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Promising Efforts to CombatChildhood Obesity?
William H. Dietz, M.D., Ph.D.
Division of Nutrition and Physical Activity
Centers for Disease Control and Preventionand Physical Activity
Centers for Disease Control and Prevention
Disclaimer
The findings and conclusions in thisreport have not been formallydisseminated by the Centers forDisease Control and Prevention andshould not be construed to representany agency determination or policy.
Adult per Capita Cigarette Consumption andMajor Environmental and Policy Changes in
the US 1900-1990
Year
Thousands peryear
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
Great Depression
End ofWW II
US Surgeon General’s first report
Broadcastadvertising ban
Federal cigarettetax doubles
First Medical reportslinking smoking and cancer
Fairness Doctrinemessages on radio
and televisionNonsmoker’s rightsmovement begins
Lessons from Tobacco Control
Surveillance – advocacy and policyComprehensive, multidimensionalEfficacy and effectiveness researchAdvocacy frames the issueFunded programsExplicit, measurable goals and objectivesThreshold spendingLocal initiatives fed national action
Overview of Efforts to Control Obesityand Other Chronic Diseases
Problem Definition Assessment Prevalence Disease burden
Strategy Development Social Ecologic Model Evidence development Translation
Implementation State Programs, Steps Policy/environmental Interventions Media
Evaluation
Overweight Prevalence by Race/Ethnicity for Adolescent Boys Aged 12 - 19 Years
Perc
enta
ge
Source: JAMA, 2004;291:2847
Overweight Prevalence by Race/Ethnicity for Adolescent Girls Aged 12 - 19 Years
Source: JAMA, Oct. 9, 2002, Vol. 288, No. 14:1731
Perc
enta
ge
Consequences of Childhoodand Adolescent Obesity
Common Uncommon•Growth•Psychosocial•Hyperlipidemia•Hepatic steatosis•Abnormal glucose metabolism•Asthma•Persistence into adulthood
•Hypertension
•Sleep apnea
•Pseudotumor
•PCOD
•Cholelithiasis
•Orthopedic
BMI and Distribution of Morbid Obesity
BMI @99%tile* > BMI 40** % > 99%tileMales 16yo 33.9 1.6% 8.1% 17yo 34.4 0.3% 6.4% 18yo 35.0 0.1% 3.6%
Females 16yo 39.1 1.6% 1.6% 17yo 40.8 2.3% 2.0% 18yo 42.9 1.7% 0.7%
*CDC growth charts **NHANES 1999-2002
Overview of Efforts to Control Obesityand Other Chronic Diseases
Problem Definition Assessment Prevalence Disease burden
Strategy Development Social Ecologic Model Evidence development Translation
Evaluation
Implementation State Programs, Steps Policy/environmental Interventions Media
A Public Health Framework to Prevent and Control Overweightand Obesity
Energy Intake Energy Expenditure
Energy Balance
Prevention of Overweight and ObesityAmong Children, Adolescents, and Adults
Note: Adapted from“Preventing ChildhoodObesity.” Institute ofMedicine, 2005.
IndividualFactors
BehavioralSettings
Social Normsand Values
Home andFamily
School
Community
Work Site
Healthcare
Genetics
Psychosocial
Other PersonalFactors
Food andBeverage Industry
Agriculture
Education
Media
Government
Public HealthSystems
HealthcareIndustry
Business andWorkers
Land Use andTransportation
Leisure andRecreation
Community- andFaith-basedOrganizations
Foundations andOther Funders
Food and Beverage Intake
Physical Activity
Sectors ofInfluence
Principal Targets
Reduce energy intakeIncrease low ED foodsReduce sugar-sweetened beveragesReduce television timeReduce portion size
Increase energy expenditureIncrease daily physical activity
Breastfeeding
Strategies to Increase Fruitand Vegetable Consumption
Early exposureAccessCommunity and school gardensFarmers’ MarketCompetitive pricingStealth interventions (Garden Market)
Agreement between the Alliance for a HealthierGeneration and the Soft Drink Companies
Elementary schoolsH2O8 oz juice without added sweetenersFF and LF regular and flavored milk
Middle schoolsSame standards, 10 oz portions
High schoolsNo and low kcal drinks, light juices, sports drinks50% must be H2O and no or low Kcal;100Kcal/container
Policy/LegislationNYCDHMH, Amend Article 47, NYC Health Code;
Applies to Group Day Care in NYC
Television, video and other visual viewing– Cannot be used for children <2 yo– Limited 60 minutes per day of educational
programs or programs that actively engagechild movement for children 2+ yo
60’ physical activity requiredEliminate sugar-sweetened beveragesProvide low or no-fat milk
Principal Targets
Reduce energy intakeIncrease low ED foodsReduce sugar-sweetened beveragesReduce television timeReduce portion size
Increase energy expenditureIncrease daily physical activity
Breastfeeding
Effective Interventions to PromotePhysical Activity
• Informational– Community-wide education– Point of decision prompts
• Behavioral and social– School-based PE– Non-family social support– Individually adapted behavior change
• Environmental and policy– Enhanced access with outreach– Urban design and land use
Principal Targets
Reduce energy intakeIncrease low ED foodsReduce sugar-sweetened beveragesReduce television timeReduce portion size
Increase energy expenditureIncrease daily physical activity
Breastfeeding
Strategies to Increase Rates ofBreastfeeding
Maternity care practicesPrenatal counselingBaby-friendly hospitals
Workplace support for breastfeedingPeer support – peer counselingProfessional support and educationPublic acceptance
Shealy et al. Breastfeeding Interventions: www.cdc.gov/breastfeeding
Overview of Efforts to Control Obesityand Other Chronic Diseases
Problem Definition Assessment Prevalence Disease burden
Evaluation
Strategy Development Social Ecologic Model Evidence development Translation
Implementation State Programs, Steps Policy/environmental Interventions Media
Settings for the Prevention and Treatment of Obesity
• Industry
• Medical Settings
• School
• Work Site
• Community
Chronic Care ModelEnvironment Medical System
Family
School
Worksite
Community
Family/PatientSelf-Management
Information Systems
Decision Support
Delivery System Design
Self Management Support
Chronic Care ModelEnvironment Medical System
Family
School
Worksite
Community
Family/PatientSelf-Management
Information Systems
Decision Support
Delivery System Design
Self Management Support
BCBS of MassachusettsEcological Approach
Community Community Based GrantsPeer LeaderTrainingVolunteer Outreach TrainingChildren’s Museum ExhibitCoalition Partnerships
SchoolHealthy Choices Middle GrantsAnnual Conference Teacher ToolkitBest in Class Awards
HealthcareClinician Toolkit Medscape BMI CME Treatment Program Grants PCP Incentive Program NICHQ Physician Collaborative
FamilyParent Toolkit Parent Advocacy WorkshopWorksite Seminar 2’sDays Challenge
MediaMillion Ways Contest Million Reasons Contest CBS-TV4 CampaignWBOS/MIX Radio Contest
Pediatric Initiatives
CDC/AMA/HRSA support forExpert Committee
Maine and Massachusettscollaboratives
NICHQ Summit – networkdevelopment
Settings for the Prevention and Treatment of Obesity
• Industry
• Medical Settings
• School
• Work Site
• Community
Potential Effect of Urban Form on Obesityand Other Chronic Diseases
Urban Form
PhysicalActivityleisuretransportationoccupationalhousehold
Obesity andother chronicdiseases
Adapted from Ewing et al; Am J Health Prom 2003; 18:47
Food accessFood quality
Successful Community-basedInterventions for Children
• El Paso Texas(Paso del Norte HealthFoundation)
• Somerville Massachusetts• Colac (Australia)• EPODE (Ensemble Prevenons
L’Obesite des Enfants – FleurbaixLaventie, FR)
Paso del Norte El Paso Project
• CATCH in elementary schools (Coordinated Approach to ChildHealth)
• Bike/walk paths• Walk El Paso• Que Sabrosa Vida
Changes in the Prevalence of Overweight:Paso del Norte El Paso Project
2001-02 2004-054th grade 26% 23%8th grade 19% 15%
What HEAL Looks Like in California
• KP’s HEAL-CHI– Locations: Richmond, Santa
Rosa, Modesto– Investment: $1.5M per
site/5years• Healthy Eating, Active
Communities (HEAC)– Multi-level & multi-sectoral– Health sector leadership– Community engagement &
ownership– Evidence informed– Focus on disparities
Overview of Efforts to Control Obesityand Other Chronic Diseases
Problem Definition Assessment Prevalence Disease burden
Evaluation
Strategy Development Social Ecologic Model Evidence development Translation
Implementation State Programs, Steps Policy/environmental Interventions Media
“To obtain more evidence-basedpractice we need more practice-based evidence”
Greeen L, Ottoson JM. In Hiss et al, From Clinical Trialsto Community: the Science of Translating Diabetes andObesity Research, NIH, 2004.
Obesity Prevention Requires AllSectors
of Influence Working Together
Agriculture
Schools
Trans-portation
LandUse
Food & Beverage Industry
MedicalSystem
WorkSite
Media
Community
Science Base
For Obesity Prevention
Active Livingand
Healthy Eating
Potential Foundation Investmentsfor Weight Control
Convene networks or coalitions – multiple sectorsGenerate local dataAddress disparitiesSupport evaluationAdvocateReframe the problem
Grantmakers in Health. Reversing the Obesity Epidemic. Issue Brief28, 2/2007.
References
cdc.gov/nccdphp/dnpacdc.gov/nccdphp/dashcdc.gov/breastfeedingnichq.org
The RE-AIM Framework
R ReachE EffectivenessA AdoptionI ImplementationM Maintenance
Glasgow RE et al. Ann Behav Med 2004;27:3-12