Progress in Preventing Childhood Obesity: How Do We Measure Up

1
Progress in Preventing Childhood Obesity How Do
We Measure Up?

• Eduardo Sanchez, M.D., M.P.H.Director, Institute
  for Health Policy
• University of Texas School of
• Public Health
• eduardo.j.sanchez_at_uth.tmc.edu
• November 3, 2006

2
Discussion Points

• Background
• Obesity prevalence and related health trends
• Conclusions
• Elements of an effective response
• Evaluation framework and approach
• Recommendations
• Next steps

3
Background

• 2004
• Congressional request
• Sponsors DHHS (CDC, NIH, ODPHP),
• RWJF
• 19-member IOM committee
• Blueprint for comprehensive action plan
• 2006
• Sponsor RWJF
• 13-member IOM committee
• Assess progress in preventing
• childhood obesity
• Conduct 3 regional workshops

4
IOM Committee on Progress in Preventing
Childhood Obesity

• JEFFREY KOPLAN (Chair)
• Emory University
• ROSS BROWNSON
• St. Louis University
• ANN BULLOCK
• Health and Medical Division,
• Eastern Band of Cherokee Indians
• SUSAN FOERSTER
• California Department of Health Services
• JENNIFER GREENE
• University of Illinois Urbana-Champaign
• DOUGLAS KAMEROW
• RTI International
• MARSHALL KREUTER
• Georgia State University
• RUSSELL PATE
• University of South Carolina

• JOHN PETERS
• Procter Gamble Company
• KENNETH POWELL
• Georgia Division of Public Health
• THOMAS ROBINSON
• Stanford University
• EDUARDO SANCHEZ
• Texas Department of State Health Services
• ANTRONETTE YANCEY
• UCLA School of Public Health
• Consultants
• SHIRIKI KUMANYIKA
• University of Pennsylvania
• DONNA NICHOLS
• Texas Department of State Health Services
• IOM Staff
• VIVICA KRAAK, CATHY LIVERMAN, SHANNON WISHAM, JON
  SANDERS

5
IOM Regional Symposia

• Three regional symposia
• June 2005, Wichita, KS Focus on schools
• October 2005, Atlanta, GA Focus on communities
• December 2005, Irvine, CA Focus on industry
• Discuss current and promising initiatives
• Identify barriers and assets to sustainability
  and evaluation of interventions
• Identify areas of convergence and next steps for
  stakeholders and sectors

6
Definitions

• Obesity refers to children and youth who have a
  BMI for age at or above the sex-specific 95th
  percentile of the BMI charts developed by the CDC
  in 2000.
• At risk for obesity refers to children and youth
  BMI for age at or above the sex-specific 85th
  percentile but less than the 95th percentile of
  the CDC BMI charts.
• In most children, BMI values 95th percentile
  indicate elevated body fat and reflect the
  presence or risk of related diseases.
• U.S. has no BMI-for-age references for children lt
  2 years.
• CDC uses overweight instead of obesity for
  children and youth.

7
National Obesity Prevalence for Children and
Youth

• One third (33.6 percent) of 2- to 19-year olds
  are obese or at risk
• Obesity (defined as BMI 95th percentile) for
  based on NHANES data
• 13.9 percent in 19992000
• 15.4 percent in 20012002
• 17.1 percent in 20032004 (obese) 16.5 percent
  (at risk)
• By 2010, an estimated 20 percent of U.S. children
  and youth in the United States will be obese if
  the current trajectory continues
• Sources Ogden et al. (2006) Sondik
  (2004)

8
U.S. Obesity Epidemic Trends for Children and
Youth by Age and Time Frame, 1963-2004
Source Ogden et al., 2006
9
U.S. Childhood Obesity Epidemic Trends by Sex
and Race/Ethnicity, 2003-2004
Obese (BMI 95th percentile)
At Risk ( 85th percentile BMI lt 95th percentile)
At Risk Obese
Source Ogden et al., 2006
10
Obesity in Diverse Populations

• NHANES 2003-2004, non-Hispanic African American
  and Mexican-American children and adolescents,
  2-19 years, have a greater obesity prevalence
  than whites.
• Children and youth at highest risk for obesity
  often experience other social, economic, and
  health disparities concurrently and do not live
  in environments that support healthy behaviors.

11
Adverse Childhood Experiences (ACE) Study

• As a follow-up, Kaiser Permanente CDC conducted
  As a follow-up, Kaiser Permanente CDC conducted
  ACE study
• Study involved 19,000 mostly middle class, middle
  aged adults
• Results show childhood abuse household
  dysfunction led to chronic diseases decades later
• Traditionally viewed as public health problems,
  behaviors may also be coping mechanisms
• ACE study
• Study involved 19,000 mostly middle class, middle
  aged adults
• Results show childhood abuse household
  dysfunction led to chronic diseases decades later
• Traditionally viewed as public health problems,
  behaviors may also be coping mechanisms

12
Other Health Trends

• Doubling of type 2 diabetes among children and
  youth over past decade
• SEARCH for Diabetes in YOUTH Study (2006)
  provides population-based sample for type 1 and
  type 2 diabetes
• Prevalence lower for children ages 0-9 years (.79
  cases/1,000)
• 10-19 year olds (2.8 cases/1,000)
• Type 2 diabetes found in all racial/ethnic groups
  but less common than type 1 except for American
  Indian youth
• One million 12- to 19-year-olds have the
  metabolic syndrome (3 of 5 metabolic
  abnormalities)

13
U.S. Adult Obesity Prevalence

• CDC has tracked adult obesity trends in 50 states
  from 1985 to present
• CDC Maps for U.S. Adult Obesity Trends (BRFSS),
  1985 to 2004
• U.S. adult obesity rates
• 2004 15-19 in 7 states, 20-24 in 33 states
  25 percent or more in 9 states
• 2003-2005 rates exceeded 20 in 43 states DC
  (Trust for Americas Health, 2006)

14
Conclusions from IOM ReportHealth in the Balance

• Childhood obesity is a serious nationwide health
  problem with multi-factorial causes requiring a
  population-based prevention approach and a
  comprehensive response.
• The goal is energy balancehealthy eating
  behaviors and regular physical activity to
  achieve a healthy weight while protecting health
  and normal growth and development.
• Preventing childhood obesity is a collective
  responsibilitymultiple sectors and stakeholders
  must be involved in societal changes at all
  levels.

15
Sectors to Involve in Childhood Obesity Response

• Government (federal, state, local)
• Industry (food, beverage, restaurant, food
  retailers, entertainment, recreation, leisure)
• Media (unpaid and paid)
• Communities (nonprofits, foundations, faith-based
  groups, child- and youth-related organizations,
  health care sector)
• Schools (e.g., preschool, after school, child
  care)
• Home (families and care providers)

16

• Government
• Public Health
• Health Care
• Agriculture
• Education
• Media
• Land Use and Transportation
• Communities
• Foundations
• Industry
• Food
• Beverage
• Retail
• Leisure and Recreation
• Entertainment

• Communities
• Worksites
• Health Care
• Schools and Child Care
• Home

Social Norms and Values
Sectors of Influence
Behavioral Settings

• Demographic Factors (e.g., age, sex, SES,
  race/ethnicity)
• Psychosocial Factors
• Gene-Environment Interactions
• Other Factors

Individual Factors
Physical Activity
Food Beverage Intake
Energy Intake
Energy Expenditure
Energy Balance
17
Conclusions from IOM ReportHow Do We Measure Up?

• Marked underinvestment in childhood obesity
  prevention interventions - current investment
  does not match extent of problem.
• A robust evidence base is needed to identify
  promising practices so effective interventions
  can be scaled-up and supported in diverse
  settings
• Need for collective responsibility and collective
  action.
• Evaluation of ongoing efforts is needed -
  adequate resources need to be committed to
  evaluation.

18
Recommendations

• Lead and commit to childhood obesity prevention
• Evaluate policies and programs and build
  evaluation capacity
• Monitor progress and conduct research
• Disseminate promising practices

19
Promising and Best Practices

• Promising Practices
• Interventions likely to reduce childhood obesity
  and have been evaluated but lack sufficient
  evidence to link it to reducing childhood obesity
  and co-morbidities
• Promising practices always have evaluation
  components
• Best Practices
• Interventions with sufficient evidence to provide
  certainty that they are linked to reducing
  childhood obesity and co-morbidities
• Very few best practices available to guide
  childhood obesity prevention efforts

20
Characteristics of Effective Interventions

• Evaluation built into interventions from the
  outset
• Consider diverse perspectives and attend to
  community and population context
• Link with other programs to produce synergistic
  effect
• Include relevant outcome measures given the scope
  of intervention
• Range of interventions across all sectors and all
  types of outcomes should be measured

21
Obesity Prevention Evaluation Framework

• Sectors
• Resources and inputs
• Strategies and actions
• Continuum of outcomes
• Policy (e.g., structural, institutional,
  systemic) outcomes
• Environmental outcomes
• Social and cognitive outcomes
• Behavioral outcomes
• Health outcomes

22

IOM Evaluation Framework for Obesity Prevention
Policies and Interventions
SECTORS
STRATEGIES ACTIONS
OUTCOMES
RESOURCES INPUTS

• Programs
• Policies
• Surveillance
• and Monitoring
  Research
• Education
• Partnerships
• Coalitions
• Coordination
• Collaboration
• Communication
• Marketing
• and Promotion
• Product
• Development
• New Technologies

Government Industry Communities Schools Home
Leadership Strategic Planning Political
Commitment
Structural, Institutional, Systemic Outcomes
Health Outcomes Reduce BMI Levels in the
Population Reduce Obesity Prevalence Reduce
Obesity-Related Morbidity
Cognitive and Social Outcomes

• Behavioral Outcomes
• Dietary
• Physical Activity

Adequate Funding and Capacity Development
Environmental Outcomes
Cross-Cutting Factors that Influence the
Evaluation of Policies and Interventions Age
sex socioeconomic status race and ethnicity
culture immigration status and acculturation
biobehavioral and gene-environment interactions
psychosocial status social, political, and
historical contexts.
23
Examples of Promising Practices Government

• USDA and DoD Fresh Fruit and Vegetable Program
• CDCs 5-year VERB campaign had positive
  evaluation results in promoting physical activity
  among tweens (funding discontinued in 2006).
• CDCs Nutrition and Physical Activity Program to
  Prevent Childhood Obesity and Other Chronic
  Diseases (16 million to 28 states in 2005-06
  provided to increase capacity to implement
  programs and evaluations).
• Federal Safe Routes to School Program (initiated
  in 2005) has evaluation underway.

24
Examples of Promising PracticesIndustry Media

• Changes by food, beverage, restaurant, recreation
  and entertainment companies based on company
  market testing and consumer marketing research.
• Companies developed new or reformulated products,
  changed packaging (100-calorie packs), expanded
  meals to help consumers adhere to DGA.
• Most evaluations not publicly available many
  innovative interventions not evaluated.
• Media - Small Step (PSA awareness) Coalition for
  Healthy Children (2 evaluations).

25
Examples of Promising Practices Communities

• Coalitions are tracking changes in policies and
  programs to promote physical activity and expand
  access to healthier foods and beverages (built
  environment).
• HHS Steps to a Healthier US Initiative (Steps
  Program) supports 40 communities nationwide
  (35.8 million provided for FY 2004-2006) and has
  evaluation underway.
• Community-academic partnerships
• Public-private partnerships (implement statewide
  obesity prevention action plans GA, WV, NC, TX).

26
Role of Foundations

• Many public-private partnerships involve support
  from corporate or private foundations
• Foundations are becoming important leaders in the
  response to childhood obesity
• Foundations have several advantages
• Greater flexibility in their funding mechanisms
  than government agencies
• Support to explore untested or promising
  approaches and evaluation of natural experiments
• Important funding source for grantees at the
  community level and often require the submission
  of an evaluation plan to accompany a grant
  application

27
Examples of Promising Practices Foundations

• Corporate Foundations
• Produce for Better Health Foundation, General
  Mills Foundation, PepsiCo Foundation, IFIC
  Foundation, Aetna Foundation
• Private Foundations (national, regional, state)
• W.K. Kellogg Foundation, William J. Clinton
  Foundation, California Endowment
• Sunflower Foundation, Healthcare Georgia
  Foundation, Kansas Health Foundation
• Robert Wood Johnson Foundation
• Active Living by Design and Active Living
  Leadership initiatives
• Healthy Eating Research initiative
• Ad Councils Coalition for Healthy Children

28
Examples of Promising Practices Schools

• School nutrition standards
• Awards programs for healthy schools (e.g., Utah
  Gold Medal Schools Program)
• Public-private partnerships
• Alliance for a Healthier Generation has
  evaluation underway
• After-school programs
• CATCH Kids Club, Georgia Fit Kid Project, SPARK
• Need to systematically evaluate school wellness
  policies as they are adopted and promoted
• Kansas Coordinated School Health Program
• Local school wellness policies

29
Examples of Promising Practices Home

• Fit WIC, pilot-tested in 4 states in 1999,
  evaluated parents behaviors to reduce obesity in
  preschoolers. Parents who participated were more
  likely to introduce positive behaviors to their
  children.
• Hip Hop to Health Jr., a preschool intervention
  with low-income African-American children in Head
  Start provided incentives to parents to encourage
  healthy eating behaviors and physical activity in
  children.
• Stanfords Student Media Awareness to Reduce
  Television classroom curriculum reaches parents
  to reduce 3rd-4th graders leisure screen time.

30
Next Steps for Addressing the Childhood Obesity
Epidemic Government

• Establish high-level task forces (federal, state,
  local) to identify priorities for action,
  coordinate public-sector efforts, and establish
  effective interdepartmental collaborations.
• Provide sustained commitment and long-term
  investment in childhood obesity prevention
  initiatives and surveillance efforts.

31
Next Steps for Addressing the Childhood Obesity
Epidemic Industry Media

• Support and market product innovations and
  reformulations.
• Independent and periodic evaluations of
  industrys efforts.
• Develop and strengthen publicprivate
  partnerships
• Share proprietary data that can expand
  understanding of consumer purchasing and
  marketing trends.
• Evaluate progress in developing and communicating
  storylines and programming that promote healthy
  lifestyles.

32
Next Steps for Addressing the Childhood Obesity
Epidemic Communities

• Develop community health index toolkit through
  governmentacademiccommunity partnerships to
  help examine factors relevant to creating
  healthy communities.
• Expand collection and dissemination of local data
• Compile and widely share community-based
  evaluation results, lessons learned, and
  community action plans.

33
Next Steps for Addressing the Childhood Obesity
Epidemic Foundations

• Community stakeholders (including private and
  corporate foundations) should establish and
  strengthen the local policies, coalitions, and
  collaborations needed to create and sustain
  healthy communities.
• Industry (including corporate foundations) should
  use the full range of available resources and
  tools to create, support, and sustain consumer
  demand for products and opportunities that
  support healthy lifestyles including healthful
  diets and regular physical activity.

34
Next Steps for Addressing the Childhood Obesity
Epidemic Foundations

• Community stakeholders should partner with
  foundations, government agencies, faith-based
  organizations, and youth-related organizations to
  strengthen evaluation efforts at the local level
  and support community-academic partnerships.
• Schools and school districts should partner with
  state and federal agencies, foundations, and
  academic institutions to develop, implement, and
  support evaluations of all school-based programs
  and publish and widely disseminate the evaluation
  results of school-based childhood obesity
  prevention efforts and related materials and
  methods.

35
Next Steps for Addressing the Childhood Obesity
Epidemic Schools

• Elevate the priority placed on sustaining a
  healthy school environment.
• Increase resources for technical assistance to
  evaluate changes in schools (physical activity
  and diet).
• Expand surveillance and data collection efforts
• Compile and widely share school-based evaluation
  results and lessons learned.

36
Next Steps for Addressing the Childhood Obesity
Epidemic Home

• Families should assess the home environment to
  ensure that foods and beverages supporting a
  healthful diet are consumed by children and youth
  at home and served in reasonable portion sizes.
• Families should emphasize physical activity as a
  family priority and establish rules or guidelines
  that limit leisure screen time (e.g., television,
  DVDs, videos, movies, videogames, and computers).

37
For More Information

• Fact sheets
• www.iom.edu/obesity/
• Read the book online or purchase the report
• www.nap.edu
• RWJF TV Health Series