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childhood obesityJune 2012 | Volume 8, Number 3© Mary Ann liebert, inc.doi: 10.1089/chi.2012.0004

review

Introduction

Over the past several generations, societal changes have led to the obesity epidemic, with attendant health and economic consequences demanding

new scientific approaches, policy, and actions.1 Obesity is a complex problem involving contributing factors at mul-tiple levels of social organization, including the family (and its lifestyle habits), community structures and ser-vices (that provide or impede access to healthy food and safe activity), and broad societal forces (and related poli-cies, public understanding, and funding).2 There is grow-ing evidence that risk for childhood obesity is already present during gestation and even before pregnancy via maternal weight and epigenetic influences from the prior generation.3–8 Figure 1 provides a schematic view of the developmental and intergenerational effects of obesity, identifying six elements in an ongoing cycle of obesity risk and transmission. High-risk adolescent girls become

high-risk mothers who have high-risk infants, who in turn become high-risk children and adolescents, and the cycle continues. This information suggests that interrupting the effects of “obesogenic systems”9 early in life holds prom-ise.

In the United States, obesity now affects over 10% of preschool children; an additional 10% are overweight.10 Among low-income children, rates are even higher, with 14% being obese.11–13 Obese preschoolers are likely to be obese later in childhood14 and suffer obesity-related co-morbidities. Adverse effects of obesity appear as early as 3 years old, with obese children exhibiting inflamma-tory biomarkers linked to risk for later heart disease.15 The potential for childhood obesity to be precociously “locked in,”16 along with the persistence of obesity from early childhood to adolescence and adulthood,3,17 support the need for interventions to begin early in the life cycle. The resulting burden—poor health, health disparities, and related costs—is likely to continue to accumulate for

1Department of Pediatrics, University of California, San Diego, La Jolla, CA. 2Department of Health Promotion and Social and Behavioral Health, University of Nebraska Medical Center, Omaha, NE. 3Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 4Center on Social Dynamics and Policy, The Brookings Institution, Washington, DC. 5Departments of Pediatrics and Preventive Medicine, Northwestern University, Chicago, IL.

AbstractThere is an urgent need for effective, sustainable child obesity prevention strategies. Progress toward this goal requires strength-

ening current approaches to add a component that addresses pregnancy onward. Altering early-life systems that promote intergen-erational transmission of obesity holds promise for interrupting the continuing cycle of the obesity epidemic. A 2011 Institute of Medicine (IOM) report emphasizes the need for interventions early in life to prevent obesity. A 2010 IOM report called for address-ing gaps in existing obesity research evidence by using a systems perspective, simultaneously addressing interacting obesity pro-moting factors in multiple sectors and at multiple societal levels. A review of evidence from basic science, prevention, and systems research supports an approach that (1) begins at the earliest stages of development, and (2) uses a systems framework to simultane-ously implement health behavior and environmental changes in communities.

Next steps in obesity Prevention: Altering early life systems to support healthy Parents, infants, and toddlers

Philip R. Nader, M.D.,1 Terry T.-K. Huang, Ph.D., M.P.H.,2 Sheila Gahagan, M.D., M.P.H.,1 Shiriki Kumanyika, Ph.D., M.P.H.,3 Ross A. Hammond, Ph.D.,4

and Katherine Kaufer Christoffel, M.D., M.P.H.5

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decades18 unless we implement sustainable prevention measures earlier in the life cycle.

MethodsThe co-authors, a multidisciplinary group of senior

investigators, conducted a series of discussions on our understanding of the strengths and weaknesses of cur-rent approaches to the prevention of childhood obesity. A targeted literature review was conducted using PubMed, beginning with the search terms "obesity," "prevention," and "intervention." The search was narrowed to include publications related to pregnant women, infants, children, and adolescents. We began with review articles and used the bibliographies to identify primary studies. We then identified studies that cited those studies to insure the most current literature review. This review process was extensive beginning with 1438 references. We used the U.S. Preventive Services Task Force system to rank evi-dence and to rank order studies to include in our review. Results of the review were used to support the need for and refine a broader early life cycle approach to the pre-vention of childhood obesity.

ResultsMost efforts to combat childhood obesity have focused

on school-aged children and adolescents. The latest

Cochrane review19 suggests that obesity prevention inter-ventions may produce the largest magnitude of effect early in life. Despite this optimistic evidence, how-ever, the epidemic of childhood obesity persists19 and the impact of fetal overnutrition as a risk for continuing adult obesity may continue to reinforce this vicious cycle at the population level in the United States.20,21 Two Institute of Medicine (IOM) reports emphasize both the need for interventions early in life22 and the use of a “systems per-spective”23 to fill in gaps in obesity research evidence that can more effectively guide policy. There is no currently available framework or strategy that has been proposed to translate these IOM recommendations into action. On the basis of the results of our review of evidence from basic science, prevention, and systems research, presented below, and applied to pregnancy and before and infancy through preschool, this article presents for discussion a strategy to interrupt the continued progression of the childhood obesity epidemic. The twin premises of the approach we propose are: (1) Intervention is necessary before, during, and after pregnancy, and for very young children, and (2) systems approaches are needed for sus-tainable prevention of childhood obesity and its conse-quences.

Pregnancy and BeforeParental overweight conveys a major risk for over-

weight in children, for which both parents’ long-term overweight or obesity is the strongest single predictor.24

nader et al.196

Figure 1. Developmental and intergenerational effects of obesity. Significant interstage events include: 1, Intrauterine programming; 2, breastfeeding, early food exposure, attachment stage; 3, early childhood growth, child care, habit formation; 4, brain maturation, self-management, puberty, health behavior change, increased salience of peer effects and school effects; 5, independence, increasing life stress; 6, preconceptual health, parental health status, prenatal care.

Reproductiveage Adolescence

Childhood

ToddlerhoodInfancy

Pregnancy

Inte

rgen

erat

iona

l im

pact

of

ris

ksC

arry over effects across developm

ental stages

1

6

5

2

3

4

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Maternal obesity before and during pregnancy disrupts glucose homeostasis, insulin sensitivity, amino acid syn-thesis, and fat metabolism, increasing risk for subsequent obesity and disease in the offspring.25,26 Furthermore, ges-tational weight gain is an independent risk factor for obe-sity in the child.27 Both high and low birth weights (linked to maternal obesity) are also associated with higher maternal and infant complications and the development of childhood obesity. Therefore, interventions in pregnancy and early life offer promise for decreasing obesity preva-lence, as both are sensitive periods in which rapid weight gain creates risk for obesity.28 Preventing preconception obesity and excessive pregnancy weight gain and avoid-ing postpartum weight retention are important strategies for reducing obesity prevalence in adult women.29 In Proj-ect Viva, walking and vigorous physical activity in mid-pregnancy were protective against excessive gestational weight gain.30 Individual counseling, self-monitoring of diet and activity, and education paired with motivational interviewing are effective strategies in limiting excessive weight gain. In addition, postpartum weight loss reduces the likelihood of high birth weight and risk for later obe-sity in the next child.31

Infancy to Preschool Rapid weight gain during infancy significantly increas-

es the risk of later obesity.32–35 Therefore, monitoring infant weight gain and attention to nutrition during the first 12 months is crucial. Breastfeeding is associated with a small but significant reduction in risk for obesity, and breastfeeding promotion interventions can be successful.36 Recent analyses from the Feeding Infants and Toddlers Study indicate that the diets of young children remain less than optimal, with too many “empty calorie” foods consumed by children, even in the first year.37,38 Pairing breastfeeding with healthful weaning foods is likely to promote healthy weight trajectories.39–43

Attention to nutrition, physical activity, and screen time are important strategies in early childhood, and parents are important influences on all three. A recent review of effectiveness of interventions aimed at reducing screen time found that while overall there was no evidence of impact on BMI, interventions among the preschool age group held promise.44 A primary care–based intervention directed to 2- to 6-year-old overweight and obese chil-dren did not impact BMI, but the authors suggested that broader approaches could be more effective than primary healthcare interventions alone.45 Nutrition and physical activity practices in nonparental child care sites impact 61% of U.S. children less than 6 years old.46 The IOM report on early childhood obesity prevention22 calls atten-tion to community environmental influences on childhood obesity. Individual-, family-, and center-based early child-hood obesity interventions have been effective, using a combination of nutrition education, guided physical activ-ity, limitation of television viewing, and/or remuneration for participation. Attention to environmental determinants

and adequate intervention and follow-up time increased the likelihood of effectiveness.47

In summary, current evidence supports increased emphasis in obesity prevention efforts on promoting: Optimal preconceptual weight, avoiding excessive ges-tational weight gain, returning toward a healthy postpar-tum weight, breastfeeding promotion, monitoring infant growth for rapid weight gain, promotion of healthy wean-ing foods, limiting screen time, and child care practices48 that promote healthy nutrition and physical activity in young children.

A Systems ApproachA systems approach is one that explicitly focuses on the

interconnections between different aspects of the environ-ment and between individuals and the environment. This is what distinguishes a systems approach from a tradition-al multilevel or multicomponent model. Multicomponent interventions are not the same as systems interventions. Adding systems approaches to whole community—mul-tilevel, multicomponent—interventions allows investiga-tors from the onset to determine the interactions among the systems and sectors that will be required to result in intervention sustainability (persistence of changes made and ongoing adoption of new ones), scalability (diffusion across settings), and reach (across population subgroups).49–52 This is a crucial addition that may well assure adequate strength of the interventions and lead to a wider population change that will impact the course of the epidemic. The concept of multilevel influences on human behavior is well established in public health research and practice as the “ecological model.”53 Socioecological models advocate for combining individual and environ-mental approaches, but do not address how the different levels influence each other and whether that makes a dif-ference in the overall outcomes. Socioecological models also do not inform what is the optimal mix and sequence of intervention strategies to bring about sustained popula-tion-wide impact. This is important given new evidence that adult weight gain and loss do not occur in a linear trajectory,54 suggesting that different combinations and/or sequences of interventions of varying modalities may be needed throughout the developmental pathway to bring about sustained population impact across the age span influenced by early life-cycle systems.

Evolving systems methods49 offer tools to anticipate and leverage complex interactions, feedbacks, and conse-quences in planning interventions. For example, aligning priorities in disparate sectors (e.g., early child care sys-tems, public schools, health agencies, and primary care providers) will lead to new interactions between sectors. These interinstitutional alignments can be defined by sys-tems interactions and can estimate the synergistic effects of coordinating separate sector interventions. Systems methods can also identify key mechanisms at work that affect the evaluation of interventions. Complex interac-

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tion effects, nonlinearities, and dynamic feedback can be difficult to capture in traditional statistical approaches and randomized controlled trial interventions and designs. Systems modeling can provide a valuable complement to conventional research methods.50,55 Systems tools can also help us anticipate unintended consequences when other-wise well-intended interventions are implemented.49,50

Although there is broad agreement that obesity is deter-mined by factors at multiple levels of social organization and across sectors—from the food industry to transporta-tion policy—public health and healthcare systems have been somewhat slow to embrace a systems approach to prevention. However, whole community interventions to prevent obesity in the United States and elsewhere are documented and continue to be evaluated.56–61 Many of these interventions focus on changing social norms via community health promotion (nutrition education and media), school and community mobilization, leadership by political officials, business participation, and attempts to remove individual-level barriers to healthy eating and physical activity. Examples include the multicomponent

projects Shape Up Somerville62 (a city-wide campaign to increase daily physical activity and healthy eating in Somerville, MA) and “Together Let’s Prevent Childhood Obesity”63 (EPODE, in numerous cities and towns in Europe). These interventions have resulted in less weight gain in older children and adolescents. Whole community systems approaches aimed much earlier in the life cycle remain to be tested.

A Systems Framework To Prevent Obesity by Targeting Early Life

To provide a framework to guide the implementation of a systems approach targeting early life, Figure 2 illustrates how policies and practices at the local, state, and national level directly and indirectly affect community-level physi-cal and social environments, the economic environment, healthcare systems, and family and individual health behaviors. These systems influence health behaviors and environments that impact both adults and children simul-

Figure 2. A community systems framework of early intervention of childhood obesity with feedbacks between individuals and the environment. Systems pathways: 1. Policies related to urban planning, housing, transportation, parks and recreation, food availability, access, financing and marketing, and edu-cation. 2. Policies on media and information, housing segregation, industry practices, labor, individual incentives (tax, insurance). 3. Policies on healthcare infrastructure, financing, delivery mode. 4. Interplay between social and physical environment. 5. Social and physical environments enable and/or constrain family and individual behavior. Individuals can also shape their environment. 6. Preventive and treatment services to families and individuals. 7. Healthcare providers’ behaviors and practices, policies, and as advocates for social and environmental changes to promote healthy lifestyles. 8. Individual empowerment and community mobilization to effect policy change.

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199childhood obesity June 2012

taneously, principally in the family setting, but also within community institutions, such as child care and schools for children, work site and neighborhoods for adults, and healthcare systems for both children and adults.64 Systems interaction pathways (1–8, see Fig. 2) are identified, giv-ing a template for designing interventions that specifically enhance pathways that promote healthy behaviors, and dis-rupt pathways that perpetuate obesity, requiring program-ming impacting both adults and children.

System pathways impact behaviors that ultimately determine weight status. As illustrated in Figure 2, for mothers and young children, these eating and activity behaviors are nested within family and cultural beliefs, customs and habit, and adult behaviors and role model-ing related to child feeding and physical activity. Parental choices for their own and their children’s behaviors are influenced by the relative costs involved for parents. Interventions that deal with relative cost issues to families may yield faster change than those related to family cul-tural norms and attitudes. Supports in physical environ-ments (e.g., settings where children and young families spend time, neighborhood characteristics) and social environments (e.g., social relationships, social norms, and cultural influences) are shown as key factors that enable or constrain family and individual behavior. Because the physical environment can shape the social and cultural environment over time, and the social and cultural envi-ronment can perpetuate the status quo in the physical environment, both need to be addressed simultaneously to disrupt the lockstep cycle that prevents progress and change. Physical and social environments are influ-

enced by local, state, and national policies and can also be changed through advocacy by individuals, families, and institutions. Advocacy and policy go hand in hand. Examples of physical environments include lack of access to fresh vegetables and fruits in certain neighborhoods (“food deserts”), or lack of safe places to walk, exercise, or ride bikes. Healthcare and community systems provide obesity prevention and treatment services to individuals and families and are also influenced by local, state, and national policies. Direct advocacy by primary care health practitioners and others who work within community health systems is an important pathway to change physi-cal and social environments in communities.

Complex systems-oriented inteventions65 are geared toward generating solutions to real-world situations that continually change. Such system issues become critical to intervention design, and effectiveness, with focused attention to contextual issues unique to each community. Because obesity prevalence among children and adults var-ies by geographic area, race/ethnicity, and socioeconomic status,66,67 “place-based” community and family interven-tions aiming to prevent excessive maternal weight gain during pregnancy and caloric balance in young mothers and children are proposed. Little is known about cost-effec-tiveness68 of obesity prevention strategies and the potential of systems approaches69 at this early stage.

Evidenced-based sustainable behavior change interven-tions70,71 that parallel policy and environmental change efforts are key components, with a common set of health behavior goals for the three target developmental stag-es—pregnancy, infancy, and toddler. The goals (shown in Table 1) are categorical rather than specific in recog-nition that prevailing guidelines will change over time. Table 2 gives examples of what this approach would look like to influence change through the pathways in Figure 2. For example, access to fresh foods could be enhanced via pathways 1 and 2 through policies promot-ing use of food stamps for fresh fruits and vegetables at farmer’s markets. The primary healthcare sector can implement the latest patient care protocols supporting healthy weight in mothers and young children and make available family-based health promotion behavior change classes (pathway 6). The health sector can also advocate (pathway 7) with government, schools, early child care groups, and birthing hospitals to adopt policies that cre-ate environments that support families to carry out the behavioral goals listed in Table 1. Table 3 summarizes examples of policy, professional action, and public edu-cation targets for early life systems change organized by developmental stage.

DiscussionBeginning obesity prevention in pregnancy has been

suggested before,26 but not with the supporting rationale and systems strategies proposed in this paper. Whole community interventions addressing both policy and

Table 1. Early Life Systems: Key Behavior Intervention TargetsPregnancy

• Engage in early prenatal, post-natal, and inter-conceptual care

• Achieve healthy gestational weight gain

• Post-partum return towards a healthy weight

• Prepare to breast feed

Infancy

• Initiate and maintain breast feeding

• Appropriate introduction of other beverages and foods

• Support for healthy sleep patterns

• Support for appropriate soothing, not always using food

• Support for motor development

• Avoid excessive weight gain in infancy

• Avoid screen time

Toddler Years

• Active play at least one hour per day, limitation of screen time

• Consumption of healthy foods, snacks, and un-sweetened beverages in appropriate portion sizes

• Healthy nutrition and activity standards in childcare settings

• Limit screen time

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behavior change have led to leveling of the progression of overweight in targeted groups. Applying place-based early life systems–oriented health behavior change inter-ventions combined with simultaneously implemented

supportive environmental changes is the next logical step in obesity prevention efforts.

Combining simultaneous behavioral and environmental change marks a notable departure from existing single

Table 2. Pathways for Early Life SystemsSystems pathways framework (Figure 2) Examples of systems interactions

1. Policies related to urban planning, housing, transportation, parks and recreation, food availability, access, financing and marketing, and education

Increased access to safe places for physical activity using primary medical care “Rx for physical activity” honored by local recreation centers; joint use agreements between parks and recreation and schools.

2. Policies on media and information, housing (e.g., segregation), industry practices, labor, individual incentives (tax, insurance, etc.)

Policies on advertising to young children, WIC incentives for breastfeeding, lactation support for working mothers; day care food and activity policies and certification.

3. Policies on healthcare infrastructure, financing, delivery mode

Culturally relevant family behavior change programs, use of lay health outreach educators connecting primary care and community prevention; institution of baby-friendly practices in birthing institutions and prenatal care; community prevention campaigns, surveillance and monitoring of population health outcomes (BMI).

4. Interplay between social and physical environment Attempt to change social and physical environments through social networks and urban redevelopment to shift social norms and culture.

5. Social and physical environments that enable and/or constrain family and individual behavior; Individuals shaping their environment

Identify barriers and supports for families and provide tools to help them make small changes in their immediate environment.

6. Preventive and curative services to families and individuals Update pregnancy, postpartum, and pediatric clinical protocols to provide same age-appropriate health messages and services to interconceptual and pregnant women, and postnatal nutrition and activity goals.

7. Healthcare providers’ behaviors, policies, and practices, and as advocates for social and environmental changes to promote healthy lifestyles

Develop toolkits to equip providers with advocacy skills; provider training on latest IOM/ACOG policies and health system guidelines; support provider engagement with community agencies such as WIC, and child care providers.

8. Individual empowerment and community mobilization to effect policy change

Use grassroots advocacy and civic participation to promote policy change.

IOM, Institute of Medicine; ACOG, American Congress of Obstetricians and Gynecologists; WIC, Women, Infants and Children Program.

Table 3. Strategies for Policy, Professional Behavior, and Public Education Supporting Individual and Family Health Behavior Changes for Pregnancy, Infancy, and Toddlers

In addition to policies and built environments supporting safety, walkability, access to healthy foods and water, and active transportation

Pregnancy Infancy Toddler

PO

LIC

Y • Baby-friendly policies in prenatal care and birthing institutions

• Work site and service site lactation support policies

• Day care food and activity policies and certification

• Creation of children’s zones to encourage healthy behaviors

PR

OF

ES

SIO

NA

L

• Incorporate most recent IOM/ACOG guidelines in prenatal/interconceptual care

• Consistent health recommendations regarding breastfeeding and infant nutrition from prenatal and postnatal health providers

• Monitor infant growth with appropriate infant nutrition recommendations

• Provider encouragement and reinforcement of family activity behavior and home environment change, parenting, sleeping and infant soothing techniques other than feeding

• Provider advocacy for work site lactation support

• Day care and health provider encouragement and reinforcement of family health behavior changes in food and snack choices, sweetened foods and beverages, portion size, and screen time

• Provider encouragement of daily activity/play time

• Provider advocacy for healthy day care environments

ED

UC

AT

ION

• Community support systems for timely prenatal care and breastfeeding preparation

• Community support for and awareness of maintaining a healthy maternal weight before, during, and after pregnancy

• Same current health messages from all infant care providers

• WIC support and incentives to continue breastfeeding

• Community systems support ability of families with infants to achieve a healthy home environment

• Day care encouragement and modeling of changes in food and snack choices, sweetened foods and beverages, portion size, and screen time

• Family and community resource centers reinforce same targeted health behaviors

IOM, Institute of Medicine; ACOG, American Congress of Obstetricians and Gynecologists; WIC, Women, Infants and Children Program.

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modality approaches (behavior change only or environ-mental change only). Whitaker72 noted that traditional research methods, such as the randomized trial, are lim-ited in addressing the complex factors involved in child-hood obesity. The approach presented here uses systems methods that take into account attitudes and norms in a defined community, as well as the challenges imposed by broader societal values and physical, social, and institu-tional barriers to change. The public message would be to promote well-being as opposed to avoiding poor health outcomes. For example, providing the best chances for a healthy life for an expected offspring is likely to be more valued by the average person than linking motivation for behavior changes to a distant goal of avoiding extra weight because of increased risks for chronic disease later in life.

To see if building early life systems–oriented solutions to obesity works, we propose a series of community-driven, coordinated, place-based interventions that are rigorously evaluated. Sites with experience in cross-sector collaboration, with strong research methodologists and community leadership and partnerships, would be selected through a competitive mechanism with national oversight from a major public health research institu-tion. For example, selection of 8–10 specific communi-ties reflecting diverse populations would implement and evaluate interventions tailored to the unique strengths and constraints of participating local communities. The evalu-ation would combine the strengths of community-based participatory research with the rigor of the randomized clinical trial. The interventions would be standardized, but intentionally variable with regard to delivery meth-ods, cultural tailoring, and real-world problem solving. Comparisons could be done with cluster randomization, or simulated through multiple baselines, or interrupted time series analyses in a single population. Iterations in several communities add validity to overall conclu-sions of effectiveness. Standardized outcome measures and analytical methods will be employed. Design and oversight responsibilities are shared by research method-ologists and community leaders. This method has been suggested as a “multisite translational community trial” to test the real-world community efficacy of complex health promotion interventions.73

The series of interventions would be evaluated by the outcomes of healthier weight for childbearing women and their infants and young children. Follow-up should con-tinue long enough to track adult and child weights, and to document the sustainability, costs, and any demographic changes over time.

Is it feasible to implement and evaluate this added emphasis to current obesity prevention efforts? Feasibil-ity is linked to prioritization of financial resources, which potentially contrasts the values of remaining with the sta-tus quo intervention and research methods, compared to the costs of testing a broader paradigm and methods. Both need to be referenced to the estimated costs of a continu-

ing obesity epidemic. Currently, obesity-related diseases account for 10% of U.S. medical spending, or an estimat-ed $147 billion/year. Estimates of medical costs associat-ed with treatment of obesity related diseases are projected to increase by $48 to $66 billion/year in the United States by 2030.74 The National Institutes of Health (NIH) spent $971 million in fiscal 2010 on obesity research. In 2010, the CDC awarded $372.8 million to 44 communities for “Communities Putting Prevention to Work” (CPPW) grants to improve nutrition and physical activity, reduce obesity, and prevent smoking. An additional $100 mil-lion has been allocated for “Community Transformation Grants” to prevent chronic diseases and health disparities. Funds for testing this approach could conceivably come from prioritizing existing and planned funding streams directed toward reducing the economic and health bur-dens of a continuing obesity epidemic. Using a systems approach might eventually result in cost savings because of cost-efficiencies gained through coordination of exist-ing policy and behavior change interventions and the avoidance of redundancies, as well as rapid identification and remedy of costly unintended consequences.75

One of the first multilevel, multicomponent, school-based interventions to simultaneously address both policy and behavioral interventions was the Child and Adolescent Trial for Cardiovascular Health/Coordinated Approach to Child Health (CATCH) study. At that time (1987–1996), multicomponent interventions were novel to researchers. Today, there is substantial experience with policy (e.g., baby-friendly and lactation support policies) and health behavior intervention research (e.g., limiting excessive gestational weight gain and early childhood interventions). What remains to be done is to implement and evaluate policy change and health behavior change at the same time in the same place, using systems-based methods that include the interactions among individuals and environments. The current experience of U.S. com-munities that have already implemented environmental changes, such as those participating in CDC’s CPPW and Community Transformation Grants, provides a pool of communities that could be ready to implement and test this combined approach applied to the systems impacting early life.

ConclusionThe approach proposed in this paper—to focus a new

effort on evaluating multiple place-based (defined com-munity) systems-oriented interventions designed around pregnancy, resulting in a healthy weight for women and their offspring—is intended to launch a discussion among private and public health practitioners and investigators, leaders in maternal and child health, policy makers, gov-ernment agencies, and private foundations on the merits of adding this approach to obesity prevention efforts. Federal and private agency initiatives reflect a growing momentum to alter the systems that feed the continuation

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of the obesity epidemic. We believe this is the next logical step in obesity prevention, built upon the tools and expe-rience gained over the last 30 years and that the nation could be prepared to take on this challenge.

AcknowledgmentsThe authors gratefully acknowledge: Natalia Veronique

Lotz, medical student, Eastern Virginia Medical School, and Matthew Cappiello, medical student, University of Cali-fornia, San Diego School of Medicine, for their assistance with literature review for this paper. We also appreciate the careful manuscript preparation and review by Christine Williams, M.P.H., and Estela Blanco, M.P.H., M.A. In addi-tion, thanks to Melinda Bender, R.N., Ph.D., and Yvette La Coursiere, M.D., M.P.H., Assistant Clinical Professor, Department of Obstetrics and Gynecology, Reproductive Medicine, University of California, San Diego, for their suggestions of literature pertaining to intervention with preschool Latino children and relevant studies and policies related to maternal overweight before and during pregnancy.

Author Disclosure Statement No competing financial interests exist for Drs. Nader, Huang, Gaha-gan, Kumanyika, Hammond. Northwestern University receives salary support from CDC/ CPPW for Dr. Kaufer Christoffel.

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Address correspondence to:Philip R. Nader, M.D.

Professor Emeritus of PediatricsDepartment of Pediatrics

University of California, San Diego9500 Gilman Drive, MC 0927

La Jolla, CA 92093-0927E-mail: pnader@ucsd.edu

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