Running head: ECOLOGICAL APPROACH TO OBESITY PREVENTION 1

An Ecological Approach to Child and Adolescent Obesity Prevention in Stanislaus County

Rachel Cox
University of San Francisco, School of Nursing and Health Professions










ECOLOGICAL APPROACH TO OBESITY PREVENTION 2

Purpose of Program
The target population of this program is elementary, junior high, and high school youth in
Stanislaus County, California. Stanislaus County is located in Californias Central Valley, a
diverse area with a high agricultural focus, high poverty rate, and low level of educational
attainment. Although Stanislaus County produces a wide variety of fresh foods to supply the
nation, its own population consumes fewer servings of fruits and vegetables each day than the
average Californian. In addition to poor diet, lack of proper exercise has led to high rate of
overweight children at risk for obesity.
In 2005, 36.7% of Stanislaus County children ate five or more servings of fruits and
vegetables daily, while the same was true for 39.5% of Californians. Furthermore, while
Stanislaus County reported a higher percentage of 7
th
, 9
th
, 11
th
grade students that engaged in at
least 20 minutes of physical activity than the California average (78%, 76%, 67% vs. 70%, 69%,
56%), the percentage of students achieving five or more fitness standards in 5
th
, 7
th
, 9
th
grades
has been consistently lower than California average since 2002. These standards have resulted in
24% of children being overweight and at risk for obesity in Stanislaus County. The Stanislaus
County Community Health Assessment 2008 produced all previously stated data.
Overweight children are more likely to be obese as adults and are at risk for health
problems once considered adult diseases high cholesterol, high blood pressure, and type 2
diabetes. Preventing and treating childhood obesity can significantly reduce the chance of
developing these diseases. Healthy People 2020 set targets for the percentage of overweight
children and adolescents nationwide: 15.7% for children 6 to 11 years; 16.1% for adolescents 12
to 19 years. To address childhood obesity in Stanislaus County residents, this program employs
the ecological model to move toward goal levels set by Healthy People 2020. It focuses on
ECOLOGICAL APPROACH TO OBESITY PREVENTION 3

improved physical activity and nutrition through education, community organization, and policy
action to ensure awareness of and ability to utilize necessary resources for childhood weight
reduction and management. Homes and schools will encourage healthy eating and physical
activity, community agencies will ensure access to affordable fresh foods and health seminars,
and policy initiatives will provide improved infrastructure.
Ecological Model as Program Framework
The ecological model holds that behavior change requires a supportive environment and
focuses on environmental policies that facilitate individual healthy choices. For example,
improving the quality and safety of local parks will improve the likelihood of children visiting
them. The environment described by the model is both physical and social and affects
individuals at the intrapersonal, interpersonal, organizational, community, and policy levels.
Four key principles tie the levels together: 1. Multiple levels of factors influence health behavior,
2. Influences interact across levels, 3. Multi-level interventions should be most effective in
changing behavior and 4. Ecological models are most powerful when they are behavior-specific
(Glanz, 2008).

Because the proposed program addresses multiple levels of influence and is
behavior specific to weight reduction, it offers a comprehensive approach to reducing the number
of overweight children in Stanislaus County.
Several studies suggest that an ecological approach to childhood obesity prevention is
best for influencing individuals and their environment to produce sustained behavior change.
Gentile (2009) studied over 1,300 children across two states and found a significant increase in
fruit and vegetable consumption as well as positive self-perception of change (23-62%) 6-months
post-intervention. Results came after advertising promoting healthy eating was increased and
families were provided with monthly materials to facilitate adoption of healthy behaviors. While
ECOLOGICAL APPROACH TO OBESITY PREVENTION 4

Gentile found little evidence of decreased Body Mass Index (BMI), Galvezs (2010) review
states that renovated parks have seen as much as a 4-fold increase in number of visitors and
found an association between perceived access to facilities and fewer overweight children.
Because the proposed program targets children and adolescents, who typically need
assistance and encouragement making decisions to affect individual change, interpersonal and
community support is essential for sustained behavior change. At the intrapersonal level, the
program requires individual behavior change regarding nutrition and physical activity, which
will be supported by interpersonal (parent/family/coach) influence to improve self-efficacy.
Organizational and community influence will be incorporated through schools and youth- and
faith-based organizations, which will implement wellness policies, increase health coaching and
develop regular, health-focused communication with members. County government will work to
increase the quality and quantity of parks, improve walking and cycling paths, update school
field equipment and ensure improved standards for obesity prevention education in schools.
Using an ecological approach provides additional levels of support that individual theories may
lack, but which strengthen success in children by going beyond individual decisions

(Lytle,
2009). This will likely facilitate healthy lifestyle maintenance beyond program inclusion.
The initial phase of the program will be one calendar year, coinciding with the start of the
academic year in August 2014 (August 2014 August 2015). Evaluations, which will survey
participant consumption of fruits and vegetables, physical activity level, and overall percentage
of overweight child/adolescent participants, will occur in May 2015 and again in August 2015,
after a summer period without programming. Results will be compared with previous county
levels and Healthy People 2020 goals. Positive evaluation and increased funding will likely
result in program continuation and expansion.
ECOLOGICAL APPROACH TO OBESITY PREVENTION 5

Program Outline
Program participants will be selected from local schools and community organizations to
align with county demographics on age, race, sex, family size, socioeconomic status, diet,
activity level, and current BMI. Each participating community school/organization will recruit a
team of peer coaches to work with site leaders, students, and families. Peer coaches will help
promote lifestyle changes and neighborhood improvements resulting from policy initiatives. In
addition to mandatory 2-week meeting periods, peer coaches and site leaders will be available to
schedule to additional meetings with participants at any time (academic year and summer).
Policy initiatives will occur year round and changes will be promoted at the organizational level
to educate families and encourage individual use. Biweekly seminars and weekly
communication topics will be decided based on participant input during initial 2-week meeting
period in September 2014 and mid-year evaluation in January 2015. Each participant/family will
be required to attend two biweekly seminars per semester; subscribing to biweekly
emails/picking up biweekly flyers will be optional. Site wellness policies will include:
encourage walking and biking to school/community activities, eliminate advertising of unhealthy
foods and beverages, adopt improved standards for vending machine offerings, expand physical
activity opportunities, make achievable and sequential goals lists available for students/members
to adopt.
Month/Year Program intention
August 2014 Schools and organizations officially
adopt wellness policies
Recruitment of peer coaches
Initial communication to
school/organization members
Recruitment of participants
September 2014 2-week mandatory survey period to
acquire recent data
o Participant nutrition habits,
ECOLOGICAL APPROACH TO OBESITY PREVENTION 6

physical activity levels, current
BMI
2-week mandatory period for each
participant/family to meet with peer
coach and site leader to discuss
individual goals and desired program
components
October December 2014 Biweekly, onsite educational seminars
on varying topics and available
community activities
Biweekly health-focused communication
through email and onsite flyers
Weekly farmers market rotates school
sites
January 2015 2-week optional survey period to
evaluate participant progress
o Participant nutrition habits,
physical activity levels, current
height/weight, use of
community facilities and
programs
2-week optional period to meet with
peer coaches and site leaders
(note: changes to programming will be made if
necessitated by optional January evaluations)
January May 2015 Biweekly, onsite educational seminars
on varying topics and available
community activities
Biweekly health-focused communication
through email and onsite flyers
Weekly farmers market rotates school
sites
May 2015: 2-week mandatory period to
meet with peer coaches and site leaders
to evaluate progress before summer.
May 2015: 2-week mandatory survey
period for evaluation
o Participant nutrition habits,
physical activity levels, current
BMI, use of community
facilities and programs
June July 2015 (academic summer period) No programming
Purpose is to re-evaluate participant
progress after period without regular
reminders and education
ECOLOGICAL APPROACH TO OBESITY PREVENTION 7

August 2015 2-week mandatory period to meet with
peer coaches and site leaders to discuss
summer maintenance
2-week mandatory master evaluation to
evaluate year-long progress and
maintenance over summer (participants
will not have had bi-weekly seminars
and physical activity in school)
o Participant nutrition habits,
physical activity levels, current
BMI, use of community
facilities and programs

Program Goals and Objectives
The overarching goal of the program is to promote healthy lifestyles among Stanislaus
County youth through healthy eating, active lifestyles, and community participation while
lowering the percentage of overweight children and adolescents residents. While quantitative
improvement is key to program continuation, success will be measured in both level of sustained
participation (qualitative) and raw percentage of lifestyle improvement (quantitative). Raw
percentages will be calculated in regard to: number of participants consuming five or more
servings of fruits and vegetables each day, number of participants partaking in at least 20
minutes of physical activity three times each week, and number of participants considered
overweight at the conclusion of the first calendar year (August 2015). Although the program is
designed to improve obesity prevention in line with Healthy People 2020 targets, complete
success cannot be expected in just one year. For this reason, a realistic goal for the master
evaluation will be a 1.3% reduction in number of participants considered overweight. This is
based on an 8% reduction goal over the remaining 6 years to move from 24% to about 16% of
children considered overweight. Individual successes based on study group demographics (age,
race, sex, family size, socioeconomic status, diet, activity level, and current height/weight) will
help inform how well an expanded program will benefit county levels outside the initial
ECOLOGICAL APPROACH TO OBESITY PREVENTION 8

participating schools and organizations. Qualitative data collected from optional and mandatory
evaluations will inform future program improvements, including coaching and seminar topics,
regularity of health coach meetings, needed policy initiatives, utilization of community activities,
and obesity prevention education in schools. Ideally, participants and their families will continue
to regularly utilize health coaching, biweekly seminars, and improved infrastructure upon
completion of the initial year-long program.
If the goal of 1.3% reduction is far from attainable after one year, thorough program re-
evaluation will be necessary. Similarly, if programming and successful policy initiatives are not
regularly utilized throughout the year, additional re-evaluation and participant input will be
required.
Conclusion
The proposed programs ecological approach intends to provide individual participants
with the knowledge, support, and resources to initiate and sustain behavior change leading to
weight reduction. As children and adolescents are the target population, family and community
support is essential to a successful intervention. The ecological model proposed facilitates
multiple levels of interacting support to provide a comprehensive weight reduction and obesity
prevention program for Stanislaus County. By examining both personal and community
environments, the program allows for increased understanding of individual obesity causes,
informs future programming and policy initiatives, and provides long-term resources needed for
sustained, successful behavior change.



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References
Galvez M, Pearl M, eds. Childhood Obesity and the Built Environment: A Review of the
Literature from 2008-2009. Curr Opin Pediatr. 2010 April; 22(2), 202-207.
Gentile D, Welk G, eds. Evaluation of a multiple ecological level child obesity prevention
program: Switch what you Do, View, and Chew. BMC Medicine. 2009; 7, 49.6.
Glanz K, Rimer BK, eds. Health Behavior and Health Education Theory, Research and Practice.
4th ed. San Francisco, California: Jossey- Bass; 2008.
Healthy People 2020. Objectives NWS-10.2, 10.3.
http://www.healthypeople.gov/2020/topicsobjectives2020. Accessed April 28, 2013.
Lytle L. Examining the Etiology of Childhood Obesity: The IDEA Study. Am J Community
Psychol. 2009 December; 44(3-4), 338.
Stanislaus County Community Health Assessment. 2008.
http://www.schsa.org/PublicHealth/pdf/dataPublications/communityHealthAssessment/2008
%20CHA%20Full%20Report.pdf. Accessed April 28, 2013.