Active Early: one-year policy intervention to increase physical activity among early care and education programs in Wisconsin.

BACKGROUND: Early childcare and education (ECE) is a prime setting for obesity prevention and the establishment of healthy behaviors. The objective of this quasi-experimental study was to examine the efficacy of the Active Early guide, which includes evidenced-based approaches, provider resources, and training, to improve physical activity opportunities through structured (i.e. teacher-led) activity and environmental changes thereby increasing physical activity among children, ages 2-5 years, in the ECE setting. METHODS: Twenty ECE programs in Wisconsin, 7 family and 13 group, were included. An 80-page guide, Active Early, was developed by experts and statewide partners in the fields of ECE, public health, and physical activity and was revised by ECE providers prior to implementation. Over 12 months, ECE programs received on-site training and technical assistance to implement the strategies and resources provided in the Active Early guide. Main outcome measures included observed minutes of teacher-led physical activity, physical activity environment measured by the Environment and Policy Assessment and Observation (EPAO) instrument, and child physical activity levels via accelerometry. All measures were collected at baseline, 6 months, and 12 months and were analyzed for changes over time. RESULTS: Observed teacher-led physical activity significantly increased from 30.9 ± 22.7 min at baseline to 82.3 ± 41.3 min at 12 months. The change in percent time children spent in sedentary activity decreased significantly after 12 months (-4.4 ± 14.2 % time, -29.2 ± 2.6 min, p < 0.02). Additionally, as teacher led-activity increased, percent time children were sedentary decreased (r = -0.37, p < 0.05) and percent time spent in light physical activity increased (r = 0.35, p < 0.05). Among all ECE programs, the physical activity environment improved significantly as indicated by multiple sub-scales of the EPAO; scores showing the greatest increases were the Training and Education (14.5 ± 6.5 at 12-months vs. 2.4 ± 3.8 at baseline, p < 0.01) and Physical Activity Policy (18.6 ± 4.6 at 12-months vs. 2.0 ± 4.1 at baseline, p < 0.01). CONCLUSIONS: Active Early promoted improvements in providing structured (i.e. teacher-led) physical activity beyond the recommended 60 daily minutes using low- to no-cost strategies along with training and environmental changes. Furthermore, it was observed that Active Early positively impacted child physical activity levels by the end of the intervention. However, resources, training, and technical assistance may be necessary for ECE programs to be successful beyond the use of the Active Early guide. Implementing local-level physical activity policies combined with support from local and statewide partners has the potential to influence higher standards for regulated ECE programs.

A Qualitative Pilot Study of Pediatricians' Approach to Childhood Obesity.

IMPORTANCE: Over the past 3 decades, rates of childhood obesity have tripled. Given the gravity of this health concern, it is important that physicians intervene early. However, physicians continue to underdiagnose and undertreat childhood overweight and obesity. OBJECTIVE: The aim of this pilot study was to identify current tools and strategies used by pediatricians in regard to childhood obesity, as well as to reassess barriers to success, and to uncover areas for improvement. DESIGN: One-on-one interviews were conducted with pediatricians during the summer of 2013. Seven of the interviews occurred in person, and 10 occurred via telephone. Each interview lasted 30 to 60 minutes. All interviewees (n = 17, 13.2% response rate) were Wisconsin pediatricians, representing 7 different health systems. MAIN OUTCOMES: Themes relating to pediatrician's experiences in addressing and managing childhood obesity. RESULTS: Pediatricians interviewed in this survey are comfortable identifying and diagnosing pediatric obesity with the widespread use of electronic health records. They have several tools and strategies at their disposal for the treatment and management of obesity, but do not often achieve the desired outcome of achieving healthy body weight. Most of them lack connections to community resources and the ability to effectively communicate with referral systems outside of their clinic, such as with dietitians. CONCLUSIONS: Building stronger connections between physicians and dietitians, as well as between physicians and the local community, may allow physicians to feel more empowered when it comes to managing childhood obesity.

Developing and Implementing "Waupaca Eating Smart": A Restaurant and Supermarket Intervention to Promote Healthy Eating Through Changes in the Food Environment.

PURPOSE: Restaurants and food stores are suitable settings for healthy eating interventions. A community-academic partnership developed and implemented "Waupaca Eating Smart" (WES), a healthy eating program in restaurants and supermarkets of a rural, Midwest community. Previous interventions targeted either restaurants or small food stores nearly all in urban areas. Intervention design and implementation is rarely documented, making replication difficult for interested researchers and communities. In this article, we report the activities we undertook to develop and implement WES. METHODS: Working with a local nutrition and activity coalition, we used evidence-based strategies guided by the social ecological model and social marketing principles to inform the content of WES. Formative assessment included a review of the literature, statewide key informant interviews and focus groups with restaurant and food store operators and patrons, a local community survey, and interviews with prospective WES businesses. WES was implemented in seven restaurants and two supermarkets and evaluated for feasibility and acceptance using surveys and direct observation of WES implementation. FINDINGS: Prior to this intervention, only one of seven restaurants had three or more meals that met WES nutrition criteria. By the end of the program, 38 meals were labeled and promoted to restaurant customers, and the team had staffed four side salad taste tests for supermarket customers. Four and 10 months after intervention launch, the majority of the program's strategies were observed in participating outlets, suggesting that these program's strategies are feasible and can be sustained. Operators reported strong satisfaction overall. CONCLUSIONS: A combined restaurant- and supermarket-based healthy eating intervention is feasible and positively valued in rural communities. Further research is needed to better understand how to foster sustainability of these interventions and their impact on customer food choices.

The Obesity Prevention Initiative: A Statewide Effort to Improve Child Health in Wisconsin.

BACKGROUND/SIGNIFICANCE: Obesity rates have increased dramatically, especially among children and disadvantaged populations. Obesity is a complex issue, creating a compelling need for prevention efforts in communities to move from single isolated programs to comprehensive multisystem interventions. To address these issues, we have established a childhood Obesity Prevention Initiative (Initiative) for Wisconsin. This Initiative seeks to test community change frameworks that can support multisystem interventions and provide data for local action as a means for influencing policies, systems, and environments that support individuals' healthy eating and physical activity. APPROACHES/AIMS: The Initiative is comprised of three components: (1) infrastructure to support a statewide obesity prevention and health promotion network with state- and local-level public messaging and dissemination of evidence-based solutions (healthTIDE); (2) piloting a local, multisetting community-led intervention study in 2 Wisconsin counties; and (3) developing a geocoded statewide childhood obesity and fitness surveillance system. RELEVANCE: This Initiative is using a new model that involves both coalition action and community organizing to align resources to achieve health improvement at local and state levels. We expect that it will help lead to the implementation of cohesive and sustainable policy, system, and environment health promotion and obesity prevention strategies in communities statewide, and it has the potential to help Wisconsin become a national model for multisetting community interventions to address obesity. Addressing individual-level health through population-level changes ultimately will result in reductions in the prevalence of childhood obesity, current and future health care costs, and chronic disease mortality.

Neighborhood Disparities in the Restaurant Food Environment.

IMPORTANCE: Restaurant meals account for a significant portion of the American diet. Investigating disparities in the restaurant food environment can inform targeted interventions to increase opportunities for healthy eating among those who need them most. OBJECTIVE: To examine neighborhood disparities in restaurant density and the nutrition environment within restaurants among a statewide sample of Wisconsin households. METHODS: Households (N = 259) were selected from the 2009-2010 Survey of the Health of Wisconsin (SHOW), a population-based survey of Wisconsin adults. Restaurants in the household neighborhood were enumerated and audited using the Nutrition Environment Measures Survey for Restaurants (NEMS-R). Neighborhoods were defined as a 2- and 5-mile street-distance buffer around households in urban and non-urban areas, respectively. Adjusted linear regression models identified independent associations between sociodemographic household characteristics and neighborhood restaurant density and nutrition environment scores. RESULTS: On average, each neighborhood contained approximately 26 restaurants. On average, restaurants obtained 36.1% of the total nutrition environment points. After adjusting for household characteristics, higher restaurant density was associated with both younger and older household average age (P < .05), all white households (P = .01), and urban location (P < .001). Compared to rural neighborhoods, urban and suburban neighborhoods had slightly higher (ie, healthier) nutrition environment scores (P < .001). CONCLUSIONS AND RELEVANCE: The restaurant food environment in Wisconsin neighborhoods varies by age, race, and urbanicity, but offers ample room for improvement across socioeconomic groups and urbanicity levels. Future research must identify policy and environmental interventions to promote healthy eating in all restaurants, especially in young and/or rural neighborhoods in Wisconsin.

Community-Led Collaborative Action to Prevent Obesity.

At the population level, turning the tide on obesity requires not only health education and promotion programs, but also systemic changes in our society. However, few of these changes can be implemented by single agencies or organizations acting in isolation. Broader community-driven efforts are needed to advance and maintain systematic changes across multiple settings. We introduce 2 promising approaches for local action to achieve changes: coalition action and community organizing. Understanding differences between the two approaches makes it clear that while each has distinct advantages, there are also possibilities for synergies between them. We also clarify how community-driven efforts can be catalyzed and supported, and describe our efforts as part of the Wisconsin Obesity Prevention Initiative to identify and implement best practices for building and sustaining the necessary local community capacity to carry out systematic changes. We are working with communities to launch initiatives in which residents are engaged through grassroots organizing, and local agencies, businesses, and other institutions are engaged in pursuit of collective impact on obesity prevention. This will allow us not only to compare the effectiveness of the 2 types of initiatives for driving local changes, but also to explore the potential for the two to work together in pursuit of systemic changes for preventing obesity.

Developing a Strategy Menu for Community-Level Obesity Prevention.

Childhood obesity is a complex problem influenced by policies, systems, and environments, and its prevention requires changes across a range of community settings. To address this, we developed an obesity prevention strategy menu and an ongoing study to pilot its use and provide technical support for its implementation. The strategy menu is comprised of a set of effective approaches communities can use to develop tailored, context-specific health interventions based on local community needs and capacity. It was developed by a multidisciplinary team of researchers and practitioners who reviewed evidence and organized it to incorporate effective policy, systems, and environmental changes for reducing and preventing childhood obesity. Eventually, it will be part of a web-based point of access that complements the foundational relationships built between communities, researchers, and practitioners. By developing a framework to engage communities in the selection and implementation of multisetting obesity prevention strategies, we aim to create and sustain momentum toward a long-term reduction in obesity in Wisconsin children.

The Wisconsin Early Childhood Obesity Prevention Initiative: An Example of Statewide Collective Impact.

INTRODUCTION: The Wisconsin Early Childhood Obesity Prevention Initiative (Initiative), established in 2007, seeks to address and prevent obesity in the early care and education system through nutrition and physical activity environmental and policy changes. The collaborative includes professionals from 3 state of Wisconsin Departments, the University of Wisconsin-Extension, the University of Wisconsin-Madison, and public health and early care and education organizations. This paper explores the efforts of the Initiative to advance our understanding of collective impact in practice and its value to health promotion efforts. METHODS: Evaluators conducted a mixed methods case study to evaluate the application of collective impact principles by the Initiative. This included a survey of Initiative partners, review of archival documents, and qualitative interviews with Initiative leaders. RESULTS: Initiative partners noted progress in establishing the conditions for collective impact. Archival documents and interviews describe both formal and informal practices that helped set a common agenda, align and coordinate partner activities, and promote communication among Initiative leaders. Results also detail the important current and potential roles of "backbone" staff from healthTIDE to support the Initiative. Additionally, results suggest particularly challenging aspects of the Initiative's impact model related to shared measurement and broader stakeholder communication. While the Initiative is still setting in place the conditions for collective impact, it has achieved significant policy, systems, and environment changes since its formation. Inclusion of nutrition and physical activity criteria in the state's quality rating improvement system for child care centers is one of its outcomes. CONCLUSIONS: This case study offers several important insights about the application of collective impact in health promotion efforts, particularly in relation to the transition from previous collaborative activities, the value of establishing a clear common agenda among partners, the roles of backbone staff, and time and partner relationships in collective impact.

Lessons From a Pilot Community-Driven Approach for Obesity Prevention.

INTRODUCTION: The Wisconsin Obesity Prevention Initiative has piloted a novel approach for community action for obesity prevention that incorporates both coalition and community organizing efforts in 2 counties. This article describes lessons learned to date from this experience. METHODS: A description of the progress made in these communities and the support provided by Initiative staff and other partners are drawn from process evaluation of the pilot from November 2014 through December 2015, as well as the reflections of community partners. RESULTS: In Marathon County, building towards coalition action required thoughtful re-engagement and restructuring of an existing obesity-focused coalition. Community organizing surfaced local concerns related to the root causes of obesity, including poverty and transit. In Menominee County, coalition and community organizing efforts both have drawn attention to cultural assets for health promotion, such as traditional food practices, as well as the links between cultural loss and obesity. CONCLUSIONS: Building coalition action and community organizing varies across community contexts and requires addressing various steps and challenges. Both approaches require critical local examination of existing community action and stakeholders, attention to relationship building, and support from outside partners. In coalition action, backbone staff provide important infrastructure, including member recruitment and facilitating group processes towards collaboration. Community organizing involves broad resident engagement to identify shared interests and concerns and build new leadership. A community-driven systems change model offers potential to increase community action for obesity prevention.

Utilizing Wisconsin Afterschool Programs to Increase Physical Activity in Youth.

BACKGROUND: Approximately 31.7% of children in the United States are overweight or obese. Interventions in the afterschool setting may help combat childhood obesity. Research exists on interventions in school settings, but a few data exist for interventions about afterschool programs. This study investigates increasing physical activity (PA) in Wisconsin afterschool programs. METHODS: A literature review was used to develop key informant interviews. Utilizing a constant comparative method, interview data were coded and themes were identified. The themes, literature review, and expert opinions were used to formulate recommendations for improving PA in afterschool programs. RESULTS: Programs had success in utilizing different resources to improve PA. Key barriers to improving PA included grant-imposed academic restrictions, the need for provider education, fears of conflict and competitiveness, and a lack of understanding between health and sedentariness. CONCLUSIONS: There is a clear need for additional exploration into improving PA in Wisconsin afterschool programs. This study resulted in specific recommendations to increase PA in afterschool programming, including utilizing school wellness policies and staff professional development to improve PA in afterschool programs.

Community-based restaurant interventions to promote healthy eating: a systematic review.

INTRODUCTION: Eating in restaurants is associated with high caloric intake. This review summarizes and evaluates the evidence supporting community-based restaurant interventions. METHODS: We searched all years of PubMed and Web of Knowledge through January 2014 for original articles describing or evaluating community-based restaurant interventions to promote healthy eating. We extracted summary information and classified the interventions into 9 categories according to the strategies implemented. A scoring system was adapted to evaluate the evidence, assigning 0 to 3 points to each intervention for study design, public awareness, and effectiveness. The average values were summed and then multiplied by 1 to 3 points, according to the volume of research available for each category. These summary scores were used to determine the level of evidence (insufficient, sufficient, or strong) supporting the effectiveness of each category. RESULTS: This review included 27 interventions described in 25 studies published since 1979. Most interventions took place in exclusively urban areas of the United States, either in the West or the South. The most common intervention categories were the use of point-of-purchase information with promotion and communication (n = 6), and point-of-purchase information with increased availability of healthy choices (n = 6). Only the latter category had sufficient evidence. The remaining 8 categories had insufficient evidence because of interventions showing no, minimal, or mixed findings; limited reporting of awareness and effectiveness; low volume of research; or weak study designs. No intervention reported an average negative impact on outcomes. CONCLUSION: Evidence about effective community-based strategies to promote healthy eating in restaurants is limited, especially for interventions in rural areas. To expand the evidence base, more studies should be conducted using robust study designs, standardized evaluation methods, and measures of sales, behavior, and health outcomes.

Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial.

BACKGROUND: Research suggests that the food environment influences individual eating practices. To date, little is known about effective interventions to improve the food environment of restaurants and food stores and promote healthy eating in rural communities. We tested "Waupaca Eating Smart " (WES), a pilot intervention to improve the food environment and promote healthy eating in restaurants and supermarkets of a rural community. WES focused on labeling, promoting, and increasing the availability of healthy foods. METHODS: We conducted a randomized community trial, with two Midwestern U.S. communities randomly assigned to serve as intervention or control site. We collected process and outcome data using baseline and posttest owner and customer surveys and direct observation methods. The RE-AIM framework was used to guide the evaluation and organize the results. RESULTS: Seven of nine restaurants and two of three food stores invited to participate in WES adopted the intervention. On a 0-4 scale, the average level of satisfaction with WES was 3.14 (SD=0.69) for restaurant managers and 3 (SD=0.0) for store managers. On average, 6.3 (SD=1.1) out of 10 possible intervention activities were implemented in restaurants and 9.0 (SD=0.0) out of 12 possible activities were implemented in food stores. One month after the end of the pilot implementation period, 5.4 (SD=1.6) and 7.5 (SD=0.7) activities were still in place at restaurants and food stores, respectively. The intervention reached 60% of customers in participating food outlets. Restaurant food environment scores improved from 13.4 to 24.1 (p < 0.01) in the intervention community and did not change significantly in the control community. Food environment scores decreased slightly in both communities. No or minimal changes in customer behaviors were observed after a 10-month implementation period. CONCLUSION: The intervention achieved high levels of reach, adoption, implementation, and maintenance, suggesting the feasibility and acceptability of restaurant-and food store-based interventions in rural communities. Pilot outcome data indicated very modest levels of effectiveness, but additional research adequately powered to test the impact of this intervention on food environment scores and customer behaviors needs to be conducted in order to identify its potential to promote healthy eating in rural community settings.

Farm to elementary school programming increases access to fruits and vegetables and increases their consumption among those with low intake.

OBJECTIVE: To assess the effectiveness of Wisconsin Farm to School (F2S) programs in increasing students' fruit and vegetable (FV) intake. DESIGN: Quasi-experimental baseline and follow-up assessments: knowledge and attitudes survey, food frequency questionnaire (FFQ), and lunch tray photo observation. SETTING: Wisconsin elementary schools: 1 urban and 8 rural. PARTICIPANTS: Children, grades 3-5 (n = 1,117; 53% male, 19% non-Caucasian). INTERVENTION(S): Farm to School programming ranging from Harvest of the Month alone to comprehensive, including school garden, locally sourced produce in school meals, and classroom lessons. MAIN OUTCOME MEASURES: Knowledge, attitudes, exposure, liking, willingness; FFQ-derived (total), and photo-derived school lunch FV intake. ANALYSIS: t tests and mixed modeling to assess baseline differences and academic-year change. RESULTS: Higher willingness to try FV (+1%; P < .001) and knowledge of nutrition/agriculture (+1%; P < .001) (n = 888), and lunch FV availability (+6% to 17%; P ≤ .001) (n = 4,451 trays), both with increasing prior F2S program exposure and across the year. There was no effect on overall dietary patterns (FFQ; n = 305) but FV consumption increased among those with the lowest intakes (FFQ, baseline very low fruit intake, +135%, P < .001; photos: percentage of trays with no FV consumption for continuing programs decreased 3% to 10%, P ≤ .05). CONCLUSIONS AND IMPLICATIONS: Farm to School programming improved mediators of FV consumption and decreased the proportion of children with unfavorable FV behaviors at school lunch. Longer-term data are needed to further assess F2S programs.

Supermarket and grocery store-based interventions to promote healthful food choices and eating practices: a systematic review.

INTRODUCTION: Increasingly high rates of obesity have heightened interest among researchers and practitioners in identifying evidence-based interventions to increase access to healthful foods and beverages. Because most food purchasing decisions are made in food stores, such settings are optimal for interventions aimed at influencing these decisions. The objective of this review was to synthesize the evidence on supermarket and grocery store interventions to promote healthful food choices. METHODS: We searched PubMed through July 2012 to identify original research articles evaluating supermarket and grocery store interventions that promoted healthful food choices. We categorized each intervention by type of intervention strategy and extracted and summarized data on each intervention. We developed a scoring system for evaluating each intervention and assigned points for study design, effectiveness, reach, and availability of evidence. We averaged points for each intervention category and compared the strength of the evidence for each category. RESULTS: We identified 58 articles and characterized 33 interventions. We found 7 strategies used alone or in combination. The most frequently used strategy was the combination of point-of-purchase and promotion and advertising (15 interventions); evidence for this category was scored as sufficient. On average, of 3 points possible, the intervention categories scored 2.6 for study design, 1.1 for effectiveness, 0.3 for reach, and 2 for availability of evidence. Three categories showed sufficient evidence; 4 showed insufficient evidence; none showed strong evidence. CONCLUSION: More rigorous testing of interventions aimed at improving food and beverage choices in food stores, including their effect on diet and health outcomes, is needed.

Promoting healthy food consumption: a review of state-level policies to improve access to fruits and vegetables.

Research indicates poor nutrition is a leading determinant of the development of chronic disease, and increasing fruit and vegetable consumption is one method for decreasing obesity. Many policies have focused on increasing the demand for fruits and vegetables through price reductions and coupons. However, without ensuring a stable supply, increased demand can continue to raise prices, crowding out individuals who may otherwise have purchased fruits and vegetables and ultimately leading to continued disparities in access. This paper presents a review of selected state-level policy options recently proposed or implemented in states across the United States, and provides an evidence-based lens through which food access policy can be shaped in the Midwest. This review and potential framework uses Wisconsin to illustrate the feasibility of different state-level decisions and their potential impact on particular populations. Future supply-side policies to consider include expanding Electronic Benefit Transfer to the Special Supplemental Nutrition Program for Women, Infants and Children (WIC),program and farmers markets, incentivizing the purchase of locally grown produce, assisting local specialty farmers directly, and/or establishing a state-level food policy council. This review reveals that a food policy council would create a more sustainable policy analysis process to better ensure future policy adoption is truly comprehensive, encompassing the production, distribution and purchase of locally grown fruits and vegetables.

Preliminary findings from an evaluation of the USDA Fresh Fruit and Vegetable Program in Wisconsin schools.

INTRODUCTION: In 2002, the US Department of Agriculture (USDA) created the Fresh Fruit and Vegetable Program (FFVP) to improve nutrition and help reduce the prevalence of childhood overweight and obesity. The FFVP provides funding for students from selected schools in each participating state to receive a free fresh fruit or vegetable snack daily for an academic year. In November 2005, Wisconsin was added to this program. In this study, we evaluate whether the Wisconsin FFVP resulted in positive changes in children's attitudes and behavior related to eating fruits and vegetables. METHODS: In 2006, 25 Wisconsin schools were selected by the Wisconsin Department of Public Instruction for FFVP participation. Study measures included a pre-test and post-test survey given to 4th, 7th, and 9th graders in the intervention and controls schools. Post-test data from all 25 intervention schools were not yet available for analysis. Our sample, therefore, consisted of 1127 participants: 784 students in 10 intervention schools and 343 students in 10 control schools. Independent samples t tests and multivariate probit regression analyses were used to examine attitudinal and behavioral program effects. RESULTS: Compared to controls, intervention students reported an increased willingness to try new fruits (24.8% versus 12.8%, P<0.01) and vegetables (25.1% versus 18.4%, P=0.01) at school. CONCLUSIONS: Findings indicate positive changes in attitudes and behavior among children participating in the Wisconsin FFVP.

Competitive food initiatives in schools and overweight in children: a review of the evidence.

BACKGROUND: Recent research has shown significant increases in the rates of obesity in US adults and children. Despite the widespread discussion about childhood overweight, relatively little discussion focuses on solutions. METHODS: We reviewed the literature on school programs and policies that address competitive foods-commonly called "junk" foods. These foods tend to be high in sugar or fat and provide minimal nutritive value. RESULTS: Sugar-sweetened beverages such as sodas contribute to weight gain and poor nutrition among students-the average student consumes 31 pounds of sugar in these drinks annually. The sale of competitive foods in schools often competes with the more nutritious school lunch programs. With minimal federal and state policies addressing the sale of competitive foods, individual school districts in Wisconsin and elsewhere have explored various alternatives to improve school nutrition. The evidence suggests that these policies can be effective and at the same time increase food sale revenue. CONCLUSION: Communities may be able to improve childhood nutrition through school-based nutrition programs and policies that address the sale of competitive foods.

Effects of nutrition education and exercise in obese children: the Ho-Chunk Youth Fitness Program.

BACKGROUND: Type 2 diabetes is increasingly common, primarily because of increases in the prevalence of a sedentary lifestyle and obesity. This is even more apparent in certain minority populations, such as Native Americans. Whether the risk of type 2 diabetes can be decreased by interventions that affect the lifestyles of children at high risk is not known. METHODS: The Ho-Chunk Youth Fitness Project, aimed at dietary and exercise instruction and intervention, consists of 38 native (Ho-Chunk Tribe, Wisconsin) and non-native children (ages 6-18 years). Children underwent evaluation including medical exam, nutrition, exercise assessment, metabolic testing of fasting plasma insulin, plasma glucose, plasma cholesterol, and percent body fat before and after a 24-week intervention. Intervention consisted of twice weekly classes with supervision for both nutrition and exercise. RESULTS: Mean fasting plasma insulin decreased from 22 +/- 7.7 microIU/ml to 11 +/- 6 microIU/ml (normal < 15 microIU/ml) after 24 weeks of training (P < 0.05). Percent body fat (30.2 +/- 6.4%), glucose (91 +/- 9 mg/dL), and total cholesterol (182 +/- 22 mg/dL) remained unchanged during this time. CONCLUSIONS: Risks for insulin resistance and type 2 diabetes, as measured by fasting insulin (an indirect measurement of insulin sensitivity in obese children), can be decreased by supervised nutrition and exercise intervention. Furthermore, hyperinsulinemia in overweight children can be reduced without decreasing body fat.