March 2012





Battling obesity with better mathematical models

Feb. 23, 2012, Medical Express

By Katharine Gammon

Traditionally, nutritionists and researchers have assumed that all you need to do to lose weight is cut calories — about 500 calories per day to lose a pound per week for most dieters, from the assumption that each pound of weight lost represented 3,500 calories in reduced calorie intake or increased exercise.

“People have used this rule of thumb for decades, and it turns out to be completely wrong,” Kevin Hall, a scientist with the National Institutes of Health, said at the American Association for the Advancement of Science annual meeting in Vancouver.

Hall [a contributor to the National Collaborative on Childhood Obesity Research via the Envision project] said the reality is that losing weight slows a person’s metabolism, and the mathematical model typically used doesn’t take this slowing into account. When dieters report a “yo-yo” sequence, of weight loss, reaching a plateau in weight and then slowly regaining previously lost pounds, this is part of the reason.

New models may have some of the answers. The science of weight loss isn’t new; scientists have been struggling to understand it for almost 40 years, said Carson Chow, a senior investigator at the National Institutes of Health in Bethesda, Md. [and contributor to the NCCOR Envision project].

Chow said that what’s different now is that scientists are compiling many data sets into a single model.

Hall and Chow are part of a team that has created a new model, and an online weight simulation tool that shows what happens when people of varying weights, diets and exercise habits try to change their weight. Their model was first published last fall in the journal The Lancet.

“Instead of using that old rule of thumb, people input their goal weight in a certain period, and the model shows them what you have to do in [the] short term to get to goal weight and then what they’d have to do permanently,” explained Hall. The model takes into account differences in sex and body-fat content.

At the moment, the online tool is not very user-friendly, say the researchers, so it’s primarily intended for physicians and researchers who help guide people toward better health. Obesity is on the rise: two-thirds of the adult U.S. population is classified as overweight or obese, and around the globe, obesity rates have doubled in the past 30 years.

Outdated calculations predicted that people could lose weight forever, if they stuck to the calorie-reduction rules. The new model predicts slower weight loss.

“If I want to lose 10 pounds of weight eventually, I have to cut 100 calories per day out of my diet,” Hall explained. “You’ll get halfway there in about a year, and then you will eventually plateau, [reaching the goal] after about three years.”

Math can also help to drive policy decisions, said Boyd Swinburn of the World Health Organization Collaborating Centre for Obesity Prevention in Australia [and a contributor to the NCCOR Envision project]. He explained that many of the “best buy” policies that tend to have a real impact, such as restricting marketing to kids, taxing sugary substances, and increasing labeling, also tend to be the policies that governments do not want to undertake.

The less cost-ineffective interventions, like after-school programs, tend to be the ones that governments are more interested in undertaking, said Swinburn.

“You get a huge spread in the relative effectiveness of these programs,” said Swinburn, adding that mathematical perspectives that parse out health improvements per dollar help shed light on policy interventions.

Questions remain about the science of weight loss. For example, is a calorie of butter burned the same way in the body as a calorie of fruit? Like many other parts of the equation, said Hall, it may vary from person to person. The same is true of exercise.

“For small changes, exercise is more potent than cutting calories, it speeds up weight loss,” said Hall. But at some point, a person will reach a tipping point, where cutting calories will have a larger impact.

That’s because someone who is 200 pounds will lose more calories doing the same exercise than someone who is 150 pounds.

“The heavier you are, unlike the popular notion, the more calories you’re burning,” said Hall.


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Publications & Tools

IOM report: Measuring Progress in Obesity Prevention

Feb. 23, 2012, Institute Of Medicine

The Institute of Medicine (IOM) workshop report, Measuring Progress in Obesity Prevention, which features citations from several NCCOR members, is now available online for download. This publication reports on a March 2011 workshop planned by the IOM Committee on Accelerating Progress in Obesity Prevention (APOP).


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2012 OECD obesity update

The obesity epidemic slowed down in several Organization for Economic Cooperation and Development (OECD) countries during the past three years. Rates grew less than previously projected, or did not grow at all, according to new data from 10 OECD countries. Child obesity rates also stabilized in England, France, Korea and United States. However, rates remain high and social disparities in obesity are unabated.

Many governments have stepped up efforts to tackle the root causes of obesity, embracing increasingly comprehensive strategies and involving communities and key stakeholders. There has been a new interest in the use of taxes on foods rich in fat and sugar, with several governments (e.g. Denmark, Finland, France, Hungary) passing new legislation in 2011. This policy brief presents an update of analyses of trends and social disparities in obesity originally presented in OECD’s report, Obesity and the Economics of Prevention: Fit not Fat, published in 2010.


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Childhood Obesity Research & News

New guidelines for school vending machines planned

Feb. 20, 2012, The New York Times

By Ron Nixon

The government’s attempt to reduce childhood obesity is moving from the school cafeteria to the vending machines.

The Obama administration is working on setting nutritional standards for foods that children can buy outside the cafeteria. With students eating 19 percent to 50 percent of their daily food at school, the administration says it wants to ensure that what they eat contributes to good health and smaller waistlines. The proposed rules are expected within the next few weeks.

Efforts to restrict the food that schoolchildren eat outside the lunchroom have long been controversial.

Representatives of the food and beverage industries argue that many of their products contribute to good nutrition and should not be banned. Schools say that overly restrictive rules, which could include banning the candy sold for school fund-raisers, risk the loss of substantial revenue that helps pay for sports, music and arts programs. A study by the National Academy of Sciences estimates that about $2.3 billion worth of snack foods and beverages are sold annually in schools nationwide.

Nutritionists say that school vending machines stocked with potato chips, cookies and sugary soft drinks contribute to childhood obesity, which has more than tripled in the past 30 years. The Centers for Disease Control and Prevention (CDC) estimate that about one in every five children are obese.

No details of the proposed guidelines have been released, but health advocates and snack food and soft drink industry representatives predict that the rules will be similar to those for the government’s school lunch program, which reduced amounts of sugar, salt and fat.

Those rules set off a fight between parents and health advocates on one side, who praised the standards, and the food industry, which argued that some of the proposals went too far. Members of Congress stepped in to block the administration from limiting the amount of potatoes children could be served and to allow schools to continue to count tomato paste on a pizza as a serving of vegetables.

Nancy Huehnergarth, executive director of the New York State Healthy Eating and Physical Activity Alliance in Millwood, N.Y., said she expected a similar fight over the vending machine rules.

“I think the food and beverage industry is going to fight tooth and nail over these rules,” Huehnergarth said.

But representatives of the food and beverage industry say they generally support selling healthier snacks and drinks in schools. “But we are a little concerned that they might make the rules too stringent,” said James A. McCarthy, president of the Snack Food Association, a trade group in Washington.

McCarthy said the industry supported nutritional snacks and was working with the American Heart Association and the William J. Clinton Foundation, headed by the former president, in an initiative called the Alliance for a Healthier Generation to establish voluntary guidelines for healthier foods in schools.

The foods include baked rather than fried potato chips, dry-roasted nuts and low-sodium pretzels, McCarthy said.

Christopher Gindlesperger, director of communications for the American Beverage Association, whose members include Coca-Cola and Pepsi, said his industry had also worked with schools to reduce or eliminate sugary drinks and replace them with healthier alternatives.

“Our members have voluntarily reduced the calories in drinks shipped to schools by 88 percent and stopped offering full-calorie soft drinks in school vending machines,” Gindlesperger said.

But a study in the Archives of Pediatrics and Adolescent Medicine released this month shows that despite industry efforts and those of others, snacking behavior among children remains largely unchanged. One reason is that healthier snacks were being offered alongside less nutritious offerings.

Between 2006 and 2010, the study found, about half of the schools had vending machines, stores and cafeterias that offered unhealthy foods.

The availability of high-fat foods in schools followed regional patterns. In the South, where rates of childhood obesity are the highest, less nutritious food was more prevalent. In the West, where childhood obesity rates are lower, high-fat food was not as common, the study found.

Health advocates say the study points to the need for national standards. Jessica Donze Black, director of the Kids’ Safe and Healthful Foods Project at the Pew Charitable Trusts in Washington, gave the food industry credit for trying to reduce sugary drinks and fatty snacks, but said the voluntary guidelines did not go far enough.

“What we have is a fragmented system where some schools do a good job of limiting access to junk food and others don’t,” she said. “We need a national standard that ensures that all schools meet some minimum guidelines.”

Still, some school districts question whether students would buy healthy foods offered in vending machines and school stores. Frequently vending machines with healthy alternative snacks are ignored, and children bring snacks from home or buy them at local stores off-campus during lunch periods. Roger Kipp, food service director for the Norwood school district in Ohio, said children could be persuaded to eat healthy foods and schools could still make a profit.

Two years ago, Kipp eliminated vending machines and school stores in his district and replaced them with an area in the lunchroom where they could buy wraps, fruit or yogurt. Children ate better, and the schools made some money.

“It took a while, but it caught on,” Kipp said. “You have to give the kids time. You can’t replace 16 years of bad eating habits overnight.”



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Obese children outgrowing kids' clothing and furniture

Feb.15, 2012, CNN

By Madison Park

In middle school, Taylor LeBaron struggled to fit into his seat. The desks in class had a ceramic plate attached to the chair.

“I was so large, I couldn’t fit in there,” said LeBaron, now 19. “Every other student could. I couldn’t get my legs to fit underneath the desk or my stomach to fit between the chair without getting the desk stuck with me. “It was really embarrassing. When class is over, everyone gets up, I would take a few minutes extra, tactfully maneuvering out without looking like a fool.”

But LeBaron, who weighed nearly 300 pounds at age 14, never requested a separate table and chair because he didn’t want to draw more attention to himself.

As children are getting bigger, their clothing, their furniture and other objects that support their weight must also expand. 17 percent of children are obese, according to data from the Centers for Disease Control and Prevention (CDC). And one in three kids is obese or overweight. The rate of childhood obesity has tripled to the point that pediatricians say growth charts no longer apply to today’s kids.

To accommodate larger kids, some schools have instructions for teachers to provide separate chairs and desks for students who cannot fit into the pupil chairs. And school furniture makers are increasing the size of chairs and desks to accommodate larger students.

“Other students snickered as I would try to get out of my chair,” LeBaron recalled. “You could hear them snickering. You don’t forget how that feels — that embarrassment and that redness in your face.”

Being set apart from peers by sitting in a different chair means “their peers recognize them as large, different,” said Dr. Phil Wu, a pediatrician who leads Kaiser Permanente’s pediatric obesity prevention and treatment effort. “At all ages, kids don’t want to feel different,” Wu said. “They get ostracized by the peers in subtle and not-so-subtle ways. It’s more of that social psychological impact that’s insidious in a way that’s more profound than what the child might experience than sitting in a standard seat.”

Hertz Furniture, a company that resells office and school furniture, started offering 19-inch chairs for schools three years ago. The biggest desks available before had a height of 18 inches. The taller chairs have deeper depth and wider seating.

“The desks are getting larger, because if their thighs are larger, you have to move the desks up,” said Amy Hoffman, Hertz’s director of marketing.

Newer student desks with adjustable heights can accommodate bigger bodies. The student seats are designed to look just like the other ones, so they don’t make obese students appear different from their peers. “That is an obesity trend reflected in the furniture,” said Tom Brennan, president of School Outfitters, which sells school furniture.

“For perspective, when we look at import product from China, you can tell the difference from the China market and the U.S. market. The buckets are generally not wide enough. They have to be designed specifically for the U.S.”

Shawn Green, vice president of design and product marketing for KI, a company that designs and manufactures school and hospital furnishings, said the diameter of the metal, the supporting structure and the width, depth and height of school chairs have to be modified to work in the American market.

“People are not only heavier but also getting taller,” Green said. “In general, we’re getting bigger in scale; that affects children as well.”

Chairs made for older and bigger students are being used in middle and elementary schools to comfortably fit overweight and obese students. Schools prefer the “big and tall” sizes for educational furniture, said Tony Ellison, CEO of, which sells office and school furniture.

In the past five years, the biggest seats have been selling better than the standard sizes, he added. These items also cost more. It’s not just school desks that don’t fit.

A 2005 Pediatrics study found limited child safety seats for the increasing number of obese young children.

“There was a risk of kids not being covered for safety,” said the study author, Lara McKenzie. “If there are bigger kids, maybe there are some safety devices or equipment that wouldn’t fit them properly.”

The study suggested that car seats should maximize “the protection of obese children.”

Another study in 2009 suggested that most children in the study were too heavy to be compliant with child safety seat laws. Childhood obesity affects their safety in matters beyond child seats and ill-fitting school furniture. Obese kids are more likely to get heart disease, high cholesterol and high blood pressure and are more prone to diabetes, bone and joint problems.

Their health problems are also more likely to follow into adulthood. In extreme cases, pediatricians have reported toddlers with hip displacement problems from carrying too much weight and metabolic abnormalities in their insulin, liver enzymes and cholesterol — usually problems detected in older adults.

Children of this generation have exceeded the growth charts used in the United States since 1977. These charts are a series of percentile curves that illustrate how young children grow.

“Right now, if we say that 15 or 17 percent of all kids are over 95th percentile for obesity, statistically that doesn’t make sense,” Wu said. But that’s what has happened. “Compared to a population of Americans when these growth charts were created, more and more people today are exceeding what would’ve been the top percentile for weight and BMI back then,” he said.

It’s not a matter in whether the growth charts need to be redone, Wu said. “Our population today has become so large that now, it looks like more and more people are over the limits. It just highlights the problem that we have.”

LeBaron, who wrote about his battle with teenage obesity in his book “Cutting Myself in Half,” said the safety bar at amusement park rides barely locked over his abdomen. He couldn’t find T-shirts with the style he liked in his size. Clothing is often an issue.

Many obese kids and teenagers find that the plus sizes aren’t fashionable. At his peak weight, LeBaron wore 42-inch-waist pants and triple-X-large shirts.

People of that size don’t have many choices except sheet-like T-shirts in bland solid colors, LeBaron said.

“It was difficult because I’d go into Walmart or another clothing store, I found something cool, like a video game T-shirt, and I wanted to get it,” he said. “It’s not in my size. If they did, I’d have to dig through special drawer of extended sizes. It really hurt. They’re setting you apart.”

In recent years, the apparel industry has paid more attention to the growing size of kids, tweens and teens. Retailers such as the Gap, Forever 21, Old Navy and Target have plus-sized clothing lines for kids and teenagers. The boy’s plus sizes with bigger waist sizes and baggier tees are called “husky.”

It’s a growing trend criticized by MeMe Roth, founder and president of the National Action Against Obesity.

“Anyone making money off this health crisis for children should be ashamed of themselves,” she said. “I’m not surprised people want to benefit from it. There’s such a demand. That’s a societal failing that there’s a hyper growth for plus-sized children.”

Kids should be able to dress in fashionable clothing, but Roth said the fact that children need special sizes is a major health concern.

“Our kids should be the healthiest,” she said. “If outside influences were causing damage to our children this way, a nation or a group, we would be at war. … We should be angry that this is happening to children.”

The shame and embarrassment didn’t motivate LeBaron to get healthier, he said. Instead, it just made him depressed and overcame the confidence that he could ever change. He would retreat home and eat junk food. What helped, he explained, was having people around him who brought a balance of honesty and compassion, who wanted him to feel good about himself by encouraging healthy choices.

Receiving a gym membership gift from his grandparents and hitting 290 pounds spurred LeBaron to start exercising. LeBaron, now a college freshman in Georgia, lost 152 pounds. One of his proudest moments was being able to shop at Macy’s instead of a special plus-size store.


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Why is it so hard for kids to lose weight?

Feb. 16, 2012, CNN

By Jacque Wilson

Lyn McDonald is doing everything right.

After losing more than 80 pounds, she taught her kids how to control their portion sizes, shop at the farmers market, eat vegetables with every meal and avoid a lot of sugar.

Her efforts are working. At a time when approximately one-third of American children are overweight or obese, McDonald’s kids are at healthy weights. So why is every day still a struggle for the blogger and mother of five?

“I have had to deal with teachers who hand out Skittles, candy bars, lollipops and giant frosted sugar cookies to the children in class … before 10 a.m.,” McDonald says. “I think this is setting kids up for failure and un-teaching the healthy habits I have instilled.”

The fact that doughnuts and cupcakes are given out as a reward after soccer practice or dance class is a paradoxical hurdle in the fight against childhood obesity. As doctors and parents struggle to encourage healthy behaviors, our sugar-filled, sedentary surroundings resist every step.

Think about it, says Dr. Stephen Daniels, chief pediatrician at Children’s Hospital Colorado. Every day kids are exposed to advertising about fast food instead of home-cooked meals. They’re surrounded by vending and soda machines at school. They have hundreds of channels on TV, own three video game systems and live in neighborhoods that were built without sidewalks.

“Our environment is constantly pushing kids in the wrong direction.” Childhood obesity isn’t just a cosmetic issue; although studies have shown overweight children are often isolated and bullied by their peers. Obese youth are more likely to suffer from cardiovascular disease, diabetes, sleep apnea, liver disease and bone and joint problems, according to the Centers for Disease Control and Prevention (CDC). Excess fat has also been linked to many types of cancer. About two-thirds of obese children grow up to be obese adults.

Gary Evans is an environmental and developmental psychologist at Cornell University. His latest study, published this year in the journal Pediatrics, analyzed the effects of stress on weight gain in children and adolescents. Researchers know that both adults and children seek higher fat foods in response to stress. Evans and his team found that stress also damages a child’s ability for self-control, which leads to a higher body mass index as a teen.

Evans examined children who were dealing with stressful situations, such as poverty, single parenthood, housing problems and domestic violence. In the study, stress hormones hurt the brain’s pre-frontal cortex — the one responsible for our ability to plan and avoid temptations — at the cellular level.

It’s kind of a quadruple whammy, Evans notes. Lower income children have less healthy food stores nearby, more junk food available because it’s cheap, fewer places to play outdoors and, as his team found out, a harder time curbing bad impulses.

“If you are born poor, your life expectancy is less,” Evans wrote in an e-mail. “Perhaps even more striking … upward mobility does not remove the ill effects of early childhood poverty on subsequent health and well-being.” For parents trying to raise healthy kids, this is all kind of depressing. “What we need to do as a society is work to make the healthier choice the easier choice,” says Daniels.

There has been movement in that direction. Policy makers are issuing new rules for healthier food in schools and local programs are encouraging more activity. But realistically, an environmental overhaul could take years. There’s a danger in being too pessimistic about the influence we have on the ways our kids live, Daniels says. Research shows that children who lose weight are less likely to gain it back than teenagers or adults.

“As hard as it is to make a change at age 10, it’s that much easier than at 30 or 40.”

Twins Molly and Chris McGann, 15, are perfect examples of this. In third grade, Molly was bullied for being overweight. The McGanns started attending the Shape Down program at Children’s Hospital Colorado. Shape Down’s instructors taught the whole family how to measure their food, cook with different colors — broccoli, red peppers, carrots — and include exercise in their daily lives. Molly dropped the extra pounds and is still at a healthy weight.

Her twin Chris hit a tough spot in middle school when undiagnosed sleep apnea caused his weight to creep up. As a teenager he is finding it more difficult to stay on track because of peer pressure. His school cafeteria, for instance, has a pizza buffet and a long line of desserts available every day. “My friends eat the pizza and the Little Debbie cakes and they’re all as thin as rails,” he says. “It’s really hard to walk by that stuff because it looks so good. I just think I want to be healthy, I want to lose weight and I know if I eat those things it’s not going to happen.”

Daniels doesn’t talk about dieting or weight loss with his patients. He talks about getting the entire family on board to eat healthier and be more active.

“You have to understand what kinds of behaviors are leading to the problem and the changes to take,” he says. “It’s helpful to go slow. It’s about simple goals. You don’t have to get to a perfect weight in order to have the health benefits.”


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Pushing to keep exercise in the school curriculum

Feb. 11, 2012, The New York Times

By Katharine Mieszkowski

On the blacktop at Clifford School recently, a fourth-grade class played two-on-two keep-away with basketballs. Jessica Mazeau, a physical education instructor who teaches at Clifford five days a week, led the students in dribbling and passing drills.
She does not actually work for the school or for the Redwood City School District.

The school’s parent-teacher organization pays $71,000 a year to Rhythm and Moves, a company based in Burlingame, which sends Mazeau to the school along with sports equipment including hula hoops, jump ropes and basketballs. Clifford has its own physical education teacher for students in grades six through eight, but none for younger students. Parents fear that without Rhythm and Moves there would be no physical education instruction for kindergarten to fifth grade.

“Clearly, if we don’t fund it the kids are not getting any activity outside, except for minimum recess time and lunch time,” said Marilyn Ezrin, co-president of the Clifford School Parent-Teacher Organization.

But experts say such efforts are a symptom of how physical education has become a luxury as California schools have cut budgets.

The state requires students in grades one through six to receive 200 minutes of physical education every 10 school days. Schools in Redwood City have struggled for years to meet that mandate. Statewide, it is fairly common for younger students to receive less physical education than the state requires, said Doug Jann, education programs consultant for the California Department of Education.

The Redwood City School District’s budget for physical education has shrunk with the state budget crisis, leaving fewer than nine positions in the subject for all 16 schools in the district, which borders two towns where some of the wealthiest people in Silicon Valley live.

It employs no physical education teachers who instruct younger students and has not done so for many years, according to Naomi Hunter, a district spokeswoman. Responsibility for teaching physical education to younger students falls to the classroom teachers, who may not have the same enthusiasm for the subject as for math or reading.

A patchwork approach to teaching physical education to younger students has emerged throughout the district, relying on parents to donate time and money, as well as support from foundations and nonprofit organizations. “We have found creative ways to make sure that students are getting P.E.,” said John Baker, deputy superintendent for the district.

But that is not good enough for many health experts.

“It’s a Band-Aid,” said Drisha Leggitt, executive director of the California Association for Health, Physical Education, Recreation and Dance, a nonprofit organization. “Let’s say the parent-teacher organization had a bad year, or the parent volunteer’s kid moved into a different school. What happens with the P.E. program?”

At seven schools in the district, coaches from Peninsula Community Center, a fitness club, teach weekly sessions of sports like basketball, volleyball, Frisbee and soccer while classroom teachers observe from the sidelines.

Serve the Peninsula, a nonprofit in Redwood City that supports public schools, created the program three years ago. It now costs about $160,000 annually, supported by the Sequoia Healthcare District, which receives its financing through property taxes.

At Hoover Community School, Michele McLaren, a teacher, watched from a bench as her 31 third- and fourth-grade students played capture the flag with a Frisbee on a turf field. Coaches from Peninsula Community Center led the game, chose the teams, explained the rules and comforted disappointed players who had been tagged out.

“We don’t have P.E. when they are not here,” McLaren said. “Most of the exercise my students are getting is through this program and recess at school.” Ninety-four percent of Hoover students are on the free and reduced school lunch plan. “In our neighborhood, there is more fear of sending out your kids to play in the streets,” said Amanda Rothengast, the principal.

Less than 10 percent of Hoover’s fifth graders who took the statewide 2011 Physical Fitness Test got healthy scores in all six of the test’s measurements of fitness, which range from aerobic capacity to flexibility. Statewide, 25 percent of fifth graders received healthy scores in all areas.

A survey done in 2005 and 2006 for the district found very few of its schools were able to meet the state’s physical education expectations. In March 2008, the California Department of Education found that the Redwood City School District was failing to provide the required instructional minutes for physical education.

The district responded by creating a “FitFun Game Guide” to help teachers integrate physical activity throughout the school day. Recommended activities for the kindergarteners, first and second graders include “wiggles” — jogging in place at their desks while wiggling various parts of their bodies.

“P.E. minutes are mandated by the state, but the state hasn’t given us sufficient funds to cover that,” said Rothengast, the Hoover principal. “It’s hard to find time to fit in the P.E., and the teachers do the best that they can.”

At Roy Cloud School, parent docents, including Meredith McLean, co-president of the school’s parent-teacher organization, lead physical education in kindergarten through second grade.

During a recent class, Ms. McLean led the children through a warm-up, including 14 jumping jacks in honor of Valentine’s Day. Their teacher, Denise Chappelle, gamely jumped along with them.

“With all the cuts, we need the parents to step it up,” Chappelle said. The district’s budget shrank by $13 million in the last five years. Resources for physical education also shrank, even as the number of students grew. In the 2007-8 school year, the district had 11.7 physical education positions. This school year, it has 8.5, with all of those dedicated to students in grades six through eight.

Before the state budget crisis, Hunter said, schools had more discretionary money, which some principals directed toward physical education for younger students.

Rothengast, the Hoover principal, said, “Now, with all the budget cuts, we can’t afford anything additional. We are just trying to supply the classrooms with the basics.”

The Redwood City Education Foundation will distribute $15,000 in grants this year to district schools to pay for programs that may include dance or yoga.

“Physical education is not really taken seriously as part of the core curriculum at the elementary level in the way that it should be,” said Heather Diaz, an assistant professor in the Department of Kinesiology and Health Science at California State University, Sacramento. “If a child is unhealthy, that carries through all the other subject matters.”


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