A Critique of Maine’s Childhood Obesity Campaign: Sara Lammert
Introduction: Obesity as a Public Health Problem
Adult obesity rates have continued to increase over the past 30 years, leading to major public health concerns not only for the nation, but also for individual states, including Maine. According to the Behavioral Risk Factors Surveillance Survey conducted in 2012, 62.9% of Maine adults were considered overweight (BMI > 25), while 26.8% were considered to be obese (BMI > 30). (1) Although Maine was below the national obesity levels in 2010 (35.7%), it is estimated that by 2030, 55.2% of the adult population in Maine will be considered obese. (2,3) These trends are similar in the youth of Maine as well and are also increasing at an alarming rate. According to the 2009 Youth Risk Behavior Survey, 15.1% of Maine’s adolescents were considered to be overweight, while 12.5% were considered obese. (1) Additionally, Maine has the highest prevalence of obesity in high school students compared to all other states in New England. (4) Children who are overweight or obese are more likely to be overweight or obese as adults, predicting increase obesity rates in the future. (5)
There is not one contributing cause of obesity; it is a multi-dimensional epidemic with genetic, social, environmental, dietary, and physical factors playing roles in multiple aspects of daily life. (5) However, many argue that obesity is most proximately caused by poor nutrition as well as a lack of physical activity. (6) Maine adolescents are not eating adequate quantities of healthy foods or participating in enough physical activity on a daily basis according to the 2009 Youth Risk Behavior Survey (1):
o 66% ate fruits or drank 100% fruit juice less than 2 times per day
o 86.2% at vegetables less than 3 times per day
o 29.2% drank a can, bottle, or glass or soda or pop at least one time per day
o Only 17.9% were physically active for at least 60 minutes per day for a week
o 18.0% did not participate in at least 60 minutes of physical activity on any day in the past week (1)
Public health interventions to combat the rate of childhood obesity are extremely important not only to protect the health of the children of Maine, but to prevent obesity related disorders in the future. Obesity related disorders once rare in children including heart disease, diabetes, high blood pressure, high cholesterol bone and joint problems, and sleep apnea, are becoming more frequent in overweight and obese children, indicating longer time diagnosed with obesity-related disorders. (5,7-8) Public health interventions are also necessary to prevent the economic impacts of obesity and obesity related diseases and illness as individuals are diagnosed with these issues earlier. According to a study conducted by the University of Maine, medical costs in Maine related to obesity could reach 1.2 billion dollars through 2034. (3) In order to combat and reverse the childhood obesity trends, effective public health interventions are necessary in the state of Maine. One such program is the Let’s Go! 5-2-1-0 campaign.
Let’s Go! 5-2-1-0
Let’s Go! 5-2-1-0 is a public health campaign aimed to prevent childhood obesity and was launched in 2006 in Portland as well as other communities in Cumberland County, Maine. (9) Research has shown that fruit, vegetable and sugar based drinks consumption as well as the quantity of screen time and physical activity are four major factors contributing to the obesity epidemic and should be used when creating targets or goals for childhood obesity prevention programs. (8) Let’s Go! 5-2-1-0 works in 6 settings (schools, early childhood programs, after school programs, healthcare offices, workplaces, and communities) to promote the four dietary and physical activity aims of the campaign through education and awareness (9)
1. 5 or more fruits and vegetables
2. 2 hours or less of recreational screen time
3. 1 hour or more hour of physical activity every day
4. 0 sugary drinks (9)
Unfortunately, many public health interventions and campaigns, including the Let’s Go! 5-2-1-0, are flawed in the design and application. Before launching this campaign into other cities and counties around the state of Maine, social and behavioral theories need to be consulted to make necessary changes to improve the effectiveness of the campaign. First, Let’s Go! 5-2-1-0 fails to recognize important physical, social, and financial barriers preventing children and their parents from incorporating healthy behaviors into their lives on a daily basis regardless how aware individuals are of the campaigns objectives. Secondly, Let’s Go! does not take into consideration principles of psychological reactance: the explicit 5-2-1-0 message of the campaign causes reactance in children and potentially their parents. Thirdly, the model in which the theory is based, the Theory of Planned Behavior, models that through awareness and education, children will intend to follow the guidelines of the Let’s Go!5-2-1-0 program, increasing their own self-efficacy, and then change their behavior. However, it does not take into account other factors that may prevent children from fully participating in the aims of the campaign regardless of their own self-efficacy.
Socioeconomic, Geographical Barriers
The Let’s Go 5-2-1-0 campaign focuses on the most proximal causes of obesity: poor nutrition and lack of physical activity. (6) However, there are many societal, socioeconomic, and geographical barriers that may have a more distal effect on childhood obesity as they create barriers to access to healthy nutrition and physical activity. The Let’s Go! campaign originated in Portland, Maine, along with other communities in Cumberland County. (9) The median household income in Cumberland County is $57,267, which is the highest in state, while the median household income in Maine is $47,898. (10) Individuals, families, and their schools, on average, have higher socioeconomic levels than the rest of the state of Maine. When the Let’s Go! 5-2-1-0 campaign is launched in other parts of the state, it is assumed that children’s families will have the same financial ability to purchase healthy foods or the ability to drive farther distances to obtain that food. However, the ability to provide at least 5 fruits and vegetables a day to a child has a relationship to the socioeconomic status of the child’s family, as well as the availability of such food within a reasonable distance to the family. This is supported by studies showing that individuals from counties with lower median household income, on average, have a higher probability of being overweight or obese than counties with higher median household incomes. (11)
Additionally, Cumberland county and the Greater Portland area is a larger urban area, while much of the remainder of the state is considered rural. Studies have indicated that individuals living in rural areas are more likely to be overweight or obese than individuals living in urban areas. (11, 12) A study conducted at the University of Southern Maine in 2009 found that the prevalence of overweight and obese children in 6 rural areas in Maine were 47.9% and 27.7% respectively, which are above the average levels in the state. (11) Because Cumberland County is a mostly urban area, proximity to multiple types of grocery stores in shorter distances is more common. In order for the Let’s Go! campaign to be effective in rural parts of the state, dynamics of rural communities need to be a focus of the intervention. Studies in rural areas have shown that the most frequent source of food were convenience stores, where fresh fruit, vegetables, or healthier foods may be limited or non-existent. (11,12) Therefore, children and their families in rural parts of Maine may not have access to larger supermarkets or grocery stores where fresh fruit and vegetables and healthy options are more readily available.
Along with financial and geographical barriers for access to healthy food, physical activity may also be prevented in Maine due to climate issues. The only time many children are able to participate in physical activity is during school hours or during after school activities. During the summer, fall, and spring months, it may be warm enough and there may be enough day light hours for children to obtain physical activity outside. However, during the winter months, more physical barriers, such as daylight hours and temperature, prevent continuous physical activity. During the winter months, the days are shorter so safe physical activity after school hours may not be conducive. Additionally, if the weather is too cold, children may be forced to stay indoors for recess or after school. The relationship between climate conducive for outdoor physical activity and BMI was conducted by the Department of Geosciences at the Georgia State University. In this study, researchers found a relationship between climate allowing for ample quantity of outdoor physical activity and county-level BMI. (13) This indicates that counties with less time available outdoors for physical activity, on average, have higher BMI’s. (13) This is because, with less frequent time available outside of play, children are forced to spend the majority of their time after school indoors, where there is less mobility to enjoy physical activity, and more available sedentary activities, such as watching television or playing video or computer games. While schools still allow for recess indoors, many schools may not have the capacity to allow children to run participate in rigorous physical activity indoors to elevate their heart rate enough to have it count as physical activity. The Let’s Go! 5-2-1-0 assumes that children will always have financial and geographical access to fruits, vegetables, and other healthy food options and have access to an uninterrupted hour for physical activity; however, due to financial, geographical, and physical climate barriers, this may not be the case.
Violation of Psychological Reactance
The premise of the Let’s Go 5-2-1-0 campaign in Maine focuses on what children should and should not do, which is similar to the campaign the National Cancer Institute launched in 1991 called the 5 A Day for Better Health. (14) It educates parents, children, and their schools about the necessary quantity of fruits and vegetables children should eat, the maximum number of hours children should watch television or play computer and video games, the minimum number of hours of physical activity children should have on a daily basis, and that children should not drink any carbonated or sugary drinks, such as soda or pop. (9) Because the aims of the campaigns are directive, the Let’s Go! 5-2-1-0 campaign violates the theory of psychological reactance. (15) By explicitly telling people what to do not only in the program aims and name of the campaign, parents and children may feel as if their control on choosing their own dietary needs and physical activities is being threatened. Instead of viewing the aims of the program as goals to be reached, the goals of the program may be perceived as a violation to individual freedom or autonomy, a highly regarded core value among Americans. This violation of psychological reactance may ultimately backfire and children and their families may actively choose not to follow the aims of the Let’s Go! 5-2-1-0 campaign.
Psychological reactance, in relation to childhood obesity, theorizes that when children or their parents become engaged with the Let’s Go! 5-2-1-0 campaign, they may feel as if their freedom or choice to choose what they eat or drink, how much physical activity or hours of television watching they participate in has been taken away from them. (6, 15-16) Instead of following those recommended behaviors of the Let’s Go! 5-2-1-0 campaign, they will try to gain back that freedom they believe is threatened by participating in behaviors the Let’s Go! 5-2-1-0 program is trying to eliminate. (6, 15-16) Even if parents or children know that eating health and engaging in physical activity is extremely important for a healthy lifestyle, because they feel as if the campaign is taking away their sense of freedom or control, they will experience reactance and will try to gain that freedom back. (15-16) Although they know that not following the aims of the campaign may be detrimental to their health, children and their parents may not consume the necessary amounts of fruits or vegetables, or not participate in enough or frequent physical activity, in an attempt to gain back control of their freedom.
This same phenomenon occurred with the 5 A Day for Better Health campaign. The 5 A Day campaign was started in the United States in 1991 in order to increase the average daily consumption of fruits and vegetables to 5 per day. (14) At the time of the launch, the necessity of this campaign was apparent as the baseline survey conducted by the National Cancer Institute found that only 23 percent of people consumed 5 or more servings of fruits or vegetables a day. (14) However, childhood obesity continued to increase during the 1990’s, even with the introduction of this program. (2) The Let’s Go! 5-2-1-0 campaign has multiple similarities to the 5 A Day campaign. Not only does the Let’s Go! 5-2-1-0 campaign put “goals” on the number of fruits and vegetables children should eat every day and the amount of physical activity they should receive on a daily basis, it also creates limits and restrictions on the number of hours children should be watching television, playing video games, or being on the computer, as well as “forbidding” the consumption of all types of sugary soft drinks, such as soda. (9) Not only does it have a basis in the failed 5-A day campaign, it also increases the number of limits and regulations on children’s daily lives ultimately increasing their experience of reactance. The structure of the campaign, due to psychological reactance, could backfire completely as children experience reactance and try to gain the control of what they can and cannot do from the Let’s Go! 5-2-1-0 campaign.
In additional to experiencing reactance for the consumption of fruits, vegetables, and sugary drinks, children will most likely experience reactance when told how much exercise they should participate in on a daily basis. As children get older, they become more independent and have more control on their decision making process compared to younger children. (17) Research has shown that as children get older, they expect to be able to make personal decisions in their life, particularly about their physical activity. (17) Because children are making decisions about their own physical activity, if they are experiencing reactance, children may be less likely to participate in sports or other extracurricular activities that may decrease their likelihood of becoming overweight or obese and participating in activities where the social norm of fitness is valued regardless of their knowledge about how important physical activity is for their health.
Limited Perception to Change Behavior
Lastly, the Let’s Go! 5-2-1-0 campaign in Maine is based on the Theory of Planned Behavior:
“The program is based on the premise that if families are exposed to health promotion messages through several settings, and if those settings have policies and environments that support healthy choices, they will be more likely to adopt or maintain the behaviors in their daily lives (9).”
The Theory of Planned Behavior is on the individual level, with both individual and group level factors contributing to attitudes towards a particular behavior: the individual’s attitude and how the person perceives what the social norms are towards that behavior. (18) The Let’s Go! 5-2-1-0 program focuses on childhood obesity in individual children, with influences coming from both the individual and parents, as well as societal level norms present in local schools, towns, states, and nationally. The Theory of Planned Behavior indicates that individuals will balance both the outcome and expectations along with social norms to formulate an intention to change behavior. (6, 18) According to the Theory of Planned Behavior, after balancing particular individual and social norms regarding a behavior, an individual will form an intention, and as long as the individual perceives he or she can accomplish that behavior, he or she will complete that behavior. (18)
However, as good as the intention to eat healthy or participate in physical activity on a daily basis, the ability to do so may not be actually feasible, especially in the public school setting. Therefore, the policies and environments that are meant to be in place to promote the transition from intention to behavior are not there. According to the Maine School Health Profiles, there is still a lot of work to be done at the school level in order to provide a healthier school environment for children. Among high school students in the state of Maine, only 48% were required to take 2 or more health education courses, while only 28% of schools surveyed did not sell less nutritious foods and beverages anywhere outside the school food service program. (19) Even if the children had the intention to eat healthy food at school and had the perception they would be able, there are still barriers to the behavior. Therefore, in order for the program to be effective, the Let’s Go! 5-2-1-0 needs to work with individuals regarding Maine education policy in order to create environments that allow for intention and perception of the ability to eat well and exercise daily in order to change behavior.
In addition to society level barriers preventing the perception of ability to change behavior, there are also additional individual barriers preventing the perception of an ability to change behavior. The 2010 Pediatric Nutrition Surveillance System found that 17.1% of Maine’s children between the ages of 2 and 5 were overweight, while 14.3% were obese. (1) If children and teenagers have been obese or overweight since their were very young children, they may feel as if they will never be able to reverse their situation. This may be especially true if they have overweight or obese parents. Studies have shown that children’s perceptions of the ability to lose weight is associated with their parents perception of whether or not the child will be able to lose weight. (20) If children’s parents don’t indicate that they believe their child can overcome obesity, the child will not have the perception that they can lose weight, and therefore, will be unable to change their behavior. Additionally, studies have shown that normal weight children and adolescents have higher physical activity motivation than children who are obese. (17) As children are becoming obese and overweight at younger ages, their perception that they have the ability to change their behavior will continue to diminish as the longer they are overweight or obese.
As previously mentioned, there is not one cause of obesity. Obesity is a multi-dimensional public health issue that must be addressed from multiple different angles. By not taking into consideration demographic, socioeconomic, and geographical differences between the demonstration site in Cumberland county and the dissemination sites in other more rural parts of the state; by violating the theory of psychological reactance leading to children experiencing reactance; and by not taking into consideration social and individual barriers to children’s perception to change behavior, the Let’s Go! 5-2-1-0 campaign will most likely follow in the footsteps of the 5 A Day for Better Health campaign. Although interventions to prevent childhood obesity are critically important, especially as researchers expect childhood and adult obesity rates to continue to increase, these interventions must be created and framed taking into consideration social factors of different families and communities, use the theory of psychological reactance to decrease the experience and reactance, as well as improve children’s perception that they have the ability to change their behavior. By reframing the issue in a way that children are able to claim their future and their life and less as a health and obesity issue, then children may be more willing and open to following the guidelines of the Let’s Go! 5-2-1-0 campaign.
In order to best reverse the childhood obesity epidemic in the state of Maine, many changes and additions need to be made in the Let’s Go! 5-2-1-0 campaign in order for it to work in reducing the prevalence of childhood obesity in the state. The proposed intervention will still have the same goals as the initial campaign, but it will frame and advertise the issue so by participating in the campaign, children will gain freedom and have control of their freedom, rather than their freedom and control of their freedom being taken away. First, the proposed intervention will change it’s name from Let’s Go! 5-2-1-0 to Let ME Move! The program will work with policy and law makers in the state of Maine as well as health organization to create environments that are conducive for healthy behaviors, most specifically access to fresh fruits and vegetables as well as continuous outdoor physical activity. It will allow for remote access for fresh fruits and vegetables through mobile food trucks throughout parts of rural Maine where distances to grocery stores with healthy food options are large. Additionally, it will work with schools, especially elementary school age children, to create education policies that promote physical activity in classroom and after school activities. Additionally, each elementary and middle school participating in the program will host competition between all classes or different schools in a community to select a winning class or school. Every time a student participates in 60 minutes of physical activity a day, or eats 5 fruits and vegetables a day will be given a point value. Every month, the winning class at the school will win a prize from the Let ME Move! campaign.
While residents of the urban centers of Maine may have more access to and choices for different grocery venues, residents in more rural areas of the state may have less venues for healthy grocery shopping, as well as a farther distance to get to those places. In order to increase assess to fruit and vegetables for consumption, the initiative will promote the delivery of fresh produce to town or community centers, specifically in Northern or Central Maine where the travel time to go to grocery stores would be too high. The food truck will also stop at local high schools or middle schools during the day, so if parents are unable to reach the designated areas of the food truck, orders could be made and dropped off at the local schools. Additionally, fruits and vegetables should be subsidized so the prices of the healthy foods are not a deterrent for parents or schools to purchase.
Additionally, because much of the children’s physical activity is obtained at school during recess or school related activities, children should have access to cold weather gear especially during the winter months. By working with local public health organizations and charities, donations for winter apparel will be a main priority. Schools should have access to extra snow pants and winter weather gear to ensure that children are not prevented from going outside for recess solely on the fact that they cannot afford the proper winter weather gear. Additionally, if forced to have indoor recess, especially during the winter months, children should have access to large areas where they are allowed to run around in and play games. In addition to recess, gym should be a daily requirement for children as there has been evidence to suggest that the only school-based intervention programs that significantly affected children’s BMI’s were ones the required daily physical education. (17) Therefore, the intervention will work with education policy makers in the state to create legislation and policies that support daily physical education.
The 5 A Day campaign failed on the premise that children experienced reactance after being told through the campaigns media and advertisements that they needed to eat 5 fruits or vegetables on a daily basis. The Let’s Go! 5-2-1-0 is not only telling children about the necessary consumption of fruits and vegetables, it is also informing children on the maximum number of screen time, the amount of physical activity, and the absence of all types of sugary beverages.
The Let’s Go! 5-2-1-0 campaign’s name is the first proposed changed to the intervention. The name itself has implications that are informing children and their parents what to do. By eliminating the “5-2-1-0” portion of the name and changing the name to “Let ME Move!” may reduce the initial experience of reactance after changing the name. Additionally, the use of “M-E” also have both individual and state level implications, therefore, children in the state of Maine will relate to the program on both an individual and a state level. Instead of the program telling the children what they need to do, children will feel as if they are in control; they can tell policy makers, teachers, their parents, to “Let ME Move!” Parents, additionally, need to be educated about the effect parents have in creating reactance in children: more pressure from parents regarding eating habits or physical activity may cause children or adolescents to react in opposition to the message. (21)
Secondly, the brochures and pamphlets need to frame the issue in a way that minimizes the experience of reactance. They need to show in their media and advertising that Let’s Go! doesn’t eliminate individual feeling of control, it actually gives children the power to control their lives. By doing this, children and their parents may be more willing to follow the health suggestions of the program. The Let ME Move! campaign should incorporate media techniques used by Nike. The implicit health message should not be state implicitly in the message; instead, the commercials need to be framed in a way that children feel as if they are empowered to make changes in their lives in order to gain control of their future. (22)
Improve Perception to Change Behavior through Policies
Lastly, Let ME Move! must focus on bridging the causal pathway between intention and behavior, by increasing the perception that the children have the ability to change their behavior regarding healthy nutrition and physical activity. Because of growing rates of obesity in younger children, specifically between the ages of 2 and 5, the improved perception to be able to change behavior must be targeted at earlier ages. (1) One way to improve this is to work with local city council members to improve or create local parks for children to play in, as well as increase the numbers of sidewalks in town centers that promote walking or biking. (23) As the number of opportunities to participate in recreational physical activity increase, the prevalence of obesity has been shown to decrease. (24) If local norms within the city promote outdoor physical, and there are venues that allow for the participation in that activity, children from a young age and their parents may be more likely to participate in that behavior.
Additionally, collaboration with school boards is essential to make the social norm about healthy behaviors important within the school community. By providing healthy food options over ones high in calories or fat and promoting physical activity in multiple aspects of the child’s day will give children the perception that they have the ability to change their behavior, and there will be a causal pathway between intention and behavior. By incorporating a competition between classes or schools, especially at the younger age levels, may lead to an increased motivation to participate in the campaign, and therefore, increase participation in the program, increasing fruit and vegetable consumption as well as physical activity on a daily basis. (25)
By reframing the issue of childhood obesity from one in which quantified requirements and limitations are placed in children’s lives to one that gives children freedom to control their lives, the Let ME Move! campaign will have a better foundation to make significant improvements in the childhood obesity epidemic in Maine. However, there is not just one solution to the problem. Along with the proposed intervention, policies aimed at minimizing socioeconomic disparities, improving access to healthy foods, increased infrastructure that allows to physical activity outdoors, as well as improvements for self-awareness that the obesity epidemic is reversible. With these improvements on the local, state, and national level, the prevalence of obesity in the nation’s children will begin to decrease.
1. State of Maine nutrition, physical activity, and obesity profile. September 2012;CS233917-AP.
2. Ogden C, Carroll M, Kit B, Flegal K. Prevalence of obesity in the united states, 2009–2010. 2012;NCHS data brief, no 82.
3. Farwell J. More than half of Maine adults will be obese by 2030, report projects. Bangor Daily News. September 18, 2012 2012. Available from: http://bangordailynews.com/2012/09/18/health/more-than-half-of-maine-adults-will-be-obese-by-2030-report-projects/.
4. Mills DA. Top 10 health issues faced by Maine people. Maine Policy Review.
5. Hammond RA. A complex systems approach to understanding and combating the obesity epidemic. Center on Social and Economic Dynamics; 2008.
6. Dooley JA, Deshpande S, Adair CE. Comparing adolescent-focused obesity prevention and reduction messages. Journal of Business Research. 2010;63(2):154-160.
7. Dunton GF, Kaplan J, Wolch J, Jerrett M, Reynolds KD. Physical environmental correlates of childhood obesity: A systematic review. Obesity Reviews. 2009;10(4):393-402. doi: 10.1111/j.1467-789X.2009.00572.x.
8. Tucker S, Lanningham-Foster L, Murphy J, et al. A school based community partnership for promoting healthy habits for life. J Community Health. 2011;36(3):414-422.
9. Let's Go!5-2-1-0. Let's Go! It's Working: Greater Portland Demonstration project. .
10. U.S. Census Bureau. State and county QuickFacts. data derived from population estimates, American community survey, census of population and housing, state and county housing unit estimates, county business patterns, nonemployer statistics, economic census, survey of business owners, building permits, consolidated federal funds report. http://quickfacts.census.gov/qfd/states/23/23005.html.
11. Hartley D, Anderson N, Fox K, Lenardson J. How does the rural food environment affect rural childhood obesity? Childhood Obesity (Formerly Obesity and Weight Management). 2011;7(6):450-461.
12. Lutfiyya MN, Lipsky MS, Wisdom‐Behounek J, Inpanbutr‐Martinkus M. Is rural residency a risk factor for overweight and obesity for US children? Obesity. 2012;15(9):2348-2356.
13. Lin G, Spann S, Hyman D, Pavlik V. Climate amenity and BMI. Obesity. 2012;15(8):2120-2127.
14. National Cancer Institute. 5 A day for better health program evaluation report: Origins. http://dccps.nci.nih.gov/5ad_3_origins.html. Updated 2006.
15. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology. 2005;27(3):277-284.
16. Miller CH, Burgoon M, Grandpre JR, Alvaro EM. Identifying principal risk factors for the initiation of adolescent smoking behaviors: The significance of psychological reactance. Health Commun. 2006;19(3):241-252.
17. Power TG, Ullrich-French SC, Steele MM, Daratha KB, Bindler RC. Obesity, cardiovascular fitness, and physically active adolescents’ motivations for activity: A self-determination theory approach. Psychol Sport Exerc. 2011;12(6):593-598.
18. Edberg M. Individual health behavior theories. In: Essentials of health behavior: Social and behavioral theory in public health. Sudbury, MA: Jones and Bartlett Publishers; 2007:35-49.
19. Centers for Disease Control and Prevention. The obesity epidemic and Maine students. 2011.
20. Huang JS, Donohue M, Becerra K, Xu R. Relationship between parents' and children's weight perceptions results of a survey. ICAN: Infant, Child, & Adolescent Nutrition. 2009;1(1):15-20.
21. Lessard J, Greenberger E, Chen C. Adolescents’ response to parental efforts to influence eating habits: When parental warmth matters. Journal of youth and adolescence. 2010;39(1):73-83.
22. Lucas S. NIKE'S COMMERCIAL SOLUTION girls, sneakers, and salvation. International Review for the Sociology of Sport. 2000;35(2):149-164.
23. Cutts BB, Darby KJ, Boone CG, Brewis A. City structure, obesity, and environmental justice: An integrated analysis of physical and social barriers to walkable streets and park access. Social Science and Medicine. 2009;69(9):1314.
24. Michimi A, Wimberly MC. Natural environments, obesity, and physical activity in nonmetropolitan areas of the United States. The Journal of Rural Health. 2012.
25. Sharma M. School‐based interventions for childhood and adolescent obesity. Obesity Reviews. 2006;7(3):261-269.