SCHOOL-BASED CHILDHOOD OBESITY PREVENTION TARGETING MIDDLE SCHOOLS: A GRANT PROPOSAL

A THESIS Presented to the Department of Social Work California State University, Long Beach

In Partial Fulfillment of the Requirements for the Degree Master of Social Work

Committee Members: Jeffrey J. Koob, Ph.D. (Chair) Estela Andujo, Ph.D. Rebecca A. Lopez, Ph.D. College Designee: John Oliver, Ph.D.

By Meghan E. Shannon B.A., 2000, University of California, Los Angeles May 2009

UMI Number: 1466312

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ABSTRACT SCHOOL-BASED CHILDHOOD OBESITY PREVENTION TARGETING MIDDLE SCHOOLS: A GRANT PROPOSAL By Meghan E. Shannon May 2009 The purpose of this project was to design a program, identify potential funding sources, and write a grant to fund an obesity prevention program. The purpose of the program is to reduce the increasing rates of obesity and obesity related problems in children, including the psychosocial consequences. An extensive literature review was conducted to increase the knowledge about the prevalence and causes of childhood obesity. Previous attempts at school-based obesity prevention were also examined in order to design a program to best meet the needs of obese children and families. A search for potential funding sources resulted in the selection of the National Institute of Health as the best funding source for this project. A grant was written to support an obesity prevention program at Washington Middle School in Long Beach, California.

ACKNOWLEDGEMENTS I would like to thank my committee chair, Dr. Jeffrey Koob, for all of his assistance and guidance in completing my thesis. I would also like to thank the other chair members, Dr. Rebecca Lopez and Dr. Estela Andujo, for their time and helpful feedback. I would like to sincerely thank my family and friends for their support during the thesis process, and especially during my 4 years of completing my Masters program. In particular my dad, sister, and best friend, who helped motivate me to continue and not give up. I know I could not have successfully completed the program without their support and encouragement.

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CONTENTS Page ACKNOWLEDGEMENTS TABLES CHAPTER 1. INTRODUCTION Purpose of the Project Agency Social Work Relevance Multicultural Relevance 2. LITERATURE REVIEW Definition of Obesity Prevalence and Causes Risk Factors for Obesity Demographic and Socio Economic Status Differences Consequences of Childhood Obesity School-Based Obesity Prevention Programs Pathways Planet Health Texas Trial HEALTH-KIDS Study CATCH Behavior Modification Program Just For Kids Relevance of School-Based Obesity Programs 3. METHODOLOGY Potential Funding Source Identification and Selection Strategies Target Population Resources for the Grant Writing Statement 1 2 2 3 3 5 5 6 9 10 11 14 14 16 17 19 21 22 23 24 25 25 28 28 iii vi

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CHAPTER 4. GRANT APPLICATION Description of Proposed Project Areas Affected by the Project Proposed Project Dates Congressional Districts Specific Aims of Project Objective 1: Conduct Needs Assessments Objective 2: Increase Nutrition Knowledge Among all Students Objective 3: Increase Physical Activity Objective 4: Promote Family Involvement Objective 5: Provide Counseling Services Background and Significance Project Site Location Project Evaluation Estimated Project Funding Project Budget 5. LESSON LEARNED Steps in Grant Writing Challenges Strategies Used to Increase Likelihood of Funding Relevance to Social Work Policy and Practice REFERENCES

Page 29 29 30 31 31 31 32 32 33 33 33 34 35 35 35 36 39 39 40 41 41 43

TABLES TABLE 1. Line-Item Budget Page 37

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CHAPTER 1 INTRODUCTION Childhood obesity is a great health concern in the United States. Obesity prevalence in children increased from 5% in 1963 to 1970, to 17% in 2003 to 2004 (Ogden et al., 2006). Obesity can lead to other chronic diseases and puts a large burden on our healthcare system. Obesity is now one of the most common pediatric health problems, and it has significant adverse effects on physical and psychosocial health in childhood and adulthood (Hughes & Dennison, 2008). Obesity affects one in five children in the United States (Dietz, 1998). "Since the 1970s, the prevalence of obesity has more than doubled among preschool and adolescent populations, and has more than tripled among children aged 6-11 years" (Findholt, 2007, p. 565). Due to its prevalence, research on childhood obesity factors and funding for this research has increased. Low self-esteem, high blood pressure, cardiovascular disease, type 2 diabetes, and certain types of cancer are some of the potential consequences of obesity that contribute to diminished quality of life and life expectancy (Budd & Volpe, 2006). Obesity and overweight can have an adverse effect on a child's psychosocial status. Studies have shown a relationship between childhood obesity, low self-esteem, discrimination, stigmatization, and peer rejection, particularly in educational settings (Shaya, Flores, Gbarayor, & Wang, 2008). 1

Preventive and treatment services are needed to address this critical issue. Education about the adverse health effects of eating fast food needs to be given to lowincome communities. American children could become the first generation in more than a century to have a shorter life span than their parents (Delvi, 2008). The prevalence rate of obesity was higher among adolescent non-Hispanic Black boys (22.9%) and Mexican American boys (21.1%) than among non-Hispanic White boys (16.0%; Ogden, Carroll, & Flegal, 2008). The school setting is an obvious choice to attempt to address childhood obesity. More than 97% of children 5 years and older spend 6 to 8 hours a day in school for 9 to 10 months a year (Leviton, 2008). Additionally, the family should be involved in the program in order to better address the eating patterns of the family. Purpose of the Project The purpose of this project was to develop a grant to request funding for a school-based outreach for overweight and obese children at Washington Middle school in Long Beach. The program will partner with existing school employees to provide nutrition counseling, education, exercise, and family counseling. The primary goal of this project was to reduce the increasing rate of childhood obesity, particularly in the Hispanic population. Behavior modification, emphasis on family involvement, and a multidisciplinary approach will differentiate this program from previous attempts at school based obesity prevention programs. Agency Washington Middle School is located in the Long Beach Unified School District. It is located near downtown Long Beach and teaches sixth through eighth 2

grade. School enrollment is 970 students. During the 2007-2008 school year 72.7% of its enrollment were students with Hispanic or Latino ethnic backgrounds (California Department of Education [CDE], 2008). This school was chosen due to its high Hispanic population. Obesity is disproportionately affecting Hispanics. Social Work Relevance In addition to the widespread health consequences of childhood obesity, psychosocial consequences are prevalent in obese children. Obese children become targets of discrimination which affect their psychological development and self esteem (Dietz, 1998). The problem of childhood obesity is relevant to social workers in schools, child welfare, and hospitals. Obese children are targets of bullying and discrimination in schools (Leviton, 2008). Studies show that obese adolescents develop negative self-images that appear to persist into adulthood (Dietz, 1998). The psychosocial effects may both contribute to and result from obesity. This preoccupation with weight can also lead to eating disorders (Dietz, 1998). As a result of weight bias and discrimination, obese children suffer psychological, social, and health related consequences (Puhl & Latner, 2007). Social Workers are in a strategic position to help children deal with the problem of obesity so that it does not continue into adulthood and cause other psychosocial problems. Multicultural Relevance Many studies have confirmed that the rates of overweight, obesity, and related health problems are highest and rising fastest for African-American, Latino, Native American, Asian American, and Pacific Islander children living in low-income communities (Lavizzo-Mourey, 2007). Low-income families are required to eat food 3

that is inexpensive, which leads to over consumption of fast food and unhealthy options. During the last 30 years, studies have shown that childhood obesity is more common in families with low income and in families with parents of low educational levels (Davis et al., 2007). Childhood obesity is a problem that affects all races, but is disproportionately represented in the African American and Latino communities. In 2003-2004, the prevalence rates for obesity were particularly high among Black girls (24%) and among Mexican-American boys (22%; Barlow, 2007). If current trends continue, it appears likely that one third of all children born today, and even higher proportions of Hispanic and Black children, will develop type 2 diabetes during their lifetimes and can expect a shortened life expectancy (Nestle, 2005). Rates have also increased among Native American and Asian American youths (Gordon-Larsen, Adair, & Popkin, 2003). Childhood obesity is a multi-cultural problem. The proposed grant will specifically address the rising obesity rates among Hispanic children by targeting a largely Hispanic school in Long Beach.

CHAPTER 2 LITERATURE REVIEW Definition of Obesity This review of the literature will help document the need for school-based obesity prevention programs for middle school students. Schools are an important venue for intervention and prevention because children spend approximately 6 hours per day in the school environment, one to two meals are served there, and resources such as school nurses, social workers and physical education programs are already in place (Story, 1999). Research vital to this topic includes childhood obesity prevalence and causes, socioeconomic status differences, risk factors for obesity, effects of childhood obesity, and existing school-based obesity prevention programs. Childhood obesity is defined as having a body mass index greater than the 95th percentile for children of the same age and gender (Dietz, 1998). This definition is consistent in the literature. The Centers for Disease Control and Prevention (CDC) 2000 growth charts are the preferred reference for defining obesity in children (Krebs et al., 2007). The CDC identifies two levels of overweight for children: (1) at risk for overweight is defined as a Body Mass Index (BMI) between the 85th and 95 th percentiles and (2) overweight defined as > the 95 percentile (Ogden et al., 2002). In 2005, the Institute of Medicine elected to define children with BMI > 95 th percentile for age and gender as obese, rather than overweight (Krebs et al.). Obesity has become one 5

of the most common pediatric health problems, and has been shown to have adverse side effects on physical and psychosocial health in childhood and adulthood (Hughes & Dennison, 2008). Prevalence and Causes Obesity has become an increasing health concern in the United States. The prevalence of overweight has doubled for United States children aged 6-11 years and tripled for American teenagers over the past 2 decades (Shaya et al., 2008). The prevalence of children classified as "at risk for overweight" or "overweight" has tripled in the past 20 years and currently exceeds > 30% (Hedley et al., 2004). Approximately 17% of children and adolescents between the ages of 2 and 19 years are considered overweight and 34% are at risk of becoming overweight (CDC, 2007). Determining the causes of the rise in childhood obesity is difficult. Anderson and Butcher (2006) examined the trends of childhood obesity and attempted to define its causes. It was found that the obese share of the United States population for both children and adults was fairly stable between 1971-1974 and 1976-1980 and only begun to increase thereafter. Therefore, researchers focused primarily on the environmental changes that began between 1980 and continued into the 1990s. The increase of fast food intake, sweet soda consumption, and lethargic activities is often blamed for childhood obesity. Anderson and Butcher hypothesized that changes in the family, particularly an increase in dual-career or single-parent working families, may also have increased the demand for food away from home or pre-prepared foods. Also, children are less likely to walk to school and travel in cars more due to changes in the environment. And finally, children spend more time doing sedentary activities, such as 6

playing on computers, viewing television, and playing video games (Anderson & Butcher). Anderson and Butcher (2006) were not able to pinpoint one specific cause for the rise in obesity among children. Rather, it was found that there were many complementary changes that simultaneously increased children's energy intake and decreased their energy expenditure. Anderson and Butcher examined the changes in the food market, in the built environment, in schools and childcare facilities, and in the role of parents. In regards to the food market, Putnam and Gerrior (1999) found a marked increase in overall consumption of carbonated soft drinks over the last several decades. The consumption of non diet sodas markedly rose in 1987, and rose steadily in the 1990s. The rise in soda consumption correlates with the rise in childhood obesity (Putnam & Gerrior). Increased spending on advertising can be attributed to the increase in soda consumption (Harris, 2002). Another notable change in the food market is portion size. Young and Nestle (2002) examined 181 products and identified the date when their portion size increased. They found that very few products increased their portion sizes in the 1970s, fewer than 10 times every 5 years. The products increased their portion size about 20 times in the first half of the 1980s and then about 40 times in the first half of the 1990s. During the last half of the 1990s, portion sizes increased more than 60 times (Young & Nestle). This timeline also correlates with the rise in childhood overweight and obesity (Anderson & Butcher, 2006).

Anderson and Butcher (2006) state that the change in the amount of physical activity has contributed to the increase in obesity in children. In the past, physical activity was a daily part of life and one did not have to purposefully be physically active. Urban sprawl increases automobile travel. In 1977, 15.8% of trips by children aged 5 to 15 were by foot or bicycle. By 1990, the trips by foot or bicycle had fallen to 14.1% and by 1995 to 9.9%. Children are no longer walking to school due to distance, child safety, and fear of abduction. Just a little more than 70% of parents report that they walked or rode their bikes to school as children, compared to 22% of children in 2006. In addition to getting to school, the school environment has changed over the years as well. The types of food available at school have changed, as well as the physical education requirements. Physical education has been reduced in schools to make room for academics (Anderson & Butcher). Anderson and Butcher (2006) also comment on the changing role of parents. Statistics show that maternal employment has increased and the result is an increase in a child's probability to become obese. This is attributed to more food consumed away from home, and less time for supervision of active play. Also, school-age children having both parents in the workforce, increases the child's unsupervised afternoon hours, and therefore television viewing may increase. In 1999, 77% of sixth graders had a television in their room (Roberts, 1999). According to Savage, Fisher and Birch (2007), parents powerfully shape children's early experiences with food and eating, providing both genes and environments for children. The first 5 years of life are a critical time of rapid physical growth and change. These are years when eating behaviors that can serve as a 8

foundation for future eating patterns are developed. During the first 5 years, children are learning what, when, and how much to eat based on cultural and familial beliefs, attitudes, and practices surrounding food and eating (Savage et al.). Risk Factors for Obesity Obesity occurs when susceptible people, those who are genetically predisposed to obesity, are placed in adverse environments (Sothern & Gordon, 2003). Dietz (1994) has suggested that there are 3 critical periods for the development of obesity: (1) the intrauterine environment or early infancy, (2) 5 to 7 years of age, and (3) adolescence. Genetics also play a large role in obesity. Studies have concluded that about 25 to 40% of BMI is inheritable (Collip, 1975). However, genetics cannot solely explain the recent increase in childhood obesity, because the gene pool cannot change that rapidly (Anderson & Butcher, 2006). The risk factors for obesity determined by Sothern and Gordon (2003) are parental obesity, sedentary behaviors such as television viewing and video games, poor nutrition, unhealthy food attitudes and practices, low socioeconomic status, low birth weight, and formula fed infants versus breast feeding. In young children under 6 years of age, the most important environmental factor that contributes to obesity is parental obesity (Hill & Throwbridge, 1998). Strauss and Knight (1999), Dietz and Gortmaker (2001), Fogelholm, Nuutinen, Pasanen, Myohanen, and Saatela (1999), and Dowda, Ainsworth, Addy, Saunders, and Riner (1999) all agree that the environment of the family plays a key role in the development of obesity in young children. Research shows that parent inactivity strongly predicts child inactivity and that parental influences are earl determinants of food attitudes and 9

practices in young children (Sothern & Gordon, 2003). Children with two obese parents have an 80% chance of developing obesity during their lifetime (Sothern & Gordon). Obesity has been shown to develop in only 7% of children born to lean parents (Sothern & Gordon). Demographic and Socio Economic Status Differences The obesity epidemic has disproportionately affected some racial and ethnic groups. In 2003-2004, the prevalence rates for obesity were particularly high among Black girls (24%) and among Mexican-American boys (22%; Barlow, 2007). Rates have also increased among Native American and Asian American youths (GordonLarsen et al., 2003). National Health and Nutrition Examination surveys show that obesity rates are higher among minorities and low-income children. In 1999-2000, 29.1% of African American Children were defined as obese as compared to 28% of all children (Anderson & Butcher, 2006). During the last 30 years, studies have shown that childhood obesity is more common in families with low income and in families with parents of low educational level (Davis et al., 2007). The National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study examined 9- and 10-year-old White and African-American girls with regard to the relationship of socioeconomic status to childhood obesity (NHLBI Growth and Health Study Research Group, 1992). It became evident that the association between childhood obesity and socioeconomic factors was different for girls depending on their race (Kimm et al., 2001). Singh, Kogan, and van Dyck (2007) studied the state and regional disparities in obesity prevalence among 46,707 United States children and adolescents aged 10-17 10

years. The South Central regions of the United States had the highest prevalence, > 18%, and the Mountain region the lowest prevalence, 11.4%. Children in West Virginia, Kentucky, Texas, Tennessee, and North Caroline had over twice the odds of being obese than their Utah counterparts. Individual characteristics such as race/ethnicity, household socioeconomic status, neighborhood social capital, television viewing, recreational computer use, and physical activity accounted for 55% of the state and 25% of the regional disparities in obesity. Area poverty rates accounted for an additional 18% of the state variance. Singh et al. concluded that prevention efforts for childhood obesity should address individual risk factors, as well as contextual social and environmental factors. Consequences of Childhood Obesity Consequences of childhood obesity can be seen in adulthood, as well as immediately in young children. Must and Strauss (1999) examined various studies linking health problems in children and obesity. They concluded that the health and social consequences of childhood obesity are substantial. The obese child may develop type 2 diabetes, gallstones, hypertension, arthritis, sleep apnea and increased intracranial pressure (Johnston et al., 2007). There are few organ systems that obesity does not affect during childhood (Must & Strauss). Diabetes is one of the most serious complications of childhood obesity. Children with pre-diabetes According to the American Diabetes Association (2008), there are 20.8 million children and adults in the United States, or 8% of the population, who have diabetes. Two million adolescents, or 1 in 6 overweight adolescents, have pre-diabetes. Studies have shown that people with pre-diabetes who lose weight and 11

increase their physical activity can prevent or delay diabetes and return their blood glucose levels to normal (CDC, 2008). As many as 45% of children with newly diagnosed Diabetes mellitus have type 2 rather than type 1 disease (Barlow, 2007). The National Institute of Health (2008) states that the prevalence of diabetes is 2 to 3 times higher in Mexican-Americans than in Non-Hispanic Whites. The risk factors are the same for Hispanics as for non-Hispanics and include obesity, physical inactivity, and hyperinsulinemia. If current trends continue, it appears likely that one third of all children born today, and even higher proportions of Hispanic and Black children, will develop type 2 diabetes during their lifetimes and can expect a shortened life expectancy (Nestle, 2005). Rising rates of diabetes and obesity resulted from profound changes in society over the last 20 years, such as more working parents, neighborhoods and parks perceived as unsafe, limits of school physical education, increased demand for convenience foods, greater consumption of food prepared outside the home, increased use of computers, and increased marketing to children (Nestle). Diabetes is a precursor for other serious medical conditions. These conditions include heart disease and strokes, high blood pressure, blindness, kidney disease, complications of the nervous system, amputation, dental disease and complications in pregnancy (CDC, 2008). Mallory, Fiser, and Jackson (1989) studied the sleep patterns of 41 children who were determined obese. Approximately one third reported symptoms consistent with sleep apnea, one third had abnormal sleep studies. Two patients had severe sleep apnea (Mallory et al.). Further, there is evidence that obese children with obstructive sleep

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apnea demonstrate clinically significant decrements in learning and memory function compared to obese children without obstructive sleep apnea (Rhodes et al., 1995). Gallstones are another physical consequence of obesity in children. Obesity accounts for 8 to 33% of gallstones in children (Halcomb, O'Neill, & Halcomb, 1980). It is estimated that the relative risk of gallstones in adolescent girls with obesity compared to those of normal weight is approximately 4.2 (Honore, 1980). Also, rapid weight loss increases the risk of gallstones (Kiewiet, Durian, Van cap Leersum, Hesp, & Van Vliet, 2006). In addition to gallstones, fatty liver and decreased liver function can occur in obese children (Must, & Strauss, 1999). Gastrointestinal problems such as acid reflux disease and constipation are also exacerbated by obesity (Hampel, Abraham, & El-Serag, 2005). Early onset of menstruation among adolescent girls is associated with obesity. Obese girls are observed to experience earlier menarche, typically before the age of 10 (Dietz, 1998). In addition, hormonal patterns typical of polycystic ovary syndrome are increasingly described in obese children (Dietz, 1998). Puhl and Latner (2007) examined the social and emotional consequences of obesity. They found that these consequences may have immediate and potentially lasting effects on obese children's well being, as well as the adverse medical outcomes. There is growing literature demonstrating that overweight and obese children and adolescents are targets of societal stigmatization. Research suggests that overweight and obese youths are the victims of bias and stereotyping by peers (Brylinsky & Moore, 1994; Kraig & Keel, 2001; Latner & Stunkard, 2003), and educators (Bauer, Young, & Austin, 2004). This bias and stereotyping can be particularly detrimental to children
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when they are trying to form social relationships (Puhl & Latner). One study demonstrated that children as young as age 3 ascribed targets portrayed as "chubby" with negative characteristics such as mean, stupid, loud, lazy, ugly, sad, and lacking in friends (Brylinsky & Moore). According to Puhl and Latner the school setting is a venue for ongoing stigmatization and discrimination for overweight and obese youths from nursery school through college. As a result of weight bias and discrimination, obese children suffer psychological, social, and health related consequences (Puhl & Latner). School-Based Obesity Prevention Programs Pathways The objective of the Pathways study was to evaluate the effectiveness of a school-based, multi-component intervention for reducing percentage body fat in American Indian schoolchildren. Cabellero et al. (2003) developed the intervention study which was a randomized, controlled, school-based trial involving 1,704 children in 41 schools conducted over 3 consecutive years. The children were in third to fifth grades in schools serving American Indian communities in Arizona, New Mexico, and South Dakota. The study consisted of two phases. Phase one involved defining the body fat measurement, all components of the intervention were developed and tested, and measurement instruments were validated. The second phase consisted of implementation for 3 consecutive years (Caballero et al.). School selection was based on eligibility criteria: (1) a projected 3 rd grade enrollment of > 15 children, (2) > 90% of third grade children of American Indian ethnicity, (3) retention from third to fifth grade over the past 3 years of > 70%, (4) 14

school meals prepared and administered on site, (5) availability of minimum facilities to deliver a physical activity program at the school, and (6) approval of the study by school, community, and tribal authorities (Caballero et al., 2003). The study intervention consisted of four components: classroom curriculum, food service, physical activity, and family involvement. The intervention combined constructs from social learning theory and principles of American Indian culture and practices. The classroom curriculum for third, fourth, and fifth graders focused on nutritional education and promoting physical activity. The food service component of the intervention provided nutrient guidelines and practical tools for reducing the fat content of school meals. The physical education program focused on increasing the energy expenditure while at school by implementing a minimum of three 30 minute sessions per week of moderate to vigorous exercise. In addition, the program included exercise breaks during class time of 2-10 minutes. The family involvement component aimed at introducing the Pathways intervention to the families and assisting them in creating a supportive environment at home. The family involvement included take home family action packs, including healthy snack options and educational materials, and family events at school, which included cooking demonstrations and activities for a healthier lifestyle (Caballero et al., 2003). The results of the Pathways Trial were not encouraging. The intervention group did not show a statistically significant drop on BMI among the participants or percentage of body fat. This can be attributed to the limited changes in the food served to the children. Although many of the high fat food were removed, it was a slowly implemented and federal regulation sets a requirement of how many calories must be 15

served. They occurred late in the trial to have had a real affect on the children's weight. The intervention showed positive but no statistically significant trend in the level of physical activity during school time. The results suggest that more intense or longer interventions were needed to modify the continuing trend toward higher adiposity in the Native American population (Caballero et al., 2003). Planet Health Planet Health was developed by Gortmaker et al. (1999) to evaluate the impact of a school-based health behavior intervention on obesity among boys and girls in Grades 6 to 8. The study was a randomized, controlled field trial with five intervention schools and five control schools. The students consisted of 1,295 ethnically diverse Grade 6 and 7 students from public schools in four Massachusetts communities. Students participated in a school-based interdisciplinary intervention over 2 school years. The sessions were integrated in to the existing curricula using classroom teachers. Sessions focused on decreasing televisions viewing, decreasing consumption of high fat foods, increasing fruit and vegetable intake, and increasing moderate and vigorous physical activity. They used concepts from behavioral-choice, and socialcognitive theories of individual change, with a distinctive focus on reducing television viewing. By allowing children choice over alternative activities when television viewing time is reduced, their perceived sense of control over the alternatives is increased, and this can reinforce physical activity. The activity and dietary components of the intervention were designed to emphasize lifestyle changes in behavior. Planet Health was designed to provide students with cognitive and behavioral skills to enable change in target behaviors, practice using skills to strengthen perceived competence in 16

using new behaviors effectively, and support for behaviors by multiple classroom and physical education teachers. Planet Health was implemented for all students, in order to change the distribution of obesity in the population, as well as limiting the risk of stigmatizing obese students. The results of the Planet Health intervention developed by Gortmaker et al. (1999) showed a decrease in obesity prevalence for girls in the intervention schools, but not for boys. Television and video viewing decreased for girls and boys in the schools receiving the intervention compared with the control schools. There was a decline in the prevalence of obesity in female students from 23.6% to 20.3% in the intervention group. The controlled schools saw an increase in obesity prevalence, from 21.5% to 23.7% over the 2 school year intervention periods. Among the boys, obesity prevalence declined in both the intervention and control schools. There was no significant difference in outcome for the boys. The results of this study are encouraging in that it did affect obesity prevalence among girls. The difference in obesity prevalence results for boys and girls could be attributed to different causal factors that may operate among boys and girls. The decrease in television viewing affected the girls' obesity prevalence. The researchers indicate that further research is needed to evaluate the extent to which the changes persisted over time. Texas Trial Johnston et al. (2007) conducted a study in order to evaluate an intensive healthy lifestyle program designed to result in weight reduction on overweight Mexican American middle school children in Texas. They targeted Mexican American children because the prevalence of at risk for overweight, and overweight in Mexican American 17

children and adolescents is higher than any other minority (Ogden et al., 2006). They compared an intensive weight management program and a self-help only condition for weight reduction in at risk middle school children. A total of 60 overweight students were randomly assigned after baseline measurements were taken, with 40 in treatment and 20 in the control group. Children were between the ages of 10 and 14 years and in the sixth or seventh grade. All children identified as Mexican American. Participants included 33 boys and 27 girls. Both conditions focused on increasing healthy eating and physical activity by using behavioral strategies to individualize the plans to the specific needs of the participants. Children in the self-help condition used a 12-week parent guided manual intended to promote weight loss and long term maintenance of changes. Children in the intervention condition participated in an instructor led intervention for 12 weeks of daily, Monday through Friday, sessions followed by 12 weeks of bi-weekly sessions. Sessions were administered during study hall. During the 12-week sessions, participants received nutrition instruction 1 day per week and 4 days of physical activity training. Also, their parents were invited to attend monthly meetings to teach them how to adapt family meals and activities to promote these changes. They were also given bi-weekly quizzes to ensure that they were retaining the information. A token economy system was implemented for positive reinforcement. Students would receive points for trying new foods, keeping their bodies moving during physical activities, and for meeting goals. Points were then exchanged for prizes. All parental education was given in English and Spanish, and extended family members were encouraged to participate also.

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The results of the Johnston et al.'s (2007) trial were encouraging. Children in the intervention group significantly reduced their BMI, down 0.16, when compared with the children in the self-help group, up 0.05 after 6 months. Children in the intervention group also reduced their total cholesterol and low density lipoprotein (LDL) cholesterol. Johnston et al. attribute the success of their trial to the individualized nature of the interventions. Trained staff worked with the children to adapt to their specific lifestyle patterns using program principles. They emphasize the importance of having professionals trained in nutrition, physical activity, and behavior modification to provide the necessary intensity to see results. HEALTH-KIDS Study Wang et al. (2006) designed this study to test the feasibility and effectiveness of a school-based intervention program using environmental approaches for the prevention and treatment obesity among low socioeconomic African-American students in Chicago. The project was named the HEALTH-KIDS (Healthy Eating and Active Lifestyles from school to Home for Kids). The study had four specific aims. To assess the needs and test the feasibility of delivering a school-based intervention in the target population. This was accomplish by conducting focus groups to gather information from teachers, students, parents to better understand all the elements that contribute to overweight. Secondly, to test the effectiveness of the actual intervention. Thirdly, to conduct a process evaluation. And lastly, to examine the influence of a variety of social, cultural, environmental and behavioral factors that may contribute to the epidemic of childhood obesity in inner-city low socioeconomic African-American schoolchildren. 19

Wang et al. (2006) selected four Chicago public schools and randomly assigned the control and intervention groups. The intervention was scheduled to last for 1.5 years. The intervention program was designed according to Social Cognitive Theory (Bandura, 1986) and the Task and Technology Interaction (TTI) theory (Flay & Petraitis, 1994). The TTI is an effective model to guide interventions for reducing youth risk behaviors (Bandura; Flay, Graumlich, Segawa, Burns, & Holliday, 2004). Til includes seven tiers of causes of behaviors and three streams of influence that flow through the tiers: cultural-environmental influences on knowledge and values-attitudes, social situation contextual influences on social bonding and social learning-social normative beliefs, and intrapersonal influences on self-determination/control and social skills-self efficacy (Flay et al.). This study also used the CDC (1997) model for schoolbased intervention programs. This includes curriculum, counseling and psychology programs, food service, health service, health environment, physical education (PE) classes, health promotion programs for faculty and staff, and family and community linkages. It is a multidisciplinary approach (Wang et al., 2006). Over 450 fifth to seventh graders participated in this study. The preliminary findings of Wang et al. (2006) showed that only 26% of the participants reported spending > 20 minutes engaged in vigorous-moderate exercise on 5 or more days during a week. On average, 42% reported spending 4 hours or more each day watching television, playing video games or using the computer, while 29% spent 5 hours or more each day. In addition, these children consumed too many fried foods and soft drinks. When questioned how often they ate a certain food over the last 7 days, the children reported that 36% consumed fried food two to three times a day and 20

19% did so four or more times a day. The children also reported that 48% reported drinking soft drinks two to three times per day, and 22% reported four or more times per day. Wang et al. (2006) HEALTH-KIDS study is still being implemented. The preliminary findings show a great need for health promotion programs that target low socioeconomic African-American communities. However, low socioeconomic communities face other challenges, such as raising students academic test scores, which take priority and may affect funding for healthy eating programs. CATCH Luepker et al (1996) developed the Child and Adolescent Trial for Cardiovascular Health to address children's dietary patterns and physical activity. A total of 5,106 initially third grade students from Minnesota and Texas participated. The study consisted of a randomized, controlled field trial at four sites with 56 intervention and 40 control elementary schools. Twenty-eight schools participated in a third grade through fifth grade intervention including school food service modifications, enhanced physical education, and classroom health curricula. Twenty-eight additional schools received these components plus family education. The results of the CATCH collaborative (Luepker et al., 1996) were that the percentage of energy from fat in school lunches fell from 38.7% to 31.9% as opposed to control lunches, 38.9% to 36.2%. Also, physical activity in PE classes increased in the intervention schools. Self reported daily energy intake was reported to drop from 32.7% to 31.9% in the intervention schools. Overall, the body size, cholesterol and blood pressure measures did not vary significantly between treatment groups. However 21

the CATCH intervention was able to modify the fat content of school lunches, increase moderate to vigorous physical activity in physical education classes, and improve eating and physical activity behaviors in children during 3 school years. Behavior Modification Program Brownell and Kaye (1982) proposed a 10 week school based program involving behavior modification, nutrition education, and physical activity in order to address childhood obesity. This was one of the first multidisciplinary trials. This program was based on the premise that changes in eating and exercise habits are the key to long term weight loss. A total of 77 children participated, 63 in program and 14 in the control group. The obese children were aged 5-12, in grades kindergarten through 5 in Fort Myers, Florida. The children were from predominantly lower middle class families. The participants consisted of 62 White children and 15 African American children. The average child was 34.2% overweight for their age, sex, and height (Brownell & Kaye). Brownell and Kaye's (1982) treatment consisted of procedures to create a positive social environment in which the overweight child received support from parents, the nurse's aide, teachers, and the physical education instructor. The nurse's aide distributed detailed guides to the students, teachers, parents, and school administrators. The guides contained information on behavior modification, nutrition, and physical activity. The behavior modification portion focused on recording food intake, limiting situations for eating, and slowing the rate of eating. The result of the Behavior Modification program proposed by Brownell and Kaye (1982) were encouraging. Of the 63 program children, 60 lost weight, compared to 3 of the 14 control children. The mean weight ranges were a loss of 4.4 kg for the 22

children in the program, and a gain of 1.2 kg for the control children. Boys and girls in their program did not differ significantly in their weight loss or their change in percentage overweight. The encouraging results suggest that a program focusing not only on nutrition and exercise, but also on behavioral methods for encouraging changes in both areas, is more likely to get positive results. Just For Kids Just for Kids was developed by researchers at the University of California, San Francisco School of Medicine. Rodgers, Johnson, Tschann, Chesterman, and Mellin (2001) tested this school based application in the San Francisco School District. The objective of the Just for Kids program was to decrease obesity, improve cardiovascular fitness and physical fitness, and increase knowledge regarding the fat content of foods in 4th grade students. The intervention consisted of one hour of instruction in the classroom for 10 consecutive weeks. Students completed weekly readings and homework assignments, participated in role plays, practiced problem solving techniques, learned about the fat content of foods, learned to talk about their feelings, and were asked to exercise each day for 30 minutes. Outcomes were tested by BMI, triceps skinfold thickness, blood pressure, 3 minute step test and 1 minute recovery heart rate, and a food questionnaire to test nutrition knowledge. Results showed that triceps skinfold thickness decreased, as well as diastolic blood pressure. Nutrition knowledge also increased for over the 10 weeks. There were not significant results for the BMI, 1 minute testing heart rate, 3 minute step test, or 1 minute recovery heart rate. The short time period for the intervention suggests

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that a longer, more intensive intervention program may result in more changes in BMI (Rodgersetal.,2001). Relevance of School-Based Obesity Programs Various attempts have been made to address the increasing problem of childhood obesity. Multiple studies have used classroom curriculum, nutrition education, and physical activity (Cabellero et al., 2003; Gortmaker et al., 1999; Johnston et al., 2007). Due to the large amount of time spent in school by children, schools are the most appropriate setting to intervene to stop the epidemic of obesity. In addition to nutrition and physical activity, a behavior modification and therapeutic approach should also be implemented to address the reasons why children overeat and their feelings surrounding their weight.

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CHAPTER 3 METHODOLOGY Potential Funding Source Identification and Selection Strategies Funding Sources were investigated using several methods. An internet search was first conducted to locate various grant opportunities and requirements pertaining to childhood obesity prevention. General search terms were first used to locate grant databases. Terms such as grants, education grants, grant funding and obesity grants were used. Databases which were then located were www.grants.gov, www.ed.gov, www.grants.nih.gov, and www.grantsalert.com. These databases were then searched for particular grants that provided funding for obesity prevention. Terms searched were obesity prevention, childhood obesity, and obesity education. Foundations were also looked at as possible funding sources. The Robert Wood Foundation, the Blue Cross and Blue Shield Association, and the National Childhood Obesity Foundations were considered. There are many funding opportunities for obesity prevention research and programs, due to its prevalence in today's society. More and more people are viewing it as a social problem, and therefore funding opportunities are increasing. The Robert Wood Johnson Foundation (RWJF) provides grants for projects in the United States and U.S. territories that advance their mission to improve the health and health care of all Americans. RWJF has developed three integrated strategies to reverse the childhood obesity epidemic: evidence, action and advocacy. Investments 25

in building the evidence base will help ensure that the most promising efforts are replicated throughout the nation. Their action strategy for communities and schools focuses on engaging partners at the local level, building coalitions, and promoting the most promising approaches. As they learn from their evidence and action strategies, they share results by educating leaders and investing in advocacy, building a broad national constituency for childhood obesity prevention (Robert Wood Foundation, n.d.). The Blue Foundation for a Healthy Florida, Inc., is the philanthropic affiliate of Blue Cross and Blue Shield Association created as a 501(c)(3) philanthropic foundation that supports community-based solutions that enhance access to quality health-related services for the uninsured and underserved in Florida. The Blue Foundation funds several programs in the state of Florida (The Blue Cross and Blue Shield Association, 2009). The National Childhood Obesity Foundation was created for the general purpose of proactively developing, uniting, integrating, targeting, and communicating a positive ecologically and scientifically based health care empowerment nutrition and physical activity education intervention program message to those directly and indirectly affected by the national obesity epidemic (National Childhood Obesity Foundation, 2008). In addition to searching the internet, various agency websites were also explored to research funding. These included the National Center for Chronic Disease Prevention and Health Promotion (www.cdc.gov), The Finance Project (www .financeproject.org), and the National Institute of Health website (www.nih.gov). 26

A publication was located titled, "Financing Childhood Obesity Programs: Federal Funding Sources and other Strategies." This publication is compiled by The Finance Project, which is a specialized non-profit research, consulting, technical assistance and training firm for public and private sector leaders nationwide. The Finance Project's mission is to support decision-making that produces and sustains good results for children, families, and communities. The Finance Project develops and disseminates research, information, tools, and technical assistance for improved polices, programs, and financing strategies. The Finance Project was founded in 1994 with support from a consortium of national foundations interested in ensuring the viability and sustainability of promising initiatives that contribute to better futures for children, families, and communities (The Finance Project, 2005). The Finance Project's publication gives financing strategies for supporting programs and services for healthy lifestyle and obesity prevention. The suggestions given are to make better use of existing resources, maximize federal and state revenue, create more flexibility in existing categorical funding, build public-private partnerships, and creating new dedicated revenue systems. Primarily, the Finance Project focuses on federal funding, due to the fact that the federal government has increased its focus on obesity and there are funds available for core programming and program supplements targeting obesity (The Finance Project, 2005). The funding selected was located on the grants.gov website. The grant is funded by the National Institute of Health and is specific for school-based interventions to prevent obesity. This funding opportunity announcement encourages the formation of partnerships between academic institutions and school systems in order to develop and 27

implement controlled, school-based intervention strategies designed to reduce the prevalence of obesity in children. This grant opportunity best correlated with the topic, target population, goals, and eligibility specifications. Target Population The target population for this grant is children in grades 6 through 8 in Long Beach Unified School district. Specifically students at Washington Middle School. Studies have shown that obesity is prevalent in adolescence, and often leads to health consequences as an adult. By implementing prevention strategies at ages 11 through 14, children can be prepared with the knowledge and tools to keep them healthy in their teenage years. Washington Middle School's total enrollment is 970 students, and 72.7% are Hispanic or Latino (CDE, 2008). Washington Middle school presents an opportunity to address the problem of childhood obesity in general, and specifically the disproportionate rates among Hispanic children. Resources for the Grant Writing Statement Statistics from the Center for Disease Control, American Diabetes Association, and the National Institute of Health will be used to show the prevalence of obesity among children. In addition, the results from previous obesity prevention programs from around the country will be evaluated. These results can be obtained from the National Institute of Health and the Center for Chronic Disease control and Health Promotion, as well as publications of previously attempted programs and their results. The Long Beach Unified School District's DataQuest website gives information regarding school enrollment and ethnicity reports. Long Beach Unified School Districts direct website gives information about the existing school programs and staff. 28

CHAPTER 4 GRANT APPLICATION Description of Proposed Project This grant seeks to fund a school-based obesity prevention program. Due to the large number of adolescents and high school students who are obese, this project will target middle school children in the sixth through eighth grades. Obesity is on the rise among children and can lead to serious medical and psychological consequences. The Hispanic population is particularly affected. Considering that children spend the majority of time in a school setting, this program will implement a multi disciplinary obesity prevention intervention at Washington Middle School in Long Beach, California. The overall goal of the proposed obesity prevention program is to decrease the number of obese children at Washington Middle School. In addition, the program aims to decrease the likelihood that these children will become obese by providing education, physical activity and behavior modification support. The program will be for 3 academic years, beginning in Grade 6 and following the students through Grade 8. In addition to providing nutrition education, physical activity, and behavior modification, individual counseling services will be available to obese children and their families. Program components include individual needs assessments on children categorized as overweight or obese, weekly classroom education for all students, monthly monitoring 29

of progress, daily physical activity, monthly parent education seminars, and, as needed, individual and family counseling services for those children requiring more intensive intervention. Areas Affected by the Project Washington Middle School is located in Long Beach, California. Long Beach covers approximately 52 square miles on the southern coast of Los Angeles County. With a current population of 491,564, Long Beach is the second largest city in Los Angeles County and the fifth largest city in the state (U.S. Census Bureau, 2005). It is a diverse and dynamic city that, based on the 2005 Census, has the following ethnic breakdown: 43.7% White, 39.7% Hispanic, 14.2% Asian, 13.1% Black, 0.5% Pacific Islander, 0.5% American Indian, Eskimo, and 24.3% all other ethnicities. The median household income, according to the 2005 Census data, was $43,746. According to the State of California Employment Development Department (2009), the preliminary unemployment Rate in Long Beach was 11.9%. More specifically, Washington Middle School is located in the Southwest area of Long Beach. This area is made up of 158,599 people. The average household income is $37,408. The demographics of the Southwest area of Long Beach is 49% Hispanic, 18% White, 15% Black, and 13% Asian. According to the City of Long Beach Department of Planning and Building (2007), 42% do not have a high school diploma and 15% have college degrees. The Long Beach Unified School District is the third largest public school system in California, serving 93,408 kindergarten through 12th grade students in 2004. The district's 95 schools are located in Long Beach, Signal Hill, Lakewood, and on Catalina 30

Island. In Long Beach in 2004,19.5% of children ages 5 to 19 were at risk for being overweight, and 23.9% were overweight. In comparison, 18.3% of children ages 5 to 19 in California were at risk of overweight and 22.4% were overweight (City of Long Beach Health and Human Services Department, 2008). In Los Angeles County, overweight is highest among boys and among Latino children overall (Los Angeles County Health Survey, 2005). When surveyed, 32.4% of children (2-17 years old) in Long Beach reported they ate fast food in the past 24 hours compared to 25.8% in Los Angeles County (Los Angeles County Health Survey, 2005). Proposed Project Dates This program will start in the beginning of the school year, September 2009 and commence at the conclusion of the school year, June 2010. Congressional District Washington Middle School is located in the 37th Congressional District and is represented by Laura Richardson. Specific Aims of Project The goal of this program is to reduce the rate of obesity among students at Washington Middle School. To reach this goal, the program will conduct needs assessments on students measured as overweight or obese, increase nutrition knowledge, implement a physical activity program, bring families and parents together for monthly educational seminars, and provide individual counseling to obese students. The multidisciplinary team will consist of the School Nurse, Physical Activity Coordinator, Nutritionist, and Masters Level Program Director.

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Objective 1: Conduct Needs Assessments The program will initially weigh all sixth grade students and measure their BMI. The school nurse will conduct these measurements as part of annual health assessments. The results of the measurements will then be shared with the program director. Needs assessments will then be conducted on students whose BMI is over the 95th percentile. Parental consent will be collected on these students. The needs assessment will look at eating habits, environmental factors, family eating habits, self esteem, and social skills. The information will be gathered by interviews, and questionnaires given to parents. The results of the needs assessments will be used to develop individualized programs for students measured as obese or near obese. Children and their parents who wish to participate will be offered individual and family counseling. The counseling will focus on the areas identified in the needs assessments. Objective 2: Increase Nutrition Knowledge Among all Students Weekly classroom curriculum will be given to all sixth grade students. This curriculum will consist of nutritional information on healthy eating habits based on the Just for Kids workbooks developed by Rodgers et al. (2001). In addition to nutritional information, the curriculum will aim to educate students about the health consequences of making poor food choices. The curriculum will also consist of homework assignments that will encourage family involvement. Coping skills and emotional eating will also be discussed. The curriculum will be taught by a certified nutritionist and will be culturally competent.

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Objective 3: Increase Physical Activity This objective will be met by offering an after school physical fitness program. Although organized competitive sports are offered, often obese students do not feel comfortable competing in organized sports. This activity program will focus on increasing the students cardio endurance through different forms of exercise, including cardio drills and strength training. The physical activity coordinator will provide a supportive environment for students of all skill levels. Students will also be asked what types of activities they enjoy doing in order to incorporate those activities in the plan. Objective 4: Promote Family Involvement Families will be encouraged to participate in monthly educational seminars conducted by the multidisciplinary team. Parents and siblings will be given information on nutrition and family activities that can involve physical activity. Healthy recipes will be distributed and potlucks will be encouraged. Grocery shopping techniques, as well as ways to eat healthy on a budget will be discussed. Parents will be asked for their feedback and participation in order to involve them in the process. Culturally sensitive material will be given. The seminars will be open parents of all students. Objective 5: Provide Counseling Services Individual and family counseling will be offered to those students measured as obese or at risk of obese. Weekly counseling sessions will address behavior modification techniques to assist the child in making better food choices and address emotional eating patterns. In addition, the counseling will focus on self esteem building exercises. These exercises will promote positive self esteem and address any bullying victimization. The family counseling will aim to help the family work on any issues or 33

concerns they have that may be contributing to the child's obesity. The counseling will be culturally competent and address cultural issues which affect obesity. Background and Significance Obesity and overweight has become an increasing health concern in the United States. The prevalence of overweight has doubled for United States children aged 6-11 years and tripled for American teenagers over the past 2 decades (Shaya et al., 2008). The prevalence of children classified as "at risk for overweight" or "overweight" has tripled in the past 20 years and currently exceeds > 30% (Hedley et al., 2004). Approximately 17% of children and adolescents between the ages of 2 and 19 years are considered overweight, and 34% are at risk of becoming overweight (CDC, 2007). The increase of fast food intake, sweet soda consumption, and lethargic activities is often blamed for childhood obesity. The risk factors for obesity determined by Sothern and Gordon (2003) are parental obesity, sedentary behaviors such as television viewing and video games, poor nutrition, unhealthy food attitudes and practices, low socioeconomic status, low birth weight, and formula fed infants versus breast feeding. Obesity in children can lead to diabetes, gallstones, hypertension, arthritis, sleep apnea, and low self esteem. The prevalence rate of obesity was higher among adolescent non-Hispanic Black boys, 22.9% and Mexican-American boys, 21.1% than among non-Hispanic White boys, 16.0% (Ogden et al., 2008). Previous studies have attempted to address childhood obesity in the school environment. This program will differ from previous attempts in that it will combine the successful components of previous programs. It will provide classroom education, a physical activity program, encourage family involvement as well as offer counseling 34

services to those students who are obese. Previous studies have shown that long term, individualized interventions can be successful. Project Site Location The program will be implemented at Washington Middle School, located in Long Beach, California. Project Evaluation Each part of the program will be evaluated: nutrition education, physical activity, and psychological counseling. Measures will be taken at the start and completion of each program. Where standardized measures are available, they will be used. If measures are not available, they will be developed. Objective data, such as weight, food intake, and amount of exercise will be measured daily. All parties involved will be responsible for completing outcome measures: the child, the parent/group home parent, the social worker, the physical activity coordinator, and the nutritionist. Cumulative results will be presented at the multidisciplinary monthly meetings so that if changes are needed, they can occur at monthly intervals. Objective data (e.g., weight, eating, exercise), however, will be evaluated daily. Estimated Project Funding This overall program spans 3 years. This timeframe was based on the consensus of many evidence based programs which conclude that a long term approach to obesity is needed. The requested funding is for 1 year of the program. Results of the initial year will then be evaluated to support request for future funding. The projected funding covers salaries for the Program Director (Master of Social Work [MSW]), Licensed Nutritionist, Physical Activity Coordinator, Educational supplies, physical activity 35

supplies, office supplies, and cost for evaluating the results at the end of the year. The requested funding is $224,650. Project Budget See Table 1 for Project Budget. The Program Director will hold a Masters in Social Work. The director will be responsible for overall program implementation and facilitate the counseling services. The director will also be responsible for ensuring that outcome measurements are being taken accurately and track progress. The Program Director will oversee the monthly team meetings and assist in coordinating the monthly family seminars, with the assistance of the entire multidisciplinary team. The Physical Education Coordinator is a full time position that will facilitate the afterschool program as well as participate in the multidisciplinary team meetings and family seminars. This position will be a Bachelors level in kinesiology or a related field. The Physical Education Coordinator will be responsible for tracking the daily and weekly physical activity measurements in order to track outcomes. This position will also provide the physical education expertise to the monthly family seminars. The Nutritionist will be a part time position. The Nutritionist will teach the weekly classroom curriculum, and participate in the multidisciplinary team meetings and family seminars. The Nutritionist will assist in developing the information given at the family seminars and be available for consultation. The Administrative assistant will be a part time position to assist with administrative tasks and funding pursuits. The Administrative Assistant will assist the Program Director in tracking the outcome measurements and statistics.

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TABLE 1. Line-Item Budget

Expenses

Amount

Salaries and Benefits Project Director (MSW)-FTE = 100% Benefits @ 27% Physical Activity Coordinator- FTE = 100% Benefits @ 27% Licensed Nutritionist -PTE = 50% Administrative Assistant -PTE= 50% 20 hrs per week at $15/hour x 44 weeks = Total Salaries with Benefits Direct Program Costs Educational Supplies (Curriculum Materials, etc.) Office Supplies (Computers, Furniture, Resource Books, etc.) Printing Food Supplies (Parent Meetings, Committees, etc.) Recreation Equipment Total Direct Costs Indirect Program Costs Evaluation Cost Total Indirect Program Costs Total Project Cost

$55,000 $14,850 $30,000 $8,100 $25,000 $13,200 $146,150

$25,000 $10,000 $7,500 $6,000 $5,000 $53,500 $25,000 $25,000 $224,650

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In addition to the positions described above, the school nurse will also be a part of the multidisciplinary team. The school nurse is a Long Beach Unified School District employee and will consult with the multidisciplinary team in order to facilitate the needs assessments. The school nurse will also assist in tracking the weight and BMI measurements of the participants in order to measure the outcomes of the program. The Direct costs of the program include Educational supplies, including the materials that will be distributed as part of the classroom curriculum and family seminars. The office supplies will include computers for outcome tracking and research materials. The printing of educational supplies and informational pamphlets is also included. Food supplies encompass the refreshments that will be served at the monthly family seminars, as well as demonstration for healthy recipes. Recreation equipment will be used by the Physical Education Coordinator for the after school program. The Indirect costs cover the consultation services for the evaluation of the program. The evaluation is vital to receiving future funding. These costs will cover an outside firm to analyze the data and outcome measurements.

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CHAPTER 5 LESSONS LEARNED Steps in Grant Writing This thesis project has enhanced the knowledge of grant writing, as well as the needs of the obese children. Childhood obesity is a popular topic for research and therefore there was an extensive amount of literature on this topic. Identifying an area where there is need is the first step in grant writing. Then determining the best way to meet those needs is the next step. This is done by researching other research and studies done to address the need. The California State University, Long Beach library website was very helpful in finding scholarly journals and articles pertaining to childhood obesity. Some articles were not available online, and further research was physically done at the library. Statistics, demographics, prevalence rates, and treatment suggestions were also located using the internet. These resources assisted in building an argument for the necessity for funding the project to meet the need. Partnering with a host agency and aligning their mission and values with the goals of your program is essential in implementing a successful program and succeeding in having it funded. Also, finding an agency with a service gap that can be filled by your program is helpful. The school setting was ideal for this project, especially considering the current budget cuts that are affecting the funding for physical education and nutrition.

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The internet was a very useful tool in identifying potential funding sources and information about grant writing in general. Grants.gov is a very extensive website which gives numerous government funding opportunities categorized by type and subject. In addition the actual grant application, the National Institute of Health gives access to a detailed, 183 page application manual, which gives information and instructions on completing the necessary documents for grant funding from the National Institute of Health and Public Health agencies. This was very helpful. Also, the requirements for various grant funding opportunities varied. Many government grants were able to be completed online. In addition to the Grants.gov website, general searches for foundations and funding opportunities also yielded favorable results. Searching for terms such as "childhood obesity funding," and "childhood obesity foundations" yielded funding opportunities and the various foundations that are working to decrease the high rate of childhood obesity. In actually writing the grant proposal, the grant writer must remember that they are trying to convince the funding agency to provide a large amount of money for their program. Therefore, they must provide substantial information as to why they should fund your program. There is competition for funding and the grant writer must take into account the other proposals these agencies may be reading. The grant writer must supply all requested documents and information in order to be taken seriously for funding. Challenges There are challenges in developing a grant and receiving the appropriate funding. When economic times are hard, there are more agencies competing for less 40

available funding. This makes it more difficult for grant writers to find the appropriate funding opportunities that match their projects goals and criteria. When a project is already being implemented, it becomes necessary to research future funding options and keep track of deadlines to not miss out on various opportunities. It is vital to keep track of deadlines for funding and required documentation. A challenge for this proposed program will be to identify future funding opportunities as available funding decreases. Strategies Used to Increase Likelihood of Funding Strategies to increase the likelihood of funding included an extensive review of the literature, and the grant writer's knowledge of the problem's scope and seriousness. The literature review allowed the grant writer to cite previous research and programs that gave validity to the proposed program's tactics. It is important to show how your program is going to address the problem and how that progress will be measured. Relevance to Social Work Policy and Practice The health concern of childhood obesity is not limited to the healthcare industry. Childhood obesity needs to be addressed by a multidisciplinary approach in order to address all the various causes and consequences. Childhood obesity is relevant for social workers due to the social and psychological consequences that occur in obese youth. Obese youth suffer discrimination, bullying, and low self esteem, in addition to the adverse health consequences (Budd & Volpe, 2006). They may also use food as a coping mechanism for other problems (Dietz, 1998). Obesity is also often a family problem and should be examined in the context of the entire family. Research has shown that one dimensional approaches targeting solely physical activity or nutrition

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are not as effective as a multidisciplinary approach that also targets the emotional effects of obesity (Cabellero et al., 2003; Johnston et al., 2007; Wang et al., 2006). In addition to the topic of childhood obesity being relevant to social work policy and practice, the skill of grant writing is also very important. Various social work programs rely heavily on funding from grants in order to serve their clients. The skill of grant writing allows social workers to bring their expertise and knowledge about social work issues into the grant proposals and increase the likelihood of funding.

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REFERENCES

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REFERENCES American Diabetes Association. (2008). Total prevalence of diabetes and pre-diabetes. Retrieved October 20, 2008, from http://www.diabetes.org/utils Anderson, P. A., & Butcher, K. F. (2006). Childhood obesity: Trends and possible causes. The Future of Children, 16(1), 19-45. Bandura, A. (1986). Social foundation of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. Barlow, S. E. (2007). Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity; summary report. Journal of the American Academy of Pediatrics, 120, 164-192. Bauer, K. W., Yang, Y. W., & Austin, S. B. (2004). How can we stay healthy when your throwing all this in front of us?" Findings from focus groups and interviews in middle schools on environmental influences on nutrition and physical activity. Health, Education, & Behavior, 31, 34-46. The Blue Cross and Blue Shield Association. (2009). The Blue Foundation for a Healthy Florida. Retrieved December 21, 2008, from http://www.bcbs.com/ news/plans/the-blue-foundation-for-a-heal.html Brownell, K. D., & Kaye, F. S. (1982). A school-based behavior modification, nutrition education, and physical activity program for obese children. The American Journal of Clinical Nutrition, 35, 277-283. Brylinsky, J. A., & Moore, J. C. (1994). The identification of body build stereotypes in young children. Journal of Research in Personality, 28, 170-181. Budd, G., & Volpe, S. L. (2006). School based obesity prevention: Research, challenges, and recommendations. Journal of School Health, 76(10), 485-495. Cabbellero, B., Clay, T., Davis, S. M , Ethelbach, B., Rock, B. H., Lohman, J. N., et al. (2003). Pathways: A school-based, randomized controlled trail for the prevention of obesity in American Indian schoolchildren. American Journal of Clinical Nutrition, 78, 1030-1038.

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City of Long Beach Department of Planning and Building. (2007). Long Beach demographics. Retrieved February 2, 2009, from http://www.longbeach.gov /civica/filebank/blobdload.asp?BlobID=10397 City of Long Beach Health and Human Services Department. (2008). Childhood obesity fact sheet. Retrieved February 2, 2009, from http://www.longbeach.gov /civica/filebank/blobdload.asp?BlobID=18164 Centers for Disease Control and Prevention. (1997). Guidelines for school and community programs to promote lifelong physical activity among young people. Mortality and Morbidity Weekly Report, 46, 1-36. Centers for Disease Control and Prevention. (2003). Physical activity levels among children aged 9-13 years-United States. Mortality and Morbidity Weekly Report, 52(33), 785-788. Centers for Disease Control and Prevention. (2007). National diabetes fact sheet. Retrieved February 2, 2009, from http://www.cdc.gov/diabetes/pubs /factsheet07.htm Centers for Disease Control and Prevention. (2008). Prevent diabetes. Retrieved January 4, 2009, from http://www.cdc.gov/diabetes/consumer/prevent.htm Collip, P. J. (1975). An obesity program in public schools. Pediatric Annals, 1, 276282. California Department of Education. (2008). Data quest. School level enrollment report. Retrieved February 5, 2009, from http://datal.cde.ca.gov/dataquest Davis, M. M., Gance-Cleveland, B., Hassink, S., Johnson, R., Paradis, G., & Renicow, K. (2007). Recommendations for prevention of childhood obesity. Journal of the American Academy of Pediatrics, 120, 229-253. Delvi, S. (2008). Progress on childhood obesity patchy in the USA. Retrieved March 2, 2008, from www.thelancelot.com Dietz, W. H. (1994). Critical periods in childhood for the development of Obesity. American Journal of Clinical Nutrition, 59, 955-959. Dietz, W. H. (1998). Health consequences of obesity in youth: Childhood predictors of adult disease. Journal of the American Academy of Pediatrics, 101, 518-525. Dietz, W. H., & Gortmaker, S. L. (2001). Preventing obesity in children and adolescents. Annual Review of Public Health, 22, 337-357. 45

Dowda, M., Ainsworth, B.E., Addy, C.L., Saunders, R., & Riner, W. (1999). Environmental influences, physical activity, and weight status in 8 to 16-yearolds. Archives of Pediatric & Adolescent Medicine, 155, 711-717. The Finance Project. (2005). Financing childhood obesity prevention programs. Retrieved February 15, 2009, from http://www.flnanceproject.org /publications/obesityprevention.pdf Findholt, N. (2007). Application of the community based readiness model for childhood obesity prevention. Public Health Nursing, 24(6), 565-570. Fogelholm, M , Nuutinen, O., Pasanen, M., Myohanen, E., & Saatela, T. (1999) Parentchild relationship of physical activity patterns and obesity. International Journal of Obesity & Related Metabolic Disorders, 23, 1262-1268. Flay, B. R., Graumlich, S., Segawa, E., Burns, J. L., & Holliday, M. Y. (2004). Effects of 2 prevention programs on high-risk behaviors among African American youth: A randomized trial. Archives of Pediatric & Adolescent Medicine, 158, 377-384. Flay, B. R., & Petraitis, J. (1994). The theory of triadic influence: A new theory of health behavior with implications for preventive interventions. In G. Albrecht (Ed.), Advances in medical sociology, Vol. 4: A reconsideration of health behavior change (pp. 19-44). Greenwich, CT: JAI Press. Gordon-Larsen, P., Adair, L. S., & Popkin, B. M. (2003). The relationship of ethnicity, socioeconomic factors, and overweight in U.S. adolescents. Obesity Research, 11, 121-129. Gortmaker, S. I., Peterson, K., Wiecha, J., Sobol, A. M., Dixit, A., Fox, M. K., et al. (1999). Reducing obesity via a school-based interdisciplinary intervention among youth. Archives of Pediatric & Adolescent Medicine, 153, 409-418. Halcomb, G. W., O'Neill, J. A., & Halcomb, G. W. (1980). Cholecysitis, cholelithiasis and common duct stenosis in children and adolescents. Annals of Surgery, 191, 626-635. Hampel, H., Abraham, N. S., & El-Serag, H. B. (2005). Meta-analysis: Obesity and the risk for gastroesophageal reflux disease and its complications. Preview Annals of Internal Medicine, 143(3), 199-215. Harris, J. M. (2002). The U.S. food marketing system: 2002: Competition, coordination, and technological innovations into the 21s' century. USDA Agricultural Economic Report, 811. Retrieved December 21, 2008, from http://www.ers.usda.gov/publications/aer811 46

Hedley, A. A., Ogden, C. L., Johnson, C. L., Carroll, M. D., Curtin, L. R., & Flegal, K. M. (2004). Prevalence of overweight and obesity among U.S. children, adolescents, and adults, 1999-2002. Journal of the American Medical Association, 291, 2847-2850. Hill, J., & Throwbridge, F. (1998). The causes and health consequences of obesity in children and adolescents. Pediatrics, 101, 497-575. Honore, L. H. (1980). Cholesterol cholelithiasis in adolescent females. Archives of Surgery, 115, 62-64. Hughes, S., & Dennison, C. R. (2008). Progress in prevention: Cardiovascular nurses called to don public health hats. Journal of Cardiovascular Nursing, 23(6), 536537. Johnston, C. A., Tyler, C , McFarlin, B., Poston, W. S. C , Haddock, C. K., Reeves, R., et al. (2007). Weight loss in overweight Mexican American children: A randomized, controlled trial. Journal of the American Academy of Pediatrics, 120, 1450-1457. Kiewiet, R. M , Durian, M. F., Van Leersum, M., Hesp, F. L., & van Vliet, A. C. (2006). Gallstone formation after weight loss following gastric banding in morbidly obese Dutch patients. Obesity Surgery, 16, 592-596. Kimm, S. Y. S., Barton, B. A., Obarzanek, E., McMahon, R. P., Sabry, Z. I., Waclawiw, M. A., etal. (2001). Racial divergence in adiposity during adolescence: The NHLBI growth and health study. Pediatrics, 107(3), 34-41. Kraig, K. A., & Keel, P. K. (2001). Weight-based stigmatization in children. International Journal of Obesity, 25, 1661-1666. Krebs, N. F., Himes, J. H., Jacobson, D., Niklas, T. A., Guilday, P., & Styne, D. (2007). Assessment of child and adolescent overweight and obesity. Journal of the American Academy of Pediatrics, 120, 193-228. Latner, J. D., & Stunkard, A. J. (2003). Getting worse: The stigmatization of obese children. Obesity Research, 11, 452-456. Lavizzo-Mourey, R. (2007). Childhood Obesity. Journal of the American Medical Association, 298(8), 920-922. Leviton, L. C. (2008). Children's healthy weight and the school environment. The ANNALS of the American Academy of Political and Social Science, 615, 38-54.

47

Los Angeles County Health Survey. (2005). Obesity and overweight. Retrieved October 2, 2008, from http://publichealth.lacounty.gov/ha/docs/bmi2005.xls Luepker, R. V., Perry, S. M., McKinlay, S. M , Nadar, P. R., Parcel, G. S., Stone, E. J. et al. (1996). Outcomes of a field trial to improve children's dietary patterns and physical activity. The child and adolescent trail for cardiovascular health, Journal of the American Medical Association, 275(10), 768-776. Mallory, G. B., Fiser, D. H., & Jackson, R. (1989). Sleep-associated breathing disorders in morbidly obese children and adolescents. Journal of Pediatrics, 115, 892-897. Must, A., & Strauss, R. S. (1999). Risks and consequences of childhood and adolescent obesity. International Journal of Obesity & Related Metabolic Disorders, 23, S2-S11. National Heart, Lung, and Blood Institute Growth and Health Study Research Group (1992). Obesity and cardiovascular disease risk factors in black and white girls: The NHLBI Growth and Health Study. American Journal of Public Health, 82, 1613-1620. National Childhood Obesity Foundation. (2008). Overview. Retrieved January 24, 2009, from http://www.ncof.org/programming/overview.shtml National Institute of Health. (2008). Guidelines on overweight and obesity. Retrieved January 2, 2009, from http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk /ratnl/211.htm Nestle, M. (2005). Preventing childhood diabetes: The need for public health intervention. American Journal of Public Health, 95(9), 1497-1499. Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. A., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the United States, 19992004. Journal of the American Medical Association, 295, 1549-1555. Ogden, C. L., Carroll, M. D., & Flegal, K. M. (2008). High body mass index for age among U.S. children and adolescents, 2003-2006. Journal of the American Medical Association, 299, 2401-2405. Ogden, C. L., Kuczmarski, R. J., Flegal, K. M., Mei, Z., Guo, S., Wei, R., et al. (2002). Centers for Disease Control and Prevention 2000 Growth Charts for the United States: Improvements to the 1977 National Center for Health Statistics Version. Pediatrics, 109(1), 45-61.

48

Puhl, R. M., & Latner, J. D. (2007). Stigma, obesity, and the health of the nation's children. Psychological Bulletin, 133(4), 557-580. Putnam, J., & Gerrior, S. (1999). Trends in the U.S. food supply, 1970-1997. USDA Agriculture Information Bulletin, 750, 133-159. Rhodes, S. K., Shimoda, K. C, Waid, L. R., Mahlen, P., Oexmann, R. J., Collip, N. A., et al. (1995). Neurocognitive deficits in morbidly obese children and obstructive sleep apnea. Journal of Pediatrics, 127, 741-744. Robert Wood Foundation. (n.d.). Mission and values. Retrieved February 15, 2009, from http ://www.rwj f.org/pr/topic.j sp?topicid= 1024 Roberts, D. (1999). Kids & media at the new millennium. Kaiser Family Foundation Report. Retrieved January 20, 2009from http://www.kff.org/entmedia/1535index.cfm Rodgers, D. V., Johnson, S. R., Tschann, J. M., Chesterman, E. A., & Mellin, L. M. (2001). The evaluation of a school-based obesity prevention program among fourth grade students. Retrieved January 22, 2009, from http://www.just-forkids.org/links.htm Savage, J. S., Fisher, J. O., & Birch, L. L. (2007). Parental influence on eating behavior: Conception to adolescence. Journal of Law, Medicine & Ethics, 55(1), 22-34. Shaya, F. T., Flores, D., Gbarayor, C. M., & Wang, J. (2008). School-based obesity preventions: A literature review. Journal of School Health, 78(4), 189-195. Singh, G. K., Kogan, M. D., & van Dyck, P. C. (2007). A multilevel analysis of state and regional disparities in childhood and adolescent obesity in the United States. Retrieved December 10, 2008, from http://www.springerlink.com.mccl .Iibrary.csulb.edu/content/cj226034u5607417/fulltext.html Sothern, M. S., & Gordon, S. T. (2003). Prevention of obesity in young children: A critical challenges for medical professionals. Clinical Pediatrics, 42(2), 101112. State of California Employment Development Department. (2009). Monthly labor force data for cities and counties. Retrieved March 8, 2009, from http://www.calmis .ca.gov/file/lfrnonth/allsubs.xls Story, M. (1999). School-based approaches for preventing and treating obesity. International Journal of Obesity, 23, S43-S51.

49

Strauss, R. S., & Knight, J. (1999). Influence of the home environment on the development of obesity in children. Pediatrics, 103, e85-e85. Young, L. R., & Nestle, M. (2002). The contribution of expanding portion sizes to the U.S. obesity epidemic. American Journal of Public Health, 92, 246-249. U.S. Census Bureau. (2005). Long Beach, California fact sheet. Retrieved February 2, 2009, from http://www.census.gov Wang, Y., Tussing, L., Odoms-Young, A., Braunschweig, C , Flay, B., Hedeker, D., et al. (2006). Obesity prevention in low socioeconomic status urban African American adolescents: Study design and preliminary findings of the HEALTHKIDS study. European Journal of Clinical Nutrition, 60, 92-103.

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