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

Eduardo Sanchez, M.D., M.P.H.Director, Institute for Health PolicyUniversity of Texas School of Public Healtheduardo.j.sanchez@uth.tmc.edu

November 3, 2006

Discussion Points

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

Background 2004

• Congressional request• Sponsors – DHHS (CDC, NIH, ODPHP), • RWJF• 19-member IOM committee• Blueprint for comprehensive action plan2006 • Sponsor – RWJF• 13-member IOM committee• Assess progress in preventing childhood obesity• Conduct 3 regional workshops

IOM Committee on Progress in

Preventing Childhood Obesity JEFFREY KOPLAN (Chair)

Emory UniversityROSS BROWNSON

St. Louis UniversityANN 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 YANCEYUCLA School of Public Health

ConsultantsSHIRIKI KUMANYIKA

University of PennsylvaniaDONNA NICHOLS

Texas Department of State Health Services

IOM StaffVIVICA KRAAK, CATHY LIVERMAN, SHANNON

WISHAM, JON SANDERS

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

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 < 2 years.CDC uses overweight instead of obesity for children and youth.

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 1999–2000 • 15.4 percent in 2001–2002• 17.1 percent in 2003–2004 (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)

U.S. Obesity Epidemic Trends for Children and Youth by Age and

Time Frame, 1963-2004

455

465

75

7

11 1112

1716

0

10

20

2-5y 6-11y 12-19y

1963-1970 NHES 1971-1974 NHANES I 1976-1980 NHANES II1988-1994 NHANES III 1999-2004 NHANES

Source: Ogden et al., 2006

U.S. Childhood Obesity Epidemic Trends by

Sex and Race/Ethnicity, 2003-2004

Source: Ogden et al., 2006

0

5

10

15

20

25

30

35

40

45

Wh

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Bla

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Mexic

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Am

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All

Wh

ites

Bla

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Mexic

an

Am

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All

Wh

ites

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Mexic

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Co

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ined

To

tal

Boys ages 2-19 yrs Girls ages 2-19 yrs

Obese (BMI ≥ 95th percentile)

At Risk ( 85th percentile ≥ BMI < 95th percentile)

At Risk + Obese

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.

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

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)

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 America’s Health, 2006)

Conclusions from IOM Report

Health 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 balance—healthy 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 responsibility—multiple sectors and stakeholders must be involved in societal changes at all levels.

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)

Energy Intake Energy Expenditure

Energy Balance

Individual Factors

Behavioral Settings

Social Norms and Values

Communities

Worksites

Health Care

Schools and Child Care

Home

Demographic Factors (e.g., age, sex, SES, race/ethnicity)

Psychosocial Factors

Gene-Environment Interactions

Other Factors

Government

Public Health

Health Care

Agriculture

Education

Media

Land Use and Transportation

Communities

Foundations

Industry

Food

Beverage

Retail

Leisure and Recreation

Entertainment

Physical Activity

Sectors of Influence

Food & Beverage Intake

Conclusions from IOM Report

How 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.

Recommendations• Lead and commit to childhood obesity prevention• Evaluate policies and programs and build

evaluation capacity• Monitor progress and conduct research• Disseminate promising practices

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

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

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

SECTORS STRATEGIES & ACTIONS

OUTCOMES

Leadership Strategic Planning Political Commitment

Cross-Cutting Factors that Influence the Evaluation of Policies and InterventionsAge; sex; socioeconomic status; race and ethnicity; culture; immigration status and acculturation;

biobehavioral and gene-environment interactions; psychosocial status; social, political, and historical contexts.

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

Structural, Institutional, Systemic Outcomes

RESOURCES & INPUTS

Environmental Outcomes

Health Outcomes

Reduce BMI Levels in the Population

Reduce Obesity Prevalence

Reduce Obesity-Related Morbidity

GovernmentIndustry CommunitiesSchoolsHome

Adequate Funding andCapacity Development

Cognitive and Social Outcomes

Behavioral Outcomes• Dietary • Physical Activity

IOM Evaluation Framework for Obesity Prevention Policies and Interventions

Examples of Promising Practices Government

• USDA and DoD Fresh Fruit and Vegetable Program • CDC’s 5-year VERB campaign had positive evaluation

results in promoting physical activity among tweens (funding discontinued in 2006).

• CDC’s 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.

Examples of Promising Practices

Industry & 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).

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).

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

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 Council’s Coalition for Healthy Children

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

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.

• Stanford’s Student Media Awareness to Reduce Television classroom curriculum reaches parents to reduce 3rd-4th graders’ leisure screen time.

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.

Next Steps for Addressing the Childhood Obesity Epidemic

Industry & Media

• Support and market product innovations and reformulations.

• Independent and periodic evaluations of industry’s efforts.

• Develop and strengthen public–private 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.

Next Steps for Addressing the Childhood Obesity Epidemic

Communities

• Develop community health index toolkit through government–academic–community 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.

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.

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.

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.

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).

For More Information

• Fact sheets

www.iom.edu/obesity/Read the book online or purchase the report

www.nap.edu• RWJF TV Health Series