schools, pouring contracts have been made public, and each school district has formed a local advisory committee. The CHAC made more than sixty recommendations to the ABE that have become new rules in schools governing nutrition and physical activity. Additional activities not specified through the act but stimulated by the statewide focus on childhood obesity include establishment of tertiary clinics to address identified clinical issues, funding mechanisms through Medicaid to support obesity-related diagnoses, and continuing medical education to disseminate new treatment guidelines to health care professionals.

Arkansas is in the third year of BMI assessments across the state. Although it is still early in the process, results showing that overall BMI rates for Arkansas school children did not increase at the end of year two hint that a halt in the progression of the epidemic might have occurred.²² Data showing a three-year trend are expected by September 2006.

Arkansas Act 1220 includes recommendations for addressing childhood overweight developed by panels of national experts. Chief among the act’s achievements has been the provision of important health information to the parents of Arkansas students and changes in school environments. Stakeholders and child health advocates agree that the first step in arresting the obesity epidemic is raising awareness of the issue among those affected.

Although much of the actual impact of Act 1220 on stemming the rise in obesity has yet to be fully determined, initial reports from the College of Public Health’s evaluation show some positive changes. Before child health reports were sent to parents, 40 percent accurately classified their children who were overweight or at risk for overweight, while afterward 53 percent correctly identified weight problems in their children. Parents’ awareness of health problems associated with overweight in childhood has also increased, although attitudes and beliefs remain unchanged. The evaluation also showed that more families are limiting chips, sodas, and sweets (from 76 percent to 80 percent), sitting down for family meals every evening (from 27 percent to 46 percent), and modifying recipes daily (from 14 percent to 19 percent). Also, 57 percent of physicians surveyed reported that they had at least one parent bring in a child’s BMI child health report.²³

Implementation of Act 1220 has made possible a unique longitudinal BMI database containing annual information for approximately 450,000 public school students. By providing a mechanism for monitoring BMIs across time, state policy-makers will have a measure to assess targeted interventions in selected pilot areas.

What is unknown regarding interventions? Through the activities described, Arkansas now has a comprehensive strategy under way to address the causes and impact of childhood obesity. Several questions about the activities in Arkansas and other states are still to be answered: (1) Have obesity rates been affected by changes in school environments? (2) If such environmental approaches are effective, what is the time period required for positive results to be demonstrated? (3) If health improvements are generated, can they be maintained without erosion? (4) Importantly, does modifying school environments have unintended and negative consequences? These questions will be answered as Arkansas and other states continue to develop, implement, and evaluate policies that fight childhood obesity.

TRANSLATING LIMITED PUBLIC HEALTH AND clinical science evidence into meaningful policy and practice requires careful navigation of the political process, strategic sequencing of program deployment, and, perhaps most important, positive exploitation of opportunities. Building on personal interest and express decisions by government and community leaders, Arkansas has deployed a broad approach to combating childhood obesity. The framework presented includes public health, health care, and educational components to support families. Ongoing efforts to evaluate the impact of these programs and better understand the policy development process that will lead to ongoing support are warranted to guide approaches to similar health threats facing the nation.

Editor's Notes

 
Jennifer Shaw provided key assistance with the concept and design of this manuscript.

NOTES

Top Background A Case Study: Obesity... A Framework For State... NOTES

 

1. C.L. Ogden et al., "Prevalence and Trends in Overweight among U.S. Children and Adolescents, 1999–2000," Journal of the American Medical Association 288, no. 14 (2002): 1728–1732[Abstract/Free Full Text]; and A.A. Hedley et al., "Prevalence of Overweight and Obesity among U.S. Children, Adolescents, and Adults, 1999–2002," Journal of the American Medical Association 291, no. 23 (2004): 2847–2850.[Abstract/Free Full Text]
2. U.S. Department of Health and Human Services, "The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity," 13 December 2001, http://www.surgeongeneral.gov/topics/obesity (accessed 24 October 2005); J.P. Koplan, C.T. Liverman, and V.A. Kraak, eds., Preventing Childhood Obesity: Health in the Balance (Washington: National Academies Press, 2005); and Centers for Disease Control and Prevention, Office of Communication, Media Relations, "Telebriefing Transcript—Overweight and Obesity: Clearing the Confusion," 2 June 2005, http://www.cdc.gov/od/oc/media/transcripts/t050602.htm (accessed 11 January 2006).
3. Office of the Surgeon General, "Overweight and Obesity: A Vision for the Future," http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_vision.htm (accessed 7 November 2005).
4. Regarding the probability of obesity in adulthood, see W.H. Dietz, "Childhood Weight Affects Adult Morbidity and Mortality," Journal of Nutrition 128, no. 2 Supp. (1998): 411S–414S; Office of the Surgeon General, "The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity: Overweight in Children and Adolescents," http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm (accessed 13 April 2006); and M.K. Serdula et al., "Do Obese Children Become Obese Adults? A Review of the Literature," Preventive Medicine 22, no. 2 (1993): 167–177.[CrossRef][Web of Science][Medline]Regarding the association with increased morbidity in adulthood, see W.H. Dietz, "Health Consequences of Obesity in Youth: Childhood Predictors of Adult Disease," Pediatrics 101, no. 3, Part 2 (1998): 518–525[Abstract/Free Full Text]; and D.S. Freedman et al., "Relationship of Childhood Obesity to Coronary Heart Disease Risk Factors in Adulthood: The Bogalusa Heart Study," Pediatrics 108, no. 3 (2001): 712–718.[Abstract/Free Full Text]
5. N.F. Krebs and M.S. Jacobson, "Prevention of Pediatric Overweight and Obesity," Pediatrics 112, no. 2 (2003): 424–430.[Abstract/Free Full Text]
6. Koplan et al., eds., Preventing Childhood Obesity; and Institute of Medicine, "Fact Sheet: Overview of the IOM’s Childhood Obesity Prevention Study," September 2004, http://www.iom.edu/?id=22718 (accessed 13 April 2006).
7. Arkansas Annotated Code, 20-7-133-135, 2003.
8. Ibid.
9. Action for Healthy Kids, The Learning Connection: The Value of Improving Nutrition and Physical Activity in Our Schools, October 2004, http://www.actionforhealthykids.org/pdf/Learning%20Connection%20-%20Full%20Report%20011006.pdf (accessed 13 April 2006).
10. 82d General Assembly, Regular Session, 1999, SCR 8.
11. State of Arkansas Obesity Task Force, The Impact of Obesity: Economics, Health, Prevention, and Treatment, 2000, http://www.healthyarkansas.com/newsletters/obesity_report.pdf (accessed 14 November 2005).
12. J.G. Wheeler et al., "Obesity in Arkansas: From Contemplation to Action—The 2002 Arkansas Preventive Nutrition and Physical Activity Summit," Journal of the Arkansas Medical Society 100, no. 8 (2004): 268–272.
13. CHAC members represent the Arkansas Division of Health of the Department of Health and Human Services; Arkansas Dietetic Association; Arkansas Academy of Pediatrics; Arkansas Academy of Family Practice; Arkansas Association for Health, Physical Education, Recreation, and Dance; jointly the Arkansas Heart Association, the American Cancer Society, and the American Lung Association; Arkansas College of Public Health of the University of Arkansas for Medical Sciences; Arkansas Center for Health Improvement; Arkansas Advocates for Children and Family; University of Arkansas Cooperative Extension Service; Arkansas Department of Education; Arkansas School Food Service Association; Arkansas School Nurses Association; Arkansas Association of Education Administrators; and Arkansas Parent Teacher Association.
14. Arkansas Department of Education, "Rules Governing Nutrition and Physical Activity Standards in Arkansas Public Schools," August 2005, http://arkedu.state.ar.us/rules/pdf/current_rules/ade_215_nutrition_and_physical_activity_standards.pdf (accessed 13 April 2006).
15. See the Arkansas Center for Health Improvement Web site, http://www.achi.net/current_initiatives/obesity.asp, for additional information (accessed 28 March 2006).
16. J. Bleed, "Governor Tells Schools to Heed Vending Rules," Arkansas Democrat-Gazette, 26 July 2005.
17. ADE, "Rules."
18. "State’s Anti-Fat Crusade," Arkansas Democrat-Gazette, 10 August 2003; E. Abercrombie, "Body Fat Reports Tend to Humiliate, Not Help," Arkansas Democrat-Gazette, 26 September 2004; and B. McCutchen, "Not Government’s Role," Benton County Daily Record, 16 September 2003.
19. "In Arkansas, Schools Plan to Score Children’s Weights," Wall Street Journal, 20 August 2003.
20. C. Storey, "Girth Guide: Body Fat Monitors Are Only Good for Estimates," Arkansas Democrat Gazette, 14 July 2003; and CDC, "Overweight and Obesity: Frequently Asked Questions (FAQs)," 22 March 2006, http://www.cdc.gov/nccdphp/dnpa/obesity/faq.htm (accessed 15 May 2006).
21. Arkansas Annotated Code, 20-7-135(c), 2003.
22. J.W. Thompson et al., "Overweight among Students in Grades K–12—Arkansas, 2003–04 and 2004–05 School Years," Morbidity and Mortality Weekly Report 55, no. 1 (2006): 5–8.
23. Fay W. Boozman College of Public Health, "Year Two Evaluation, Arkansas Act 1220 of 2003 to Combat Childhood Obesity," January 2006, http://www.uams.edu/coph/reports/Act1220Eval.pdf (accessed 27 March 2006).

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