education, policy and environmental change, and evaluation

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

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

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.

Obesity Trends* Among U.S. Adults, BRFSS 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%


No Data <10% 10%–14% 15%–19%


No Data <10% 10%–14% 15%–19% ≥20%


No Data <10% 10%–14% 15%–19% 20%–24% ≥25%


No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%







Evaluation

Dietary Behaviors

Increased consumption of sugar

sweetened beverages

Continued low consumption of

fruits and vegetables

Dietary Behaviors

Increased frequency of meals eaten away from home

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

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.

“ 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

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

% o

f T

rip

s

Car

Bus

Walk/bike

Public Transit

McDonald NC. Am J Prev Med 2007;32:509


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.


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







Evaluation

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.

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.







Evaluation

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

Human Services

Socio-Ecological Model

Knowledge, skills, attitudes, beliefs and behaviors

Family and peers that influence an individual

Social networks and norms

Public Policy

Community

Organizational

Interpersonal

Individual

Federal, state and local policies, laws and regulations

Rules, regulations, formal and informal policies and procedures

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

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

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

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

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

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

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

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

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

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

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

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

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.

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







Evaluation

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?

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?

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,


Baby-Friendly Hospital Initiative,

http://www.centertrt.org/?p=intervention&id=1094&section

=1






http://www.centertrt.org/?p=intervention&id=1094&section=1

http://www.centertrt.org/?p=intervention&id=1094&section=1

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/LatinoCampa

ign.aspx (Practice-tested)



http://www.cdph.ca.gov/programs/cpns/Pages/LatinoCampaign.aspx



… “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)

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_20

10_Action_Guide.pdf

http://www.cdc.gov/brfss/

http://www.cdc.gov/physicalactivity/downloads/PA_State_Indicator_Report_2010_Action_Guide.pdf


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_20

10_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)



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: [email protected]

Web: www.cdc.gov

mailto:[email protected]

http://www.cdc.gov/

Question Slide

education, policy and environmental change, and evaluation

Health & Medicine

higher prevalence of

higher obesity prevalence

obesity epidemic2

obesity trends

obesity statisticsbetween

obese bmi

sex specific bmi

recent data