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Bar Journal - March 1, 2003

Manchester's Child Obesity Initiative



During the past decade, the City of Manchester has experienced an increasing incidence of childhood obesity, part of a major health phenomenon now being documented nation-wide.1 The Manchester Public Health Department has been documenting statistics on obesity for first grade students in the city's school system for a number of years.2 In the school year 2000-2001, the percentage of first-grade students falling within the medical definition of obesity (as measured by the Body Mass Index) was approximately 19% city-wide. From a demographic perspective, there was a higher incidence of obesity among those first-grade students from lower-income families than among those first-grade students from other income levels and from the city as a whole. The obesity rate for the first-grade students from lower-income families was 23%. However, if a broader definition of obesity is used, the at-risk element among first-grade students city-wide rises to approximately 37.7% Whatever standard is used, the data is startling. (See Chart I)

Obesity in children is of great concern to physicians and public health specialists because it increases the risk of elevated cholesterol levels, high blood pressure, cardiovascular disease and Type II diabetes.3 In addition, the economic, social and healthcare costs of obesity in children are profound; and if the level of child obesity continues to increase, it will produce an increased burden on the healthcare system and those who pay for it for years to come.4 In July 2002, the Center for Disease Control and Prevention noted that obesity is challenging smoking as the nation's Public Health Enemy No. 1.5 In New Hampshire, the Department of Health and Human Services has made child obesity a part of its "Healthy New Hampshire 2010" program;6 and a Dartmouth economist has analyzed the link between childhood obesity and maternal employment outside the home - with very interesting conclusions.7

Community-Based Initiatives

Although this issue has been explored as a public health issue on a national level for a number of years,9 including reports from prominent foundations and from the Center for Disease Control, local communities are just now dealing with the problem on a community level. In Palm Beach County, Florida, for example, a working group is now wrestling with the same critical issue as Manchester, with similar health statistics in each city. A pilot program now underway in Palm Beach County seeks to measure what impact (a) a rigorous physical education curriculum and (b) a nutrition education program will have on altering behaviors in children.

The Palm Beach work-group includes health specialists, legislative leaders, school district officials, the representatives of two major hospitals, and the Director of the Health District, among others. This work-group decided to construct a school-based initiative, utilizing the schools as a method of measuring and addressing the problem on a long-term basis.

The Manchester Initiative: "Get Moving Manchester."

Manchester has a similar work-group concerned with child obesity. The manner in which that group came to focus on child obesity is instructive. In the fall of 2001, a work-group was convened to discuss a broad range of healthcare issues. The initial focus was upon how health care dollars are spent and the question, "How can we use our limited healthcare dollars more efficiently?" The Milbank Memorial Fund, the nation's oldest health foundation with headquarters in New York, helped convene the work-group and lent its expertise to the group as it discussed health indicators. 10 After a number of general sessions dealing with healthcare barriers and healthcare costs, the work-group decided to focus upon one single issue - child obesity. It sought to organize a large-scale, community-wide event to educate the general public and familiarize it with the problem.

"How can we use our limited healthcare dollars more efficiently?"

Unlike the Palm Beach work-group, the effort in Manchester is not school-based. On the contrary, the Manchester initiative is broader and is named "Get Moving Manchester." Its strategy is to address the problem on several levels: first, by organizing a major community event in 2003 - a Health Day; and second, by focusing upon the underlying causes of obesity (a sedentary life-style, an unhealthy diet, among others). The effort involves drawing upon all of the community's resources, including nurses and teachers, police officers and high school athletes, Boy Scouts and Girl Scouts, the Chamber of Commerce and the United Way, among others. This community initiative is important because it "localizes" a critical health care issue, deciding what can be done at the local level to reverse an unhealthy trend in its population.

The immediate objectives

The immediate objectives of the work-group include:

  • Mayor's Walk for Fitness, to raise community awareness and generate enthusiasm for physical activity;
  • athletic mentoring, with high school athletes serving as mentors for elementary school students, encouraging healthy behaviors;
  • Manchester Monarchs hockey team promotions, with local sports teams sending positive messages in pre-game announcements and other activities.

There is a range of long-term objectives that other communities are discussing, especially a reassessment of the physical education requirements for students. Some communities are discussing the wisdom of allowing vending machine sales in their schools, where only foods and beverages with minimal nutritional value are generally sold.11 Still other communities seek to make their streets and parks more exercise-friendly by constructing biking paths and walking paths and thinking differently about public health and urban design.

The national discussion about child obesity has begun in earnest and the goals being discussed throughout the nation appear to center on steps required to intervene with youth on obesity issues, before serious and expensive healthcare complications arise. The objective is to decrease the percentage of youth classified as obese, teach preventive behaviors, encourage a community-wide increase in the level of physical activity and underscore the need for balanced nutrition. At a time when federal and state healthcare dollars are limited, and the ability of charitable foundations to allocate dollars for healthcare initiatives has become more difficult, the emergence of local, community-based initiatives is a welcome step forward.


The focus by Manchester on child obesity, attempting to deal with it on a local basis, is part of a larger tapestry evolving in New Hampshire. It grows out of the New Hampshire Legislature's enactment of RSA 7:32 (the Community Benefits statute) in 1999. That statute required nonprofit hospitals, nonprofit community health centers and other nonprofit health entities to work more closely with communities and public officials in identifying health problems and in developing community benefit plans. In this process, each community helps define what the core healthcare issues may be and discusses ways in which to proceed.

A review of the community benefits plans filed with the New Hampshire Attorney General's Office during the past three years demonstrates the flexibility and imagination that is being used in achieving those objectives.12 For example, a number of New Hampshire's nonprofit hospitals have focused upon dental care for the indigent or those individuals who are uninsured as a major healthcare issue. Wentworth-Douglass Hospital in Dover, Catholic Medical Center in Manchester, and Lakes Region Hospital in Laconia have some type of program addressing this particular unmet healthcare need.

The child obesity initiative in Manchester is part of a second aspect of the Community Benefits statute that has developed quickly during the past three years: the building of nonprofit coalitions or collaborations to identify healthcare issues and needs.13 In addition to the Manchester initiative, two of the most interesting coalitions are the north country initiative (described in another article in this issue of Bar Journal) and the Upper Valley collaborative. In the Upper Valley, a coalition of nonprofit health providers meets regularly, including representatives from Dartmouth Hitchcock. Although it is too early to draw definite conclusions about the role of these coalitions, they do have the potential to strengthen community-based initiatives, much like the Manchester initiative on child obesity.


Healthcare is an extraordinarily complex sector, with much of the complexity and costs being driven in ways that local communities cannot control. However, the continued role of local communities in identifying and addressing healthcare problems holds great promise, especially in a state like New Hampshire that has always placed a great premium on local innovation.


1. See, the web sites for the Robert Wood Johnson Foundation ("Kids in Crisis") at and the Center for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, The Robert Wood Johnson site provides a calculator for measuring your individual body mass.
2. Anna J. Thomas, the Public Health Epidemiologist at Manchester's Department of Health, has prepared a series of graphs and report cards on health indicators within Manchester. The data referenced in this article is based upon her work. For those seeking additional information, Anna Thomas may be contacted by email at In addition, Dr. Rosemary Caron, Ph.D., MPH, Environmental Toxicologist and Chronic Disease Epidemiologist also specializes in child obesity and may be reached at See also, Robert A. Nordgren, M.D., "Childhood Obesity: A Public Health Epidemic," in Child Health Services "Community Report," Fall 2002, page 1.
3. U.S. News and World Report, July 1, 2002, Vol. 133, No. 1, page 4
4. "Childhood Obesity Expert Recommends Simple Interventions," Health & Medicine Week, Nov. 25, 2002, page 7.
5. Id., U.S. News and World Report.
6. See,, where baseline data for 1999 and target goals for 2010 are set forth on obesity. The "Healthy NH 2010" document states the issue bluntly: "Excesses coupled with inactivity have resulted in an alarming increase in the number of overweight and obese children and adults in the past decade."
7. See,, "Mother's work, child obesity: connected? Researcher looks for patterns across socio-economic strata," News & Events, Office of Public Affairs, Dartmouth College, January 20, 2003.
8. Anna J. Thomas, Public Health Epidemiologist, Manchester Department of Health.
9. See Flegal, Katherine M., Margaret D. Carroll, Cynthia L. Ogden and Clifford L. Johnson, "Prevalence and Trends in Obesity Among U.S. Adults, 1999-2000," JAMA, October 9, 2002, Vol. 288, No. 14, pp. 1723-1727.
10. The initial Manchester work group included representatives from local hospitals and community health center, elected school board members, United Way and Chamber of Commerce officials, among others.
11. See for school-based nutritional issues, an inventory of initiatives taken by local schools boards, and a list of additional resources.
12. Nearly 100 health organizations now file community benefits reports with the Attorney General's Office annually. Those reports contain a wealth of data and are open to inspection by any person at the Attorney General's Office during business hours.
13. In 2002, a study committee was created by the Legislature (HB 424) to examine the community benefits provided by nonprofit health entities and their tax status. The work of that Legislative Study Committee may be extended in 2003. In November 2002, a state-wide Community Benefits Conference was held to report on the best practices of the nonprofit healthcare entities.

The Author

Michael S. DeLucia is the Director of Charitable Trusts and Senior Attorney General at the New Hampshire Attorney General's Office, Concord, New Hampshire.

The Author

Christine DeLucia is a freshman at Harvard College and a news editor at the "Harvard Crimson."


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