Education, Policy and Environmental Change, and Evaluation
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Transcript of 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%
Obesity Trends* Among U.S. Adults, BRFSS 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. Adults, BRFSS 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. Adults, BRFSS 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. Adults, BRFSS 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. Adults, BRFSS 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. Adults, BRFSS 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. Adults, BRFSS 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. Adults, BRFSS 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. Adults, BRFSS 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. Adults, BRFSS 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. Adults, BRFSS 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. Adults, BRFSS 2002 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. Adults, BRFSS 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. Adults, BRFSS 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. Adults, BRFSS 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. Adults, BRFSS 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. Adults, BRFSS 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. Adults, BRFSS 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. Adults, BRFSS 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
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
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
Community Design & the
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.
Community Design & the
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
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
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.
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
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
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
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,
http://centertrt.org/?p=intervention&id=1093
Baby-Friendly Hospital Initiative,
http://www.centertrt.org/?p=intervention&id=1094§ion
=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)
… “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
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
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