Patricia Coleman, Nutrition and Health Programs Team Leader
PREVALENCE OF YOUNG CHILD OVERWEIGHT AND OBESITY IN THE US AFFILIATED PACIFIC
REGION: A META ANALYSIS FROM THE CHILDREN’S HEALTHY LIVING PROGRAM (CHL)*
RACHEL NOVOTNY1, MARIE KAINOA FIALKOWSKI1, FENFANG LI1, DONALD VARGO2, YVETTE PAULINO3, PATRICIA COLEMAN4, ANDREA BERSAMIN5, CLAUDIO R
NIGG1, JODI LESLIE1, RACHAEL LEON GUERRERO3, JONATHAN DEENIK1, JANG KIM4, LYNNE R WILKENS1
1UNIVERSITY OF HAWAII, 2AMERICAN SAMOA COMMUNITY COLLEGE, 3UNIVERSITY OF GUAM, 4NORTHERN MARIANAS COLLEGE, 5UNIVERSITY OF ALASKA,
FAIRBANKS
Introduction: US NHANES is not conducted is US Affiliated Pacific (USAP) Region (USAP Islands, Hawai`i ,
Alaska).
Method: A meta-analysis of published literature and publicly available agency reports was conducted to
estimate overweight and obesity prevalence of 2-8 year (y) old USAP children. Contiguous US data
(NHANES) served as reference. Literature search was limited to resources in English and 2-8y USAP
children data from 2000 to 2013 and used CDC 2010 overweight and obesity reference data. USAP region
sources (n=23) and NHANES articles (n=3; the contiguous U.S reference) included. Data were
disaggregated into single years of age. The children measured for the age group were divided equally and
the prevalence was assigned to each individual age. A mixed model regressed the prevalence on a
polynomial in age, accounting for the prevalence variance and another model compared jurisdictions.
Results: Overweight plus obesity increased from 21% at 2y, to 39% at 8y (p<0.0001) for the USAP. In
comparison, combined overweight plus obesity increased from 24 % at 2y to 35% at 8y (p<.0001) for
NHANES. USAP data showed with a sharp increase in prevalence at 5y. Obesity alone increased from 10%
at 2y, doubling to 24% at 8y (p<0.0001)whereas overweight prevalence was stable from 2y (13%) to 8y
(15%).
Discussion: Further examination, monitoring and understanding of USAP young child obesity is needed.
*TO BE PRESENTED AT AMERICAN SOCIETY OF NUTRITION ANNUAL MEETING IN SAN DIEGO, APRIL 2014 & ABSTRACT PUBLISHED IN FASEB JOURNAL. PAPER
SUBMITTED TO AJPH.
Methods
• Meta-analysis of published literature and
publicly available agency reports for Hawaii,
Alaska, and US-Affiliated Pacific Islands
• English only, 2-8 year olds
• Year 2000 & newer, CDC overweight and
obesity reference data
• Data disaggregated into single years of age
Methods cont.
• Children measured for the age group were
divided equally and prevalence was assigned
to each individual age
• Mixed model regressed the prevalence of a
polynomial in age
Results
• OWOB increased from 21.0% at 2y to 39.2% at
8y (p<.0001) for the USAP
• NHANES increased from 24.2% at 2y to 34.8%
at 8y (p<.0001)
• Sharp increase in prevalence at age 5y
• USAP obesity alone increased from 10.2% at
2y to 23.6% at 8y (p<.0001)
CHL Population
U.S. Affiliated Pacific Region Need
• Obesity - minimal data, no NHANES
• Capacity - few trained professionals
• Unique geography and culture - need
culturally tailored approach
CHL Annual Meeting,
Guam June 2013
7
CHL Vision
We envision sustainable community-based
systems and environments to raise healthy
children in the Pacific Region
Children from the
Republic of the
Marshall Islands
CHL Mission
In partnership with our
community, our mission is to
elevate the capacity of the
region to build and sustain a
healthy food and physical
environment to help maintain
healthy weight and prevent
obesity among young children
in the Pacific region
Tafuna
Elementary,
American
Samoa,
April 2013
CHL Goal
The goal of CHL is to build social/cultural,
political/economic, and physical/built
environments that will promote active play
and intake of healthy food to prevent young
child obesity in the Pacific Region
Children from Yap State,
Federated States of
Micronesia
External Advisory Committee
Jennifer Anderson
Kathryn Kolasa
Suzanne Murphy
Wendy Snowdon
Boyd Swinburn
Principal
Investigator
Novotny
Program Steering Committee
Lead Site Co-I :
Deenik, Kim, Bersamin,
Leon-Guerrero/Barber, Novotny,
Vargo/Ropeti
Performance Sites
FAS: FSM, RMI, Palau;
CNMI; Alaska;
Guam; Hawaii; Am. Samoa
Coordinating Center
Program Director: Novotny
Assistant Program Director: Fialkowski
Program Administrator: Yan
Conference Coordinator: Chun
IT Manager: DeBusk
Local Advisory
Committees
LG Dir. Chair:
Currie, Samson,
Taro;
Manglona; Sparrow,
Yudin, Gallo, Aga
Data Center
Lead: Wilkens
Data Coordinator: Li
Training / Education Center
Lead: Dunn / Fialkowski
Education Coordinator: Leslie / Delormier
External Communication Center
Lead: Hollyer / Takahashi
Intervention Center
Situation Analysis Center
Lead: Fialkowski / DeBaryshe
Lead: Nigg / Braun
Intervention Coordinator: Butel
CHL Target Population
• Grant requirement: children ages 2 – 8 y
–
–
–
–
–
–
–
–
Head Start
Preschool
Day Care
Kindergarten
Community Health Centers
Community Centers
Images from CHL brochure,
courtesy of Center on the
Community Events
Family
Supplemental Feeding Program for Women, Infants, &
Children
CHL Objectives
1.
Conduct program / data inventories & situation analysis – Situation Analysis
Work Group
2.
(Degree) Train 22 professionals & paraprofessionals in obesity prevention –
Training Work Group
3.
Develop Pacific food, nutrition & physical activity data management &
evaluation system – Data & External Communications Work Groups
4.
Develop & conduct an environmental intervention (to prevent, maintain or
decrease young child overweight & obesity in the Pacific Region) –
Intervention and External Communication Work Groups
5.
Evaluate the community - based primary - prevention environmental
intervention – Data Center Work Group
6.
Incur at least one obesity prevention policy change per state / jurisdiction –
Program Steering Committee Work Group
CHL (6 behavioral outcomes, 3 health outcomes)
Primary
1. Sleep by 15 min/day
2. Moderate to vigorous physical activity by 10 min/day
3. Fruit & vegetable intake by 1 serving/day (1/2 c/day)
4. Water intake by ½ cup/day
5. Sedentary behavior (screen time) by 10 min/day
6. Sweetened beverage intake by ½ cup/day
1. Prevalence of obesity by 8% (0.10 kg/m2 decrease in
BMI z- score)
2. Waist circumference by 2%
Secondary
3. Acanthosis nigricans by 5%
Positive acanthosis nigricans
screen, CHL Study
Effective Evidence-Based Strategies
from Randomized Controlled Trials
Decrease in
SSB intake
Policies to
ban SSB
Product &
shelf labeling
Increase in
F/V intake
Increase in
water intake
Decrease in
leisure screen
time
Policies:
Policies to
Policies to
promote F/V promote water reduce screen
consumption
intake
time
Product &
shelf
labeling
Increase
access to
clean Water
Increase in
PA
Increase
in sleep
Policies to
promote PA
Change Built
Environment
to promote PA
Gardening
Healthy
lifestyle
Education
Healthy
lifestyle
education
Healthy
lifestyle
education
Healthy
lifestyle
education
Healthy
lifestyle
education
Healthy
lifestyle
education
ANGELO –Analysis Grid for Elements Linked to Obesity (Swinburn and colleagues)
CHL SITUATIONAL
ANALYSIS
& SCAN
MERGE
PRIORITIZE
FORMULATE
Action
Plans
Demographic, health,
risk, and other data
Strategies
from:
Importance
Community
suggestions to address
obesogenic
environments
 Physical
 Social
 Policy
Community
Do-ability
Scientific literature
Literature
GOALS
Healthy Eating
1. Decrease in SSB
intake
2. Increase in water
intake
3. Increase in fruit &
vegetable intake
Physical Activity
4. Decrease in leisure
screen time
5. Increase in sleep
6. Increase in physical
activity
Top Strategies from Communities (Nov 2011-Feb 2012)
Overall Priorities
1. Educate parents, siblings, grandparents, children,
communities on healthy living
Alaska Am Sam CNMI Guam
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
2. Importance of family, teachers, leaders, other respected
figures as role models setting a healthy living example
3. Better and more free community activities and
resources to promote healthy living
4. Community resources maintained and accessible during
all times making physical activity easier
Hawaii
5. Improve drinking water access/facilities
X
X
X
X
6. School policies need to be changed to make school
lunches healthier, encourage water intake, increase
physical activity, and reduce sugar sweetened beverage
X
X
X
X
X
X
X
X
X
X
X
7. Change government policies to promote healthy
lifestyle, prohibit use of food stamps to buy junk food,
control stray dogs and moose
8. Limit screen time
9. Healthy local-grown, garden-fresh produce should be
easily accessible and affordable
X
X
X
X
MERGE -- Much of what the community wants
is supported by the literature
Supported by Supported by
literature
community
Policies
Access to water
Environmental changes for PA
Healthy living education
Product and shelf labeling
Access to affordable produce
(including gardening)
X
X
X
X
X
X
X
X
X
X
X
PRIORITIZE - Communities prioritized the
merged list of strategies (May-June 2012)
Merged list of strategies posted on flip chart paper
Presented to 10 selected communities, 2 each in:
•
•
•
•
•
Alaska
American Samoa
CNMI
Guam
Hawaii
Participants prioritized based on
•
•
Importance
Feasibility (Do-ability)
FORMULATE– Intervention Community
Action Planning (LAC)
1. Bring together key stakeholders,
including parents, teachers, and
leaders to implement the strategy
2. Adapt the strategy to the locale
3. Promote and implement the
strategy
4. Establish a mechanism to
monitor fidelity and outcomes
5. Use data to improve
implementation
Other communities are testing interventions to
reduce childhood obesity,
AND
they are willing to share their materials and ideas!
In implementing these strategies, CHL:
• Partners with, supports, and “adds value” to existing
programs that are conducting activities related to our 6
behavioral outcomes.
• Builds local capacity to sustain programs and policy
changes.
• Promotes a common CHL message.
• Collects data on the timeline of implementing strategies
and on the extent to which strategies are implemented at
given time points.
Cross-cutting Functions
1. Review assessment data for policy &
physical environment related to the 6 CHL
behaviors
2. Partner & advocate for environmental
change
3. Promote the CHL message
4. Train the trainers
CHL Intervention: Cross-Cutting Functions, Activities & Behavioral Targets
Review Assessment Data for Policy & Physical Environment related to the 6 CHL behaviors
a. Review preschool wellness policy assessment data to identify training needs
b. Review community assessment data to identify areas for advocacy for PA env.
Partner and Advocate for Environmental Change
a. Work with coalitions to advocate for
i. Better access to parks that are safe & inviting
ii. Better access to clean water
iii. Safer environments for walking & biking
iv. Better food placement in stores
v. Gardens & hydroponics
b. Partner with existing entities to purchase or obtain sponsorship for
i. Water in the preschools
ii. Gardening supplies for preschool kids
iii. Sports equipment for preschool kids
iv. Campaigns & messages
Promote the CHL Message
a. Support role models to deliver CHL messages in various
b. Enhance existing social marketing campaigns related to 6 CHL behaviors
c. Advertise CHL or other activities that promote 6 CHL target behaviors
Train the Trainers
a. Train individuals to promote gardening in preschools & communities
b. Train individuals to lead interactive, hands-on, & family-based sessions
c. Train preschool providers on wellness policies
d. Train preschool providers in curricula related to 6 CHL target behaviors
e. Train role models (community champions, role celebrities, role models)
↓
SSB
↑
F/V
↑
PA
X
X
X
X
X
X
↑
↓
↑
Water Screen Sleep
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
CHL TEAM CNMI
Jang Ho Kim, Tayna Belyeu-Camacho, Rose Castro, Jesse Deleon Guerrero,
Marilynn Duenas, Randall Nelson, & me 
25
CNMI work w/role models (RM)
• Village focused instead of CNMI-wide focus
• RM identified by key informants, knowledge of
community
• Empowerment of stakeholders/role models
• Training and technical support
• Building on assets, strengths, influences of role
model group—integral role in driving the
intervention
• Diverse backgrounds
Village Logos
TASA Role Models
Enhancing the Built Environment in
Kagman
Policy:
Child
Care
Licensing
Regulations
Policy & Advocacy
• Require each child care
center to have policies that
focus on the
implementation of the CHL
behaviors
• Require procedures/plans
for implementation
• Align inspection checklist
with policy requirements
• Mobilize partners for
support
• Get approval from governor
Training
• First training slated for Maydemonstrate burden of
COWOB, critical role they playget buy-in
• Include child care
administrators, owners,
managers, and child care
providers
• Write the policy in
• Subsequent trainings to focus
on implementation of one or
two CHL behaviors
• CCDF benefits
Prevalence Survey
Freely Associated States: Palau, Marshalls, Chuuk, Kosrae, Pohnpei, Yap
•
Determine the prevalence rates of underweight,
overweight, and obesity in a representative sample of
young children, ages 2 – 8y, from each jurisdiction
•
Provide descriptive information on similar measures as
CHL Intervention Study
•
Approximate sample size 200 per jurisdiction Marshalls, Kosrae,
Pohnpei, Chuuk, Yap, Palau)
•
Data: Anthropometry, Acanthosis Nigricans, Accelerometry,
Questionnaire (Sleep etc...),Food and Activity logs, Community
obesity prevention environmental assessment, Food & Utility cost
survey
•
Most Survey elements completed in Pohnpei (Oct 28-Nov 8, 2013)
and RMI ( Jan 1-Feb 4, 2014)
•
Palau survey: April 7-18, 2014; Chuuk Survey July 14 to Aug 14,
2014; Yap October 2014; Kosrae Jan 2015
31
Capacity Building Through Training
I. CHL Scholarship Program
Provide academic degree training for indigenous students in
CHL region- 2 from each jurisdiction, including 2 from each state
of Freely Associated States of Micronesia
II. CHL Capacity Building Program for the Pacific Region
Help develop sustainable, culturally appropriate, nutrition
courses & programs & within existing academic institutions
in the region
CHL Students – Cohort 1
CHL Students – Cohort 2
CHL Phases
Phase 1: Situation
Analysis
• Inventories
• Community
Meetings
• Community
Readiness
Training
Phase 2:
Measurement
•Participant
•Community
•Data entry
Phase 3:
Intervention
3,919
•Implementation
•Monitoring
•Data entry
Phase 4:
Measurement
•Participant
•Community
•Data Entry
Phase 5: Evaluation,
Dissemination, Policy
& Data Systems
Development
Children’s Healthy Living
Program
Environmental Changes
Social/Cultural Env.
Examples:
•Family, teachers, church leaders,
other respected role models setting
example of healthy living
Political/Economic Env.
Examples:
•Influence leash laws
Physical/Built Env.
Examples:
•Ensure water fountains are available
& maintained
Promote
Outcomes
Healthy
Food Intake
Obesity
Prevention
• Decrease in sugarsweetened beverage intake
• Increase in water intake
• Increase in fruit and
vegetable intake
Overall
Outcome:
Healthy
Young
Child
Physical
Activity
• Decrease in recreational
screen time
• Increase in sleep
• Increase in physical
activity
36
Si yu’us maase yan olomwaay!