Multiple approaches to obesity prevention

1. Education, Policy and Environmental Change, and Evaluation: Combining Multiple Approaches to Nutrition Education & Obesity Prevention Kathleen Cullinen, Ph.D., RD Rutgers Cooperative Extension of Morris County

2. Presentation Overview
1.Overview of the Obesity Epidemic
2.How Did We Get Here?
3.Why Should We Care?
4.What Can Be Done?
5.Community-Based Planning and Evaluation

3. Obesity Statistics
Between 1980–2008, obesity prevalence among U.S. adults doubled, and recent data indicate an estimated 34% of adults are obese (BMI ≥ 30).
More than one in six U.S. children is obese, three times the rate in the 1970’s (BMI at or above the 95% percentile of the sex specific BMI for age growth charts).
According to 2006-2008 self reported data, Blacks had 51% higher prevalence of obesity, and Hispanics had 21% higher obesity prevalence compared with whites.

4. Obesity Trends* Among U.S. Adults, BRFSS 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%

5. Obesity Trends* Among U.S. Adults, BRFSS 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

6. Obesity Trends* Among U.S. Adults, BRFSS 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

7. Obesity Trends* Among U.S. Adults, BRFSS 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

8. Obesity Trends* Among U.S. Adults, BRFSS 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

9. Obesity Trends* Among U.S. Adults, BRFSS 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

10. Obesity Trends* Among U.S. Adults, BRFSS 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

11. Obesity Trends* Among U.S. Adults, BRFSS 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

12. Obesity Trends* Among U.S. Adults, BRFSS 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

13. Obesity Trends* Among U.S. Adults, BRFSS 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

14. Obesity Trends* Among U.S. Adults, BRFSS 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

15. Obesity Trends* Among U.S. Adults, BRFSS 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

16. Obesity Trends* Among U.S. Adults, BRFSS 2002 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

17. Obesity Trends* Among U.S. Adults, BRFSS 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

18. Obesity Trends* Among U.S. Adults, BRFSS 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

19. Obesity Trends* Among U.S. Adults, BRFSS 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

20. Obesity Trends* Among U.S. Adults, BRFSS 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

21. Obesity Trends* Among U.S. Adults, BRFSS 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

22. Obesity Trends* Among U.S. Adults, BRFSS 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

23. Obesity Trends* Among U.S. Adults, BRFSS 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

24. Presentation Overview
1.Overview of the Obesity Epidemic
2.How Did We Get Here?
3.Why Should We Care?
4.What Can Be Done?
5.Community-Based Planning and Evaluation

25. Dietary Behaviors
Increased consumption of sugar
sweetened beverages
Continued low consumption of
fruits and vegetables

26. Dietary Behaviors
Increased frequency of meals eaten away from home

27. The Food Environment
Increased number of fast food establishments in the U.S.
Lack of access to full service grocery stores selling affordable healthful foods
Less healthy food & beverage advertising aimed at children

29. Physical Activity
36% of adults do not engage in recommended levels of physical activity for health benefits and 25% of adults report no leisure-time activity
In 2009, 82% of high school students did not participate in 60 or more minutes of physical activity on any day of the previous 7 days.
Only 30% of high school students, grades 9- 12, have daily P.E.

31. “ It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural and physical environment conspire
against such change.”
Institute of Medicine

32. Community Design & the
Built Environment
Standardized Share of Mode for Trips to School:
National Personal Transportation Survey
0
10
20
30
40
50
60
1969 1977 1983 1990 1995 2001
Year
% of Trips
Car
Bus
Walk/bike
Public Transit
McDonald NC. Am J Prev Med 2007;32:509

33. Community Design & the Built Environment
Environmental factors beyond the control of individuals contribute to increased obesity rates by reducing the likelihood of healthy eating and active living behaviors.

34. Community Design & the Built Environment
Environmental factors that influence physical activity behavior:
Lack of infrastructure supporting active modes of transportation (i.e., sidewalks & bike facilities)
Access to safe places to play and be active
Access to public transit
Mixed use & Transit Oriented Developments

35. Presentation Overview
1.Overview of the Obesity Epidemic
2.How Did We Get Here?
3.Why Should We Care?
4.What Can Be Done?
5.Community-Based Planning and Evaluation

36. Why Should We Care?
Obesity is common. More than one-third of U.S. adults (over 72 million people); co- existence of obesity, poverty and food insecurity
Obesity begins in childhood. Seventeen percent (17%) of U.S. children are obese. Children are more likely to become obese adults, and increase their risk of heart disease, diabetes, and some cancers.

37. Why Should We Care?
Obesity is costly. Annual cost of obesity to the U.S. healthcare system is $147 billion, double the amount a decade ago; 23% is financed by Medicare and 19% by Medicaid (Finkelstein et al., 2009)
Annual medical expenses for the obese are estimated to be 42 percent higher than for a person of a healthy weight.

38. Presentation Overview
1.Overview of the Obesity Epidemic
2.How Did We Get Here?
3.Why Should We Care?
4.What Can Be Done?
5.Community-Based Planning and Evaluation

39. Based on the National Prevention Strategy Action Plan, U.S. Department of Health & Human Services

40. Socio-Ecological ModelKnowledge, skills, attitudes, beliefs and behaviorsFamily and peers that influence an individualSocial networks and normsPublic PolicyCommunityOrganizationalInterpersonalIndividualFederal, state and local policies, laws and regulationsRules, regulations, formal and informal policies and procedures

41. Nutrition Education and Obesity Prevention Approaches
Individual or group-based nutrition education, health promotion, and intervention strategies
Comprehensive, multi-level interventions at multiple complementary organizational and institutional levels
Community and public health approaches to improve nutrition

42. Target Behaviors for Change
1.Increase physical activity
2.Increase consumption of fruits and vegetables
3.Increase breastfeeding initiation, duration, and exclusivity
4.Decrease consumption of sugar sweetened beverages
5.Decrease consumption of high energy dense, nutrient poor, foods
6.Decrease television viewing

43. Policy, System and Environmental (PSE) Change
Policy: Written organizational positions, decisions, or course of action, resources, implementation, evaluation, and quality assurance/reinforcement
System: Unwritten, ongoing, often qualitative organizational changes that result in changes reaching large numbers of people it serves
Environmental: Includes the visible environment (built or physical), and economic, social, normative, and messaging environments

44. Policy and Environmental Interventions
Aim to improve the health of all people through better nutrition, not just small groups of motivated or high-risk individuals
Reach populations by influencing availability, access, pricing, promotion, and information
May have greater impact because they influence the overall environment, reach many people, and are less costly and more enduring than clinical, individually oriented, or small group educational interventions

45. Schools
Foods not used
as reward
or punishment
Adequate time
to eat
breakfast & lunch
More fruits &
vegetables on
school breakfast
and
lunch menus
Healthy fundraisers
(not candy)
School gardens
Farm-to-School
Programs
Healthy foods
& beverages in
vending
machines
Policies
Programs
Environments

46. Childcare
Foods not used
as reward
or punishment
Rooms in which
breastfeeding mothers
can nurse their babies
Mandatory nutrition
training for child care
providers
Refrigerated storage
for breastmilk
Nutrition education
for parents, staff
and
children
Nutrition guidelines for
foods and beverages
served and brought
from home
Menus consistent
with the
Dietary Guidelines
Policies
Programs
Environments

47. Worksites
Nutrition &
calorie information
at point
of purchase
Healthy food
and
beverage options
in cafeterias
Healthy foods and
beverages at
meetings
Adequate break
times
for breastfeeding
mothers
Breastfeeding room
for employees
Farmers Markets
Healthy foods
& beverages in
vending
machines
Policies
Programs
Environments

48. Healthcare
Routine nutrition
assessments at
annual
preventive visits
Insurance coverage
for obesity
prevention services
BMI and nutrition
assessment, counseling
& treatment included
In quality assurance
measures.
Breastfeeding
rooms
& adequate break
times for breastfeeding
mothers
Nutrition
assessment,
counseling &
treatment training
in health
professional
schools
Culturally and
linguistically
appropriate
counseling
Routine BMI
measurement and
discussion with patient at
annual preventive visits
Policies
Programs
Environments

49. Communities
Financial
incentives
for supermarkets
in low income
communities
Healthy food
& beverage
options in
restaurants
Zoning ordinances
limiting the number
of fast food outlets
Fruit and vegetable
promotions in
grocery stores
Community
Gardens
Farmers Markets
Restaurants with
calorie and nutrition
information at
point of purchase
Policies
Programs
Environments

50. Local Government Can Be Part of the Solution
Local government officials can enact policies that support healthy community design such as local zoning ordinances & economic incentives affect the presence and absence of:
Parks and open spaces for
recreation
Bike facilities
Mixed use developments
Health food retailers &
farmers’ markets

51. Local Government Can Be Part of the Solution (con’t)
Policies and environments that affect peoples’ health are determined by a variety of local government entities, including:
City Councils/County Commissions
Zoning Boards
School Districts
Transportation & Planning departments
Parks & Recreation departments

52. Call To Action
Enact policy and environmental initiatives that support healthy eating and active living
Partner with a variety of local agencies to leverage resources and achieve greater impact (i.e., Planning Dept, Economic Redevelopment Agency, Parks & Recreation Dept, Public Health Dept)
Set SMART short- and long -term goals to address assessment-based needs of communities
Evaluate performance and adjust goals as necessary

53. Example: Somerville, MA
Goal: Increase access to affordable healthier foods
Environmental Change: Implemented a farmers market that was culturally and economically appropriate for the community.

54. Outcomes: Somerville, MA
Created an incentive program for WIC & food stamp beneficiaries to shop at the market
Instructions for vendors on how to accept food stamps
Promotional materials produced in four languages
Increases in attendance; the percentage of foreign born and low income patrons; & the redemption rate of WIC Special Supplemental Nutrition Program vouchers

55. Presentation Overview
1.Overview of the Obesity Epidemic
2.How Did We Get Here?
3.Why Should We Care?
4.What Can Be Done?
5.Community-Based Planning and Evaluation

57. Evaluation Questions
Individual-level: To what extent does programming improve participants’ diet, physical activity, and health?
Environmental-level: To what extent does programming facilitate access and create appeal for improved dietary and physical activity choices in the settings where nutrition education is provided?

58. Evaluation Questions (con’t)
Sectors of Influence: To what extent is programming integrated into comprehensive strategies that collectively impact lifelong healthy eating and active living in low-income communities?
Social and Cultural Norms and Values: To what extent do community-level obesity and related chronic disease prevention strategies impact the public’s priorities, lifestyle choices, and values for healthy living?

59. Research-Tested Planning and Evaluation Resources
Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), http://centertrt.org/?p=intervention&id=1091
Smarter Lunchrooms Movement, http://smarterlunchrooms.org/
Baltimore Healthy Stores, http://centertrt.org/?p=intervention&id=1093
Baby-Friendly Hospital Initiative, http://www.centertrt.org/?p=intervention&id=1094&section=1

60. Research-Tested Planning and Evaluation Resources (con’t)
African-American Campaign, paired with Body & Soul, http://www.innovations.ahrq.gov/content.aspx?id=2347
Latino Campaign, with Toolbox for Community Educators, http://www.cdph.ca.gov/programs/cpns/Pages/LatinoCampaign.aspx (Practice-tested)

61. … “linking or sharing of information, resources, activities, and capabilities by organizations in two or more sectors to achieve jointly an outcome that could not be achieved by organizations in one sector separately” (Bryson et al., 2007)

62. References
1.BRFSS, Behavioral Risk Factor Surveillance System, http://www.cdc.gov/brfss/
2.Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among U.S. adults, 1999-2000. JAMA. 2002 Oct 9; 288 (14); 1723- 1727.
3.Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006 Apr 5; 295 (13); 1549-55.
4.National Center for Health Statistics. Health, United States, 2009: With Special Feature Medical Technology. Hyatsville, MD. 2010.
5.Cynthia L. Ogden; Margaret D. Carroll; Lester R. Curtin; Molly M. Lamb; Katherine M. Flegal. Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008 JAMA. 2010;303(3):242-249.
6.Centers for Disease Control & Prevention. Differences in Prevalence of Obesity Among Black, White, & Hispanic Adults—United States, 2006-2008. MMWR 2009; 58 (27); 740-744.
7.Centers for Disease Control and Prevention. (2010). State Indicator Report on Physical Activity, 2010 National Action Guide. Retrieved from: http://www.cdc.gov/physicalactivity/downloads/PA_State_Indicator_Report_2010_Action_Guide.pdf

63. 8.Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance — United States, 2009. Surveillance Summaries, [6-4-2010]. MMWR 2010;59(5).
9.Centers for Disease Control and Prevention. (2010). State Indicator Report on Physical Activity, 2010 National Action Guide. Retrieved from: http://www.cdc.gov/physicalactivity/downloads/PA_State_Indicator_Report_2010_Action_Guide.pdf
10.Resources for State and Community Programs March 2010. “CDC’s Guide to Strategies for Increasing Physical Activity in the Community.” CD‐ROM. Centers for Disease Control and Prevention, 2010.
11.Heath GW, Brownson RC, Kruger J, et al. The effectiveness of urban design and land use and transport policies and practices to increase physical activity: A systematic review. J Phys Act Health. 2006;3(suppl 1):S55–S76.
12.Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood). 2009 Sep-Oct;28(5):w822-31
13.Active Living by Design. (2006). Shape-Up Somerville, Somerville Massachusetts. Chapel Hill, NC: Author.
References (con’t)

64. Acknowledgement
All photos and data (unless otherwise noted) have been provided by the U.S. Centers for Disease Control and Prevention:
Centers for Disease Control and Prevention
1600 Clifton Road NE
Atlanta, GA 30333
800-CDC-INFO (800-232-4636)
E-mail: cdcinfo@cdc.gov
Web: www.cdc.gov

65. Question Slide