① Hcs 341 Human Resource Management Paper

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Hcs 341 Human Resource Management Paper



Monahan and D. Jennifer Verity Gleed. In addition, the measurements will be integrated into Summary Of The Three Musketeers new survey module that Retelling: A Short Story Of A Great Medicine Man be available to all members of ICMA's Center for Performance Hcs 341 Human Resource Management Paper. Extended Hcs 341 Human Resource Management Paper figures and tables. ClientEarth CE Ms. Healthier food and beverage choices need to be both available and affordable for persons to consume Hcs 341 Human Resource Management Paper. These services Hcs 341 Human Resource Management Paper typically limited Hcs 341 Human Resource Management Paper essential services required to avoid placement in a residential care facility.

HCS 341 Entire Course Version 1 Human Resources in Health Care

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For more information, check our Revision Policy. Calculate the price of your paper Type of paper needed. You will get a personal manager and a discount. Academic level. Continue to order. Our features. We've got everything to become your favourite writing service. For assistance, please send e-mail to: mmwrq cdc. Type Accommodation and the title of the report in the subject line of e-mail. Approximately two thirds of U. During , obesity prevalence among U. Being either obese or overweight increases the risk for many chronic diseases e.

Reversing the U. Environmental factors including lack of access to full-service grocery stores, increasing costs of healthy foods and the lower cost of unhealthy foods, and lack of access to safe places to play and exercise all contribute to the increase in obesity rates by inhibiting or preventing healthy eating and active living behaviors. Recommended strategies and appropriate measurements are needed to assess the effectiveness of community initiatives to create environments that promote good nutrition and physical activity.

The objective of the Measures Project was to identify and recommend a set of strategies and associated measurements that communities and local governments can use to plan and monitor environmental and policy-level changes for obesity prevention. This report describes the expert panel process that was used to identify 24 recommended strategies for obesity prevention and a suggested measurement for each strategy that communities can use to assess performance and track progress over time. The 24 strategies are divided into six categories: 1 strategies to promote the availability of affordable healthy food and beverages , 2 strategies to support healthy food and beverage choices, 3 a strategy to encourage breastfeeding, 4 strategies to encourage physical activity or limit sedentary activity among children and youth, 5 strategies to create safe communities that support physical activity, and 6 a strategy to encourage communities to organize for change.

Telephone: ; Fax: ; E-mail: ldk7 cdc. Obesity rates in the U. Data for and indicated that approximately two thirds of U. Although diet and exercise are key determinants of weight, environmental factors beyond the control of individuals including lack of access to full-service grocery stores, high costs of healthy foods, and lack of access to safe places to play and exercise contribute to increased obesity rates by reducing the likelihood of healthy eating and active living behaviors States and communities are responding to the obesity epidemic in the United States by working to create environments that support healthy eating and active living 8,9 and by giving public health practitioners and policy makers an opportunity to learn from community-based efforts to prevent obesity.

However, the absence of measurements to assess policy and environmental changes at the community level has impeded efforts to assess the implementation of these types of population-level initiatives for preventing obesity. The goal of the Measures Project was to identify and recommend a set of obesity prevention strategies and corresponding suggested measurements that local governments and communities can use to plan, implement, and monitor initiatives to prevent obesity. For the purposes of the Measures Project, a measurement is defined as a single data element that can be collected through an objective assessment of policies or the physical environment and that can be used to quantify the performance of an obesity prevention strategy..

Community was defined as a social entity that can be classified spatially on the basis of where persons live, work, learn, worship, and play e. The Measures Project process was guided by expert opinion and included a systematic review of the published scientific literature, resulting in the adoption of 24 recommended environmental and policy level strategies to prevent obesity. This report presents the first set of comprehensive recommendations published by CDC to promote healthy eating and active living and reduce the prevalence of obesity in the United States. This report describes each of the recommended strategies, summarizes available evidence regarding their effectiveness, and presents a suggested measurement for each strategy that communities can use to assess implementation and track progress over time.

The recommended strategies presented in this document were developed as a result of a systematic process grounded in available evidence for each strategy, expert opinion, and detailed documentation of the project process and decision-making rationale. A few exploratory strategies for which no evidence was available were included in the recommendations on the basis of expert opinion and to determine the effectiveness of the strategy for preventing obesity. To identify potential environmental and policy-level strategies for obesity prevention, the Measures Project Team searched PubMed for reviews and meta-analyses published during January 1, July 3, using the following search terms:. The Measures Project Team conducted a literature search over a relatively short publication period 2 years because reviews and meta-analyses were assumed to contain and summarize research that was published before The PubMed search yielded articles.

On the basis of a preliminary review, articles were deemed inappropriate because they did not focus on environmental or policy-level change, resulting in a total of 94 articles. Seven additional reports and studies recognized as "seminal documents" also were recommended for inclusion 8, The Measures Project Team completed a full review of the 94 articles and seven seminal documents, resulting in the identification of potential obesity prevention strategies. Similar and overlapping strategies were collapsed, resulting in a final total of environmental or policy-level strategies for obesity prevention. To assist in prioritizing the strategies identified in the literature search, the Measures Project Team developed a set of strategy rating criteria based on the efforts of similar projects Through an online survey, members of the Select Expert Panel rated each obesity prevention strategy on the following criteria: reach, mutability, transferability, potential effect size, and sustainability of the health impact Box 1.

The Select Expert Panel met to discuss and rank order the strategies on the basis of the results of the online survey. The Panel identified 47 strategies as most promising, including 26 nutrition strategies, 17 physical activity strategies, and four other obesity-related strategies. Next, the CDC Workgroup met to review the strategies from a public health perspective, which resulted in the selection of 46 strategies. The Measures Project Team then identified 22 policy- and environmental-level strategies that were given the highest priority for preventing obesity at the community level. One additional strategy was added on the basis of expert opinion supporting the need for exploratory policy and environmental strategies that consider local food systems and the production, procurement, and distribution of healthier foods for community consumption.

A total of 26 environmental and policy strategies for obesity prevention were selected to move forward to the measurement nomination and selection phase of the project process. After the 26 strategies were selected, the Measures Project Team created a summary for each strategy that included an overview of the strategy, a summary of available evidence in support of the strategy, and potential measurements that were used to assess the strategy as described in the literature. When available, the summaries also included examples of how the strategy has been used by local communities. Content area experts specializing in nutrition, physical activity, and other obesity-related behaviors assisted the Measures Project Team in selecting potential measurements that communities can use to assess the recommended obesity prevention strategies.

Three persons were assigned to each strategy according to their area of expertise. Each three-person group included at least one member of the CDC Workgroup and one external member of the Select Panel; for many strategies, a local government expert recruited by ICMA also participated. Experts reviewed the strategy summary and nominated up to three potential measurements per strategy. Experts also rated each measurement as high, medium, or low for three criteria: utility, construct validity, and feasibility Box 2.

After potential measurements were nominated, the experts were convened via teleconference to select a first- and second-choice measurement for that strategy. Each nominated measurement was discussed briefly, and experts had the opportunity to refine the measurement or create a new measurement before voting on the first- and second-choice measurements. After the teleconferences, the Measures Project Team reviewed the proposed first and second choice measurements to ensure they were feasible for local governments to collect and that the use of definitions and wording were consistent.

Next, a panel of six measurement experts two from CDC, two from the Select Expert Panel, and two from ICMA specializing in measurement development and evaluation reviewed the measurements for utility, construct validity, and feasibility and provided suggestions for improvement. The Measures Project Team reviewed the measurement experts' suggestions and made minor modifications to the measurements on the basis of their feedback. None of the concerns raised by the Measurement Experts warranted exclusion of any of the first-choice measurements. Two additional changes were made after a further review by the Measures Project Team and a technical review by CDC's Division of Nutrition, Physical Activity, and Obesity: 1 the first-choice measurement for the personal safety strategy was replaced with the second-choice measurement which focused more appropriately on assessing environmental and policy-level change; and 2 two similar pricing strategies for healthier foods and beverages and for fruits and vegetables were merged.

This resulted in a total of 25 recommended strategies and a corresponding suggested measurement for each strategy. Twenty local government representatives, including city managers, urban planners, and budget analysts, who participate in ICMA's Center for Performance Measurement CPM , volunteered to pilot test the selected measurements. To limit the burden of the pilot test for individual local government participants the communities were divided into three groups, each of which included a mix of small, medium, and large communities.

Each group was assigned eight or nine measurements pertaining to both nutrition and physical activity. In addition, the local government participants also were asked to provide general feedback on their ability to report on each measurement, the level of effort required to gather the necessary data, and the perceived utility of each measurement. Demographic information also was obtained to compare the responses and feedback among communities of similar size and population. The communities were given 6 weeks to complete the pilot test. Responses and feedback from the pilot test were summarized by ICMA and served as the basis of discussions at an end-user meeting that was held in January The end-user meeting was facilitated by the Measures Project Team and was attended by the local government representatives who had pilot tested the measurements, members of the Select Expert Panel, and CDC content and measurement experts.

The results of the pilot test were presented at the meeting; the overall response was positive. A number of challenges associated with responding to the measurements and suggestions for improvement were identified, as a result of which, minor word changes and clarifications were made to 13 measurements. Three measurements were modified to include additional venues for data collection, such as schools or local government facilities. In addition, four substantive changes were made to the measurements: 1 the measurement related to school siting was changed to be more focused on assessing environmental and policy-level change; 2 the focus of the measurement related to enhancing personal safety in areas where persons are physically active was changed from street lighting to vacant buildings, which experts believed to be a more meaningful indicator of personal safety; 3 the measurement related to increasing the availability of supermarkets, including full-service grocery stores, was modified to focus on the number of stores located in underserved census tracts rather than the percentage of supermarkets within easy walking distance of a transit stop; and 4 the measurement related to increasing affordability of healthier foods and beverages was combined and replaced by the measurement related to pricing strategies.

These modifications resulted in a total of 24 recommended environmental and policy level obesity prevention strategies and their corresponding suggested measurement Table. The recommended strategies and corresponding suggested measurements are grouped in six categories; for each strategy, a summary is provided that includes an overview of the strategy, followed by a summary of evidence that supports the strategy and the corresponding suggested measurement for the strategy. Key terms used throughout this report have been defined separately see Appendix for a complete listing of these terms. For persons to make healthy food choices, healthy food options must be available and accessible.

Families living in low-income and minority neighborhoods often have less access to healthier food and beverage choices than those in higher-income areas. Each of the following six strategies aims to increase the availability of healthy food and beverage choices, particularly in underserved areas. Limited availability of healthier food and beverage options can be a barrier to healthy eating and drinking. Healthier food and beverage choices include, but are not limited to, low energy dense foods and beverages with low sugar, fat, and sodium content Schools are a key venue for increasing the availability of healthier foods and beverages for children. Other public service venues positioned to influence the availability of healthier foods include after-school programs, child care centers, community recreational facilities e.

Improving the availability of healthier food and beverage choices e. CDC's Community Guide reports insufficient evidence to determine the effectiveness of multicomponent school-based nutrition initiatives designed to increase fruit and vegetable intake and decrease fat and saturated fat intake among school-aged children 22, However, systematic research reviews have reported an association between the availability of fruits and vegetables and increased consumption 24, Farm-to-school salad bar programs, which deliver produce from local farms to schools, have been shown to increase fruit and vegetable consumption among students A policy exists to apply nutrition standards that are consistent with the Dietary Guidelines for Americans 27 to all food sold e.

Communities that do not use the Dietary Guidelines for Americans can still meet the measurement criteria if they follow other standards that are similar to or stronger than the national standards. Healthier foods generally are more expensive than less-healthy foods 28 , which can pose a significant barrier to purchasing and consuming healthier foods, particularly for low-income consumers. 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 Healthier food and beverage choices need to be both available and affordable for persons to consume them.

Strategies to improve the affordability of healthier foods and beverages include lowering prices of healthier foods and beverages and providing discount coupons, vouchers redeemable for healthier foods, and bonuses tied to the purchase of healthier foods. Pricing strategies create incentives for purchasing and consuming healthier foods and beverages by lowering the prices of such items relative to less healthy foods. Pricing strategies that can be applied in public service venues e. Research has demonstrated that reducing the cost of healthier foods increases the purchase of healthier foods 29, For example, one study indicated that sales of fruits and carrots in high-school cafeterias increased after prices were reduced In addition, interventions that reduced the price of healthier, low-fat snacks in vending machines in school and work settings have been demonstrated to increase purchasing of healthier snacks 32, Furthermore, interventions that provide coupons redeemable for healthier foods and bonuses tied to the purchase of healthier foods increase purchase and consumption of healthier foods in diverse populations, including university students, recipients of services from the Supplemental Nutrition Program for Women, Infants, and Children WIC , and low-income seniors 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. Supermarkets and full-service grocery stores have a larger selection of healthy food e.

However, research suggests that low-income, minority, and rural communities have fewer supermarkets as compared with more affluent areas 39, 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 For example, a cross-sectional study of approximately 10, 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.

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 One cross-sectional study linked height and weight data from approximately 70, adolescents to data on food store availability 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 The number of full-service grocery stores and supermarkets per 10, 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. Because some jurisdictions have numerous census tracts that meet the underserved criteria, the measurement limits the assessment to the three largest i. 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. 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 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 To address this issue, communities can provide incentives to food retailers e.

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 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.

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 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 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 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. 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.

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. 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. Access to farm foods varies between agricultural and metropolitan areas.

The total annual number of farmer-days at farmers' markets per 10, 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. Currently the United States is not producing enough fruits, vegetables, whole grains, and dairy products for all U. 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. Definitions of "local" vary by place and context but may include the area of the foodshed i.

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 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. 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.

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.

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. 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. 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 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.

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 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 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. Portion size can be defined as the amount e. 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 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 This finding holds across a wide variety of foods and different types of portions e. Clinical studies conducted in nonlaboratory settings demonstrate that increased portion size leads to increased energy intake 61, 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 Intervention studies are underway that evaluate the impact of limiting portion size, combined with other strategies to prevent obesity in workplaces 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. 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 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 years 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, However, cross-sectional time-series studies of tobacco-control efforts suggest that an association exists between advertising bans and decreased tobacco consumption 22, Limited bans of advertising, which include some media but not others e.

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.

Consumption of sugar-sweetened beverages e. 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 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 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. 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. Exclusive breastfeeding is recommended for the first 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 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 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 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. 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 Evidence directly linking environmental interventions that support breastfeeding with obesity-related outcomes is lacking.

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. 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 Furthermore, evaluations of individual interventions aimed at supporting breastfeeding in the workplace demonstrate increased initiation rates and duration of breastfeeding compared with national averages 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. 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. This strategy supports the Healthy People objective objective no. School-based PE increases students' level of physical activity and improves physical fitness 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 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 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 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.

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 minutes per week of PE in public elementary schools and a minimum of 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 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.

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. 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 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 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 The policy needs to apply to all grade levels to meet the measurement criteria.

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 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 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 minutes of moderate to vigorous physical activity per day. Lack of access is a barrier that might limit the impact of increased availability of 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. 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. 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, 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. 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 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 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. 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. 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 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 A comprehensive review of 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 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 Another study that used self-report and GIS data concluded that longer distances and the presence of barriers e.

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. For consistency across jurisdictions, the measurement focuses on the entrance points to outdoor recreational facilities, although many recreational facilities have multiple points of entry.

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. 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 , 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. 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. 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 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 , However, some systematic reviews indicated no evidence of an association between the presence of sidewalks and physical activity Other reviews indicated associations, but only for certain subgroups of subjects e.

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 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 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. 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, A simulation modeling study conducted by the U.

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. 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.

Krebs, Robert E. Avelife Ltd. Peter Colley. Foster Hcs 341 Human Resource Management Paper Charles Hartman.

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