shape up somerville shape up somerville: a community-based environmental change obesity prevention...
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Shape Up SomervilleShape Up Somerville:A Community-Based Environmental Change A Community-Based Environmental Change
Obesity Prevention InterventionObesity Prevention Intervention
Christina Economos, Ph.D.Christina Economos, Ph.D.
New Balance Chair in Childhood NutritionNew Balance Chair in Childhood Nutrition
Friedman School of Nutrition Science and PolicyFriedman School of Nutrition Science and Policy
Tufts University, Boston MATufts University, Boston MA
R06/CCR121519-01 from the Centers for Disease Control and Prevention.
Additional support was provided by Blue Cross Blue Shield of Massachusetts, United Way of Mass Bay, The Potato Board, Stonyfield Farm, and Dole Foods.
BACKGROUND
• Proactive strategies required to prevent childhood obesity
• Individual behaviors must be addressed in the context of societal and environmental influences
• Most prevention studies target school environments
• Summer weight change recently shown to outpace expected gains with growth and development
• Community-based interventions that have a theoretical framework and are mutli-level and participatory in nature are needed to catalyze social change
The Society-Behavior-Biology Nexus as depicted in multidimensional space
Glass and McAtee Social Science & Medicine Volume 62, Issue 7, April 2006, Pages 1650-1671
Learn from other movements (tobacco, recycling, seat belts, breastfeeding)
Call for a Crisis Build on a sound scientific base Nurture spark plugs Recognize the importance of economics Develop coalitions and advocacy Use government strategically Employ mass communication
Create environmental and policy changes
Develop a clear plan
How do you spark social change?
Economos, C, Brownson, S, DeAngelis, M, Foerster, S, Tucker Foreman, C, Kumanyika, S, Pate R. What Lessons Have Been Learned From Other Attempts To Guide Social Change? Nutrition Reviews 2001; 59(3):40-56
• A community-based, participatory, environmental approach to prevent childhood obesity
• A 3 year controlled trial to study 1st – 3rd grade culturally and ethnically diverse children and their parents from 3 cities outside Boston
• Goals: – To examine the effectiveness of the model on the
prevention of undesirable weight gain in children
– Transform a community and inform social change at the national level
Shape Up Somerville: Eat Smart. Play Hard.
CBPR• Community-based participatory research
(CBPR) includes a collaborative partnership with the community in all phases of the research:– identifying the problem
– designing, implementing and evaluating the intervention
– building community capacity
– identifying how data informs actions to improve health within the community
Potential to influence cultural and social norms
Community Engagement Model
CommunityMapping:
Understanding connections
ParticipationAssessment:
Identifying partners
Information Gathering &
Delivery
Capacity Building:
Making it happen
Model Adapted from National Resources Canada
Employ The Social Change Model of Leadership Development
Hold community meetings
Community council formation
Perform environmental assessments
Logo and brand development
Conduct focus groups &key informant interviews
Listen…Build Relationships
&
Establish Trust
Identify the problem as a community priority
Capitalize on social injustices
Identify champions
Study Timeline
Planning and monitoring yearOct 02-Sept 03
Year 1Intervention
Oct 03-Sept 04
Year 2 Intervention
Oct 04-Sept 05
Baseline Pre School Year 1
MeasurementOct 03
Post School Year 1
Measurement
May 04 Pre School
Year 2Measurement
Sept 04
Post School Year 2
MeasurementMay 05
Summer
Baseline Overweight Prevalence
0
5
10
15
20
25
30
U.S. Intervention Control 1 Control 2
at risk
overweight
At risk: 85th to < 95th percentileOverweight: 95th percentileReference: CDC 2000Ogden JAMA 2006, Economos, 2003
INTERVENTION• Designed to increase energy expenditure (EE) of up
to 125 kcals per day beyond the increases in EE and energy intake that accompany growth
• Variety of increased opportunities for physical activity
• Availability of foods of lower energy density, emphasizing fruits, vegetables, whole grains, and low-fat dairy; foods high in fat and sugar were discouraged
• Multi-level approach:– Before, during, after school, home, community
Early MorningEnvironment
During School Environment
Afternoon Environment
At HomeSafe Routes to School Maps
Walking to School (-30 kcals)Healthier Home Breakfast
Fiber, Sugar, FatAppropriate Portion Sizes
Before School ProgramHealthier School Breakfast
Fiber, Sugar, FatAppropriate Portion SizesIncreased Fresh Fruits Breakfast Coordinator
Reinforcing Environments
Home Environment (~15 kcal)Parent Newsletter w/ couponsGrowth Reports Screen TimePromotional Gifts
Community EnvironmentCommunity “Champions”Restaurant ParticipationPediatrician Training & SupportCommunity TV AppearancesEthnic Group OutreachCommunity PA Resource GuideCommunity Events
At homeSafe Routes to School Maps Walking Home (-30 kcals)Healthy Home Snack Fiber, Sugar, Fat
After School ProgramCurriculum:
Cooking LessonsPhysical Activity (-30 kcals)Nutrition EducationProfessional Development
Classroom Micro UnitsPhysical Activity (- 25 kcals) 5 days/wk (10 min)Nutrition & Physical Activity Education 1 day/wk (30 min)
Healthier Fundraising Alternatives
Professional DevelopmentTeachersAdministratorsFood Service StaffPE Teachers
Physical Activity Equipment for Recess Physical Activity (- 25 kcals)
Healthier School LunchFiber, Sugar, Fat
Increased Fresh Fruits & VegetablesAppropriate Portion SizesImproved Presentation and AtmosphereSocial Marketing in CafeteriaAlternative “Healthier” A La Carte ItemsNew Food Service Equipment
(~25 kcals)
Home:Parent, Child, Family
Home:Parent, Child, Family
Home:Parent, Child, Family
School:Child, teachers, administration, staff
School:Child, teachers, administration, staff
School:Child, teachers, administration, staff
Community:After school programs
Community: Ethnic groups
Local Government
Health Care System
Community: RestaurantsMedia
Skills Development
Experiential Learning
Demonstrations
A La Carte Options: Before Shape Up….
After…Improved A La Carte Options
A La Carte Snack Sales Data• Sales fell from Sept. 2003 to Dec. 2003, making about $7,000 - $9,000/month less in revenues compared to 2002 data.
• Sales began to increasing in winter of 2004, showing increased student acceptance for new mix of products
• As of Oct. 2004 sales are now fairly even with sales prior to intervention
• Data is consistent with trends reported from other school systems.
Revenues per day by school year
600
800
1000
1200
1400
September October November December January February March
Months
Re
ve
nu
e
Revenue per Day School year 2002-2003 Revenue per Day School year 2003-2004
Revenue totals include Paid Lunches, Milk Purchases, and Teacher Sales in addition to A La Carte sales
HEAT Club: After School Program
Before school : Walking School Bus
Support from Community Champions
A year of consultation and guidance for being a visible role model
• Mayor Joe Curtatone• Aldermen • School Committee Members
Growing food, knowing food
School Gardens and Nutrition Education
Shape Up Somerville : Results• Engaged 90 teachers in 100% of 1-3 grade classrooms
(N=81)• Participated in or conducted 100 community events and 4
parent forums• Trained 50 medical professionals • Recruited 21 restaurants • Reached 811 families through 9 parent newsletters, and
353 community partners through 6 community newsletters • Reached over 20,000 through a monthly media piece (11
months) • Recruited all 14 after-school programs • Developed community-wide policies to promote and
sustain change
Demographic Characteristics at Baseline
Intervention Control 1 Control 2
N=342 N=485 N=207
Age (y) 7.90 ± 1.09 7.32 ± 0.93 7.82 ± 1.03
Grade (%)
One 31.3% 48.0% 38.2%
Two 32.2% 24.7% 27.1%
Three 36.5% 27.2% 34.8%
Ethnicity (%)
White 50.3% 37.5% 51.7%
Black 8.5% 25.6% 6.3%
Hispanic 19.0% 9.7% 23.7%
Asian 8.8% 2.3% 7.2%
Other 13.5% 24.9% 11.1%
Non-English Home Language (%)
33.6% 14.8% 34.3%
Variables Control 1 Control 2 Control 1 + 2
Intervention (Somerville vs.) -0.1307 -0.1048 -0.1005 (0.0203) (0.0235) (0.0011) Baseline BMI z-score -0.0328 -0.0448 -0.031 (0.3466) (0.2204) (0.1516) Sex 0.00003 -0.0058 -0.0022 (0.9963) (0.4323) (0.6475) Grade -0.0304 -0.0228 -0.0208 (0.3389) (0.5026) (0.3249) Age (in months) 0.0013 0.0011 0.0007 (0.5409) (0.6276) (0.6510) Ethnicity 0.0009 0.0052 0.0027 (0.0251) (0.5024) (0.3540) Primary language spoken at home 0.0079 0.0076 0.0129 (0.6279) (0.6837) (0.3255) Constant -0.0099 -0.0322 -0.0136 (0.8986) (0.6862) (0.8277)
Results of Change in BMI z-score PRE-POST Intervention (N = 1178),
Coefficients with p-values
Adjusted for all variables shown above plus the 30 participating schools
First Year Results
First Year Results
Limitations / Strengths• Controlled, but not randomized • Up-front investment both time and labor intensive • Dissemination and replication will require
community collaboration• Measured and followed a subset of the eligible
population
• Recruited and retained a large sample of ethnic and racially diverse, high-risk children from three communities
• One of the first community-based obesity prevention project to demonstrate prevention of weight gain
IMPLICATIONS
• Comprehensive strategies that involve changes in multiple environments reinforced with policies that ensure healthy living are a viable and necessary direction for the future
Nurture and follow the championsSome community members may need a little nudge to get them to initiate things on their own; others are already leading.
Build initial relationships through key informant interviews The process of asking community members for their opinions and input informs, empowers, and lays the foundation for trust.
School Administration buy-in is key If you want anything to happen on a school-wide level you need approval and support from the principals and
superintendent.
Global Lessons Learned: Build Support Networks
Keep the community informed of what you are doing. Build community support and recognition of the
project by informing community leaders who may not be involved in your specific work.
Engage people with family and community newsletters, letters to the editor, by publicizing events and by participating in discussions at town meetings and other committees.
Global Lessons Learned: Communications
Create mechanisms to hold people accountableEnvironments that have enforced policies, monthly meetings, and/or consistent monitoring are easier to work with.
When appropriate, ask programs and individuals to sign contracts, memorandums of commitment, or pledges.
Global Lessons Learned: Accountability
Provide professional development opportunities for those involved in your intervention i.e. teachers, food service directors, after school program leaders
Trainings allow for:
Reinforcement and transfer of knowledge
Relationship growth
Continued empowerment
Sense of personal investment
Program Sustainability
Global Lessons Learned: Professional Development
Say yes when you can in the communityPut your program agenda aside to build relationships and trust. Support other initiatives and issues in the community even if they have no direct link to your work.
During your planning year – LISTENBe realistic in your planning year: think about what you have heard, rather than what you want to achieve. There’s much to learn from others.
Global Lessons Learned: Community Relations
Provide stipends when you can.Respect the time of professionals by offering compensation. It will open doors and encourage collaboration.
Being present at events is key, not the materials you bring Go to as many community events as possible. Reach out to other providers and learn about other community issues.
Reach out to Community LeadersYou are surrounded by experts and sources of knowledge. Network with them.
Global Lessons Learned: Community Relations
Bring key stakeholders to the tableHaving the right people helps your project move ahead. Constantly
assess whether or not you have the key decision makers as part of your discussions. These players can change over time; be sure to know who does what in your community.
Parent engagement is easiest through personal connection Ask your partners to invite parents that they know to your events.
Global Lessons Learned:Don’t be Shy
Each community has different strengths and resources
Social change is slow and dependent on the health and strength of relationships
Focus on interventions that have:• Designated leadership• Designated meeting times for leadership• Sustainability potential
Global Lessons Learned: There is no MAGIC bullet
Replicating the intervention across the country through a RCT with 6 urban communities. RFA available at www.childreninbalance.org
Adapting and implementing the intervention through a RCT in 8 communities in rural America (CA, MS, KY, SC) with Save the Children
Distributing the HEAT Club after school curriculum through live and online trainings throughout the U.S. (>150 ASPs in 20 states) including an RCT
Tipping the Scales for HPHCF
Beyond Somerville
Tipping the Scales
• MA, ME, NH
• Key informant interviews – 75 to date
• Research and programmatic activities
• Wellness policies
• Legislation
• BMI data
Tipping the Scales
• Data analysis underway
• Preliminary observations – Awareness is high
– Interest in and efforts to control further growth of the problem are widespread and cross many sectors within the three states
– Appreciation for pressures schools face
– Impressive number of activities underway• Limited number include an evaluation component.
• Differences of opinion about the role of growth monitoring
• Physician’s efforts encouraging
• Exciting efforts to develop resources to increase physical activity
www.childreninbalance.org