Catalyzing Communities to
Reduce Obesity
Sonya Irish Hauser, PhD
June 29, 2009
U.S. Childhood Obesity
y National Trends
20
17
 Double
Quadrupled
12 12.4
10
5
11
7
4
5
4
16
Tripled
11
7
5
17 6
17.6
17
6
5
0
2-5yy
1963-1970 NHES
1988-1994 NHANES III
6-11yy
12-19yy
1971-1974 NHANES I
1999-2004 NHANES
1976-1980 NHANES II
2003-2006 NHANES
Background:
Behavioral contributors to childhood obesity
• Physical Activity
• Dietary Behaviors
Policy
Community
Media
School
Home
Dietary
Behaviors
&
Physical
y
Activity
Family
After School
Food
Availability
Recreation
Availability
Development of Childhood
Obesity
Low cost/energy
dense foods
Increased
Portion Sizes
Food Advertising
Sugar Sweetened
Beverage Consumption
Fat
Stores
Multi Media
Saturation
PE &
R
Recess
Cuts
Declines in
Physical Activity
Changing Built
Environment
BACKGROUND
• Proactive strategies required to prevent childhood obesity
• Individual behaviors must be addressed in the context of
societal and environmental influences
• School environments ideal for intervention
• Learn from other movements (tobacco, recycling, seat
belts, breastfeeding) to spark social change
– Economos, C, et al. What Lessons Have Been Learned From Other
Att
Attempts
t T
To G
Guide
id Social
S i l Change?
Ch
? Nutrition
N t iti Reviews
R i
2001;
2001 59(3):40-56
59(3) 40 56
• Community-based interventions that have a theoretical
framework and are mutli-level and participatory in nature
are needed.
Shape Up Somerville:
Eat Smart. Play Hard.
• A community-based,
community based participatory,
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
R06/CCR121519-01 from the Centers for Disease Control and Prevention.
Additional support by Blue Cross Blue Shield of Massachusetts, United Way of Mass Bay, The US Potato Board, Stonyfield Farm, and Dole Foods
Intervention
Energy e
Energ
expenditure
pendit re up
p to
125 kcals p
per day
y
CBPR
• Community-based participatory research includes a collaborative partnership with the
community
it iin allll phases
h
off th
the research:
h
– identifying the problem
– designing, implementing and evaluating the
intervention
– building community capacity
– identifying
id tif i h
how d
data
t iinforms
f
actions
ti
tto iimprove
health within the community
Potential to influence cultural and social norms
Study
Timeline
Post School
Year 1
Measurement
May 04
Baseline
Pre School Year 1
Measurement
Oct 03
Pre School
Year 2
M
Measurement
t
Postt School
P
S h l
Year 2
Measurement
Mayy 05
Sept 04
Summer
Planning and
monitoring year
Oct 02-Sept 03
Year 1
Intervention
Oct 03-Sept 04
Year 2
Intervention
Oct 04-Sept 05
Study Subject Numbers
Eligible students
N=5940
Consented to participate
N=1721
Pre/Post Year 1 (Oct 03-May
03 May 04)
N=1178
Pre/Post Year 2 (Oct 04-May 05)
N=1100
Pre/Post Years 1 & 2 (Oct 03-May 05)
N=1034
Baseline Overweight/Obesity
30
25
20
Overweight
Obesity
y
15
10
5
0
U.S.
Intervention
Ogden JAMA 2006, Economos, 2003
Control 1
Control 2
At risk:  85th to < 95th percentile
Overweight:  95th percentile
Reference: CDC 2000
INTERVENTION
• Designed to increase energy expenditure (EE) of
up to 125 kcals per day beyond the increases in
EE and
d energy intake
i t k that
th t accompany growth
th
– Variety of increased opportunities for physical activity
– < 2 hr.
h per day
d off Screen
S
Time,
Ti
No
N TV in
i bedroom
b d
– Increased availability of foods of lower energy density,
emphasizing fruits, vegetables, whole grains, and low-fat
dairy
– Foods high in fat and sugar were discouraged
– Family Meals encouraged – structure, modeling,
education,
d
ti
emotional
ti
l connection:
ti
practice
ti as often
ft as
possible
• Multi-level
Multi level approach:
– Before, during, after school, home, community
Early Morning
Environment
At Home
Safe Routes
to School Maps
Home:
 Walking to School (-30 kcals)
Parent,
Family
HealthierChild,
Home Breakfast
 Fiber,
Fiber  Sugar,
Sugar  Fat
Appropriate Portion Sizes
During School
Environment
Before School Program
Child,,
Physical Activity Equipment for Recess

Physical Activity (- 25 kcals)
Healthier School Lunch
Child,
Afternoon
Environment
Fiber,School:
Sugar,
Fat
Increased Fresh Fruits & Vegetables
teachers,
administration,
staff
Appropriate Portion
Sizes
Improved Presentation and Atmosphere
S i l Marketing
Social
M k ti in
i Cafeteria
C f t i
Alternative “Healthier” A La Carte Items
New Food Service Equipment
At home
Safe Routes
to
School Maps
Home:
 Walking Home (-30 kcals)
Parent,
Family
Healthy Child,
Home Snack
 Fiber,  Sugar,  Fat
Healthier School Breakfast
 Fiber,
 Sugar,  Fat
School:
Appropriate Portion Sizes
teachers,
, administration,
,
Increased
Fresh Fruits
(~25 kcals)
Breakfast Coordinator
staff
Classroom Micro Units
Physical Activity (- 25 kcals) 5 days/wk (10 min)
Nutrition & Physical Activity Education 1 day/wk
(30 min)
Healthier School:
Fundraising Alternatives
Child, teachers,
staff
Professional administration,
Development
Teachers
Administrators
Food Service Staff
PE Teachers
After School Program
Curriculum:
Community:
Cooking
Lessons
Activity
(-30 kcals)
AfterPhysical
school
programs
Nutrition Education
P f i
Professional
l Development
D l
Home Environment (~15 kcal)
Community
Environment
Community:
Ethnic groups
ParentHome:
Newsletter w/ coupons
Community “Champions”
Growth Reports
Restaurant Participation
Child,
Family
Health
Care System
Reinforcing Parent,
g & Support
pp
Pediatrician Training
Screen Time
Environments Promotional Gifts
Community TV Appearances
Local Government
Ethnic Group Outreach
Community PA Resource Guide
Community: Restaurants
Community Events
Media
Skills Development
Experiential Learning
Demonstrations
A La Carte Options:
p
Before Shape
p Up….
p
After…Improved A La Carte Options
Before school : Walking School Bus
HEAT Club: After School Program
Support from Community Champions
Visible role models
• Mayor Joe Curtatone
• School Committee
Members
Growing food, knowing food
School Gardens and Nutrition Education
SUS Approved Restaurants
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
p
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
g
sustain change
City Wide Policy Changes
•
School Department
– Wellness policy, snack policies, classroom
curriculum
•
Food Service Department
– Union negotiations, fresh produce prepped & served
d il
daily
•
After School Curriculum
•
Walkability
– Thermoplastic crosswalks, bike racks
•
Research
– YRBS, weight screening,
•
City Employee Wellness
– $200 reimbursement
RESULTS: BMI z-score at 4 time points
Control 1 & 2
Year 1 Change
Intervention vs. Control 1 + 2
Estimate -0.1005
P = 0.0011
0 00
N = 1178
Obesity 2007;15:1325-1336
N = 922
Estimated Intervention Effect Over 8 Months on a Child
at the 75th percentile BMIBMI-z score
Boys
Girls
Baseline
Without
intervention
With
intervention
Baseline
Without
intervention
With
intervention
8 yr
8 yr 8 mo
8 yr 8 mo
8 yr
8 yr 8 mo
8 yr 8 mo
Height (in)*
50.35
51.85
51.85
50.23
51.66
51.66
BMI**
17.00
17.40
17.17
17.27
17.70
17.45
Weight (lb)***
61.43
66.50
65.68
61.97
67.18
66.24
BMI z-score**
**
0 68
0.68
0 68
0.68
0 8
0.58
0 68
0.68
0 68
0.68
0 8
0.58
BMI z-score change
0.00
-0.09
0.00
-0.09
Weight change (lb)
5.07
4.25
5.21
4.26
Intervention effect (lb)
-0.82
0 82
-0.95
0 95
*Height is 50th percentile at each age, baseline and without intervention.
**BMI and ***BMI z-score are 75th percentile.
Weight at baseline is calculated from baseline BMI and height
height.
***Weight
Economos C, Hyatt R, Goldberg J, Must A, Naumova E, Collins J, Nelson M. A Community-Based Environmental Change
Intervention Reduces BMI z-Score in Children: Shape Up Somerville First Year Results. Obesity. 2007;15:1325-1326.
Results: Pre-Post Summer BMI z-score
N 1120
N=1120
School Nutrition Policy Initiative: Results
Figure 1: Unadjusted incidence, remission, and prevalence of overweight (85.0th94 9th percentiles) at 2 years
94.9
years. Statistically significant differences between the
intervention and control schools after controlling for race/ethnicity, gender, age,
and baseline prevalence for the prevalence outcome.
Foster, G. 2008 Pediatrics; 121;e794-e802
Implications / Future Directions
Comprehensive strategies with
changes
h
iin multiple
lti l environments
i
t
reinforced with policies
that ensure healthy living are a viable and
necessary direction for the future
Q
Questions?
ti
?
christina.economos@tufts.edu
sonya irish@tufts edu
sonya.irish@tufts.edu
Maintenance of effective programs
p g
Phase 2:
Controlled
C
t ll d h
hypothesis
th i
testing
Phase 1:
Phase 3:
Theory-based
hypothesis
development
& research design
Replication &
dissemination
Phase 4:
Long-term
maintenance
Beyond Somerville
Replicating the intervention across the country through a RCT
with
ith 6 urban
b communities.
iti
Th
The BALANCE P
Project
j t
Adapting and implementing the intervention through a RCT in
8 communities in rural America (CA, MS, KY, SC) with Save the
Children. The CHANGE Project
Distributing the HEAT Club after school curriculum through live
and online trainings throughout the U.S. (>200 ASPs in 20
states)
t t ) including
i l di a RCT
Expanding
p
g the work to target
g new immigrants
g
through
g a new
NIH grant
www.childreninbalance.org
Beyond Somerville
Replicating the intervention across the country through a RCT
with
ith 6 urban
b communities.
iti
Th
The BALANCE P
Project
j t
Adapting and implementing the intervention through a RCT in
8 communities in rural America (CA, MS, KY, SC) with Save the
Children. The CHANGE Project
Distributing the HEAT Club after school curriculum through live
and online trainings throughout the U.S. (>200 ASPs in 20
states)
t t ) including
i l di a RCT
Expanding
p
g the work to target
g new immigrants
g
through
g a new
NIH grant
www.childreninbalance.org
OM Evaluation Framework for Obesity Prevention
Adapted for Shape Up Replication
SECTORS
Local
Government
RESOURCES & INPUTS
Leadership
Strategic Planning
Political Commitment
Schools
After school
programs
Home
Community
organizations
Adequate Funding and
Capacity Development
OUTCOMES
STRATEGIES &
ACTIONS
• Programs
• Policies
• Monitoring
• Evaluation
• Education
• Partnerships
• Coalitions
• Coordination
• Collaboration
• Communication
• Marketing
M k ti
and Promotion
Community
awareness,
participation,
and involvement
School and
after school
curriculum,
food service,
and policy
change
Anticipated,
or Measured
Health
Outcomes*
Reduce BMI
Environmental
and policy
change
g
throughout
community
Health care
leadership,
practice and
policy change
Health Care
Reduce
Obesity
Prevalence
Reduce
ObesityRelated
Morbidity
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.
* Health outcomes will not be measured as part of the replication project, but are the proximal outcomes of interest
The BALANCE Project:
j
Goals & Objectives:
• Replicate the Shape Up Somerville (SUS) model in underserved, urban communities in the US with similar community
characteristics (i
(i.e.
e size
size, SES) and level of community
readiness
• Nationwide RFP process
• Two
T
year study
t d – Spring
S i 2008
2008-Spring
S i 2010
• Community and school-level environmental & policy outcomes
Balance Study Sites
RCT
3 Intervention
Balance Study Applications (N=22)
Balance Study Sites (N=6)
3 Control
Outcome Evaluation: BALANCE
Measurable end results that will allow comparison between the intervention and control communities (n=6)
iti ( 6) in order to identify a program’s impact.
i
d t id tif
’ i
t
Outcome
Evaluation Tool
Timeline
Community Readiness
Community Readiness Model
C
i R di
M d l
Spring 2008, Spring S i 2008 S i
2009, Spring 2010
Built Environment/ B
il E i
/
Community Policy
Completion of community assessment C
l ti
f
it
t
tool.
Fall 2008, Spring F ll 2008 S i
2009, Spring 2010
Food Service Direct Observation
Income and expenditure data
I
d
dit
d t
Nutrient analysis done by school
Participation rates
Production records /Recipes
Food Service Director Interview
F d S i Di t I t i
Fall 2008, Spring 2009 S i 2010
2009, Spring 2010
same as above
same as above
same as above
Same as above
S
b
Yale Tool for evaluating existing policies
Wellness Policy Checklist/Survey Tool
W ll
P li Ch kli t/S
T l
Abbreviated interview with school principals
Fall 2008, Spring 2009, Spring 2010
same as above
b
same as above
Benchmark: National Guidelines: 2005 Dietary Guidelines for Americans and 2008 Healthier US Schools Guidelines
Wellness Policy
Quality of policy language Extent of Implementation Mean
Overall CRS
4.2
Background: Rural America
•
•
•
•
•
•
•
•
•
Difficult to define
Chronic, entrenched poverty
Declining job opportunities and population loss
Low education and literacy
Racism
Less developed transportation infrastructure
Lack of access to services and amenities
Safety concerns
Isolation and stigma
C t lV
Central
Valley
ll
Mississippi River Delta
S th
Southeast
t
Appalachia
Rural Population
p
Weight
g Status
Child Weight Status
39.4% Healthy weight
22.2% Overweight
38.4% Obese
61% of children
are overweight
or obese
Hennessy 2008
Parental weight status
6.1% Underweight
17.2% Healthy weight
24.2% Overweight
33.3% Obese
19.2% Extremely obese
77% of parents
are overweight
or obese
The
eC
CHANGE
G Study
Creating Healthy, Active, and Nurturing
Growing-up
Growing
up Environments
– Adapt and implement elements from the Shape Up Somerville model
– Test for effectiveness in a rural setting through a RCT with an ASP
comparison
– 2100 1st- 6th g
grade children in four rural regions
g
of the US
• 22 randomly selected after school programs CHANGE !
• 8 new schools/communities CHANGE II
– IIndividual,
di id l ffamily,
il community
it and
d school-level
h ll
l environmental
i
t l&
policy outcomes
– Long term goal: to disseminate childhood obesity research that will
empower individuals and communities to catalyze change in rural
environments
CHANGE II Study Sites
RCT
4 Intervention
(1 / state)
CHANGE Study Sites (N=8)
4 Control
(1 / state)
Outcome Evaluation: CHANGE Measurable end results that will allow comparison between the intervention and control communities (n=8) in order to identify a program’s impact.
Outcome
Evaluation Tool
Evaluation Tool
Timeline
Individual (child) Level BMI (Height and Weight)
Child Survey: Diet, Physical Activity, Screen time, and Perceived Parental Support oYounger child version (grades 1‐2)
Y
hild
i ( d 1 2)
oOlder child version (grades 3‐6)
Spring 2008, Fall 2008, Spring 2009
Family Level Family Survey
Fall 2008, Spring 2009
Community Readiness
Community Readiness Model
d
d l
Summer 2008, Spring 2009
Built Environment/ B
il E i
/
Community Policy
Completion of community assessment tool
Completion of community assessment tool.
Fall 2008, Spring 2009
F ll 2008 S i 2009
Food Service Income and expenditure data
Nutrient
Nutrient analysis done by school
analysis done by school
Participation rates
Production records /Recipes
Interview: What changes did/did not occur with food service this year? Fall 2008, Spring 2009
same as above
same as above
same as above
same as above
Spring 2009
Yale Tool for evaluating existing policies
Wellness Policy Checklist/Survey Tool
Abbreviated interview with school principals
Fall 2008, Spring 2009
same as above
same as above
Benchmark: National Guidelines: 2005 Dietary Guidelines for Americans and 2008 Healthier US Schools Guidelines
Wellness Policy
Quality of policy language Extent of Implementation Assessing and Preventing Obesity in New Immigrants
Obesogenic
Environment
Stressors
Isolation
Education
Financial constraints
Lack of transportation
Lack basic
nutrition
knowledge
Access to healthy food
Culture shock
Lack of time/multiple jobs
Opportunities to exercise
Fast food consumption
Minimal access to
healthcare
Violence
Discrimination
Language barrier
Fear
Unemployment
No formal
education
Disruption in Energy Balance
Energy Expenditure
Energy Intake
Weight Gain
Obesity