Youth nex physical health & well being conference

THE 3rd ANNUAL

YOUTH-NEX CONFERENCE

Physical Health & Well-Being for Youth October 10 & 11, 2013

A Discussion to Promote Physical Activity, Nutrition, Health, and Well-Being in Children and Adolescents.

Table of Contents Introduction p. 2-3 Keynote p. 4-7 Panel 1 Overview of Physical Activity and Healthy Eating p. 8-11 Lunch Symposium How Do Our Built Environments Impact Youth? p. 12-13 Panel 2 Strategies to Increase Physical Activity p. 14-21 Panel 3 Nutrition and Healthy Eating p. 22-27 Panel 4 The Mind-Body Connection p. 28-37 Panel 5 Injury Prevention and Treatment p. 38-49 Wrap-Up p. 50-57 List of Conference Presenters p. 58-59

The Setting: The University of Virginia

by Ellen Daniels, Patrick Tolan, and Art Weltman with the assistance of the conference Prepared byPrepared Ellen Daniels, Patrick Tolan, and Art Weltman with the assistance of the conference presenters.presenters.

Resources p. 60-61 Image Credits p. 62-63

1

INTRODUCTION Arthur Weltman, Ph.D.

Conference Chair

Behavior undertaken in adolescence shapes a lifetime of habits and health

long into adulthood. What can we do now to ensure our children’s well-being at this important time of development?

Arthur Weltman, Ph.D. is professor and chair of Kinesiology at the University of Virginia’s Curry School of Education; professor of Medicine, School of Medicine; and program director at Youth-Nex for Promoting Healthy Eating and Activity for Youth.

L

Resource

2

Curry School of Education - www.curry.virginia.edu

eaders from across the country convened to focus on the physical and mental health of youth in the context of Positive Youth Development.

We listened to the latest and best research, exemplary practices, and key policy considerations to inspire each other’s work and spark new ideas to improve the well-being of youth in Virginia and throughout the nation.

3

KEYNOTE

Physical Activity Guidelines Children should get one or more hours a day of physical aerobic activity that: > is moderate to vigorous > is vigorous for three days a week

WHAT CAN WE DO TO INCREASE PHYSICAL ACTIVITY FOR YOUTH WILLIAM H. DIETZ, M.D., PH.D.

?

Taking the Pulse > Seventeen percent of children and adolescents in the United States are still obese. > Obesity trends in girls are flat-lining but increasing in boys.

> includes muscle-strengthening at least three days per week

> includes bone-strengthening at least three days per week

> is age-appropriate, enjoyable and offers variety

Parents need to understand that PE in schools will help kids academically.

> Being active at each life-stage increases the likelihood of being active for the next phase of life.

Resource

6 4

Centers for Disease Control and Prevention (CDC) - www.cdc.gov

William Dietz is the former director of the Centers for Disease Control and Prevention’s Division of Nutrition, Physical Activity, and Obesity.

THE SCHOOL DAY DESERVES TO BE A MAJOR FOCUS FOR PHYSICAL ACTIVITY

Afterschool Time Before School ˜60 minutes/day

School Day Recess

PE

&

Breaks

Classroom

˜6-7 hrs/day

Afterschool Programs Intramural Sports Extramural Sports ˜2-3 hours/day

Active Commute To

Active Commute From

Only about 30% of 16-19 year olds are meeting the requirement of 60 minutes of exercise per day. Most get around 20-30 minutes per day.

6

Kohl HW III, Cook HC. Educating the Student Body, IOM 2013.

KEYNOTE

Opportunities for School-Wide Physical Activity

Inequities Schools that don’t provide recess to first-graders, have higher levels of minority, poor, or urban youth.

School-based PA Interventions > Implement Physical Activity Guidelines > Mobilize Parents > Convene relevant groups to develop and implement a strategic plan

Conditions for Collective Success > Common agenda > Mutually reinforcing activities > Continuous communication

Strategies to Increase Activity > Provide portable play equipment on playgrounds and play spaces > Increase outdoor time > Integrate PA into teaching and learning activities > Train all staff in delivery of structured PA and increase PA session time

7

Panel 1: OVERVIEW OF PHYSICAL ACTIVITY AND HEALTHY EATING RUSSELL PATE, PH.D. - CHARLES HILLMAN, PH.D. - DEANNA HOELSCHER, PH.D., R.D., L.D.

» brain health | CHARLES HILLMAN, PH.D. Can a single bout of physical activity impact cognition?

We know there are physical h ealth ben efits to ph but there are h ysical acti uge gaps that vity, limit the ability to develop pol icies, practices , and recommendations that will ultimately benefit children.

Russell Pate, Ph.D. It appears so. A study by Hillman’s group had kids come in to their lab for 2 conditions: a 20 minute

bout of walking and 20 minutes of sitting quietly. Each condition was followed by a test of inhibition and an academic achievement test. (Citation in Resources section) Scores on the inhibitory task were significantly better after exercise than in the sitting condition. After exercise, kids improved in reading and math by a whole grade level compared to the sitting condition.

Cardiovascular fitness is associated with improvements in cognitive control, which is inherent in academic achievement.

Resources Institute of Medicine - www.iom.edu/Reports/2011/Early-Childhood-Obesity-Prevention-Policies/Recommendations.aspx The effect of acute treadmill walking on cognitive control and academic achievement in preadolescent children. CH Hillman, MB Pontifex, LB Raine, DM Castelli, EE Hall, AF Kramer Neuroscience 159 (3), 1044-1054.

8

Pictured at right: Deanna Hoelscher, Russell Pate, Charles Hillman.

Did you know?

We’ve had federally mandated dietary guidelines for 25 years, but no physical activity guidelines. Physical activity guidelines were finally mandated in 2008.

5

panel 1

» healthy eating | DEANNA HOELSCHER, PH.D.

THE STATE OF LUNCH BAGS High income families have an abundance of fruits, vegetables and whole grains available, Y E T

Under the Influence: Kids see: 153 ads per year promoting healthy eating and 7600 ads per year promoting unhealthy snacks.

These youth’s lunches contained few fruits and vegetables and 77% of the bread products were refined.

Nutrition education at school is not mandated.

What should we focus on?

>>> Abandoning the concept of “kid” food, which sets up a culture of non-nutritious foods. >>> Learning more specifically about pre-school nutrition—there has been limited research in this area. >>> Studying more about nutrition only, versus activity and nutrition. >>> Structuring interventions knowing that appetite increases throughout the day. >>> Decreasing food availability - many of us eat too often. Let’s take more breaks from food!

10

11

Lunch Symposium

HOW DO OUR BUILT ENVIRONMENTS IMPACT YOUTH? Matthew Trowbridge, M.D., M.P.H.

Researchers worked with local architects to create a cutting edge school environment in order to improve student well-being. The team’s approach yielded many innovations including a teaching kitchen, composting garden, and nutrition resource library to impact the health behaviors of school children at Buckingham Elementary in Dillwyn, Virginia.

The dining commons was transformed into a classroom with a teaching kitchen and food labs.

“A pediatrician’s recommendation that a patient get regular physical activity loses its salience if this patient’s everyday world lacks opportunities to walk, play, or run.” - Matt Trowbridge

The lounge area — complete with activity-promoting stools and chairs.

Schoolyard garden Students and teachers help maintain a community-developed garden on school premises.

More about the project Impact of School Architecture on School Habits - http://bit.ly/_arch Project Video - http://bit.ly/archvideo

12

13

Panel 2: STRATEGIES TO INCREASE PHYSICAL ACTIVITY DIANNE WARD, Ed.D. - JOSEPH DONNELLY, Ed.D. - PHIL WENDEL, CHRISTINA ECONOMOS, PH.D.

Preschool and at Home

» early childhood

obesity prevention | DIANNE WARD, Ed.D.

Infants: • Should interact with parents or caregivers in daily physical activities and in settings that encourage, not restrict, activity.

Toddlers and Preschoolers: • Should engage in at least 60 minutes – up to several hours per day – of unstructured activity.

Childcare settings should engage kids in 120 minutes of physical activity per day.

Often this is the only activity children get.

• Toddlers should accumulate 30 minutes of structured physical activity each day.

• Preschoolers should get 60 minutes of structured physical activity each day.

How Does Parenting Style Affect Physical Activity?

With regard to physical activity, a warmer and responsive parenting style works well with supportive practices, such as:

-engaging kids in active play, and modeling physical activity -educating and encouraging kids about being active -involving kids in family activities - it works less well with controlling practices such as monitoring rules for indoor and outdoor play and setting limits for screen time.

A more authoritarian or demanding parenting style works well with more controlling practices, such as:

-monitoring rules for inside & outdoor play -monitoring screen time Although the long-term effects of this style practice are unknown.

Inconsistent parenting where activity was encouraged didn’t produce more active kids.

* Institute of Medicine, Washington, 2011.

14

15

Panel 2 » physical and academic achievement in elementary school | JOSEPH DONNELLY, Ed.D., FACSM

Schools are Sedentary

BEHAVE BE QUIET STOP MOVING AROUND BEHAVE BE QUIET STOP BEHAVE QUIET STOP MOVING AROUND BEHAVE BE QUIET AND STOP MOVING AROUND BEHAVE BE QUIET STOP MOVING BE SILENCE

BEHAVE BE QUIET STOP SILENCE BEHAVE STOP QUIET

There is no evidence that removal of physical activity programs results in greater academic achievement.

Physical education by itself is not adequate to provide fitness.

Schools are Sedentary

“Before kids are in school, they are always running around and engaged in activity. Once they go to kindergarten, they are basically told to sit down and be quiet for the next 12 years.”

– Joseph Donnelly, Ed.D. INTERVENTION

Physical Activity Across the Curriculum - (PAAC):

A classroom-based approach to reduce sedentary behavior while maintaining the focus on academics. The curriculum:

Delivers Academic Instruction Through Movement • For a spelling lesson, playing a hopscotch-like game, hopping from letter to letter to spell different words.

Does Not Decrease Academic Instruction Is Low Cost, Has Low Teacher Burden

16

17

Panel 2 » fitness club programs for children and adolescents| PHIL WENDEL The for-profit youth sports industry is providing physical activity opportunities for children due to the vacuum created by the absence of physical activity in the public schools. Fitness clubs can help bridge the gap between the growing number of competitive, pay-to-play sports teams and fewer school-based programs.

—Phil Wendel, Owner ACAC (Atlantic Coast Athletic Club)

Phil Wendel opened ACAC in 1984 in Charlottesville, Virginia.

Because of a lack of activity for children in the past 15 years, the club began offering robust programs for youth as well as adults.

In the summer, ACAC serves about 1000 5 – 11-year-olds per week in summer camps where they are very physically active.

ACAC picks up children whose parents can’t be home when school is out. ACAC buses transport them to the club, where they participate in supervised study halls and physical activities.

Some Richmond area schools have outsourced their physical education classes to ACAC clubs – students get credit for participating in activities there.

Resources Book: The Most Expensive Game in Town, Mark Hyman - www.themostexpensivegameintown.com

18

19

Panel 2 » catalyzing communities | CHRISTINA ECONOMOS, PH.D.

How Do you Spark the SOCIAL

CHANGE

Needed to Shift the Way we View Health?

[recycling, seat belts, tobacco, etc.]

Nurture Change-maker “spark plugs” Leaders: teachers, researchers, etc.

Know Economics are Important

Call for a Crisis

Develop Advocacy

Build on a Sound Scientific Base

Use Media

Develop a Clear Plan

Learn from Other Movements

Use Government Strategically

Create Environmental & Policy Changes

To increase youth activity levels In Somerville, Massachusetts, researchers engaged a wide range of community members including..... > families > teachers > every pediatrician > all 14 after-school programs > restaurants > local government They applied multiple proven interventions: BEFORE SCHOOL: Walking programs and healthy breakfasts. DURING SCHOOL: Micro units of activity, nutrition education, professional development for PE teachers.

AFTER SCHOOL: Cooking and nutrition programs, improvements in environment - walkability and bikeability.

RESULTS: Body Mass Index z-score (BMI z-score) went down during the school year; sugary beverage consumption and screen time decreased; participation in sports and activities increased.

CAUTIONARY TALE

Summertime inactivity undoes much of what is accomplished during the school year.

Kids gained up to 10 pounds over the summer (Summer school helps minimize this effect).

Scaling up Nationally 20

SOMERVILLE, MA Inspirational Change in One Community

Resource: childobesity180.org

“Ultimately,

relationships made it work.”

FAMILI }

Panel 3: NUTRITION AND HEALTHY EATING KIRSTEN DAVISON, PH.D. - RANDY BIRD - NOAH CARPENTER & BET HOWRIGAN

2-year study

» creating sustainable family-based obesity interventions | KIRSTEN DAVISON, PH.D.

CHALLENGE:

Reaching Families

STRATEGY:

Maintain contact with families over time Partner with organizations that reach families

Even before intervention implementation, we often encounter challenges...

CHALLENGE:

Parents not interested if don’t see immediate need

STRATEGY:

Design program around the needs & interests of families

Family Action-Based Model of Intervention Layout and Implementation

Researchers developed interventions that empowered parents and caregivers to foster healthy family lifestyles and establish systems-level change that reinforces family change. They used family development theory; formed an advisory board including parents; and used a mixed approach to determine needs of families.

Intervention: Health communication campaign delivering health facts versus myths Letters sent home about children’s BMI that were easy to interpret Family coffee hour with nutrition counseling Parent-led sessions to increase knowledge about available resources

RESULTS CHALLENGE:

Passive Refusals (consent but don’t show up)

STRATEGY:

Build the intervention into the programs they are involved with

> >

CHALLENGE:

Priorities for interventions don’t match priorities for families

> > >

STRATEGY:

Ask family members what they hope to gain by participating

Children: Declines in % of obesity Increases in light physical activity Families: Improvement in dietary profiles Parents: Improvements in all aspects of resource empowerment Improvements in diet and physical activity The greater the amount of exposure to components of the program, the greater the improvement in diet and physical activity in families.

See the study Published in International Journal of Behavioral Nutrition and Physical Activity IJBNPA - www.ijbnpa.org/content/10/1/3

22

23

Panel 3 » game-breaking nutrition for the young athlete | RANDY BIRD Eat the rainbow: cherries,strawberries, carrots,bananas,squash,peaches,broccoli,lettuce,raisins,blueberries,plums, nuts,olive oil,whole grains

Drink early and often > Eat a variety of different foods > Eat early and often

No! Carbohydrates are the athlete’s fuel. Lack of carbohydrates leads to:

Fatigue Irritability Nutrient deficiencies Poor athletic performance Bad breath

Quality Matters

SHOULD WE AVOID FATS? NO! We do need some fat in our diets. > > > >

They are needed for proper hormone functioning They help control satiety (makes you feel full) They store fat-soluble vitamins (A, D, E, K) They deliver our essential fatty acids ...and as with carbohydrates; quality of fats matter.

Healthy fats include: avocado, organic butter, almonds, olive oil.

Choose high fiber, and slower-to-digest carbs, such as: Fresh Fruit, Whole Grains, and Oatmeal.

PROTEIN

• Builds & repairs muscles • Enhances the immune system • Produces hormones • Replaces red blood cells

Nutri-Nugget: Which food has the most vitamin C? a. A Glass of Orange Juice b. An Orange c. Beans d. Red Bell Pepper Answer on right-hand page. > > > >

FAT

Specifically...

• Eat breakfast daily • Eat every few hours (5 – 6 times) • Try to choose the least processed foods • Eat a variety of colors - aim for a wide range of colors in one week • Include a lean protein source at every meal • Consume a combination of carbs and protein before and after workouts • Stay hydrated • Get adequate sleep

ARE CARBS FATTENING?

> Most people do get enough protein in their daily diet.

> > > > > > > > > > > > > > > > > > > > > > > >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >

Answer:

Red Bell Pepper

>

24

Nutrition Foundations

Active Bodies Want to Know:

25

Panel 3 » ‘Fuel Up To Play 60’ students inspire school health | NOAH CARPENTER & BET HOWRIGAN

‘Fuel Up to Play 60’ can be customized to fit a school’s unique needs. Students are encouraged to be leaders.

There are 73,000 schools, 11 million students, and 8,000 student ambassadors, like Noah, involved in Fuel Up To Play 60.

As ambassador at Fairfield Center School in Vermont, Noah helped initiate: Taste Tests

To introduce classmates to new, healthy foods such as smoothie pops.

Activity Breaks During Class

Brief, focused, in-class breaks for physical activity that won’t disrupt the classroom.

Before school, students run or walk a lap around the school. They can also participate in other activities like Wii bowling before school.

Shelter Soup Drive

The week before the Super Bowl, classmates organized a soup drive for the local food shelter.

There were coloring contests and activities at every grade level, such as “Tailgate Party” with dancing and tasty and healthy food.

Farm to Classroom Student Ambassador

Noah Carpenter TAKING ACTION

Fuel Up to Play 60 is an in-school nutrition and physical activity program launched by National Dairy Council (NDC) and National Football League (NFL), with additional partnership support from U.S. Department of Agriculture (USDA). The program encourages youth to consume nutrient-rich foods and achieve at least 60 minutes of physical activity every day. It is designed to engage and empower youth to take action for their own health by implementing long-term positive changes for themselves and their schools.

Students learn plant and grow their own vegetables. They also learn how to prepare and cook them as part of nutritious meals.

The program works to complement,

not compete with, an

academics-focused environment.

Learn More

26

Fuel Up to Play 60 - FuelUptoPlay60.com

27

Panel 4: The Mind-Body Connection

M I N D F U L N E S S

PATRICIA JENNINGS, M.ED., PH.D. - SHERI RAND, M.ED. - ALI SMITH

promoting learning through mindfulness | PATRICIA JENNINGS, M.ED., PH.D.

Mindfulness is paying attention, in a particular way, on purpose, in the present moment, nonjudgmentally. It’s an awareness of one’s conduct and the quality of one’s relationships, inwardly and outwardly....(Kabat-Zinn,

There’s a growing body of research showing positive effects of mindfulness practices (e.g. mindful breathing, meditation, etc.) with adults.

These include: > Enhanced memory > Increased concentration > Increased capacity for empathy and compassion > Brain changes that support emotion regulation

What are the implications for school children and classrooms?

2009/2011).

28

29

Panel 4 - promoting learning through mindfulness (cont’d)

| PATRICIA JENNINGS, M.ED., PH.D.

Evidence-Based Programs for Children InnerKids Foundation (citation in Resources Section)

MindUPTM Informed by research in cognitive neuroscience,

Randomized Controlled Trial

social-emotional learning, mindfulness training and positive psychology.

Results:

(12 weeks, 99 children, 4th & 5th graders)

Curriculum:

> 24% increase in positive social behaviors

- Getting Focused

> 15% increase in math achievement

- Sharpening Your Senses

> 20% increase in self-reported social-emotional competencies and skills

- Attitude - Mindfully Taking Action

Based on mindfulness stress-reduction for younger children.

Taught through games, activities, instruction and sharing.

> 24% decrease in aggressive behavior

Learning to Breathe A strengths-based mindfulness curriculum for adolescents that aims to enhance emotion regulation in order to strengthen attention and performance, support pro-social behavior, build stress management skills, and improve health and well-being.

Composed of 3 units: - Attention & Five Senses - Balance & Movement - Clarity & Compassion

Pilot Trial

(120 high school seniors)

Randomized Controlled Trial

(8 weeks, 64 children, around 8 y.o.)

Results Included:

Results:

> Increased calmness, self-acceptance, emotional regulation > Reductions in negative mood, tiredness, aches/pains > 64.6% of participants reported practicing mindfulness techniques outside of class time > The most important skill reported by almost 50% of participants: Learning to let go of distressing thoughts and feelings in order to control their stress level

> Improved Executive Function (Executive Function includes decisionmaking, organizational skills, planning)

Additional Resources for Learning to Breathe Resources

Book

InnerKids - www.susankaisergreenland.com/inner-kids.html MindUpTM - www.thehawnfoundation.org/mindup Garrison Institute - www.garrisoninstitute.org Learning to Breathe - www.learning2breathe.org/

Learning to Breathe: A Mindfulness Curriculum for Adolescents to Cultivate Emotion Regulation, Attention, and Performance by Patricia C. Broderick, Ph.D., New Harbinger Publications, Inc.

PANAS (Positive and Negative Affect Schedule) Watson, Clark & Tellegen, 1988 www.gse.uci.edu/childcare/pdf/instrumental_docs/PANAS%20ID.pdf DERS (Difficulties in Emotion Regulation Scale) Gratz, & Roemer, 2004 www.nctsnet.org/content/difficulties-emotion-regulation-scale Somatization Index (Achenbach, 1991) Qualitative Process Assessment (Broderick, 2007)

30

31

Panel 4 - what does it mean to educate the whole child?

| SHERI RAND, M.ED.

A Vermont school district promotes mindfulness in the classroom.

Searching for ways to help children grow strong and resilient.

Vermont Educators in the South Burlington School District (SBSD) found that stressors, including socio-economics, overstimulation, and academic pressure, were translating into more anxiety, anger and difficulty regulating emotions and focus. What was often missing in the classroom was a true presence on the part of the child and sometimes on the part of the teacher.

It’s important for the adults to experience the benefits of the practice and to be able to model what they are learning and teaching. — Sheri Rand, M.Ed. Adults are offered a professional development course to learn self-care, calming practices, evidence-based emotional self-regulation skills, empathy and compassion. Teachers then implement and imbed mindfulness strategies into their classroom through discrete curriculum, literature, and/or a variety of mindfulness based activities.

At SBSD, mindfulness practices are an intentional part of a Wellness and Resilience Program (WRP) aimed at giving children tools, beginning in Pre-K, for self-control, reflection, and relaxation. Among these techniques are breathing exercises, body scan, sensory perception and social connection exercises, mindful eating, and journaling.

When children are able to calm their bodies and minds, they are more available for learning.

Resources South Burlington Wellness & Resilience Program - bit.ly/sthburl_mindful UCSD Center for Mindfulness - https://ucsdcfm.wordpress.com/tag/sheri-rand/

32

33

Panel 4 Âť the holistic life foundation - from inner health to outer health | ALI SMITH

2010 Crime Rate Indexes Baltimore County, MD 0

100

200

300

400

500

600

700

Murder Risk

The Holistic Life Foundation is

a Baltimorebased organization committed to nurturing the wellness of children and adults in underserved communities. Using a comprehensive approach, they help children develop their inner lives through yoga, mindfulness, and self-care, while fostering community well-being.

Rape Risk

Robbery Risk

Assault Risk

Burglary Risk

Larceny Risk

Motor Vehicle Theft Risk

Baltimore County, MD

Maryland

United States

T h i n g s w e n o t i c e d In the community: Lack of connection | Lack of compassion | Extreme hypervigilance | High Stress Lack of Healthy Foods | High Trauma | Lack of Physical Activity | Lack of Peace | Hopelessness

Learn More

34

Holistic Life Foundation - www.hlfinc.org

35

Panel 4  the holistic life foundation - from inner health (cont’d) to outer health | ALI SMITH Youth who practiced

Mindfulness

Showed

IMPROVEMENTS in Self Regulation Concentration & Focus Conflict Resolution Thought & Emotional Awareness Anger Management Stress Reduction Compassion Interconnectedness

HLF partnered with Johns Hopkins University Bloomberg School of Public Health and Penn State University to conduct the only randomized controlled trial with urban youth and yoga. Students showed increased concentration, ability to control emotions and decreased rumination.

Empowerment Social & Emotional Wellness Physical Health

Learn More Holistic Life Foundation - www.hlfinc.org

36

37

Panel 5: Injury Prevention and Treatment youth sports Âť encouraging life-long physical activity

| MICHAEL BERGERON, PH.D., FACSM

National Youth Sports Health & Safety Institute The NYSHSI advocates for advancing and disseminating the latest research and evidence-based education, recommendations and policy to enhance the experience, development, health and safety of youth in sports.

The NYSHSI views these areas of focus as urgent: 1. SPORTS TRAUMA: Sport Concussion, etc.

2. ENVIRONMENTAL CHALLENGES: Exertional Heat Illness/Stroke, etc.

3. TRAINING and COMPETITION OVERLOAD: Overuse Injuries, Over-scheduling, etc.

4. PLAYING with CHRONIC DISEASE & DISABILITY: Athletes with Type 1 diabetes, sickle cell trait, physical disabilities, etc.

Comprehensive vision for safety & youth sports:

To increase awareness, advance research, educate, inform policy.

91%

of Americans feel sports participation is important for children and adolescents as a part of an active, healthy lifestyle.

94%

Resources

feel more needs to be done to ensure the health and safety of youth athletes.

38

2011 Survey

National Youth Sports Health & Safety Institute - www.nyshsi.org Datalys Center for Sport Injury Research - www.datalyscenter.org National Collegiate Athletic Association (NCAA) - www.ncaa.org/health-and-safety/ncaa-sport-science-institute National Federation of State High School Associations (NFHS) - www.nfhs.org

39

Panel 5 » youth sports - encouraging life-long physical activity | MICHAEL BERGERON, PH.D., FACSM

(cont’d)

Success takes time.

Less than

.1%

>>> The Chances A High School Youth Athlete Will Become a Pro Athlete.

Young athletes shouldn’t be driven to train so strenuously and with such pressure. They should get progressive and diversified exposure through childhood and adolescence. >>> Injury will be reduced; and athletic capacity and sustained performance will be enhanced.

Sports Participation Rates Drop by the Late Teens.

Why?

5%

>>> The Chances A High School Youth Athlete Will Get a College Sports Scholarship.

Young athletes should participate in sports for reasons other than playing in college or professionally. >>> Done the right way, youth sports can set a foundation for life-long physical activity, fitness, and health!

Partly because the workload and other demands are unsustainable.

Overuse injuries 20 years ago, 10-15% of injuries seen by pediatricians were from overuse. Now it’s 60-80%.

• A child typically gets overloaded with excessive training when s/he exhibits the most potential— around 12-13 years old. With such rapid growth at this age, it is the worst time for this kind of training because of greater vulnerability to injuries.

• Early specialization in one sport, versus diversity, lends itself to injury.

• There is often not enough rest and recovery between matches, games, bouts of training. This is one of the biggest competition/training errors and contributors to poor performance and injury risk.

• Prior injury is the largest predictor of future injury risk. Athletes must fully recover, rehabilitate, and correct any contributing deficiencies or other factors before re-engaging in sport.

The responsibility to enforce rest and recovery is on the adults — parents, organizations, event directors, sports associations....

40

Resources American College of Sports Medicine - www.acsm.org Nike “Designed To Move” - www.nikeinc.com/designed-to-move

41

Panel 5 » sports concussions | DONNA BROSHEK, PH.D.

Acute Symptoms {Observable within minutes or hours}

Confusion Nausea and/or Vomiting Amnesia Dizziness Vertigo

Persisting Symptoms

Con • cus• sion A complex physiological process affecting the brain, induced by traumatic force. >>> May be from a blow to head or body that transmits force to the brain >>> Athlete may or may not lose consciousness >>> Symptoms usually resolve spontaneously but symptoms may evolve over minutes or hours. >>> Changes are typically functional but not structural (so won’t show up on CT scans, etc.)

Headaches Nausea Dizziness / Poor Balance Light / Sound Sensitivity Fogginess Cognitive Fatigue Inattention Memory Deficits Sleep Disturbances Irritability Decrease in Frustration Tolerance Sadness Anxiety

Resource AAN Guidelines - Sports Concussion Toolkit - www.aan.com/concussion

42

43

Panel 5 » sports concussions | DONNA BROSHEK, PH.D.

(cont’d)

HOW TO RETURN TO ACTIVITY [Zurich Consensus Statement]

After a concussion, athletes should complete each phase symptom-free before advancing to the next phase. Minimum of 48 hours at each stage.

Brain Changes Occurring with Concussion • There is an abrupt change to the normal cellular function of brain cells. The cellular pump mechanism goes into overdrive in an attempt to restore energy. There’s an increase in the demand for glucose that the body cannot deliver.

• This causes a metabolic crisis which the brain needs to recover from in order to heal.

Recovery • At college level, it takes 5-10 days to recover. Youth can take 30 days to recover—younger children need to be managed more conservatively.

• The first 10 days are the most critical for preventing occurrence of a second concussion.

• Youth recover at widely varying rates, so there’s no “cookie-cutter” answer in terms of how long recovery should take. Concussion management should be individualized.

• Baselines need to be taken into account for what is back to “normal” for each child.

Rehabilitation Stage

Functional Exercise at each Stage of Rehabilitation

No activity

Complete physical and cognitive rest

Recovery

Light aerobic exercise

Walking, swimming, or stationary cycling, < 70% MHR. No resistance training.

Increase heart rate

Sport-specific exercise

Skating drills - ice hockey, running drills soccer. No head impact activities.

Add movement

Non-contact training drills

Progression to more complex training drills (passing). May start progressive resistance training.

Exercise, coordination, cognitive load

Full contact practice

Following medical clearance, participate in normal training activities.

Restore confidence, assessment of functional skills by coaching staff

Return to play

Normal game play.

Objective at each Stage

From the 4th International Conference on Concussion in Sport, Zurich, November 2012. McCrory et al.

British J Sport Med. 2013

• Once beyond the acute phase of recovery, light exercise (e.g., walking) enhances cognitive recovery.

44

45

Panel 5 » the psychological and social impact of sports concussions and injury on youth

| TAMARA VALOVICH MCLEOD, PH.D.

• There are more than

The Cost of Injury 3 million $1.3 billion

injuries annually that cause time lost from organized sports.

• Estimated cost (1996) of these visits was over • Sports injuries account for more than •

35%

12 million 20 million

• Resulting in

annually.

of all medical visits in 5-17 year-olds.

student athletes between the ages of 5-22 will suffer a sports-related injury this year.

lost days of school

If we want to rehabilitate the injury, we have to look at the whole person

Resources Athletic Training Practice-Based Research Network (AT-PBRN) - www.atpbrn.org Agency for Healthcare Research and Quality (AHRQ) - www.ahrq.gov A.T. Still University Sport-Related Concussion Research - www.atsuconcussion.com

47

Panel 5 » the psychological and social impact of sports concussions and injury on youth

| TAMARA VALOVICH MCLEOD, PH.D. (cont’d)

Male athletes report higher well-being than females for psychological, physical, emotional and school functioning, but not social functioning. gender difference should be considered during injury evaluation and management.

ATHLETES

»»» »»» Report higher health-related quality of life (HRQOL) than non-athletes and higher HRQOL than healthy adolescent peers - particularly in emotional functioning.

Time away from the sport due to injury was most strongly related to school functioning.

AFTER INJURY

Athletes report lower social functioning and quality of life in general. They lose the identity they had as a player; their sense of self is affected. They also miss out on the social interaction they had pre-injury. They are likely to mask symptoms, saying they are more well than they really are. This can also affect the child-parent relationship.

Youth who have suffered concussions report: > Increased depression, mood disturbance, and fatigue.

OVERALL

48

Quality of Life

suffers with injury

“Anger, sadness, I can’t, it’s you know, I’ve cried a lot, it’s hard to deal with....”

—Injured Youth

49

Panel 6: WRAP-UP SENATOR JOHN MILLER, ALETA MEYER, PH.D., KARIN ADDISON, PATRICK TOLAN, PH.D.

» becoming an advocate for change

| VIRGINIA SENATOR JOHN MILLER

Senator Miller’s Tips to promote change Request a meeting with your legislators (when legislature is not in session) As an advocate, be on a first-name basis with your legislator or bring someone to the meeting who is.

> When legislators don’t hear feedback on a bill, they assume the bill has no opposition. So let them know how you feel about it.

> Phone calls are least effective, email is best.

Might physically ACTIVE

interventions be a better match between developmental theory, and

desired change?

> Ask to be a resource for your legislator.

Advocacy is about relationships.

Legislators want to hear constituents’ opinions and from those who are knowledgeable about the issues.

» impact of adversity & chronic stress on youth well-being | ALETA MEYER, PH.D. STRESS

> Early adversity negatively impacts health & well-being

in childhood and throughout life (e.g. poverty, natural disaster, etc.).

> Adult health and employment status were negatively impacted if they suffered more than 2 traumatic life events.

Resources Virginia Public Access Project - www.vpap.org Senator John Miller - www.senatorjohnmiller.com

> How might interventions help children exposed to frequent and prolonged stress?

51

Wrap-Up Âť Obesity in the Commonwealth | KARIN TALBERT ADDISON

Prediction:

One-third of all 77% of VA students report more than 2 hours of screen time per day

children born after 2000 will suffer from

diabetes Only 24% of VA high school students met the recommended 60 minutes of physical activity per day.

at some point in their

lives.

Over the past 3 decades, child obesity rates have tripled. ot eat the n id d s t n e d s each day le hool stu b c a s t h e g ig e h v A d V n 83% of nt of fruits a u o m a d e d n recomme

(Higher in African American and Hispanic communities where almost 40% of children are obese or overweight.)

Resources The Virginia Youth Survey - www.vdh.state.va.us/ofhs/youthsurvey Virginia Obesity Survey - www.vfhy.org/obesity/resources/virginia-childhood-obesity-survey

53

Wrap-Up » positive youth development and physical health & well-being | PATRICK TOLAN, PH.D.

Our Challenges Challenges >> We need clear goals that are integrated into society. >> How do we “get it right” versus “get it done”? >> An agency’s needs sometimes drive the agenda, versus prioritizing collaboration. >> What is the role of evaluation?

What We Learned >> 70% of schools don’t have recess >> We need to apply knowledge to practice early and often in order to form good habits

>> Usability - Can what we’ve developed really work? >> Type of evidence

>> There are multiple ways to influence health and well-being >> It’s best to build-in opportunities, rather than lecture; it’s best to emphasize adding in positive actions rather than have people stop what they are doing >> These positive actions can take place in arenas of health care, education, community, after-school programs >> Positive messaging about health and nutrition can inform habits and lifestyles of our youth

Resource Youth-Nex - www.curry.virginia.edu/youth-nex

54

“COOPETITION”— How can we best cooperate to achieve our goals?

55

Wrap-Up » positive youth development and physical health & well-being | PATRICK TOLAN, PH.D.

(cont’d)

Types of Scientific Evidence - What is the Quality of the Information you Have? >> We have inferences from studies showing correlations, but this is not the same thing as proving that a certain intervention will work in ways we intend. >> We need to develop a roster of programs that demonstrate practices that work. >> Summarize best practices, benchmarks for practices, methods of managing and evaluating; adaptability and usability. >> Models are not the same as action. We need to do more than say we need health and well-being.....we need to figure out how to do it.

“We

need to

continually think about bringing facts to the discussion and test beliefs we have, whether they’re scientific, political, religious, social, and see which things really make a difference so when we do meet with legislators, we have facts to give them and it becomes harder to be ignored.”

– Patrick Tolan

56

57

Conference Presenters Keynote & Plenary Remarks William H. Dietz, M.D., Ph.D.

Former Director, Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention

Arthur Weltman, Ph.D.

Professor and Chair of Kinesiology, University of Virginia; Professor of Medicine, School of Medicine, University of Virginia; Program Director, Youth-Nex

Megan A. Witherspoon

Manager, Corporate Contributions and Community Relations, Altria Client Services

Robert C. Pianta, Ph.D.

Dean, Novartis Professor of Education, Curry School of Education, University of Virginia

Speakers Karin Talbert Addison

Former Policy Advisor to the Secretary of Education and Secretary of Health and Human Services, Early Childhood Education and Children’s Health.

Michael F. Bergeron, Ph.D., FACSM

Executive Director, National Youth Sports Health & Safety Institute; Professor, Department of Pediatrics, Sanford School of Medicine, University of South Dakota’s Sanford USD Medical Center

Randy Bird

Director of Sports Nutrition, University of Virginia

Donna K. Broshek, Ph.D.

Associate Professor; Co-Director, Neurocognitive Assessment Lab, University of Virginia Medical School

58

Noah Carpenter

Bet Howrigan

Vermont State Student Ambassador for Fuel Up to Play 60

Educator, Fairfield Center School, Vermont; Program Advisor, Fuel Up to Play 60

Kirsten Davison, Ph.D.

Patricia Jennings, Ph.D., M.Ed.

Associate Professor of Nutrition, Harvard School of Public Health

Associate Professor, Curry School of Education, University of Virginia

Joseph E. Donnelly, Ed.D., FACSM

Tamara Valovich McLeod, Ph.D.

Professor, Internal Medicine; Director, Energy Balance Laboratory and Center for Physical Activity and Weight Management, Cardiovascular Research Institute, The University of Kansas Medical Center and The University of Kansas-Lawrence

Christina Economos, Ph.D.

Vice-Chair and Director, ChildObesity180; Associate Professor, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University

David Germano, Ph.D. - Moderator

Director, Contemplative Sciences Center; Director, Tibet Center; Professor, University of Virginia

Jay Hertel, Ph.D., A.T.C.- Moderator

Joe H. Gieck Professor of Sports Medicine; Professor, Kinesiology and Physical Medicine and Rehabilitation, Curry School of Education, University of Virginia

Charles Hillman, Ph.D.

John P. Wood, D.O., Endowed Chair for Sports Medicine; Professor, Athletic Training Program, A.T. Still University

Aleta L. Meyer, Ph.D.

Senior Social Science Research Analyst, Administration for Children and Families (ACF), Office of Planning, Research, and Evaluation, Division of Family Strengthening

Director, Youth-Nex; Professor, Curry School of Education, and Department of Psychiatry and Neurobehavioral Sciences, School of Medicine, University of Virginia

Matthew Trowbridge, M.D., M.P.H.

Physician and Assistant Professor, University of Virginia School of Medicine

Dianne Ward, Ed.D.

Professor of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill

Phil Wendel Founder ACAC

Senator John Miller Virginia State Senator

Russell R. Pate, Ph.D.

Professor and Director, Children’s Physical Activity Research Group, University of South Carolina Arnold School of Public Health

Sheri Rand, M.Ed.

Program Administrator, South Burlington Vermont School District Wellness and Resilience Program; Assistant Principal, Frederick H. Tuttle Middle School

Professor, Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign

Susan Saliba, Ph.D., A.T.C, P.T., F.N.A.T.A - Moderator

Deanna Hoelscher, Ph.D., R.D., L.D.

Ali Smith

John P. McGovern Professor in Health Promotion and Behavioral Sciences; Director, Michael & Susan Dell Center for Healthy Living at The University of Texas School of Public Health, Austin Regional Campus

Patrick H. Tolan, Ph.D.

Associate Professor; Director of Kinesiology undergraduate program, Curry School of Education, University of Virginia

Founder, Holistic Life Foundation, Baltimore, Maryland

59

Resources Video of All Presentations

Panel 4 (cont’d)

http://bit.ly/YNCONF13

MindUpTM - www.thehawnfoundation.org/mindup

Keynote & Plenary Presentations Curry School of Education - www.curry.virginia.edu Centers for Disease Control and Prevention (CDC) www.cdc.gov

Panel 1 Institute of Medicine www.iom.edu/Reports/2011/Early-Childhood-ObesityPrevention-Policies/Recommendations.aspx Research: “The Effect of Acute Treadmill Walking on Cognitive Control and Academic Achievement in Preadolescent Children.”

CH Hillman, MB Pontifex, LB Raine, DM Castelli, EE Hall, AF Kramer. Neuroscience 159 (3), 1044-1054.

Lunch Symposium Impact of School Architecture on School Habits http://bit.ly/_arch Buckingham School Project Video http://bit.ly/archvideo

Panel 2 Book: The Most Expensive Game in Town, by Mark Hyman www.themostexpensivegameintown.com

LearningToBreathe - www.learning2breathe.org Book: Learning to Breathe: A Mindfulness Curriculum for Adolescents to Cultivate Emotion Regulation, Attention, and Performance, by Patricia C. Broderick, Ph.D., New Harbinger Publications, Inc. Research: Broderick, P. C. & Metz, S. (2009). “Learning to BREATHE: A pilot trial of a mindfulness curriculum for adolescents.” Advances in School Mental Health Promotion, 2, 35-46.

Garrison Institute www.garrisoninstitute.org PANAS (Positive and Negative Affect Schedule) Watson, Clark & Tellegen, 1988 www.gse.uci.edu/childcare/pdf/instrumental_ docs/PANAS%20ID.pdf DERS (Difficulties in Emotion Regulation Scale) Gratz, & Roemer, 2004 www.nctsnet.org/content/difficulties-emotionregulation-scale

Child Obesity Program childobesity180.org

Somatization Index (Achenbach, 1991)

Panel 3

Research: Holistic Life Foundation Mendelson, T., Greenberg, M.T., Dariotis, J.K., Feagans Gould, L., Rhoades, B.L. & Leaf, P.J. (2010). Feasibility and preliminary outcomes of a school-based mindfulness intervention for urban youth, Journal of Abnormal Child Psychology, 38, 985-994.

International Journal of Behavioral Nutrition and Physical Activity (IJBNPA) Study - www.ijbnpa.org/content/10/1/3 Fuel Up to Play 60 FuelUptoPlay60.com

Panel 4 InnerKids - www.susankaisergreenland.com/inner-kids.html Research: Flook, Lisa, Smalley, Susan, L., Kitil, M. Jennifer, Galla, Brian M., Kaiser-Greenland, Susan, Locke, Jill, Ishijima, Eric and Kasari, Connie (2010) “Effects of Mindful Awareness Practices on Executive Functions in Elementary School Children” Journal of Applied School Psychology, 26: 1, 70-95

60

Research: Schonert-Reichl, K. A., Oberle, E., Stewart Lawlor, M., Abbot, D., Thompson, K., Oberlander, T. F., Diamond, A. (under review). “Enhancing cognitive and social-emotional development through a simple-to-administer school program.”

Qualitative Process Assessment (Broderick, 2007)

Panel 5 National Youth Sports Health & Safety Institute www.nyshsi.org Datalys Center for Sport Injury Research www.datalyscenter.org National Collegiate Athletic Association (NCAA) www.ncaa.org/health-and-safety/ncaa-sport-science-institute National Federation of State High School Associations (NFHS) www.nfhs.org American College of Sports Medicine - www.acsm.org Nike “Designed To Move” www.nikeinc.com/designed-to-move AAN Guidelines - Sports Concussion Toolkit www.aan.com/concussion Athletic Training Practice-Based Research Network (AT-PBRN) www.atpbrn.org Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov A.T. Still University Sport-Related Concussion Research www.atsuconcussion.com

Wrap-up Panel Virginia Public Access Project www.vpap.org Senator John Miller www.senatorjohnmiller.com

South Burlington Wellness & Resilience Program bit.ly/sthburl_mindful

The Virginia Youth Survey www.vdh.state.va.us/ofhs/youthsurvey

UCSD Center for Mindfulness https://ucsdcfm.wordpress.com/tag/sheri-rand/

Virginia Obesity Survey www.vfhy.org/obesity/resources/virginia-childhood-obesity-survey

Holistic Life Foundation www.hlfinc.org

Youth-Nex www.curry.virginia.edu/youth-nex

61

Image Credits PAGES: Front Cover - (Two Girls Standing) Larry Jackson; (Girls with Apple) Jane Haley/U.Va. University Communications; (Soccer) By Deutsche Sport Privatschule (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons Inside Cover - Dan Addison/U.Va. University Communications 1 - (Conference Logo) Ellen Daniels 2, 3 - Stacey Evans 4 - Curry School of Education Image Library 5 - Stacey Evans 6 - (Bus) By Echtner (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons 7 - By Luis Miguel Bugallo Sánchez (Lmbuga Commons)(Lmbuga Galipedia) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY- SA-3.02.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons 8 - By BohPhoto (originally posted to Flickr as soccer_0081) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons 9 - (Brain Scans) By H.M. Dixon (Flickr: Brain page 368) [Public domain], via Wikimedia Commons; (Panelists) - Stacey Evans 11 - (Twinkies) Image by Larry D. Moore, used under a Creative Commons ShareAlike License; (Red Chard) By Sanjay Acharya (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons 12, 13 - VMDO Architects/Alan Karchmer Photography 14 - Author Unknown, CC-zero, Public Domain via Wikimedia Commons 15 - (Illustration) Ellen Daniels 16, 17 - Larry D. Moore [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons 19 - By Thomas Ricker (Flickr: Sebastiaan floaties) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons 20 - Courtesy of ChildObesity180 21 - (School) By Daderot (Own work) [CC0], via Wikimedia Commons; (Classroom) Courtesy of ChildObesity180 22 - (Collage, Top Left: Child) Courtesy UNC Children’s Healthy Weight Research Group; (Collage, Top Right: Donut) Cole Geddy/U.Va. University Communications; (Collage Bottom Left: Children); Curry School of Education Image Library (Collage Bottom Right: Apple) Jane Haley/ U.Va. University Communications 23 - Courtesy UNC Children’s Healthy Weight Research Group 24 - (Tomato) By ©2005 User: FoeNyx (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0 (http://creativecommons.org/ licenses/by-sa/3.0/) or CC-BY-SA-1.0 (http://creativecommons.org/licenses/by-sa/1.0)], via Wikimedia Commons 25 - Left to Right: (Tennis) Jane Haley/U.Va. University Communications; (Lettuce) Selena von Eichendorf at the Polish language Wikipedia [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons; (Bread) By Zantastik (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons; (Baby) By MasterFinally (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons; (Fruit) By Christopher Hind, http://www.flickr.com/photos/94556645@N00/ via Wikimedia Commons; (Hockey) By Battle Creek CVB (Flickr: Hockey in Battle Creek) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons; (Nuts) By H. Zell (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Common Bottom of page: (Hazelnut Plant) By H. Zell (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

62

26 - Stacey Evans 27 - Courtesy of ChildObesity180 28, 29 - By Jdontfight (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons 30, 31 - (Line Drawings) Ellen Daniels based on By Nobody60 (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons; (Child Painting) By Bureau of Land Management [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons 33 - By lululemon athletica (SSC Yoga with Eoin Finn) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons 34, 36, 37 - Larry Jackson 38 - By Knightgal at en.wikipedia [Public domain], from Wikimedia Commons 40 - By U.S. Navy photo by Mass Communication Specialist 2nd Class Ricardo J. Reyes [Public domain], via Wikimedia Commons 42 - Images are generated by Life Science Databases(LSDB). [CC-BY-SA-2.1-jp (http://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)], via Wikimedia Commons 44 - Jim Daves 47 - By David Shapinsky from Washington, D.C., United States [CC-BY-SA-2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons 49 - By Hank Eber, for So Salem (“Josh Adkins”) [CC-BY-SA-2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons 50 - Stacey Evans 51 - Jane Haley/U.Va. University Communications 52 - (Fries) By Evan-Amos (Own work) [CC0], via Wikimedia Commons 53 - Cole Geddy/U.Va. University Communications 54 - Stacey Evans 55 - Curry School of Education Image Library 57 - Courtesy of ChildObesity180

63

This Youth-Nex conference was supported by a grant from Philip Morris USA, an Altria Company.

We gratefully acknowledge this important support. The work of Youth-Nex is solely determined by itself and Youth-Nex does not represent the official views of the sponsor.

CURRY SCHOOL of EDUCATION