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By Celez Suratos, MS, RD, ACCN15 Blogger

Motivational interviewing (MI) is a technique used to incite positive behavior change. It is directive and client/patient-centered. Healthcare providers (including registered nurses and dietitians) use MI to direct self-motivational statements from the patient. Hence, allowing patients to be in charge of setting and meeting their own goals. Dr. Kathryn I. Pollack from the Duke University School of Medicine facilitated an interactive workshop on MI at this year’s Advances and Controversies in Clinical Nutrition Conference (ACCN). The main focus was to inform healthcare providers of the “spirit” of MI, as well as putting MI techniques into practice through role-playing.

Most of us are familiar with the phrase, “it’s not what you say, it’s how you say it.” But did you know that communication is approximately 90 percent body language? MI is more than a methodological counseling approach. It also causes a healthcare provider be more present and aware of how he/she is communicating to the patient. According to Dr. Pollack, the “spirit” of MI embodies four key principles to elaborate on such a concept; Partnership, Acceptance, Evocation, and Compassion.

A healthcare provider may have the tendency to dominate the conversation by supplying the patient with numerous facts about the status of his/her health, likely telling the patient what he/she “must” do in order to prevent the “worst-case scenario” from happening to them. However, in MI, a provider should focus on building a partnership-like relationship rather than one that is hierarchical. One can do this by initially asking permission before sharing information and giving advice. This allows patients a choice to discuss their health based on their own readiness to handle the information you want to give them. Alternatively, a provider can ask the patient what concerns he/she may have in order to allow the patient to set the agenda, giving the patient the power to discuss what he/she may already be thinking about improving.

Acceptance goes beyond the concept of non-judgment. This means the healthcare provider accepts the patient’s motivation, commitment, and choices in totality. This relates back to non-verbal communication. If you are feeling judgment, you are also likely exhibiting judgment, which then means your patient can see your judgment. Think about it – do you ever cross your arms or furrow your brow when you disagree with a statement? Letting go of judgment will not only improve your skills as a practitioner, but can be freeing as well.

A healthcare provider may be able to provide a patient with beneficial reasons to improve his/her health status. However, evocation is the idea that people are motivated by their own reasons. In MI, the provider facilitates a conversation that allows the patient to find his or her own motivation for adopting positive change. One way to help patients find their motivation is to prompt them with questions to discuss their readiness to change. Such questions may include asking patients to rank their readiness to change (i.e., on a scale of 1 to 7 –with 1 being least ready to change and 7 being most ready for change, for example), then asking why they chose that particular number on the scale, what it would take for them to rank their readiness for change even higher (if not already ranked as a priority), and when will they be ready to implement their plan. Evocation extracts information from the patient, such as reasons to change, identifies barriers to change, and eventually a self-actualized plan to get patients to reach their goal(s).

Dr. Pollack also mentioned ‘compassion’ as a novel principle to the spirit of MI, particularly in the provider-patient relationship. It comes from the idea that providers should use open-ended questions, reflective statements, and summarize the conversation when they interact with their patients. This demonstrates active listening, versus a series of agreeable head-nods or dismissive “uh huh” verbal responses. Compassion also calls on providers to give patients affirmation with each step they take to reach their goal(s), even during times of perceived setbacks.

Dr. Pollack summarized that only the patient can make change happen for him or herself. The patient is the one who needs to put in the work to see results. Motivational interviewing is not only a tool healthcare providers can use as a catalyst for positive change, but is also a specific skill that takes practice and time to perfect.

By Banaz Al-khalidi

Losing weight is hard enough. Keeping it off is even harder. Despite decades of scientific advancement in our understanding of energy intake and energy expenditure, weight regain after weight loss remains a major issue in obesity treatment. What could we be missing in this energy balance equation? Rethinking this problem, I think it is worth asking ourselves whether we live to eat or eat to live. There is a huge difference. Given the abundance of food in our environment, the majority of us will live to eat. But what drives this motivation or simply put, what are the determinants of healthy versus unhealthy behaviors?

Generally, healthy lifestyle interventions including diet, exercise, and behavioral strategies, such as keeping a food log, have proven to be effective for weight loss in the short term. However, participants’ lack of adherence to the intervention coupled with subsistence of unhealthy behaviors result in weight regain in the long term. According to a research on cardiovascular health behaviors and health factor changes in the US population from 1988 to 2008, healthy diet scores changed minimally (from 0.3% to 1.4% between 1999 and 2008), and physical inactivity levels decreased by only 7-10% from 1999 to 2006. Furthermore, by 2020, it is estimated that 43% of American men and 42% of American women will have a BMI of ≥ 30 kg/m2 (i.e., obese category). Despite the established risks and benefits associated with diet and physical activity, it seems that health behaviors tend to be incredibly resistant to change.

A recent report from a panel of obesity experts convened at the National Institutes of Health discussed the issue of weight regain after weight loss. The authors highlighted the problem of behavioral fatigue, in which patients grow weary of strict lifestyle regimens, especially when weight loss declines after the first 6 months. Specifically, the authors mentioned that “Initially, the positive consequences of weight loss (e.g., sense of accomplishment, better fit of clothes) outweigh the cognitive and the physical effort needed to lose the weight. Later, when the goal is to maintain lost weight, the positive feedback is less compared to the effort required to keep adhering to the same regimen. Thus, the benefits no longer seem to justify the costs”. In other words, the costs of adherence to these interventions exceed the benefits as time progresses, and patients seem to justify their behavior by re-thinking about the cost/benefit ratio in the long run. How can we then increase the long-term benefits while decrease the costs associated with weight maintenance?

There is a need to understand what factors allow people to successfully maintain a behavior over a long period of time. In recent years, obesity and behavioral scientists have started to explore strategies that involve incorporating ‘mindfulness’ to promote the sustainability of healthy behaviors. Mindfulness is defined as: awareness of the present moment, and paying attention to one’s moment-to-moment experiences non-judgmentally. This attention leads to a clear awareness of one’s own thoughts as well as one’s environment in that one observes what is happening, but instead of reacting, the mind views these thoughts as inconsequential. This does not mean disconnection from life; rather, the mind is actively engaged and flexible. Mindfulness is not a technique but it is a way of being.

You might ask, what does this have to do with obesity and health behaviors? They’re all related. Mindfulness-based interventions (MBIs) have recently become a focus for the treatment of obesity-related eating behaviors. A recent review paper examined the effectiveness of MBIs for changing obesity-related eating behaviors. Of the 21 studies included in the review, 18 studies reported positive results for obesity related eating behavior outcomes. Specifically, mindfulness enhanced self-awareness and self-regulation (i.e. long lasting self-motivation) by improving awareness of emotional and sensory cues, which may be effective for sustaining a behavior in the long term. It’s about acceptance of the moment we’re in and feeling whatever we feel (accepting both positive and negative emotions) without trying to resist, change or control it. Under emotional stress, most of us will try to comfort ourselves by putting something into our mouths, but being aware of the negative emotions, and having greater self-control skills may help us resist the urge to eat large quantities of food or unhealthy food. Thus, greater awareness and self-control skills may help an individual to better monitor and regulate their dietary intake as well as their engagement in physical activity.

When we live to eat, we tend to engage in the act of mindless eating because we tend to see food as a source of reward or entertainment, and we shovel food into our mouths without paying attention to what we’re eating and whether we feel full. However, when we’re more mindful or self-aware (i.e. eating to live), we become more conscious of what goes into our bodies by focusing fully on the act of eating and eating related decisions. The bottom line is mindfulness may help patients identify internal and external eating cues, manage food cravings, and enhance self-regulation and resilience- all factors important to counteract the behavioral fatigue that tends to occur in lifestyle interventions over time. Perhaps, when we’re more mindful, we’ll tune into our bodies instead of our thoughts (i.e., thinking about the costs/benefits), and will start to look at food as nourishment rather than as emotional comfort blanket. It is important to note that research in this area is still preliminary but exploring and understanding the relationship between mindfulness and health behaviors may hold promise for long-term weight management.

By Teresa Johnson, MSPH, RD

A symposium chaired by Bahram Arjmandi, PhD, RD, and Carmen Castaneda-Sceppa, MD, PhD, provided insights into the etiology and pathophysiology of osteosarcopenic obesity, and presented suggestions for pharmacological and dietary treatment strategies.

Jasminka Ilich-Ernst, PhD, RD, a professor at Florida State University, outlined the problem and scope of osteosarcopenic obesity, a term first coined in 2012. Characterized by the coexistence of three distinct musculoskeletal disorders—osteopenia/osteoporosis, sarcopenia, and obesity—osteosarcopenic obesity is a complex condition, for which the proof-of-concept was established only recently.

A major concern with osteosarcopenic obesity, Ilich-Ernst said, lies in age-related fat redistribution and subsequent infiltration into bone and muscle. Typically bone, muscle, and fat progenitor cells differentiate in a balanced distribution to enable normal tissue development. But with aging, a sedentary lifestyle, poor nutrition, and low-grade inflammation, differentiation patterns become altered and fat production predominates.

Whereas current nutritional and lifestyle management recommendations address the individual components of osteosarcopenic obesity, they do not address the collective triad. Ilich-Ernst suggested adhering to current recommendations to achieve peak bone mass before age 30, gain and maintain adequate muscle mass, and maintain a health weight, but she added that increasing dietary protein to 25 percent of total energy and limiting carbohydrate consumption to approximately 40 percent of total energy might further reduce risk of developing osteosarcopenic obesity.

Further insights into the interconnected nature of bone, muscle, and fat were provided by Clifford J. Rosen, MD, a professor of medicine at Tufts University and research scientist at the Maine Medical Center Research Institute. Rosen explained that the three tissues derive from a single progenitor cell type, and their responses to various cytokines, hormones, and regulatory input, primarily the sympathetic nervous system, are similar.

He then described newly identified “beige,” or brown-like, adipocytes, which contain more mitochondria and are more thermogenic than classic white adipocytes. Beige adipocytes share a common progenitor cell with smooth muscle. As such, they can be viewed as a sort of “hybrid” between fat and muscle cells. Intermittent cold exposure induces beige adipogenesis, a process referred to as “browning,” and promotes weight loss by increasing sympathetic tone—a potential non-pharmacological approach to body fat loss.

However, Rosen noted, whereas sympathetic tone enhances fat loss, it uncouples the process of bone remodeling, promoting bone loss. He added that many of the new classes of drugs that target beige adipogenesis might have similar, deleterious off-target effects on bone.
Ronenn Roubenoff, MD, MHS, of Novartis Institutes for Bone Research, and a professor of medicine and nutrition at Tufts University, compared the effects of dietary versus pharmacological approaches to treating sarcopenia. Sarcopenia, Roubenoff said, is an age-related loss of muscle mass due to type II muscle fiber atrophy. He said that preventing sarcopenia might increase life span and improve quality of life in older adults.

Although some research suggests increasing dietary protein intake might reduce muscle wasting, few data support changing current recommendations, Roubenoff said. In addition, the muscle-sparing effects of dietary protein differ in women versus men. Whereas women benefit from increased intake, men (who experience a U-shaped curve in response to intake) benefit from more moderate intake.

Roubenoff added that muscle, unlike other organs, doesn’t senesce; rather, it remains plastic, providing the potential for older adults to regain muscle mass and function. However, muscle in older adults exhibits “anabolic resistance”—an inability to integrate and build muscle. Emerging pharmacological approaches target this resistance to reverse muscle wasting.

Finally, Wayne Campbell, PhD, a professor of nutrition science at Purdue University, described the differential effects of dietary protein intake during weight loss on bone, muscle, and fat. Specifically, Campbell addressed the question of how older adults can purposefully lose weight without compromising musculoskeletal function.

Campbell and his colleagues analyzed NHANES data from 1999-2004, a period that included dual energy X-ray absorptiometry data. They partitioned the data based on thresholds of the Recommended Dietary Allowance regarding bone health, and noted that whereas inadequate protein intake had an adverse effect on bone health in adults over age 50, high protein had variable effects. Campbell then described his research with whey supplementation and noted that groups that consumed higher amounts of a whey protein supplement lost more fat than groups consuming lesser amounts. However, they experienced no change in bone status, consistent with the epidemiological data.

At a minimum, Campbell said, adults should consume adequate protein. But he added that high dietary protein intake during weight loss has a positive effect on body composition, inducing greater fat loss while maintaining lean muscle mass. In addition, he noted that high protein intake has variable effects, depending on protein type. In particular, whereas protein from dairy and plant sources likely provides greater benefit to bone, protein from non-dairy animal sources likely benefits soft tissue.

The other day I was sitting in class and the professor showed us a music video that compared sugar to drugs, which really got me thinking about the types of nutrition messaging. There are many campaigns out there targeting nutrition-related areas for change, particularly in the childhood obesity arena. However, many of these campaigns use bold images and scare-tactics to convey the message. Is this the approach we should be taking to create a healthier change?

The obesity epidemic has sparked an urgent need for preventative action. The Institute of Medicine released a report in 2012, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, which expressed the need for transformative approaches to changing the environment, especially for “messaging environments.” Due to the increased use of social marketing, product marketing and labeling, and public media campaigns, the potential for utilizing communication in the prevention of obesity is great (1). There have been many campaigns floating around the media in the past decade. A memorable one was Strong4Life, which was created in 2011 by Children’s HealthCare of Atlanta, a leading pediatric hospital. This initiative used “in-your-face advertising” to aggressively fight Georgia’s childhood obesity problem (1). The initial advertisements featured somber children describing their struggles with obesity (1).

These advertisements generated concern among public health experts due to the fear that the portrayals of overweight children could intensify the weight-based stigma (1). This type of message emphasized the negative health and social consequences of obesity. Health communications can be framed to emphasize either the benefits of participating in a type of behavior (a gain-frame), or the consequences of not participating in a type of behavior (a loss-frame) (2). There is evidence that suggests non-stereotypical, positive media portrayals of obese and overweight individuals can effectively decrease weight-based stigma, while negative portrayals may even worsen the stigma (3). Further, gain-framed communications seem to be more effective than loss-framed communications in endorsing prevention behaviors (2). When the message is framed to stimulate core values, the persuasion factor increases, since the person is more likely to pay attention and accept the message (4).

Campaigns should highlight information that is new to the desired audience and necessary for behavior change (5). It would be useful for health communications to incorporate the “how to” and “when to” knowledge in order to support behavior change (5). Also, misconceptions about the issue may need to be addressed, along with other real and perceived barriers to behavior change (5). Ideally, before public release, communication strategies should be evaluated to determine how effective they would be in supporting the target outcome and without exacerbating any sort of stigma (1). As the use of technology continues to increase, there certainly will be no shortage of health campaigns. Hopefully, the messages will be effective in inspiring positive health changes without creating negative stigma or fear.

References
1. Barry CL, Gollust SE, McGinty EE, Niederdeppe J. Effects of messages from a media campaign to increase public awareness of childhood obesity. Obesity, 2014; 22: 466–473. doi:10.1002/oby.20570
2. Gallagher KM, Updegraff JA. Health message framing effects on attitudes, intentions, and behavior: A meta-analytic review. Ann Behav Med, 2012; 43: 101–116. doi:10.1007/s12160-011-9308-7
3. Pearl RL, Puhl RM, Brownell KD. Positive media portrayals of obese persons: impact on attitudes and image preferences. Health Psychol, 2012; 31: 821–829. doi:10.1037/a0027189
4. Gollust SE, Niederdeppe J, Barry CL. Framing the consequences of childhood obesity to increase public support for obesity prevention policy. Am J Public Health, 2013; 103: e96–e102. doi:10.2105/AJPH.2013.301271
5. Snyder, LB. Health communication campaigns and their impact on behavior. J Nutr Educ Behav, 2007; 39: S32–S40. doi:10.1016/j.jneb.2006.09.004

By Sheela Sinharoy, Student Blogger

Is weight loss always recommended for obese persons, or are there some individuals for whom weight loss may not be necessary or may even be harmful? In a session on Saturday, Dr. Julie Locher looked at this question in relation to seniors. Given that 14% of Americans – or one in seven – are over age 65, and that this proportion is expected to increase to 20% by 2030, it is important to understand the needs and special requirements of this group.

As the proportion of Americans who are over age 65 increases, so too does the prevalence of overweight and obesity. According to Dr. Locher, approximately 35% of older persons are obese. Many of these individuals experience co-morbidities and functional limitations, which are often associated with or impacted by obesity. However, the effects of weight loss treatment in older adults have not been extensively studied.

The benefits of weight loss in older adults are similar to those found in the general population, including reduced markers of inflammation and improved cardiovascular health. As co-morbid conditions increase with age, weight loss may address some of these conditions. Especially when weight loss occurs through a combination of diet and exercise, research has shown that muscle quality and physical function also improve, as does global cognition.

At the same time, some studies have found being overweight to be potentially beneficial. For older adults in particular, a number of studies indicate that being overweight yields no extra risk of mortality, and in fact, may be associated with a lower risk of mortality than being normal weight. Obesity is also associated with increased bone mineral density and decreased osteoporosis as well as with decreased risk of hip fracture.

In addition, weight loss in overweight seniors carries certain risks. First, intentional weight loss is associated with a loss of bone mineral density. Also, weight cycling – when individuals lose and then regain weight – may be a more serious concern with older adults because of their different body composition. When seniors regain weight, it is disproportionately fat, especially abdominal fat, compared to lean muscle. This is associated with higher cardiometabolic risk and an increased risk of disability and mortality.

Even among older adults, needs may differ between sub-populations. For example, as the proportion of older adults continues to rise, the fastest-growing segment is those ages 85 and over. These individuals may require a different therapeutic approach than younger seniors, and improving physical function and quality of life may be more important than obesity treatment.

As some providers move increasingly toward personalized medicine, this may be one more way in which recommendations and a therapeutic approach may need to be tailored to the individual patient. Depending on their bone health, metabolic health, and a range of other factors, doctors may decide that weight loss is not always the best approach for obese older adults. For some seniors, the risks of weight loss may in fact not outweigh the benefits.

By Sheela Sinharoy, Student Blogger

Do you consider sugar to be controversial? From reading the mainstream media, where it is not uncommon to see “sugar” and “toxic” in the same sentence, one might assume that any debates about sugar have been resolved. However, Friday’s session on sugars and health made it clear that questions remain about sugar’s role in body weight, cardiovascular disease, insulin resistance, and dental caries.

In many people’s mind, a clear relationship exists between sugar and body weight. However, as Dr. John Sievenpiper explained, a 2013 systematic review and meta-analyses of dietary sugars and body weight (http://www.bmj.com/content/346/bmj.e7492) found no relationship between sugar and weight in isoenergetic comparisons (i.e., in trials where researchers substituted sugar with other carbohydrates, but held total calories equal). The study did find that an increased sugar intake was associated with increased weight, but Sievenpiper argued that this was simply due to increased calories, not to any unique properties of sugar. As he stated, when addressing weight gain, it is important to focus on overconsumption of all caloric food, including those high in added sugars.

Focusing next on cardiovascular disease, Dr. James Rippe shared evidence from a series of trials investigating the relationship of sugars with LDL, HDL, total cholesterol, triglycerides, blood pressure, total body fat, and abdominal fat. The trials found no relationship between sugars and any of the outcomes except for HDL and triglycerides. For these latter two outcomes, Dr. Rippe, like Dr. Sievenpiper, argued that these findings were due more to the excess calories than to any unique contribution of sugars.

The story with sugar and insulin resistance was, again, similar. Dr. Ian Macdonald explained that in animal models, evidence exists of large doses of fructose and sucrose leading to insulin resistance. However, this does not necessarily translate to human nutrition, and randomized controlled trials in humans have been inconclusive. Some studies have shown an effect of high doses of fructose on insulin resistance and liver fat, while others show no relationship.

The most conclusive evidence of an effect of sugar exists in relation to dental caries, which Dr. Paula Moynihan pointed out is the most prevalent chronic disease worldwide. As part of the World Health Organization (WHO) guideline development process, Dr. Moynihan led a systematic review on the relationship between sugar intake and dental caries. Based on the results, WHO has issued strong recommendations for reduced intake of free sugars throughout the life course and for intake of free sugars to be no more than 10% of total energy.

Throughout the conference, a number of speakers have referenced Americans’ changing dietary patterns and increases in consumption. This session was no different, as the overall message seemed to be that sugars alone cannot explain increases in overweight and obesity, cardiovascular disease, insulin resistance and diabetes. Rather, sugars are part of a larger constellation of factors that include dietary patterns and lifestyle patterns as a whole, which should be researched and addressed together in order to reduce the prevalence of chronic disease.

By Jonelle Agurs, ASN Intern

According to the National Health and Nutrition Examination Survey (NHANES), national reports indicate a steady increase in childhood obesity levels, in preschoolers up to four years of age. However, state-specific studies of data retrieved from the Pediatric Nutrition Surveillance System (PedNSS) tell a slightly different story: in 2011, nineteen U.S. states/territories reported a drop in obesity prevalence among low-income preschoolers up to 2.6%, with the greatest decline observed in the Virgin Islands. Although national obesity levels among this age group still range from 9.2-17.9%, we must acknowledge the sporadic, yet significant lapse in prevalence rates of this medical condition from state-to-state.

Childhood obesity is associated with a variety of physical complications, such as high blood pressure, diabetes, and asthma, which in turn, contribute to mental health setbacks that affect a child’s self-esteem and motivation to perform daily tasks. Obese preschoolers are five times as likely to become obese adults, as compared to their non-obese peers, and low-income households are particularly vulnerable to chronic obesity – inexpensive fast food options, that boast great taste, but have little nutritional value, are disproportionately marketed in low-income, minority communities. Using cross-promotion marketing tactics, 71% of food products use third-party licensed characters to appeal to adolescent audiences, but less than 20% meet nutritional guidelines set for children. A public health intervention at this impressionable stage of a child’s life is crucial in ensuring better health habits for a lifetime.

So, why do some states show significant improvements in obesity levels? It is most likely because these state and county agencies play a unique role in the success of their communities – a role that involves everyone from the enthusiastic teacher in a child’s preschool class, to the soccer coach in charge of physical education after school, to the local grocer who provides fresh fruits and vegetables for the community. Local and state initiatives, aimed to implement healthier food and recreational options for the communities they serve, have aligned their WIC programs with the Dietary Guidelines for Americans, which gives nutritional recommendations for consumers at every level.

In my home state of Maryland, for example, county health departments have already begun to equip families and healthcare providers with strategies to manage and prevent obesity in pediatric clients. In 2013, the Montgomery County Government initiated Be Active Montgomery! – a series of summer fitness events, in partner with Montgomery County schools, that promote physical fitness and family community building. In 2014, the Howard County Health Department in Columbia, MD issued a Childhood Obesity Prevention Toolkit to educate families on how to encourage healthy dietary/physical habits at home, and they also provided website access to a WIC Vendor Locator that would assist families in finding stores in their communities. I believe that local strategies such as these have contributed to the decrease in low-income pediatric obesity rates in Maryland from 2008-2011, despite the steady population increase.

Childhood obesity in America is one of those issues that is entangled in a web of possible causes. Food deserts in low-income communities promote consumption of quick-and-easy, fatty meal solutions. Highway expansion results in more vehicles per capita and an increase in traffic safety concerns for parents whose children walk and bike around the neighborhood. Public transportation, however useful, proves inconvenient for expectant, single mothers, who are incapable of transporting loads of groceries to their homes. All in all, the solution to the obesity epidemic in America may seem elusive; however health professionals should approach the situation with a modicum of hope that children will be our nation’s saving grace. Regardless of personal opinion, if the movers and shakers of this country made every effort to, literally, think of the children, perhaps we can redesign our environmental and socioeconomic constructs as a nation, to afford every child access to a proper community that promotes healthy living.

Hot Topics in Obesity will be discussed on Friday, December 5 during the fourth annual Advances and Controversies in Clinical Nutrition conference. Dr. William H. Dietz, Director of Redstone Global Center for Prevention and Wellness at GWU in Washington, DC, will give an address “What Explains the Reported Declines in Childhood Obesity?” Dr. Rebecca Puhl will address obesity and weight-related stigma during the same session. Read an interview with her.

The conference runs December 4-6 at the Gaylord National Resort & Convention Center in National Harbor, MD, and features a dynamic program with topics ranging from dietary supplements to nutrition and cancer. To learn more about this year’s conference, please visit the website.

References
1. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6231a4.htm
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449228/
3. http://www.apa.org/pi/families/resources/newsletter/2012/07/childhood-obesity.aspx
4. http://www.ncbi.nlm.nih.gov/pubmed/19719889
5. http://journals.cambridge.org/download.php?file=%2FPHN%2FPHN13_03%2FS1368980009991339a.pdf&code=f5a13f391d3239a1ff41ae708a1ef5e1
6. http://www.howardcountymd.gov/displayprimary.aspx?id=4294969221
7. http://www.montgomerycountymd.gov/rec/bam/index.html
8. http://assets.thehcn.net/content/sites/montgomery/Final_Draft_Obesity_Action_P