2005-2015 Georgia's nutrition and physical activity plan to prevent and control obesity and chronic diseases in Georgia

Ta b l e o f C o n t e n t s
Letter from Governor Perdue
Letter from BJ Walker, Department of Human Resources, Commissioner and Dr. Stuart T. Brown, Division of Public Health, Director
Acknowledgements
Special Thanks
Chapter 1: Introduction and Description of the Problem...............................................................1
Chapter 2: Development of State Plan......................................................................................11 Task Force Development Framework for the Plan Planning Process
Chapter 3: Integration of the Plan and Current Efforts...............................................................17
Chapter 4: Use and Sustainability of the Plan.............................................................................26
Chapter 5: Overall Plan Goal, Objectives and Strategies............................................................29 Overall Goal Long Term Objectives Intermediate Objectives and Strategies State Partnership/Infrastructure Community Faith-based Organizations Health Care School Worksite Data, Evaluation and Research
Chapter 6: Surveillance and Evaluation ......................................................................................52
References............................................................................................................................55
Appendices I-VI.................................................................................................................... 57 I. Task Force Members II. Detail about Estimating the Burden of Overweight and Obesity III. Georgia Collaborative Task Force Terms of Reference IV. Summary of Regional Planning Meetings V. Survey of Breastfeeding, Nutrition and Physical Activity Programs and Initiatives in Georgia VI. Take Charge of Your Health, Georgia! Task Force Organizational Structure
Georgia's Nutrition and Physical Activity Plan

B.J. Walker, Commissioner
Georgia Department of Human Resources Suite 29.250 Two Peachtree Street, NW Atlanta, Georgia 30303-3142 404/651-6314
Dear Partners and Stakeholders:
The Georgia Department of Human Resources convened a statewide wide group of nutrition and physical activity professionals to develop a ten-year Nutrition and Physical Activity Plan that addresses the alarming rise of obesity in our state. More than sixty percent of adult Georgians are obese or overweight. Obesity is a major public health challenge for Georgia and for the nation. Obesity increases the risk of heart disease, diabetes, several forms of cancer and other chronic health problems. It can reverse the progress we have made fighting these diseases, increase human suffering and contribute to the escalating cost of our health care system.
Citizens, schools, healthcare organizations and communities are acknowledging the seriousness and far-reaching impact of the obesity epidemic and have recognized that something must be done. Since obesity is a vast problem affecting over half of Georgia's population, solutions and strategies must be implemented where Georgians live, work, and play. Therefore, we are presenting in the plan, a broad and evidenced based approach to preventing and controlling obesity.
With leadership from the Georgia Department of Human Resources and the Take Charge of Your Health Georgia Task Force, the plan was developed over the past year with input from citizens from all over Georgia, representing different communities, organizations and interest groups. The Task Force worked diligently to identify strategies and activities that could become instrumental in helping improve the health of our state in communities, healthcare settings, schools, worksites and faith-based organizations. While some of the recommendations are broad in scope, addressing key environmental barriers and policy issues, others encourage families and individuals to eat healthier and be more active together. Other recommendations are to promote and educate the public on the need and benefits of making healthier lifestyle choices, through efforts such as the Live Healthy Georgia Campaign.
Everyone has a role to play in creating a healthier Georgia. We encourage you to review the strategies in the enclosed plan and identify ones that you can support in your community, agency or organization. While we acknowledge there is no quick fix to this problem, we know that obesity is preventable. Prevention and control require small steps and effective messages that are consistently delivered and supported throughout our communities. To achieve success we must involve individuals and families, business and industry, government and non-government organizations, healthcare and policy makers at all levels. We challenge everyone to work together with patience and persistence to achieve this important vision.
Thank you.
Sincerely,

B. J. Walker Commissioner Georgia Department of Human Resources

Dr. Stuart Brown, M.D. Director Division of Public Health

In partnership with Governor Perdue's Live Healthy Georgia Campaign

Acknowledgements
Georgia Department of Human Resources B.J. Walker, Commissioner
Division of Public Health Stuart T. Brown, M.D., Director
Family Health Branch Rosalyn K. Bacon, M.P.H., Director
Nutrition Section Frances H. Cook, MA, RD, LD, Director Chronic Disease Prevention and Health Promotion Branch Carol B. Steiner, R.N., M.N., Acting Director Women, Infants and Children (WIC) Branch Alwin K. Peterson, M.A., M.P.A., Director Epidemiology Branch Paul A. Blake, M.D., M.P.H., Director
For more information on 2005-2015 Georgia's Nutrition and Physical Activity Plan
please contact: Mara Galic, MHSc, RD, LD, Project Coordinator
Nutrition Section, Family Health Branch Division of Public Health
Georgia Department of Human Resources Two Peachtree Street NW, Suite 11-222 Atlanta, Georgia 30303 migalic@dhr.state.ga.us Tel: 404-657-2884 Fax: 404-657-2886
Suggested Citation: Georgia Department of Human Resources, Division of Public Health. Georgia's Nutrition and Physical Activity Plan to Prevent and Control Obesity and Chronic Diseases in Georgia, July 2005. Publication Number: DPH05/048HW
Georgia's Nutrition and Physical Activity Plan

Special Thanks
We gratefully acknowledge the expertise, contributions and time of all the members of the Take Charge of Your Health, Georgia! Task Force (see Appendix I for a list of members).

A very special mention to the Steering Committee for their time, expertise and dedication towards this effort.

Lorrine Bizzell, MS, RD, LD USDA, FNS/WIC
Annette Bomar Hopgood, MEd, LD Department of Education, School and Community Nutrition
Jennifer Buechner, RD, CSP Children's Healthcare of Atlanta
Sophia Autrey, MPH Women, Infants and Children Branch
Carolyn Aidman, PhD Family Health Branch, DHR Georgia Department of Human Resources
Susan Burns, MS, RD, LD American Academy of Pediatrics Georgia Chapter and Obesity Action Network
Frances Cook, MA, RD, LD Director, Nutrition Section, Family Health Branch Georgia Department of Human Resources
Kelly Cordray, MS, RD, LD University of Georgia, Cooperative Extension
Jon Ducote Chronic Disease Prevention and Health Promotion Branch Georgia Department of Human Resources
Matthew Falb, MHS Project Epidemiologist, Epidemiology Branch Georgia Department of Human Resources
Melodi Ford Verizon Wireless
Mara Galic, MHSc RD, LD Project Coordinator, Family Health Branch Georgia Department of Human Resources
Bethany Holloway, MS Family Health Branch Georgia Department of Human Resources

Rachel Krause, MEd Family Health Branch Georgia Department of Human Resources
Carol MacGowan, MPH, RD, LD, IBCLC Family Health Branch Georgia Department of Human Resources
Elana Morris, MPH Family Health Branch Georgia Department of Human Resources
Arlene Murrell, MS, RD, LD Nutrition Services Director Fulton County Department of Health and Wellness
Rhonda Page Family Health Branch Georgia Department of Human Resources
Beth Passehl, MS Children's Healthcare of Atlanta
Vicki Pilgrim, MEd Chronic Disease Prevention and Health Promotion Branch Georgia Department of Human Resources
Diane Roberts Ayers, MPH, RD, LD, IBCLC Nutrition Coordinator, Family Health Branch Georgia Department of Human Resources
Leslie Rodriguez-Zeigler, MA, RD, LD Hispanic Health Coalition University of Georgia
Alice Smith, MS, RD Children's Healthcare of Atlanta
Lois Stifel Kids' Health, Inc.

Robert Holmes, MS Decatur/DeKalb, YMCA

Lisa Stone/Carol Mushett Johnson, MAEd, CTRS, CSC Georgia Coalition for Physical Activity and Nutrition

Dafna Kanny, PhD Epidemiology Branch Georgia Department of Human Resources

Lee Tanenbaum, MA, MPH Family Health Branch Georgia Department of Human Resources

Debra Kibbe, MS, PHR International Life Sciences Institute, Center for Health Promotion
Christy Kay, MEd Kids' Health, Inc.
Mimi Kiser, RN, MPH, CHES Interfaith Health Initiative

Robin Tanner, MS, RD, LD Physical Activity Coordinator Chronic Disease Prevention and Health Promotion Branch Georgia Department of Human Resources
Brian W. Tobin, PhD Mercer University School of Medicine

Georgia's Nutrition and Physical Activity Plan

Chapter One:
Introduction and Description of the Problem

Georgia's Nutrition and Physical Activity Plan

1

One
Introduction
In July 2003, the Georgia Department of Human Resources, Division of Public Health was one of 17 states awarded a five-year grant from the Centers for Disease Control and Prevention (CDC) to support state nutrition and physical activity programs that work to prevent obesity and other chronic diseases. This strategic plan fulfills a major deliverable of the grant, to engage statewide stakeholders to develop a statewide nutrition and physical activity plan for Georgia.
The goal of Take Charge of Your Health, Georgia! is to prevent obesity and other chronic diseases. This ten-year strategic plan focuses on improving nutrition and physical activity to prevent obesity and other related chronic diseases, specifically: increasing breastfeeding, improving healthy eating, increasing physical activity and decreasing television viewing/screen time in a variety of settings through educational, policy and environmental approaches. A continued and sustained commitment from diverse partners representing expertise and resources from multiple sectors is required to implement and achieve the objectives of this plan which comprehensively addresses the complex issue of obesity prevention. The target population for the plan is all Georgians, which includes children and their families (especially low income families), adults, older adults, and specific racial and ethnic groups (such as African Americans and Latinos).

2

Georgia's Nutrition and Physical Activity Plan

One

Burden
Overweight Children and Youth in Georgia
Overweight among young children ages 2 to <5 years has increased 60% over the past decade. The Georgia Pediatric Nutrition Surveillance System1 (2002) found that 26% of children enrolled in the Women, Infants, and Children (WIC) Program were at risk for overweight (14%) or overweight (12%). Hispanic WIC children were more likely to be at risk or overweight than any other race or ethnic group* (Figure 1).
Figure 1. Prevalence of at risk for overweight and overweight among children aged 2 to <5 years, by race and ethnicity, Georgia, 2002

Percent

At risk for Overweight * Overweight 40
35

30

26

24#

18

20

11

11

10

15

14

17

0

White, Non Hispanic

Black, NonHispanic

Hispanic

* Body mass index between 85th percentile but <95th percentile

Body mass index for age 95th percentile

#Proportions may not add up due to rounding

Source: Pediatric Nutrition Surveillance system (PedNSS)

22
12 10
Asian

The Georgia Student Health Survey2 (2003) indicates that one in three (33%) of middle school students aged 11-14 years and more than one in four (26%) high school students aged 14-18 years are at increased risk for overweight or overweight* (Figure 2).
Figure 2. Prevalence of at risk for overweight and overweight among students by school type, Georgia, 2003

Percent

At risk for Overweight * Overweight 50

40

33

30

26

14

20

11

10

19

0 Middle School

15
High School

* Body mass index between 85th percentile but <95th percentile Body mass index for age 95th percentile
Source: Georgia Student Health Survey

Georgia's Nutrition and Physical Activity Plan

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One

Middle school males (36%) are more likely to be at risk for overweight than middle school females (30%). High school males (30%) are more likely to be at risk for overweight than high school females (22%). Black students are more likely to be at risk or overweight than white students. Notably, the prevalence of at risk or overweight for white females is about half that of other race-, sex- groups (Figure 3).

Figure 3. Prevalence of at risk for overweight and overweight among students by school type, race and sex, Georgia, 2003

Percent

At risk for Overweight * Overweight

50

40

41

39

35

33

33

30

17 15 19

29 10

20# 20

13 19

7

14

10

24 12

20 20

4 23 10

16 14

0

WF BF

WM BM

WF BF

WM BM

Middle School

High School

* Body mass index between 85th percentile but <95th percentile Body mass index for age 95th percentile #Proportions may not add up due to rounding

Source: Georgia Student Health Survey

* Classifications of BMI for children are derived from the Centers for Disease Control and Prevention's Growth Charts (www.cdc.gov/growthcharts) that show the distribution of weight-for-height across a range of ages and sex for a reference population. Children with a BMI-for-age 85th percentile but <95th percentile are classified at risk for overweight. Children with a BMI-for-age 95th percentile are classified as overweight.

4

Georgia's Nutrition and Physical Activity Plan

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Overweight and Obese Adults in Georgia
Overweight and obese adults are at increased health risk for cardiovascular disease, diabetes, stroke, hypertension, gall bladder disease, osteoarthritis and certain cancers. In 2002, 59% of adults in Georgia were overweight or obese with 35% being overweight (having a body mass index (BMI) of 25 to 29.9) and 24% obese (having a BMI of 30 or more).3 The percent of adults who are overweight or obese has been increasing since the Georgia Behavioral Risk Factor Surveillance System (BRFSS) data were first collected in 1984, rising from 37% in 1984 to 61% in 2003 (Figure 4). This represents an average relative increase of 3% per year. In 2002, almost two-thirds of adult men (65%) and over half of adult women (53%) were overweight or obese (Figure 5).
Figure 4. Overweight or obese adults, Georgia, 1984-2003
70
60
50
40
30
20
10
0 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03
Source: Georgia Behavioral Risk Factor Surveillance System

Percent

Figure 5. Overweight and obese adults, by sex, Georgia, 2002

Percent

Overweight* Obese

70

65#

60

53#

50

23

40

24

30

20

41

30

10

Male
* Body mass index between 25.0-29.9 Body mass index greater than or equal to 30.0 #Proportions may not add up due to rounding Source: Georgia Behavioral Risk Factor Surveillance System

Female

Georgia's Nutrition and Physical Activity Plan

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One

White, non-Hispanic adults (21%) were less likely than black, non-Hispanic adults to be obese (31%). Hispanic males were more likely to be overweight or obese than males or females of any race or ethnicity. Black non-Hispanic females were more likely to be obese than females and black non-Hispanic males were more likely to be obese than males of any race or ethnicity. White non-Hispanic females were least likely than males or females of any race or ethnicity to be overweight or obese (Figure 6). Adults between 45-64 years of age were most likely than any other age group to be overweight or obese (Figure 7).

Figure 6. Overweight and obese adults, by sex and race, Georgia, 2002

Percent

Overweight* Obese

90

80

70

64

66

68#

60

50

22

47

29

33

40

19

30

20

42

28

37

34

10

0

White,

White, non- Black, non- Black, non-

non-Hispanic Hispanic

Hispanic

Hispanic

Male

Female

Male

Female

78 23
55
Hispanic Male

* Body mass index between 25.0-29.9 Body mass index greater than or equal to 30.0 #Proportions may not add up due to rounding
Source: Georgia Behavioral Risk Factor Surveillance System

57# 25
31
Hispanic Female

58 13
45
Other Male

44# 20
25
Other Female

Figure 7. Overweight and obese adults, by age group, Georgia, 2002

Percent

Overweight * Obese

80

70 60

67

67#

62 58

60

50

21

27

29

28

22

40

36#

30

12

20

10

25

37

35

38

40

38

0

18-24

25-34

35-44

45-54

55-64

65+

* Body mass index between 25.0-29.9 Body mass index greater than or equal to 30.0 #Proportions may not add up due to rounding

Source: Georgia Behavioral Risk Factor Surveillance System

6

Georgia's Nutrition and Physical Activity Plan

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College graduates were less likely than adults with less than a high school education to be overweight or obese (Figure 8). Adults with a higher household income were less likely than adults with a lower income to be overweight or obese (Figure 9).
Figure 8. Overweight and obese adults, by years of education, Georgia, 2002

Percent

Overweight * Obese

70

64

60

50

32

40

30

20

32

10

0 Less than High
School

62#

57

28

21

35

36

Less than High School

Some College

* Body mass index between 25.0-29.9 Body mass index greater than or equal to 30.0 #Proportions may not add up due to rounding
Source: Georgia Behavioral Risk Factor Surveillance

54 17
37
College Grad

Figure 9. Overweight and obese adults, by household income, Georgia, 2002

Percent

Overweight * Obese

70

64

61

60

50

35 40

29

30

20

10

29

32

0

<$15,000 $15,000$24,999

61 26
35
$25,000$34,999

59 23
36
$35,000$49,999

60 22
38
$50,000$74,999

57 17
40
$75,000+

* Body mass index between 25.0-29.9 Body mass index greater than or equal to 30.0
Source: Georgia Behavioral Risk Factor Surveillance System

Georgia's Nutrition and Physical Activity Plan

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One

Among the 19* Health Districts in Georgia, the prevalence of overweight or obesity in 2002 ranged from 51% to 68%. The rise in the prevalence of overweight and obesity in Georgia from 1984 to the present has affected all health districts (Figures 10-12).
Figure 10. Overweight or obese adults by Health District, Georgia, 1993-1996

3-3
Source: Georgia Behavioral Risk Factor Surveillance System

1-2

1-1

3-1

3-4

3-6

10-0

< 50 % 50%-<55%

4-0

5-2

55%-<60%

6-0

60 % or more

5-1

9-1

7-0

9-3

8-2

9-2

8-1

Figure 11. Overweight or obese adults by Health District, Georgia, 1997-1999

1-2

2-0 1-1

3-1 3-4 3-6

10-0

3-3

4-0

5-2

5-1 7-0

< 50 % 50%-<55% 55%-<60% 60 % or more
6-0
9-1

Source: Georgia Behavioral Risk Factor Surveillance System

8-2 8-1

9-2 9-3

Figure 12. Overweight or obese adults by Health District, Georgia, 2000-2003

3-3
Source: Georgia Behavioral Risk Factor Surveillance System

1-2

1-1

2-0

3-1 3-4 3-6

10-0

4-0

5-2

5-1 7-0

< 50 % 50%-<55% 55%-<60% 60 % or more
6-0
9-3

8-2 8-1

9-2 9-3

* As of January 2005, there are 18 health districts.

8

Georgia's Nutrition and Physical Activity Plan

One

Contributing Behavioral Risk Factors
Georgians have not made significant progress with adopting health promoting behaviors such as regular physical activity, consumption of five or more servings of fruits and vegetables per day, and limited television viewing. Only 68% of middle school and 59% of high school students are vigorously active, 17% of high school students eat 5 or more servings of fruit and vegetables per day, and approximately half of middle (52%) and high school (42%) students watch at least 3 hours of television per school day. Similar to youth, far too many adults do not engage in health promoting behaviors. Only 40% of adults are regularly active and 23% consume the recommended number of daily servings of fruit and vegetables.
Figure 13. Prevalence of physical activity, fruits and vegetables consumption, and TV viewing among youth and adults, Georgia

Percent

Middle School

80

70

68

60

59

High School

50
40
40

30
23

20

17

10

0
Vigorously active (youth)*

5+ Fruits &

and regularly active (adults)

Vegetables/day*#

Sources:

*Georgia Student Health Survey 2003

Behavior Risk Factor Surveillance System 2001

#Behavior Risk Factor Surveillance System 2002

Adults 52
42
3+ hrs TV/school day*

Georgia's Nutrition and Physical Activity Plan

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One
Contributing Environmental Factors
Policies and environments supporting healthy eating and physical activity may shape the attitudes and behavior of the population. Results from the School Health Education Profile (2002)4 showed only 6% of middle and 11% of high schools in Georgia had a policy to offer fruits and vegetables at school settings. Sixty-two percent of middle and 94% of high schools require students to take one course in physical education. The 2002 Georgia Worksite Survey5 found only 17% of worksites in Georgia offered physical activity or fitness programs and only 10% of worksites offered healthy eating or weight management classes or counseling to employees.
Community design and growth has lead to urban sprawl which encourages individuals to drive rather than walk to work, school or stores. A recent study 6 provided evidence for the association between increased rates of obesity and indicators of the built environment and urban sprawl in the metro Atlanta region. Residents living in areas of more land-use mix, spending less time in their car per day, and walking more each day are less likely to be obese.
Cost of Overweight and Obesity
Population attributable risk# (PAR) calculations show that 10% of total adult deaths in Georgia in 2000-2003, or 6,700 deaths, would not have occurred if all Georgia adults were of optimal weight. More deaths attributed to excess body weight occurred among the obese (5,200) than among the overweight (1,500).
The annual cost of obesity in Georgia is estimated at $2.1 billion ($250 per Georgian per year), which includes direct health care costs and lost productivity from morbidity and mortality (indirect costs).7

# These estimates are based on PAR, a measurement of the proportion of deaths caused by a particular risk factor. The PAR represents the proportion of deaths in a population that could be eliminated if the risk factor were removed from the population. The PAR from overweight and obesity is the fraction of all deaths that would not occur if everyone were of optimal (normal) weight. The PAR from overweight and obesity can be estimated based upon the prevalence of overweight and obesity in Georgia and the relative risk of dying from overweight and obesity compared with normal weight. See Appendix II for further definitions and methods for population attributable risk.

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Georgia's Nutrition and Physical Activity Plan

One
Summary
Overweight and obesity is epidemic in Georgia, affecting all segments of the population. The immediate cause of the epidemic is an imbalance between energy intake (food consumption) and energy output (physical activity). The causes of the imbalance are related to a complex and incompletely understood combination of behavioral, environmental, cultural, political, and socioeconomic factors.
The burden of the epidemic is inequitably distributed among Georgians. The rates of overweight and obesity are highest in adults between the ages of 45 and 64 years, living in low income households, and earning less than a high school education. Black middle school and high school students are more likely to be at risk for overweight or overweight than white students. Hispanic children between ages 2 to <5 are more likely to be at risk or overweight than children of any other race or ethnicity served by the Women, Infants, and Children (WIC) Program.
Overweight and obesity is associated with increased mortality as well as higher rates of cardiovascular disease, diabetes, stroke, hypertension, gall bladder disease, osteoarthritis, and some types of cancer. In addition to the heavy morbidity and mortality burden, the annual cost of obesity in Georgia is estimated at $2.1 billion ($250 per Georgian per year).7

Georgia's Nutrition and Physical Activity Plan

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Chapter Two:
Development of State Plan

12

Georgia's Nutrition and Physical Activity Plan

Two
Ta s k F o r c e D e v e l o p m e n t
In November 2003, the Department of Human Resources (DHR), Division of Public Health convened stakeholders to lead the development and implementation of a nutrition and physical activity plan for Georgia. The statewide collaborative group, Take Charge of Your Health, Georgia! Task Force (TCYHG), is composed of the DHR Division of Public Health; state departments of education, transportation, and parks and recreation; leaders from faith-based organizations; leaders from community-based organizations; health care professionals (e.g., registered dietitians, physicians, nurses); universities; and statewide coalitions. Their collective expertise includes nutrition, physical activity, breastfeeding, evaluation, community development, strategic planning, social marketing, communication, and advocacy. A listing of Task Force members can be found in Appendix I.
The Task Force structure includes a Steering Committee to provide oversight for the initiative; workgroups to complete the capacity-building or planning phase (setting-specific work groups are being formed for the implementation phase); and the Division of Public Health Internal Planning Team (see Task Force Terms of Reference and Structure for more details in Appendix III). During the capacity-building phase, the following planning workgroups focused on developing the plan: Breastfeeding, Healthy Eating, Physical Activity and TV Viewing. A fifth workgroup developed the data and evaluation component of the plan. A final workgroup was formed to review and enhance partnership opportunities and to develop the communication component of the plan.
The Task Force focuses on all Georgians including children and their families (especially low income families), adults, older adults, and specific racial and ethnic groups (e.g. African Americans and Latinos).

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Two
Framework for the Plan
The socio-ecological model provided the framework for the Georgia Nutrition and Physical Activity Plan. At the center of the socio-ecological model is the individual surrounded by increasingly larger spheres of influence: interpersonal, organizational, community, and societal. The socio-ecological model is a framework for planning health promotion interventions where there is a spotlight on the relationship between the environmental and behavioral determinants of health. The relationship is thought to be reciprocal; the environment affects health-related behaviors, and individuals can, through their actions, affect the environment. Based on the complex dynamics of the socio-ecological model and the identified partnerships and state resources, the Georgia Nutrition and Physical Activity Plan was conceptualized to systematically target public policy changes, community changes, organizational changes, and interpersonal changes to ultimately impact individual behavior change.
Socio-Ecologic Model
Society
nation, state
Community
county, municipality, coalitions
Organizational
organizations, social institutions
Interpersonal
family, friends, social networks
Individual
knowledge, attitudes, skills
Source: Adapted from McLeroy, et, al, an ecological perspective on health promotion program a Health Education Quarterly 1988, 15:351-77
Individual: awareness, knowledge, attitudes, beliefs, values, preferences Interpersonal: family, friends, peers that provide social identify and support Institutional/Organizational: rules, policies, procedures, environment, informal structures Community: social networks, norms, standards and practices Society/State: state, and federal governmental policies, regulations, and laws

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Georgia's Nutrition and Physical Activity Plan

Two

Planning Process

The Planning Workgroups met monthly from December 2003 until November 2004. The workgroups utilized the spheres of influence within the socio-ecological model as a framework for planning goals, objectives, and strategies in five settings for target populations. The five settings included Community, Faith-based Organizations, Schools, Worksites, and Healthcare. The target populations included infants and toddlers, school age children, college/university age, adults, and older adults. During this process, new and existing initiatives and interventions were incorporated into the plan and strategies were prioritized based on the following criteria established by the Steering Committee: Is the strategy feasible? Is it evidence-based? And does it build on existing initiatives/resources? Are they culturally and linguistically sensitive?

During the planning process, the Task Force gathered input from partners at the local level. Seven regional planning meetings were held across the state (representing urban, suburban and rural areas) Atlanta, Gainesville, Augusta, Savannah, Macon, Columbus and Albany. The purposes of the meetings were to obtain local input and buy-in and support from partners at the community and state level, for the acceptability and implementation of the plan. See Appendix IV for Regional Planning Meeting Results.

The Task Force also utilized other relevant meetings, conferences, and initiatives as opportunities to inform the development of the plan:
Georgia Public Health Association Meeting (September 2003) Health Matters Conference (October 2003) Environmental Scan of Current Activities (conducted by Georgia State University,
Health Policy Center, December 2004)
In addition, national documents informed the strategies in Georgia's Nutrition and Physical Activity Plan. These include: CDC's Guidance Document to Prevent Obesity and Other Chronic Diseases
(http://www.cdc.gov/nccdphp/dnpa/obesityprevention.htm) Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity (2001) U.S. Department of Health and Human Services' Healthy People 2010 (2000) Guide to Community Preventive Services Chapter on Physical Activity (2002) Georgia's Physical Activity Report 2001 Institute of Medicine's Prevention of Obesity in Children and Youth (2004) World Health Organization's Global Strategy on Diet, Physical Activity, and Health (2004).
The Georgia State University's Health Policy Center conducted a literature review to assist in identifying evidence-based strategies to be included in the plan. The literature review and these national documents assisted in the development of objectives and strategies and will continue to inform specific action steps during the implementation phase.

Environmental Scan of Current Activities to Promote Breastfeeding, Healthy Eating and Physical Activity

In support of the development of Georgia's plan, the Georgia State University, Health Policy Center conducted a scan of current breastfeeding, nutrition, and physical activity programs and initiatives in Georgia from December 2004 through January 2005. Over three hundred (347) members of the Task Force and state and local public health staff received the survey by email. Of the 347 surveys disseminated, 126 individuals completed the survey, 77 stated they did not have an applicable program, and 144 have not responded to the follow-up email, or the follow-up phone calls made in the two weeks from January 13 to January 26. Additional follow-up is planned. The 126 respondents completed a total of 143 surveys (respondents responsible for more than one program completed multiple surveys). Partners were able to respond via the web-based survey or via mail. See Appendix V for survey questionnaire and summary of results. The results of the survey will be used to identify programs/initiatives in Georgia related to healthy eating, physical activity, and breastfeeding, and identify any potential gaps to be included in the state plan.

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Chapter Three:
Integration of the Plan and Current Efforts

16

Georgia's Nutrition and Physical Activity Plan

Three

Integration of the Plan with Existing Nutrition, Physical Activity, and Chronic Disease Initiatives
The Georgia Department of Human Resources, Division of Public Health collaborates with a broad spectrum of partners for planning, training and program implementation for obesity and chronic disease prevention. As shown in figure 16, the Take Charge of Your Health, Georgia! Task Force will serve as the synchronizing and leadership body that will coordinate and integrate nutrition and physical activity initiatives statewide and will guide the implementation of this plan. The Division of Public Health has four Branches that develop and implement nutrition and physical activity initiatives. The following describes the key nutrition and physical activity collaborations and initiatives within the Division of Public Health and partners.
Figure 16. Take Charge of Your Health, Georgia! Initiative Structure
Georgia Department of Human Resources

Division of Aging Services

Division of Family and Children's
Services

Division of Public Health

Family Health Branch

WIC Branch

Chronic Disease Prevention and Health Promotion
Branch

Epidemiology Branch

Take Charge of Your Health, Georgia!
(Nutrition and Physical Activity Initiative)

State Level (Macro-Level Environment)

State-wide Coalitions and State Agencies
- State Government Agencies - Georgia Coalition for Physical Activity and Nutrition - Obesity Action Network - Action for Healthy Kids Georgia Team - 5 A Day Committee - Georgia Parent Teacher Association

Local/Community (Micro-Level Environment)

- Local Public Health Departments - Local Nutrition and Physical Activity Coalitions/Taskforces - Local Schools, Worksites, Communities, Healthcare Facilities - Community-based Organizations - Local Community Members - Local Non-Profit Health Organizations

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Three
Georgia Department of Human Resources Division of Public Health
Family Health Branch
Over the past five years Family Health has reorganized to deliver population-focused services through a Programs and Services Section that coordinates the work of four population teams: Women's Health, Infant and Child Health, Children with Special Needs, and Adolescent Health and Youth Development. The Nutrition and Oral Health Sections provide cross-cutting technical assistance to these teams.
The Nutrition Section is the designated leader within Family Health and across Public Health for integration of nutrition programs and initiatives at the individual, community and population levels. Key focus areas include promoting fruit and vegetable consumption/Georgia's 5ADay Program, breastfeeding, obesity prevention, infant and child nutrition, prenatal nutrition, folic acid awareness, osteoporosis prevention and workforce development. Nutrition Section consultants provide technical assistance and training on these focus areas to local health district staff, external partners and the general public. The Nutrition Section houses the State Breastfeeding Coordinator, and the Project Coordinator and Nutrition/5ADay Coordinator for the CDC-funded obesity prevention initiative (Take Charge of Your Health, Georgia!).
The Nutrition Section also has a long-standing memorandum of understanding (MOU) with the Women, Infants and Children Program (WIC) Branch for the Nutrition section to provide all the nutrition-related leadership, coordination and technical assistance to Georgia's WIC program. Initiatives such as Loving Support Breastfeeding Peer Counseling Program is coordinated through the Nutrition Section.
Georgia's Coordinated School Health Program under the School Health Coordinator is housed within the Infant and Child Health Team. There is also a recent MOU with Bright from the Start: Department of Early Care and Learning. The MOU is designed to facilitate the development of a comprehensive, coordinated, statewide system of early care and education in Georgia. Nutrition and physical activity are components of this coordinated system.
The Policy, Planning and Evaluation (PPE) Section within Family Health provides technical assistance in program assessment, planning, implementation, and evaluation. PPE provides in-kind evaluation support to the Take Charge of Your Health, Georgia! Initiative.
The Data Team supports the Family Health Branch in the development of data collection systems and building capacity to utilize and analyze data for decision-making, program development, planning, evaluation, equitable allocation of funds, and accountability to stakeholders. The Data Team staff support to the Take Charge of Your Health, Georgia! initiative includes developing a partnership database.

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Women Infants and Children (WIC) Branch
The Georgia WIC Branch provides policy direction, technical assistance and funding allocations to the local agencies and two contract agencies in Georgia. The Georgia WIC Program currently contracts service delivery through 19 local WIC agencies, 267 local clinics and over 1800 retail vendors that sell WIC approved foods. The WIC Program's objective is to improve pregnancy outcome, reduce infant mortality and give children a healthy start through the provision of nutritious food supplements and delivery of nutrition education. The WIC Branch currently has several initiatives in progress through its five sections within the Branch, the Nutrition Section of the Family Health Branch and the Maternal and Child Health Epidemiology Section in the Epidemiology Branch.
The Farmer's Market Program (FMP), currently being administered through the Vendor Management Section of the Georgia WIC Branch, is aimed at providing fresh fruits and vegetables to eligible WIC participants. This program is located in every health district. The Seniors Farmer's Market Program which is an extension of the FMP provides fresh fruits and vegetables to eligible individuals 65 years and older.
The Peer Counseling and Loving Support Breastfeeding Initiatives, with joint administration between the Georgia WIC Branch and the Family Health Branch, is aimed at providing breastfeeding education using a peer educational support model. There is evidence suggesting that peer breastfeeders are effective modelers for promoting breastfeeding initiation and continuation. Thus, one of the aims of the initiative is to train peer educators on how to provide supportive counseling to women who may experience complications during breastfeeding, thereby effecting change.

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Chronic Disease Prevention and Health Promotion Branch
Cardiovascular Health Initiative The Georgia Cardiovascular Health Initiative (GA CVHI), funded by CDC program announcement 02045, The Heart Disease and Stroke Prevention Program, seeks to change policies and the environment in the domains of worksite, the healthcare setting, schools---especially focusing on schools as a worksite---and the community at large. The CVHI was funded at the capacity building level in 1998 and moved to basic implementation status in 2000. Georgia has been the lead for the 33 CDC funded states in the worksite arena. Highlights for the Georgia CVHI include: service on the CDC Business Expert Panel, identification of one of six model worksites in the nation by the Expert Panel as a promising practice (other models are: LL Bean, Johnson & Johnson, General Motors, Duke University, and Highsmith). The GA CVHI presented the abstract on Fieldale Farms at the 5th International Heart Health Conference in Milan in June 2004. The promising practice model, Fieldale Farms, a poultry plant in Baldwin, GA, with 4200 employees from four diverse cultures, has been interviewed by the Associated Press and NBC News. The GA CVHI has presented at the CDC 2003 and 2004 National Conferences on Chronic Disease Prevention and Control, the National Stroke Conference in 2004, and provided training on how to engage worksites to the 33 funded CVH states.
The Physical Activity Program in the Chronic Disease Prevention and Health Promotion Branch collaborates with the disease prevention programs and partners with other groups and organizations on a statewide-basis to promote, develop and implement physical activity programs. Partners include recreation and park agencies, senior centers, area agency on aging programs, community centers, church groups and various other community organizations. Activities include education and awareness, walking programs and sports competition. The program also develops and implements worksite wellness programs and trainings and provides consultation and technical assistance to health districts and businesses.
Live Healthy Georgia Campaign In an effort to help the people of Georgia live healthier lives and to reduce the burden of chronic disease and other illnesses, the Georgia Department of Human Resources is partnering with Governor Sonny Perdue and other state agencies, community-based organizations, and companies around Georgia to launch the Live Healthy Georgia Campaign. The campaign is designed to raise awareness and provide education about the prevention of chronic diseases and the promotion of healthy behaviors. The five key messages of the campaign are Get Checked, Be Smoke Free, Be Active, Eat Healthy and Be Positive. The Campaign was officially launched in March 2005.
Chronic Disease Prevention Initiative (CDPI) is funded through tobacco-settlement dollars to provide a CDPI Coordinator in each of the eighteen public health districts in Georgia. Coordinators implement evidence-based physical activity and nutrition interventions, promote policy and environmental changes and provide education, awareness and training on chronic disease prevention and health promotion. Intervention sites include worksites, schools, community, and healthcare settings.
Georgia's Diabetes Prevention and Control Program is funded with a grant from the Centers for Disease Control and Prevention. The program has several goals related to nutrition and physical activity such as identifying community barriers which limit physical activities and healthy food choices, collaborating with local partners to investigate accessibility issues through exploration of neighborhood and park walkability and access to fruits and vegetables, and encouraging patients participating in diabetes treatment programs to consume five fruits and vegetables per day and walk or participate in some form of moderate exercise for at least 30 minutes a day.

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The Georgia Osteoporosis Initiative is a state-funded program to reduce the incidence of osteoporosis-related fractures by helping Georgians reduce their risk for developing osteoporosis through lifestyle modifications and early screening and detection programs. The Georgia Osteoporosis Strategic Plan targets all age, gender, and racial and ethnic groups. The overall educational and intervention goals revolve around improving dietary choices and increasing physical activity to promote optimal bone health in children and adolescents and to reduce bone loss in adults. The program has provided small grants to health districts and community organizations to sponsor education programs and interventions that promote calcium-rich diets and weight resistant exercise across the life-span.
The Georgia Arthritis Program is funded through a grant with the Centers for Disease Control and Prevention to increase awareness of the burden of arthritis among health care providers and the general public and to improve the quality of life of persons with arthritis. Arthritis is a leading cause of disability in Georgia. Obesity is a significant risk factor for the development of several forms of arthritis. Appropriate physical activity is a core element in disease self-management for arthritis. The program encourages awareness among health care providers treating persons with arthritis of the importance of recommending physical activity and weight management. Most program efforts are directed to increasing availability of the evidence-based physical activity program, PACE (People with Arthritis Can Exercise), developed by the Arthritis Foundation. The Arthritis Foundation Georgia Chapter provides training and technical assistance to health districts. Health districts recruit PACE sites and facilitate and coordinate local community education and awareness efforts. The Georgia Program also uses the CDC-developed health communications campaign, "Physical Activity...the Arthritis Pain Reliever," to recruit participants to PACE classes.
The Cancer Education and Risk Reduction Program promotes education and awareness through the media, Rural Cancer Projects, Prostate and Colorectal Task Force groups, and the Community Partners Project to professionals and the general public. The program is currently in the process of integrating the five key messages of the Live Healthy Georgia Campaign: Be Active, Eat Healthy, Be Smoke Free, Get Checked and Be Positive.
The goals of Georgia's CDC-funded Asthma Prevention and Control Program that are related to nutrition and physical activity include supporting safe and healthy school environments to reduce asthma triggers (menu options and exercise activities) and supporting safe, enjoyable physical education, nutritional education and activity opportunities for students with asthma.

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Epidemiology Branch
The Epidemiology Branch assures that data and science guide the development and implementation of all Public Health programs. Within the Epidemiology Branch, the Chronic Disease, Injury, and Environmental Epidemiology Section assures the quality and accessibility of standard mortality, morbidity, risk factors, policy and environmental data to assist in program planning and evaluation through the Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavioral Surveillance System (YRBSS) and other surveys. The Maternal and Child Health Epidemiology Section collects and disseminates breastfeeding, infant and child health, as well as pregnancy-related data through the Pregnancy Risk Assessment and Management System (PRAMS), the Pregnancy Nutrition Surveillance System (PNSS), and the Pediatric Nutrition Surveillance System (PedNSS).
Georgia Department of Human Resources Division of Aging Services
The DHR Division of Aging Services (DAS) is a state organizational unit designated by the Governor. As the state agency, DAS is responsible for programs and services for the elderly. The mission of the Division is to provide state leadership in assisting older individuals, their families, and caregivers to achieve safe, healthy, independent and self-reliant lives. The Division receives both federal (Administration on Aging) and state grants to administer programs for the elderly. A wide array of services is offered through Georgia's Aging Network. Nutrition and Wellness Program services are provided to promote healthy aging and healthy living. The Nutrition Services provided include: congregate meals (provided at senior centers), home delivered meals, nutrition screening/assessment, nutrition education/counseling and shopping assistance. The Wellness Program activities include: medications management, physical activity programs, chronic disease prevention/management programs, fall prevention programs, stress reduction programs, etc. The Division has developed and successfully implemented the "Take Charge of Your Health for Older Adults", a community intervention program to promote nutrition and physical activity in older adults.
Georgia Department of Human Resources Division of Family and Children's Services
The DHR Division of Family and Children Services (DFCS) is responsible for Temporary Assistance for Needy Families (TANF), food stamp benefits, and social services to assist lowincome families or families in crisis. DFCS also administers the Food Stamp Nutrition Education program for Food Stamp recipients. Through the Family Nutrition Program, funded and conducted in partnership with USDA through the Georgia DHR State Food Stamp Nutrition Education Plan, Family and Consumer Sciences Extension provides comprehensive nutrition education to food stamp-eligible audiences in 108 Georgia counties. The goal of Food Stamp Nutrition Education is to improve the likelihood that Food Stamp Program participants and applicants will make healthy food choices within a limited budget and choose active lifestyles consistent with the current Dietary Guidelines for Americans and the Surgeon General's physical activity recommendations.

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Other State Agencies and Statewide Collaborative Efforts
In addition to the Department of Human Resources programs, there are other state agencies and several statewide collaborative efforts that will support the implementation of the Take Charge of Your Health, Georgia! initiative. Figure 16 graphically illustrates the partners involved in the implementation of this state plan and is followed by a brief description of key partners and their initiatives. With leadership from the Division of Public Health, Take Charge of Your Health, Georgia! Task Force and plan will serve as the synchronizing body linking other state agencies and local partners in the implementation of the plan.
Bright from the Start: Georgia Department of Early Care and Learning (DECAL) is the agency responsible for overseeing child care and educational services for children ages birth through four and their families and for administering the USDA food program for children and adults. Bright from the Start's responsibilities include the following: administering Georgia's Pre-K program, licensing approximately 3,000 child care learning centers and group day care homes; registering more than 5,000 family day care homes; administering two federal nutrition programs: The Child and Adult Care Food Program and the Summer Food program; housing the Head Start State Collaboration office; implementing the Standards of Care Program to enhance the quality of child care provided to infants, toddlers and three year olds; funding/partnering with the child care resource and referral agencies; collaborating with Smart Start Georgia to blend federal, state, and private monies to enhance early care and education; and distributing federal child care development funds.
There is a Memorandum of Understanding (MOU) between the Division of Public Health, Family Health Branch and Bright from the Start: Georgia Department of Early Care and Learning. The MOU is designed to facilitate the development of a comprehensive, coordinated, statewide system of early care and education in Georgia. Both parties to the agreement co-lead the Early Childhood Comprehensive Systems grant funded by the MCH Bureau of the Health and Human Resources and Services Administration, as well as work to ensure that all children in Georgia receive appropriate medical care and are healthy and ready to learn when they enter school.
The Community Health Development & Advocacy Department of Children's Healthcare of Atlanta offers comprehensive healthy lifestyle development programming, focusing on childhood obesity prevention and intervention. Children's Healthcare of Atlanta supports the development of health behaviors early in life through the Take Charge of Your Family's Health Program (Stress-Free Feeding and FIT KIDS 3-5 years), teaching parents and providers the positive steps of healthy eating practices and other healthy lifestyle behaviors for children ages birth to 5 years. The FIT KIDS 6-12 program teaches families of school-age children to be physically active, have regular family meals together and decrease sedentary habits. The Type 2 Diabetes Prevention Program was developed as a model for providing physical activity and nutrition intervention, to those children at greatest risk for developing Type 2 Diabetes, in a primary care setting. Kids on the Move (KOTM) is an after school activity and healthy lifestyles program developed in response to an identified increase in cardiovascular disease risk factors among children in high-risk populations. Through health education and structured active play, KOTM aims to reduce cardiovascular risk factors such as obesity and increase opportunities for physical activity in children ages 8 to 12.
Public Health has strengthened working relations with the Department of Education (DOE), at the state and local school levels, through several successful partnerships. Public Health and the DOE provide joint leadership in the Georgia Partnership for School Health, which aims to promote the eight components of the Coordinated School Health Model in partnership with member organizations and individuals. Following the National Healthy Schools Summit, in November 2002, the Georgia Partnership for School Health, formed the Georgia Action for Healthy Kids sub-committee to promote nutrition and physical activity for children and youth in school settings. Family Health Branch's School Health Coordinator and DOE's School and Community Nutrition Coordinator co-chair this Committee.

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The Georgia Action for Healthy Kids Team will collaborate with the Take Charge of Your Health, Georgia! Task Force on goals and strategies that ensure that all food options offered in schools/school food programs are low in fat, calories, and added sugars, such as fruit, vegetables, whole grains and low-fat dairy foods; and increase efforts to provide adequate daily physical activity opportunities in the classroom and after school for elementary and middle school-aged children.
The Georgia Coalition for Physical Activity and Nutrition (G-PAN) initially received seed funding from the Division of Public Health's Nutrition Section and USDA Food Stamp Program. Today, they are a self-sustaining non-profit coalition. There are nearly 300 members that represent more than 80 public and private organizations in G-PAN. The coalition is committed to facilitating information and resource sharing, promoting the Take Charge of Your Health social marketing campaign through its membership, implementing the Georgia on the Move Program, and advocating for healthy eating and physical activity for school-age children. G-PAN recently received funding from Healthcare Georgia Foundation and the Atlanta Falcons Youth Foundation to hire an Executive Director, advocate for increased physical activity for school-age children and educate legislators about the importance of physical activity through a Legislative Fitness Challenge. G-PAN has also received funding from America on the Move for a Program Coordinator to promote Georgia on the Move, a key community strategy in this plan.
The Georgia Health Policy Center, housed within the Andrew Young School of Policy Studies at Georgia State University provides evidence-based research, program development and policy guidance locally, statewide and nationally to improve community health status. Now in its tenth year, the Center focuses on solutions to the toughest issues facing health care today, including insurance coverage, long-term care, children's health, and the development of rural and urban health systems.
For nearly two decades, the Division of Public Health, Family Health Branch, Nutrition Section has taken a lead role in Georgia in developing partnerships and infrastructure to increase breastfeeding rates. In 1985, the Nutrition Section created the Georgia Task Force for Breastfeeding, representing Public Health, hospitals, private health care providers, lactation consultants, and others. The goal is to increase breastfeeding rates throughout the state. The Nutrition Section is establishing links among state coalitions and providers of services to breastfeeding families through activities of the Georgia Breastfeeding Task Force, Healthy Mothers, Healthy Babies of Georgia, and the Georgia Chapter of the American Academy of Pediatrics, Physicians Breastfeeding Advisory Committee. Due to the scope and success of breastfeeding collaboration and the incorporation of best practices, Georgia has witnessed a steady increase in breastfeeding initiation rates among WIC participants, from 31% in 1995 to 49% in 2002, and received national recognition for this success.
The ILSI Center for Health Promotion (ILSI CHP) is a non-profit research and education organization dedicated to the promotion of health in individuals and populations on a global basis. Programs within the Center include the Physical Activity and Nutrition (PAN) Program, which promotes healthful physical activity and nutrition among children, adolescents, and adults. In the past four years, ILSI Physical Activity and Nutrition (PAN) Program has emerged as a leader in research and education concerning prevention of childhood obesity and overweight, and promotion of energy balance, good nutrition, and physical activity. Developed by ILSI CHP, the TAKE 10! Program adds at least ten minutes of physical activity to the elementary classroom while simultaneously helping teachers pursue academic goals. With TAKE 10!, children are active while learning language arts, math, social studies, science, character education, nutrition, and health concepts.
The Hispanic Health Coalition of Georgia (HHCGA) works to promote health and social change in Latino/Hispanic communities by connecting individuals and organizations, and by providing leadership and advocacy on health issues affecting the Latino community. HCGA's vision is to empower the Latino community in order for them to achieve optimal health and quality of life.

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The Interfaith Health Program (IHP) of the Emory University, Rollins School of Public Health has been promoting collaboration between the faith community and public health for 12 years. Over the last 6 years, IHP has worked with Georgia DHR to identify, strengthen, and replicate successful models of faith and public health partnerships. Currently there are strong committed leaders throughout the public health infrastructure who have effective working relationships with networks of religious leaders. The IHP is the hub of these relationships and capacities, sponsoring gatherings at district and state levels to further learning and practice with these two important partners in Georgia. Current IHP initiatives add synergy and strength to Georgia's Nutrition and Physical Activity Plan.
The Obesity Action Network (OAN) was established in 2000 by the Nutrition Section, the Georgia Chapter of the American Academy of Pediatrics, Committee on Nutrition and International Life Sciences Institute (ILSI), Center for Health Promotion. Individuals, primary care providers and organizations that support research or provide programs in the area of assessment, prevention and treatment of obesity in children in the healthcare setting participate in the OAN. Member organizations include: Public Health (Family Health Branch, Chronic Disease Prevention and Health Promotion Branch, WIC Branch, epidemiologists), physicians (American Academy of Pediatrics), Kaiser Permanente, Children's Healthcare of Atlanta, Georgia Department of Community Health, Department of Education, and others.
Policy Leadership for Active Youth (PLAY) is a three-year policy research initiative of the Georgia State University, Institute of Public Health, in partnership with the Georgia Center for Obesity and Related Disorders (GCORD), the University of Georgia, and the Medical College of Georgia. PLAY collaborates with G-PAN and other stakeholders such as DHR, Division of Public Health to identify and assimilate emerging and promising strategies to increase physical activity, decrease sedentary behaviors and prevent childhood overweight with emphasis on providing the scientific expertise to direct innovative health policies to address these health problems in Georgia.
Philanthropic Collaborative for a Healthy Georgia is an informal, loosely structured and evolutionary group that brings Georgia's grantmakers together to better understand and respond to the health-related challenges facing our State. The primary purpose of the Collaborative is to enable foundation staff and trustees to be more informed and effective in their own health-related grant making activities. The Collaborative has addressed several critical health issues in Georgia, including school health, rural health, cancer prevention and control, and, most recently, childhood obesity. To enable decision makers to have access to comprehensive and reliable data about the physical fitness and activity levels of Georgia's school-aged children, the Philanthropic Collaborative is launching the Georgia Youth Fitness Assessment project. The study will be based on a sampling of 4,000 students: 2,000 elementary school students and 2,000 middle school students in a minimum of 60 schools at each of the two grade levels.
The University of Georgia (UGA) Cooperative Extension serves as an outreach arm of the University and is comprised primarily of the College of Agricultural and Environmental Sciences and the College of Family and Consumer Sciences. Through multi-county programming, Family and Consumer Sciences (FACS) Extension Agents, collaborate with state agencies, institutions, and industry to plan, train and implement research-based general nutrition programs to Georgia families. Program topics include general nutrition and physical activity, weight management, breastfeeding, prevention of chronic diseases, and more. Extension programs include Walk-a-Weigh, nutrition and walking program for adults; Right Bite Diabetes Cooking School; The Expanded Foods and Nutrition Education Program; and the Family Nutrition Program. Extension nutrition programs are delivered to youth and adults of diverse audiences, including limited-resource, at-risk populations. FACS Agents blend federal, state, and county funding to serve local needs.

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Chapter Four:
Use and Sustainability of the Plan and Task Force

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Use and Sustainability of the P l a n a n d Ta s k F o r c e
Use of the Plan
Georgia's Nutrition and Physical Activity Plan serves as a blueprint for action. The plan is divided into 6 action areas: state partnership/infrastructure, community, worksites, healthcare, schools, and faith-based organizations. Each setting identifies objectives related to the different levels of the socio-ecological model (community, organizational, interpersonal and individual). Strategies have been identified to meet these objectives. These strategies represent the major focus areas of the plan: increased breastfeeding, improved healthy eating, increased physical activity and decreased television viewing/screen time. These are strategies that can be used by partners in worksite, community, healthcare, schools and faith-based settings to begin or continue their work to improve overall healthy eating and increase physical activity of Georgians. Partners are encouraged to implement a combination of strategies that address multiple levels of the socio-ecological model, i.e. behavior change approaches for individuals as well as strategies to bring policy and environmental changes at the organizational, community, or society/state level.
Throughout the plan, "healthy eating" refers to the Dietary Guidelines for Americans.
Key Highlights
Choose a variety of fruits and vegetables.
Consume 3 cups of non-fat or low-fat milk everyday or equivalent milk products.
Consume 3 or more ounce equivalents of whole grain products per day.
When selecting and preparing meat, poultry and dry beans, make choices that are lean, low-fat or fat free.
Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt and alcohol.
Maintain a body weight in a healthy range, balance calories consumed from foods and beverages with calories expended.
Source: 2005 Dietary Guidelines for Americans

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Sustainability of the Plan
The Take Charge of Your Heath, Georgia! Task Force is currently moving into the Implementation or "Moving to Action" Phase (see structure in Appendix VI.) and recognizes that more detailed planning will need to occur to fully implement the ten year plan. The planning work groups will transition into setting level workgroups to focus on developing the implementation action steps.
The Steering Committee will oversee the implementation of the plan and will review the plan on an annual basis. The Data and Evaluation workgroup will oversee the monitoring and evaluation of state plan activities. The Communication and Partnership workgroup will facilitate the development of partnerships as well as communication-related activities of the plan.
The Take Care of Your Health, Georgia! Task Force will utilize professional, system, and financial resources from collaborative partners to sustain the implementation of this ten-year plan. The collaborative partners bring public and private funds, diverse expertise, communication networks, and political influence to the Task Force to implement nutrition and physical activity strategies for obesity and chronic disease prevention.
The Task Force recognizes the need for communities to find solutions through partnership and that everyone, the health sector, state and local governments, worksites, schools, communities, parents and caregivers and individuals, has a role to play, to maintain a sustained effort. The DHR Division of Public and the Task Force will continue to build partnerships and alliances to support the implementation of the plan.

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Chapter Five
Overall Plan Goal, Objectives and Strategies

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Overall Plan Goal
To prevent and control obesity and other chronic diseases such as Type-2 diabetes, asthma, cardiovascular disease,
stroke and some forms of cancer.
Long Term Objectives
Long term objectives for the plan reflect changes in overweight/obesity prevalence, increased physical activity, decreased television viewing, increased breastfeeding initiation and duration, and increased fruit and vegetable consumption. For each objective, Healthy People 2010 goals are referenced.
1. By 2015, reduce the proportion of Georgia's children and youth who are overweight (BMI-for-age > 95th percentile). (HP 2010 19-3)
Children aged 2-<5 years in WIC from 12% (PedNSS 2002) to 11%; Middle school students 14% (YRBS 2003) to 12%; High school students from 11% (YRBS 2003) to 10%.
2. By 2015, increase the proportion of Georgia adults who are at a healthy weight (BMI 18.0 25.0) from 41% (BRFSS 2002) to 45%. (HP 2010 19-1: 60%)
3. By 2015, reduce the proportion of Georgia adults who are obese (BMI30) from 24% (BRFSS 2002) to 22%. (HP 2010 19-2: 15%)
4. By 2015, increase the proportion of Georgia high school students who engage in moderate physical activity for at least 30 minutes on 5 or more of the previous 7 days from 25% (YRBS 2003) to 27%. (HP 2010 22-6: 35%)
5. By 2015, increase the proportion of Georgia youth who engage in vigorous physical activity that promotes cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion. (HP 2010 22-7: 85%)
Middle school students from 68% (YRBS 2003) to 75%; High school students from 59% (YRBS 2003) to 65%.
6. By 2015, reduce the proportion of Georgia adults who engage in no leisure-time physical activity from 26% (BRFSS 2002) to 20%. (HP2010 22-1: 20%)
7. By 2015, increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day from 30% (BRFSS 2003) to 33%. (HP 2010 22-2: 30%)
8. By 2015, increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion from 25% (BRFSS 2003) to 28%. (HP 2010 22-3: 30%)
9. By 2015, increase the proportion of Georgia youth who view television 2 or fewer hours on a school day. (HP 2010 22-11: 75%)
Middle school students from 48% (YRBS 2003) to 53%; High school students from 58% (YRBS 2003) to 64%.
10. By 2015, increase the proportion of Georgia high school students who consume five or more servings of fruits and vegetables per day from 17% (YRBS 2003) to 21%. (HP 2010 19-5 and 19-6)
11. By 2015, increase the proportion of Georgia adults who consume five or more servings of fruits and vegetables per day from 23% (BRFSS 2002) to 29%. (HP 2010 19-5 and 19-6)
12. By 2015, increase the proportion of Georgia women who initiate breastfeeding (HP 2010 16-19a: 75%) and who continue to breastfeed for at least 6 months (HP 2010 16-19b: 50%).
Initiation from 49% (PedNSS) to 54% among WIC participants and from 64% (PRAMS 1998) to 70% in general population. At least 6 months duration from 16% (PedNSS 2002) to 20% among WIC participants and from 28% (Ross 2001) to 35% in general population.

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Intermediate Objectives and Strategies
Intermediate objectives to be achieved by 2010 and strategies for each are reflected under the following:
State Partnership and Infrastructure Community Setting Faith-based Setting Healthcare Setting School Setting Worksite Setting Data, Evaluation, and Research
State Partnership and Infrastructure Objectives
Sphere of Influence: Policy (examples: state policies and laws, media campaigns)
State Partnership and Infrastructure #1. By 2010, increase from baseline the number of state-level policies, resolutions and/or legislative actions that are planned, initiated or modified related to healthy eating, breastfeeding, physical activity, preventive screening, and obesity and chronic disease prevention and control.
Evaluation Indicators: Policies, resolutions and legislative actions Contributing Partners: Division of Public Health, Department of Education; Local Public Health District Staff (Nutrition Services Directors, Chronic Disease Prevention Coordinators, School Health Coordinators); Local Schools; Community Partners; Georgia Coalition for Physical Activity and Nutrition (G-PAN); Policy Leadership for Active Youth Initiative (PLAY); Georgia Parent Teacher Association, Georgia Association for Health, Physical Education, Recreation and Dance (GAPHERD), Kid's Health; Local Physicians; Take Charge of Your Health, Georgia! Task Force
Priority Strategies:
1. Identify and track current state-level policies, resolutions and legislative actions related to healthy eating, physical activity, obesity and chronic disease prevention and control.
2. Develop and implement a height, weight, BMI-for-age screening initiative in schools to track and monitor overweight, based on existing Georgia rules.
3. Advocate for funded regulatory or legislative changes to mandate daily physical education in grades Kindergarten-12.
4. Enhance health-related fitness through annual fitness testing (Fitnessgram/Activitygram), goal setting, and development and implementation of a self-improvement plan in grades 4-12.

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Sphere of Influence: Community (examples: coordinating efforts, mobilizing, local environments and policies)
State Partnership and Infrastructure #2. By 2008, establish collaborative infrastructure and secure resources at the state-level to coordinate the implementation of this state plan.
Evaluation Indicators: Number of partners, in-kind and financial resources Contributing Partners: G-PAN; Obesity Action Network; Interfaith Health Initiative; Department of Education; Division of Public Health; Georgia Public Health Association Nutrition Section; Georgia Rural Health Association; TCYHG Task Force; University of Georgia Cooperative Extension
Priority Strategies:
1. Coordinate multi-sector state level partners to provide leadership and consistent messages for state and local dissemination and implementation of the plan.
2. Coordinate central clearinghouse to disseminate most current information on existing breastfeeding, healthy eating, and physical activity programs.
3. Inventory existing resources (financial, organizational, and professional) among state agencies that are aligned with and can be leveraged for the implementation of the plan.
4. Develop the tools and resource guides for each setting of the plan to assist with implementation of strategies.
5. Seek and secure diverse financial resources (federal, state, private, and foundation funds) for the implementation of the plan.
6. Provide joint funding for a Physical and Health Education Consultant within the Georgia Department of Education.
7. Coordinate state plan with the Department of Human Resources' and Governor's joint initiative Live Healthy Georgia Campaign.

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Community Setting Objectives
Sphere of Influence: Policy (examples: state policies and laws, media campaigns)
Community Setting #1. By 2010, implement and evaluate a state-wide community campaign to promote healthy eating, physical activity, decreased sedentary activity, and breastfeeding.
Evaluation Indicators: Number of communities reached, number of media hits, number of exposures, awareness of campaign messaging in targeted communities Contributing Partners: Department of Human Resources; Local Public Health District Breastfeeding Coordinators; Georgia's Physician's Breastfeeding Advisory Committee; TCHYG Task Force
Priority Strategies:
1. Expand the implementation of the Loving Support Breastfeeding Campaign. 2. Develop/adapt and implement a social marketing campaign for families on
preventive strategies (based on each focus area of plan) in the home and community to prevent obesity and other chronic diseases. 3. Promote the implementation of the Department of Human Resources and Governor's joint initiative Live Healthy Georgia Campaign.
Sphere of Influence: Community (examples: coordinating efforts, mobilizing, local environments and policies)
Community Setting #2. By 2007, increase the number of on-going programs for healthy eating, breastfeeding, and physical activity that are implemented and evaluated.
Evaluation Indicators: Number of ongoing programs, number of new programs developed, number of programs evaluated Contributing Partners: Children's Healthcare of Atlanta, Division of Aging; Family Health Branch Nutrition Section; Georgia WIC Program District Breastfeeding Coordinators; G-PAN; GOM Coordinator; Head Start; Local Public Health Districts, TCYHG Task Force; UGA Cooperative Extension, WIC Branch, YMCA
Priority Strategies:
1. Expand implementation of the Peer Counselor Breastfeeding Support Program.
2. Integrate breastfeeding, healthy eating and physical activity into existing programs for parents/caregivers, older adults, children and youth (e.g., parenting programs, senior center programs, etc.)
3. Expand the implementation and evaluation of the Georgia on the Move Program (GOM) to reach target audience of 171,000 Georgians enrolled in GOM.

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Community Setting #3. By June 2007, all public health districts will develop and implement a coordinated healthy eating, breastfeeding, and physical activity plan in collaboration with partners.
Evaluation Indicators: Number of district plans developed, number of health district plans implemented, number of partners involved in plan development and implementation Contributing Partners: TCYHG Task Force; Division of Public Health; Local Public Health Districts; Community Partners; Family Connections; UGA Cooperative Extension; Division of Aging; G-PAN
Priority Strategies:
1. Identify the number of health districts with a coordinated healthy eating, physical activity and breastfeeding plan, in order to establish baseline.
2. Provide training and train-the-trainer workshops that train local public health staff, community service providers and community leaders on strategies (planning process, coalition building, asset mapping) to plan for and mobilize communities to improve breastfeeding, healthy eating, and physical activity, and reduce television viewing/sedentary activity.
Community Setting #4. By 2010, increase changes in built environment (healthy community design) to foster smart growth communities (mixed land use, trails, connectivity, safety and Americans with Disabilities Act (ADA) compliant transportation systems).
Evaluation Indicator: Number of changes in the built environment Contributing Partners: Children's Healthcare of Atlanta (Safe Kids); City Government; Division of Public Health; Department of Transportation; Family Connections; Georgia Bikes!; Local Public Health Districts; Georgia Recreation and Park Agencies; Local community partners/coalitions, City/County Commissioners/Mayors and Organizations
Priority Strategies:
1. Define healthy community design and assess elements of healthy community design (e.g. mixed land use, trails, sidewalks, connectivity, safety ADA compliant transportation systems) to establish baseline.
2. Develop community assessment tool to assess and enhance the local healthy community design.
3. Educate community officials and planners on the issues related to the built and physical environment and health.
4. Promote the development and implementation of city/county ordinances to increase sidewalks, bike paths, and green space.
5. Promote use of existing bike and pedestrian transportation systems (e.g., trails, bike paths).

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Five

Sphere of Influence: Organizational (examples: policies, practices, environment of organization)
Community Setting #5. By 2010, increase from baseline the number of community locations that provide access to healthy food choices.
Evaluation Indicators: Number of community locations (Parks and Recreation, restaurants, and Government Buildings (local and state), number of healthy choices, purchasing of healthy choices Contributing Partners: 5 A Day Coalition; Athens Health District "Let's Eat Out" Restaurant Program; Chronic Disease Prevention Initiative Coordinators; Division of Aging; Division of Public Health; Family Health Branch, Nutrition Section; Georgia Recreation and Park Agencies; Local Community Partners; Local Nutrition Services Directors; Local Public Health Districts; Georgia Restaurants; Rome Health District's "Fit to Eat" Program; UGA Cooperative Extension; Southeast United Dairy Association; USDA-WIC, WIC Branch; YMCA
Priority Strategies:
1. Develop baseline to assess the number of community locations that provide access to healthy choices.
2. Provide/promote availability of water, low-fat milk and 100% fruit juice and healthy snacks in vending machines in parks and recreation facilities and government buildings.
3. Implement a year-round pilot intervention with the WIC Program to include fresh, frozen and/or canned fruits and vegetables as part of the WIC food package.
4. Promote and expand existing efforts to offer healthy food choices, appropriate portion sizes, and nutrition information on menus in restaurants.
5. Provide access to fruits and vegetables through community gardens, gleaning projects, farmers' markets, WIC farmer's market, and senior farmers' market program.

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Five
Community Setting #6. By 2010, increase the number of nutrition and physical activity programs offered at Parks and Recreation Centers, and community recreation centers. Evaluation Indicators: Number of programs Contributing Partners: City/County Officials; Division of Public Health; Local Community Partners; Local Public Health Districts; Georgia Recreation and Park Association
Priority Strategies: 1. Develop baseline to assess the current number of programs offered at parks and
community recreation centers. 2. Promote an increase in the number of programs offered in community recreation
centers or community centers, especially in rural areas. 3. Expand community recreation center schedules and provide transportation to
accommodate resident needs. 4. Promote existing sidewalks, walking trails, community pools, and public
playgrounds in communities as close-to-home places for physical activity.
Sphere of Influence: Interpersonal (example: social support)
Community Setting #7. By 2010, increase the number of programs that incorporate social support for healthy eating, breastfeeding, and physical activity at the community level. Evaluation Indicator: Number of programs Contributing Partners: Adult Day Care Centers, Department of Family and Children's Services; Family Health Branch Nutrition Section; Child Care Providers; Families/Parents/Caregivers; Head Start; Local Nutrition Services Directors; Local Chronic Disease Prevention Coordinators, Local Public Health District Breastfeeding Coordinators Local Schools; Local Parks and Recreation, Senior Centers; Take Charge of Your Health, Georgia! Task Force, UGA Cooperative Extension; YMCA
Priority Strategies:
1. Implement programs for peer support of breastfeeding (Loving Support Program). 2. Promote the importance of family meals. 3. Encourage parents/caregivers and family caregivers to be appropriate role
models for healthy eating, breastfeeding, and physical activity. 4. Encourage families to engage in physical activity together as opposed to
television viewing. 5. Promote physical activity in public places through point of decision prompts. 6. Promote buddy walking clubs through existing walking club programs such as
Georgia Striders.

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Five
Sphere of Influence: Individual (example: behavior)
Community Setting #8. By 2008, increase knowledge and skills related to breastfeeding, healthy eating and physical activity among community members. Evaluation Indicators: Change in knowledge and skills Contributing Partners: Children's Healthcare of Atlanta; Georgia Recreation and Park Association; Community-based organizations; Community Recreation Centers; Centers for Older Adults (including multi-purpose centers); Faith-based Organizations; Parent Teacher Association; Health Care Organizations and Facilities; Schools; YMCA; Local Public Health Districts
Priority Strategies:
1. Incorporate skill-building/hands-on activities for breastfeeding, healthy eating, and physical activity into existing community health programs and events.
2. Offer affordable, regular, ongoing healthy eating, breastfeeding, and physical activity skill-building and behavior change programs for parents, older adults/grandparents, children and youth, such as Take Charge of Your Health for Older Adults, Golden Olympics, Georgia Striders Walking Clubs, PACE programs.
3. Provide healthy eating/cooking classes for parents/caregivers in after-school or community programs.

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Five
Faith-Based Organization Setting Objectives
Sphere of Influence: Community (examples: coordinating efforts, mobilizing, local environments and policies)
Faith-Based Organization Setting #1. By 2010, increase the number of programs for healthy eating, breastfeeding, and physical activity that are implemented and evaluated within Faith-Based Organizations (FBO).
Evaluation Indicator: Number of programs implemented and evaluated Contributing Partners: American Cancer Society-Georgia Chapter; Division of Public Health; District Breastfeeding Coordinators; Interfaith Health Initiative; Healthy Dekalb Initiative, Faith-Based Workgroup; Local Community Coalitions; Parish Nurses
Priority Strategies:
1. Establish a baseline of existing programs within FBOs. 2. Expand existing faith-based programs developed to promote healthy eating, and
physical activity, such as the Body Soul Program, Fit 4 Life, Search Your Heart. 3. Offer breastfeeding support groups for prenatal and breastfeeding women in FBO
for members and non-members. 4. Partner with local community to promote the development and accessibility of
walking trails, sidewalks and physical activity facilities for community use.
Faith-Based Organization Setting #2. By 2010, increase capacity among FBOs to implement and sustain healthy eating, breastfeeding, and physical activity initiatives (through training, community mobilization, community resources identification, and grant writing).
Evaluation Indicators: Number of trainings, number of coalitions, and number of initiatives Contributing Partners: Division of Public Health; Faith-based Coalitions; Interfaith Health Initiative; Local Public Health Districts
Priority Strategies:
1. Assess current capacity of FBOs to implement and sustain healthy eating, breastfeeding and physical activity initiatives.
2. Provide training/train-the-trainer workshops that train community service providers, community leaders, and faith-based organization leaders on faith-based resource guide (evidence-based strategies for promoting breastfeeding, healthy eating, physical activity, and reduced TV viewing); grant writing; coalition building; asset mapping and planning.
3. Create a network of local faith-based coalitions that have physical activity, healthy eating, breastfeeding, and/or obesity prevention as priorities.
4. Encourage community coalitions to include FBOs to participate in developing a local action plan for creating a breastfeeding, healthy eating, and a physically active community.

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Five
Sphere of Influence: Organizational (examples: policies, practices, environment of organization-worksite/school)
Faith-Based Organization Setting #3. By 2009, develop and implement five (5) healthy eating, breastfeeding and physical activity practices/guidelines in faith-based organizations for the prevention or control of obesity and other chronic diseases.
Evaluation Indicators: Number of new practices/guidelines developed and implemented Contributing Partners: Faith-Based Coalitions; Interfaith Health Initiative; Division of Public Health; Take Charge of Your Health, Georgia! Task Force; Chronic Disease Prevention Coordinators
Priority Strategies:
1. Develop/adapt a resource guide/toolkit for faith-based organizations to implement a healthy eating, breastfeeding or physical activity practices/guidelines.
2. Promote adoption of healthy food/nutrition policy for foods offered and prepared for events in faith-based settings.
3. Promote development and adoption of faith-based organization breastfeeding policy.
Sphere of Influence: Individual (example: behavior)
Faith-Based Organization Setting #4. By 2006, increase knowledge, awareness and skills related to breastfeeding, healthy eating and physical activity among targeted faith-based organizations and their members. Evaluation Indicators: Change in knowledge and skill Contributing Partners: Interfaith Health Initiative; Faith-Based Organizations
Priority Strategy:
1. Incorporate knowledge and skill-building opportunities for breastfeeding, healthy eating, and physical activity into existing faith-based programs and events.

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Five
Health Care Setting Objectives
Sphere of Influence: Community (examples: coordinating efforts, mobilizing, local environments and policies)
Health Care Setting #1. By 2010, increase the number of partnerships and referrals between health care providers, managed care organizations and community providers for obesity and its related conditions.
Evaluation Indicators: Number of referrals, number of partnerships Contributing Partners: Health Care Providers; Take Charge of Your Health, Georgia! Task Force; (ILSI-CHP); Georgia Chapter of the American Academy of Pediatrics (GA-AAP); Georgia Hospital Association; Department of Community Health; Professional Associations; Local Community Partners; Obesity Action Network; Georgia Academy for Family Physicians
Priority Strategies:
1. Assess and address health care provider perceived barriers and challenges to partnering with and referring to community providers.
2. Promote access to and usage of a referral directory for nutrition counseling, nutrition and physical activity community programs and breastfeeding support services.
3. Encourage hospitals and managed care organizations to provide physical activity and healthy eating opportunities in their facilities that are open to the community.
Sphere of Influence: Organizational (examples: policies, practices, environment of organization-worksite/school)
Health Care Seting #2. By 2010, all medical and 75% of residency, allied health and mental health programs in Georgia adopt a standard education curriculum that includes core competencies in obesity prevention (breastfeeding promotion, healthy eating, increased physical activity, and decreased sedentary activity), assessment of weight status and weight management (Healthy People 2010 Objective 1-7).
Evaluation Indicators: Curriculum developed, number of medical schools that adopt all or part of curriculum Contributing Partners: Division of Public Health, Georgia Hospital Association; Mercer University School of Medicine; Medical Schools (Morehouse, Medical College of Georgia, Emory); National Center for Primary Healthcare (Morehouse); Take Charge of Your Health, Georgia! Task Force
Priority Strategies:
1. Assess current medical school and primary care residency program curriculums. 2. Develop and implement a standardized medical education curriculum with learning
objectives for each of the key focus areas of this plan.

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Five

Health Care Setting #3. By 2009, increase the number of trainings that licensed health care providers offer for continuing education in obesity prevention (breastfeeding promotion, healthy eating, increased physical activity, and decreased sedentary activity), assessment of BMI, and weight management (Healthy People 2010 Objective 1-7).
Evaluation Indicators: Number and type of trainings, types of health care professionals trained Contributing Partners: Obesity Action Network; ILSI CHP; Children's Healthcare of Atlanta; Division of Public Health; Georgia Association for Family Physicians; GA-AAP; Georgia Dietetics Association; Health Students Being Active Together; Take Charge of Your Health, Georgia! Task Force
Priority Strategies:
1. Assess current number of obesity prevention accredited trainings offered by different health care professional associations/providers.
2. Develop a collaborative network among Georgia medical, nursing, nutrition and other health professional schools and internship programs to build skills and enhance knowledge of breastfeeding, healthy eating, and physical activity.
3. Provide joint-training opportunities (including CMEs and CEUs).
Health Care Setting #4. By 2010, increase the number of licensed insurance companies in Georgia and state-funded health coverage that provide reimbursement/benefits for prevention and treatment of obesity (Healthy People 2010 Objective 1-2). (Baseline: two out of six Health Maintenance Organizations reimburse for nutrition and physical activity, Georgia Health Plan Survey 2004)
Evaluation Indicator: Number of insurance companies that provide reimbursement/benefits Contributing Partner: Take Care of Your Health, Georgia! Task Force; Georgia Department of Community Health; Insurance companies; Local Nutrition Services Directors; medical associations; Nutrition Reimbursement Committee
Priority Strategies:
1. Educate health insurance plan providers and legislators on the benefits of prevention and the high costs of treatment.
2. Promote reimbursement for nutrition services and medical nutrition therapy by Medicaid, Peachcare, private insurance and state health benefits plan.

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Five
Sphere of Influence- Individual (example: behavior)
Health Care Setting #5. By 2010, increase the number of targeted health care professionals that routinely assess and monitor body mass index (BMI) in adults and BMI-for-age percentile in children and youth (2-20 years) and provide appropriate nutrition and physical activity counseling (Healthy People 2010 Objective 11-6).
Evaluation Indicator: Number of targeted health care providers Contributing Partners: Children's Healthcare of Atlanta; Mercer University; Division of Public Health; Health Students Taking Action Together (H-STAT); GA-AAP; Georgia Family Physicians Association; ILSI Center for Health Promotion
Priority Strategies:
1. Establish baseline of the number of health care providers that assess and communicate BMI to clients.
2. Promote and disseminate National Institute of Health guidelines and expert recommendations that outline protocols for assessment and treatment of pediatric overweight and adult overweight and obesity.
3. Educate targeted health care staff on the importance of assessing BMI and communicating key nutrition/physical activity messages.
Health Care Setting #6. By 2009, increase the number of targeted health care providers and their staff (i.e. clerical staff, home health aides, dietitians, nurse practitioners, physician assistants, nurse assistants, physicians) who are trained on healthy eating, breastfeeding, physical activity and behavior change.
Evaluation Indicator: Number of health care professionals trained Contributing Partners: Division of Public Health; ILSI Center for Health Promotion; Children's Healthcare of Atlanta; Georgia Family Physicians Association; Mercer University; H-STAT; GA-AAP; Georgia Family Physicians Association; Kaiser Permanente; OAN
Priority Strategies:
1. Establish baseline to assess the number of health care providers who have received training related to breastfeeding, healthy eating, and physical activity.
2. Educate targeted healthcare staff on motivational interviewing, assessing readiness to change, promoting healthy lifestyle through breastfeeding, healthy eating, physical activity, reducing TV viewing and referrals to programs in the community.
3. Disseminate coordinated and consistent messages and educational materials for patient education.

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Five
School Setting Objectives (includes schools K-12, early child care centers and after-school programs)
Sphere of Influence - Community (examples: coordinating efforts, mobilizing, local environments and policies)
School Setting #1. By 2010, increase the number of early child care centers that implement breastfeeding, healthy eating, and physical activity programs.
Evaluation Indicator: Number of new interventions implemented by targeted early child care facilities Contributing Partners: Children's Healthcare of Atlanta; Division of Public Health, Department of Early Care and Learning, Family Health Branch Nutrition Section; Local District Breastfeeding Coordinators; UGA Cooperative Extension
Priority Strategies:
1. Assess existing early child care centers for breastfeeding, healthy eating and physical activity interventions/policies.
2. Educate early child care providers on how to support breastfeeding mothers. 3. Ensure that young children in day care settings have healthy food choices, daily
physical activity and are taught (including parents and caregivers) the benefits of healthy eating and being physically active. 4. Promote the development of policy that incorporates staff breastfeeding education into all early childcare centers and Head Start Programs.
School Setting #2. By 2006, increase the proportion of Georgia schools K-12 that develop and implement wellness polices for healthy eating and physical activity (based on 2004 Federal Child Nutrition Reauthorization Act).
Evaluation Indicator: Number of schools that develop and implement a wellness policy Contributing Partners: Action for Healthy Kids GA Team; Department of Education (School and Community Nutrition); Family Health Branch Nutrition Section; Georgia School Nurses Association; Georgia Parent Teacher Association; Kid's Health Inc.; Local School Nurses; Local Schools
Priority Strategies:
1. Assess the number of wellness policies in schools (for nutrition and physical activity) to establish a baseline.
2. Develop/adapt, distribute and train on a resource guide for schools to develop wellness policies.
3. Assist schools in developing wellness (school health) councils. 4. Provide training to schools and other local partners on implementing wellness
policy resource guide.

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Five
Sphere of Influence- Organizational (examples: policies, practices, environment of organization- worksite/school)
School Setting #3. By 2010, increase the proportion of schools that implement one or more specific components of Coordinated School Health Programs (adapted from Healthy People 2010 7-2) Specific components: quality physical activity and school nutrition programs, healthy school environments, family and community involvement and health promotion programs for staff.
Evaluation Indicator: Number of targeted schools that offer components of Coordinated School Health Program Contributing Partners: Action for Healthy Kids- Georgia Team; Children's Healthcare of Atlanta; Department of Education (School and Community Nutrition); Georgia Recreation and Park Association; Georgia Partnership for School Health; ILSI-CHP; Kid's Health Inc; local schools; local school nurses; Georgia Association of Health,Physical Education, Recreation, and Dance; Georgia School Board Association; Local School Boards; Morehouse School of Medicine; UGA Cooperative Extension; YMCA
Priority Strategies:
1. Educate key decision makers in the school setting and legislature on the benefits of coordinated school health approach and its link to academic achievement.
2. Implement annual fitness testing (Fitnessgram/Activitygram) including fitness goal setting, and development and implementation of a self-improvement plan in grades 4-12.
3. Offer and promote evidence-based programs that promote physical activity during school and after-school such as SPARK, CATCH, Take 10!, Planet Health, Kid's Walk to School program, Kids on the Move.
4. Provide skill-building opportunities for students, staff and parents related to healthy eating including the importance of fruits and vegetables, label reading, meal planning and preparation, food shopping, gardening in schools.
5. Support the implementation of a policy encouraging public schools to provide access to their physical activity spaces and facilities for all persons outside of normal school hours.
6. Increase the variety and availability of after-school programs that provide opportunities for physical activity and healthy eating.

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Five

School Setting #4. By 2010, increase the proportion of Georgia's public schools that require daily physical education for all students (Healthy People 2010 22-8).
Evaluation Indicator: Number of Georgia schools that require daily physical education Contributing Partners: Department of Education; G-PAN; Georgia Association for Health, Physical Education, Recreation, and Dance (GAHPERD); Georgia PTA; Kid' Health Inc.; Local School Boards; Parents, Policy Leadership for Active Youth Initiative; Take Charge of Your Health, Georgia! Task Force
Priority Strategies:
1. Establish baseline by assessing the number of schools that require daily physical education; investigate quality of physical education programs provided; and assess qualifications of individuals providing physical education programs.
2. Support the adoption of daily physical education for grades K-12 based on National Association for Sport and Physical Education (NASPE) standards. (Adapted from the Georgia Cardiovascular Health Plan, School Plan Objective 3)
3. Support the development and implementation of a comprehensive, continuous curriculum for nutrition and physical education from preK-12.

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Five
School Setting #5. By 2009, increase the number of schools and early child care centers that create environments to promote healthy eating and physical activity.
Evaluation Indicator: Number of environmental support changes in schools and early child care centers Contributing Partners: Family Health Branch Infant and Child Health; Local Public Health Districts; Chronic Disease Prevention Coordinators; Georgia Department of Early Care and Learning; Local Schools; Local Food Service Directors; Georgia Department of Education; Georgia Parent Teacher Association; Action for Healthy Kids-Georgia Team; School Health Coordinators
Priority Strategies:
1 Implement the School Health Index for physical activity and healthy eating annually and develop action plan, based on assessment. (Adapted from Georgia Cardiovascular Health Plan, Objective 1)
2. Promote the adoption of state standards for healthy eating and physical activity in daycare settings based on the Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC) Tool (based on Memorandum of Understanding between DHR and Department of Early Care and Learning).
3. Educate schools on ways to offer healthy choices (food and beverages) in vending machines, cafeterias, fundraisers and school functions. (Adapted from Georgia Cardiovascular Health Plan, Objectives 5 and 6)
Sphere of Influence- Individual (example: behavior)
School Setting #6. By 2010, increase the proportion of Georgia's school-aged children who eat five or more servings of fruits and vegetables every day. (Baseline: 17% (YRBS 2003) to 21 % of high school students)
Evaluation Indicator: Proportion of students who eat five or more servings each day Contributing Partners: Department of Education School and Community Nutrition; Division of Public Health; Food Service Directors; Georgia Parent Teacher Association
Priority Strategies:
1. Assess baseline fruit and vegetable consumption for elementary and middle school students.
2. Educate children/students on availability of healthy choices and how to make healthy choices in school.
3. Promote the 5 A Day Program in schools. 4. Continue to maintain/expand National School Lunch Program and School
Breakfast Program standards and participation, and increase offering of fruits and vegetables.

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Five

School Setting #7. By 2015, increase the proportion of Georgia children and adolescents who engage in moderate physical activity for at least 30 minutes daily from 25% (YRBS 2003) to 27% (Healthy People 2010 22-6 35%).
Evaluation Indicator: Proportion of children and adolescents reporting 30 minutes of moderate physical activity daily Contributing Partners: Take Charge of Your Health, Georgia! Task Force; Local Chronic Disease Prevention Coordinators, PEDS, Metro Atlanta Safe Routes to School Coalition
Priority Strategies:
1. Encourage local schools to promote safe ways/routes to walk or bike to school. 2. Promote and implement "walking school bus" programs before and after school.

Worksite Setting Objectives
Sphere of Influence - Organizational (examples: policies, practices, environment of organization- worksite)
Worksite Setting #1. By 2010, increase the proportion of worksites that offer employee risk reduction/ health promotion programs that address physical activity, healthy eating and breastfeeding for their employees (Healthy People 2010 7-5). (Baseline: 17% to 20% of physical activity/fitness programs and 10% to 12% of nutrition/weight management classes, Georgia Worksite Health Promotion Policies and Practices Survey 2002)
Evaluation Indicator: Proportion of worksites that offer employee risk reduction/health promotion programs Contributing Partners: Cardiovascular Health Initiative (CVHI) Healthy Solutions; Chronic Disease Prevention Coordinators; Take Charge of Your Health, Georgia! Task Force; Worksites
Priority Strategies:
1. Educate employers and local public health staff on how to engage local health providers and insurance carriers to place an effective risk reduction program that uses evidence-based medical standards to identify employees at highest health risk and provide programs that normalize lab values and decrease risk. Program will include focusing on the CVHI "Essential Elements".
2. Educate targeted employers on the benefits and cost savings of existing evidence based healthy worksite programs and policies for breastfeeding, healthy eating and physical activity.
3. Identify list of current worksite resources and programs to increase breastfeeding, improve healthy eating, and/or increase physical activity.
4. Assist worksites in developing/adapting and implementing incentive-based worksite wellness programs to increase breastfeeding, improve healthy eating, and/or increase physical activity.
5. Encourage employers to hire a worksite wellness coordinator (such as exercise physiologists or Registered/Licensed Dietitian).
6. Encourage employers to establish worksite wellness committee with management support.

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Five
Worksite Setting #2. By 2010, increase the proportion of worksites that develop and implement policies and/or environmental supports that promote healthy eating, physical activity and/or breastfeeding. (Baseline: Examples of indicators, 2% encourage commute by foot or bike, 6% subsidize cost of public transportation, Georgia Worksite Health Promotion Policies and Practices Survey 2002)
Evaluation Indicator: Number of worksites that have implemented a policy or environmental support change Contributing Partners: Cardiovascular Health Initiative Healthy Solutions; Chronic Disease Prevention Coordinators; Health Underwriters of Georgia; Human Resource Directors; State Merit System Heath Benefit Plans; Take Charge of Your Health, Georgia! Task Force; Worksites
Priority Strategies:
1. Offer healthy choices in cafeterias and vending areas, mobile vendors and convenience stores.
2. Partner with fruit and vegetable vendors to provide weekly, on-site farmer's market.
3. Implement a worksite breastfeeding policy and provide a workplace facility (breastfeeding room) to accommodate breastfeeding at work (e.g., USDA "Babies are Welcomed Here").
4. Encourage worksites to provide on-site employee health/exercise incentive programs (to stress importance of incorporating physical activity and healthy lifestyle habits).
5. Encourage worksites to display point of decision prompts to promote physical activity.
6. Encourage human resource directors to include coverage for preventive care and promote physical activity, healthy eating, and breastfeeding support programs in employee health benefit plans.
Sphere of Influence - Individual (example: behavior)
Worksite Setting #3. By 2010, increase the proportion of employees who participate in employer-sponsored breastfeeding, nutrition and physical activity programs and maintain behaviors. (Healthy People 2010 7-6).
Evaluation Indicator: Proportion of employees who participate in nutrition and physical activity programs Contributing Partners: Cardiovascular Health Initiative Healthy Solutions; Take Charge of Your Health, Georgia! Task Force; Worksites
Priority Strategy:
1. Provide skill-building opportunities as part of worksite wellness programs to improve healthy eating and/or increase physical activity.

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Five
Data, Evaluation and Research Objectives
Goal: Monitor obesity rates, related behaviors and health conditions, and policy and environmental supports for planning, evaluation and implementation of activities.
Objective #1. By 2007, create a system for data collection, monitoring and reporting activities. Evaluation Indicator: Data collection system developed and implemented Contributing Partners: Academic Partners; Department of Education; Division of Public Health; Data and Evaluation Workgroup; Georgia Health Policy Center; Philanthropic Collaborative for a Healthy Georgia
Priority Strategies:
1. Develop an advisory group to identify components of a standardized data collection, monitoring and reporting tool related to activities in Georgia's plan.
2. Maintain and enhance current surveillance systems (such as BRFSS, YRBS, PEDNSS, PNSS) to monitor nutrition and physical activity behaviors and gaps in data.
3. Develop and implement tools to monitor and track policy and environmental changes related to nutrition and physical activity at State and community level in various settings.
4. Collaborate with the Philanthropic Collaborative for a Healthy Georgia to conduct a Youth Fitness Assessment project.
5. Identify and implement a system to address prevalence of overweight in children and related nutrition and physical activity behaviors and policies/environmental supports.
Objective #2. By 2009, develop and implement a research agenda related to obesity prevention to enhance/adjust current initiatives and strategies.
Evaluation Indicator: Research agenda supports and informs obesity prevention. Contributing Partners: Academic Partners; Division of Public Health Epidemiology Branch; Data and Evaluation Workgroup
Priority Strategies:
1. Convene a research advisory group to develop a research agenda for Georgia. 2. Develop and implement research agenda priorities.

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Chapter Six
Surveillance and Evaluation

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six

Surveillance and Evaluation
Success of the implementation of Georgia's Nutrition and Physical Activity plan will be evaluated based upon process and outcome measures through current surveillance systems and surveys in place, new surveillance tools to be developed, and special surveys as needed to address gaps in data for each of the settings in the plan.
The following is a list of existing surveillance systems that will assist in the monitoring of changes in overweight/obesity and behaviors related to breastfeeding, healthy eating, physical activity and TV viewing/screen time.

SOURCE BRFSS
YRBS PRAMS PNSS PedNSS

TOPIC AREA
Risk Factors Physical activity (PA) Exercise

DATA COLLECTION YEARS

POPULATION

On-going since 1984 Every odd year Every year

Representative statewide and 18 public health districts samples of adults 18 years and older

Fruits & vegetable Weight control Height & weight

Every even year Every odd year Every year

PA, Physical education, Fruits & vegetables, TV viewing, Height & weight, Body weight

2003 Every odd year

Representative statewide sample of public middle and high school students

Breastfeeding, obesity, pregnancy weight gain

1993-1997 2000

Representative statewide of women who have had a live birth in the previous 6 months

Demographics, prepregnancy weight status, weight gain during pregnancy, anemia, smoking, alcohol, medical care, parity,
breastfeeding trends, pregnancy outcome

On-going since 1995, Yearly

Prenatal and post-partum participants of the Georgia Women, Infants and Children (WIC) program

Weight-for-age, height-for-age, anemia and iron status, breastfeeding

On-going since 1992, Yearly

Infant and child participants of the Georgia Women, Infants and Children (WIC) program

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Six
The DHR Division of Public Health, Epidemiology Branch has also developed surveys to assess changes in policies, practices and the environment in a number of settings.
Worksite Setting
The Georgia Worksite Health Promotion Policies and Practices Survey, modeled after the National Worksite Health Promotion Survey, was conducted for the first time in 2002 to document existing policies, environments, and programs affecting the health of Georgia workers. Computer-assisted telephone interviews were conducted with the director of human resources or employee health. Survey findings represent a random sample of private sector worksites with at least 15 employees identified from the Dun and Bradstreet database. Worksites were stratified into three size cate-gories: small (15-99), medium (100-249), and large (250+) and four industry categories. A total of 1,085 worksites completed the survey with a response rate of 54%. Final data were weighted so that each stratum represented its true proportion in the worksite population.
Health Care Setting
In 2004, a Health Plan Policy survey was administered to Georgia Health plans and managed care organizations. The survey assessed whether health plans and managed care organizations have policies or guidelines to routinely provide or reimburse for assessment and counseling for physical activity and medical nutrition therapy for plan members as part of their standard package.
School Setting
The Georgia School Health Profiles Survey asks school principal and lead health educators questions related to the implementation, organization, structure, and support of health education in their schools. The survey consists of two surveys developed by the CDC. The survey findings represent a random sample of all public middle and high schools in Georgia having at least one of grades 6 through 12. Georgia has administered the mailed survey biannually during the spring semester since 1996 with the exception of 2004.
In 2000 and 2002, school transportation modes were assessed in households with children through the Child Asthma Survey.
Community Setting
The community setting is an area in which additional Georgia data and monitoring is needed. The major indictors that require monitoring include: state and local policies/ordinances that support physical activity and healthy eating; easily accessible (close to home) opportunities for physical activity of all ages and access to healthy food choices.

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References

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Seven
References
1. Pediatric Nutrition Surveillance 2002: Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention.
2. Kanny D, Powell KE. 2003 Georgia Student Health Survey Report. Georgia Department of Human Resources, Division of Public Health, November 2003. Publication Number: DPH03/144.
3. Behavioral Risk Factor Surveillance System: Atlanta, GA. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
4. Kanny D, Choi HS, Hammond DA. School Health Education in Georgia: Results from the 2002 School Health Education Profile (SHEP) Survey. Georgia Department of Human Resources, Division of Public Health, February 2004. Publication number DPH04.181HW.
5. Choi HS, Bricker SK, Troy K, Kanny D, Powell KE. Worksite Health Promotion Policies and Practices in Georgia: 2002 Georgia Worksite Survey. Georgia Department of Human Resources, Division of Public Health, January 2004. Publication number DPH03/156HW.
6. Frank LD, Martin A, Andersen MA, Schmid TL. Obesity Relationships with Community Design, Physical Activity, and Time Spent in Cars. American Journal Preventive Medicine. 2004;27(2):87-96.
7. Finkelstein EA, Fiebelkorn IC, Wang Guijing. State-level estimates of annual medical expenditures attributable of obesity in the United States. Obesity Research. 2004; 12:18-24.

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Appendices I-VI

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Appendix

A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name
Shonika Abuey Ramona Adams J.F.Agel Carolyn Aidman Eileen Albritton Diane Allensworth Bethany Amero Leila Anderson Chrysta Andrews Jim Annesi Elaine Armster Sophia Autrey Sharon Bagatell
Cree Barnes
JK Barnette Athon Barron Izzie Beier Cecil Bendush Luke Beno Annetta Berry Fred Beykin Hansa Bhargava Gayle Bina Kitty P. Bishop Lorine Bizzell Cyndee Bonacci Sarah Boyd Carolyn Bradley Virginia Bradshaw Alan Brands Maribeth Brannen Sabrena Brawley Paulette Breeden Michelle Brenner Marsha Britton Jennifer Buechner Kimarie Bugg Patrice Bullock Beth Burgin

Agency/Organization
West Central Health District 7-0 University of Georgia, Extension Expanded Food & Nutrition Education Program DeKalb County Board of Health, District 3-5 Georgia Department of Human Resources, Family Health Branch West Central Health District 7-0 Kids' Health, Inc. Northside Hospital Kid's Journey North Health District 2-0 YMCA of Metropolitan Atlanta Georgia Department of Transportation Georgia Department of Human Resources, WIC Branch Atlanta Bicycle Campaign
Georgia Department of Human Resources, Chronic Disease Prevention and Health Promotion Branch Southwest Health District 8-2 Your Health America, Inc YMCA Community Healthcare Center Savannah Kaiser Permanente Family Connection Partnership Metro Atlanta Safe Routes to School Coalition Children's Healthcare of Atlanta Medical Center of Central Georgia Georgia Partnership for School Health USDA/FNS/WIC Southeast Region Snellville Parks and Recreation Department Chattahoochee Valley Region Library System Georgia Association of Health, Physical Education, Recreation and Dance McDuffie County Health Department I4 Learning Georgia Department of Education LaGrange Health District 4-0 Walker County Department of Education Medical College of Georgia Southside Health Center Children's Healthcare of Atlanta Emory University Ellenton Clinic Pastoral Institute

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A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name

Agency/Organization

Charles Burhanan Jr. Gina Burke Constance M. Burke Juanita Burney Susan Burns Susan Butler Adam Butler Linda Byams Margarita Callahan Kevin Carr Beverly Chapman Gloria Chen Lisa Cherry Teresa Chubb Debora Clark Sonya Cochran Mamie Coker Debbie Connell O.J. Conner Kelly Cordray Leslie Cottrell Tracy Crider David Crites Cindy Kanarek Culver Katherine Cummings Cathy T. Curlette Teresa Daub Edna Davis Catherine Davis Ernest Davis, Jr. Monique Davis-Smith Deborah Dean Blanche DeLoach
Don Dixon

Slim and Tone Southeast Health District 9-2 Cultural Competency Training Richmond County Health Department American Academy of Pediatrics, Georgia Chapter Emory University, Rollins School of Public Health Neighborhood Improvement Project Teens Exercise Macon Central School District Dearing Elementary School Early County School System Georgia Department of Human Resources, Family Health Branch Alpharetta Recreation and Parks Department Teen Plus Resource Center Partnership for Community Action West Central Health District 7-0 Hall County School Communities in Schools Roswell Recreation and Parks Department University of Georgia, Cooperative Extension University of West Georgia Floyd Medical Center Georgia Bikes! Cobb County School District, Food & Nutrition Services Georgia Rural Health Association Consultant DeKalb County Board of Health East Central Health District 6-0 Medical College of Georgia Bethel AME Church, Inc. Family Health Center Children's Special Services LaGrange Health District 4-0 Georgia Department of Human Resources, Division of Family and Children's Services

Gail Dorner Belva Dorsey Barbara Downey

Southwest Health District 8-2 Enrichment Services Program, Inc. Murray County Health Department

Jon Ducote

Georgia Department of Human Resources, Chronic Disease Prevention and Health Promotion Branch

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Appendix

A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name

Agency/Organization

Debra Dugan Gwendolyn Durnell Nicole Dye Elizabeth Eckert Pam Ehret Betty English Kiran Fatania Anderson Flen Donna Ford Melodi Ford Jerry Foreman Marilyn Fowler Pat Freeman Fay Fulton Tamala Fulton Cecilia Galvis Carlotta Gardner

State University of West Georgia CSRA Partnership for Community Health Ellaville Primary Medicine Center Armstrong Atlantic State University Coastal Health District 9-1 University of Georgia Extension Service City of Roswell Recreation and Parks North Health District 2-0 Carrollton Parks, Recreation and Cultural Arts Department Verizon Wireless CSRA Partnership for Community Health American Cancer Society Legacy Link, Inc. Georgia Academy of Family Physicians Chatham County Health Department Saint Joseph's Mercy Care Services Citizen

Sabriena Gibbs

Georgia Department of Human Resources, Division of Family and Children Services

Brent Gibbs

South Central Health District 5-1

Janice Giddens

Student

Edith Gierlatowicz

St. Francis Hospital

Jodie Gilfillan

Alpharetta Recreation and Parks Department

Kim Gilman

Phoebe Worth Medical Center

Annette Givney

Columbus Parks and Recreation

Gene Godfrey

South Health District 8-1

Katie Golden

Long County Health Department

Amy Goodwin

Georgia Department of Transportation

Allison Goolsby

Project Open Hand

Teresa T. Graham

LaGrange Heath District 4-0

Louie Greene

Spalding County Parks and Recreation

Clinton Gregory

Fit II Play Health and Performance Academy

Susan Griffin

Georgia Dietetic Association

Gary Gunderson

Emory University

Barbara Ann Hammett Burke County Health Department

Blainette Hanson

Ellenton Clinic

Donna Hardy

Wilkes Wild About Wellness

Andi Harmon

Gainesville Parks and Recreation

Marie Harrell

University of Georgia Cooperative Extension Service

Aubrey Harris

Family Connection Partnership

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A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name

Agency/Organization

Dorothy Hart Johnathan Hart Cindi Hart Pam Hatch Kim Hathcock Chrissy Haupt Chad Hendley Jaclyn Hensley Mary Hepburn Kelly Higgins Connie Hill Melba Hill-Paschal Tammie Hiney Eloise Hodges Nancy Hoehn Sally Holland Linda Holland Bethany Holloway Robert Holmes Sandra Holt Annette Bomar Hopgood Barbara Hopkins Jody G. Horne Eveann Howard Gretchen Hulon Marcia Hunter Angela Hurst Bob Hutchinson Angie Inge Phil Ingram Mary Jackson Pamela Jackson Connie James Nancy Jeffery Brandi Jessemy Dawn Johns Linda D. Johnson Debbie Johnson Carol Ann Johnson Patricia Jones

Richmond County Health Department Georgia Institute of Technology Bulloch County Health Department Gwinnett County Parks and Recreation Houston County School Food Service Hall County Government Satilla Regional Medical Center Stephens County Schools Macon County Health Department City of Alpharetta Recreation and Parks West Georgia RESA Interfaith Health Initiative Floyd Medical Center Coastal Health District 9-1 St. Joseph Hospital Burke County Schools Macon-Bibb County Health Department Georgia Department of Human Resources, Family Health Branch DeKalb YMCA Newnan Hospital, Health & Fitness Center Georgia Department of Education Georgia State University Colquitt County Health Department West Georgia RESA Northeast Georgia Medical Center East Metro Health District 3-4 Colquitt County Health Department Boys and Girls Clubs of Albany, Inc. Terrell County Family Connection I4 Learning Healthy Mothers, Healthy Babies Georgia Coalition for Physical Activity and Nutrition West Central Health District 7-0 Bibb County Health Department DeKalb Board of Health (District 3-5) Colquitt Regional Medical Center Fort Valley State University WIC/FNS/USDA Southeast Region Fort Valley State University City of Ellaville

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Appendix

A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name
Ellen Jurgens Terry Kaley Dafna Kanny Warren Karp Nancy Karp Christi Kay Brenda Kelley Chinaro Kennedy Karen Kennedy Brenda Kennedy Debbie Kibbe Shenica King Diane King Kurt Kirby Mimi Kiser Rachel Krause Dianne Lariscy Laurie Lattimore-Volkmann
Helen Lawler Nan Lee Jeanne Lee Marty Lee Sandra Leonard Bruce Leonard Suzanne Levine Richard D. Lewis Mary Lewis Naima G. Lewis Vickie Lewis Jack Lockwood Cora Locust Cleta Long Mirta Lorenzo Vamella Lovett Wanda Lowe Rodney Lyn Imani Ma'at Linda Mack Josephine Mack

Agency/Organization
Georgia Dietetic Foundation University of Georgia, Department of Foods and Nutrition Georgia Department of Human Resources, Epidemiology Branch Medical College of Georgia, Member of Columbia County Board of Health Citizen/Physical Therapist Kids' Health University of Georgia Cooperative Extension Georgia Department of Human Resources, Epidemiology Branch HealthPlus Medical Office Center Urban League of Greater Columbus ILSI Center for Health Promotion Cobb/Douglas Health District 3-1 Randy Cronic Medical Practice City of Alpharetta Emory University Georgia Department of Human Resources, Family Health Branch Richmond County Recreation Department
Georgia State University
Floyd County Health Department Economic Development for McDonough, Georgia University Hospital Pierce County Health Department Georgia Department of Human Resources, Family Health Branch AIM 2010 Juice Plus University of Georgia, College of Family and Consumer Sciences Early County Health Department Hy-Dy, Inc. Monroe High School West Central Health District 7-0 Georgia Coalition for Black Women Bibb County Schools Fulton County Department of Health and Wellness 3-2 Dougherty County Health Department West Georgia Health System Georgia State University, Institute of Public Health Morehouse School of Medicine West Georgia Health System Richmond County Board of Education, School Nutrition Program

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A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name

Agency/Organization

Laura Madden

Consultant

Julie Schlegel Maina Valdosta State University

Michael Maina

Valdosta State University

Joy Maltese

LaGrange Health District 4-0

Jo Manning

Coastal Health District 9-1

Kathryn Martin

East Central Health District 6-0

Tom Martin

Georgia Recreation and Park Association

Traci Mason

Johnson & Johnson

Debra McAlmont

DeKalb Board of Health 3-5

Danny McCarty

Albany Area YMCA

Sundra McClain

Dougherty County School System

Teresa McCullen

Medical College of Georgia

Lisa McKinney

Northeast Health District 10

Jeanette Merriweather Augusta State University

JoAnn Milam

University of Georgia, Cooperative Extension Service

Coretta Miller

Wilkes Wild about Wellness

Debi Miller

L.E.A.P. of West Georgia

Jackie Miller

West Central Health District 7-0

Julie Miller

Southwest Health District 8-2

Vicky Moody

Northeast Health District 10

Colethia Moore

West Central Health District 7-0

Wylene Moore

Georgia Department of Human Resources, Family Health Branch

Marybeth Moore

Emory University, Rollins School of Public Health

Robyn Morgan

Georgia State University

Clarence Morgan

Effingham County Recreations and Parks

Macceo Moss

Center for Youth Leadership and Family Development

Rebecca Mullis

University of Georgia

Al Mungin

Chatham County Health Department

Jean Murphy

Atlanta Intercultural Ministries

Arlene Murrell

Fulton County Department of Health and Wellness 3-2

Carol Mushett-Johnson Georgia Coalition for Physical Activity and Nutrition

Patty NeSmith

Northwest Health District 1-2

Brooke Nicholas

Georgia Institute of Technology

Frances Nichols

Worth County Board of Commissioners

Amy Nichols

Northeast Georgia Diagnostic Clinic

Anne O'Brien

Palmyra Medical Center

Stacey Odom

Spring Creek Health Cooperative

Carrie Odom

Let's Talk About the Family

Kokayi Olushola

QER, Inc.

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Appendix

A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name

Agency/Organization

Mary Ortwein Joseph Palladi Betsy Pape Beth Passehl Phyllis Pemerton Murray Perry Eric Pfeifer Mary Ann Phillips Marsha Pierce

Walker County Health Department Georgia Department of Transportation Citizen Children's Healthcare of Atlanta Floyd Medical Center Union Mission Georgia State Games Commission Philanthropic Collaborative for a Healthy Georgia Coastal Health District 9-1

Vicki Pilgrim
JoAnn Pittman Phyllis Plummer Ken Powell Louise W. Primrose Renee Prince Debbie Purvis Lisa Quinton Helen Raczkawski Linda Ratchiffe Sudha Reddy Priscilla Register Joyce Reid Rebekah Revels Susan Reyher Velvet Riggins Nancy Rithmire Lynn Roberts Michele Robinson Karen Robinson Joyce Rockwell Leslie Rodriguez-Zeigler LaQuita Rogers Denine Rogers Jackie Romain Sue Rowe Kay Rushing Emily Ryan Tamara Salman Sarah Salter

Georgia Department of Human Resources, Chronic Disease Prevention and Health Promotion Branch US Food and Drug Administration Dougherty County Health Department Georgia Department of Human Resources, Epidemiology Branch Mt. Hebrew Baptist Church Camden County Schools Colquitt County Extension Service Northwest Health District 1-2 Wayne Memorial Hospital Liberty/Long/Bryan County Health Department Georgia Department of Human Resources, Division of Aging Services South Health District 8-1 Georgia Hospital Association Candler County Health Department Dougherty County Health Department Girl Scouts of Southwest Georgia Forsyth County Schools Worth County Board of Education Cooperative Extension Office Georgia Department of Early Care and Learning Worth County Health Department Hispanic Health Coalition West Central Health District 7-0 West End Medical Center Georgia Department of Early Care and Learning West Central Health District 7-0 Children's Tree House University of Georgia, Cooperative Extension Service Graduate Student Sumter County Health Department

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A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name

Agency/Organization

Monique Salter Rita Samuels Cindy Savage Patricia Schneider Kelly Schriver Bernard Scuggins Ann Sears Jan Seay Carren Sellers Beverly Sessums Wilma Sexton Patti Shannon Jahazel Shepherd Henry Sims Amanda Sloan Gaye Morris Smith Mandel Smith Alice Smith Diane Smith John H. Smith, Sr. Jackie Snapp Katie Sobush Amy Spangler Don Speaks Bobbie St. Clair Inger Stallmann-Jorgensen
Nealy Stapleton Dannika Stevenson Kay Stewart Leslie Stewart Lois Stifle Anne C. Stokes Peggy Swigert Nan Swindell Molly Szymanski Kristin Taylor McKinley Thomas Marie Thompson Robin Tillman Brian Tobin

North Health District 2-0 Georgia Coalition for Black Women Lanier Elementary School School Nutrition Muscogee County School District Southeast United Dairy Association Albany Area Health Care, Inc. Northeast Health District 10-0 Dougherty County Mental Health Registered/Licensed Dietitian St. Francis Hospital Northeast Georgia Health District 1-1 Wayne County Health Department Monroe Comprehensive High School Spalding county Parks & Rec. Department Medical College of Georgia HealthSTAT Family Connection Partnership University of Georgia Cooperative Extension Dougherty County Children's Healthcare of Atlanta Northeast Health District 1-1 Dougherty County Health Department Hall County Parks & Leisure Services Georgia Bikes! Maternal & Child Health Consultant Speaks & Associates Worth County Health Department
Georgia Prevention Institute
Southwest Georgia Area Health Education Center Citizen Emory University, Department of Health, Physical Education and Dance Perimeter North Family Medicine Kids' Health Inc. Dougherty for Children/Family Connection St. Teresa's School McIntosh County Health Department Southeast United Dairy Association North Health District 2-0 Augusta State University North Health District 2-0 Colquitt Regional Medical Center Mercer University School of Medicine

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Appendix

A p p e n d i x I . Ta s k F o r c e M e m b e r s

Name

Agency/Organization

Arlene Toole

Grady Health System

Rebecca Towle

Girl Scout Council of Savannah, Georgia Inc.

Fredrick L. Trowbridge Trowbridge & Associates Inc.

Margaret Turner

South Central Health District (Healthy Start)

Kayellen Umeakunne Morehouse School of Medicine, Clinical Research Center

Constance Walker

Board of Education

Linda Welch

Cobb County School District, Food & Nutrition Services

Anne Wheeler

Waycross Health District 9-2

Woodrow White

Metro Atlanta Skate School

Jane Wiggins

Columbia County Board of Education

Debbie Wilburn

University of Georgia Cooperative Extension Service, Forsyth & Hall Counties

Cathy Wiley

Northwest Georgia Health District 1-1

Amber Wilhoit

Wayne Memorial Hospital

Frances Wilkinson

East Central Health District 6-0

Armenia M. Williams Georgia State University

Paulette Williams

Georgia Department of Education

Sharon Williams

Lee County Library

Shannon Williams

ILSI Center for Health Promotion

Naomi Williams

Enterprise Community Healthy Start

Ella Williamson

St. Joseph's/Candler African-American Health Information and Resource Center

Carolyn T. Willis

Monroe Comprehensive High School

Donna Wilson

East Central Health District

Pam Wilson

Georgia Department of Human Resources, Chronic Disease Prevention and Health Promotion Branch

Nan Wilson Andrea Wimbush Jo Wright Fran Zolomy Jo Zurbrugg

JuicePlus East Metro Health District 3-4 Coastal Health District 9-1 American Heart Association Healthy Futures for Children

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Appendix II. Details About Estimating the Burden of Overweight and Obesity
Population Attributable Risk:
Population attributable risk (PAR) is an estimate of the proportion of deaths or other measures of disease burden caused by a particular risk factor. The PAR estimates the proportion of disease in a population that would be eliminated if the risk factor were removed from the population. For example, the PAR for overweight and obesity is the fraction of deaths that would not occur if everyone were of normal weight.
As a formula, PAR is expressed: # of Total Deaths (actual) # of Total Deaths (if all normal weight)
(1) PAR = ___________________________________________ x 100 # of Total Deaths (actual)
Because the value for "# of Total Deaths (if all normal weight)" cannot be directly measured, PAR is usually calculated using another formula that requires the prevalence of the risk factor and the relative risk for dying among those with the risk factor compared to those without the risk factor.
Pexp(i)* (RRi 1) (2) PAR = x 100
1+ [Pexp(i)* (RRi 1)]
In this equation, Pexp is the prevalence of the exposure, RR is the relative risk, and (i) is the level of exposure to the risk factor if there is more than one level of the risk factor. The categories of excess weight used in this report provide two levels of risk, one level for those who are overweight and one level for those who are obese.
Calculating the PAR using formula 2, above, assumes that the prevalence of other risk factors would not change if the risk factor of interest disappeared, and that other risk factors, known or unknown, are unassociated with the risk factor of interest. These assumptions and others make the PAR an imperfect estimate of the proportion of deaths caused by a specific risk factor. Nevertheless, the PAR provides a useful approximation of the potential gains from reducing the prevalence of a particular risk factor, in this case excess body weight.
Relative risk for death from overweight and obesity:
In 1995, the World Health Organization (WHO) recommended a classification for three "grades" of overweight using BMI cutoff points of 25, 30, and 40.1 In 1998, the expert panel from the US National Institutes of Health (NIH) released a report that provided definitions for overweight and obesity similar to those used by the WHO. The panel identified overweight as a BMI > 25 kg/m2 to less than 30 kg/m2 and obesity as a BMI > 30 kg/m2. These definitions are widely used by the US federal government and by the broader medical and scientific communities.

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Appendix II. Details About Estimating the Burden of Overweight and Obesity
The majority of epidemiologic studies show that all-cause mortality begins to increase with BMIs above 25 kg/m2, 1-5 and the increase in mortality tends to be modest until a BMI of 30 kg/m2 is reached.1,2,4,5 For persons with a BMI of 30 kg/m2 or above, mortality rates from all causes are 50 to 100 percent above that of persons with BMIs in the range of 20 to 25 kg/m2.1,4,5 In the few studies with sufficient numbers of older persons (>64 years of age), the relative risk for death due to overweight and obesity was lower among older persons than younger.
Details of the PAR calculations in this report:
In this report, we classify overweight and obesity according to the NIH published guidelines: overweight was defined as BMI between 25.0 to 29.99 kg/m2 and obesity as BMI 30.0 kg/m2 and above. The prevalence of overweight and obesity among adults in Georgia was obtained from the Georgia Behavior Risk Factor Surveillance System (BRFSS) for years 2000-2003.
The relative risks for dying from overweight and obesity were derived through a comprehensive literature review. We included those studies which 1) used the BMI groupings that allowed use of the current NIH categories; 2) had as the reference group those with BMI value between 18.5 and 24.9 kg/m2; 3) measured adjusted relative risk for all-cause mortality based on multivariate analysis; 4) included at least 1000 subjects in the study. A total of nine articles describing thirteen studies were selected to estimate the relative risk for all-cause mortality from overweight and obesity.6-14 Because relative risk is lower among older persons 6,7,9 and because the prevalence of overweight and obesity differs between sexes, we calculated PARs for eight BMI-age-sex-specific groups (2 BMI groups, 2 age groups, 2 sex groups) (Table 1-1). We used weighted averages of the relative risks from the thirteen studies for persons 18-74 years of age. Although the evidence of reduced relative risk of mortality from overweight and obesity was convincing, the articles provided insufficient consistent quantitative estimates for persons 75 years and older for us to use directly or to average as we had done for younger adults. Instead, for persons 75 years and older we arbitrarily reduced the relative risk by half for overweight males and females and obese males. We reduced the relative risk by three-quarters for obese females because the available data suggested it.
The total number of deaths among Georgia residents from 2000 to 2003 was obtained from Georgia Vital Statistics data.

Table 1-1. Relative risks, prevalence, and population attributable risk due to overweight and obesity
Average annual total number of deaths
Relative Risk (estimated from literature)
BMI 25-29 BMI 30+
Prevalence (from BRFSS) BMI 25-29 BMI 30+
PAR % BMI 25-29 BMI 30+ Total
PAR number, average annual BMI 25-29 BMI 30+
Total

Male

18-74 yrs

75+ yrs

18712

12135

1.10 1.60
42.7% 24.4%
3.6% 12.3% 15.9%
670 2300 2980

1.05 1.30
39.7% 13.0%
1.9% 3.7% 5.6%
230 450 670

Female 18-74 yrs 75+ yrs

12712

19512

1.10 1.60
27.5% 28.9%
2.3% 14.4% 16.7%
290 1840 2130

1.05 1.15

29.3% 22.7%

1.4% 3.2% 4.6%
270 630 910

Total 1460 5220
6680

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References for Appendix II:
1. World Health Organization. Physical status: The use and interpretation of anthropometry. Report of a WHO Expert Committee. WHO Technical Report Series; 1995;854:1-452.
2. VanItallie TB, Lew EA. Overweight and Underweight. In: Lew EA, Gajewski J, eds. Medical Risks: Trends in Mortality by Age and Timed Elapsed. Vol 1. New York: Praeger; 1990: Chapter 13.
3. VanItallie TB. Health implications of overweight and obesity in the United States. Ann Intern Med. 1985; 103:983-988.
4. Manson JE, Stampfer MJ, Hennekens CH, Willett WC. Body weight and longevity. A reassessment. JAMA. 1987;257:353-358.
5. Troiano RP, Frongillo EA Jr, Sobal J, Levitsky DA. The relationship between body weight and mortality: a quantitative analysis of combined information from existing studies. Int J Obes Relat Metab Disord. 1996;20:63-75.
6. Stevens J, Cai J, Pamuk ER, Williamson DF, Thun MJ, Wood JL. The effect of age on the association between body-mass index and mortality. NEJM. 1998;338:1-7.
7. Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Health Jr. CW. Body-mass index and mortality in a prospective cohort of U.S. adults. NEJM. 1999;341:1097-1105.
8. Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual Deaths Attributable to Obesity in the United States. JAMA. 1999;282:1530-1538.
9. Baik I, Ascherio A, Rimm EB, Giovannucci E, Spiegelman D, Stampfer MJ, Willett WC. Adiposity and Mortality in Men. AJE. 2000;152:264-271.
10. Wei M, Kampert JB, Barlow CE, Nichamna MZ, Gibbons LW, Paffenbarger, Jr. RS, Blair SN. Relationship between Low Cardiorespiratory Fitness and Mortality in Normal-Weight, Overweight, and Obese Men. JAMA. 1999;282:1547-1553.
11. Stevens J, Cai J, Juhaeri, Thun MJ, Wood JL. Evaluation of WHO and NHANES II standards for overweight using mortality rates. Journal of The American Dietetic Association. 2000;100:825-827.
12. Farrell SW, Braun L, Barlow CE, Cheng YL, Blair S. The relation of Body Mass Index, Cardiorespiratory Fitness, and All-Cause Mortality in Women. Obesity Research. 2002; 10:417-423.
13. Meyer HE, Sogaard AJ, Tverdal A, Selmer RM. Body mass index and mortality: the influence of physical activity and smoking. Medicine and Science in Sports and Exercise. 2002; 34: 1065-1070.
14. Engeland A, Bjorge T, Selmer RM, Tverdal A. Height and Body Mass Index in Relation to Total Mortality. Epidemiology. 2003;14:293-299.

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Appendix

Appendix III.

Take Charge of Your Health, Georgia! Task Force for the Prevention of Obesity Prevention and Other Chronic Diseases
("Task Force") Terms of Reference/Operating Guidelines

(created on Dec 5, 2003, v5 January, 2005)

TASK FORCE GOAL
To prevent obesity and other chronic diseases and promote healthy lifestyles by developing, coordinating, and implementing evidence-based breastfeeding, nutrition and physical activity strategies in a variety of settings through partnership with public and private partners.

TASK FORCE OBJECTIVES
Capacity Building Phase Objectives 1. To develop a sound program infrastructure for breastfeeding, nutrition and physical activity at the state and local level.

2. To collaborate and coordinate with state and local government and, private partners throughout planning process.

3. Conduct a planning process that leads to a comprehensive nutrition and physical activity plan that reflects the socio-ecological model, to prevent and control obesity and other chronic
diseases.

4. Identify, assess and maintain existing data sources and surveillance systems to further define and monitor the burden of obesity.

5. Develop and evaluate a pilot intervention to prevent obesity and other chronic diseases, using social marketing as the planning process.

6. Evaluate the progress and impact of the state plan and intervention projects.
7. To identify nutrition and physical activity initiatives in existence in the community, by looking for opportunities to address gaps and enhance existing initiatives.

Implementation Phase Objectives 1. To maintain and expand program infrastructure for nutrition, physical activity and breastfeeding at the state and local level.

2. To continue to enhance and expand partnership efforts between state and local government, private partners throughout planning and implementation process.

3. Implement the State Nutrition and Physical Activity Plan interventions/strategies based on implementation work plan.

4. Provide mini-grant opportunities to communities to implement interventions identified in the state plan.

5. Identify, assess and maintain existing data sources and surveillance systems to further define and monitor the burden of obesity.

6. Evaluate progress and impact of State Plan and intervention projects.

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Appendix III.
Guiding Principles
1. Collaborate with community partners to share resources, plan state and local initiatives and set priorities.
2. Focus on the primary prevention of obesity and related chronic diseases.
3. Focus on the importance of health not weight or weight loss alone, especially with children and adolescents. Weight management not seen as a cosmetic or esthetic issue but a health issue.
4. Ensure that healthy eating and physical activity recommendations are aligned with national guidelines/documents, such as the CDC, Dietary Guidelines for Americans, Healthy People 2010 and National Association for Sports and Physical Education, and best/promising practices.
5. Plan and implement initiatives that: embrace one or more of the key focus areas (breastfeeding, healthy eating, physical activity and TV Viewing); consider the broader determinants of health; and utilize strategies from programs that are evidence-based.
6. Promote healthy lifestyles using the socio-ecological model as a framework and a variety of approaches including awareness, and skill building, creating supportive environments, and policy development.
7. Promote health throughout the life cycle by supporting health behaviors, healthy social and physical environments and healthy public policy.
8. Plan for sustainability of initiatives and their outcomes/benefits where appropriate.
Funding
The funding for the Task Force and its projects comes from the financial contributions of the CDC, Division of Nutrition and Physical Activity Grant Award 03022, staff support provided by the Georgia Division of Public Health, the in-kind contributions of the Task Force partners, and other funding sources as needed.
Task Force Member Roles
Participation is open to all organizations and individuals throughout Georgia who support the goals and objectives of the Task Force. Task Force member roles consist of: Steering Committee, Work Group and Affiliate/Advisory Members.
1. Affiliate/Advisory Role: Participation is encouraged from individuals and organizations who are not able to send a representative to actively participate as a member of the Task Force, but would like to remain informed of the activities of the Task Force by receiving minutes and/or updates and/or act in an advisory capacity depending upon area of expertise. Such members are entitled to participate at meetings or assist on projects, when possible.
2. Work Group Role: Participation is open to individuals from the community or organizations, who are interested in actively participating in Task Force activities by contributing at a workgroup level to develop, implement and evaluate the State Plan and other grant activities.
3. Steering Committee Role: Participation is open to individuals or organizations who are interested in actively participating in the Task Force to support its' goals and objectives and represent the various sectors such as schools, community, worksite, faith-based community, academia, etc. Steering committee members have the ultimate responsibility for guiding the activities as required by the CDC Grant funding and the Department of Human Resources.

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Appendix
Appendix III.
Task Force Structure (see Attachment 1.)
Steering Committee:
1. Members of the steering committee shall consist of the following: chair (Project Coordinator), Project Staff: Nutrition Coordinator, Physical Activity Coordinator, Epidemiologist), workgroup co-chairs, and other members of the Task Force who come from different settings and bring skills and/or knowledge of: evaluation, chronic disease prevention and healthy lifestyles promotion, project management, cultural competence, social marketing, policy development and the determinants of health.
2. The committee will consist of a maximum of 15 members. Steering committee members will be selected at the semi-annual or annual Task Force meeting.
3. Steering committee members shall commit to a 2 (two) year term.
4. Membership may be terminated if a member misses two consecutive meetings.
5. Quarterly meetings will be held, with additional meetings or teleconferences scheduled as required.
6. Quorum consists of 2/3 of Steering Committee members.
7. Decision-making is by consensus where possible. Conflict of interest will be declared and recorded in the minutes. When a vote is called, a simple majority will be needed to reach a decision. Financial matters will require a recorded vote.
Work Groups:
1. Work Groups will be formed according to the four focus areas for the CDC Grant (Breastfeeding, Vegetable and Fruit/Healthy Eating, Physical Activity, TV Viewing) and other areas deemed necessary such as Data and Evaluation and Communication and Partnership. Other workgroups will be formed pending directions set by the Steering Committee and can be established and dismantled as required.
2. Priorities for Work Groups will be established by Task Force and in conjunction with Project Coordinator.
3. Members include representation from the Task Force, which are individuals and organizations who are interested in a specific focus area or workgroup.
4. Work Group members/agencies shall commit to a 5-year term.
5. Regular meetings will be held as established by the Co-Chairs of the Work Group.

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Appendix III.
Task Force Roles and Responsibilities
1. Affiliate/Advisory Members:
a. Participate in development and implementation of CDC Grant and Task Force activities, as time permits.
b. Provide updates on the initiative to their respective organizations, agencies and/or communities.
c. Attend Task Force meetings or send representative (2 times/year).
.
2. Steering Committee Chair/Project Coordinator:
a. Responsible for implementing any Task Force policies and ensuring Terms of Reference are followed.
b. Presides over all Task Force and Steering Committee meetings. c. Prepares and distributes agendas in conjunction with Project Staff. d. Writes and distributes minutes of Steering Committee meetings in conjunction with
Project Staff. e. Represents the Task Force in an official capacity. f. Acts as spokesperson for Task Force events and releases, or ensures a designate is
appointed. g. Ensures that responsibilities and decisions are clear.
3. Work Group Co-Chairs:
a. Ensure facilitation of Work Group meetings. b. Oversee the achievement of workgroup activities and milestones. c. Contribute to the development and implementation of the State Plan and other
CDC Grant activities. d. Communicate agenda, location and time of meetings to members. e. Prepare regular reports to Steering Committee. f. Ensure one co-chair of the Work Group attends quarterly Steering Committee meetings. g. Act as spokespersons for Work Group/Task Force to media or ensures a designate and
informs the Steering Committee of all media releases, designated spokespersons and events before they occur. h. Represent (or designates a representative for) the Work Group at public events and in appropriate communications. i. Ensure minutes are recorded and distributed to members, and a copy kept on file as official Task Force record. j. Upon completion of a project, ensure a summary report is provided to Steering Committee.

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Appendix III.
4. DHR Project Staff:
a. Works in partnership with Steering Committee but has no voting privileges. b. Supports membership of the Task Force. c. Facilitates new partnerships with the community and among members. d. Acts as a resource to work group planning, implementation, and evaluation activities e. Responsible for coordinating/compiling reports to CDC. f. Deals with all correspondence on behalf of the Task Force and maintains all Task Force
documents including the Terms of Reference and Members List. g. Works in conjunction with Co-chairs to distribute minutes, agendas, Work Group reports,
ensure meeting times and locations are set, and arrange refreshments. h. Oversees the development and implementation of the Project budget; makes financial
recommendations to Steering Committee; and reviews year-end written report to the CDC.
5. Steering Committee Members: Functions of the Steering Committee include: Review Terms of Reference annually.
a. Review Terms of Reference annually. b. Make financial recommendations for Task Force projects according to guiding principles,
workplan goals and objectives and DHR policy. c. Review, approve, give input into draft plans submitted from workgroups. d. Monitor and evaluate progress related to the development and implementation of the State
Plan and other grant activities to ensure they are being implemented as intended. e. Develop, in consultation with the Task Force, and implement operational policies for the
Task Force, as needed. f. Approve a spokesperson for any Task Force event or release, operational policies and
communication guidelines.
6. Work Groups Members: Functions of Work Group members include:
a. Participate in development and implementation of CDC Grant and Task Force activities. b. Provide updates on the initiative to their respective organizations/agencies/communities. c. Attend workgroup meetings as scheduled. d. Attend Task Force meetings (2 times/year).
Approved: INSERT DATE
Revised: March 8, 2004, March 16, 2004, July 14, 2004, Nov 22, 2004, January 2005

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Appendix III. G l o s s a r y o f Te r m s
Determinants of Health
Health is closely tied to the environment around us where we live, work and play. The `determinants of health' is the name given to factors which influence our health and well-being. Determinants of health and the interactions among them include income equality, social inclusion/exclusion, employment and job security, early childhood care, working conditions, education, food security, and housing. These are often referred to as the social determinants of health.
Healthy People 2010 is a set of health objectives for the Nation to achieve over the first
decade of the new century. It can be used by many different people, States, communities, professional organizations, and others to help them develop programs to improve health. The Leading Health Indicators are Breastfeeding, Physical Activity, Overweight and Obesity, Tobacco Use, Substance Abuse, Responsible Sexual Behavior, Mental Health, Injury and Violence, Environmental Quality Immunization, Access to Health Care. Visit http://www.healthypeople.gov/ for the full document.
US Dietary Guidelines
Nutrition and Your Health: Dietary Guidelines for Americans is published jointly every 5 years by the Department of Health and Human Services (HHS) and the Department of Agriculture (USDA). The Guidelines provide authoritative advice for people two years and older about how good dietary habits can promote health and reduce risk for major chronic diseases. They serve as the basis for federal food and nutrition education programs. The 2005 Dietary Guidelines can be found at www.health.gov/dietaryguidelines and mypyramid.gov.
NASPE - The National Association for Sport and Physical Education seeks to enhance knowledge
and professional practice in sport and physical activity through scientific study and dissemination of research-based and experiential knowledge to members and the public. NASPE recently released the National Standards for Physical Education. An essential tool for developing, implementing and evaluating K-12 school physical education programs, the national standards clearly identify what students should know and be able to do as a result of a quality physical education program.

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Appendix III. Attachment 1.

Georgia Obesity Prevention and Control Initiative Organizational Structure Planning Phase

Take Charge of Your Health, Georgia! Collaborative Task Force for the prevention
of obesity and other chronic diseases
Steering Committee

Georgia Department of
Human Resources
and Project Staff

Workgroups

Vegetable and Fruit, Healthy
Eating

Breast feeding

Physical Activity

TV Viewing

Data and Evaluation

Communication and
Partnership

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Appendix IV.
Summary of Regional Planning Meetings Obesity Prevention Summary of Top 5 Strategies November 2004
The following is a summary of the top 5 strategies that participants of the regional planning meeting identified for inclusion in Georgia's Nutrition and Physical Activity Plan.
Gainesville Regional Meeting (Nov 1, 2004)
1. Mandatory PE in schools (support legislation) 2. Offer healthy choices in vending machines (including schools) 3. More Community Recreation Centers & Activities and Better Hours for Activities
(esp in rural areas) 4. Develop community campaign to educate families to increase physical activity and
decrease sedentary activity (i.e. turn off TV, eat together, board games, and readings 5. Develop marketing/education campaign to promote breastfeeding using local
media outlets 6. Show nutrition content on menu items
Macon Regional Meeting (Nov 2, 2004)
1. Increase media's involvement by involving GA Assoc. of Broadcasting in developing campaign for TV and radio to promote physical activity
2. Mandate physical activity in schools (daily PE) 3. Educate men, women, and media on the benefits of breastfeeding 4. Replace all vending machines with healthy choices 5. Develop partnerships between faith-based community, political leaders, families, extension on
how to prepare healthy menus on a budget
Columbus Regional Meeting (Nov 10, 2004)
1. Mandate requirement for PE Pre K 12 2. Legislate funding for required PE in schools K-12 3. Offer healthy choices & remove sodas in vending machines in school 4. Provide nutrition education beginning in daycare to high school 5. Add nutrition education to school curriculum at all age levels-so children may help make
changes for entire family
Savannah Regional Meeting (Nov 15, 2004)
1. PE back into all schools with emphasis on middle & high school 2. Educate community, churches, worksites, schools, B&G Club on proper nutrition/healthy eating 3. Encourage employers to support breastfeeding mothers 4. Educate pediatricians, ob/gyns, private providers on importance of breastfeeding promotion 5. Sidewalks, walking trails, pools, playground equipment in communities

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Appendix IV.
Augusta Regional Meeting (Nov 17, 2004)
1. Mandatory physical ed. in schools everyday and every year 2. Eliminate vending machines in schools or provide healthy selections (such as v&f, water,
low fat dairy) 3. Media campaign to show relationship between obesity & breastfeeding 4. Parent education regarding reducing TV/screen time 5. Promote Take Charge of Your Health Campaign focusing on 5 A Day, Take Action and
Take Down Fat 6. Increase workplace wellness programs/promotion [offer incentives for physical activity]
Atlanta Regional Meeting (Nov 22, 2004)
1. Mandatory physical education in grades K-12 2. Offer more physical activity during after-school, PE time, more programming 3. Raise awareness and social acceptance of breastfeeding as the norm through media &
entertainment channels (eg sitcom to include breastfeeding as a topic, role modeling), billboards in different languages 4. Promote family eating together (Eat Better, Eat Together) 5. Remove sodas and junk food from vending machines in schools, parks, and healthcare facilities and include nutritious beverages and snacks
Albany Regional Planning Meeting (Jan 12, 2005)
1. Designate food stamp spending to include healthy choices 2. Restaurants will offer healthy choices (eg a "Georgia Nutrition Menu") with specific information
on serving size, ingredients and how food was prepared 3. Mandatory PE in schools K-12 (include legislation) 4. Provide education on proper portion sizes based on current dietary guidelines 5. Promote interactive games that encourage health and exercise

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Appendix V.
Survey of Breastfeeding, Nutrition, and Physical Activity Programs and Initiatives in Georgia
Instructions
Thank you for participating in this survey. For the purposes of this survey, a program is a collection of activities and/or services designed to address a specific need or problem. A program may also be called an initiative or project. For this purpose, a program, an initiative, or a project is NOT just one specific activity such as a health fair. Some of you may administer or manage more than one program related to breastfeeding, nutrition, and physical activity. Please complete one survey for each program you administer.
You may complete and submit the survey in one of the following four ways: 1. Complete survey in Microsoft Word Format and return it via email. Open the attached file. Save the file on your computer or to a disk, and name the file using your first initial, last name and the word "survey". If you are completing more than one survey, save each survey with the same filename and add the number of the survey to the end. For example, John Smith would save his survey as jsmithsurvey. If he had two programs he would save the first as jsmithsurvey1 and the second as jsmithsurvey2.
2. Complete survey in Microsoft Word Format and return it via U.S. mail. Open the attached file, complete one survey for each program. It is recommended that you save each survey per the instructions above, under returning the survey via email. Print a copy of each survey, and mail the copy(ies) to Obesity Program Survey, Bernette McColley, Georgia Health Policy Center, 14 Marietta Street, Suite 221, Atlanta, GA 30303.
3. Complete survey in Microsoft Word Format and return it via fax. Open the attached file, complete one survey for each program. It is recommended that you save each survey per the instructions above, under returning the survey via email. Print a copy of each survey, and fax the surveys to Bernette McColley's attention at 404-651-3147.
4. Complete survey on-line. See the on-line instructions included in the email containing this survey or the on-line instructions attached within that email.
**Please note that, due to Zoomerang website maintenance, the survey will not be available for completion from 9:00 p.m. Wednesday, December 15 to 5:00 a.m. Thursday, December 16.

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Appendix V.

Survey of Breastfeeding, Nutrition and Physical Activity Programs in Georgia
Georgia Collaborative Task Force for the Prevention of Obesity and Other Chronic Diseases
Name of Agency Contact Person Title Address Phone number Fax number Email address Website

Program Name: __________________________________________________________________

1. Please briefly describe, in 50 words or less, the objectives of the breastfeeding, nutrition, and/or physical activity program or intervention. (e.g.)
__________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________

2. Please provide the following background information on the program. Please check all that apply.

Date Program Started

Funding Source

Status of Program

Frequency and Duration of Program

Number of Staff

___________ (Month/year)

Federal Gov't
CDC FMNP Food Stamps HHS (NIH, HRSA) MCH Block Grant SFSP Title XX USDA WIC State Gov't County/City Grant Philanthropic Grant Business/Industry Other_______________

Permanent
program
Pilot project/
demonstration
End date (mth/yr): _______________
Time limited
grant (non-pilot)
End date (mth/yr): _______________

Frequency of Program
Continuous
(all year round)
OR
On a periodic basis
throughout year
Duration of Program (length of program each session/time it's offered)
______ day(s) ______ week(s) ______ month(s) ______ quarter(s) ______ other: ______

How often is program offered? ____________ ____________________

Full-time
Employees
Part-time
Employees
Volunteers
Interns/Students

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Appendix V.

3. Describe the coverage area of the program. Please check all that apply.

___ Statewide
___ County(ies) _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________,

___ City(ies) _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________, _________________,
Setting

___ Adult Day Care ___ Child Care Centers ___ Church/Faith-Based Setting ___ Community Center ___ Health Care Setting
(hospital/clinic other than Public Health) ___ Home I

___ Housing Authority ___ Public Health Department ___ Schools ___ Senior Center ___ Universities/Colleges ___ Worksite Other____________________________

4. Please provide the following information about the target audience of the program.
In each column, please check all that apply.

Age Group/Number of Participants

Race

Gender

Infant (0-2 years)
________# of participants
Preschool (2-5 years)
________# of participants
School age (6-18 years)
________# of participants
Adults (18-64 years)
________# of participants
Seniors (65+ years)
________# of participants

All races/
ethnicities
Specific race/
ethnicity
Check those that apply
American
Indian/Alaska Native
Asian Black/African
American
Hispanic/ Latino Native Hawaiian
or Other Pacific Islander
White or
Caucasian

Male Female Both

Socioeconomic
Status

Population Served

Specific Reason(s)

<$28,500 $28,600- $56,500 >$56,500 All Don't Know

Individuals
Families
Individual
and Families
Community

Mandated by
funding
High health risk
Low Income
Determined by
Needs Assessment

Other
_______________

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Appendix V.

5. Which of the following focus areas does the Program address?
Please check all that apply.
Breastfeeding initiation/duration Fruit and vegetable consumption
Other nutrition topics ___ Calcium and dairy ___ Eating foods away from home ___ Family/parental involvement and/or role modeling ___ Fat intake ___ Fiber intake ___ Meal preparation/Menu planning
Portion size Other, specify __________________________________________
Physical activity Television viewing and other screen time (computer/video games)
Other, specify ________________________________________________

6. What activities are included in the program?
Please check all that apply.
Classes that include skill building (i.e. physical activity, cooking demonstrations/classes, label reading, food budgeting, menu planning, etc.)
Counseling, group Counseling, individual
Creating breastfeeding, healthy eating or physical activity policies (e.g.,in workplace, community centers, health department)
Displays (in workplaces, community centers, malls) Education through self-directed learning (kiosks, websites etc.) Grocery store tours Large scale presentations (Presentations to large number of people) Media (e.g., radio, TV, newspaper articles) Small group education classes State or local policy and/or environmental change. Other, please specify_____________________

7. Does the program partner with other organizations? Yes
If yes, please identify partner and partner's contribution.

No

Name of partner

What does partner contribute?

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Appendix V.
8. Name three major barriers/challenges, other than funding, that you have experienced in implementing this program? 1. 2. 3.
9. What three things have contributed most to the success of this program? 1. 2. 3.
10. Has your program been evaluated? Yes No (Skip to question 12) If yes, please indicate the type of evaluation conducted.
Type of Evaluation
Formative
--Evaluation that occurred before program implementation, used to assess current activities/materials/methods, etc.
Process
--Evaluation that occurred during program implementation, used to measure how you are doing things.
Outcome
--Evaluation that occurred after implementation, used to measure how well objectives were achieved.
Other____________________________
11. Please describe three specific quantifiable successful/unsuccessful outcomes. 1. 2. 3.

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Appendix V.

12. From your experience, what do you think are the three most helpful training and/or technical assistance activities that can be provided to you or your staff? On the list below, please place a 1 next to the most important need, a 2 next to the second most important need, and a 3 next to the third most important need.
___ Behavior change theories ___ Best practices/model programs-identification, planning, implementing ___ Coalition/partnership development ___ Community assessment/identification of health priorities ___ Finding funding opportunities ___ Grant writing ___ Nutrition and physical activity knowledge ___ Policy and environment change assessment, development and implementation ___ Program evaluation, including data evaluation/interpretation ___ Social marketing ___ Strategic planning-establishing measurable nutrition and physical activity objectives, outcome ___ Strategies for working with specific audiences: school, worksite, and communities ___ Surveillance ___ Other___________________________________________

13. Are there other physical activity and nutrition programs that you are aware of, but are not responsible for, in your area? Yes No (Go to Question 14)
If yes, in the section below, please list the name of the program/initiative, indicate what type of program/initiative it is (Education/Awareness, Skill-building, Policy Change, Environmental Support, Infrastructure Building), and provide contact information (name, phone number, mailing address, email address).

Name of Program/Initiative

Type of Program
Check all that apply
___ Education/Awareness ___ Skill-building ___ Policy Change ___ Environmental Support ___ Infrastructure Building
___ Education/Awareness ___ Skill-building ___ Policy Change ___ Environmental Support ___ Infrastructure Building

Contact Information
(Name, Address, Phone, Email)

___ Education/Awareness ___ Skill-building ___ Policy Change ___ Environmental Support ___ Infrastructure Building

14. Are there other physical activity and nutrition programs that you are responsible for? Yes No (If yes, please complete this survey for that program-Save this file first.)

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Appendix V.

Purpose and Results of Survey of Breastfeeding, Nutrition, and Physical Activity Programs and Initiatives in Georgia
Overview and Purpose
The Georgia Health Policy Center, under contract with the Georgia Department of Human Resources, Division of Public Health, is managing the dissemination, collection, and (pending) analysis of the Survey of Breastfeeding, Nutrition, and Physical Activity Programs in Georgia. The Division of Public Health and the Georgia Health Policy Center collaborated in the development of the survey instrument. The purpose of the survey was to obtain information about breastfeeding, nutrition, and physical activity programs, initiatives, and training needs at the state and local level. Both public and private programs were targeted.
Survey Recipients
The survey instrument was designed to be completed by the person responsible for administering the program or initiative. The requested information related to program purpose, resources, needs, and impact. The Division of Public Health provided a list of survey recipients (329 individuals) that included WIC Nutrition Services Directors, District Chronic Disease Prevention Initiative Coordinators, and members of the Georgia Collaborative Task Force for the Prevention of Obesity & Other Chronic Diseases. In addition, in an effort to be as inclusive as possible and obtain input from a wide variety of individuals and organizations, the initial survey recipients were asked to help identify others in their communities administering breastfeeding, nutrition or physical activity programs or initiatives. Based on returned surveys, it appears that eighteen surveys were forwarded to other individuals. Thus, a total of 347 individuals received the survey.
Survey Dissemination and Collection
In December 2004 the Georgia Health Policy Center disseminated the survey via email. The instrument was prepared in two formats: a web-based survey tool (using Zoomerang) and a Microsoft Word version. Survey responses could be submitted online through the web-based tool, or, the Microsoft Word version could be emailed, faxed, or mailed to the Georgia Health Policy Center.
Survey recipients were asked to complete and return the survey by December 21, 2004. Follow-up emails (with survey completion directions) were sent January 4, 2005 to individuals who had not yet responded. Beginning January 13, follow-up phone calls were made to individuals who had not responded to the second email and to those who had submitted incomplete surveys. The follow-up phone calls significantly increased the response rate from approximately 20% to about 60%. As of January 26, 2005, of the 347 surveys disseminated, 126 individuals completed the survey, 77 stated they did not have an applicable program, and 144 have not responded to the follow-up email, or the follow-up phone calls made in the two weeks from January 13 to January 26. Additional follow-up is planned. The 126 respondents completed a total of 143 surveys (respondents responsible for more than one program completed multiple surveys).
Data Analysis
Once the survey data is entered, an aggregate data analysis will be conducted on certain variables such as program background, coverage areas and service settings, demographics of target audience, focus areas, and program activities. This information will be provided to the Division of Public Health as a preliminary report of the survey findings. Review and analysis of individual responses will be conducted in the second phase of the analysis of survey data.

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Appendix VI.

Take Charge of Your Health, Georgia Task Force Organizational Structure Implementation Phase

Take Charge of Your Health, Georgia! Collaborative Task Force for the prevention of obesity and other chronic diseases

Steering Committee

Georgia Department of Human Resources and
Project Staff

Moving to Action Workgroups

Community

Faithbased

Schools

Worksites

Healthcare

Tween Pilot Intervention
Health Matters DHR on the Move
Worksite Pilot

Data and Evaluation

Communication and
Partnership

Rev: Jan 2005, CDC-funded initiative

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In partnership with Governor Perdue's Live Healthy Georgia campaign